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Intravenous thrombolysis with alteplase bolus followed by infusion is a global standard of care for patients with acute ischaemic stroke. We aimed to determine whether tenecteplase given as a single bolus might increase reperfusion compared with this standard of care.In this multicentre, open-label, parallel-group, registry-linked, randomised, controlled trial (AcT), patients were enrolled from 22 primary and comprehensive stroke centres across Canada. Patients were eligible for inclusion if they were aged 18 years or older, with a diagnosis of ischaemic stroke causing disabling neurological deficit, presenting within 4·5 h of symptom onset, and eligible for thrombolysis per Canadian guidelines. Eligible patients were randomly assigned (1:1), using a previously validated minimal sufficient balance algorithm to balance allocation by site and a secure real-time web-based server, to either intravenous tenecteplase (0·25 mg/kg to a maximum of 25 mg) or alteplase (0·9 mg/kg to a maximum of 90mg; 0·09 mg/kg as a bolus and then a 60 min infusion of the remaining 0·81 mg/kg). The primary outcome was the proportion of patients who had a modified Rankin Scale (mRS) score of 0-1 at 90-120 days after treatment, assessed via blinded review in the intention-to-treat (ITT) population (ie, all patients randomly assigned to treatment who did not withdraw consent). Non-inferiority was met if the lower 95% CI of the difference in the proportion of patients who met the primary outcome between the tenecteplase and alteplase groups was more than -5%. Safety was assessed in all patients who received any of either thrombolytic agent and who were reported as treated. The trial is registered with ClinicalTrials.gov, NCT03889249, and is closed to accrual.Between Dec 10, 2019, and Jan 25, 2022, 1600 patients were enrolled and randomly assigned to tenecteplase (n=816) or alteplase (n=784), of whom 1577 were included in the ITT population (n=806 tenecteplase; n=771 alteplase). The median age was 74 years (IQR 63-83), 755 (47·9%) of 1577 patients were female and 822 (52·1%) were male. As of data cutoff (Jan 21, 2022), 296 (36·9%) of 802 patients in the tenecteplase group and 266 (34·8%) of 765 in the alteplase group had an mRS score of 0-1 at 90-120 days (unadjusted risk difference 2·1% [95% CI - 2·6 to 6·9], meeting the prespecified non-inferiority threshold). In safety analyses, 27 (3·4%) of 800 patients in the tenecteplase group and 24 (3·2%) of 763 in the alteplase group had 24 h symptomatic intracerebral haemorrhage and 122 (15·3%) of 796 and 117 (15·4%) of 763 died within 90 days of starting treatment INTERPRETATION: Intravenous tenecteplase (0·25 mg/kg) is a reasonable alternative to alteplase for all patients presenting with acute ischaemic stroke who meet standard criteria for thrombolysis.Canadian Institutes of Health Research, Alberta Strategy for Patient Oriented Research Support Unit.

Background: Pain is a common symptom in Parkinson's disease (PD) patients. Scales to rate pain in PD are marred by several flaws, either not being available in other languages or not specific for PD. Objectives: To assess the frequency of pain among bilingual Indian PD patients using “King's Parkinson's disease pain scale” (KPPS) and to validate it. Methods: We randomly administered KPPS in Hindi/English to all consecutive bilingual persons with PD. The results were appropriately analyzed. Results: A total of 119 PD patients were enrolled with a mean age of 64.34 (± 9.57) years. Median Hoehn and Yahr stage was 2 (42.85%). Pain was present in 62 (52.1%) PD patients. The most common type was musculoskeletal (74.19%). The mean total KPPS score was 16.02 ± 10.57. KPPS score was significantly higher in women and correlated positively with unified Parkinson's disease rating scale (UPDRS) part 2 and 4 scores (r = 0.27 and r = 0.25). Risk factors for pain were female gender, higher H and Y stage, total UPDRS score, and individual UPDRS part 3 and 4 scores. Difficulty falling asleep (P = 0.01), frequent awakenings (P = 0.01), diminished smell sensation (P = 0.003), diminished speech volume (P = 0.02), gait freezing (P = 0.03), and falls (P = 0.001) correlated with the presence of pain. The interclass correlation coefficient between the Hindi and English versions of KPPS was 0.835, while Bland–Altman analysis showed 96.7% agreement suggesting excellent correlation and validation. Conclusions: KPPS is an easy tool for characterization, scoring, and follow-up of pain in PD patients. The Hindi version has good agreement with the original English version.

Neuropathic tremors are often encountered in both hereditary as well as acquired inflammatory demyelinating neuropathies, such as IgM paraproteinemic neuropathy and chronic inflammatory demyelinating polyradiculoneuropathy and occasionally during the recovery phase of Guillain-Barre syndrome (GBS). Acute motor axonal neuropathy (AMAN) accounts for up to 30–65% the patients with GBS in East Asia and is rarely associated with a neuropathic tremor. We report a patient with AMAN, who presented with pure motor quadriplegia with bulbar symptoms and a prominent atypical resting head tremor during the acute phase of illness, which showed an excellent response to topiramate therapy.

Dystonia can be encountered in a small subset of patients with spinocerebellar ataxia (SCA), but task specific dystonia is extremely rare. We report a case of a 48-year-old male with confirmed SCA Type 1 (SCA1) with mild progressive cerebellar ataxia and a prominent and disabling Writer’s cramp. This case highlights the ever-expanding phenotypic heterogeneity of the SCA’s in general and SCA1 in particular.

In the last four decades, great strides have been made in understanding the pathophysiology and management of movement disorders. Several new molecules and methods of their delivery have made management of these disorders free of complications. New discoveries of genetic abnormalities have helped in better classification of these disorders along with improved prognostication. Improved imaging techniques that help in better localization of target for deep brain stimulation, refinement of stereotactic procedure, and development of safer anesthetic procedure have together encouraged more patients opting for deep brain stimulation for treatment. In the near future, it is expected that more genetic varieties of disorders will be known which may help in genetic intervention for therapy.

A 22-year-old man presented with a 5-year history of focal seizures and a pulsatile bump on the forehead (figure, A; video on the Neurology ® Web site at [Neurology.org][1]). He had subtle right hemiparesis with facial palsy, Mini-Mental State Examination score of 22/30, and audible bruit on forehead swelling, suggesting cerebral proliferative angiopathy (CPA). This condition differs from arteriovenous malformation in in that hemorrhages are uncommon; it has a typically large size, with normal brain parenchyma between vascular spaces (figure, B).1 There are multiple arterial feeders (figure, C) with prominent draining veins (figure, D).1,2 Embolization or surgical resections are not usually possible with a CPA diagnosis.1 [1]: http://neurology.org/lookup/doi/10.1212/WNL.0000000000001686

Hemifacial spasm is characterised by unilateral contractions of the facial muscles. Though considered to be benign by many people, it can lead to functional blindness and a poor quality of life due to social embarrassment for the suffering individual. Botulinum toxin therapy is an excellent noninvasive tool to treat this condition. However, surgical decompression of the aberrant vessel is also an upcoming approach to therapy for this condition.

Context: With advances in neuroimaging, traditional views regarding the clinicoanatomic correlation in stroke patients with aphasia are being challenged and it has been observed that lesions at a given cortical or subcortical site may manifest with different aphasia profiles. Aims: To study as to whether there is a strict clinicoanatomical correlation between the type of aphasia and lesion site in patients with first ever stroke. Settings and Design: Observational study, based in a tertiary care center. Materials and Methods: Stroke patient′s ≥18 years of age were screened and those with first ever stroke and aphasia were subjected to a detailed stroke workup and language assessment using the Hindi version of Western Aphasia Battery (WAB). Statistical analysis was done with χ2 test with Yates correction and Kruskal-Wallis test. The level of significance was set at P < 0.05. Results: Overall aphasia was detected in 27.9% of the 260 screened cases with stroke. Amongst 60 cases with first ever stroke and aphasia, the aphasia type was: Global (33.33%), Broca′s (28.3%), transcortical motor (13.33%), transcortical sensory (10%), Wernicke′s (8.33%), anomic (5%), and conduction (1.67%) aphasia. A definite correlation between the lesion site and the type of aphasia as per the traditional classification was observed in 35% cases only. Conclusions: No absolute correlation exists between the lesion site and the type of clinical aphasia syndrome in majority of the patients with cortical and subcortical stroke.