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Contains fulltext : 235277.pdf (Publisher’s version ) (Closed access) BACKGROUND: Balancing the risks of recurrent ischaemic stroke and intracranial haemorrhage is important for patients treated with antithrombotic therapy after ischaemic stroke or transient ischaemic attack. However, existing predictive models offer insufficient performance, particularly for assessing the risk of intracranial haemorrhage. We aimed to develop new risk scores incorporating clinical variables and cerebral microbleeds, an MRI biomarker of intracranial haemorrhage and ischaemic stroke risk. METHODS: We did a pooled analysis of individual-patient data from the Microbleeds International Collaborative Network (MICON), which includes 38 hospital-based prospective cohort studies from 18 countries. All studies recruited participants with previous ischaemic stroke or transient ischaemic attack, acquired baseline MRI allowing quantification of cerebral microbleeds, and followed-up participants for ischaemic stroke and intracranial haemorrhage. Participants not taking antithrombotic drugs were excluded. We developed Cox regression models to predict the 5-year risks of intracranial haemorrhage and ischaemic stroke, selecting candidate predictors on biological relevance and simplifying models using backward elimination. We derived integer risk scores for clinical use. We assessed model performance in internal validation, adjusted for optimism using bootstrapping. The study is registered on PROSPERO, CRD42016036602. FINDINGS: The included studies recruited participants between Aug 28, 2001, and Feb 4, 2018. 15 766 participants had follow-up for intracranial haemorrhage, and 15 784 for ischaemic stroke. Over a median follow-up of 2 years, 184 intracranial haemorrhages and 1048 ischaemic strokes were reported. The risk models we developed included cerebral microbleed burden and simple clinical variables. Optimism-adjusted c indices were 0·73 (95% CI 0·69-0·77) with a calibration slope of 0·94 (0·81-1·06) for the intracranial haemorrhage model and 0·63 (0·62-0·65) with a calibration slope of 0·97 (0·87-1·07) for the ischaemic stroke model. There was good agreement between predicted and observed risk for both models. INTERPRETATION: The MICON risk scores, incorporating clinical variables and cerebral microbleeds, offer predictive value for the long-term risks of intracranial haemorrhage and ischaemic stroke in patients prescribed antithrombotic therapy for secondary stroke prevention; external validation is warranted. FUNDING: British Heart Foundation and Stroke Association.

Background and Purpose— Acute minor neurological deficits are a common complaint in the emergency department and differentiation of transient ischemic attack/minor stroke from a stroke mimic is difficult. We sought to assess the ability of white matter hyperintensity (WMH) volume to aid the diagnosis in such patients. Methods— This is a post hoc analysis of the previously published SpecTRA study (Spectrometry in TIA Rapid Assessment) of adult patients that presented to the emergency department with acute minor neurological deficits between December 2013 and March 2017. WMH volumes were measured if fluid-attenuated inversion recovery imaging was available. Outcomes of interest were final diagnosis, symptoms at presentation, and 90-day stroke recurrence. Results— WMH volume was available for 1485 patients. Median age was 70 years (interquartile range, 59–80), and 46.7% were female. Mean WMH volume was higher in transient ischemic attack/minor strokes compared with stroke mimics (1.71 ln mL [95% CI, 1.63–1.79 ln mL] versus 1.15 ln mL [95% CI, 1.02–1.27 ln mL], P P =0.035). Conclusions— The combination of diffusion-weighted imaging positivity and high WMH volume was associated with lower odds of focal symptoms at presentation in patients seen with minor neurological deficits in the emergency department. This suggests that WMH volume might be an important consideration and the absence of focal symptoms at presentation should not discourage clinicians from further investigating patients with suspected cerebral ischemia.

Background and Purpose— White matter lesions (WML) are associated with cognitive decline, increased stroke risk, and disability in old age. We hypothesized that superimposed acute cerebrovascular occlusion on chronic preexisting injury (leukoaraiosis) leads to worse outcome after minor cerebrovascular event, both using quantitative (volumetric) and qualitative (Fazekas scale) assessment, as well as relative total brain volume. Methods— WML volume assessment was performed in 425 patients with high-risk transient ischemic attack (TIA; motor/speech deficits >5 minutes) or minor strokes from the CATCH study (CT and MRI in the Triage of TIA and Minor Cerebrovascular Events to Identify High Risk Patients). Complete baseline characteristics and outcome assessment were available in 412 patients. Primary outcome was disability at 90 days, defined as modified Rankin Scale score of >1. Secondary outcomes were stroke progression, TIA recurrence, and stroke recurrence. Analysis was performed using descriptive statistics and regression models including interaction terms. Results— Median age was 69 years, 39.8% were female. Sixty-two patients (15%) had unfavorable outcome with disability at 90 days (modified Rankin Scale score >1). Higher Fazekas scores were strongly correlated with higher WML volume ( r =0.79). Both higher Fazekas score and higher WMH volume were associated with disability at 90 days in univariate regression (odds ratio 1.22; 95% confidence interval, 1.04–1.43 and odds ratio, 1.25 per milliliter increase; 95% confidence interval, 1.02–1.54, respectively) but not with stroke progression, TIA recurrence, or stroke recurrence. In multivariable-adjusted analyses, additive interaction terms were associated with unfavorable outcome (adjusted odds ratio 3.99, 95% confidence interval, 1.87–8.49). Conclusions— Our data suggest that quantitative and qualitative WML assessments are highly correlated and comparable in TIA/minor stroke patients. WML burden is associated with short-term outcome of patients with good prestroke function in the presence of intracranial stenosis/occlusion.

Background: Urethroplasty in pediatric patients is a challenging task. In this study, we have tried to assess the complexity and evaluate the outcome of progressive perineal anastomotic urethroplasty in prepubertal children. Materials and Methods: Retrospective data of all the prepubertal children who underwent progressive perineal urethroplasty between March 2009 and April 2014 were analyzed. Patients were evaluated with history, examination, essential laboratory investigations, retrograde urethrogram, and voiding cystourethrogram. Before subjecting the patients for definitive surgery, antegrade and retrograde endoscopic assessment was done. The surgery was performed by the transperineal route with the help of ×2.5 magnification. Patients were followed up with uroflowmetry for every 3 months in the 1 st year and for every 6 months in the subsequent years. Results: Mean age of the patients was 7.3 (range 5-11) years. Mean urethral distraction defect was 1.7 (range 1-2.5) cm. All the patients were successfully managed by the perineal approach. Crural separation was performed in all the patients while additional inferior pubectomy was required in six patients. Mean operating time was 298 (range 180-400) min. Mean blood loss was 174 (range 100-500) ml. One patient had the left calf hematoma in the immediate postoperative period. Seven out of nine (77.7%) patients had successful urethroplasty. Two patients had failed urethroplasty who were successfully managed by redo-urethroplasty. Transient incontinence was observed in one patient. Erectile function could not be assessed in these patients. Conclusion: This study shows the feasibility of progressive perineal urethroplasty by the perineal route in prepubertal children. An endoscopic assessment should be performed before the definitive surgery. Use of loupe helps in performing better anastomosis and hence yielding a better result.

Atherosclerotic cardiovascular disease, a chronic inflammatory condition of multifactorial etiology, is the leading cause of death worldwide. The concept of ‘bacterial persistence’ has been proposed as one of several contributing factors to this disease. We hypothesized that the infectious agent(s) found at the site of the atheroma may be dormant but perpetuate virulence in response to host defense and other physiological triggers. In this study, we sought to identify the source of persistent infection in human atherosclerotic plaque and define how pathogen virulence and host defenses mediate plaque vulnerability. Whole genome sequencing (WGS) was used to identify bacteria from pure cultures obtained from atherosclerotic tissues of living subjects diagnosed with more than 70% occlusion of the carotid artery undergoing carotid endarterectomy (CE). WGS identified the predominant species as S. pasteuri (Spv) in all CE isolates grown in pure culture except one isolate which was identified as B. licheniformis. All S. pasteuri isolates (Spvs) were found to contain genes for widespread virulence, invasion, and intracellular resistance. As macrophages (Mφs) play a decisive role at all stages of this disease we treated mouse Mφs (RAW 264.7) with Spvs. While all Spvs tested demonstrated their ability to survive phagocytosis, the highly virulent Spvs also activated Mφs and induced trans-endothelial cell migration of these cells which was mediated via the CC chemokine CCL1 and its receptor CCR8. In conclusion, we show that Spvs are found in CE plaques, have the capacity to survive phagocytosis and induce the transmigration of Mφs across an endothelial barrier in a CCL1-CCR8 dependent process. These findings highlight the significance of carotid vessels as a reservoir for S. pasteuri, a pathogen found in products used routinely in human consumption; this may explain how microbial pathogenicity modulates plaque vulnerability in atherosclerosis.

Contains fulltext : 208975.pdf (Publisher’s version ) (Open Access) BACKGROUND: Cerebral microbleeds are a neuroimaging biomarker of stroke risk. A crucial clinical question is whether cerebral microbleeds indicate patients with recent ischaemic stroke or transient ischaemic attack in whom the rate of future intracranial haemorrhage is likely to exceed that of recurrent ischaemic stroke when treated with antithrombotic drugs. We therefore aimed to establish whether a large burden of cerebral microbleeds or particular anatomical patterns of cerebral microbleeds can identify ischaemic stroke or transient ischaemic attack patients at higher absolute risk of intracranial haemorrhage than ischaemic stroke. METHODS: We did a pooled analysis of individual patient data from cohort studies in adults with recent ischaemic stroke or transient ischaemic attack. Cohorts were eligible for inclusion if they prospectively recruited adult participants with ischaemic stroke or transient ischaemic attack; included at least 50 participants; collected data on stroke events over at least 3 months follow-up; used an appropriate MRI sequence that is sensitive to magnetic susceptibility; and documented the number and anatomical distribution of cerebral microbleeds reliably using consensus criteria and validated scales. Our prespecified primary outcomes were a composite of any symptomatic intracranial haemorrhage or ischaemic stroke, symptomatic intracranial haemorrhage, and symptomatic ischaemic stroke. We registered this study with the PROSPERO international prospective register of systematic reviews, number CRD42016036602. FINDINGS: Between Jan 1, 1996, and Dec 1, 2018, we identified 344 studies. After exclusions for ineligibility or declined requests for inclusion, 20 322 patients from 38 cohorts (over 35 225 patient-years of follow-up; median 1.34 years [IQR 0.19-2.44]) were included in our analyses. The adjusted hazard ratio [aHR] comparing patients with cerebral microbleeds to those without was 1.35 (95% CI 1.20-1.50) for the composite outcome of intracranial haemorrhage and ischaemic stroke; 2.45 (1.82-3.29) for intracranial haemorrhage and 1.23 (1.08-1.40) for ischaemic stroke. The aHR increased with increasing cerebral microbleed burden for intracranial haemorrhage but this effect was less marked for ischaemic stroke (for five or more cerebral microbleeds, aHR 4.55 [95% CI 3.08-6.72] for intracranial haemorrhage vs 1.47 [1.19-1.80] for ischaemic stroke; for ten or more cerebral microbleeds, aHR 5.52 [3.36-9.05] vs 1.43 [1.07-1.91]; and for >/=20 cerebral microbleeds, aHR 8.61 [4.69-15.81] vs 1.86 [1.23-1.82]). However, irrespective of cerebral microbleed anatomical distribution or burden, the rate of ischaemic stroke exceeded that of intracranial haemorrhage (for ten or more cerebral microbleeds, 64 ischaemic strokes [95% CI 48-84] per 1000 patient-years vs 27 intracranial haemorrhages [17-41] per 1000 patient-years; and for >/=20 cerebral microbleeds, 73 ischaemic strokes [46-108] per 1000 patient-years vs 39 intracranial haemorrhages [21-67] per 1000 patient-years). INTERPRETATION: In patients with recent ischaemic stroke or transient ischaemic attack, cerebral microbleeds are associated with a greater relative hazard (aHR) for subsequent intracranial haemorrhage than for ischaemic stroke, but the absolute risk of ischaemic stroke is higher than that of intracranial haemorrhage, regardless of cerebral microbleed presence, antomical distribution, or burden. FUNDING: British Heart Foundation and UK Stroke Association.

Background and Purpose— Transient focal neurological episodes occur in cerebral amyloid angiopathy (CAA) and can mimic transient ischemic attack (TIA). Risk factors and outcomes of minor ischemic stroke or TIA might differ in patients with and without cerebral microbleeds (CMBs), including CAA-consistent lobar CMB. Methods— Baseline magnetic resonance imaging (MRI) was analyzed for CMBs and cortical superficial siderosis in 416 patients in the prospective computed tomography and MRI in the CATCH study (Triage of TIA and Minor Cerebrovascular Events to Identify High Risk Patients). Clinical symptoms, baseline characteristics, recurrence, and 90-day modified Rankin Scale were prospectively collected. MRI white-matter hyperintensity was measured using the Fazekas scale. Results— CMBs were detected in 65 (15.6%) and cortical superficial siderosis in 11 patients (2.6%). Lobar CMBs were present in 49 (11.8%). In multivariable logistic regression adjusted for risk factors and age, subcortical Fazekas score was associated with lobar CMB (odds ratio, 2.07; 95% confidence interval, 1.23–3.48; P =0.006). Forty-two patients (10.1%) had lobar-only CMBs with or without cortical superficial siderosis consistent with modified Boston criteria for possible/probable CAA. The possible/probable CAA pattern was not predictive of recurrent TIA (odds ratio, 0.42; 95% confidence interval, 0.05–3.31; P =0.41), stroke (odds ratio, 1.24; 95% confidence interval, 0.26–5.99; P =0.79), or 90-day modified Rankin Scale score ≥2 (odds ratio, 1.38; 95% confidence interval, 0.62–3.07; P =0.42). Conclusions— CMBs in TIA and minor stroke are moderately common but do not predict recurrence or 90-day outcome. CAA-related transient focal neurological episodes and TIA have overlapping clinical symptoms, suggesting that MRI may be needed for differentiation.

Objective To assess the perioperative morbidity and early outcome of buccal mucosal graft (BMG) urethroplasty in patients with urethral stricture awaiting renal transplantation. Methods Thirteen patients awaiting renal transplantation underwent BMG urethroplasty for long anterior urethral stricture between June 2011 and March 2013. The management issues, complications, and outcome of the BMG urethroplasty in this cohort of patients were studied. Results Mean age of the patient was 38.7 ± 12.7 years. History of urethral manipulation was present in 8 patients. Mean stricture length was 6.92 ± 2.90 cm. Mean serum creatinine of the patient was 8.1 ± 3.6 mg%. Three patients required oral exploration for bleeding. Two patients had urinary extravasation, 3 patients had infected hematoma, and 1 patient developed dry gangrene of the glans. One patient had sepsis due to pyonephrosis in the postoperative period and succumbed to it. Mean follow-up of the patients was 34.54 ± 6.46 months. Three patients underwent VIU for recurrence of the stricture in the follow-up. At 3-month follow-up mean Qmax was 23.8 mL/sec, whereas at 6-month and 1-year follow-up, Qmax was 23.6 and 23.4 mL/sec, respectively. Conclusion This study shows a relatively higher complication rate of urethroplasty in prerenal transplant patients. Although the number of cases is too small to arrive at any definite conclusion, this study does gives an insight into the management issues, complications, and success of urethroplasty in this group of patients.

Hirayama disease, also known as Sobue disease is a rare nonprogressive spinal muscular atrophy. Here, we report a case series of three young males presenting with atrophy of distal upper limb and Hirayama disease as their clinico-radiological diagnosis. Magnetic resonance imaging (MRI) revealed loss of cervical lordosis with focal areas of lower cervical cord atrophy in a neutral position. MRI in flexion position revealed, anterior displacement of the detached posterior dura from the underlying lamina compressing the thecal sac and widened posterior epidural space with flow voids seen better on 3D-CISS images. All the three patients were managed conservatively.

Objective: To evaluate early clinical outcome for anaplastic gliomas (AG) treated in the era of modulated radiotherapy (RT) and concurrent plus adjuvant temozolomide (TMZ) in an Indian setting. Materials and Methods: Fifty-three patients with AGs treated with modulated RT and concurrent (95%) and adjuvant TMZ (90%) were analyzed. About 80% of patients had Karnofsky performance status (KPS) at least 90 with 30% seizure at presentation. Postoperative magnetic resonance imaging was available in 65% cases and RT dose was 60 Gy in 30 fractions. First posttreatment imaging was performed at 1 month and then at 3 and 6 months post-RT and then every 3 months. Kaplan–Meier analysis was used to estimate disease-free survival (DFS) and overall survival (OS), and analysis was done using SPSS version 18.0. Results: With median follow-up of 25 months, 2-year DFS and OS were 75% and 88%. There were only 5% symptomatic central nerves system and 8% symptomatic hematological toxicities. At the 1 st evaluation, 30.4% had complete response (CR), at 3 months 40%, and at 6 months 43%. At 6 months, only 4% had progressive disease. Forty-six patients were evaluable till the last follow-up with and 55% had stable to CR. On univariate analysis for DFS, KPS at presentation >90 ( P = 0.001) and response at 6 months ( P = 0.02) were significant and for OS KPS at presentation ( P = 0.004) alone. Conclusion: Modulated RT with TMZ among Grade III glioma patients resulted in minimum treatment-related toxicities and encouraging survival. Molecular prognostic markers will determine most favorable groups in future.

Laparoscopic kidney transplantation (LKT) is well accepted modality of treatment for ESRD patients at our center. Usually, the kidney is inserted through small Pfannenstiel incision. With the permission of the Internal Review Board, we carried out LKT in eight female recipients following insertion of the kidney through the vagina. The kidney was procured by the retroperitoneoscopic approach. Antibiotic prophylaxis was given. All cases were carried out successfully with immediate graft function and 100% graft and patient survival at 1 year of follow-up. Estimated glomerular filtration rate at 1 month and 1 year was similar to eight randomly selected female recipients who underwent open kidney transplantation (OKT). No analgesia was required in seven out of eight patients after the 3rd postoperative day. In summary, vaginal insertion of kidney and LKT is safe and feasible in a selected group of patients. It is associated with better analgesia and has similar allograft function as compare to OKT.

Objective Decline in cognitive function begins by the 40s, and may be related to future dementia risk. We used data from a community-representative study to determine whether there are age-related differences in simple cognitive and gait tests by the 40s, and whether these differences were associated with covert cerebrovascular disease on magnetic resonance imaging (MRI). Methods Between 2010 and 2012, 803 participants aged 40 to 75 years in the Prospective Urban Rural Epidemiological (PURE) study, recruited from prespecified postal code regions centered on 4 Canadian cities, underwent brain MRI and simple tests of cognition and gait as part of a substudy (PURE-MIND). Results Mean age was 58 ± 8 years. Linear decreases in performance on the Montreal Cognitive Assessment, Digit Symbol Substitution Test (DSST), and Timed Up and Go test of gait were seen with each age decade from the 40s to the 70s. Silent brain infarcts were observed in 3% of 40- to 49-year-olds, with increasing prevalence up to 18.9% in 70-year-olds. Silent brain infarcts were associated with slower timed gait and lower volume of supratentorial white matter. Higher volume of supratentorial MRI white matter hyperintensity was associated with slower timed gait and worse performance on DSST, and lower volumes of the supratentorial cortex and white matter, and cerebellum. Interpretation Covert cerebrovascular disease and its consequences on cognitive and gait performance and brain atrophy are manifest in some clinically asymptomatic persons as early as the 5th decade of life. Ann Neurol 2015;77:251–261

Kidney transplantation from deceased donors is in its infancy in India. Cadaver organ donation was accepted legally in 1994 by the “Human Organs Transplantation Act.” Marginal donors are now accepted by many centers for kidney transplantation. We report a case of procurement of both kidneys from a young deceased donor having recurrent primary brain tumor, transplanted into two adult recipients with successful outcome.

Background: Magnetic resonance imaging (MRI) is proposed as the preferred imaging modality to investigate patients with transient ischemic attack (TIA). This is mainly based on a higher yield of small acute ischemic lesions; however, direct prospective comparisons are lacking. In this study, we aimed to directly compare the yield of acute ischemic lesions on MRI and computed tomography (CT) in the emergency diagnosis of suspected TIA or minor stroke. Methods: Consecutive patients aged 18 years or older presenting with minor stroke (NIHSS Results: A total of 347 patients were included, 168 with TIAs, 147 with minor strokes and 32 with a final diagnosis of a mimic. Acute ischemic lesions were detected in 39% of TIAs by using MRI versus 8% by using CT (p < 0.0001) and in 86% of minor strokes by using MRI versus 18% by using CT (p < 0.0001). Compared to MRI, CT had a sensitivity of 20% and a specificity of 98% in identifying an acute ischemic lesion. The infarct volume on diffusion-weighted MRI was larger in cases where the CT also showed an acute ischemic lesion (median 5.07 ml, IQR 10) as compared to lesions seen only on MRI (median 0.68 ml, IQR 1.31, p < 0.0001). Conclusion: MRI is superior to CT in detecting the small ischemic lesions occurring after TIA and minor stroke. Since these lesions are clinically relevant, MRI should be the preferred imaging modality in this setting.

Background and Purpose— Transient or minor ischemic stroke is associated with an early risk of deterioration. Baseline perfusion–diffusion mismatch may predict clinical deterioration and infarct growth in this population. Methods— High-risk transient ischemic attack and minor stroke (National Institutes of Health Stroke Scale ≤3) subjects were prospectively enrolled and imaged with MRI within 24 hours of symptom onset as part of sequential derivation and validation cohorts. Baseline diffusion-weighted imaging, perfusion-weighted imaging ( T max ≥4 s), mismatch ( T max ≥4 s-diffusion-weighted imaging), and follow-up fluid-attenuated inversion recovery infarct volumes were measured. Primary outcome was infarct growth on fluid-attenuated inversion recovery, and secondary outcome was symptom progression. Results— One hundred thirty-seven and 281 subjects were included in the derivation and validation cohorts, respectively. Infarct growth occurred in 18.5% of the derivation and 5.5% of the validation cohorts. Symptom progression occurred in 9.5% of the derivation and 4.5% of the validation cohorts. In the derivation cohort, subjects with baseline mismatch were significantly more likely to show infarct growth on fluid-attenuated inversion recovery (relative risk [RR], 13.5; 95% confidence interval [CI], 4.2–38.9) and symptom progression (RR, 7.0; 95% CI, 2.0–7.3). A baseline mismatch volume of 10 mL in the derivation cohort was the optimal threshold to predict infarct growth (area under the curve, 0.89; 95% CI, 0.80–0.98). This threshold was highly predictive of infarct growth in the validation cohort ( P =0.001). Baseline mismatch was associated with clinical deterioration in the derivation (area under the curve, 0.81; 95% CI, 0.67–0.96) and validation cohorts (area under the curve, 0.66; 95% CI, 0.46–0.85). Conclusions— Among subjects with high-risk transient ischemic attack and minor stroke, diffusion-weighted imaging–perfusion-weighted imaging mismatch predicts infarct growth and clinical deterioration. These findings suggest that reperfusion strategies would be beneficial in this population.

Background and Purpose— The use of magnetic resonance imaging (MRI) after transient ischemic attack (TIA) or minor stroke may be affected by the relative timing of imaging. We measured the impact of scanning an individual patient late versus early after TIA and minor stroke. Methods— Two hundred sixty-three TIA or minor stroke (National Institute of Health Stroke Scale score ≤3) patients with a baseline MRI completed within 24 hours of symptom onset and a follow-up MRI at 90 days were included. Baseline and 90-day scans were assessed independently for the presence of any stroke lesions that could explain the presenting symptoms. The presence and pattern of any stroke lesions were compared at the 2 time points. Results— The presence of a stroke (acute or chronic) in any location was more common on baseline MRI versus 90-day MRI (68% vs 56%; P =0.005). Thirty percent of subjects with negative scans at 90 days had a clearly identifiable stroke at baseline. When interpreted blinded to the baseline scan, the presumed relevant lesion on the 90-day MR scan was the correct lesion in only 53% patients. One-third (34%) of patients had a different lesion pattern on the baseline scan compared with the 90-day scan. Ninety percent (80/89) of these patients had more lesions on the baseline MRI and 10% (9/89) had new lesions on the 90-day MRI. Conclusions— Delayed MRI after TIA or minor stroke reduces the diagnostic yield and results in missed understanding of the lesion pattern. MRI of minor stroke and TIA patients should occur early after symptom onset, and delayed imaging should be interpreted with caution.

Background: Transient focal neurological episodes (TFNE) can occur in cerebral amyloid angiopathy (CAA) and can mimic transient ischemic attack (TIA). Hypothesis: Risk factors and outcomes of patients with minor stroke or TIA would differ in patients with and without cerebral microbleeds (CMB), including in patients with lobar microbleeds potentially consistent with CAA. Methods: 431 of 510 patients with high-risk TIA (motor or speech deficits > 5 minutes) or minor stroke in the previously reported CATCH (CT and MRI in the triage of TIA and minor cerebrovascular events to identify high risk patients) study underwent baseline MRI. 416 scans with sufficient quality were analyzed for presence and location of CMB and cortical superficial siderosis. Clinical symptoms, baseline characteristics, recurrent TIA or stroke and 90 day modified Rankin scale (mRs) were prospectively collected. Results: CMB were detected in 65/416 (15.6 %), with a predominantly lobar pattern (75.4 %), and superficial siderosis in 11/416 (2.6 %). In a multivariable logistic regression model adjusted for number of risk factors age was associated with presence of CMB (odds ratio (OR) 1.04; 95 % confidence interval (CI) 1.02 - 1.06, P = 0.001). Presence of CMB was not associated with recurrent stroke or TIA (9.2 % vs. 11.1 %, P=0.65) or unfavorable mRS (> 1) at 90 days (20 % vs. 16 %, P =0.42). Superficial siderosis was present in 11/416 (2.6%). 42 patients (10.1 %) fulfilled modified Boston criteria for possible or probable CAA. Presenting symptoms were not different between patients with vs. without possible/probable CAA, when considering either all patients or just those with TIA. Possible/probable CAA was not associated with recurrent stroke or TIA (7.1 % vs. 11.2 %, P = 0.42) or unfavorable mRs (> 1) at 90 days (23.8 % vs. 15.8 %, P = 0.18). Conclusions: CMB in TIA and minor stroke patients are moderately common but do not strongly predict clinical recurrence and or 90-day functional outcome. Clinical presentations for CAA-related TFNE and TIA might be overlapping, suggesting that MRI may be needed to differentiate them.

There is no consensus on how the reliability and predictive ability of noncontrast computed tomography (NCCT) and computed tomography angiography source image (CTASI) change over time from acute ischemic stroke onset. We hypothesized that the reliability for detecting early ischemic changes (EIC) would be lower in early time periods and that changes identified on CTASI would be more reliable across examiners than changes identified on NCCT. To address this, we compared the relationships between CTASI, NCCT, and final infarct in patients with initial computed tomography (CT) imaging at different time points after stroke onset. Patients with acute ischemic stroke with proximal anterior circulation occlusions (internal carotid artery, middle carotid artery M1, proximal M2) from Calgary CT Angiography (CTA) database were studied. The cohort was categorized in four groups based on time from stroke onset to baseline NCCT/CTA: 0–90 mins ( n = 69), 91–180 mins ( n = 88), 181–360 mins ( n = 46), and >360 mins ( n = 58). Median scores of NCCT-Alberta Stroke Program Early CT Score (ASPECTS), CTASI ASPECTS, and follow-up ASPECTS among different time categories were compared. To determine reliability, a subsample of NCCT brain and CTASI were interpreted at separate sessions weeks apart by two neuroradiologists and two stroke neurologists in random order. Median and mean ASPECTS ratings on NCCT and CTASI were higher than final ASPECTS in each time category ( P < 0·001 for all comparisons). CTASI ASPECTS was lower than NCCT ASPECTS in each time category, and differences were significant at 0–90 mins and 91–180 mins ( P < 0·001). The least agreement among readers was in detection of EIC on NCCT brain in the ultra-early phase (

Quicker recanalization results in better clinical outcomes in patients with acute ischemic strokes. We describe our experience with the use of a self-expanding, fully retrievable stent in acute intracranial occlusions. Patients who underwent intra-arterial procedures with a self-expanding, fully retrievable stent for acute ischemic strokes at our center in 2009 were included in this study. The primary outcome was recanalization [Thrombolysis in Myocardial Infarction (TIMI) grade 2/3] at end of procedure. Secondary endpoints were procedural interval times, incidence of vasospasm, rupture of vessels, device-related complications, groin complications, postprocedural intracerebral hemorrhage (ICH) on noncontrast CT, and all-cause mortality. Fourteen patients (mean age 62.1 years, range 34–81 years; six males) were included in the study. Sites of occlusion are as follows: M1 middle cerebral artery (MCA, n = 8), M2 MCA (n = 1), proximal basilar artery (n = 1), and distal basilar artery (n = 4). An additional device or technique was used in 9 of 14 patients prior to the use of the retrievable stent. Twelve out of 14 (85.7%) achieved TIMI 2–3 recanalization with 4 of 14 (28.6%) achieving TIMI 3. Eight of 14 (57.1%) patients had modified Rankin Scale (0–2) at 3 months or discharge. ICH on follow-up CT was noted in 28.6% (4 of 14) of patients. All-cause mortality was 2 of 14 (14.3%). Use of a novel self-expanding, fully retrievable stent resulted in fast and very high recanalization rates in acute ischemic strokes with intravascular occlusions.

Objective:To assess the feasibility of iPhone-based teleradiology as a potential solution for the diagnosis of acute cervico-dorsal spine trauma.Materials and Methods:We have developed a solution that allows visualization of images on the iPhone. Our system allows rapid, remote, secure, visualization of medical images without storing patient data on the iPhone. This retrospective study is comprised of cervico-dorsal computed tomogram (CT) scan examination of 75 consecutive patients having clinically suspected cervico-dorsal spine fracture. Two radiologists reviewed CT scan images on the iPhone. Computed tomogram spine scans were analyzed for vertebral body fracture and posterior elements fractures, any associated subluxation-dislocation and cord lesion. The total time taken from the launch of viewing application on the iPhone until interpretation was recorded. The results were compared with that of a diagnostic workstation monitor. Inter-rater agreement was assessed.Results:The sensitivity and accuracy of detecting vertebral body fractures was 80% and 97% by both readers using the iPhone system with a perfect inter-rater agreement (kappa:1). The sensitivity and accuracy of detecting posterior elements fracture was 75% and 98% for Reader 1 and 50% and 97% for Reader 2 using the iPhone. There was good inter-rater agreement (kappa: 0.66) between both readers. No statistically significant difference was noted between time on the workstation and the iPhone system.Conclusion:iPhone-based teleradiology system is accurate in the diagnosis of acute cervico-dorsal spinal trauma. It allows rapid, remote, secure, visualization of medical images without storing patient data on the iPhone.

The Penumbra system is a newly approved mechanical device for the treatment of acute stroke designed for better and faster recanalization. We describe our initial experience with the use of this device. We studied 27 consecutive patients with acute ischemic strokes due to arterial occlusions presenting at our center from January to October 2009. The primary outcome was the degree of recanalization measured by thrombolysis in myocardial infarction (TIMI grade 2/3) at the end of the procedure. Secondary end points were the proportion of patients who achieved a modified Rankin scale (mRS) ≤2 at 3 months, all-cause mortality and intracerebral hemorrhage (ICH) on non contrast computed tomography at 24 h. Procedural complications were also recorded. Of 27 patients (13 male, mean age 61 years) in the study, 22 (81%) patients had anterior circulation strokes and five (18%) had posterior circulation strokes. Twenty-three (85%) patients achieved TIMI grade 2/3 recanalization at completion of the procedure. Excluding five patients who needed use of a second device, the Penumbra system achieved TIMI grade 2/3 recanalization in 67% of patients. Thirteen (48%) patients had mRS ≤2 at 3-month follow-up. Procedural and post-procedural complications included vasospasm (3.7%), distal emboli (48.1%), and ICH (33.3%). The distribution of ICH is as follows: hemorrhagic infarct type 1 (25.9%), parenchymal hemorrhage type 1 (3.7%), and parenchymal hemorrhage type 2 (3.7%). All-cause mortality was 19%. High recanalization rates and good clinical outcomes are achievable with the Penumbra system. Complication rates are comparable to a previously published literature.

Medical management of urinary calculus disease is a challange for modern science. In the present trial Ayurvedic drug "Herbmed," which is made up of varuna (Crataeva nurvala) and banana stem (Musa paradisiaca) was assessed to see reduction and/or expulsion of urinary calculi and also to assess the role of these drugs to reduce pain during expulsion.In this prospective randomized, double-blind, placebo control trial, total 77 patients with calculi more than 5 mm were included. All patients were evaluated either by X-ray KUB or USG KUB for 3 months. All patients were divided into two groups: group A included patients with calculi 5-10 mm (n = 31) and group B with calculi10 mm (n = 30) with either active treatment or placebo in both the groups. All patients were asked to keep a record of number of pain episodes, while severity of pain was measured on a visual analogue scale (VAS).In group A, there was 33.04% reduction in the size of calculi in the active arm while there was a 5.13% increase in the same group in the placebo arm (p = 0.017). In the other group B, there was an 11.25% reduction in the active arm and a 1.41% reduction in the same group with placebo. In the active arm there was statistically significant lower VAS as compared to the placebo arm in the form of the highest VAS (p = 0.008), average VAS (p = 0.001) and VAS at the first episode of pain (p0.0001).Our preliminary experience suggests that the Ayurvedic formulation "varuna and banana stem" has promise for the management of upper urinary-tract calculi, especially renal calculi. It helps to dissolve renal calculi and facilitate their passage. In addition, it also helps in reduction of pain due to renal/ureteric calculus disease. A larger phase III study with a longer follow-up is required.

Background: Prospective, core lab adjudication of 24 hour post randomization head CT in IMS3 enabled analysis of the association between 24 hour infarct volume (24HRIV) and clinical outcomes in patients randomized to IV tPA alone or IV/IA approach. Methods: Manually calculated volumes of hypodense areas deemed acute and found within the affected territory on the IMS 3 follow-up CT scans expressed in cc were termed 24HRIV. These were correlated with several variables of interest in the IMS3 database including clinical outcomes expressed as modified Rankin score (mRS), baseline NIHSS (bNIHSS), follow-up NIHSS at 24 hours (fNIHSS), treatment allocation and occlusion location assessed on baseline CTA. Results: Of the 656 randomized patients, 502 (76.5%) had available 24HRIV’s and were included in the analysis. Good outcomes (defined as mRS 0-2) were noted in 197 (39.2%) of patients. Mean (median) 24HRIV in patients with favorable outcomes was 24.2 (12.2) cc vs. 115 (75.11) cc in those with unfavorable outcomes (p< 0.00001). A strong correlation was noted between the 24HRIV and clinical outcomes across the entire spectrum of the mRS scale (Figure1). Mean (median) 24HRIV’s were not significantly different in the IV vs IV/IA group 76.8 (34.5) vs 84.8 (37.8) cc, p= 0.38. No differences in 24HRIV were noted between IV and IV/IA groups in patients with ICA occlusion on baseline CTA (mean 24HRIV 125.8 vs 123.8 cc's respectively, p=0.9) or MCA occlusion (mean 24HRIV 54.4 vs 54.6 cc's respectively, p=0.9). A strong correlation was found between 24HRIV and fNIHSS (spearman rho=0.7, p Conclusions: In IMS 3, a significant correlation between 24 hour infarct volume on CT and clinical outcomes both at 24 hours and at 90 days was demonstrated. No significant differences in 24 hour infarct volumes were noted between the IV and the IV/IA group, suggesting that endovascular reperfusion strategies utilized during IMS3 overall lacked added effectiveness compared to IV t-PA alone.

ence of an intracranial occlusion (RR 9.6, 95% CI 4–22). Sites of occlusion were as follows: intracranial internal carotid artery (ICA) 12/52 (23%), middle cerebral artery (MCA) 31/52 (60%; MCA-M1 7/52; MCA-M2 15/52; MCA-M3 9/52), posterior cere-bral artery (PCA) 5/52 (10%; PCA-P1 3/52, PCA-P2 2/52), and basilar artery (BA) 2/52 (4%). Detailed sites of occlusion and pro-gression rates are shown in table 1 . Our analysis was limited due to the small number of patients in each group, but neurological worsening was seen in patients with both proximal and distal ves-sel occlusions.In this retrospective sub-study of the CATCH study [2], we did not find any clear pattern in the site of vessel occlusion and risk of stroke progression. This finding leads us to suggest that studies us-ing intracranial occlusion as an entry criterion in a TIA and minor stroke population should not exclude patients based simply on oc-clusion location. Finally, this study did not allow us to determine the mechanism explaining neurological deterioration, although we suspect that hemodynamic fluctuations [7] or support by the col-lateral circulation play a determinant role. Future studies could further analyze the relationship between site of occlusion, collat-eral circulation, and symptom progression. Patients affected by TIA and minor stroke are at a high risk of recurrent events, symptom progression, and disability, especially if an intracranial occlusion is documented on a CT-angiogram (CTA) [1, 2] . Despite a risk of poor outcome, these patients are often excluded from thrombolysis treatment because of mild or improving symptoms [3] . Recurrent events are phenomenologi-cally either distinct recurrent strokes or symptomatic progression of the presenting event [4]. Unlike in major stroke, where proximal occlusion is an independent predictor [5] , it remains unclear whether the exact site of vessel occlusion influences outcome in TIA and minor stroke patients [6]. Our aim was to explore the re- lationship between the location of intracranial occlusion and stroke progression in this population. The CATCH study [2] prospectively enrolled consecutive pa-tients with minor stroke (NIHSS 1 or were treated with thrombolysis for this event. All patients had a brain CT and CTA of neck and circle of Willis within 24 h of symptom onset. A neuroradiologist identified the site of vessel occlusion. Stroke progression was defined as clin-ical worsening referable to the same arterial territory as the base-line symptoms without any imaging evidence of a new infarct sep-arate from the baseline imaging [4] . Experienced stroke neurolo-gists assessed the outcomes within 24 h of the index event. The relationship between vessel occlusion site and stroke progression was explored. If a patient had more than one intracranial occlu-sion, the most proximal site was used for analysis. Fisher’s exact test was used to compare proportions, and interpreted with a Bon-ferroni correction for multiple comparisons. For each individual comparison, patients with other sites of intracranial occlusion were removed from the analysis. 510 patients were enrolled. Intracranial occlusion was ob-served in 10% (52/510) of patients. Overall, stroke progression occurred in 4% (19/510) and was more likely to occur in the pres

Introduction: Shock wave lithotripsy has become first line treatment modality for renal calculi due to its noninvasiveness. However, the destructive forces like dispersion of cavitation bubbles can cause trauma to thin-walled vessels and renal parenchyma during fragmentation of the stones. Antioxidants are our first line of defense against oxidative stress. The aim of this study was to investigate whether oral administration of Vitamin C and E help in a reduction of the serum level of inflammatory mediator by serial measurement of high sensitivity C-reactive protein (hs-CRP) and by this reduction in the risk of renal damage. Patients and Methods: A total of 107 subjects were recruited in three groups. Group A served as a control group, and Group B and Group C received oral medication of Vitamin E 800 mg/day and Vitamin C 1000 mg/day respectively, start from 2 days prior the lithotripsy and continued for total 7 days. The level of hs-CRP was used as a mediator of the inflammatory response following lithotripsy and thus for long term renal injury. Serum level of hs-CRP was measured on 2 days prior the lithotripsy and day 2, 7 and 28 after the lithotripsy. Results: Patients who were given either Vitamin C or Vitamin E showed a significant reduction of serum level of hs-CRP when compared to control the group. Conclusion: Oral administration of Vitamin C and E helps in reduction of serum levels of the inflammatory marker for acute renal injury and thus they can be useful in minimizing the kidney injury following lithotripsy for renal stone disease.

Background: The assortment of patients based on the underlying pathophysiology is central to preventing recurrent stroke after a transient ischemic attack and minor stroke (TIA-MS). The causative classification of stroke (CCS) and the A-S-C-O (A for atherosclerosis, S for small vessel disease, C for Cardiac source, O for other cause) classification schemes have recently been developed. These systems have not been specifically applied to the TIA-MS population. We hypothesized that both CCS and A-S-C-O would increase the proportion of patients with a definitive etiologic mechanism for TIA-MS as compared with TOAST. Methods: Patients were analyzed from the CATCH study. A single-stroke physician assigned all patients to an etiologic subtype using published algorithms for TOAST, CCS and ASCO. We compared the proportions in the various categories for each classification scheme and then the association with stroke progression or recurrence was assessed. Results: TOAST, CCS and A-S-C-O classification schemes were applied in 469 TIA-MS patients. When compared to TOAST both CCS (58.0 vs. 65.3%; p < 0.0001) and ASCO grade 1 or 2 (37.5 vs. 65.3%; p < 0.0001) assigned fewer patients as cause undetermined. CCS had increased assignment of cardioembolism (+3.8%, p = 0.0001) as compared with TOAST. ASCO grade 1 or 2 had increased assignment of cardioembolism (+8.5%, p < 0.0001), large artery atherosclerosis (+14.9%, p < 0.0001) and small artery occlusion (+4.3%, p < 0.0001) as compared with TOAST. Compared with CCS, using ASCO resulted in a 20.5% absolute reduction in patients assigned to the ‘cause undetermined' category (p < 0.0001). Patients who had multiple high-risk etiologies either by CCS or ASCO classification or an ASCO undetermined classification had a higher chance of having a recurrent event. Conclusion: Both CCS and ASCO schemes reduce the proportion of TIA and minor stroke patients classified as ‘cause undetermined.' ASCO resulted in the fewest patients classified as cause undetermined. Stroke recurrence after TIA-MS is highest in patients with multiple high-risk etiologies or cryptogenic stroke classified by ASCO.

Objective/Background:We describe the internal cerebral vein (ICV) sign, which is a hypo-opacification of the ICV on computed tomogram angiography (CTA) as a new marker of increased cerebral blood transit-time in ipsilateral internal carotid artery occlusions (ICAO).Methods:A retrospective analysis of 153 patients with acute unilateral M1 middle cerebral artery (MCA) occlusions ± ICAOs was performed. The degree of contrast opacification of the ICV on the ipsilesional side was compared to that of the unaffected side.Results:Of 153 patients in our study, 135 had M1 MCA occlusions ± intra-cranial ICAO (M1±iICAO) and 18 had isolated extracranial ICAO (eICAO). In the patients with proximal M1±iICAO, 57/65 (87.1%) showed the ICV sign. Of the 8 patients without the ICV sign in this group, 6 had prominent lenticulostriate arteries arising from the non-occluded M1 segment, 1 had a recurrent artery of Huebner, and 1 had filling of distal ICA/M1 segment through prominent Circle of Willis collaterals. For the 70 patients with isolated distal M1±iICAO, 7/70 (10%) showed the ICV sign, with all 7 showing occluded lenticulostriate arteries. Of the patients with eICAO, 8/18 showed the ICV sign, all 8 with the ICV sign had poor Circle of Willis collaterals.Conclusions:The ICV sign correlates well with presence of proximal M1±iICAO in patients with either occluded lenticulostriate arteries or poor Circle of Willis collaterals. In patients with eICAO, the sign correlates with reduced Circle of Willis collaterals and may be a marker of increased ipsilateral cerebral blood transit time.

Background: MRI is not always completed early after TIA or minor stroke and this may affect its utility. We measured the impact of scanning an individual patient late versus early in the investigation of TIA and minor stroke. Methods: 263 patients with a TIA or minor stroke (NIHSS Results: Stroke of any age, in any location was more common on the baseline MRI versus 90day MRI (68% versus 58%, p=0.005). A substantial proportion of the negative scans at 90 days had a clearly identifiable stroke on the baseline scan (35/115: 30%) that was missed on the 90day scan. All of these lesions were acute or subacute DWI lesions on the baseline scan showing non-specific white matter hyperintensity or no abnormality on the 90day scan. Among 104 patients with a stroke lesion on the 90 day MRI considered as a cause for the presenting symptoms, this lesion was the correct lesion in only 78 (53%) patients. 89 (34%) patients had a different lesion pattern on the baseline scan versus the 90day scan. The main difference observed was that patients with multiple DWI lesions on the baseline scan were either seen as a single or no lesions on the 90day MRI. Conclusion: Completing an MRI in a delayed fashion after TIA or minor stroke reduces the diagnostic yield of the imaging. Not only does it reduce lesion detection, but also the pattern of the lesions is missed. Conclusions regarding the original event may be false if based only on a delayed MRI. If minor stroke and TIA patients are going to be scanned with MRI this should be completed early after symptom onset.

Background: classification of Transient Ischemic attacks (TIA) and minor stroke is challenging, as there is no classification systems developed specifically for the TIA and minor stroke patient population. Hypothesis: We hypothesize that the newly developed Causative Classification System (CCS) and the Atherosclerosis Small Vessel Disease Cardiac Source Other Source (ASCO) classification would reduce the proportion of patients classified as cause undetermined compared with The Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification in a large prospectively evaluated TIA and Minor stroke population. Methods: Using published algorithms for TOAST, CCS, and ASCO, a single rater classified the etiology in patients presenting with a high-risk TIA (weakness or speech disturbance lasting ≥ 5minutes) or minor ischemic stroke (National Institute of Health Stroke Scale score ≤ 3) who underwent CT/CTA and subsequent MRI as part of the CATCH study. Results: 419 patients with TIA or Minor stroke were classified using TOAST, CCS, and ASCO. The proportion of patients with an undetermined etiology was 51.3% (215/419) with TOAST. This was significantly reduced by both CCS 36% (151/419, p< 0.001) and ASCO 41% (172/419, p< 0.001). CCS was also less likely to have an undetermined etiology as compared to ASCO (36% versus 41%, p = 0.024). When compared with TOAST, there was a 23.9% (95%CI:18.1- 29.7, P< 0.001) and 17.4% (10.1- 24.7, P< 0.001) reduction in the proportion of patients assigned to the undetermined group using CCS and ASCO respectively. The 8.5 % reduction in the undetermined group between CCS and ASCO was also statistically different P=0.031). Compared with ASCO1, CCS increased the assignment of patients to large artery disease (relative increase 7.4% {4.3-10.4}, P< 0.001) and Cardio-embolism/cardio-aortic categories (relative increase 8.1% {4.6-11.5}, P< 0.001). Conclusions: Both CCS and ASCO were superior to TOAST in assigning fewer patients to an undetermined etiology category. CCS was superior to ASCO at reducing the proportion of patients with undetermined etiology. This was largely driven by increased assignment in the large artery and Cardio-aorto embolic categories.

Precision and accuracy are sometimes sacrificed to ensure that medical image processing is rapid. To address this, our lab had developed a novel level set segmentation algorithm that is 16× faster and96% accurate on realistic brain phantoms.This study reports speed, precision and estimated accuracy of our algorithm when measuring MRIs of meningioma brain tumors and compares it to manual tracing and modified MacDonald (MM) ellipsoid criteria. A repeated-measures study allowed us to determine measurement precisions (MPs) - clinically relevant thresholds for statistically significant change.Speed: the level set, MM, and trace methods required 1:20, 1:35, and 9:35 (mm:ss) respectively on average to complete a volume measurement (p0.05). Accuracy: the level set was not statistically different to the estimated true lesion volumes (p0.05). Precision: the MM's within-operator and between-operator MPs were significantly higher (worse) than the other methods (p0.05). The observed difference in MP between the level set and trace methods did not reach statistical significance (p0.05).Our level set is faster on average than MM, yet has accuracy and precision comparable to manual tracing.