Vessel wall magnetic resonance and arterial spin labelling imaging in the management of presumed inflammatory intracranial arterial vasculopathy.

Optimal criteria for diagnosing and monitoring response to treatment for infectious and inflammatory medium-large vessel intracranial vasculitis presenting with stroke are lacking. We integrated intracranial vessel wall MRI with arterial spin labelling into our routine clinical stroke pathway to detect presumed inflammatory intracranial arterial vasculopathy, and monitor disease activity, in patients with clinical stroke syndromes. We used predefined standardized radiological criteria to define vessel wall enhancement, and all imaging findings were rated blinded to clinical details. Between 2017 and 2018, stroke or transient ischaemic attack patients were first screened in our vascular radiology meeting and followed up in a dedicated specialist stroke clinic if a diagnosis of medium-large inflammatory intracranial arterial vasculopathy was radiologically confirmed. Treatment was determined and monitored by a multi-disciplinary team. In this case series, 11 patients were managed in this period from the cohort of young stroke presenters (<55 years). The median age was 36 years (interquartile range: 33,50), of which 8 of 11 (73%) were female. Two of 11 (18%) had herpes virus infection confirmed by viral nucleic acid in the cerebrospinal fluid. We showed improvement in cerebral perfusion at 1 year using an arterial spin labelling sequence in patients taking immunosuppressive therapy for >4 weeks compared with those not receiving therapy [6 (100%) versus 2 (40%) P = 0.026]. Our findings demonstrate the potential utility of vessel wall magnetic resonance with arterial spin labelling imaging in detecting and monitoring medium-large inflammatory intracranial arterial vasculopathy activity for patients presenting with stroke symptoms, limiting the need to progress to brain biopsy. Further systematic studies in unselected populations of stroke patients are needed to confirm our findings and establish the prevalence of medium-large artery wall inflammation.

Safe use of streptokinase in myocardial infarction in patients aged 75 and over.

We have given streptokinase to 73 patients aged 75 and over admitted to medical admission wards for elderly people using strict exclusion criteria. This was safe and free from significant adverse events by comparison with other studies. The average age of the patients was 78.2 years so they formed a relatively young group compared with all patients over 75. There was a relatively long delay between presentation at the hospital and receipt of treatment.

The measurement of fetal growth during pregnancy by ultra-sound (B-scan).

We have followed fetal growth by ultrasonographic B-scans. In addition to percentile curves of the biparietal skull diameter we have established percentile curves for measurements of the fetal trunk (sagittal thoracic diameter and length of trunk). The percentile curves for the biparietal diameter were obtained from 5400 individual measurements; the percentile curves for the trunk measurements utilized 1300 individual measurements. These cases were from almost entirely unselected material from our special prenatal clinic. This resulted in a larger variation than the percentile curves for biparietal diameter of other authors [Campbell and Newman]. However, these authors selected their material for "normal pregnancy" while we insured that neither "corrections" of the normal variation nor subjective criteria for exclusion have introduced a systematic error. The advantages of ultrasonography for monitoring of the pregnancy are self-evident: repeated examinations are possible, the examination takes little time, and the method is safe. The determination of the biparietal diameter for estimation of fetal development alone is insufficient because trunk measurements may indicate developmental disturbances (dystrophy and hypertrophy) before the growth of the biparietal diameter of the skull is affected. Furthermore, comparison of the fetal skull and trunk measurement may indicate errors in measurement or malformations (hydrocephalus, microcephalus). The following percentile curves are illustrated graphically: 1. Gestational age versus biparietal diameter (Fig. 1). 2. Biparietal diameter versus weeks of gestation (Fig. 2). 3. Length of gestation versus sagittal thoracic diameter (Fig. 3). 4. Length of gestation versus length of trunk (Fig. 4). 5. Sagittal thoracic diameter versus length of trunk (Fig. 5).