Acute Ischemic Stroke Presenting Research Articles

Abstract TP412: Blood Pressure at Presentation of Acute Ischemic Stroke

Introduction: Blood pressure on presentation and control of blood pressure are known to have associations with functional outcome and stroke severity. The investigators in this study looked to see if certain systolic blood pressures are associated with specific neurological deficits on presentation of acute ischemic stroke. Hypothesis: Systolic blood pressure at presentation of acute ischemic stroke will be associated with focal neurological symptoms. Methods: We analyzed the 17,398 patients from the International Stroke Trial with confirmed ischemic stroke. Blood pressure was measured immediately before randomization and a neurological examination was performed with seven categories of focal neurological findings. For each neurological finding, a Student’s t-test was used to evaluate for differences in blood pressure mean between patients with or without the finding. Many of the neurological findings were not examined in all patients. Results: See attached image. Conclusions: Lower systolic blood pressure on presentation of acute ischemic stroke are associated with visual and neglect deficits as compared to motor, brainstem, and cerebellar deficits.

Improper Use of Thrombolytic Agents in Acute Hemiparesis Following Misdiagnosis of Acute Ischemic Stroke.

Objective Acute hemiparesis is often an early presentation of acute ischemic stroke, though it can occur in various disorders. This study aimed to investigate the improper use of thrombolytic agents for patients with acute hemiparesis, following the misdiagnosis of acute ischemic stroke.MethodsWe analyzed the clinical and radiological data of nine patients initially misdiagnosed with cerebral stroke in the emergency room from May 2013 to January 2017. All the patients were treated with tissue plasminogen activator (TPA) owing to the presence of acute hemiparesis. Subsequently, emergent computed tomography scan showed no intracranial hemorrhage. Clinical findings including neurological deficits, clinical course, and related complications were detected and analyzed.ResultsAcute hemiparesis was observed in the following conditions: spontaneous spinal epidural hematoma, Brown-Séquard syndrome caused by cervical disc herniation, cervical epidural abscess, hypoglycemia in the presence of an old stroke, and seizure or convulsion disorder. Although acute hemiparesis was regarded as a contraindication, inappropriate TPA administration did not aggravate the neurological condition in any of the patients who required surgery.ConclusionUpon presentation of acute hemiparesis, various conditions mimicking cerebral stroke should be considered to avoid misdiagnosis. We suggest that physicians should exercise caution when prescribing thrombolytic agents.

Electroencephalography Patterns and Prognosis in Acute Ischemic Stroke

Background and Purpose: The prognostic significance of interictal epileptiform discharges (IED) and periodic patterns (PP) after ischemic stroke has not been assessed. We sought to test whether IED and PP, detected on standard Electroencephalography (EEG) performed during the acute phase of ischemic stroke are associated with a worse functional outcome. Methods: One-hundred-fifty-seven patients 18 years or older with a diagnosis of acute ischemic stroke presenting within 72 h from stroke onset were prospectively enrolled and followed. Patients with a pre-stroke history of seizures or epilepsy, previous debilitating neurological disease or conditions that precluded the performance of EEG were excluded. Interpretation was performed by a blinded board certified neurophysiologist. IED and PP (grouped as epileptiform activity [EA]) were defined according to proposed guidelines. Univariable and multivariable analyses were used to identify predictors of outcome (modified Rankin Scale dichotomized ≤2 vs. ≥3) at 3 months. Results: In the univariable analysis, admission NIHSS (OR 1.20, 95% CI 1.12-1.28, p = 0.001), age (OR 1.03, 95% CI 1.01-1.05, p = 0.02), and presence of EA (OR 2.94, 95% CI 1.51-5.88, p = 0.001) were significantly associated with the outcome at 3 months. In the multivariable analysis, only admission NIHSS (OR 1.19, 95% CI 1.11-1.28, p < 0.001) and the presence of EA (OR 2.27, 95% CI 1.04-5.00, p = 0.04) were independently associated with the prognosis. Significance: The importance of EEG in the prognosis of acute ischemic stroke warrants additional research, examining the role of medication therapy on the outcome and the occurrence of seizures for those patients with specific EEG patterns.

Automatic detection of paroxysmal atrial fibrillation in patients with ischaemic stroke: better than routine diagnostic workup?

Background and purposeProlonged electrocardiogram (ECG) monitoring after ischaemic stroke increases the diagnostic yield of paroxysmal atrial fibrillation (pAF). In order to facilitate the additional workload involved in ECG analysis due to prolonged monitoring times, we investigated the effectiveness of pAF detection with an automated software algorithm (SA) in comparison to the routine staff‐based analysis (RA) during standard stroke‐unit care. Therefore, patients with acute ischaemic stroke or transitory ischaemic attack presenting with sinus rhythmus on the admission ECG and no history of atrial fibrillation were prospectively included.MethodsA 24‐h Holter ECG assessment was performed using either RA based on a computer‐aided evaluation and subsequent review by a cardiologist or a commercially available automated SA. In the case of discordant results concerning the occurrence of pAF between the two methods, the data underwent an independent external rating.ResultsOf 809 prospectively enrolled patients, 580 patients fulfilled the inclusion criteria. pAF was ultimately diagnosed in 3.3% of the cohort (19 patients). SA and RA correctly diagnosed pAF in 17 patients resulting in a comparable diagnostic effectiveness of the analysis methods (sensitivity: SA 89.5% vs. RA 89.5%; specificity: SA 99.3% vs. RA 99.1%; κ, 0.686; P < 0.001; 95% confidence interval, 0.525–0.847). RA revealed clinically relevant ECG abnormalities in an additional seven patients.ConclusionsAlthough it should not completely replace RA, SA‐based evaluation of Holter ECG reaches a high diagnostic effectiveness for the detection of pAF and can be used for a rapid and resource‐saving analysis of ECG data to deal with prolonged monitoring times.

Abstract TP9: ASPECTS Values in Patients With Large Vessel Occlusion and Time of Arrival to Emergency Department: Estimation of Eligibility for Endovascular Stroke Therapy

Background: Favorable imaging profile according to The Alberta Stroke Program Early CT Score (ASPECTS) is an important selection criterion for endovascular therapy in patients with acute stroke from anterior circulation large vessel occlusion (LVO). The goal of this study was analyze the relationship between ASPECTS values and time of arrival to emergency department (ED) after stroke onset, and its impact on patient’s eligibility for endovascular stroke therapy. Methods: analysts of ASPECTS values in consecutive patients with acute stroke from anterior circulation LVO admitted within 24 hours of onset was performed. Criteria from American Heart Association/American Stroke Association (AHA/ASA) guidelines based on the proposed class I-II recommendations, including the ‘favorable’ ASPECTS range of 6-10 were applied to determine frequency of potentially eligible patients for endovascular stroke therapy. Results: Of 641 patients with acute ischemic stroke presenting within the first 24 hours of onset, 71 (11%) had anterior circulation LVO. Medium time from arrival to ED to noncontrast head CT was 6 minutes. 72% of patients arrived to ED within the first 6 hours, 18% within 6-12 hours, and 10% within 12-24 hours of symptom onset. Based on ‘favorable’ ASPECTS criterion alone, 80% of patients with anterior circulation LVO who arrive to the ED within the first 6 hours of stroke onset would qualify for endovascular therapy. Of those who arrived to ED within 6-24 hours of stroke onset, 50% had ‘favorable’ ASPECTS. Conclusions: 50% of patients with stroke from anterior circulation LVO who arrive to ED within 6-24 hours of onset have ‘favorable’ ASPECTS, making them potentially eligible for endovascular stroke therapy.

Clinical Manifestations of Spinal Epidural Hematoma-Stroke Mimic and Pitfalls in Diagnosis

Clinical manifestations of spinal epidural hematoma are presented, and the cases mimicking acute ischemic stroke have been reviewed from the literature. Many reports described the cases of spinal epidural hematoma with acute hemiparesis mimicking ischemic stroke in which intravenous thrombolytic treatment with recombinant tissue plasminogen activator was considered. A correct diagnosis of acute ischemic stroke must be made within 4.5 hours from the onset of symptoms, a relatively short window period. A spinal epidural hematoma is a potentially important stroke mimic in a wide variety of conditions that mimic a stroke. The literature review and discussion will emphasize allowing the distinction between these hemiparetic presentation of spinal epidural hematoma and acute ischemic stroke. A spinal epidural hematoma should be considered in the differential diagnosis of patients with acute onset of hemiparesis when associated with neck pain and signs of Horner's syndrome and Brown-Sēquard syndrome.

Does prior antiplatelet treatment improve functional outcome after intra-arterial treatment for acute ischemic stroke?

Background and purpose In patients with acute ischemic stroke who receive antiplatelet treatment, uncertainty exists about the effect and safety of intra-arterial treatment. Our aim was to study whether intra-arterial treatment in patients with prior antiplatelet treatment is safe and whether prior antiplatelet treatment modifies treatment effect. Methods All 500 MR CLEAN patients were included. We estimated the effect of intra-arterial treatment with ordinal logistic regression analysis, and tested for interaction of antiplatelet treatment with intra-arterial treatment on outcome. Furthermore, safety parameters and serious adverse events were analyzed. Results The 144 patients (29%) on antiplatelet treatment were older, more often male, and had more vascular comorbidity. Intra-arterial treatment effect size after adjustments in antiplatelet treatment patients was 1.7 (95% confidence interval 0.9-3.2), and in no antiplatelet treatment patients 1.8 (95% confidence interval: 1.2-2.6). There was no statistically or clinically significant interaction between prior antiplatelet treatment and the relative effect of intra-arterial treatment ( p = 0.78). However, in patients on antiplatelet treatment, the effect of successful reperfusion on functional outcome in the intervention arm of the trial was doubled: the absolute risk difference for favorable outcome after successful reperfusion in patients on prior antiplatelet treatment was 39% versus 18% in patients not on prior antiplatelet treatment (Pinteraction = 0.025). Patients on antiplatelet treatment more frequently had a symptomatic intracranial hemorrhage (15%) compared to patients without antiplatelet treatment (4%), without differences between the control and intervention arm. Conclusions Prior treatment with antiplatelet agents did not modify the effect of intra-arterial treatment in patients with acute ischemic stroke presenting with an intracranial large vessel occlusion. There were no safety concerns. In patients with reperfusion, antiplatelet agents may improve functional outcome.

Acupuncture for a first episode of acute ischaemic stroke: an observer-blinded randomised controlled pilot study.

To determine the required sample size for, and feasibility of, a RCT examining the effectiveness of early acupuncture for acute ischaemic stroke. Thirty-eight patients aged 40-85 years with a first episode of acute ischaemic stroke presenting within 72 h of stroke onset were randomly assigned to receive manual acupuncture (MA group; n=20) plus standard care or standard care only (control group, n=18). The acupuncture treatment was provided daily for 2 weeks. The primary outcome was the change in the National Institutes of Health Stroke Scale (NIHSS) score between baseline and 4 weeks. Secondary outcomes included changes in the Fugl-Meyer assessment (FMA) and the functional independence measure scores between baseline and 4 weeks, and changes in NIHSS, Barthel Index and modified Rankin Scale scores at 12 weeks. Thirty-one patients completed the study (dropout rate=18%) and adverse effects were minimal. No significant differences were seen between groups in the improvements in NIHSS scores, although there tended to be a greater reduction in NIHSS score after 1 week in the MA group relative to the control group (p=0.066). The post-stroke motor activity at 4 weeks was associated with a significantly increased FMA score in the acupuncture group compared with the control group (p<0.05), but not supported by intergroup analysis. This pilot study indicates that acupuncture appears to be safe for patients in the acute stage of ischaemic stroke. A subsequent trial with a larger sample size (estimated at n=122) is required to confirm whether early acupuncture intervention contributes to earlier functional improvement and to assess the longer-term clinical efficacy of acupuncture. NCT02210988; Results.

To Load or Not to Load? Aspirin Loading in Acute Ischemic Stroke: A Study of Clinical Outcomes

Aspirin is known to reduce mortality and recurrent vascular events. However, there are no reports about the dose-response of loading aspirin in treating acute ischemic stroke. The objective of this study was to compare the effectiveness of different loading doses of aspirin in acute ischemic stroke presenting within 48 hours of symptom onset. This was a retrospective, hospital-based cohort study. Patients were classified as high dose (160-325 mg) or low dose (<160 mg) based on the initial loading dose of aspirin at the emergency department. The primary outcome measure was a favorable modified Rankin Scale (mRS) score of 1 or lower on discharge. Secondary outcomes included in-hospital mortality, stroke progression during admission, and bleeding events. A propensity score with 1:3 matching was used to balance baseline characteristics, and stepwise multiple logistic regression was performed for variable adjustment. From a total of 7738 available patients, 3802 patients were included. Among them, 750 patients were in the high-dose group. Multiple logistic regression after matching revealed that the high-dose group was significantly associated with a favorable clinical outcome on discharge (odds ratio: 1.49, 95% confidence interval: 1.17-1.89, P <.01), but not mortality or stroke progression. The high-dose group also experienced more minor bleeding events. A higher loading dose of aspirin (160-325 mg) can be beneficial in treating acute ischemic stroke, although there is an increased risk of minor bleeding.

Clinical Scales Do Not Reliably Identify Acute Ischemic Stroke Patients With Large-Artery Occlusion.

It remains debated whether clinical scores can help identify acute ischemic stroke patients with large-artery occlusion and hence improve triage in the era of thrombectomy. We aimed to determine the accuracy of published clinical scores to predict large-artery occlusion. We assessed the performance of 13 clinical scores to predict large-artery occlusion in consecutive patients with acute ischemic stroke undergoing clinical examination and magnetic resonance or computed tomographic angiography ≤6 hours of symptom onset. When no cutoff was published, we used the cutoff maximizing the sum of sensitivity and specificity in our cohort. We also determined, for each score, the cutoff associated with a false-negative rate ≤10%. Of 1004 patients (median National Institute of Health Stroke Scale score, 7; range, 0-40), 328 (32.7%) had an occlusion of the internal carotid artery, M1 segment of the middle cerebral artery, or basilar artery. The highest accuracy (79%; 95% confidence interval, 77-82) was observed for National Institute of Health Stroke Scale score ≥11 and Rapid Arterial Occlusion Evaluation Scale score ≥5. However, these cutoffs were associated with false-negative rates >25%. Cutoffs associated with an false-negative rate ≤10% were 5, 1, and 0 for National Institute of Health Stroke Scale, Rapid Arterial Occlusion Evaluation Scale, and Cincinnati Prehospital Stroke Severity Scale, respectively. Using published cutoffs for triage would result in a loss of opportunity for ≥20% of patients with large-artery occlusion who would be inappropriately sent to a center lacking neurointerventional facilities. Conversely, using cutoffs reducing the false-negative rate to 10% would result in sending almost every patient to a comprehensive stroke center. Our findings, therefore, suggest that intracranial arterial imaging should be performed in all patients with acute ischemic stroke presenting within 6 hours of symptom onset.

Delay in presentation of acute ischemic stroke in Lahore General Hospital, Lahore

Objectives: To find out the time interval from onset of the symptoms to admission in the hospital of patients suffering from acute ischemic stroke, in order to assess the feasibility of thrombolytic therapy in Lahore General Hospital. Design: Hospital-based, prospective and observational study Setting: Lahore General Hospital Lahore. Duration: Six months from January - June 2004. Patients: Seventy two patients with acute ischemic stroke diagnosed on basis of clinical findings and CT scan. Methods: Patients o f a cute ischemic stroke including cerebral infarct, T IA, venous infarct and lacunar infarct were diagnosed on basis of clinical history, examination and CT scan and enrolled in the study. Data was collected on a Performa. Time taken by patients to reach hospital after onset of symptoms, distance of patients` residences from hospital, education level of patients and time required to do a CT scan after arrival of patient in hospital were studied. Results: 54.2% were male and mean age of patients was 60 years. 58 patients had cerebral infarction, TIA`s and venous infarction were 8 and 6 respectively. Delay in presentation was divided in three groups. Within three hours (hrs) 15 (21%) patients arrived. 54 and 18 patients arrived in 3-- 24 hrs group and &gt;24 firs group. Mean distance was roughly 44 km. Mean distance for 0-3hrs, 3-24hrs and &gt;24hrs group was 14, 35, and 85 Km respectively. Average time required to do CT scan was nine hours after arrival of patient in emergency department. Sixty-five percent of patients coming were illiterate. Conclusion: Majority of the patients with ischemic stroke present late to. emergency department. Many factors including distance from hospital, illiteracy, non-availability of ambulance services responsible for it. Evaluation-of patients and provision of urgent CT scan is required. in hospitals.

Abstract WMP73: Interictal Epileptiform Discharges and Periodic Patterns After Acute Ischemic Stroke Are Associated With Poor Prognosis

Introduction: Seizures after acute ischemic stroke lead to a worse functional outcome. Interictal epileptiform discharges (IED) and periodic patterns (PP) after ischemic stroke increase the risk of seizures. However, their prognostic significance has not been assessed. Hypothesis: We sought to test whether IED and PP, detected on standard EEG performed during the acute phase of ischemic stroke are associated with a worse functional outcome. Methods: One-hundred-fifty-seven patients 18 years or older with a diagnosis of acute ischemic stroke presenting within 72 hours from stroke onset were prospectively enrolled and followed. Patients with a pre-stroke history of seizures or epilepsy, previous debilitating neurological disease or conditions that precluded the performance of EEG were excluded. Interpretation was performed by a board certified neurophysiologist blinded to clinical data. IED and PP (grouped as epileptiform activity - EA) were defined according to proposed guidelines. Univariable and multivariable analysis were used to identify predictors of outcome (modified Rankin Scale dichotomized ≤ 2 vs. ≥ 3) at 3 months. Results: In the univariable analysis, admission NIHSS (OR 1.20, 95% CI 1.12-1.28, p=0.001), age (OR 1.03, 95% CI 1.01-1.05, p=0.02) and presence of EA (OR 2.94, 95% CI 1.51-5.88, p=0.001) were significantly associated with the outcome at 3 months. In the multivariable analysis, only admission NIHSS (OR 1.19, 95% CI 1.11-1.28, p&lt;0.001) and the presence of EA (OR 2.27, 95% CI 1.04-5.00, p=0.04) were independently associated with the prognosis. Conclusion: The importance of EEG in the prognosis of acute ischemic stroke warrants additional research examining the role of medication therapy on the outcome and the occurrence of seizures for those patients with specific EEG patterns.

Paradigm shift in the management of Acute Ischemic stroke

The management of acute ischemic stroke has undergone a dramatic change following the introduction of recombinant tissue plasminogen activator in 1996. Since then there have been a number of trials to studying the efficacy of endovascular treatment in acute ischemic stroke as well. These trials have proved a clear benefit of endovascular treatment in acute ischemic stroke in those patients with a large vessel occlusion. 60-70% of the patients had a good outcome at the end of three months. Current guidelines state that patients with acute ischemic stroke presenting in the window period of 4.5 hours should be considered for thrombolysis. A baseline imaging with a CT Brain along with CT Angiogram of neck and intracranial vessels should be done. If there is no contraindications for IV TPA patients should receive the same. If there is evidence of a large vessel occlusion on the CT Angiogram the patient should be considered for endovascular treatment along with IVT. The window for endovascular treatment can be extended up to 6 hours. In this article we have reviewed all the major trials in the management of acute ischemic stroke from the TPA trials to the latest endovascular trials.

What is the Role for Intra-Arterial Therapy in Acute Stroke Intervention?

Intravenous recombinant tissue plasminogen activator continues to be first-line therapy for patients with acute ischemic stroke presenting within the appropriate time window, but one potential limitation is the low rate of recanalization in the setting of large artery occlusions. Intra-arterial (IA) treatment is effective for emergency revascularization of proximal intracranial arterial occlusions, but proof of benefit has been lacking until recently. Our goal is to outline the history of endovascular therapy and review both IA thrombolysis and mechanical interventions. In addition, we will discuss the impact of important trials such as the Third Interventional Management of Stroke (IMS3) trial, and the more recent trials Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE), Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial (EXTEND-IA), and Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) on acute stroke management and the implications for the practicing neurohospitalist.

Intravenous thrombolysis for acute stroke: current standards and future directions.

Intravenous thrombolysis with the recombinant tissue plasminogen activator alteplase is the standard of care for patients with acute ischaemic stroke presenting within 4.5h of symptom onset. The odds of independent survival decline steeply with longer time to treatment delivery, reflecting progressive ischaemic damage to the brain. Standards accordingly emphasise optimisation of patient pathways to minimise treatment delays. Observational data and international clinical guidelines support the safety and efficacy of alteplase in many patient groups currently excluded from treatment (e.g. seizure at onset, concomitant diabetes and previous stroke) on the basis of historical clinical trial criteria. Future evolution of thrombolysis will optimise dosing, apply advanced imaging to extend treatment to groups currently excluded and investigate novel drugs, and adjunctive drug and device therapies. To date, trials of novel therapeutic approaches that have been applied at later time points have failed to demonstrate benefit, suggesting that the future gains are likely to arise from applications within current time windows.

Acute ischemic stroke in young adults-a hospital based study in North India

Objectives: To see the risk factors, clinical presentations and radiological profile of acute ischemic stroke in young adults in a tertiary-care hospital of North India. Methods: This study was conducted among 50 acute ischemic stroke patients (clinically and radiologically confirmed) irrespective of sex within the age group of 15-45 years admitted to Department of Medicine (Emergency Unit) after getting clearance from Institutional Ethical Committee (IEC). A proforma for each of the acute ischemic stroke patients was maintained where all clinical information in brief including particulars of the subject, chief complaints, past history, proper general physical examination and systemic examinations etc were recorded. The patients had been undergone plain CT (computed tomography) scan/MRI (Magnetic Resonance Imaging) brain on admission for radiological confirmation and to localize the site of lesion in brain. Results: Hypertension (56%) was the most common risk factor among acute ischemic stroke in young adults, followed by heart disease (54%). Majority of the acute ischemic stroke patients presented with hemiplegia (84%). Beside, imaging findings confirmed left sided brain lesion in majority of the patients (52%) and anterior circulation as the most common territory involved in the brain. Conclusions: Hypertension is very common among the young acute ischemic stroke patients. Most common clinical presentation is hemiplegia. Thus, the knowledge of the risk factors, clinical presentation and radiological findings of acute ischemic stroke in young adults can help in prevention, better understanding and therapeutic decision making in the disease management.

Abstract W P293: Opportunities For Interventions In Stroke-Dizziness Presentations: A Prospective Single Center Surveillance Study

Objective: Ischemic stroke can be a diagnostic dilemma in presentations of acute dizziness and increased resources will likely be required to reduce instances of misdiagnosis. To inform the potential value of the deployment of increased resources, we sought to describe opportunities for therapeutic interventions from a series of acute dizziness-stroke patients who had diagnostic uncertainty (i.e., only mild or no general neurologic deficits) on presentation. Methods: Active and passive surveillance methods were used at a tertiary care center to identify acute dizziness patients with nystagmus or imbalance, excluding those with benign paroxysmal positional vertigo, medical causes, or moderate-to-severe neurologic deficits. Stroke was defined as any acute infarction on a clinical or research MRI performed within 14 days of dizziness onset. Results: From November 21, 2009, to March 29, 2013, we identified 26 patients with acute ischemic stroke presenting with dizziness and either mild or no general neurologic deficits. Infarction volume was small (&lt;1cm3) in 19 (73%), moderate (≥1-&lt;10cm3) in 2 (8%), and large (&gt;10cm3) in 5 (19%). The proportion of cases arriving within 3, 4.5, and 6 hours of symptom onset was 38% (10), 38% (10), and 46% (12). Two cases were treated with thrombolysis. Half of all cases were already prescribed a statin medication at the time of presentation and 42% (11) were already prescribed an antiplatelet or anticoagulant. One patient met clinical eligibility for sub-occipital craniectomy. Three patients were discharged to a skilled nursing facility (1) or acute rehabilitation (2), whereas the majority (22; 85%) were discharged home. Conclusion: In this single center study which used rigorous surveillance and imaging-based methods to capture cases of acute dizziness-ischemic stroke with only mild or no general neurologic deficits, we found that a minority of patients met time requirements for acute treatments, nearly half were already on secondary prevention medications, and the majority did not require discharge to a skilled nursing facility or acute rehabilitation.

Low Ankle Brachial Index in Acute Ischemic Stroke: Does ApoE Gene Polymorphism Have a Role?

Background: The existence of asymptomatic peripheral arterial disease among patients with acute ischemic stroke has been studied and proved. Low ankle brachial index (ABI) is considered as a marker of atherosclerosis, and its relation to stroke severity was documented in some studies. The effect of different alleles of ApoE gene on acute ischemic stroke presentation in patients with low ABI is not known. Objective: To study the effect of ApoE gene polymorphism on stroke severity, outcome and recurrence in patients with asymptomatic peripheral arterial disease identified by low ABI. Methods: Patients with acute ischemic stroke were screened for the presence of asymp-tomatic peripheral arterial disease by estimating the ABI using a pocket Doppler ultrasound device. Assay of ApoE gene was done using the real-time PCR technique. Results: Low ABI was present in 31% of patients with acute ischemic stroke. There was no significant difference among patients with different ApoE alleles regarding the severity of their symptoms. Also, there was no significant difference among patients with normal ABI and those with abnormal ABI regarding the ApoE gene polymorphism. Conclusion: The current study showed that there was no significant relation between ApoE gene polymorphism and low ABI in ischemic stroke patients who had asymptomatic peripheral arterial disease.

Alteplase in acute ischemic stroke: putting the guidelines into practice.

Intravenous recombinant tissue plasminogen activator (rt-PA or alteplase) is the only approved medical intervention for treatment of acute ischemic stroke within the first hours of symptom onset. In this article, we review the preliminary studies of rt-PA in acute ischemic stroke that led to US FDA approval of its use within 3 h of symptom onset. The studies on rt-PA for use beyond 3 h of symptom onset and future reperfusion therapies are discussed. Overviews of the clinical presentation and treatment of acute ischemic stroke and stroke systems of care are described.

A Clinical Presentation of Tumefactive Multiple Sclerosis Mimicking Acute Ischemic Stroke on MRI

Tumefactive multiple sclerosis (MS) is characterized by a magnetic resonance imaging (MRI) finding of a large, inflammatory demyelinating lesion with or without contrast enhancement. The description of non-tumefactive MS lesions is well established for a variety of MRI sequences; however, explanation of MRI characteristics for tumefactive MS lesions is limited. The findings on diffusion weighted imaging and apparent diffusion coefficient in active MS plaques are well known, but little is known about these sequences in tumefactive MS. There is data to support the use of diffusion tensor imaging (DTI) in addition to basic MR sequences when differentiating tumefactive MS from other lesions such as non-tumefactive MS plaques. The patient in this case report presented with an acute right-sided hemiparesis with a discrete hypodensity on head computer tomography, which was thought to be an ischemic stroke. The initial MRI examination showed a finding that could be consistent with ischemic stroke having decreased apparent diffusion coefficient and increased diffusion restriction. However, a subsequent MRI examination clearly revealed a demyelinating process through development of other white matter lesions. The study attempts to underline that tumefactive demyelinating disease can mimic the clinical and imaging presentation of acute ischemic stroke; therefore, cautious interpretation with clinical correlation is required for correct diagnosis.