Introduction: Stroke lesion volume on MRI or CT provides objective evidence of tissue injury as a consequence of ischemic stroke. Measurement of "final" lesion volume at 24-h following endovascular therapy (post-EVT) has been used in multiple studies as a surrogate for clinical outcome. However, despite successful recanalization, a significant proportion of patients do not experience favorable clinical outcome. The goals of this study were to quantify lesion growth during the first week after treatment, identify early predictors, and explore the association with clinical outcome. Methods: This is a prospective study of stroke patients at two centers who met the following criteria: (i) anterior large vessel occlusion acute ischemic stroke, (ii) attempted EVT, and (iii) had 3T MRI post-EVT at 24-h and 5-day. We defined "early" and "late" lesion growth as >= 10 mL lesion growth between baseline and 24-h diffusion-weighted imaging (DWI) and between 24-h DWI and 5-day fluid attenuated inversion recovery imaging, respectively. Complete reperfusion was defined as >90% reduction of the volume of tissue with perfusion delay (T-max>6 s) between pre-EVT and 24-h post-EVT. Favorable clinical outcome was defined as modified Rankin scale (mRS) of 0-2 at 30 or 90 days. Results: One hundred twelve patients met study criteria with median age 67 years, 56% female, median admit NIHSS 19, 54% received IV or IA thrombolysis, 66% with M1 occlusion, and median baseline DWI volume 21.2 mL. Successful recanalization was achieved in 87%, and 68% had complete reperfusion, with an overall favorable clinical outcome rate of 53%. Nearly two-thirds (65%) of the patients did not have late lesion growth with a median volume change of -0.3 mL between 24-h and 5-day and an associated high rate of favorable clinical outcome (64%). However, similar to 1/3 of patients (35%) did have significant late lesion growth despite successful recanalization (87%: 46% mTICI 2b/41% mTICI 3). Late lesion growth patients had a 27.4 mL change in late lesion volume and 30.1 mL change in early lesion volume. These patients had an increased hemorrhagic transformation (HT) rate of 68% with only 1 in 3 patients having favorable clinical outcome. Late lesion growth was independently associated with incomplete reperfusion, HT, and unfavorable outcome. Conclusion: Approximately 1 out of 3 patients had late lesion growth following EVT, with a favorable clinical outcome occurring in only 1 out of 3 of these patients. Most patients with no early lesion growth had no late lesion growth. Identification of patients with late lesion growth could be critical to guide clinical management and inform prognosis post-EVT. Additionally, it can serve as an imaging biomarker for the development of adjunctive therapies to mitigate reperfusion injury.

Abstract Background and objective Epilepsy is a prevalent neurological disorder that affects a significant number of individuals globally. This condition is associated with a high occurrence of psychiatric comorbidities, which can significantly affect the quality of life of individuals affected. The aim of this study was to investigate the association between antiseizure therapies and the likelihood of psychiatric comorbidities in individuals with epilepsy. Methodology Data for this study was gathered from the Neurology referral center in Islamabad, Pakistan. A standardized questionnaire was utilized to gather data from 120 individuals diagnosed with epilepsy. The survey consisted of inquiries regarding the management of seizures, the utilization of anti-seizure medications, and the presence of psychiatric comorbidities. The data was analyzed using the Statistical Package for the Social Sciences (SPSS). Results The findings indicated that individuals who were using multiple antiseizure medications had a notably higher likelihood of having psychiatric comorbidities in comparison to those who were on mono therapy (p = 0.010). suggests that patients with unsuccessful seizure control are more probable to have psychiatric comorbidities as compared to those with good seizure control (p = 0.029). Conclusion To conclude poor seizure control and poly therapy are associated with increased risk of psychiatric comorbidities.

Background: Measurement of “final” lesion volume at 24hr following endovascular therapy (post-EVT) has been used in multiple studies as a surrogate for clinical outcome. However, despite successful recanalization, a significant proportion of patients do not experience favorable clinical outcome. Methods: This is a prospective study of acute ischemic stroke patients at two stroke centers who met the following criteria: i) anterior large vessel occlusion (LVO) acute ischemic stroke, ii) attempted EVT, iii) written informed consent obtained, and iv) had MRI post-EVT at 24hr and 5-day. We defined “Early” and “Late” lesion growth as ≥10mL lesion growth between baseline and 24hr DWI, and between 24hr DWI and 5-day FLAIR, respectively. Results: One hundred fourteen patients met study criteria with median age 67 years, 56% female, median admit NIHSS 19, 54% received IV or IA thrombolysis, 67% with M1 occlusion, and median baseline DWI volume 28.2mL. Successful recanalization was achieved in 86% and 67% had complete reperfusion, with an overall favorable clinical outcome rate of 54%. Nearly two thirds (65%) of the patients did not have Late lesion growth with a median volume change of -0.2mL between 24hr and 5-days and an associated high rate of favorable clinical outcome (65%). However, ~1/3 of patients (35%) did have significant Late lesion growth despite successful recanalization (85% TICI 2b/3). Late lesion growth patients had a 26.2mL change in Late lesion volume and 19.9mL change in Early lesion volume. These patients had an increased hemorrhagic transformation rate of 68% with only 1 in 3 patients having favorable clinical outcome. Late lesion growth was independently associated with incomplete reperfusion, hemorrhagic transformation, and unfavorable outcome even after adjusting for admit NIHSS and Early lesion growth. Conclusions: Approximately 1 out of 3 patients had Late lesion growth following EVT, with a favorable clinical outcome occurring in only 1 out of 3 of these patients. Identification of patients with Late lesion growth could be critical to guide clinical management and inform prognosis post-EVT. Additionally it can serve as an imaging biomarker for the development of adjunctive therapies to mitigate reperfusion injury.

Background and objective: Not much is known about the prevalence and significance of hypodensities within hematoma after spontaneous intracerebral hemorrhage (ICH). The objective of this study was to determine the prevalence of hypodensities within hematoma after spontaneous ICH and their significance to predict poor outcome after ICH. Methods: This observational cross sectional study was conducted in the Department of Neurology, Pakistan Institute of Medical Sciences, Islamabad, from October 2021 to June 2022. Total 140 patients of acute stroke were included. Inclusion criteria was any patient of >20 years of age with confirmed diagnosis of ICH on imaging, non-traumatic, who presented within 24 hours after onset of symptoms. Data was analyzed by SPSS ver.23.0. Results: Total 150 patients were included in the study. The mean age of patients was 52.28 ± 1.29 years. There were 100 (71.4%) males and 40 (28.6%) females. Hypertension was the most common comorbid present in 87 patients (62.1%).55% of patients had on presentation National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale score of moderate severity. The mean ICH score on presentation was 2.64 +1.26. Hematoma expansion was present in 55(39.3%) patients while interventricular extension was seen in 100(71.4%) patients. Hypodensities were seen in 125(89.3%) patients( p value 0.001). When hematoma volume were compared in both groups it was also significant (p value 0.002). Conclusion: We conclude that hypodensities within hematoma are a reliable marker of hematoma expansion after spontaneous ICH. Such reliable marker can be easily employed in resource-poor countries where CT angiography is not available everywhere. The higher NIHSS score and low GCS are significantly associated with hypodensities within hematoma.

Introduction: A substantial proportion of acute stroke patients experience poor outcomes following successful endovascular therapy (EVT) and reperfusion injury to the brain and vasculature may be a contributor. The purpose of this pilot study was to characterize hyperemia following recanalization and test the association of hyperemia with evolution of the ischemic lesion. Methods: Acute stroke patients were included with: i) large vessel occlusion of the anterior circulation, ii) successful recanalization, and iii) evaluable MRI early after EVT. Presence of hyperemia on MRI perfusion was assessed by consensus using a modified ASPECTS. Three different approaches were used to quantify relative cerebral blood flow (rCBF) on early post-EVT, 24 hours, and 5 days. Two independent trained readers measured lesion volumes using a semi-automated validated approach. Results: Sixty-seven patients with median age of 66 [59-76], 57% female, met inclusion criteria. Hyperemia was present in 35/67 (52%) patients early post-EVT (Figure), in 32/65 (49%) patients at 24 hours, and in 19/48 (40%) patients at 5 days. In comparison to control regions, rCBF was elevated by greater than 50% in hyperemic regions. Patients with hyperemia had larger ischemic lesion volumes and early lesion growth. A strong association (R2=0.81, p<0.001) was found between early post-EVT hyperemia (p=0.027) and lesion growth based on DWI volume at 24 hours, after adjusting for DWI volume at 2 hours (p<0.001) and incomplete reperfusion at 24 hours (p=0.001). Conclusions: Hyperemia is frequently observed after successful EVT and is associated with lesion growth at 24 hours. Evidence of hyperemia may identify patients that may benefit from adjunctive therapy to prevent reperfusion injury, edema, and lesion growth.

Objective: The aim of study was to establish a quick way to differentiate between hemorrhagic and ischemic stroke by using siriraj stroke score and find its specificity and sensitivity by comparing it with CT scan findings. Study design: Cross-sectional study. Place and duration of study: Department of Neurology Pakistan Institute of Medical Sciences Islamabad from Jan 2021 to June 2021. Methodology: Total 110 patients of acute stroke were included. Any patient of > 20 years old, non-traumatic, focal neurological deficit < 14 days with no obvious reason other than vascular were included. Siriraj stroke score was calculated its findings were compared with a CT scan findings. Data was analyzed by SPSS ver.23.0. Results: The mean age of patients was 66.10 ± 14.58 years. There were 54 (49.10 %) males and 56 (50.90 %) females. Hypertension was the most common disease found in 79 (71.8 %). The sensitivity, specificity, PPV and NPV of Siriraj stroke score was 83.87 %, 66.6 %, 74.2 % and 71.42 % respectively for hemorrhagic stroke and 93.4 %, 80.95 %, 93.4 % and 37.03 % respectively for non-hemorrhagic stroke. Conclusion: It is an easy, cost effective and bed side scoring system which can accurately identify the stroke type without any other radiological investigation. It can be employed in areas where CT scan facility is not available and treatment can be started early which will definitely lower mortality and morbidity of stroke patients.

Introduction: Lesion volume on MRI or CT provides evidence of tissue response to successful recanalization by endovascular therapy. The most appropriate time to estimate “infarct” volume remains unclear. Largely for convenience, 24-48 hours has been used in clinical trials and registry datasets which may be too early to determine the final infarct volume. The objective of this study was to quantify the comparability of lesion volume using MRI measured at 24 hours versus 5 days in acute stroke patients following successful recanalization. Methods: Patients were included if they consented to the prospective GUARDS study between April 2018 through February 2022, had LVO of the anterior circulation, were treated with EVT, achieved complete revascularization defined as TICI 2b/3, and imaged with MRI at 2 hours, 24 hours, and 5 days post EVT. Two independent readers measured lesion volumes using a semi-automated validated approach on DWI at 2 and 24 hours, and FLAIR at 5 days. Statistical comparisons of lesion volumes across time points were performed. Lesion growth was defined as change in lesion volume and percent change compared to lesion volume at 2 hours. Results: Sixty-nine patients met all study criteria and were included. Median age was 66 years, 55% female, median admit NIHSS of 18, 62% with M1 LVO, and 46% treated with IV thrombolysis. Post-EVT median lesion volumes were 24mL, 35mL, and 45mL respectively for 2-hour DWI, 24-hour DWI, and 5-day FLAIR. Lesion growth based on median percent change from the 2-hour DWI was 39% [21-96] and 52% [12-145] at 24 hours and 5 days. The difference in lesion growth based on percent change from 24 hours to 5 days was not significant (p=0.17). However, there was a significant difference based on change in lesion volume, 12mL [2-25] at 24 hours and 16mL at 5 days (p=0.029). Fifty-one (74%) patients had DWI volumes at 24 hours that were ≥80% of their FLAIR volumes at 5 days. However, 18 (26%) patients continued to have lesion growth beyond 24 hours, median lesion growth of 18mL,with 11 (61%) of those having lesion growth >20mL. Conclusions: Lesion growth >20mL continues in some patients beyond 24 hours, suggesting that infarct volume at 5 days should be used as the imaging outcome when assessing tissue response to recanalization.

Introduction: Perihematomal edema is a consequence of primary intracerebral hemorrhage. On diffusion MRI, a corresponding heterogenous pattern of hypo- and hyper-intensity is visible on apparent diffusion coefficient (ADC), suggesting both cytotoxic and vasogenic edema. Analogously, endovascular therapy (EVT) for ischemic stroke can result in hemorrhagic transformation (HT) and a concomitant ring-like pattern, or “Rings” of mixed intensity on ADC. The objective of this study is to describe this pattern of secondary injury early after EVT. Methods: Patients were included if they consented to the prospective Natural History of Stroke GUARDS study from April 2018 to February 2022, were treated with EVT for anterior circulation LVO, achieved TICI 2b/3 reperfusion, and had early MRI, ~2h post-EVT. Two independent readers measured early and 24h DWI lesion volumes and 5d FLAIR lesion volumes using a semi-automated validated approach. Presence of any HT on GRE and Rings on ADC (Figure) on early, 24h, and 5d MRI were read independently by multiple readers who then reached consensus. The relationship of Rings with HT and lesion volume was explored. Results: Eighty-nine patients were included with median age 64y, 55% female, median admit NIHSS 18, 64% M1 LVO, and 47% IV tPA. On early MRI, 14 (16%) patients had Rings, 12 (86%) of whom also had HT (p<0.001). At 24h, 42 (50%) patients had Rings with 33 (79%) also having HT (p<0.001). There was a strong association between presence of Rings at 24h and 5d-FLAIR lesion volume, 56mL vs. 24mL in patients with vs. without Rings (p=0.002). Conclusions: Rings on ADC was seen in half of patients 24h post-EVT and appears to reflect peri-lesion edema associated with hemorrhagic transformation. This imaging marker was associated with larger lesion volumes at 5 days and may be able to serve as a target for adjunctive therapy post-EVT to mitigate edema formation.

A 17-year-old girl was admitted after acute onset of unsteady gait succeeding acute gastroenteritis. Neurological examination reported normal power in all four limbs, impaired finger-nose, heel-shin tests, areflexia and ataxic gait. We eliminated other diseases with cerebellar symptoms; for example, Wernicke encephalopathy, multiple sclerosis, cerebellar vascular disease , encephalitis in the brain stem and cerebellum. Blood serum collected from the patient during the acute phase showed no anti-ganglioside antibodies. As the patient presented with evident cerebellar ataxia without muscle weakness, ophthalmoplegia or proprioceptive sensory disruption a diagnosis of ataxic form of Guillain-Barré syndrome (GBS) after nerve conduction studies. Though ataxic GBS is not a settled impression, we should have to give heed to the potential existence of such a scarce GBS variant.

Background and objective: There is a lack of local data regarding the frequency and predictors of early seizures after stroke. The objective of this study was to determine the frequency of early seizures after stroke and identify the predictors which lead to them after first acute stroke. Methods: This cross-sectional observational study was conducted in the Department of Neurology, Pakistan Institute of Medical Sciences, Islamabad from October 2021 to June 2022. A total of 310 consecutive eligible patients of acute stroke were recruited. Key inclusion criteria included any patient of >20 years of age with confirmed diagnosis of stroke on imaging, non-traumatic, with no history of seizures in past. Data was analyzed by SPSS version 23.0. Results: The mean age of patients in the seizures group was 48.40 ± 20.9 years. Hypertension was the most common co-morbid present in 225 (76.5%) patients. Early seizures were found in 52 (16.8%) patients with 42 (80.76%) having seizures in first 24 hours of stroke (p value 0.001). On National Institute of Health Sciences Scale (NIHSS) score most patients 125 (40.3%) had moderate severity score i.e. score in between 7 to 25 (p value 0.05). Ischemic stroke was identified as the stroke variety with most of the early seizures i.e. 16 (30.76%) (p value 0.003). Conclusion: Early seizures were not infrequent after acute stroke (16.77%) in our study. Early seizures were associated with younger age, cortical region lesion, ischemic stroke, followed by cerebral venous thrombosis. Higher NIHSS score and greater disability was associated with increased incidence of early seizures.

Utilizing an emergent magnetic resonance imaging (MRI) pathway for emergency department patients with acute onset of stroke-like symptoms allows for optimization of acute ischemic stroke treatment. Emergent MRI increases the percentage of patients administered intravenous tissue plasminogen activator (IV tPA) and minimizes stroke-related long-term disabilities. MRI also reduces the overall cost of stroke-related care by (1) preventing unnecessary IV tPA administration and its associated hospital costs and (2) facilitating faster stroke etiology work-up and treatment plan initiation to reduce hospital length of stay. The primary purpose of this article is to summarize two hospitals' experience utilizing an evidence-based emergent MRI pathway for patients presenting to the emergency department with stroke-like symptoms who may be IV tPA eligible. Secondary purposes are to describe (1) emergent MRI pathway challenges with implemented mitigation strategies and (2) case examples (wake-up stroke; mild stroke-like symptoms with acute ischemic stroke confirmed by MRI).

Patients with moyamoya arteriopathy are at high risk for developing ischemic stroke in the perioperative period. We sought to evaluate whether preoperative clinical and neuroimaging biomarkers are associated with postoperative stroke and transient ischemic attack in children with moyamoya following revascularization surgery. We performed a retrospective chart review of pediatric patients who underwent revascularization surgery for moyamoya in the last 15 years. Fifty-three patients who underwent 69 surgeries met the inclusion criteria. We recorded clinical predictors of stroke or transient ischemic attack within 7 days following surgery. We used Suzuki stage and Composite Cerebrovascular Stenosis Score to analyze neuroimaging. Significant risk factors for developing postoperative stroke or transient ischemic attack were younger age at surgery ( P = .004) and transient ischemic attack less than 1 month prior to surgery ( P < .001). Children under 5 and those with recent preoperative ischemic events should be the focus of investigation to evaluate modifiable risk factors and targeted interventions.

Background: Diffusion weighted imaging (DWI) becomes hyperintense within minutes of ischemic insult to cerebral tissue. While apparent diffusion coefficient maps evolve rapidly during the days after ischemia, DWI typically remains bright for weeks to months after a stroke. This phenomenon is often referred to as “T2-shine through.” We sought to investigate factors that influence persistent hyperintensity on DWI. Methods: The study population included ischemic stroke patients who were admitted to two regional stroke centers and imaged with MRI <=4.5 hours from stroke onset and then again 30 days later. DWI images were independently reviewed for each time point. 30-day DWI images were compared to initial images and were rated accordingly: 1. absent hyperintensity, 2. mixed hyperintensity, 3. bright hyperintensity. Hyperintensity rating was treated as an continuous variable and compared with demographics, risk factors, laboratory values, imaging measurements, and outcome measures using univariate linear regression. Results: Thirty-one patients were included in the study; median age was 63 and 58% were women. Hyperintensity on DWI was absent at 30 days in 9 patients (29%), mixed in 11 patients (35%) and bright in 11 patients (35%). Greater DWI hyperintensity 30 days post stroke was associated with larger volume of the perfusion deficit on presentation (p=0.037) but not with core stroke volume (p=0.621) or mismatch ratio (p=0.719). DWI hyperintensity was not associated with demographic or clinical variables. Greater DWI hyperintensity rate was associated with worse post-stroke disability when comparing premorbid modified Rankin score (mRS) with the follow up mRS (p=0.026) as depicted in the figure that showing a box plot of change in mRS vs. degree of “T2-shine through”. Conclusions: Persistent hyperintensity on DWI a month after stroke may be an indicator of greater disability. Larger studies are needed to confirm these findings and understand their implications for further recovery.

Background and Purpose: It is well established that earlier treatment times are associated with better outcomes in acute stroke patients receiving thrombolysis. There is also an association between time from stroke onset and lesion visibility on FLAIR MRI. We hypothesized that lesion visibility on FLAIR, independent of time, may be a predictor of outcome in stroke patients with known onset. Methods: We analyzed data from acute ischemic stroke patients presenting over the last 10 years who were screened with MRI and treated with IV thrombolysis within 4.5 hours from known onset. Three independent readers assessed whether acute ischemic lesions seen on Diffusion Weighted Imaging were also FLAIR-positive based on visual inspection. Multivariable regression analysis was used to obtain an adjusted odds ratio of favorable clinical and radiological outcomes based on FLAIR-positivity. Results: Of 310 stroke patients, 24% had lesion visibility on initial FLAIR MRI. The interrater agreement for the FLAIR-positive assessment was 84% (κ=0.604, 95% CI 0.557-0.652). Patients with FLAIR-positive lesions were younger (67 vs 73 years, p=0.028), had more right hemispheric strokes (57% vs 42%, p=0.018), were imaged later (127 vs 104 minutes, p=0.010), had more frequent blood-brain barrier disruption (44% vs 26%, p=0.004), less frequent early neurologic improvement (30% vs 58%, p<0.001), and less frequent favorable 90-day functional outcome (49% vs 63%, p=0.039). Following multivariable logistic regression, older age, greater NIH Stroke Scale, lesion visibility on FLAIR, but not time-from-onset, were independently associated with less favorable outcome. Conclusions: FLAIR-positive acute ischemic stroke within 4.5 hours of known onset was associated with less favorable 90-day outcome after IV thrombolysis. When compared with time, lesion visibility on FLAIR was more strongly associated with outcome.

Introduction: The absence of an ischemic lesion on MRI fluid-attenuated inversion recovery (FLAIR) is helpful in predicting stroke onset within 4.5 h. However, some ischemic strokes become visible on FLAIR within 4.5 h. We hypothesized that the early lesion visibility on FLAIR may predict stroke outcome 90 days after intravenous (IV) thrombolysis, independent of time. Materials and Methods: We analyzed data from acute ischemic stroke patients presenting over the last 10 years who were screened with MRI and treated with IV thrombolysis within 4.5 h from onset. Three independent readers assessed whether ischemic lesions seen on diffusion-weighted imaging were also FLAIR positive based on visual inspection. Multivariable regression analyses were used to obtain an adjusted odds ratio of favorable clinical and radiological outcomes based on FLAIR positivity. Results: Of 297 ischemic stroke patients, 25% had lesion visibility on initial FLAIR. The interrater agreement for the FLAIR positivity assessment was 84% (κ = 0.604, 95% CI: 0.557–0.652). Patients with FLAIR-positive lesions had more right hemispheric strokes (57 vs. 41%, p = 0.045), were imaged later (129 vs. 104 min, p = 0.036), and had less frequent favorable 90-day functional outcome (49 vs. 63%, p = 0.028), less frequent early neurologic improvement (30 vs. 58%, p = 0.001), and more frequent contrast extravasation to the cerebrospinal fluid space (44 vs. 26%, p = 0.008). Conclusions: Early development of stroke lesion on FLAIR within 4.5 h of onset is associated with reduced likelihood of favorable 90-day outcome after IV thrombolysis.

Background and Objectives We aimed to determine whether a modified pediatric Alberta Stroke Program Early CT Score (modASPECTS) is associated with clinical stroke severity, hemorrhagic transformation, and 12-month functional outcomes in children with acute arterial ischemic stroke (AIS). Methods Children (age 29 days–<18 years) with acute AIS enrolled in 2 institutional prospective stroke registries at the Children's Hospital of Philadelphia and Royal Children's Hospital Melbourne, Australia were retrospectively analyzed to determine whether modASPECTS, in which higher scores are worse, correlated with acute pediatric NIH Stroke Scale (PedNIHSS) scores (children ≥2 years of age), was associated with hemorrhagic transformation on acute MRI, and correlated with 12-month functional outcome on the Pediatric Stroke Outcome Measure. Results One hundred thirty-one children were included; 91 were ≥2 years of age. Median time from stroke to MRI was 1 day (interquartile range [IQR] 0–1 day). Median modASPECTS was 4 (IQR 3–7). ModASPECTS correlated with PedNIHSS score (ρ = 0.40, p = 0.0001). ModASPECTS was associated with hemorrhagic transformation (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.02–1.25, p = 0.018). Among children with follow-up (n = 128, median 12.2 months, IQR 9.5–15.4 months), worse outcomes were associated with higher modASPECTS (common OR 1.14, 95% CI 1.04–1.24, p = 0.005). The association between modASPECTS and outcome persisted when we adjusted for age at stroke ictus and the presence of tumor or meningitis as stroke risk factors (common OR 1.14, 95% CI 1.03–1.25, p = 0.008). Discussion ModASPECTS correlates with PedNIHSS scores, hemorrhagic transformation, and 12-month functional outcome in children with acute AIS. Future pediatric studies should evaluate its usefulness in predicting symptomatic intracranial hemorrhage and outcome after acute revascularization therapies. Classification of Evidence This study provides Class II evidence that the modASPECTS on MRI is associated with stroke severity (as measured by the baseline PedNIHSS score), hemorrhagic transformation, and 12-month outcome in children with acute supratentorial ischemic stroke.

Mild cognitive impairment (MCI) is characterized by evidence of cognitive impairment with minimal disruption of instrumental activities of daily living and carries a substantial risk of progression of dementia. Whereas current guidelines support a relatively minimalistic workup to identify reversible or structural causes, the field has witnessed the rapid development of various sophisticated imaging, biomarker, and genetic investigations in the past few years. The role of these investigations in routine practice is uncertain. Similarly, although there are no approved treatments for MCI, neurologists may experience uncertainty about using cholinesterase inhibitors or other medications or supplements that have been studied in MCI with limited success, particularly when patients or families are keen to try pharmacologic options. Given these uncertainties, and the paucity of high-quality data in the literature, we sought expert opinion from around the globe on how to investigate and treat patients with MCI. Similar questions were posed to the rest of our readership in an online survey, the preliminary results of which are also presented.

BACKGROUND:Treatment of FLAIR-negative stroke in patients presenting in an unknown time window has been shown to be safe and effective. However, implementation can be challenging due to the need for hyper-acute MRI screening. The purpose of this study was to review the routine application of this practice outside of a clinical trial. METHODS:Patients presenting from 3/1/16 to 8/22/18 in a time window <4.5 h from symptom discovery but >4.5 h from last known normal were included if they had a hyper-acute MRI performed. Quantitative assessment based on the MR WITNESS trial and qualitative assessment based on the WAKE-UP trial were used to grade the FLAIR images. The MR WITNESS trial used a quantitative assessment of FLAIR change where the fractional increase in signal change had to be <1.15, whereas the WAKE-UP trial used a visual assessment requiring the absence of marked FLAIR signal changes. RESULTS:During the study period, 136 stroke patients presented and were imaged in the specified time window. Of these, 17 (12.5%) received IV tPA. Three patients had hemorrhage on 24-h MRI follow up; none had an increase in NIHSS ≥4. Of the 119 patients who were screened but not treated, 18 (15%) were eligible based on FLAIR quantitative assessment and 55 (46%) were eligible based on qualitative assessment. In all cases where patients were not treated, there was an identifiable exclusion based on trial criteria. During the study period, IV tPA utilization was increased by 5.6% due to screening and treating patients with unknown onset stroke. CONCLUSIONS:Screening stroke patients in an unknown time window with MRI is practical in a real-world setting and increases IV tPA utilization.

Mild cognitive impairment (MCI) is characterized by evidence of cognitive impairment with minimal disruption of instrumental activities of daily living and carries a substantial risk of progression of dementia. Whereas current guidelines support a relatively minimalistic workup to identify reversible or structural causes, the field has witnessed the rapid development of various sophisticated imaging, biomarker, and genetic investigations in the past few years. The role of these investigations in routine practice is uncertain. Similarly, although there are no approved treatments for MCI, neurologists may experience uncertainty about using cholinesterase inhibitors or other medications or supplements that have been studied in MCI with limited success, particularly when patients or families are keen to try pharmacologic options. Given these uncertainties, and the paucity of high-quality data in the literature, we sought expert opinion from around the globe on how to investigate and treat patients with MCI. Similar questions were posed to the rest of our readership in an online survey, the preliminary results of which are also presented.