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Background and Purpose— Intracerebral hemorrhage is a considerable source of morbidity and mortality. This 3-center study describes outcomes of pediatric intracerebral hemorrhage and identifies 2-year neurological outcome predictors. Methods— Children 29 days to 18 years of age presenting with intracerebral hemorrhage from March 2007 to May 2015 were enrolled prospectively. Exclusion criteria included trauma; intracranial tumor; hemorrhagic transformation of arterial ischemic stroke or cerebral sinovenous thrombosis; isolated subdural, epidural, or subarachnoid hemorrhage; and abnormal baseline neurological function. Intracerebral hemorrhage and total brain volumes were measured on neuroimaging. The Pediatric Stroke Outcome Measure assessed outcomes. Results— Sixty-nine children were included (median age: 9.7 years; interquartile range: 2.2–14). Six children (9%) died during hospitalization. Outcomes in survivors were assessed at early follow-up in 98% (median 3.1 months; interquartile range: 3.1–3.8) and at later follow-up in 94% (median: 2.1 years; interquartile range: 1.3–2.8). Over a third had a significant disability at 2 years (Pediatric Stroke Outcome Measure >2). Total Pediatric Stroke Outcome Measure score improved over time ( P =0.0003), paralleling improvements in the sensorimotor subscore ( P =0.0004). Altered mental status (odds ratio, 13; 95% confidence interval, 3.9–46; P P =0.01), and intensive care unit length of stay (odds ratio, 1.1; 95% confidence interval, 1.0–1.2; P =0.002) were significantly associated with poor 2-year outcome. Conclusions— Over one third of children experienced significant disability at 2 years. Improvements in outcomes were driven by recovery of sensorimotor function. Altered mental status, hemorrhage volume ≥4% of total brain volume, and intensive care unit length of stay were independent predictors of significant disability at 2 years.

Introduction: The CLEAR III trial found that removal of intraventricular hemorrhage was not associated with a dichotomized improvement in 6-month outcome measured by the modified Rankin Scale score (p=0.554). Despite this, shifts towards improved outcome were evident for the alteplase (n=249) versus saline (n=251) group measured by the extended Glasgow Outcome Score (GOS-E). Shared patient/physician decision-making would be aided by characterizing the magnitude of this benefit, using the common clinical metrics of number needed to treat (NNTB), number needed to harm (NNH), and benefit per hundred (BPH) treated. Methods: Analyses were performed on CLEAR III findings using a 6-level version of the GOS-E (GOS-E6), in which the 3 poorest outcome levels of the original GOS-E (extremely severe disability, vegetative state, and death) are combined into a single worst outcome category. In this way, shifts between these categories are not counted as improved outcome. For all possible dichotomizations of the GOS-E6 net NNTB values were derived by taking the inverse of absolute risk difference, and net BPHs by multiplying absolute risk difference by 100. For benefits accruing across all disability state transitions on the GOS-E6 (shift analysis), net NNTB, and net BPH, values were derived using automated, algorithmic min-max joint outcome table derivation technique. In addition, NNTB and NNH values for dichotomous and shift outcomes were derived using expert’s joint outcome tables, and are presented as the geometric mean. Results: For the 6 level GOS-E, automated algorithmic analysis indicated that the net NNTB for 1 additional patient to have a better outcome by ≥ 1 grade at 6 months, with thrombolytic rather than saline irrigation, was 7.4. Expert joint outcome table analyses indicated that the NNTB for improved final outcome at 6 months was 6.3 (range 5.8-6.7) and NNH 39.0 (32.3-47.6). For every 100 patients treated, 15.9 had a better outcome and 2.6 a worse outcome. The likelihood of help to harm ratio was 6.2. Conclusions: Thrombolytic removal of intraventricular hemorrhage confers net benefit on 9% of treated patients. Approximately 1 in 11 patients has a better outcome, while 1 in 39 has a worse outcome.

Background Positive diffusion weighted imaging (DWI) on MRI is associated with increased recurrent stroke risk in TIA patients. Acute MRI aids in TIA risk stratification and diagnosis. Aim To evaluate the feasibility and safety of TIA triage directly from the emergency department (ED) with acute MRI and neurological consultation. Methods Consecutive ED TIA patients assessed by a neurologist underwent acute MRI/MRA of head/neck per protocol and were hospitalized if positive DWI, symptomatic vessel stenosis, or per clinical judgment. Stroke neurologist adjudicated the final TIA diagnosis as definite, possible, or not a cerebrovascular event. Stroke recurrence rates were calculated at 7, 90, 365 days and compared with predicted stroke rates derived from historical DWI and ABCD2 score data. Results One hundred twenty-nine enrolled patients had a mean age of 69 years (±17) and median ABCD2 score of 3 (interquartile range [IQR] 3–4). During triage, 112 (87%) patients underwent acute MRI after a median of 16 h (IQR 10–23) from symptom onset. No patients experienced a recurrent event before imaging. Twenty-four (21%) had positive DWI and 8 (7%) had symptomatic vessel stenosis. Of the total cohort, 83 (64%) were discharged and 46 (36%) were hospitalized. By one-year follow-up, one patient in each group had experienced a stroke. Of 92 patients with MRI and index cerebrovascular event, recurrent stroke rates were 1·1% at 7 and 90 days. These were similar to predicted recurrence rates. Conclusion TIA triage in the ED using a protocol with neurological consultation and acute MRI is feasible and safe. The majority of patients were discharged without hospitalization and rates of recurrent stroke were not higher than predicted.

Introduction: Speed is critical in fibrinolytic therapy for acute ischemic stroke (AIS), but rapid decision-making may increase tPA use in stroke mimics. Complications from lytics in mimic patients, though uncommon, can be severe. Mimic treatment rates when using non-contrast CT as the only initial imaging modality have increased to as high as 34% with intensified efforts to reduce door to needle (DTN) times. Efficient imaging with MRI or multimodal CT may potentially avoid high mimic treatment rates without prolonging treatment. Methods: In a prospectively maintained registry, we examined all patients treated with IV tPA from January 2010 to June 2015. Institutional policy was to perform MRI first in AIS patients and start tPA on the MR table after DWI showed ischemia and GRE excluded hemorrhage; if MRI could not be performed, multimodal CT with CTA and CTP was performed. Results: Among 319 IV tPA treated patients, age was 71 (±15), 50% were female, and NIHSS was 13.3 (±8.0). Imaging modality before tPA was MR in 193 (61%) and CT in 126 (39%). In the entire population, the DTN time was 54 (IRQ 42-73) mins and the proportion of mimic patients was 3.1%. DTN times decreased steadily throughout the 5.5 year study period, and did not differ among patients imaged with MR vs CT (Figure). The reduction in DTN times was not associated with an increase in mimic-treated rates (Figure). Among the mimic patients, final diagnoses were migraine - 4, seizure - 3, meningitis - 1, PE - 1, and cardiac dysrhythmia - 1. Imaging modalities in mimic patients were MRI in 5 and CT in 5. Preliminary imaging reads suggested abnormality in 2/10, but final reads were normal in all. In 3/10 mimic patients, tPA infusions were stopped before full dose when ongoing imaging further clarified diagnosis. Conclusion: A rapid stroke assessment protocol using MRI or multimodal CT permits swift start of thrombolytic therapy and low rates of stroke mimic treatment. Figure. Door-to-needle time and percent stroke mimics by year.

Previous studies of pediatric intracerebral hemorrhage have investigated isolated intraparenchymal hemorrhage. The authors investigated whether detailed assessment of intraventricular hemorrhage enhanced outcome prediction after intracerebral hemorrhage. They prospectively enrolled 46 children, full-term to 17 years, median age 2.7 years, with spontaneous intraparenchymal hemorrhage and/or intraventricular hemorrhage. Outcome was assessed with the King’s Outcome Scale for Childhood Head Injury. Twenty-six (57%) had intraparenchymal hemorrhage, 10 (22%) had pure intraventricular hemorrhage, and 10 (22%) had both. There were 2 deaths, both with intraparenchymal hemorrhage and intraventricular hemorrhage volume ≥4% of total brain volume. Presence of intraventricular hemorrhage was not associated with poor outcome, but hydrocephalus showed a trend ( P = .09) toward poor outcome. In receiver operating characteristic curve analysis, combined intraparenchymal hemorrhage and intraventricular hemorrhage volume also showed a trend toward better outcome prediction than intraparenchymal hemorrhage volume alone. Although not an independent outcome predictor, future studies should assess intraventricular hemorrhage qualitatively and quantitatively.

Aim Few data exist to aid the clinician in prognosis after paediatric intracerebral haemorrhages (ICHs). Recently, ICH volume as a per cent of total brain volume (TBV) was shown to help predict outcomes in children. Thus, we sought to develop a bedside method of TBV estimation using typical hospital imaging software, and to validate the ABC/2 method for children in order to determine ICH volume and aid prognosis. Method The study group comprised 23 children and adolescents with non-traumatic, acute ICH who had undergone head computed tomography and who were available for analysis. The median age of participants, 14 males (61%) and nine females (39%), was 6 years (range 0-16 y; mean 7.8 y; SD 5.3 y). Preterm infants born at less than 37 weeks' gestation and term infants with pure intraventricular haemorrhages were excluded. Manual segmentation, which is the criterion standard for measurement of ICH volume and TBV, requires specialized software and is time-consuming. We therefore used the well-known 'ABC/2 × slice thickness' method to calculate ICH volume and TBV, thus allowing ICH size to be reported as a percentage of TBV regardless of the absolute size of ICH. Results The estimated ICH volume was highly accurate compared with the criterion standard (R(2) =0.97 and R(2) =0.93; combined R(2) =0.96), as was the estimated TBV (R(2) =0.89 and R(2) =0.77; combined R(2) =0.89). The interrater reliability was high for both ICH volume and TBV, with an intraclass correlation coefficient of 0.94 and 0.80 respectively. Therefore, using no specialized software, we accurately measured ICH volume as a percentage of TBV. Interpretation The ABC/2 × slice thickness method is a possible bedside tool for the clinician that can aid prognosis after paediatric ICH.

There is evidence for different levels of visuospatial processing with their own frames of reference: viewer-centered, stimulus-centered, and object-centered. The neural locus of these levels can be explored by examining lesion location in subjects with unilateral spatial neglect (USN) manifest in these reference frames. Most studies regarding the neural locus of USN have treated it as a homogenous syndrome, resulting in conflicting results. In order to further explore the neural locus of visuospatial processes differentiated by frame of reference, we presented a battery of tests to 171 subjects within 48 hr after right supratentorial ischemic stroke before possible structural and/or functional reorganization. The battery included MR perfusion weighted imaging (which shows hypoperfused regions that may be dysfunctional), diffusion weighted imaging (which reveals areas of infarct or dense ischemia shortly after stroke onset), and tests designed to disambiguate between various types of neglect. Results were consistent with a dorsal/ventral stream distinction in egocentric/allocentric processing. We provide evidence that portions of the dorsal stream of visual processing, including the right supramarginal gyrus, are involved in spatial encoding in egocentric coordinates, whereas parts of the ventral stream (including the posterior inferior temporal gyrus) are involved in allocentric encoding.

Background Semantic errors result from the disruption of access either to semantics or to lexical representations. One way to determine the origins of these errors is to evaluate comprehension of words that elicit semantic errors in naming. We hypothesized that in acute stroke there are different brain regions where dysfunction results in semantic errors in both naming and comprehension versus those with semantic errors in oral naming alone. Methods A consecutive series of 196 patients with acute left hemispheric stroke who met inclusion criteria were evaluated with oral naming and spoken word/picture verification tasks and magnetic resonance imaging within 48 h of stroke onset. We evaluated the relationship between tissue dysfunction in 10 pre-specified Brodmann's areas (BA) and the production of coordinate semantic errors resulting from (1) semantic deficits or (2) lexical access deficits. Results Semantic errors arising from semantic deficits were most associated with tissue dysfunction/infarct of left BA 22. Semantic errors resulting from lexical access deficits were associated with hypoperfusion/infarct of left BA 37. Conclusion Our study shows that semantic errors arising from damage to distinct cognitive processes reflect dysfunction of different brain regions.

Hemispatial neglect has been well established in adults following acute ischemic stroke, but has rarely been investigated in children and young adults following brain injury. It is known that young brains have a tremendous potential for reorganization; however, there is controversy as to whether functions are assumed by the opposite hemisphere, or perilesional areas in the same hemisphere. Patients with intractable epilepsy who undergo hemispherectomy for treatment are missing the entire cortex on one side following surgery. In these patients, only the opposite hemisphere is available to assume function. Therefore, they provide the unique opportunity to determine in what cases the left or right hemisphere can take over the spatial attention functions of the opposite hemisphere following damage. The objective of this study was to determine the incidence and types of hemispatial neglect in children and young adults following both right- and left-sided hemispherectomy; which types of spatial attention functions can be assumed by the opposite hemisphere; and whether factors like their age at time of surgery, handedness, or gender influence recovery.Thirty-two children and young adults who had previously undergone hemispherectomy were administered two tests to evaluate for two types of hemispatial neglect: a gap detection test and a line cancellation test. Egocentric neglect was defined as significantly more omissions of targets on the contralesional versus ipsilesional side of the page (by chi square analysis; p.05). Allocentric neglect was defined as significantly more errors in detecting contralesional versus ipsilesional gaps in circles.Only one of the patients displayed statistically significant hemispatial egocentric neglect on the line cancellation test, and none of the patients displayed statistically significant egocentric or allocentric neglect on the gap detection test.These results imply that reorganization to the contralateral hemisphere occurs peri-hemispherectomy, as there are no perilesional areas to assume function.

BACKGROUND AND PURPOSE: Crossed cerebellar diaschisis (CCD), the decrease in blood flow and metabolism in the cerebellar hemisphere contralateral to a supratentorial stroke, is frequently reported on positron-emission tomography (PET) and single-photon emission CT (SPECT) but is rarely described with MR perfusion techniques. This study was undertaken to determine the frequency of CCD observed in acute stroke by retrospective review of a research data base of patients with acute stroke evaluated by diffusion-weighted (DWI) and dynamic contrast susceptibility perfusion MR imaging (PWI). MATERIALS AND METHODS: PWI scans of 301 consecutive patients with acute stroke and positive DWI abnormality from a research data base were reviewed. Contralateral cerebellar hypoperfusion was identified by inspection of time-to-peak (TTP) maps for asymmetry with an absence of cerebellar abnormalities on T2-weighted scans, DWI, or disease of the vertebrobasilar system on MR angiography. In a subset of the cases, quantitative analysis of perfusion scans was performed using an arterial input function and singular value decomposition (SVD) to generate cerebral blood flow (CBF) maps. RESULTS: A total of 47 of 301 cases (15.61%) met the criteria of CCD by asymmetry of cerebellar perfusion on TTP maps. On quantitative analysis, there was corresponding reduction of CBF by 22.75 ± 10.94% (range, 7.45% to 52.13%) of the unaffected cerebellar hemisphere). CONCLUSIONS: MR perfusion techniques can be used to detect CCD, though the frequency presented in this series is lower than that commonly reported in the PET/SPECT literature. Nevertheless, with its role in acute stroke and noninvasive nature, MR perfusion may be a viable alternative to PET or SPECT to study the phenomenon and clinical consequences of supratentorial stroke with CCD.

Introduction: Unilateral neglect after acute right hemispheric stroke significantly impedes poststroke recovery. We studied patients with right hemispheric stroke to determine whether increasing age was associated with more frequent or more severe neglect. Methods: Eight neglect tests within 5 days of symptom onset (and within 24 hours of admission) were administered to 204 subjects with acute right hemispheric stroke. Size of infarct was measured, and neglect tests were scored as percent error. “Any neglect” was defined by an elevated neglect test score, standardized relative to a group of normal controls. Results: When tested for neglect soon after acute stroke admission, 69.6% of subjects older than 65 years had “any neglect” (defined by comparison to a group of normal controls), compared with 49.4% of subjects aged 65 years and younger ( p = 0.008). For every additional 10 years of age, patients were 1.83 times as likely to have neglect, even after adjusting for diffusion-weighted imaging (DWI) infarct volume and NIH Stroke Scale (NIHSS) score (95% CI 1.38–2.43). In addition, DWI volume and NIHSS independently predicted neglect. Score on virtually all of the neglect tests worsened as an effect of age. Percentage error on a line cancellation task was 3.8% higher for every additional 10 years of age, after adjustment for DWI volume and NIHSS ( p = 0.006). Similar results were found for other neglect tests. Conclusions: Increasing age in patients with acute right hemispheric stroke significantly increases the odds of unilateral neglect as well as severity of neglect, independently of size of the stroke or NIH Stroke Scale score. The reason for this finding in older patients may be because they have more brain atrophy and may be less able to compensate for cerebral infarction, or because they tend to have more cardioembolic strokes, which may be more cortically based.

Hemispatial neglect is a common and disabling consequence of stroke. Previous reports examining the relationship between gender and the incidence of unilateral spatial neglect (USN) have included either a large numbers of patients with few neglect tests or small numbers of patients with multiple tests. To determine if USN was more common and/or severe in men or women, we examined a large group of patients (312 right-handed) within 24 hours of acute right hemisphere ischemic stroke. Multiple spatial neglect tasks were used to increase the sensitivity of neglect detection. No differences based upon gender were observed for the prevalence, severity, or a combined task measure of USN.

Background and Purpose: Diffusion–perfusion mismatch has been used to estimate salvageable tissue and predict potential for recovery in acute stroke. Location of the salvageable tissue may be as important as volume or percentage in predicting potential for recovery of specific functions. Impaired naming, a common and disabling deficit after left hemisphere stroke, is often associated with tissue dysfunction of left Brodmann area (BA) 37, posterior inferior temporal cortex. We tested the hypothesis that the presence of diffusion–perfusion mismatch within left BA 37 predicts probability and extent of short-term improvement of naming. Methods: One hundred five patients with acute left hemisphere ischemic stroke had diffusion-weighted imaging, perfusion-weighted imaging, a test of picture naming, and other language tests at admission and 2 to 4 days later. Linear regression was used to determine whether diffusion–perfusion mismatch in any BA in language cortex, total volume of mismatch, or diffusion or perfusion abnormality predicted degree of improvement in naming by days 3 to 5. Results: The presence of >20% diffusion–perfusion mismatch in left BA 37 and total volumes of diffusion and perfusion abnormality at day 1 each independently predicted degree of improvement in naming. Mismatch in this area did not predict the degree of improvement in other language tests or the NIH Stroke Scale in this study. Conclusions/Relevance: Diffusion–perfusion mismatch in left Brodmann area 37 was strongly associated with acute improvement in naming, independently of volume or percentage of total mismatch or diffusion or perfusion abnormality. These data indicate that mismatch in a particular area is a marker of salvageable tissue and an important predictor of potential for recovery of functions that depend on that area. Location of mismatch before treatment may help to predict potential benefits of reperfusion. GLOSSARY: ADC = apparent diffusion coefficient; BA = Brodmann area; DWI = diffusion-weighted imaging; NIHSS = NIH Stroke Scale; PWI = perfusion-weighted imaging; TE = echo time; TR = repetition time; TTP = time to peak.

A number of previous studies have indicated that Broca's area has an important role in understanding and producing syntactically complex sentences and other language functions. If Broca's area is critical for these functions, then either infarction of Broca's area or temporary hypoperfusion within this region should cause impairment of these functions, at least while the neural tissue is dysfunctional. The opportunity to identify the language functions that depend on Broca's area in a particular individual was provided by a patient with hyperacute stroke who showed selective hypoperfusion, with minimal infarct, in Broca's area, and acutely impaired production of grammatical sentences, comprehension of semantically reversible (but not non-reversible) sentences, spelling, and motor planning of speech articulation. When blood flow was restored to Broca's area, as demonstrated by repeat perfusion weighted imaging, he showed immediate recovery of these language functions. The identification of language functions that were impaired when Broca's area was dysfunctional (due to low blood flow) and recovered when Broca's area was functional again, provides evidence for the critical role of Broca's area in these language functions, at least in this individual.

Objective To identify dysfunctional brain regions critical for impaired reading/spelling of words/pseudowords by evaluating acute stroke patients on lexical tests and magnetic resonance imaging, before recovery or reorganization of structure–function relationships. Methods A series of 106 consenting patients were administered oral reading and spelling tests within 24 hours of left supratentorial stroke onset. Patients underwent diffusion- and perfusion-weighted magnetic resonance examination the same day to identify regions of hypoperfusion/infarct of 16 Brodmann areas. Results Simultaneous logistic regression analysis demonstrated that dysfunction of left Brodmann areas 40 (supramarginal gyrus) and 37 (posterior-inferior temporal/fusiform gyrus) best predicted impairment in reading words (odds ratio [OR], 6.20 [95% confidence interval (CI), 1.54–24.96] and 2.71 [95% CI, 0.87–8.45], respectively), reading pseudowords (OR, 39.65 [95% CI 3.9–400.78] and 4.41 [95% CI, 1.1–17.51], respectively), spelling words (OR, 14.11 [95% CI 1.37–144.93] and 7.41 [95% CI, 1.48–37.24], respectively), and spelling pseudowords (OR, 4.84 [95% CI, 0.73–32.13] and 7.74 [95% CI, 1.56–38.51], respectively). Whole-brain voxel-wise analyses demonstrated voxel clusters within these regions that were most strongly associated with task deficits. Interpretation Results indicate that a shared network of regions including parts of left Brodmann areas 37 and 40 is necessary for reading and spelling of words and pseudowords. Further studies may define the precise roles of these brain regions in language. Identification of any neural regions specific to one of these tasks or one type of stimuli will require study of more patients with selective deficits. Ann Neurol 2007

The frequency of various types of unilateral spatial neglect and associated areas of neural dysfunction after left hemisphere stroke are not well characterized. Unilateral spatial neglect (USN) in distinct spatial reference frames have been identified after acute right, but not left hemisphere stroke. We studied 47 consecutive right handed patients within 48 hours of left hemisphere stroke to determine the frequency and distribution of types of right USN using cognitive testing and MRI imaging. The distribution of USN types was different from the previously reported distribution following acute right hemisphere stroke. In this left hemisphere stroke population, allocentric neglect was more frequent than egocentric neglect.

We hypothesized that distinct cognitive processes underlying oral and written picture naming depend on intact function of different, but overlapping, regions of the left hemisphere cortex, such that the distribution of tissue dysfunction in various areas can predict the component of the naming process that is disrupted. To test this hypothesis, we evaluated 116 individuals within 24 h of acute ischaemic stroke using a battery of oral and written naming and other lexical tests, and with magnetic resonance diffusion and perfusion imaging to identify the areas of tissue dysfunction. Discriminant function analysis, using the degree of hypoperfusion in various Brodmann's areas--BA 22 (including Wernicke's area), BA 44 (part of Broca's area), BA 45 (part of Broca's area), BA 21 (inferior temporal cortex), BA 37 (posterior, inferior temporal/fusiform gyrus), BA 38 (anterior temporal cortex) and BA 39 (angular gyrus)--as discriminant variables, classified patients on the basis of the primary component of the naming process that was impaired (defined as visual, semantics, modality-independent lexical access, phonological word form, orthographic word form and motor speech by the pattern of performance and types of errors across lexical tasks). Additionally, linear regression analysis demonstrated that the areas contributing the most information to the identification of patients with particular levels of impairment in the naming process were largely consistent with evidence for the roles of these regions from functional imaging. This study provides evidence that the level of impairment in the naming process reflects the distribution of tissue dysfunction in particular regions of the left anterior, inferior and posterior middle/superior temporal cortex, posterior inferior frontal and inferior parietal cortex. While occipital cortex is also critical for picture naming, it is likely that bilateral occipital damage is necessary to disrupt visual recognition. These findings provide new evidence that a network of brain regions supports naming, but separate components of this network are differentially required for distinct cognitive processes or representations underlying the complex task of naming pictures.

A 73 year-old man with past medical history of atrial fibrillation, not on warfarin, severe peripheral vascular disease, coronary artery disease, hypertension, dyslipidemia was speaking with a co-worker and suddenly lost consciousness, dropping to the floor.

We identified areas of the brain that are critical for naming pictures of objects, using a new methodology for testing which components of a network of brain regions are essential for that task. We identified areas of hypoperfusion and structural damage with magnetic resonance perfusion- and diffusion-weighted imaging immediately after stroke in 87 individuals with impaired picture naming. These individuals were reimaged after 3–5 d, after a subset of patients underwent intervention to restore normal blood flow, to determine areas of the brain that had reperfused. We identified brain regions in which reperfusion was associated with improvement in picture naming. Restored blood flow to left posterior middle temporal/fusiform gyrus, Broca's area, and/or Wernicke's area accounted for most acute improvement after stroke. Results show that identifying areas of reperfusion that are associated with acute improvement of a function can reveal the brain regions essential for that function.

Background and Purpose— The pathophysiology of the presumed perihematomal edema immediately surrounding an acute intracerebral hemorrhage is poorly understood, and its composition may influence clinical outcome. Method— Twenty-three patients from the Diagnostic Accuracy of MRI in Spontaneous intracerebral Hemorrhage (DASH) study were prospectively enrolled and studied with MRI. Perfusion-weighted imaging, diffusion-weighted imaging, and fluid-attenuated inversion recovery sequences were coregistered. TMax (the time when the residue function reaches its maximum) and apparent diffusion coefficient values in the presumed perihematomal edema regions of interest were compared with contralateral mirror and remote ipsilateral hemispheric regions of interest. Results— Compared with mirror and ipsilateral hemispheric regions of interest, TMax (the time when the residue function reaches its maximum) and apparent diffusion coefficient were consistently increased in the presumed perihematomal edema. Two thirds of the patients also exhibited patchy regions of restricted diffusion in the presumed perihematomal edema. Conclusion— The MRI profile of the presumed perihematomal edema in acute intracerebral hemorrhage exhibits delayed perfusion and increased diffusivity mixed with areas of reduced diffusion.

Background and Purpose— The intracerebral hemorrhage (ICH) score is the most commonly used clinical grading scale for outcome prediction after adult ICH. We created a similar scale in children to inform clinical care and assist in clinical research. Methods— Children, full-term newborns to 18 years, with spontaneous ICH were prospectively enrolled from 2007 to 2012 at 3 centers. The pediatric ICH score was created by identifying factors associated with poor outcome. The score’s ability to detect moderate disability or worse and severe disability or death was examined with sensitivity, specificity, and area under the receiver operating characteristic curve. Results— The pediatric ICH score components include ICH volume >2% to 3.99% of total brain volume (TBV): 1 point; ICH volume ≥4% TBV: 2 points; acute hydrocephalus: 1 point; herniation: 1 point; and infratentorial location: 1 point. The score ranges from 0 to 5. At 3-month follow-up of 60 children, 10 were severely disabled or dead, 30 had moderate disability, and 20 had good recovery. A pediatric ICH score ≥1 predicted moderate disability or worse with a sensitivity of 75% (95% confidence interval [CI], 59% to 87%) and a specificity of 70% (95% CI, 46% to 88%). A pediatric ICH score ≥2 predicted severe disability or death with a sensitivity and specificity of 90% (95% CI, 55% to 99%) and 68% (95% CI, 53% to 80%), respectively. The area under the receiver operating characteristic curve for classifying outcome as severe disability or death was 0.88 (95% CI, 0.78–0.97). Conclusions— The pediatric ICH score is a simple clinical grading scale that may ultimately be used for risk stratification, clinical care, and research.

Background The purpose of this study was to define the incidence, imaging characteristics, natural history, and prognostic implication of corticospinal tract Wallerian degeneration ( CST ‐ WD ) in spontaneous intracerebral hemorrhage ( ICH ) using serial MR imaging. Methods and Results Consecutive ICH patients with supratentorial ICH prospectively underwent serial MRI s at 2, 7, 14, and 21 days. MRI s were analyzed by independent raters for the presence and topographical distribution of CST ‐ WD on diffusion‐weighted imaging ( DWI ). Baseline demographics, hematoma characteristics, ICH score, and admission National Institute of Health Stroke Score ( NIHSS ) were systematically recorded. Functional outcome at 3 months was assessed by the modified Rankin Scale ( mRS ) and the motor‐ NIHSS . Twenty‐seven patients underwent 93 MRI s; 88 of these were serially obtained in the first month. In 13 patients (48%), all with deep ICH , CST ‐ WD changes were observed after a median of 7 days (interquartile range, 7 to 8) as reduced diffusion on DWI and progressed rostrocaudally along the CST . CST ‐ WD changes evolved into T 2 ‐hyperintense areas after a median of 11 days (interquartile range, 6 to 14) and became atrophic on MRI s obtained after 3 months. In univariate analyses, the presence of CST ‐ WD was associated with poor functional outcome (ie, mRS 4 to 6; P =0.046) and worse motor‐ NIHSS (5 versus 1, P =0.001) at 3 months. Conclusions Wallerian degeneration along the CST is common in spontaneous supratentorial ICH , particularly in deep ICH . It can be detected 1 week after ICH on DWI and progresses rostrocaudally along the CST over time. The presence of CST ‐ WD is associated with poor motor and functional recovery after ICH .

Objective: Hematoma expansion and its predictors like the “spot sign” are important research areas in adults with primary (hypertensive) intracerebral hemorrhage (ICH), but are rarely studied in secondary ICH. At one center, in adults with ICH due to brain arteriovenous malformation (AVM), aneurysm, or tumor, significant hematoma expansion (>33%) occurred in 6/30 (20%) within 24 hours. In children, the frequency of hematoma expansion and the appropriate timing of follow-up neuroimaging are unknown. We assessed the frequency and extent of hematoma expansion in children with non-traumatic ICH. Methods: From 2007 to 2012, 73 children with spontaneous ICH were enrolled in a three-center prospective study (≥37 weeks gestation-17 years). Inclusion for this sub-study: 2 head CTs obtained for clinical indications within 48 hours after presentation with ICH (28 children). Exclusion: Surgical evacuation of hematoma before 2 nd CT was obtained (2 children), IVH only (7 children), neonates Results: Of 73 children, 25 (34%) met all inclusion and exclusion criteria. Median age was 9.0 years, interquartile range (IQR) 2.1-14.1. Median time from symptom onset to first CT was 9.4 hours (IQR 4.5-20). ICH was due to coagulopathy or vascular cause in 22/25 children (88%). Median baseline ICH volume was 22.2mL (range 2-86mL). Hematoma expansion occurred in 7/25 (28%) with 2 head CTs. Median ICH volume expansion was 4mL (range 0.1-12mL), 32% (range 2-58%) of baseline ICH volume. Three had significant (>33%) expansion; all had coagulopathy or vascular etiologies of ICH. As expected, children with 2 head CTs had larger baseline ICH volumes (p=0.05) and were more likely to receive treatment for elevated intracranial pressure (ICP) (p=0.001) compared to children with ICH who had fewer than 2 head CTs within 48 hours. Conclusion: Hematoma expansion occurred in 28% of children with clinical concern for hematoma growth and was >33% in 12%. Repeat CT should be considered in those with large ICH and increased ICP. Head CTs were not obtained at prescribed time intervals; research CTs without clear benefit are not feasible in children.

Background Magnetic resonance diffusion-weighted imaging and perfusion-weighted imaging are able to identify ischaemic ‘footprints’ in transient ischaemic attack. Computed tomography perfusion (CTP) may be useful for patient triage and subsequent management. To date, less than 100 cases have been reported, and none have compared computed tomography perfusion to perfusion-weighted imaging (PWI). We sought to define the yield of computed tomography perfusion for the evaluation of transient ischaemic attack. Methods Consecutive patients with a discharge diagnosis of possible or definite transient ischaemic event who underwent computed tomography perfusion were included in this study. The presence of an ischaemic lesion was assessed on non-contrast computed tomography, automatically deconvolved CTPTMax (Time till the residue function reaches its maximum), and when available on diffusion-weighted imaging and PWITMax maps. Results Thirty-four patients were included and 17 underwent magnetic resonance imaging. Median delay between onset and computed tomography perfusion was 4.4 h (Interquartile range [IQR]: 1.9-9.6), and between computed tomography perfusion and magnetic resonance imaging was 11 h (Interquartile range: 3.8-22). Noncontrast computed tomography was negative in all cases, while CTPTMax identified an ischaemic lesion in 12/34 patients (35%). In the subgroup of patients with multimodal magnetic resonance imaging, an ischaemic lesion was found in six (35%) patients using CTPTMax versus nine (53%) on magnetic resonance imaging (five diffusion-weighted imaging, nine perfusion-weighted imaging). The additional yield of CTPTMax over computed tomography angiography was significant in the evaluation of transient ischaemic attack (12 vs. 3, McNemar, P = 0.004). Conclusions CTPTMax found an ischaemic lesion in one-third of acute transient ischaemic attack patients. Computed tomography perfusion may be an acceptable substitute when magnetic resonance imaging is unavailable or contraindicated, and has additional yield over computed tomography angiography. Further studies evaluating the outcome of patients with computed tomography perfusion lesions in transient ischaemic attack are justified at this time.

Perseverative behavior, manifest as re-cancelling or re-visiting targets, is distinct from spatial neglect. Perseveration is thought to reflect frontal or parietal lobe dysfunction, but the neuroanatomical correlates remain poorly defined and the interplay between neglect and perseveration is incompletely understood. We enrolled 87 consecutive patients with diffusion-weighted, perfusion-weighted imaging, and spatial neglect testing within 24 hours of right hemisphere ischemic stroke. The degrees of spatial neglect and perseveration were analyzed. Perseveration was apparent in 46% (40/87) of the patients; 28% (24/87) showed perseveration only; 18% (16/87) showed both perseveration and neglect; and 3% (3/87) showed neglect only. Perseverative behaviors occur in an inverted “U” shape: little neglect was associated with few perseverations; moderate neglect with high perseverations; and in severe neglect targets may not enter consciousness and perseverative responses decrease. Brodmann areas of dysfunction, and the caudate and putament, were assessed and volumetrically measured. In this study, the caudate and putamen were not associated with perseveration. After controlling for neglect, and volume of dysfunctional tissue, only Brodmann area 46 was associated with perseveration. Our results further support the notion that perseveration and neglect are distinct entities; while they often co-occur, acute dorsolateral prefrontal cortex ischemia is associated with perseveration specifically.

Background and Purpose— Diffusion-weighted imaging (DWI) is recommended for the evaluation of transient ischemic attack. Perfusion imaging can increase the yield of MRI in transient ischemic attack. We evaluated automated bolus perfusion (the time when the residue function reaches its maximum [TMax] and mean transit time [MTT]) and arterial spin labeling (ASL) sequences for the detection of ischemic lesions in patients with transient ischemic attack. Methods— We enrolled consecutive patients evaluated for suspicion of acute transient ischemic attack by multimodal MRI within 36 hours of symptom onset. Two independent raters assessed the presence and location of ischemic lesions blinded to the clinical presentation. The prevalence of ischemic lesions and the interrater agreement were1410 assessed. Results— From January 2010 to 2011, 93 patients were enrolled and 90 underwent perfusion imaging (69 bolus perfusion and 76 ASL). Overall, 25 of 93 patients (27%) were DWI-positive and 14 (15%) were perfusion-positive but DWI-negative (ASL n=9; TMax n=9; MTT n=2). MTT revealed an ischemic lesion in fewer patients than TMax (7 versus 20, P =0.004). Raters agreed on 89% of diffusion-weighted imaging cases, 89% of TMax, 87% o10f010 MTT, and 90% of ASL cases. The interrater agreement was good for DWI, TMax, and ASL (κ=0.73, 0.72, and 0.74, respectively) and fair for MTT (κ=0.43). Diffusion and/or perfusion were positive in 39 of 69 (57%) patients with a discharge diagnosis of possible ischemic event. Conclusions— Our results suggest that in patients referred for suspicion of transient ischemic attack, automated TMax is more sensitive than MTT, and both ASL and TMax increase the yield of MRI for the detection of ischemic lesions.

Background: The optimal diagnostic evaluation for patients with a spontaneous intracerebral hemorrhage (ICH) or intraventricular hemorrhage (IVH) remains controversial. We aimed to assess the utility of early magnetic resonance imaging (MRI) in the diagnosis and management of these patients. Methods: Consecutive patients with spontaneous ICH or IVH were prospectively enrolled in this NIH funded study. Patients were excluded if they had a known (pre-existing) ICH source, a known inability to undergo MRI (e.g. pacemaker) or a Glasgow coma scale score ≤5. In addition to non-contrast brain CT and laboratory testing (including a toxicology screen and EKG), patients underwent gadolinium-enhanced MRI/MRA. Catheter angiography was pursued if the patient met pre-specified criteria. Survivors returned for a 90 day follow-up clinic visit with a repeat MRI. Based on clinical admission data and the initial head CT a presumed ICH cause was assigned by the treating neurocritical care/stroke neurologist. A choice was made out of 12 pre-specified etiologies. After subsequent review of the MRI, the neurologist was given the opportunity to modify the presumed ICH cause. The ‘gold standard’ ICH etiology was determined by a panel of two outside, independent and blinded ICH clinician experts after review of the complete medical record, first without the MRI results, reference standard 1 (RS1), and then with the MRI results, reference standard 2 (RS2). Changes in diagnostic category, diagnostic confidence and management were systematically recorded. The diagnostic yield of MRI was determined for each of the 12 diagnostic categories. Results: 180 consecutive patients were prospectively enrolled. All patients underwent at least one MRI. No adverse events occurred during MRI acquisition. In 20 patients the MRI was obtained after surgical hematoma evacuation. Mean age was 62±17 years, 47% were female, and 71% had a history of hypertension. Median (IQR) GCS was 14 (10-15). Median and mean ICH volumes were 12 mL (4-35) and 24 (±28) mL. Hematoma location was lobar in 46% and deep in 39% of patients; 43% had associated IVH. Based on RS2, the final ICH diagnosis was hypertension in 44% and cerebral amyloid angiopathy in 13% of patients. MRI led to a change in diagnostic category in 14% of patients using RS1 as the reference, and 18% using RS2. MRI resulted in an improvement in diagnostic confidence in an additional 23% and 26% of patients, respectively. Management was changed in 13% of patients. Within diagnostic categories, the yield of MRI was highest for establishing diagnoses of ICH secondary to cerebral venous thrombosis (56%), ischemic stroke with hemorrhagic transformation (43%), cerebral amyloid angiopathy (35%), neoplasms (33%), and vascular malformations (31%). Conclusions: The results of this study demonstrate substantial additive clinical benefit of early routine MRI in patients with spontaneous ICH and/or IVH.

Introduction: The cause of (presumed) ischemic lesions associated with intracerebral hemorrhage (ICH) is poorly understood. We investigated the relationship between BP lowering and the incidence of ipsilateral diffusion weighted imaging (DWI) lesions in a prospective ICH cohort. Methods: We prospectively enrolled consecutive ICH patients in the NIH-funded DiAgnostic Utility of MRI in Spontaneous Intracerebral Hemorrhage (DASH) study. Two neuroradiologists reviewed the MRIs for evidence of ischemia, defined as: reduced diffusivity ipsilateral to the ICH without evidence of blood products on FLAIR or GRE. Only DWI lesions attributed to tissue compression; vessel compression; or hypoperfusion were included. Patients with post-operative MRIs or insufficient BP data were excluded. Mean arterial blood pressures (MAP) were recorded on admission, and at 6, 12, 18, and 24 hours. Chi-square and t-tests were used as appropriate. Receiver operator characteristic (ROC) curves were created to assess accuracy of predicting DWI lesions. Results: Of 160 patients, 136 met inclusion criteria (median age: 63 (IQR 50-77); median ICH volume: 10 (IQR 4-33cc); median NIHSS: 6 (IQR 2-16); median GCS: 15 (IQR 10-15); median onset to MRI 40 hrs (IQR 25-75). DWI lesions were observed in 78 (57%) patients. Patients with DWI lesions had higher ICH volumes (32 vs 12cc, p < 0.001); higher admission MAP (125 vs 113mmHg, p=0.006); higher maximal MAP reduction (46 vs 33mmHg, p=0.008); and higher mean %MAP reduction (25 vs 17% p=0.006). DWI lesions were not associated with lowest MAP (80 vs 79mmHg, p=0.97) or mean MAP (90 vs 91, p=0.62). ICH volume and maximum MAP reduction predicted DWI lesions with an area under curve (AUC) of 0.70 (95% CI: 0.61-0.78) and 0.63 (95% CI: 0.53-0.72) respectively. Controlling for ICH volume using logistic regression: for every 10% reduction in MAP the risk of DWI lesions increased substantially (OR 1.28, 95% CI: 1.01-1.62). Similarly, each 10% reduction in mean MAP over the first 24 hours had an increased risk of detecting DWI lesions (OR 1.3, 95% CI: 1.01-1.69). The likelihood of having a DWI lesion was highest in patients with > 30mmHg drop in MAP (OR 2.3, 95% CI: 1.09-4.6). In ICH < 10cc (N=70), DWI lesions were not associated with ICH volume (4.1 vs 4.8cc, p=0.40) but with higher admission MAP (125 vs 112mmHg, p=0.045); maximum MAP reduction (45 vs 31 mmHg, p=0.03); and maximum % MAP reduction (34 vs 25%, p=0.03). Conclusions: ICH volume and large BP reductions are both associated with the presence of DWI lesions. The likelihood of having a DWI lesion went up by 30% for each 10% drop in MAP from admission, and was 230% higher in patients with > 30 mmHg reduction in MAP. These data suggest that aggressive BP reduction may contribute to ICH associated ischemia, and that percentage-based BP goals may be more appropriate than “one-size fits all” for clinical trial design. Future studies are needed to clarify causation.

Background: The modified Rankin Scale score (mRS) is routinely used to evaluate functional outcome following stroke. The Short Form 12 version 2 (SF-12v2) is a 2 minute physical and mental health survey that measures 8 domains of health and is: widely used, norm-based, and comprehensive. We sought to compare physical component summary (PCS) scores, mental component summary (MCS) scores, and their sub-scores to the mRS scores. Each metric provides unique and relevant health information. Methods: Consecutive ICH patients were prospectively enrolled in the Diagnostic Accuracy of MRI in Spontaneous Intracerebral Hemorrhage (DASH) study. Three month evaluations were done in clinic when possible, while 1-year evaluations were obtained via semi-structured telephone interviews. Responses were adjusted for age and gender based on published data. Physical functioning ([PF] ability to perform activities), limitation in the amount and types of physical activities to the point that less is accomplished than desired (role physical [RP]), mental health ([MH] feelings of anxiety and depression), and PCS scores were compared to the mRS and to each other as they have the highest internal consistency based on published data. Significant depressive symptoms was defined as >10 points (1 standard deviation) below the mean. Results: Seventy-nine ICH patients had the SF12v2 and mRS available for assessment: mean age 59±17 years and ICH volume 22±27cc. Physical functioning at 3 months was correlated with mRS as assessed by: the PCS (R 2 =0.39); PF (R 2 =0.56); and RP (R 2 =0.52). At 12 months the mRS was more correlated with each sub component score and the PCS (R 2 =0.53). Feelings of anxiety and depression were not correlated with either 3 or 12 month mRS (R 2 = 0.06 and 0.15 respectively). At 3 months 6 (14%) patients with a mRS ≤2 had signs of depression and 6 (19%) of patients with mRS 3-4 had signs of depression as assessed by MH. More patients with mRS ≥2 had depressive symptoms (22% vs 4%, p=0.09) at 3 months and at 12 months (14% vs 0%, χ 2 =4.7, p=0.04) compared to those with a mRS of 0-1. Conclusions: The self reported physical components of the SF12v2 have only a fair correlation with the mRS at 3 and 12 months after intracerebral hemorrhage. Feelings of depression do not have a linear relationship with mRS, but a higher proportion of patients with increased mRS have significant depressive symptoms at one year.

Background: Predicting outcome for comatose post-cardiac arrest survivors is challenging and compounded by the use of therapeutic hypothermia and sedative agents in recent years. Previous studies suggest that brain abnormalities on MRI are predictive for poor outcome. MRI based predictive factors are attractive because they are not affected by drugs or metabolic derangements; however, most of the methods proposed require image post-processing with specialized software. We assessed the prognostic value of color apparent diffusion coefficient (ADC) maps in a prospective study. Methods: Consecutive patients who remained comatose after cardiac arrest were prospectively enrolled. Color ADC maps were created by assigning computed ADC values to 8 colors of spectrum ranging from red to blue ( Figure ). The color ADC maps were not available to the clinical teams caring for the patient. Two raters (a neurocritical care/stroke neurologist and a medical student) independently and blinded reviewed the color ADC maps and predicted 3 month outcome as poor (Glasgow Outcome Scale (GOS) 1 or 2), impaired (GOS=3) or good (GOS of 4 or 5). Both raters were “trained” by viewing 4 examples of patients with good, impaired and poor outcomes. A 3 month GOS of 3-5 was considered a favorable outcome. The agreement between raters and the predictive performance of the color ADC maps were assessed. Results: 112 color ADC maps of 94 patients (56% with poor, 12% with impaired, and 32% with good outcome) were reviewed: age 59±15 years, 36% females, 69% underwent therapeutic hypothermia, median (IQR) arrest duration 20min (14-30), and time between the arrest and MRI 82hours (60-141). Kappa with quadratic weighting for agreement on predicting all 3 levels of outcomes was 0.74, while kappa for favorable vs. unfavorable outcome was 0.76. For the two reviewers, the sensitivity for predicting poor outcome was 0.85 (95%CI 0.73-0.92) and 0.78 (0.66-0.87), the specificity 0.81(0.66-0.90) and 0.74(0.59-0.86), and the true positive predictive rate 86% (74-93%) and 81% (69-89%), respectively. After excluding early (≤24 hours) and late (>120 hours) scans (ADC changes are time dependent and most apparent after day 1 and before day 6), the specificity improved to 0.87 (0.68-0.96) and 0.77 (0.57-0.89), respectively. Conclusion: MRI color ADC maps hold promise as a useful and easy to interpret adjunct for predicting outcome of comatose post-cardiac arrest patients in the first few days after the arrest. Since these maps do not require post-processing and can be created in real-time, they can easily be implemented in the clinical setting.

Introduction: Chronic hypertension is a common cause of spontaneous intracerebral hemorrhage (ICH), but not all patients who are hypertensive on hospital presentation have an ICH caused by hypertension (htnICH). We sought to determine blood pressure (BP) thresholds that correlated with a presumed htnICH in a prospective cohort. Methods: The NIH-funded Diagnostic Utility of MRI in Spontaneous Intracerebral Hemorrhage (DASH) study prospectively enrolled consecutive ICH patients to determine the utility of routine MRI in the diagnosis and management of these patients. Contrast angiography was pursued in a predefined patient subset. At 3 months, ICH cause was determined by the treating stroke physician after review of all clinical information, including MRI in the acute and chronic phase, pathology, and clinic follow-up, as available. Statistical analyses were done using SPSS: χ2; 2 tailed t-tests; and Mann-Whitney U tests were used as appropriate. Receiver operator characteristic (ROC) curves were created and results expressed as area under curve (AUC). Results: We included 136 patients in this report (age: 63±17yrs; ICH volume: 22±27cc; NIHSS: 9±8; GCS: 13±3). Of these, 70% had a history of hypertension, 40% had an admission SBP> 180mmHg, and 22% an admission SBP >200mmHg. Sixty patients (44%) had htnICH as their final diagnosis. A history of hypertension was associated with htnICH (χ2=11.8, p 200mmHg was 90% specific and 37% sensitive, and a MAP >132mmHg was 90% specific and 45% sensitive. Using ROC analysis, MAP predicted hypertensive etiology with an AUC of 0.75 (p132mmHg on admission tended to have larger ICH volumes (44 vs 24cc, p=0.07) and higher NIHSS (10 vs 6, p=0.21), but did not differ by location from those with a MAP132mmHg was 64% specific and 95% sensitive for htnICH. Conclusions: In our cohort, a history of hypertension predicted htnICH no better than chance. An admission SBP >200mmHg or a MAP >132mmHg predicted htnICH in 90% of these patients, but missed two-thirds of cases. ICH location alone was a sensitive predictor of htnICH, but blood pressure thresholds were more specific.

Background: Intracerebral hemorrhage (ICH) trials often define poor outcome as a modified Rankin Scale Score (mRS) ≥4. While mRS score thresholds are important for demonstrating treatment effect, they do no tell physicians if a treatment outcome is “worth it.” Little self-reported quality of life (QOL) data exists to guide physicians, so opinions during academic discussions and/or family meetings may be driven by personal bias. We sought to describe both self and surrogate reported QOL in ICH survivors in relation to mRS score. Methods: Consecutive ICH patient were prospectively enrolled in the NIH-funded DiAgnostic Utility of MRI in Spontaneous Intracerebral Hemorrhage (DASH) study. Survivors were followed up at 3 months in clinic and at 12 months by telephone. At each time point, patients or surrogates were asked to rate the patient’s QOL as: excellent, good, fair, or poor. mRS scores were determined by an investigator through a semi-structured interview. Results: Self reported QOL was available in 95 patients with 143 QOL ratings, and surrogate reported QOL in 66 patients with 84 QOL ratings. Of self-reporters with a mRS of 4, 29% reported at least a good QOL, and 93% rated at least a fair QOL ( Figure 1). Of self-reporters with a mRS of 3, 58% reported at least a good QOL, and 97% rated at least a fair QOL. Patients with a mRS of 4 were less likely to report a poor QOL than surrogate raters (χ 2 =3.9, p=0.05, Figure 2). In all patients, both self-reported and surrogate reported QOL were only loosely associated with mRS (R 2 =0.25 and R 2 =0.12, respectively). Forty-eight patients had self-reported QOL at 3 and 12 months. In these patients mRS improved in 16 (33%) patients without an associated improvement in QOL. Seven patients (15%) reported an improvement in QOL, but only 3 had an improvement in their mRS between 3 and 12 months. In 3 (6%) patients, the mRS worsened while QOL remained unchanged. No change in mRS was seen in 8 (17%) patients who reported worse QOL at 12 than at 3 months. Conclusions: Self reported QOL is only loosely correlated with mRS for the individual patient. Patient surrogates are more prone to rate QOL of patients with a mRS of 4 as poor than patients themselves. These data are clinically relevant as mRS alone may not capture the satisfaction of the individual patient with their outcome.

Introduction Optimal blood pressure control following acute ICH remains controversial. Blood pressure reduction may limit hematoma expansion, but may also cause hypoperfusion and further damage in the perihematomal region. We examined the relationship between the extent and speed of systolic blood pressure (SBP) lowering and perihematomal perfusion and ischemia. Methods Consecutive prospectively enrolled ICH patients with an MRI within 24 hours of symptom onset were included. Hourly SBPs were recorded from hospital presentation to MRI acquisition. Aggressive BP lowering was defined as: ≥30% reduction from baseline and at least one BP drop of ≥35mmHg/h. Hematoma volume was considered large if ≥30cc. FLAIR, GRE and perfusion weighted images were co-registered. T max maps were generated using RApid processing of PerfusIon and Diffusion (RAPID) software. The perihematomal region was defined by outlining the perihematomal edema on FLAIR images and subtracting the inner surface of blood products on the GRE generating a perihematomal rim. Statistical analyses were done using MATLAB. Results Twenty-seven patients were included (age: 62.7±17.9years; ICH volume: 26±26cc). Six of 27 (22%) patients experienced aggressive SBP lowering. Numbers reported: mean(IQR). The aggressiveness of SBP reduction was similar in large versus small hematomas: the percentage drop in SBP was 26% (10-33) vs. 21% (13-28), and the highest SBP drop was 43mmHg/h (29-56) versus 46mmHg/h (31-51), p=0.61 and p=0.92, respectively. Patients with SBP drops ≥35mmHg/h tended to have delayed bolus arrival (high T max ), 6.1s (4.8-7.7) versus 5.3s (3.5-5.6) (p=0.06), as did patients with SBP drops ≥30%,T max values 7.3s (6.2-8.6) versus 5.3s (3.6-6.2) (p=0.014). The effect was magnified in patients with a large (≥30%) and fast (≥35mmHg/h) drop in SBP, despite hematoma volumes being equivalent (p=0.01, Figure1 ). Five of 6 patients with aggressive SBP lowering had a T max >6s. Conversely, 7 out of 8 patients with modest SBP reduction had a T max ≤6s ( Figure2 ). Out of 11 patients with T max >6s, 8 had DWI lesions (73%) versus 4 of 16 (25%) with T max ≤6s (p=0.02). Conclusions: Aggressive SBP lowering in acute ICH is associated with high T max values in the perihematomal region irrespective of hematoma volume. High T max values in turn are associated with DWI lesions.

Introduction: The diagnosis of transient ischemic attack (TIA) can be difficult. We evaluated the yield of automated CT perfusion (CTP) in addition to non contrast head CT and CT angiography for the detection of acute ischemic lesions among TIA patients and compare it with multimodal MRI [diffusion weighted imaging (DWI) and perfusion weighted imaging (PWI)] results. Methods: Consecutive patients with a final diagnosis of transient neurological symptoms secondary to ischemia who underwent acute CT, CTP and CTA were enrolled. A subset of the patients underwent multimodal MRI. Presence of symptomatic stenosis was assessed on CTA by the treating team at the time of patient evaluation. The presence and location of acute ischemic lesions was assessed on: CT, CTP, DWI, and PWI. The rater was blinded to the clinical presentation. The presence of a MR or CT perfusion lesion was assessed using TMax. TMax maps for both CT and MR were automatically generated by RApid processing of PerfusIon and Diffusion (RAPID) software. Results: Thirty-three patients were enrolled: median age was 66 years old (IQR 58-82); median ABCD2 score was 4 (IQR 3-5); median delay from symptom onset to CTP was 4.6 hours (IQR 2-9.6). MRI was performed in 23 (70%) patients after a median delay of 20.4 hours (IQR 8.3-30.6) after symptom onset and 5.5 hours (IQR 3.4-20.8) after CTP. No patient experienced recurrence between CTP and MRI. Non-contrast head CT did not demonstrate any acute ischemic lesions. CTA found 3 symptomatic vessel lesions. CTP revealed a focal ischemic lesion in 11 patients (33%). The lesion location concurred with the presumed symptom side in all but one patient, and with the 3 symptomatic vessel lesions found on CTA. DWI was performed in 23 patients, and was positive in 7 (30%). Three of these patients had a negative early CTP. CTP was positive in 3 patients with subsequent normal DWI. MR perfusion was performed in 17 patients and found an acute ischemic lesion in 8 (47%) of them. Four of these MR PWI positive patients also had a positive CTP. In 3 patients with a negative MR PWI, CTP detected an acute ischemic lesion. At least 1 of the 3 modalities (CTP, DWI, PWI) was positive among 10/17 (59%) of patients. Conclusion: The results of this exploratory study suggest that automatically processed CTP increases the yield of head CT and CTA for the evaluation of TIA patients. In some cases CTP found evidence of transient focal ischemia that was not detected by MRI, in others CTP was negative and DWI or PWI was positive. These findings suggest that CTP and MRI may be complementary techniques to confirm the ischemic nature of transient neurological symptoms.

Background: Since transient ischemic attacks (TIAs) can predict future stroke, it is important to distinguish true vascular events from non-vascular etiologies. Arterial spin labeling (ASL) is a non-contrast magnetic resonance (MR) method that is sensitive to cerebral perfusion and arterial arrival delays. Due to its high sensitivity to minor perfusion alterations, we hypothesized that ASL abnormalities would be identified frequently in TIA patients, and could therefore help increase clinicians’ confidence in the diagnosis. Methods: We acquired diffusion-weighted imaging (DWI), intracranial MR angiography (MRA), and ASL in a prospective cohort of TIA patients. A subset of these patients also received bolus contrast perfusion-weighted imaging (PWI). Two neuroradiologists evaluated the images in a blinded fashion to determine the frequency of abnormalities on each imaging sequence. Kappa (ĸ) statistics were used to assess agreement, and the χ2 test was used to detect differences in the proportions of abnormal studies. Results: 76 patients met the inclusion criteria, 48 (63%) of whom received PWI. ASL was abnormal in 62%, a much higher frequency compared with DWI (24%) and intracranial MRA (13%). ASL significantly increased the MR imaging yield above the combined DWI and MRA yield (62 vs. 32%, p < 0.05). Arterial transit artifact in vascular borderzones was the most common ASL abnormality (present in 51%); other abnormalities included focal high or low ASL signal (11%). PWI was abnormal in 31% of patients, and in these, ASL was abnormal in 14 out of 15 cases (93%). In hemispheric TIA patients, both PWI and ASL findings were more common in the symptomatic hemisphere. Agreement between neuroradiologists regarding abnormal studies was good for ASL and PWI [ĸ = 0.69 (95% CI 0.53–0.86) and ĸ = 0.66 (95% CI 0.43–0.89), respectively]. Conclusion: In TIA patients, perfusion-related alterations on ASL were more frequently detected compared with PWI or intracranial MRA and were most frequently associated with the symptomatic hemisphere. Almost all cases with a PWI lesion also had an ASL lesion. These results suggest that ASL may aid in the workup and triage of TIA patients, particularly those who cannot undergo a contrast study.

Prognosis after stroke in children is difficult given the paucity of literature regarding motor and cognitive recovery. Spatial neglect has been described in children after stroke, yet little evidence exists to guide clinicians and parents regarding its resolution. Wallerian degeneration on magnetic resonance imaging (MRI) suggests poor recovery in neonates and adults. We report near complete resolution of spatial neglect in 4 weeks and significant improvement in hemiplegia in a 9-year-old boy with a right anterior cerebral artery and middle cerebral artery infarction, despite Wallerian degeneration apparent on diffusion-weighted imaging. Serial assessment of neglect documenting the rapid course of recovery is the unique feature of this case and may help serve as a guide to pediatricians and neurologists in assessment of young patients and counseling of parents. The lack of published outcome data suggests a need for larger studies about the recovery of spatial neglect and other cognitive symptoms following pediatric stroke.

Background and Purpose— Although intracerebral hemorrhage (ICH) volume and location are important predictors of outcome in adults, few data exist in children. Methods— A consecutive cohort of children, including full-term newborns to those younger than 18 years of age with nontraumatic, acute ICH and head CT available for analysis were studied. Clinical information was abstracted via chart review. Hemorrhage volume was expressed as percentage of total brain volume (TBV) with large hemorrhage defined as ≥4% of TBV. Hemorrhages were manually traced on each head CT slice and volumes were calculated by multiplying by slice thickness. Location was classified as supratentorial or infratentorial. Logistic regression was used to identify predictors of poor neurological outcome, defined as a Glasgow outcome scale ≤2 (death or persistent vegetative state). Results— Thirty children were included, median age 6 years. Median ICH volume was 20.4 cm 3 and median ICH size as a percentage of TBV was 1.9%. Only 4 of 22 children with ICH P =0.03). In multivariate analysis, hemorrhage ≥4% of TBV (OR, 22.5; 95% CI, 1.4–354; P =0.03) independently predicted poor outcome 30 days after ICH. In this small sample, infratentorial hemorrhage location and the presence of intraventricular hemorrhage did not predict poor outcome. Conclusions— ICH volume predicts neurological outcome at 30 days in children, with worst outcome when hemorrhage is ≥4% of TBV. Location and ICH etiology may also be important. These findings identify children with ICH who are candidates for aggressive management and may influence counseling regarding prognosis.

Lesion/deficit association studies of aphasia commonly focus on one brain region as primarily responsible for a particular language deficit. However, functional imaging and some lesion studies indicate that multiple brain regions are likely necessary for any language task. We tested 156 acute stroke patients on basic language tasks (naming and spoken and written word comprehension) and magnetic resonance diffusion and perfusion imaging to determine the relative contributions of various brain regions to each task. Multivariate linear regression analysis indicated that the error rate on each task was best predicted by dysfunction in several perisylvian regions, with both common and distinct regions for the 3 tasks.

Studies of the cognitive outcome after shunt insertion for treatment of Normal Pressure Hydrocephalus have reported widely mixed results. We prospectively studied performance of 60 patients with Normal Pressure Hydrocephalus on a comprehensive battery of neuropsychological tests before and after shunt surgery to determine which cognitive functions improve with shunt insertion. We also administered a subset of cognitive tests before and after temporary controlled drainage of cerebrospinal fluid to determine if change on this brief subset of tests after drainage could predict which patients would show cognitive improvement three to six months after shunt insertion. There was a significant improvement in learning, retention, and delayed recall of verbal memory three to six months after surgery (using paired t-tests). The majority (74%) of patients showed significant improvement (by at least one standard deviation) on at least one of the memory tests. Absence of improvement on verbal memory after temporary drainage of cerebrospinal fluid had a high negative predictive value for improvement on memory tests at 3–6 months after surgery (96%;p= 0.0005). Also, the magnitude of improvement from Baseline to Post-Drainage on few specific tests of learning and recall significantly predicted the magnitude of improvement after shunt surgery on the same tests (r2= 0.32–0.58;p= 0.04–0.001). Results indicate that testing before and after temporary drainage may be useful in predicting which patients are less likely to improve in memory with shunting.

Background. Abnormalities in diffusion-weighted (DWI) and perfusion-weighted (PWI) magnetic resonance imaging (MRI) are thought to reflect the presence of brain tissue at risk for ischemic stroke. Many patients with acute ischemic stroke have a mismatch pattern in which the PWI volume is larger than the DWI lesion. This mismatch typically resolves over 24-48 hours. Little is known about the presence of DWI-PWI mismatch in later stages of stroke. Methods. This is a retrospective study of 122 patients admitted with a diagnosis of acute ischemic stroke who had DWI and PWI abnormalities on studies performed within 7 days of onset of symptoms. Patients were divided into two groups: those with MRI performed