ECG predictors of AF: A systematic review (predicting AF in ischaemic stroke-PrAFIS).

In 25% of patients presenting with embolic stroke, a cause is not determined. Atrial fibrillation (AF) is a commonly identified mechanism of stroke in this population, particularly in older patients. Conventional investigations are used to detect AF, but can we predict AF in this population and generally? We performed a systematic review to identify potential predictors of AF on 12-lead electrocardiogram (ECG). METHOD: We conducted a search of EMBASE and Medline databases for prospective and retrospective cohorts, meta-analyses or case-control studies of ECG abnormalities in sinus rhythm predicting subsequent atrial fibrillation. We assessed quality of studies based on the Newcastle-Ottawa scale and data were extracted according to PRISMA guidelines. RESULTS: We identified 44 studies based on our criteria. ECG patterns that predicted the risk of developing AF included interatrial block, P-wave terminal force lead V1, P-wave dispersion, abnormal P-wave-axis, abnormal P-wave amplitude, prolonged PR interval, left ventricular hypertrophy, QT prolongation, ST-T segment abnormalities and atrial premature beats. Furthermore, we identified that factors such as increased age, high CHADS-VASC, chronic renal disease further increase the positive-predictive value of some of these parameters. Several of these have been successfully incorporated into clinical scoring systems to predict AF. CONCLUSION: There are several ECG abnormalities that can predict AF both independently, and with improved predictive value when combined with clinical risk factors, and if incorporated into clinical risk scores. Improved and validated predictive models could streamline selection of patients for cardiac monitoring and initiation of oral anticoagulants.

Factors influencing the successful implementation of a novel digital health application to streamline multidisciplinary communication across multiple organisations for emergency care.

RATIONALE: Delivering optimal patient health care requires interdisciplinary clinician communication. A single communication tool across multiple pre-hospital and hospital settings, and between hospital departments is a novel solution to current systems. Fit-for-purpose, secure smartphone applications allow clinical information to be shared quickly between health providers. Little is known as to what underpins their successful implementation in an emergency care context. AIMS: To identify (a) whether implementing a single, digital health communication application across multiple health care organisations and hospital departments is feasible; (b) the barriers and facilitators to implementation; and (c) which factors are associated with clinicians' intentions to use the technology. METHODS: We used a multimethod design, evaluating the implementation of a secure, digital communication application (Pulsara™). The technology was trialled in two Australian regional hospitals and 25 Ambulance Victoria branches (AV). Post-training, clinicians involved in treating patients with suspected stroke or cardiac events were administered surveys measuring perceived organisational readiness (Organisational Readiness for Implementing Change), clinicians' intentions (Unified Theory of Acceptance and Use of Technology) and internal motivations (Self-Determination Theory) to use Pulsara™, and the perceived benefits and barriers of use. Quantitative data were descriptively summarised with multivariable associations between factors and intentions to use Pulsara™ examined with linear regression. Qualitative data responses were subjected to directed content analysis (two coders). RESULTS: Participants were paramedics (n = 82, median 44 years) or hospital-based clinicians (n = 90, median 37 years), with organisations perceived to be similarly ready. Regression results (F(11, 136) = 21.28, p = <0.001, Adj R2 = 0.60) indicated Habit, Effort Expectancy, Perceived Organisational Readiness, Performance Expectancy and Organisation membership (AV) as predictors of intending to use Pulsara™. Themes relating to benefits (95% coder agreement) included improved communication, procedural efficiencies and faster patient care. Barriers (92% coder agreement) included network accessibility and remembering passwords. PulsaraTM was initiated 562 times. CONCLUSION: Implementing multiorganisational, digital health communication applications is feasible, and facilitated when organisations are change-ready for an easy-to-use, effective solution. Developing habitual use is key, supported through implementation strategies (e.g., hands-on training). Benefits should be emphasised (e.g., during education sessions), including streamlining communication and patient flow, and barriers addressed (e.g., identify champions and local technical support) at project commencement.

Predicting risk of AF in ischaemic stroke using sinus rhythm ECG abnormalities: A meta-analysis.

OBJECTIVE: To identify ECG changes in sinus rhythm that may be used to predict subsequent development of new AF. METHOD: We identified prospective and retrospective cohort or case control studies evaluating ECG patterns from a 12-lead ECG in sinus rhythm taken in hospital or community predicting subsequent development of new AF. For each identified ECG predictor, we then identify absolute event rates and pooled risk ratios (RR) using an aggregate level random effects meta-analysis. RESULTS: We identified 609,496 patients from 22 studies. ECG patterns included P wave terminal force V1 (PTFV1), interatrial block (IAB) and advanced interatrial block (aIAB), abnormal P wave axis (aPWA), PR prolongation and atrial premature complexes (APCs). Pooled risk ratios reached significance for each of these; PTFV1 RR 1.48 (95% CI 1.04-2.10), IAB 2.54 (95% CI 1.64-3.93), aIAB 4.05 (95% CI 2.64-6.22), aPWA 1.89 (95% CI 1.25-2.85), PR prolongation 2.22 (95% CI 1.27-3.87) and APCs 3.71 (95% CI 2.23-6.16). Diabetes reduced the predictive value of PR prolongation. CONCLUSION: APC and aIAB were most predictive of AF, while IAB, PR prolongation, PTFV1 and aPWA were also significantly associated with development of AF. These support their use in a screening tool to identify at risk cohorts who may benefit from further investigation, or following stroke, with empirical anticoagulation.

Cerebral amyloid angiopathy related inflammation: An under recognized but treatable complication of cerebral amyloid angiopathy.

Cerebral amyloid angiopathy-related inflammation (CAA-ri) is a subset of cerebral amyloid angiopathy (CAA) causing a reversible encephalopathy characterized by seizures and focal neurological deficit. Previously, biopsy was required to make this diagnosis, distinct radiological features have allowed development for clinicoradiological criteria to assist in diagnosis. CAA-ri is an important condition to recognize as patients respond to high dose corticosteroids with significant resolution of symptoms. A 79-year-old woman presents with new onset seizures and delirium with prior history of mild cognitive impairment. An initial computed tomography (CT) brain demonstrated vasogenic oedema in the right temporal lobe, and magnetic resonance imaging (MRI) showed bilateral subcortical white matter change and multiple microhemorrhages. The MRI findings were suggestive of cerebral amyloid angiopathy. Cerebrospinal fluid analysis demonstrated raised protein and oligoclonal bands. A thorough septic and autoimmune screen demonstrated no abnormality. Following a multidisciplinary discussion, a diagnosis of CAA-ri was made. She was commenced on dexamethasone and her delirium improved. CAA-ri is an important diagnostic consideration in an elderly patient who presents with new seizures. Clinicoradiological criteria are useful diagnostic tools and may avoid the need for invasive histopathological diagnosis.

The Malay version of the attitudes and beliefs about cardiovascular disease (ABCD-M) risk questionnaire: a translation, reliability and validation study.

BACKGROUND: Cardiovascular disease (CVD) and stroke are global public health problems and cause high mortality, especially in low- and middle-income countries. Knowledge and awareness are critical points in managing the risk in the general population. The Attitudes and Beliefs about Cardiovascular Disease (ABCD) risk questionnaire was developed to evaluate the awareness of stroke and CVD risk. Thus, the government can set up a practical risk assessment and management programme. The initiative will encourage people to seek healthcare timely and reduce the possibilities of developing complications. OBJECTIVE: This study aimed to translate and validate the ABCD risk questionnaire into the Malay language and evaluate the psychometric properties of the Malay version in the general population in Malaysia. METHODS: The questionnaire was translated using a standard forward-backwards translation method. The validation was perfomed by both expert panels and a potential user group. Next, the exploratory factor analysis was conducted to examine factorial validity. The respondents were selected from the government health clinics and according to the study criteria irrespective of the CVD risk. We used Cronbach's alpha and Raykov's rho to explore the internal consistency and composite reliability of the 18 items from three domains. Finally, the confirmatory factor analysis (CFA) was conducted using a robust maximum likelihood estimator. RESULTS: The content and face validity indices were determined to be 0.94 and 0.99 respectively. Data were obtained from 179 respondents (mean age, 36.8 years; female, 68.2%; secondary level education, 51.1%). The internal consistency and composite reliability of the domains showed good results ranging from 0.643 to 0.885. The factor loadings of each item were acceptable (> 0.3), and the fit indices from the CFA resulted in a good model fit [χ2 (p-value = 0.16), SRMR = 0.054, RMSEA = 0.029, CFI = 0.99, TLI = 0.99)]. CONCLUSIONS: The Malay version of the ABCD risk questionnaire is a valid and reliable tool to assess the awareness of stroke and CVD risk in the general population in Malaysia.

Real-world, feasibility study to investigate the use of a multidisciplinary app (Pulsara) to improve prehospital communication and timelines for acute stroke/STEMI care.

OBJECTIVES: To determine if a digital communication app improves care timelines for patients with suspected acute stroke/ST-elevation myocardial infarction (STEMI). DESIGN: Real-world feasibility study, quasi-experimental design. SETTING: Prehospital (25 Ambulance Victoria branches) and within-hospital (2 hospitals) in regional Victoria, Australia. PARTICIPANTS: Paramedics or emergency department (ED) clinicians identified patients with suspected acute stroke (onset <4.5 hours; n=604) or STEMI (n=247). INTERVENTION: The Pulsara communication app provides secure, two-way, real-time communication. Assessment and treatment times were recorded for 12 months (May 2017-April 2018), with timelines compared between 'Pulsara initiated' (Pulsara) and 'not initiated' (no Pulsara). PRIMARY OUTCOME MEASURE: Door-to-treatment (needle for stroke, balloon for STEMI) Secondary outcome measures: ambulance and hospital processes. RESULTS: Stroke (no Pulsara n=215, Pulsara n=389) and STEMI (no Pulsara n=76, Pulsara n=171) groups were of similar age and sex (stroke: 76 vs 75 years; both groups 50% male; STEMI: 66 vs 63 years; 68% and 72% male). When Pulsara was used, patients were off ambulance stretcher faster for stroke (11(7, 17) vs 19(11, 29); p=0.0001) and STEMI (14(7, 23) vs 19(10, 32); p=0.0014). ED door-to-first medical review was faster (6(2, 14) vs 23(8, 67); p=0.0001) for stroke but only by 1 min for STEMI (3 (0, 7) vs 4 (0, 14); p=0.25). Door-to-CT times were 44 min faster (27(18, 44) vs 71(43, 147); p=0.0001) for stroke, and percutaneous intervention door-to-balloon times improved by 17 min, but non-significant (56 (34, 88) vs 73 (49, 110); p=0.41) for STEMI. There were improvements in the proportions of patients treated within 60 min for stroke (12%-26%, p=0.15) and 90 min for STEMI (50%-78%, p=0.20). CONCLUSIONS: In this Australian-first study, uptake of the digital communication app was strong, patient-centred care timelines improved, although door-to-treatment times remained similar.

Diabetes in ischaemic stroke in a regional Australian hospital: uncharted territory.

BACKGROUND: Stroke and diabetes mellitus (DM) are significant interrelated healthcare issues but there is a dearth of data on the prevalence of DM among Australia's regional stroke population. AIMS: We aimed to determine the prevalence of DM in stroke patients at a large regional centre, including subanalyses on stroke subtypes, glycaemic control and renal function in ischaemic stroke (IS). METHODS: We conducted a retrospective analysis of all patients (n = 323) with IS or transient ischaemic attack (TIA) admitted to Ballarat Base Hospital from January 2015 to December 2016. Demographic data, cardiovascular risk factors, aetiology/territory of IS, pre-morbid DM status, indicators of glycaemic control and renal impairment were recorded. RESULTS: DM was present in 28.5% of IS and TIA patients, including 4% being newly diagnosed. Among diabetic IS patients, 45.3% had poor glycaemic control (HbA1c ≥7.0%) while 16% had moderate to severe renal impairment (estimated glomerular filtration rate of <30). The majority of IS were partial anterior circulation stroke (53.4%) and cardioembolism was the commonest mechanism (43.5%). We found no significant association between DM and a specific stroke location or mechanism. CONCLUSIONS: Almost one-third of IS/TIA patients had DM, with a significant proportion showing poor glycaemic control. The DM prevalence in our cohort was comparable with reported rates from other developed countries. Although we found no association between DM and a particular stroke type or mechanism, it is likely a reflection of our cohort size. Our study demonstrated that DM, as a significant risk factor in IS, warrants early detection and better management strategies.

The Effectiveness of Stroke Riskometer™ in Improving Stroke Risk Awareness in Malaysia: A Study Protocol of a Cluster-Randomized Controlled Trial.

BACKGROUND: Stroke is considered the second leading cause of mortality and disability worldwide. The increasing burden of stroke is strong evidence that currently used primary prevention strategies are not sufficiently effective. The Stroke Riskometer™ application (app) represents a new stroke prevention strategy distinctly different from the conventional high-cardiovascular disease risk approach. OBJECTIVE: This proposed study aims to evaluate the effectiveness of the Stroke Riskometer™ app in improving stroke awareness and stroke risk probability amongst the adult population in Malaysia. METHODS: A non-blinded, parallel-group cluster-randomized controlled trial with a 1:1 allocation ratio will be implemented in Kelantan, Malaysia. Two groups with a sample size of 66 in each group will be recruited. The intervention group will be equipped with the Stroke Riskometer™ app and informational leaflets, while the control group will be provided with standard management, including information leaflets only. The Stroke Riskometer™ app was developed according to the self-management model of chronic diseases based on self-regulation and social cognitive theories. Data collection will be conducted at baseline and on the third week, sixth week, and sixth month follow-up via telephone interview or online questionnaire survey. The primary outcome measure is stroke risk awareness, including the domains of knowledge, perception, and intention to change. The secondary outcome measure is stroke risk probability within 5 and 10 years adjusted to each participant's socio-demographic and/or socio-economic status. An intention-to-treat approach will be used to evaluate these measures. Pearson's χ2 or independent t test will be used to examine differences between the intervention and control groups. The generalized estimating equation and the linear mixed-effects model will be employed to test the overall effectiveness of the intervention. CONCLUSION: This study will evaluate the effect of Stroke Riskometer™ app on stroke awareness and stroke probability and briefly evaluate participant engagement to a pre-specified trial protocol. The findings from this will inform physicians and public health professionals of the benefit of mobile technology intervention and encourage more active mobile phone-based disease prevention apps. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT04529681.

Horner's syndrome secondary to internal carotid artery occlusion.

Horner's syndrome results from interruption of the sympathetic innervation to the eye. This interruption may occur at three anatomical levels along the sympathetic trunk pathway. There are numerous causes of Horner's syndrome, including injury to the carotid artery, of which arterial dissection is the commonest pathology. Occlusive carotid disease secondary to atherosclerosis is a relatively rare cause of Horner's syndrome. We describe a patient with Horner's syndrome due to complete occlusion of the ipsilateral internal carotid artery.

CT brain image advancement for ICH diagnosis.

A critical step in detection of primary intracerebral haemorrhage (ICH) is an accurate assessment of computed tomography (CT) brain images. The correct diagnosis relies on imaging modality and quality of acquired images. The authors present an enhancement algorithm which can improve the clarity of edges on CT images. About 40 samples of CT brain images with final diagnosis of primary ICH were obtained from the UKM Medical Centre in Digital Imaging and Communication in Medicine format. The images resized from 512 × 512 to 256 × 256 pixel resolution to reduce processing time. This Letter comprises of two main sections; the first is denoising using Wiener filter, non-local means and wavelet; the second section focuses on image enhancement using a modified unsharp masking (UM) algorithm to improve the visualisation of ICH. The combined approach of Wiener filter and modified UM algorithm outperforms other combinations with average values of mean square error, peak signal-to-noise ratio, variance and structural similarity index of 2.89, 31.72, 0.12 and 0.98, respectively. The reliability of proposed algorithm was evaluated by three blinded assessors which achieved a median score of 65%. This approach provides reliable validation for the proposed algorithm which has potential in improving image analysis.

Prevalence and risk factors of ischaemic stroke in the young: a regional Australian perspective.

BACKGROUND: There is no universally accepted age cut-off for defining young strokes. AIMS: We aimed to determine, based on the profile of young stroke patients in our regional centre, an appropriate age cut-off for young strokes. METHODS: A retrospective analysis of all ischaemic stroke patients admitted to our centre from 2015 to 2017. We identified 391 ischaemic stroke patients; 30 patients between the ages of ≤50, 40 between 51-60 inclusive and 321 ≥ 61 years of age. We collected data on demographic profiles, risk factors and stroke classification using the Trial of Org 10 172 in Acute Stroke Treatment criteria. RESULTS: We found significant differences between the ≤50 and ≥61 age groups for most of the risk factors and similarities between the 51-60 inclusive and ≥ 61 age groups. At least one of the six risk factors assessed in the study was present in 86.7% of the youngest group, 97.5% of the intermediate age group and 97.2% in the oldest group. In terms of the mechanisms of stroke, the youngest and oldest age groups in our study differed in the prevalence of cryptogenic, cardioembolic and other causes of stroke. The middle and older age groups had similar mechanisms of stroke. CONCLUSIONS: The prevalence of vascular risk factors and mechanisms of stroke likewise differed significantly across age groups. This study suggests that 50 years is an appropriate age cut-off for defining young strokes and reinforces the importance of primary prevention in all age groups.

How can the World Stroke Organization (WSO) optimize education in stroke medicine around the world? Report of the 2018 WSO Global Stroke Stakeholder Workshop.

BACKGROUND: Education in stroke is relevant to stroke survivors, clinicians, care providers, and healthcare system administrators and is of special importance in resource-limited settings. The World Stroke Organization Education Committee undertook a program of work, culminating in a focused workshop, to establish the key educational priorities, and work toward maximizing the WSOs impact on the global burden of stroke. METHODS: A facilitated workshop took place during the World Stroke Congress in Montreal, Canada in October 2018. The workshop was developed using opinions on priority topics for World Stroke Organization educational activities obtained from web-based surveys of World Stroke Organization Members, supplemented by interviews with international stroke support organizations. The workshop included over 50 international participants, selected to represent a balance of age, gender, geographical region, and different levels of health resources. Participants also included members of the World Stroke Organization Education Committee, the World Stroke Academy, stroke support organizations, and the International Journal of Stroke editorial board. The workshop focused on understanding more about educational needs (at all levels), with emphasis on resource-limited settings. Three broad questions were posed: (1) What are the key educational needs: (a) in your region, (b) from your perspective (e.g. stroke support organization)? (2) Do the current educational activities offered by World Stroke Organization and WSA meet your needs? (3) What could World Stroke Organization/World Stroke Academy offer in your region that would meet your needs? The facilitated discussions were recorded, and the results transcribed and summarized by members of the World Stroke Organization Education Committee. RESULTS: Five key needs were identified: 1. Collaborative interdisciplinary, training in both stroke care and how to advocate for stroke. 2. Educational materials provided in a wider range of formats that could be adapted to local circumstances and clinical practices. 3. Educational activities for healthcare providers and stroke support organizations organized regionally, with the World Stroke Organization providing organizational support, and a pool of experts, therapists, nurses, etc. to deliver locally relevant materials. 4. Clear and authoritative online resources, where it is easy to find key policy and protocol guidance. 5. A range of online interactive education and training resources to help build knowledge and competence in stroke care. CONCLUSION: The results of the workshop have been presented to the World Stroke Organization Board and will be used to help to guide the educational initiatives of the World Stroke Organization and World Stroke Academy going forward.

Stroke in malignancy: complexities of diagnosis and management: a case report.

BACKGROUND: Although there is an established association between cancer and stroke, the role of malignancy as a causative agent or comorbidity is not always clear. Moreover, there are no established guidelines on the acute treatment of cancer-associated stroke or optimal anticoagulation. This case report illustrates the significance of these practice gaps. CASE PRESENTATION: A 62-year-old Caucasian woman presented to our institute with acute neurological deficits and was found to have an occluded left middle cerebral artery on a computed tomographic angiogram. She was administered intravenous alteplase and underwent unsuccessful endovascular clot retrieval. Besides smoking and her age, she had no cerebrovascular risk factors, and the results of baseline investigations for the cause of stroke were negative. Subsequent computed tomography of the chest, abdomen, and pelvis showed metastatic malignancy, and in the context of a significantly elevated serum cancer antigen 19-9, we suspected a pancreatic primary cancer. A transthoracic echocardiogram demonstrated mitral regurgitation but no visible vegetation. The patient died of her illness. We made a diagnosis of cancer-associated stroke, specifically a likely case of nonbacterial thrombotic endocarditis. CONCLUSIONS: This case highlights the importance of having a high threshold of suspicion for malignancy as a cause of stroke.

Rheumatoid meningitis: a rare cause of unilateral pachymeningitis.

An 87-year-old woman with quiescent rheumatoid arthritis, not on immunosuppressive therapy, presented with unilateral arm weakness, confusion and visual hallucinations. There were no infective symptoms or history of malignancy. Cerebrospinal fluid (CSF) analysis demonstrated lymphocytosis and raised protein, without flow cytometric or cytological abnormalities. Viral, bacterial, mycobacterial and fungal testing of CSF and serum were negative. MRI brain indicated unilateral leptomeningeal enhancement. There was no evidence of occult malignancy on CT imaging of the chest, abdomen and pelvis. Rheumatoid factor and anticyclic citrullinated peptide were strongly positive. The patient declined meningeal biopsy but responded to treatment with corticosteroid therapy.

Strategies to Improve Stroke Care Services in Low- and Middle-Income Countries: A Systematic Review.

BACKGROUND: The burden of stroke in low- and middle-income countries (LMICs) is large and increasing, challenging the already stretched health-care services. AIMS AND OBJECTIVES: To determine the quality of existing stroke-care services in LMICs and to highlight indigenous, inexpensive, evidence-based implementable strategies being used in stroke-care. METHODS: A detailed literature search was undertaken using PubMed and Google scholar from January 1966 to October 2015 using a range of search terms. Of 921 publications, 373 papers were shortlisted and 31 articles on existing stroke-services were included. RESULTS: We identified efficient models of ambulance transport and pre-notification. Stroke Units (SU) are available in some countries, but are relatively sparse and mostly provided by the private sector. Very few patients were thrombolysed; this could be increased with telemedicine and governmental subsidies. Adherence to secondary preventive drugs is affected by limited availability and affordability, emphasizing the importance of primary prevention. Training of paramedics, care-givers and nurses in post-stroke care is feasible. CONCLUSION: In this systematic review, we found several reports on evidence-based implementable stroke services in LMICs. Some strategies are economic, feasible and reproducible but remain untested. Data on their outcomes and sustainability is limited. Further research on implementation of locally and regionally adapted stroke-services and cost-effective secondary prevention programs should be a priority.

Positron Emission Tomographic Imaging in Stroke: Cross-Sectional and Follow-Up Assessment of Amyloid in Ischemic Stroke.

BACKGROUND AND PURPOSE: Cardiovascular risk factors significantly increase the risk of developing Alzheimer disease. A possible mechanism may be via ischemic infarction-driving amyloid deposition. We conducted a study to determine the presence of ß-amyloid in infarct, peri-infarct, and hemispheric areas after stroke. We hypothesized that an infarct would trigger ß-amyloid deposition, with deposition over time. METHODS: Patients were recruited within 40 days of acute ischemic stroke and imaged with computed tomographic or magnetic resonance imaging and Pittsburgh compound B (11C-PiB) positron emission tomographic scans. Follow-up positron emission tomographic scanning was performed in a subgroup ≤18 months after the stroke event. Standardized uptake value ratios for regions of interest were analyzed after coregistration. RESULTS: Forty-seven patients were imaged with (11)C-PiB positron emission tomography. There was an increase in (11)C-PiB accumulation in the stroke area compared with a reference region in the contralesional hemisphere, which was not statistically significant (median difference in standardized uptake value ratio, 0.07 [95% confidence interval, -0.06 to 0.123]; P=0.452). There was no significant increase in the accumulation of (11)C-PiB in the peri-infarct region or in the ipsilesional hemisphere (median difference in standardized uptake value ratio, 0.04 [95% confidence interval, -0.02 to 0.10]; P=0.095). We repeated (11)C-PiB positron emission tomography in 21 patients and found a significant reduction in accumulation of (11)C-PiB between regions of interest (median difference in standardized uptake value ratio, -0.08 [95% confidence interval, -0.23 to -0.03]; P=0.04). CONCLUSIONS: There was no significant increase in (11)C-PiB accumulation in or around the infarct. There was no increase in ipsilesional hemispheric (11)C-PiB accumulation over time. We found no evidence that infarction leads to sustained or increased ß-amyloid deposition ≤18 months after stroke.

Cerebral amyloid angiopathy: an important differential diagnosis of stroke in the elderly.

Cerebral amyloid angiopathy (CAA) accounts for approximately 10-20% of spontaneous intracerebral haemorrhage (ICH). This figure is thought to be higher in the elderly population. With the increasing life expectancy of our population, we anticipate that the prevalence of CAA- related ICH will increase in tandem. Although CAA-related ICH and hypertension-related ICH are distinct entities based on histopathology and imaging, the clinical presentation of the two conditions is similar. The use of brain computed tomography (CT) scans remain the ICH imaging modality of choice in Malaysia due to its availability, cost, and sensitivity in detecting acute bleeds. On the other hand, the use of brain magnetic resonance imaging (MRI) with susceptibility-weighted imaging (SWI) sequencing enables the clinician to determine the presence of chronic blood products in the brain, especially clinically silent microbleeds associated with CAA. However, the use of brain MRI scans in our country is limited and leads to a blurring of lines when differentiating between hypertension-related ICH and CAA-related ICH. How this misrepresentation affects the management of these conditions is unclear. In this study, we present two cases of ICH to illustrate this point and to serve as a springboard to question current practice and promote discussion.