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In this review article, we summarized the current advances in rescue management for reperfusion therapy of acute ischemic stroke from large vessel occlusion due to underlying intracranial atherosclerotic stenosis (ICAS). It is estimated that 24-47% of patients with acute vertebrobasilar artery occlusion have underlying ICAS and superimposed in situ thrombosis. These patients have been found to have longer procedure times, lower recanalization rates, higher rates of reocclusion and lower rates of favorable outcomes than patients with embolic occlusion. Here, we discuss the most recent literature regarding the use of glycoprotein IIb/IIIa inhibitors, angioplasty alone, or angioplasty with stenting for rescue therapy in the setting of failed recanalization or instant/imminent reocclusion during thrombectomy. We also present a case of rescue therapy post intravenous tPA and thrombectomy with intra-arterial tirofiban and balloon angioplasty followed by oral dual antiplatelet therapy in a patient with dominant vertebral artery occlusion due to ICAS. Based on the available literature data, we conclude that glycoprotein IIb/IIIa is a reasonably safe and effective rescue therapy for patients who have had a failed thrombectomy or have residual severe intracranial stenosis. Balloon angioplasty and/or stenting may be helpful as a rescue treatment for patients who have had a failed thrombectomy or are at risk of reocclusion. The effectiveness of immediate stenting for residual stenosis after successful thrombectomy is still uncertain. Rescue therapy does not appear to increase the risk of sICH. Randomized controlled trials are warranted to prove the efficacy of rescue therapy.

BackgroundProper evaluation of ocular fundi is an integral part of neurological examination. Unfortunately, neurology residents are increasingly uncomfortable performing fundoscopy and interpreting findings because of diminishing skills and lack of experience. This became more prominent during the COVID-19 pandemic as fundoscopy requires proximity to the patient. With the recent dramatic improvement of smartphone cameras, fundus photography using the PanOptic Ophthalmoscope (Welch Allyn, Skaneateles Falls, NY) with a smartphone adapter offered an alternative to direct fundoscopic examination. We present the first experience with our own design of a universal smartphone adapter.MethodsThis is a single-center case series, consecutive for a single user and certain presenting neurological symptoms, which is aimed to evaluate the feasibility and practicality of a new, universal PanOptic smartphone adapter. Presenting symptoms included headache, ocular symptoms, seizure, or encephalopathy. We used 3D modeling and printing techniques to create the adapter. We also developed a methodology of capturing stereoscopic images of the optic disc using a single smartphone camera, but the method was not systematically evaluated in this paper.ResultsHere we present our initial experience of fundus video/photography in patients, who presented with encephalopathy, headache, seizure, vision loss, and other ocular symptoms. Fundoscopic abnormalities were discovered in 11 out of 100 patients. Some were incidental findings and were unrelated to the presentation. In one case, fundoscopy played a critical role in establishing the correct diagnosis.ConclusionsOur custom-designed smartphone adapter allowed obtaining high-quality video and photo recordings using PanOptic Ophthalmoscope. The acquisition of high-quality photos enables a high-yield diagnostic tool and allows revisiting the image in the patient's chart. Improvement of smartphone cameras opens vast horizons for stereo-fundoscopy and 3D reconstruction of the ocular fundus without using sophisticated and costly equipment. Microscopic eye movements allow taking snapshots of two side-by-side photos for 3D reconstruction and stereoscopic image viewing, which is the next level of optic disc assessment.

ObjectiveWe aimed to investigate if early revascularization in patients with suspected coronary artery disease can be effectively predicted by integrating clinical data and quantitative image features derived from perfusion SPECT (MPS) by machine learning (ML) approach.Methods713 rest (201)Thallium/stress (99m)Technetium MPS studies with correlating invasive angiography with 372 revascularization events (275 PCI/97 CABG) within 90 days after MPS (91% within 30 days) were considered. Transient ischemic dilation, stress combined supine/prone total perfusion deficit (TPD), supine rest and stress TPD, exercise ejection fraction, and end-systolic volume, along with clinical parameters including patient gender, history of hypertension and diabetes mellitus, ST-depression on baseline ECG, ECG and clinical response during stress, and post-ECG probability by boosted ensemble ML algorithm (LogitBoost) to predict revascularization events. These features were selected using an automated feature selection algorithm from all available clinical and quantitative data (33 parameters). Tenfold cross-validation was utilized to train and test the prediction model. The prediction of revascularization by ML algorithm was compared to standalone measures of perfusion and visual analysis by two experienced readers utilizing all imaging, quantitative, and clinical data.ResultsThe sensitivity of machine learning (ML) (73.6% ± 4.3%) for prediction of revascularization was similar to one reader (73.9% ± 4.6%) and standalone measures of perfusion (75.5% ± 4.5%). The specificity of ML (74.7% ± 4.2%) was also better than both expert readers (67.2% ± 4.9% and 66.0% ± 5.0%, P < .05), but was similar to ischemic TPD (68.3% ± 4.9%, P < .05). The receiver operator characteristics areas under curve for ML (0.81 ± 0.02) was similar to reader 1 (0.81 ± 0.02) but superior to reader 2 (0.72 ± 0.02, P < .01) and standalone measure of perfusion (0.77 ± 0.02, P < .01).ConclusionML approach is comparable or better than experienced readers in prediction of the early revascularization after MPS, and is significantly better than standalone measures of perfusion derived from MPS.

Introduction: Coronary Arteriovenous Malformations (AVM) can lead to various cardiovascular events. The severity of clinical manifestation depends on the degree of the malformation. The significance of major arterial shunt is that they can deprive the myocardium of the necessary amount of blood, leading to myocardial ischemia, and potentially tachycardia, left ventricular dilatation and heart failure secondary to increased stroke volume and cardiac output. Cardiac computed tomography (CCT) has proven to be a good non-invasive diagnostic tool in the detection of coronary Arteriovenous Malformations., Case Presentation: We include 4 patients, who presented with various symptoms in relation to the coronary Arteriovenous Malformations. Diagnostic confirmation was made non-invasively using multi-row detector cardiac computed tomography (MDCT)., Conclusion: Coronary Arteriovenous Malformation is a rare congenital disease which can produce symptoms of varying severity depending on the size of the malformation. CCT angiography can help in non-invasively diagnosing the malformation along with revealing the anatomic details, which can be used for surgical planning, or for better medical management of the patients.