Direct to Angiosuite in Acute Stroke with Mobile Stroke Unit.

BACKGROUND: Early reperfusion has the best likelihood for a favorable outcome in acute ischemic stroke (AIS) with large vessel occlusion (LVO). Our experience with mobile stroke unit (MSU) for direct to angiosuite (DTAS) transfer in AIS patients with suspected LVO is presented. METHODS: Retrospective review of prospectively collected data from November 2019 to August 2022, of patients evaluated and transferred by the University of Alberta Hospital MSU and moved to angiosuite for endovascular thrombectomy (EVT). RESULT: A total of 41 cases were included. Nine were chosen for DTAS and 32 were shifted to angiosuite after stopping for computed tomography (CT) angiography of the head and neck (no-DTAS). Stroke severity measured by NIHSS (median with interquartile range (IQR)) was higher in patients of DTAS, 22 (14-24) vs 14.5 (5-25) in no-DTAS (p = 0.001). The non-contrast CT head in MSU showed hyperdense vessels in 8 (88.88%) DTAS vs 11 (34.35%) no-DTAS patients (p = 0.003). The EVT timelines (median with IQR, 90th percentile) including "door to artery puncture time" were 31 (23-50, 49.2) vs 79 (39-264, 112.8) minutes, and "door to recanalization time" was 69 (49-110, 93.2) vs 105.5 (52-178, 159.5) minutes in DTAS vs no-DTAS group, respectively. The workflow times were significantly shorter in the DTAS group (p < 0.001). Eight (88.88%) out of 9 DTAS patients had LVO and underwent thrombectomy. CONCLUSIONS: MSU for DTAS in patients with high NIHSS scores, cortical signs, and CT showing hyperdense vessel is an effective strategy to reduce the EVT workflow time.

How to Define Fast and Slow Progressors in Any-Type Occlusion Acute Ischemic Stroke.

The variable rate of infarct progression in acute ischemic stroke as assessed by various thresholds excludes a substantial proportion of patients due to time or core constraints. We evaluated 106 patients with any-type occlusion to compare these thresholds and assessed performance of hypoperfusion index (HI) for fast and slow rate of infarct progression. Seven (12.5%) were classified fast progressors and 23 (46%), 25 (50%), 12 (24%), and 33 (66%) slow progressors using different core and time criteria. In comparison, HI categorized 100% (n = 106) of cohort with optimal cutoff 0.5 for any-type occlusion (slow progressors: HI ≤ 0.5), sensitivity/specificity 100%/91%, AUC 0.94, and indicative of eligibility for reperfusion and clinical outcomes (median 90-day modified Rankin Scale; 2 for HI ≤ 0.5 versus 5). Estimation of progressors by HI seems comprehensive but needs external validation.

Thrombolysis in Stroke Mimics: Comprehensive Stroke Centers vs Telestroke Sites.

BACKGROUND: Hyperacute treatment of acute stroke may lead to thrombolysis in stroke mimics (SM). Our aim was to determine the frequency of thrombolysis in SM in primary stroke centers (PSC) dependent on telestroke versus comprehensive stroke centers (CSC). METHOD: Retrospective review of prospectively collected data from the Quality improvement and Clinical Research (QuICR) registry, the Discharge Abstract Database (DAD), and The National Ambulatory Care Reporting System (NACRS) of consecutive patients treated with intravenous thrombolysis for acute ischemic stroke in Alberta (Canada) from April 2016 to March 2021. RESULT: A total of 2471 patients who received thrombolysis were included. Linking the QuICR registry to DAD 169 (6.83%) patients were identified as SM; however, on our review of the records, only 112 (4.53%) were actual SM. SMs were younger with a mean age of 61.66 (±16.15) vs 71.08 (±14.55) in stroke. National Institute of Health Stroke Scale was higher in stroke with a median (IQR) of 10 (5-17) vs 7 (5-10) in SM. Only one patient (0.89 %) in SM groups had a small parenchymal hemorrhage versus 155 (6.57%) stroke patients had a parenchymal hemorrhage. There was no death among patients of thrombolysed SM during hospitalization versus 276 (11.69%) in stroke. There was no significant difference in the rate of SM among thrombolysed patients between PSC 27 (5.36%) versus CSC 85 (4.3%) (P = 0.312). The most responsible diagnosis of SM was migraine/migraine equivalent, functional disorder, seizure, and delirium. CONCLUSION: The diagnosis of SM may not always be correct when the information is extracted from databases. The rate of thrombolysis in SM via telestroke is similar to treatment in person at CSC.

The Clinical Conundrum of Managing Ischemic Stroke in Patients with Immune Thrombocytopenia.

Guidelines are lacking for management of acute ischemic stroke and stroke prevention in patients with immune thrombocytopenia (ITP). Our aim is to highlight the dilemma inherent in managing patients with both significant bleeding and thrombotic risk factors. In this review, we present two patients with history of ITP who presented with acute ischemic stroke and received tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT), a rare management strategy in this patient population. In addition, we identified 27 case reports of ischemic stroke in patients with ITP; none of them received tPA or EVT. Furthermore, there are 92 patients with significant thrombocytopenia with no available data regarding the cause of thrombocytopenia, who were acutely treated with tPA or EVT. Conclusive evidence cannot be determined based on these limited number of cases. Future multicenter prospective cohort studies in patients with ITP are needed to provide better evidence-based treatment plans. At present, treatment of acute ischemic stroke in patients with ITP requires close collaboration between hematology and vascular neurology experts to find a balance between the benefit and risk of hemorrhagic complications.

Effect of Implantable vs Prolonged External Electrocardiographic Monitoring on Atrial Fibrillation Detection in Patients With Ischemic Stroke: The PER DIEM Randomized Clinical Trial.

Importance: The relative rates of detection of atrial fibrillation (AF) or atrial flutter from evaluating patients with prolonged electrocardiographic monitoring with an external loop recorder or implantable loop recorder after an ischemic stroke are unknown. Objective: To determine, in patients with a recent ischemic stroke, whether 12 months of implantable loop recorder monitoring detects more occurrences of AF compared with conventional external loop recorder monitoring for 30 days. Design, Setting, and Participants: Investigator-initiated, open-label, randomized clinical trial conducted at 2 university hospitals and 1 community hospital in Alberta, Canada, including 300 patients within 6 months of ischemic stroke and without known AF from May 2015 through November 2017; final follow-up was in December 2018. Interventions: Participants were randomly assigned 1:1 to prolonged electrocardiographic monitoring with either an implantable loop recorder (n = 150) or an external loop recorder (n = 150) with follow-up visits at 30 days, 6 months, and 12 months. Main Outcomes and Measures: The primary outcome was the development of definite AF or highly probable AF (adjudicated new AF lasting ≥2 minutes within 12 months of randomization). There were 8 prespecified secondary outcomes including time to event analysis of new AF, recurrent ischemic stroke, intracerebral hemorrhage, death, and device-related serious adverse events within 12 months. Results: Among the 300 patients who were randomized (median age, 64.1 years [interquartile range, 56.1 to 73.7 years]; 121 were women [40.3%]; and 66.3% had a stroke of undetermined etiology with a median CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, sex category] score of 4 [interquartile range, 3 to 5]), 273 (91.0%) completed cardiac monitoring lasting 24 hours or longer and 259 (86.3%) completed both the assigned monitoring and 12-month follow-up visit. The primary outcome was observed in 15.3% (23/150) of patients in the implantable loop recorder group and 4.7% (7/150) of patients in the external loop recorder group (between-group difference, 10.7% [95% CI, 4.0% to 17.3%]; risk ratio, 3.29 [95% CI, 1.45 to 7.42]; P = .003). Of the 8 specified secondary outcomes, 6 were not significantly different. There were 5 patients (3.3%) in the implantable loop recorder group who had recurrent ischemic stroke vs 8 patients (5.3%) in the external loop recorder group (between-group difference, -2.0% [95% CI, -6.6% to 2.6%]), 1 (0.7%) vs 1 (0.7%), respectively, who had intracerebral hemorrhage (between-group difference, 0% [95% CI, -1.8% to 1.8%]), 3 (2.0%) vs 3 (2.0%) who died (between-group difference, 0% [95% CI, -3.2% to 3.2%]), and 1 (0.7%) vs 0 (0%) who had device-related serious adverse events. Conclusions and Relevance: Among patients with ischemic stroke and no prior evidence of AF, implantable electrocardiographic monitoring for 12 months, compared with prolonged external monitoring for 30 days, resulted in a significantly greater proportion of patients with AF detected over 12 months. Further research is needed to compare clinical outcomes associated with these monitoring strategies and relative cost-effectiveness. Trial Registration: ClinicalTrials.gov Identifier: NCT02428140.

Variability in the therapeutic response of Metformin treatment in patients with type 2 diabetes mellitus.

OBJECTIVE: To assess the glycemic response of metformin in patients with Type-2 Diabetes Mellitus (T2DM) as well as to see its association with reductions in BMI and GIT intolerance. METHODS: This Quasi, Experimental study was conducted at Jinnah-Allama Iqbal Institute of Diabetes and Endocrinology (JAIDE) Jinnah Hospital, Lahore from 1st March 2016 to 30th September 2016. Newly diagnosed T2DM patients were given metformin for duration of three months and later on they were categorized into Responders and Non-Responders on the basis of HbA1c (A1C) reductions, which were estimated by Hemoglobin (A1C) analyzer (TD4611A TAIDoc Tech. Taiwan) through photometry. Similarly, baseline BMI and BMI after three months therapy with metformin was also recorded. RESULTS: Among total of 200 patients, 40.5% of the patients were classified as Non-Responders whereas; 59.5% of the patients as Responders. The baseline BMI (26.09 kg/m2) was also decreased significantly after metformin therapy (25.40 kg/m2). It was found that metformin reduced the A1C in all the patients. However, the glycemic control was much better in patients with higher baseline A1C (1.13% ± 0.08) as compared to lower baseline levels (0.61% ± 0.07). Regarding GIT intolerance, 140 patients lacked the symptoms, out of which 60.7% were responders and 39.3% were non-responders. CONCLUSIONS: Metformin lead to improvement in glycemic control in 59.5% of newly diagnosed T2DM patients after taking metformin for three months but in 40.5% it did not which may be because of combined effects of various gene polymorphisms and their interaction with non-genetic factors. Metformin reduced the BMI in all the patients; however, BMI lowering activity of metformin was same regardless of its effect on HbA1C. Moreover, the signs and symptoms of GIT intolerance did not differ between the two groups.

Endovascular Revascularization of a Symptomatic Common Carotid Artery Occlusion.

Although the common carotid artery is the second most common site for extracranial carotid artery stenosis, complete symptomatic occlusion in the absence of devastating stroke is rare. We present a case of complete common carotid artery occlusion failing medical management and requiring endovascular intervention. The clinical presentation, diagnostic investigations, and management of complete carotid artery occlusions are discussed.

Adrenal Insufficiency In Pakistani Hiv Infected Patients.

BACKGROUND: Adrenal insufficiency (AI) is the most common endocrine complication among patients with AIDS/HIV infection and there are number of causes of AI in HIV patients. Human immunodeficiency virus directly as well as indirectly destroys adrenal glands. The estimates of its prevalence and severity vary. AI is the most life threatening but readily correctable endocrine complication that occurs in persons with HIV infection. This study was carried out to determine the frequency of Adrenal Insufficiency in HIV patients and their clinical features as proper diagnosis and timely treatment have been shown to improve quality of life and long-term mortality in AIDS patients. METHODS: It was a cross sectional survey conducted at HIV clinic and Jinnah Allama Iqbal Institute of Diabetes and Endocrinology, Jinnah Hospital Lahore. Sixty-four HIV positive patients, both male and female, aged above 15 years were included in the study. HIV patients who had recently taken steroids, ketoconazole or rifampicin, determined on history, were excluded from the study. The data was collected on a structured proforma and analysis was performed in SPSS-21.0. Frequency and percentages for adrenal insufficiency and its characteristics were calculated. Chi-square test was used with p<0.05 as statistically significant. RESULTS: In this study, 9 (14.06%) HIV patients were diagnosed with adrenal insufficiency, male to female ratio was 3.5:1 and AI was found statistically significantly associated with fatigue (p<0.008) and weight loss (p<0.001). CONCLUSIONS: Adrenal insufficiency was high among the patients with HIV, it was not gender specific but it was found to be associated with fatigue and weight loss.

Dose Comparison And Side Effect Profile Of Metformin Extended Release Versus Metformin Immediate Release.

BACKGROUND: Diabetes Mellitus type 2 is very common worldwide, with majority of cases in Asia Pacific region. Metformin is the first line therapy, along with lifestyle modification for all type 2 diabetics as recommended by ADA. Metformin is available as conventional Metformin Immediate Release (MIR) and Metformin Extended Release (MXR). Metformin XR has better gastrointestinal tolerability and fewer side effects as compared to Metformin IR, with similar efficacy regarding anti-hyperglycaemic effects. The objective of this study was to determine whether metformin XR is as effective as Metformin IR in maintaining glycaemic control at equivalent doses or even at reduced doses; and to compare the side effect profile of the two preparations. METHODS: This randomized control trial was conducted at Medical and Endocrinology OPD of Jinnah Hospital Lahore. A total of 90 type 2 diabetics of both genders were recruited using nonprobability purposive sampling. Patients were randomized into 3 groups; 30 in each group. Group 1 received Metformin IR 1000 mg twice daily; group 2 received metformin XR 1000 mg twice daily; and group 3 received metformin XR 500 mg twice daily, for a period of three months. HbA1c was done at baseline and after three months of therapy along with fasting blood sugars and random blood sugars weekly. RESULTS: The mean age of patients was 46±9 years, with 54% being males and 46% being females. There was a 1% reduction in HbA1c in group 1, 0.7% reduction in group 2 and only 0.4% reduction in group 3. Similarly, all three therapies were equally effective in reducing blood sugar fasting and blood sugar random at three months. Side effects namely diarrhoea, dyspepsia and flatulence were greatest with Metformin IR (40%) but less than half with Metformin XR at equivalent dose and negligible at half the dose. CONCLUSIONS: All three Metformin groups were effective in reduction of HbA1C and glycaemic control clinically and there is no statistical difference in HbA1c reduction among groups at three months.

Glycaemic Control Of Type 2 Diabetic Patients During Ramazan Fasting.

BACKGROUND: Among five main pillars of Islam Fasting is one of the key elements, all healthy adult Muslims have to observe fast from dawn till dusk during the holy month of Ramadan. According to a 2009 demographic study, Islam has 1.57 billion believers, making up 23% of the world population of 6.8 billion, and is growing by 3% per year. EPIDIAR (epidemiology of diabetes and Ramadan) study showed that 43% patients with type 1 and 79% patients with type2 diabetes observe fast during the month of Ramadan. Whereas those people who are suffering from diabetes and are fasting may be at risk of adverse outcomes and the risks may rise with longer fasting periods. Ideal management of diabetic patients who wish to fast during Ramadan needs to be done to avoid the complications. The purpose of this study was to observe the effect of fasting on glycaemic control in type 2 diabetic patients during the month of Ramadan. METHODS: This was an observational cross sectional study; it was conducted at outpatient department Jinnah institute of diabetes and endocrinology Jinnah hospital Lahore during the month of Ramadan. Patients were advised to monitor blood sugar levels for two days before and after three meals (lunch, breakfast and dinner) before Ramadan and then during Ramadan blood sugar levels were monitored for four days in first Ashra before and two hours after Sehari, for four days at noon during second Ashra and then for four days pre and two hours after Iftar in last Ashra of Ramadan. Patients were educated Pre-Ramadan about glucose monitoring and drug dosage adjustments were done along with dietary counselling. RESULTS: Blood glucose levels two days before and during Ramadan fell within range of mean glucose level of 150-187 mg/dl showing no extreme fluctuations in blood glucose levels only one patient reported symptomatic and biochemical hypoglycaemia severe enough to break the fast at noon. CONCLUSIONS: We concluded that in Ramadan fasting, type 2 diabetic patients with proper education, dietary counselling and drug dosage adjustments glycaemic control can remain in safe acceptable range preventing any life-threatening complication.

The Combination of Clinical Features, Transcranial Doppler, and Alberta Stroke Program Early Computed Tomography Score (Computed Tomography Angiography) in Predicting Outcome in Intravenous Recombinant Tissue Plasminogen Activator-Treated Patients.

BACKGROUND: Little data exist on using combined baseline clinical neuroimaging and transcranial Doppler (TCD) information in predicting clinical outcome in stroke patients treated with intravenous (IV) thrombolysis. METHODS: Stroke patients received IV recombinant tissue plasminogen activator (rt-PA) and had diagnostic TCD within 3 hours of symptom onset. The TCD result was interpreted using the thrombolysis in brain ischemia (TIBI) flow grading system. Following multiple regression analysis, a grading system was created with 1 point for each of the following: National Institutes of Health Stroke Scale (NIHSS) score of 16 or higher, TIBI score of 1 or lower, and Alberta Stroke Program Early CT Score (ASPECTS) of 6 or lower. The patients' scores were compared to modified Rankin Scale (mRS) scores at 90 days. RESULTS: A total of 349 patients were included. In unvaried analysis, age of 80 years or older (P = .002), an ASPECTS of 6 or lower (P < .001), an NIHSS score of 16 or higher (P < .001), a TIBI score of 1 or lower (P < .001), and a glucose level ≥ 200 mg/dl (P = .04) were associated with poor outcome (mRS score > 2). In the multiple regression analysis, age of 80 years or older, an ASPECTS of 6 or lower, an NIHSS score of 16 or higher, and hyperglycemia were predictors of poor outcome (P < .05). Based on our scoring system, the patients' odds ratios for poor outcome were 7 (95% confidence interval [CI]: 2-23, P = .003), 8 (95% CI: 3-25, P < .001), and 24 (95% CI: 4-151, P = .001) for scores of 1, 2, and 3, respectively, after adjustment for common stroke risk factors. The mean time to recanalization increased as the score increased (score of 0: 160 ± 45 minutes versus score of 3: 186 ± 38 (P = .70). CONCLUSION: A multimodal grading system is useful in predicting outcome in patients treated with IV rt-PA. Those withhigher scores might be candidates for interventional therapy.

Accuracy of National Institutes of Health Stroke Scale Score in Predicting the Site of Arterial Occlusion in Acute Stroke: A Transcranial Doppler Study.

BACKGROUND: In acute stroke, it is crucial to assess for intracranial large-vessel occlusion and site of occlusion. The National Institutes of Health Stroke Scale score (NIHSSS) is the frequently used clinical tool to predict the site of arterial occlusion. In this study we aimed to determine the following: (1) if there is a correlation between the site of occlusion and the NIHSSS at presentation (bNIHSSS); and (2) if there is a bNIHSSS cutoff which can distinguish proximal occlusions (PO) from distal occlusions (DO). METHODS: Up to 313 patients from CLOTBUST data bank with demonstrable intracranial arterial occlusion and having received intravenous recombinant tissue plasminogen activator (rt-PA) were included. Occlusions were classified as PO (terminal internal carotid artery, M1 segment of middle cerebral artery [M1 MCA], and basilar artery) or DO (M2 MCA, anterior cerebral artery, posterior cerebral artery, and vertebral artery). RESULTS: By univariate analysis, bNIHSSS, thrombolysis in brain ischemia (TIBI) flow grade before rt-PA, degree of recanalization after rt-PA, and modified Rankin Scale score at 3 months were significantly different between various sites of occlusion. By univariate analysis, a higher bNIHSSS, lower TIBI flow grade, and lower ASPECTS (Alberta Stroke Program Early CT Score) differentiated PO from DO. Lower TIBI flow grade and higher bNIHSSS differentiated PO from DO by logistic regression analysis. No single NIHSSS cutoff with acceptable sensitivity and specificity could be derived to differentiate PO from DO. CONCLUSIONS: Although NIHSSS are higher in PO, there is no satisfactory NIHSSS cutoff which differentiates PO from DO. A vascular imaging or transcranial doppler should be obtained to determine the site of arterial occlusion in acute stroke.

Effect Of Non- Surgical Periodontal Treatment On Glycemic Control Among Type 2 Diabetes Mellitus Patients With Periodontitis.

BACKGROUND: Periodontitis and Diabetes Mellitus are two closely, bidirectional linked disease where periodontitis is a well-known complication of diabetes it is also considered to be a cause for poor glycaemic control. The present study objective was to evaluate the glycaemic control in patients suffering from both Diabetes Mellitus and Periodontitis after non-surgical periodontal treatment. METHODS: A comparative cross-sectional study was conducted with two groups of patients attending Diabetic Clinic, Jinnah Hospital, Lahore, during six months from September 2013 to February 2014. Forty-six diabetes mellitus subjects who were undergoing non-surgical treatment of periodontal disease that includes mechanical removal of supra- and sub gingival bacterial plaque with scalers, antibiotics and or root canal if required while 46 subjects with diabetic mellitus having periodontal disease did not had treatment for periodontal disease. HbA1c was compared at base line and at three months. Data was compiled and analysed through SPSS version 16. Quantitative variables like HbA1c was presented as mean±SD. Qualitative variables like gender, education status, economic status, treatment for diabetes mellitus and periodontal disease were described by using frequency percentages. The t-test was applied to assess statistical significance in mean difference HbA1c between two groups. p-value <0.05 was considered significant. RESULTS: Forty-six subjects who received non-surgical treatment for periodontitis 43 (93.5%) received scaling only while 3 (6.5%) received scaling plus antibiotics. Fall in the level of HbA1c was observed among subjects with treatment of periodontal disease indicating a good control of diabetes while in group without treatment there was either no change or increase in HbA1c. Mean HbA1c at baseline in group with treatment of periodontitis at baseline was 7.672±.6414 and without treatment was 6.957±.3494. (t= -1.008, p<.279). Mean HbA1c after 3 months in group with treatment of periodontitis was 6.867±.6168, and in group without treatment was 6.983±.3678. (t=6.641, p<.000). CONCLUSIONS: Non-surgical periodontal treatment is associated with improved glycaemic control (reduced HbA1c level) in type 2 diabetic patients.

Adenosine Deaminase (ADA)-Deficient Severe Combined Immunodeficiency Unmasked by Persistent Lymphopenia and Prolonged Severe SARS-CoV-2 Infection in a Three-Week-Old Neonate.

Adenosine deaminase (ADA) deficiency, an autosomal recessive variant, is the second most common form of severe combined immunodeficiency (SCID). We report a unique case of a three-week-old neonate who presented with prolonged and severe SARS-CoV-2 infection associated with persistent lymphopenia, subsequently revealing ADA-deficient SCID. He presented with mild and insidious symptoms, and then his clinical condition rapidly deteriorated. He required ICU admission and mechanical ventilation and developed multiple co-infections including opportunistic pathogens. Flow cytometry and whole exome sequencing diagnosed ADA-deficient SCID.  This case highlights the importance of recognizing primary immunodeficiency disorders in children who consistently display lymphopenia and experience prolonged opportunistic and viral infections. Detecting lymphopenia should prompt consideration of SCID, serving as a straightforward and cost-effective screening approach, particularly in nations such as the United Arab Emirates where T-cell receptor excision circles (TRECs) are not part of newborn screening protocols.

Validation of the transcranial Doppler rescue criteria for mechanical thrombectomy.

BACKGROUND AND PURPOSE: Transcranial Doppler (TCD) identifies acute stroke patients with arterial occlusion where treatment may not effectively open the blocked vessel. This study aimed to examine the clinical utility and prognostic value of TCD flow findings in patients enrolled in a multicenter prospective study (CLOTBUST-PRO). METHODS: Patients enrolled with intracranial occlusion on computed tomography angiography (CTA) who underwent urgent TCD evaluation before intravenous thrombolysis was included in this analysis. TCD findings were assessed using the mean flow velocity (MFV) ratio, comparing the reciprocal ratios of the middle cerebral artery (MCA) depths bilaterally (affected MCA-to-contralateral MCA MFV [aMCA/cMCA MFV ratio]). RESULTS: A total of 222 patients with intracranial occlusion on CTA were included in the study (mean age: 64 ± 14 years, 62% men). Eighty-eight patients had M1 MCA occlusions; baseline mean National Institutes of Health Stroke Scale (NIHSS) score was 16, and a 24-hour mean NIHSS score was 10 points. An aMCA/cMCA MFV ratio of <.6 had a sensitivity of 99%, specificity of 16%, positive predictive value (PV) of 60%, and negative PV of 94% for identifying large vessel occlusion (LVO) including M1 MCA, terminal internal carotid artery, or tandem ICA/MCA. Thrombolysis in Brain Ischemia scale, with (grade ≥1) compared to without flow (grade 0), showed a sensitivity of 17.1%, specificity of 86.9%, positive PV of 62%, and negative PV of 46% for identifying LVO. CONCLUSIONS: TCD is a valuable modality for evaluating arterial circulation in acute ischemic stroke patients, demonstrating significant potential as a screening tool for intravenous/intra-arterial lysis protocols.

Vertical One-and-a-Half Syndrome with Pseudoabducens Palsy and Midbrain Horizontal Gaze Paresis.

The rostral mesencephalon may influence ocular motility in the vertical, horizontal, and torsional trajectories through intricate supranuclear, internuclear, and infranuclear neural networks. Strategic unilateral midbrain lesions may result in contralateral horizontal gaze palsy with saccadic failure due to combined interruption of supranuclear corticofugal fibers from the frontal eye field and colliculofugal fibers from the superior colliculus. In this article, we report a patient who sustained combined vertical and horizontal gaze deficits after a single infarct involving the mesodiencephalic junction. The neural substrate for each deficit is briefly discussed in light of clinical findings. This case presented a triad of three distinct syndromes of horizontal gaze paresis, vertical one-and-a-half syndrome, and pseudoabducens palsy due to damage of nuclear and supranuclear projections within the rostral mesencephalon. This combination was due to a single embolic infarct in the territory of the posterior thalamosubthalamic artery (artery of Percheron) that arises at the basilar bifurcation. Coexistence of these phenomena exemplified how rostral midbrain lesions may affect ocular motility in the vertical, horizontal, and torsional planes, along with disruption of normal vergence control.

Diagnostic Puzzle of Acute Ischemic Stroke Mimics - Seizure Versus Post-Stroke Recrudescence: A Case Report.

BACKGROUND Focal seizure with impaired awareness, post-seizure Todd's phenomenon, and post-stroke recrudescence can all present with focal neurological deficits, mimicking stroke. As acute ischemic stroke mimics, they are distractors in the emergency setting where management is time-sensitive both for seizure and stroke. Nevertheless, a timely diagnosis can be made with exploration of the clinical features supported by investigation such as computerized tomographic perfusion. CASE REPORT Our patient was a 65-year-old woman who was known hypertensive, with type 2 diabetes mellitus, and previous intracerebral hemorrhage with minimal right-sided residual deficits, but still able to ambulate independently. She was brought to the Emergency Department because 1 hour prior to presentation, she had sudden worsening of weakness of the right limbs, aphasia, aggression, and confusion. An initial impression of repeat acute stroke, focal seizure with impaired awareness, Todd's phenomenon, and post-stroke recrudescence was considered. While CT angiography was suggestive of left middle cerebral artery occlusion, CT perfusion revealed extensive hypoperfusion patterns beyond the region of the occlusion, thus suggesting a different etiology from acute ischemic stroke. In view of her previous left hemispheric lesion coupled with the presentation, our working diagnosis was seizure with Todd's phenomenon, and she was started on an anti-epileptic drug. Her condition returned to baseline within 24 h of admission and was subsequently discharged. CONCLUSIONS Our case demonstrates that adequate elucidation of clinical features in conjunction with CT perfusion, as a dual-purpose tool, can aid the diagnosis of both stroke mimics and acute ischemic stroke in the Emergency Department where rapid treatment is essential.

Clinical Characteristics, Comorbidities, and Outcome of Critically Sick Patients With COVID-19 Pneumonia Admitted in the Intensive Care Unit of a Tertiary Care Hospital in Lahore, Pakistan: A Retrospective Cohort Study.

Background Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a multisystem disease that primarily involves the respiratory tract. The first case of COVID-19 was identified in late 2019 in the province of Wuhan, China, which was followed by the rapid spread of the disease globally, becoming a present-day pandemic. Objectives The aim of this study is to describe the clinical characteristics, comorbidities, and outcomes of critically sick patients with COVID-19 pneumonia admitted to the intensive care unit (ICU) of Fatima Memorial Hospital, Lahore, from March 2021 to August 2021. A total of 133 patients were chosen for this retrospective cohort study. Results There was a total of 133 patients, out of which 65 (48.9%) were male and 68 (51.1%) were female. Of these 133 patients, 70 (52.6%) were discharged home after recovery and 63 (47.4%) died; 96 (72.2%) patients had diabetes mellitus and of these, 53 (55.2%) patients died and 43 (44.8%) were discharged, 94 (70.7%) patients had hypertension, out of which 53 (56.4%) died and 41 (43.6%) were discharged home, 40 (30.1%) patients had ischemic heart disease (IHD), out of which 28 (70%) died and 12 (30%) were discharged. A total of 48 (36.1%) patients needed invasive positive pressure ventilation (IPPV) and 78 (58.6%) patients required noninvasive positive pressure ventilation (NIPPV). Conclusion Patients with one or more underlying co-morbidities had poor clinical outcomes compared to those with no co-morbidities, with the most vulnerable group being patients with Ischemic heart disease, chronic kidney disease, hypertension, and diabetes mellitus in descending order.