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45 years old female known case of hypothyroid admitted to local nursing home with pain abdomen, vomiting and generalized weakness. She received intravenous fluids and antibiotics in a nearby hospital. She experienced hyponatremia, which hypertonic saline from 104 to 128 meq/l quickly treated. Modified Rankin scale score was >3. MRI brain done showed pituitary macroadenoma. She was transferred to our hospital after 5 days because of altered sensorium and bradykinesia of all 4 limbs with high grade fever and unexpected MRI finding. Treatment was started initially in line of meningitis but CSF study was negative. She was intubated for airway protection later tracheostomy was done. MRI brain repeated after 15 days showed pontine and extrapontine demyelination. Serum cortisol was low due to secondary adrenal insufficiency so started on steroid therapy. She improved gradually regained consciousness, started obeying commands, decannulated and discharged with Rankin score

A 52-year-old lady with hypertrophic obstructive cardiomyopathy, atrial flutter, and old right hemispheric stroke in the background underwent implantable cardioverter-defibrillator implantation for complete heart block. She was yet to start her regular anticoagulant and presented to hospital emergency with acute right middle cerebral artery (MCA) territory stroke (NIH Stroke Scale/Score of 14). After ruling out absolute contraindications, she was given intravenous thrombolysis (did not have a blood vessel target for endovascular therapy). Post thrombolysis, she had clot mobilization from the internal carotid artery to the MCA and systemic embolization to kidneys and lower limbs. The patient underwent an urgent embolectomy and lower limbs were saved from amputation. Our case highlights the importance of checking peripheral pulses in acute stroke patients post thrombolysis. Though the patient had initial deterioration after thrombolysis, she gradually improved and later achieved satisfactory modified Rankin scale underscoring the ultimate potential benefits of thrombolysis in acute stroke. There is a high chance of thrombus formation in patients with atrial flutter who undergo recent cardiac procedure especially if they are off anticoagulation for even a short period. Hence, unnecessary apprehension of anticoagulant use in proper situations may create life-threatening complications.

Background and Purpose: There is interest in what happens over time to the thrombus after intravenous alteplase. We study the effect of alteplase on thrombus structure and its impact on clinical outcome in patients with acute stroke. Methods: Intravenous alteplase treated stroke patients with intracranial internal carotid artery or middle cerebral artery occlusion identified on baseline computed tomography angiography and with follow-up vascular imaging (computed tomography angiography or first run of angiography before endovascular therapy) were enrolled from INTERRSeCT study (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography). Thrombus movement after intravenous alteplase was classified into complete recanalization, thrombus migration, thrombus fragmentation, and no change. Thrombus migration was diagnosed when occlusion site moved distally and graded according to degrees of thrombus movement (grade 0–3). Thrombus fragmentation was diagnosed when a new distal occlusion in addition to the primary occlusion was identified on follow-up imaging. The association between thrombus movement and clinical outcome was also evaluated. Results: Among 427 patients in this study, thrombus movement was seen in 54% with a median time of 123 minutes from alteplase administration to follow-up imaging, and sub-classified as marked (thrombus migration grade 2–3 + complete recanalization; 27%) and mild to moderate thrombus movement (thrombus fragmentation + thrombus migration grade 0–1; 27%). In patients with proximal M1/internal carotid artery occlusion, marked thrombus movement was associated with a higher rate of good outcome (90-day modified Rankin Scale, 0–2) compared with mild to moderate movement (52% versus 27%; adjusted odds ratio, 5.64 [95% CI, 1.72–20.10]). No difference was seen in outcomes between mild to moderate thrombus movement and no change. In M1 distal/M2 occlusion, marked thrombus movement was associated with improved 90-day good outcome compared with no change (70% versus 56%; adjusted odds ratio, 2.54 [95% CI, 1.21–5.51]). Conclusions: Early thrombus movement is common after intravenous alteplase. Marked thrombus migration leads to good clinical outcomes. Thrombus dynamics over time should be further evaluated in clinical trials of acute reperfusion therapy.

Stroke and infection have a close relationship! There is possibly interplay of inflammation with traditional risk factors of stroke such as hypertension, hyperlipidemia, diabetes, and smoking. Ricketssiae infection is already known to have multisystemic involvement. Stroke, both ischaemic and hemorrhagic though rarely reported to be associated with this infection often resulted in drastic consequences. Here, we will present a case where a gentleman who presented with stroke following a rickettsia infection only few days after he was thrombolysed for an initial event. We probably managed to avoid a catastrophe by treating the infection at earliest! Key Messages: Infection may interact with traditional risk factors of stroke and may precipitate a vascular event. Epidemiological knowledge of existing infections in community, early detection and intervention may prevent complications even if stroke is precipitated. Keywords: Ricketssiae, Postthrombolysis, Stroke.

Stroke in young is on rise in every corner of the world and is presently a very serious concern. So, a modifiable etiology of stroke if found, needs to be addressed seriously. Hyperhomocysteinemia is a prominent risk factor for vascular event in young population. It is known to play an important role in coronary artery disease, peripheral vascular disease and stroke. Perhaps, it also has a significant role in arterial dissection, a prominent stroke etiology in young population. It is proposed that hyperhomocysteinemia and genetic polymorphism probably interact with environmental factors leading to sequence of pathogenetic events resulting in arterial wall dissection. The prevalence of vegetarian diet, genetic predisposition and diet pattern subject Indians to increased chance of hyperhomocysteinemia and vascular insult. Here, we present a very rare case of isolated spontaneous vertebral arterial dissection in a young gentleman who had no vascular risk factor except very high serum homocysteine level. Perhaps, this case highlights serious consideration for addressing this modifiable vascular risk factor as a possible association with arterial dissection to avoid catastrophic events, especially in this part of the world. Keywords: Hyperhomocysteinemia, Stroke, Arterial dissection.

Sinking skin flap syndrome (SSS) is a serious complication following decompressive craniectomy (DC). Although CSF hypovolemia and exposure to atmospheric pressure have been attributed as causative factors, the definite etiologies remain elusive. We present a case where a patient had a rapid deterioration without any warning sign following a diagnostic and therapeutic lumbar puncture after DC. The patient had rapid fluctuation of symptoms with change of position. She was managed conservatively and finally achieved a full neurologic recovery without cranioplasty. This case report shows the heterogeneity of SSS and that cranioplasty may not be required in acute cases. Keywords: CSF diversion, Cerebral herniation, Hemicraniectomy

Background and Purpose— Intraluminal thrombus (ILT) is an uncommon finding among patients with ischemic stroke. We report clinical-imaging manifestations, treatment offered, and outcome among patients with ischemic stroke/transient ischemic attack and ILT in their cervico-cephalic arteries. Methods— Sixty-one of 3750 consecutive patients with acute ischemic stroke/transient ischemic attack (within 24 hours of onset) and ILT on initial arch-to-vertex computed tomography angiography from April 2015 through September 2017 constituted the prospective study cohort. Functional outcome was assessed using the modified Rankin Scale score with functional independence at discharge defined as modified Rankin Scale score ≤2. Results— Prevalence of ILT on computed tomography angiography was 1.6% (95% CI, 1.2%–2.1%). Median age was 67 years (interquartile range, 56–73), and 40 subjects (65%) were male. The initial clinical presentation included transient ischemic attack in 12 (20%) and stroke in 49 patients (80%); most strokes (76%) were mild (National Institutes of Health Stroke Scale ≤5). The most common ILT location was cervical carotid or vertebral artery (n=48 [79%]) followed by intracranial (n=11 [18%]) and tandem lesions (n=2 [3%]). The most common initial treatment strategy was combination antithrombotics (heparin with single antiplatelet agent) among 57 patients (93%). Follow-up computed tomography angiography (n=59), after a median 6 days (interquartile range 4–10 days), revealed thrombus resolution in 44 patients (75% [completely in 27%]). Twenty four of 30 patients (80%) with >50% residual carotid stenosis underwent carotid revascularization (endarterectomy in 15 and stenting in 9 patients) without peri-procedural complications a median of 9 days after symptom onset. In-hospital stroke recurrence occurred in 4 patients (6.6%). Functional independence was achieved in 46 patients (75%) at discharge. Conclusions— Patients presenting with acute stroke/transient ischemic attack with ILT on baseline imaging have a favorable clinical course in hospital with low stroke recurrence, high rate of thrombus resolution, and good functional outcome when treated with combination antithrombotic therapy.

The Alberta Stroke Program Early CT Score on non-contrast CT is a key component of prognostication and treatment selection in acute stroke care. Previous findings show that the reliability of this scale must be improved to maximize its clinical utility. Areas covered: This review discusses technical, patient-level, and reader-level sources of variability in ASPECTS reading; relevant concepts in the psychology of medical image perception; and potential interventions likely to improve inter- and intra-rater reliability. Expert commentary: Approaching variability in medical decision making from a psychological perspective will afford cognitively informed insights into the development of interventions and training techniques aimed at improving this issue.

Introduction: There is interest in understanding thrombus dynamics from IV TPA prior to endovascular thrombectomy (EVT) given the possible dichotomy amongst sites of occlusion for IV TPA benefit/harm. Kaesmacher et al reported beneficial 5+% rates of early TICI > 2a reperfusion in distal M1 or M2 MCA occlusions with IV TPA. However in more proximal occlusions this was rare; and potentially harmful worsening of perfusion seen with change of occlusion site. We aimed to examine IV TPA related thrombus dynamics including migration further across both proximal and distal occlusions in a multicenter prospective cohort study INTERRSeCT. Methods: Acute ischemic stroke patients with intracranial occlusion who had baseline CTA and follow-up CTA or initial run angio in INTERRSeCT and IV TPA were reviewed. We evaluated change of occlusion site (COS) and classified patients into 4 categories: Complete Recanalization (CR) of primary occlusive lesion with no remaining thrombus; definite Thrombus Migration (dTM) with primary occlusion site moved to a distal artery and occlusion site patent on baseline CTA; probable Thrombus Migration (pTM) with COS evident but initial occlusion extent not visualized; or No Change of occlusion site (NC). Results: A total of 462 IV TPA patients were enrolled, 41% received EVT. Median time from TPA to follow-up imaging was 133 minutes. COS was seen in 50% of cases with CR in 15% and TM in 35% (dTM 12%, pTM 23%). Distal artery occlusion and longer interval of TPA to imaging were independent predictors for COS. In 62 proximal occlusion (ICA and proximal-mid M1 MCA) patients with follow-up imaging within 60 mins after TPA (receiving EVT in 94%), any TM showed a lower rate of 90-day mRS≤2 than NC (47% vs 78%, adjusted OR 0.21, 95%CI 0.04-0.87). No CR was seen in this early group. Conclusions: Thrombus migration is common after IV TPA. Thrombus instability from IV TPA may worsen clinical outcome in proximal occlusions despite early EVT initiation, possibly due to migration of thrombus to distal arteries accelerating infarction or more challenging thrombectomy due to thrombus dispersion. The benefit of IV TPA prior to EVT at comprehensive stroke centers for ICA or prox-mid M1 occlusions require more study in randomized clinical trials.

Importance Recanalization of intracranial thrombus is associated with improved clinical outcome in patients with acute ischemic stroke. The association of intravenous alteplase treatment and thrombus characteristics with recanalization over time is important for stroke triage and future trial design. Objective To examine recanalization over time across a range of intracranial thrombus occlusion sites and clinical and imaging characteristics in patients with ischemic stroke treated with intravenous alteplase or not treated with alteplase. Design, Setting, and Participants Multicenter prospective cohort study of 575 patients from 12 centers (in Canada, Spain, South Korea, the Czech Republic, and Turkey) with acute ischemic stroke and intracranial arterial occlusion demonstrated on computed tomographic angiography (CTA). Exposures Demographics, clinical characteristics, time from alteplase to recanalization, and intracranial thrombus characteristics (location and permeability) defined on CTA. Main Outcomes and Measures Recanalization on repeat CTA or on first angiographic acquisition of affected intracranial circulation obtained within 6 hours of baseline CTA, defined using the revised arterial occlusion scale (rAOL) (scores from 0 [primary occlusive lesion remains the same] to 3 [complete revascularization of primary occlusion]). Results Among 575 patients (median age, 72 years [IQR, 63-80]; 51.5% men; median time from patient last known well to baseline CTA of 114 minutes [IQR, 74-180]), 275 patients (47.8%) received intravenous alteplase only, 195 (33.9%) received intravenous alteplase plus endovascular thrombectomy, 48 (8.3%) received endovascular thrombectomy alone, and 57 (9.9%) received conservative treatment. Median time from baseline CTA to recanalization assessment was 158 minutes (IQR, 79-268); median time from intravenous alteplase start to recanalization assessment was 132.5 minutes (IQR, 62-238). Successful recanalization occurred at an unadjusted rate of 27.3% (157/575) overall, including in 30.4% (143/470) of patients who received intravenous alteplase and 13.3% (14/105) who did not (difference, 17.1% [95% CI, 10.2%-25.8%]). Among patients receiving alteplase, the following factors were associated with recanalization: time from treatment start to recanalization assessment (OR, 1.28 for every 30-minute increase in time [95% CI, 1.18-1.38]), more distal thrombus location, eg, distal M1 middle cerebral artery (39/84 [46.4%]) vs internal carotid artery (10/92 [10.9%]) (OR, 5.61 [95% CI, 2.38-13.26]), and higher residual flow (thrombus permeability) grade, eg, hairline streak (30/45 [66.7%]) vs none (91/377 [24.1%]) (OR, 7.03 [95% CI, 3.32-14.87]). Conclusions and Relevance In patients with acute ischemic stroke, more distal thrombus location, greater thrombus permeability, and longer time to recanalization assessment were associated with recanalization of arterial occlusion after administration of intravenous alteplase; among patients who did not receive alteplase, rates of arterial recanalization were low. These findings may help inform treatment and triage decisions in patients with acute ischemic stroke.

Background Patients with proximal arterial M2-segment of the Middle Cerebral Artery (M2-MCA) occlusions were largely excluded from endovascular stroke trials. Current American Stroke guidelines are conservative in recommending thrombectomy for such patients. We sought to assess the natural history of medically- treated M2-MCA occlusion patients. Methods This is a prospective multi-central international cohort study of all acute ischemic stroke patients with intracranial occlusions on baseline imaging. Patients with M2-MCA occlusions were identified on baseline CT angiography and non-endovascular-treated patients were included. The M2-MCA segment was defined as the first-order branch of the proximal MCA, excluding the anterior temporal artery. The M2-MCA was further classified according to its visually-assessed diameter relative to the M1-MCA into: M1-equivalent (>90% of the diameter of the M1-MCA), Major (50%–90%), Minor ( Results Out of 575 patients in the entire study, there were a total of 184 M2-MCA occlusions seen. Of those, 104 patients were NOT treated with endovascular therapy: 90 patients (86.5%) received IV TPA and 14 (23.5%) patients conservative management. Among those, 23.1% (24/104) M1-equivalent, 66.4% (69/104) major, and 9.6% (10/104) minor M2-MCA. The median age was 76 years (interquartile range 19 years). The median (IQR) baseline NIHSS score of the cohort was 9 (9): M1-equivalent 12(10), major 9 (9), minor 7 (8). The median baseline ASPECTS was 9 overall and in all M2 groups. Successful recanalization was observed in 44.2% (46/104) of the medical M2 occlusion cohort overall. TPA group was 47.8% (43/90) and conservative group 21.4% (3/14). With IV TPA successful recanalization occurred in 30% (6/20) of M1-equivalent, 50% (31/62) of major, and 75% (6/8) of minor M2-MCA occlusions. In conservative management group successful recanalization occurred in 25% (1/4) of M1-equivalent, 14.3% (1/7) of major, and 50% (1/2) of minor M2-MCA occlusions. Good functional outcome (mRS 0–2) at 90 day was observed in 62.1% (64/104) of the cohort overall. Among those with successful recanalization, 76.1% (35/46) achieved good outcome. With IV TPA, the proportion of patients achieving independent functional outcome was 45% (9/20) with M1-equivalent, 70.5% (43/61) of major, and 62.5% (5/8) of minor M2-MCA occlusions. In the conservative management group, the proportion of patients achieving independent functional outcome at 90 day was 25% (1/4) with M1-equivalent, 71.4% (5/7) of major, and 50% (1/2) of minor M2-MCA occlusions. In logistic regression analyses, successful recanalization predicted independent functional outcome (OR 2.9, 95% CI 1.02 to 8.1, p 0.046). Age (OR 0.89, 95% CI 0.84 to 0.94, p Conclusion While over one half of medically-treated patients with M2-MCA segment occlusions achieve independent outcome, a subset of patients suffers poor functional outcomes at 90 days. Successful recanalization are associated with higher odds of independent functional outcome. Disclosures B. Menon: None. M. Najm: None. F. Al-Ajlan: None. M. Almekhlafi: None. J. Puig: None. M. Castellanos: None. D. Dowlatshahi: None. A. Calleja: None. S. Sohn: None. S. Ahn: None. A. Poppe: None. R. Mikulik: None. N. Asdaghi: None. T. Field: None. A. Jin: None. T. Asil:None. J. Boulanger: None. E. Smith: None. S. Coutts: None. P. Barber: None. S. Bal: None. S. Subramanian: None. S. Mishra: None. A. Trivedi: None. S. Dey: None. M. Eesa: None. T. Sajobi: None. M. Goyal: None. M. Hill: None. A. Demchuk: None.

Silent pulmonary embolism (PE) may be associated with acute ischemic stroke (AIS). We identified 10 patients from 3,132 unique patients (3,431 CT scans). We retrospectively examined CT angiogram of patients with AIS to determine the frequency of concurrent PE in AIS. The period prevalence of PE was 0.32. Seven patients had concurrent PE, whereas three had PE diagnosed 2 days after their AIS presentation. We suspected paradoxical embolism via patent foramen ovale as the cause of stroke in three patients and thrombophilia in four patients. Seven patients had poor outcome including four deaths. CT angiogram stroke protocol images from aortic arch to vertex allows visualization of upper pulmonary arteries and PE detection in AIS.

Objective: The Alberta Stroke Program Early CT Score (ASPECTS) is widely used to assess and diagnose acute ischemic stroke (AIS) patients. However, reliability of ASPECTS scoring is poor among physicians with limited expertise. We hypothesize that reliability for ASPECTS scoring can be improved by using algorithm enhanced gray-white matter (AEGWM) NCCT. Methods: Inter-rater reliability for ASPECTS scoring was assessed between plain and AEGWM NCCT by an expert and a novice reader. 50 AIS patient NCCT images were acquired acutely. NCCT images were then enhanced by skull stripping, image smoothing, histogram equalization, and JET color mapping. ASPECTS scoring was done on AEGWM color mapped NCCT and on standard 5mm NCCT images by a novice reader. ASPECTS scoring was done two days apart on standard NCCT first, followed by AEGWM NCCT. Expert (neuro-radiologist) scores on standard NCCT were then compared with scores from the novice reader on both regular and AEGWM NCCT. Results: Agreement between novice and expert for trichotomized ASPECTS (0-4, 5-7, 8-10) was best when the novice was reading ASPECTS on AEGWM NCCT (kappa=0.7093) vs. when novice read ASPECTS on standard NCCT (kappa=0.2409). Difference in scoring the full 10-point ASPECTS score was least when the novice read ASPECTS on AEGWM NCCT (mean ASPECTS difference between novice and expert for algorithm-enhanced NCCT 0.68 ± 1.1 vs. 1.48 ± 1.8 for standard NCCT). A Bland Altman plot comparing the difference is attached and the coefficient of variation was found to be 0.14 for AEGWM NCCT scoring. Conclusion: Algorithm Enhanced Gray-White Matter NCCT allows more accurate/ reliable ASPECTS scoring. Further evaluation on a larger dataset with readers with different levels of expertise is ongoing.

Introduction: As image interpretation is a visual perception task, it is affected by context and task structure. The non-contrast CT Alberta Stroke Program Early CT Score (ASPECTS) is considered an objective radiologic measure of the extent of ischemic change in cases of acute ischemic stroke. We hypothesize that variability in ASPECTS reading is because readers are susceptible to interplay between higher-order, top-down information (clinical background or other imaging) and bottom-up sensory information, and that experts are more resistant to being swayed by these factors than novices. Methods: We tested the effect of three top-down background-information conditions (no information; clinical information with affected side; clinical information plus CT angiography (CTA)) and three environment/task conditions (daylight, core lab, time pressure) on the inter-rater reliability (IRR) of NCCT ASPECTS. Three raters (trainee, fellow, neuro-radiologist) independently scored 150 NCCT scans from acute ischemic stroke patients, with 50 allocated to each environmental task. This was repeated over three sessions, with one for each background-information condition. ASPECTS on CT perfusion Tmax thresholded scans served as ground truth. Results: IRR improved when clinical information and CTA were provided (ICC 0.55 - clinical + CTA, 0.41 - clinical, 0.10 - no information). In some situations (NIHSS 180 min), IRR was greater with clinical information but without CTA. Daylight and time pressure had greater IRR than core lab (ICC 0.59 and 0.7 vs. 0.34, respectively). In general, the trainee assigned lower ASPECTS relative to the fellow and expert. The expert showed greatest concordance with CT perfusion ASPECTS (ICC 0.69), and the trainee the least (ICC 0.47). Conclusion: The cognitive framework that we propose, which includes top-down and bottom-up constraints on visual perception, can explain variability in ASPECTS interpretation on NCCT.

Introduction: Assessing Alberta Stroke Program Early CT Score (ASPECTS) and identifying hyperdense arteries on non-contrast CT (NCCT) are important components of decision-making in acute stroke. Conventional practice uses 5mm averaged slice thickness NCCT for interpretation of these features. We have systematically evaluated several post processing techniques on NCCT to determine if there is improved reliability in identification of ASPECTS and hyperdense artery. Methodology: We assessed four post-processing techniques on NCCT namely (1) 5mm averaged thickness (2) Minimum Intensity Projection (mIP) - 5mm thickness (3) thin slices (0.625mm) and (4) Maximum Intensity Projection (MIP) - 5mm thickness (Figure 1). Three raters (student, fellow and expert) independently assessed 100 NCCT scans from the PRoveIT database. All scans were read at four different times 10-14 days apart. At each time-point the post processing modality was changed and the patient order randomized. Information on side of suspected infarction was provided. Raters were asked to score ASPECTS and identify presence of hyperdense artery at each reading. Inter-rater reliability was assessed using Intra-cluster correlation (ICC) for ASPECTS and weighted kappa (wKap) for hyperdense artery. Results: The highest inter-rater reliability was found with the MIP technique (ICC 0.42; p Conclusion: The use of MIP images for ASPECTS grading and thin images for hyperdense vessel detection improves reliability on NCCT. These simple processing steps are easily available on any modern scanner and may help improve patient care.

Introduction: Alberta Stroke Program Early CT Score (ASPECTS) is a systematic approach to assess early ischemic change on non-contrast CT (NCCT). Concerns have however been expressed about its reliability when making clinical decisions in patients with acute ischemic stroke. We chose to systematically assess technical, environmental and patient specific variables that potentially affect ASPECTS interpretation. Methods: We randomly selected 150 patients with acute ischemic stroke from the PRoveIT database. All patients had baseline NCCT and CT angiography head and neck. Three raters (expert, fellow and trainee) read ASPECTS on the same NCCT three times (Sessions 1-3) at minimum interval of 10-14 days. Raters were kept blinded to follow-up data throughout the study. No baseline clinical information was provided in Session 1. Raters were provided clinical information (age, baseline NIHSS and side of stroke) in session 2 and additional multiphase CTA in session 3. Reading environment [room light and time pressure ( Results: The highest inter-rater reliability was found in session 3 (ICC 0.47; p Conclusion: ASPECTS interpretation on NCCT is most reliable when clinical and CTA information is available. Interpretation with this information is reliable even in a well-lit room and under time pressure, the environment that mimics real life acute stroke.

Introduction: Decisions to transport patients from primary to comprehensive stroke centre would be influenced by info on likelihood/timing of spontaneous or IV tPA recanalization (recan). We examined recan rates by time for a wide range of occlusion sites in the INTERRSeCT multicenter prospective cohort study. Methods: Acute stroke patients consented/enrolled at 12 centers/5 countries if intracranial occlusion present on baseline CTA; eGFR≥60 ml/min. CTA was repeated 2-6 hrs later for recan unless patient taken for EVT (first run of angio used instead). Primary outcome was successful recan (rAOL scale score 2b/3) interpreted by central core lab. Results: 619 patients enrolled, 81.6% received IV tPA. 59.9% recan by follow-up CTA and 40.1% by first run angio. Median baseline NIHSS 14 (IQR 11); mean age 70.1 yrs (SD 13); median onset to baseline CTA 115 mins (IQR 108). Recan assessment imaging median 162 mins (IQR 198) from IV tPA bolus or baseline CTA (if no IV tPA). Successful recan (rAOL 2b-3) rates comparing baseline to repeat imaging shown in Figure 1a (IV tPA red; no IV tPA blue). IV tPA had much higher recan than non-IV tPA group (30.5% vs 11%, p Conclusions: Early recan rates were low across all occlusion sites. Beyond 6 hrs post tPA, recan rates approached EVT levels except for ICA. Imaging factors such as residual flow may further refine transport/triage decisions.

Introduction: Stroke is the third leading cause of death and disability in Canada. In the hyperacute stroke setting, the treating physician must make a time critical decision on the treatment of each patient. Recent advances in imaging help the treating physician identify the subgroup of patients eligible for acute treatment of ischaemic stroke.Areas covered: In this review we will discuss Non-Contrast Computed Tomography (NCCT), CT-Angiography (CTA), and CT-Perfusion (CTP) in assessment of patients with acute ischaemic stroke and intracerebral haemorrhage. Intravenous tPA was the only proven therapy for acute ischaemic stroke presenting within 4.5 hours, until the five recent trials proved the efficacy of EVT for acute ischaemic stroke with proximal arterial occlusion. Imaging played a major role in patient selection in all five trials.Expert commentary: The challenge of rapid clinical assessment, review of imaging and timely treatment will continue to be made easier as the development and unders...

To study the genetic pattern, clinical profile and to find any correlation between them in patients of Duchenne muscular dystrophy.Patients were selected from Neurogenetic clinic on the basis of clinical features, elevated serum CPK level and electromyographic features. After history and clinical examination, molecular genetic testing was performed by Polymerase Chain Reaction (PCR) technique.Among 100 patients, 73 patients had genetically confirmed disease while 8 cases were proven by biopsy, and thus a total 81 cases were further taken up for the study. Mean age of onset of clinical symptoms was 3.9 yrs; Valley sign and calf hypertrophy were most consistent features, while about 51% had facial weakness. Out of 73 genetically confirmed cases 53 (72.6%) showed deletion in distal exons and 12 (16.4%) showed deletion in both proximal and distal exons while 8 (10.9%) had only proximal deletion. There was no correlation between genetic pattern and clinical features.The positivity of PCR- based diagnosis is higher in our study possibly related to highly selective group of patients. Phenotype and genotype correlation was not seen.