 Hello everyone, today I am going to present my paper, Susceptible Weighted Imaging and Effective Auxiliary Sequence that Enhance Insight into the Imaging of the Stroke. Coming to others, it's me Vinay Kumar, President of the D.Y. Partial Medical College and done under the guidance of Dr. Sanjay M. Kalatkarsar, he is a professor, Dr. D.Y. Partial Medical College, Pune and next under Dr. Krishnath Ejasar, Assistant Professor of the D.Y. Partial Medical College, Pune. Coming to introduction, HAKEI 1997 first proposed and patented SWI Imaging which was subsequently implemented after 2004 on commercial scanners. Susceptibility is an expression of paramagnetic components post hemorrhage like ferritin and hemocytrin. In the presence of these paramagnetic components resulting in deterioration of the MR signals from the tissue, suggesting an interpreter of the hemorrhagic incidents. It exhibits susceptibility differences in tissue showing acute hemorrhage, acute thrombus, deoxynated blood in the vein, hemocytrin, calcium and iron which exhibits susceptibility differences from the surrounding. Acute stroke can show acute thrombus, deoxynated blood in the veins and acute hemorrhage and hence is helpful in stroke evaluation. It increases the conspiracy of the hemorrhage nearly 6-folds as compared to G.R.E. Hence it should be included as part of routine imaging of the brain in stroke. Coming to the aim, aim is to evaluate the utility of the SWI sequences in stroke imaging and assess supplemental information provided by SWI in an acute stroke scenario, materials and methods, data collection and patient selection. This was a steady performing tertiary care center among 50 patients who presented with acute neurological symptoms such as limb weakness, loss of consciousness and sudden onset of severe headache. Image acquisition, a 3-T, 3-Tesla MRI machine, Vida Siemens was used. Our routine brain protocol includes T1 weighted image, T2 weighted image, flare in actual sections and diffusion weighted image, apparent diffusion coefficient image, T1 weighted subjectile, T2 weighted coronal, MRV and MRA was done if indicated. SWI sequence, image parameters were repetition time of 27 milliseconds, time to echo 20 milliseconds, fractional nsv property of 10 degrees, 1.8 mm slice thickness, the field of vision of 200 mm square, 270 seconds acquisition time. Image analysis, experienced radiologists interpreted and evaluated all brain MRA images. On phase sequence of SWI, image appears hyperinduence and the calculation appears hyperinduence in the left handed system. Coming to the results, the brain MRA with SWI was obtained in 50 patients, out of the 50 patients, 32 were males and 18 were females. The majority of the age group was more than 60 years, followed by 50 to 60 years. The age range from 28 to 76 years and the majority of the patients were from the age group more than 60 years that is 23% followed by 51 to 60 years that is 22 years. Coming to the MRA findings, the site and location and distribution of the pathology. Most of the patients had bilateral pathology, 20 of them followed by right side, 14 of them and left side and 14 of them and 2 involve the brain system. The majority of the patients had supratentorial lesions, 34 people followed by both supratentorial and infratentorial lesion in 11 patients and 5 patients had infratentorial lesion. Among 50 patients, the majority of the patients had venous sinus thrombosis, 20 patients and arterial stroke, 20 patients followed by cerebral amyloid angiopathy, 5 patients and 5 had, rather patients had hyperinduence and microgrid. This is the same table that was shown. In our study, among 20 patients with arterial stroke, the majority had middle MCA thrombosis and 10 had ACA thrombosis and 6 and posterior cerebral artery thrombosis and 3 and 1 patient had ACA thrombosis. This is the same represented in the table. Hymorrhagic transformation of the arterial stroke was seen in 18 patients. The distribution of the hemorrhage transformation of the infarct was MCA territory 9, ACA territory 5, PCA territory 5, ICA territory 1. Of these 18 patients with hemorrhagic transformation of arterial infarct, 5 had microhemorrhages and 13 had microhemorrhages within the infarct areas. You can see the image here. Here you can see a well-defined grounded hyperinduence area on the magnitude image appearing hyperinduence on the phase image that is seen in the right occipital region, suggestive of microhemorrhage. A large area of diffusion restriction on DWI in corresponding low ADC values also see. This is MCA territory acute infarct with microhemorrhage within the infarct area. In this image, you can see an acute non-hemorrhagic impact in the left cerebral hemisphere showing diffusion restriction on DWI with corresponding low ADC values. On magnitude image, the left anterior inferior cerebellar artery appears hyperinduence and it appears hyperinduence on phase image, suggestive of acute thrombosis. The dark artery sign or the susceptibility sign was seen in three patients. DWI, ADC, magnitude, phase and MR, MRA. Here you can see the SWI shows infarct in the left MCA territory with dark whistle sign in M3 and M4 branches of the right MCA which was confirmed by MRA. You can see the positive here. Cerebral venous sinus thrombosis. Among the 20 patients with cerebral venous sinus thrombosis, the majority of the patients had hemorrhagic infarcts, 8 of them followed by cortical venous thrombosis in 4 and venous sinus thrombosis in 8 cases. This is the same representing the tabular format. Here you can see the magnitude image, phase image, SWI and MIP images where you can see hyperinduence signals in the cortical veins in A and C image, in the bilateral frontal parietal region and left transverse sinus in E and G and appearing hyperinduence on the magnitude and hyperinduence on phase images, suggestive of cortical and ural venous sinus thrombosis. Correlation between CT and SWI. SWI was better as compared to CT in the detection of hemorrhagic venous sinus thrombosis. Hemorrhagic transformation of arterial infarct, cerebral amylodipathy, hypotensive and microhemorrhage. You can see the same table that was described. Coming to the discussion, SWI imaging despits slow flowing blood in small cerebral vessels due to blood oxygen level dependent effect of deoxygenated hemoglobin which is difficult to detect at the time of the flight in phase contrast magnetic resonance angiographic techniques. MIP helps in establishing continuity of the tortuous structures and has a venogram effect, thus differentiating veins from adjacent hemorrhage. Both calcium and iron are commonly deposited substances in the brain. It is distort the local magnetic field producing a low signal on SWI image just mimicking hemorrhage. Calcium can be differentiated from hemorrhage on phase image where the calcium appears dark and the hemorrhage appears bright. Iron is usually seen in the globus pallidus and substantia nigra. Iq thrombiabolism has high iron content and increases in deoxy hemoglobin content and hence is easily picked up on the SWI sequences. SWI has high sensitivity with better contrast resolution in the detection of thromboembolism in both the anterior and posterior circulation. The composition of the thromboembolism can vary. A red thromboembolism that is erythrocyte rich predominantly consists of erythrocyte while a white thromboembolism composed of platelets, fibrin and enthromatous gruel. A red thrombus usually arises from the left atrium in the atrial fibrillation while a white thrombus originates from the volumel atherosclerotic plaques. Red thrombus usually has a higher level of paramagnetic content so it causes blooming on SWI sequences with the diameter of the thrombus vessel exceeding the diameter of the contralateral normal visit. Detection of the red thrombus is a prognostic importance as it is more sensitive to intravenous tissue, plasminogen activated treatment with a better success rate of endovascular recanolation. SWI can detect distally located clots that may not be picked up on routine MRA thrombus is in particularly occluded vessel cannot be picked up in DOF or MRA which shows narrow artery. SWI can pick up thrombus at the site of an occluded vessel seen as dark vessel sign. SWI can pick up venous changes at the site of the infarct multiple prominent hypointense veins can be seen in the vicinity of the infarct due to increased oxygen extraction with a resultant increased concentration of deoxyemoglobin this help in protecting the tissue at the risk in the penumbara and has favorable outcome from the reperfusion strategy. In our study among 20 patients with arterial stroke the majority of the patients are MCI thrombosis followed by ACI PCI thrombosis are findings in favour of bill 1 at L where the SWI detected intra arterial thrombus in 122 patients compared to 97 patients detected by MRA. Extravescent hemoglobin turns into deoxyemoglobin a paramagnetic material that produces inhomogenicity SWI can identify very minute hemorrhage within the infarct because it is extremely sensitive to magnetic field inhomogenicity our study found 5 patients each with hemeloid angiopathy where you can see here the magnet phase SWI MIP images of the SWI sequence shows hypointense areas on the magnet image hyperintense areas on the phase image in the bilateral temporal region suggestive of hemeloid angiopathy our findings co-operated the findings of METAL et al showing increased sensitivity of the SWI to identify numerous micro bleeds that others go undetected on routine imaging in our study among 10 patients with venous sinus thrombosis 7 had hemorrhagic infarct followed by cortical venous thrombosis and superior sagittal thrombosis results are consistent with those of study of 39 patients with cerebral venous thrombi MIP et al which showed that the sensitivity of SWI for detecting the clots in the sinuses was 96% and 71% between the day 1 and day 3 in our study the correlation of CT with SWI detection of cerebral venous sinus thrombosis micro hemorrhage and cerebral amyloid angiopathy showed better results with SWI as compared to CT with the statical significance our findings were co-operated with those of METAL et al coming to conclusion SWI is a useful imaging sequence that provide relevant information in stroke patients and requires only an additional 3 to 4 minutes to perform SWI can identify various features such as hemorrhage intra arterial thrombosis or concomitant microbleed the detection of the micro hemorrhage which is better seen on SWI is of prognostic value and affects therapeutic decision and the use of thrombolectis in this study the detection of the CVST micro hemorrhage and cerebral amyloid angiopathy showed better results with SWI when compared to CT in conclusion SWI is a simple reliable non-invasive imaging technique SWI does not need the use of contrast medium and can be added as an auxiliary sequence in routine stroke protocol without much increase in the scan time these are the references thank you