Intravenous tissue plasminogen activator (IV-TPA), administered within 4.5 h of symptom onset, is the only therapeutic agent approved for achieving arterial recanalization in acute ischemic stroke. Current major guidelines recommend the use of a standard dose (0.9 mg/kg bodyweight; maximum 90 mg) of IV-TPA. However, comparable efficacy of IV-TPA was demonstrated in the observational studies from Japan when a lower dose (0.6 mg/kg bodyweight; maximum 60 mg) was used and later approved by the regulatory authorities. Although limited in numbers, considerable variations in the dose of IV-TPA are noted in recent publications from Asia, with variable results and optimal dose of TPA in Asia remains controversial. The authors present a systemic review of the existing literature and compare the efficacy and safety of standard-versus the low-dose IV-TPA therapy in acute ischemic stroke.

Currently employed diagnostic ultrasonography provides clinically relevant information about cerebral hemodynamic changes in patients with cerebrovascular ischemia. The information thus obtained is often helpful to the physician for establishing or confirming the diagnosis and prognosis as well as in taking appropriate therapeutic decisions. It is associated with a high temporal resolution and can be performed bedside for rapid diagnosis as well as prolonged monitoring. Transcranial Doppler (TCD) ultrasonography is a non-invasive diagnostic modality that provides physiological information regarding various intracranial hemodynamic alterations in patients with cerebrovascular ischemia. Extended applications of TCD are useful in understanding various pathophysiological mechanisms responsible for the clinical manifestations of cerebrovascular ischemia. Thus, TCD is aptly called as the 'stethoscope' of a stroke neurologist. Cerebrovascular ultrasonography is considered as an essential component of a comprehensive stroke center. We have reviewed various recent patents pertaining to the applications of cerebrovascular ultrasonography employed in the selection of stroke patients for various therapeutic interventions.

Swallowing apraxia is an intriguing type of apraxia where the patient cannot swallow despite normal neurological examinations including motor, sensory and cerebellar function. In this case report, we present a 60-year-old hypertensive male with swallowing apraxia. There was no attempt to swallow when food materials were given inside his mouth. Although he had normal examination findings including intact lip, tongue, palatal movement, and gag reflex. His cognition was also intact, as he could follow simple commands accurately. Except for a small infarct in the right precentral gyrus in the MRI (Magnetic Resonance Imaging) of the brain, his investigation findings were normal. We treated him with nasogastric feeding, and he gradually recovered over a month. Clinicians should consider swallowing apraxia as one of the clinical features of stroke when patients present with acute onset of swallowing problems. This case report is believed to increase awareness regarding this condition and add valuable information to relevant further studies.

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Moyamoya disease is a disease in which certain arteries in the brain are constricted. Blood flow is blocked by the constriction, and also by blood clots (thrombosis). A collateral circulation develops around the blocked vessels to compensate for the blockage, but the collateral vessels are small, weak, and prone to bleeding, aneurysm and thrombosis which may result in TIA, recurrent ischemic or hemorrhagic stroke or seizure. The disease may manifest in pediatric age or young adults. In May 2019 we have diagnosed a young lady with Moyamoya disease who presented with right sided hemiplegia, motor aphasia and dysphagia. She was labeled as hypertensive 6 months prior to this event and used to take anti-hypertensive irregularly and gave past history of occasional headache. Her CT scan and MRI of brain revealed left sided ischemic infarct involving frontotemporoparietal region and cerebral angiogram revealed narrowing of left MCA and non-visualization of distal part. There is extensive fine collaterals (Moyamoya vessels) giving the appearance of puffed smoke. The right ACA and MCA were also narrowed with appearance of early collateral vessels. She was treated with aspirin, PPI, NG feeding, antihypertensive medication, physiotherapy, rehabilitation therapy and other supportive care. His condition gradually improved and discharged on 2.7.19. He was referred to Department of Neurosurgery for cerebral revascularization by STA-MCA (superficial temporal and middle cerebral arteries) bypass surgery after stabilization and MR perfusion study. Journal of Armed Forces Medical College Bangladesh Vol.15 (1) 2019: 110-113