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Hi, good evening to everyone. Can I be head? Right. Um, it's just a minute past seven. I think we can give a couple more minutes and then we start right on. We aim to start on time but we need to wait for a few more people to join in. Uh We should aim to start by two more minutes time. Should that be fine? Right. All right. Mahesh. Are you able to join the backstage to project your screen? If possible? I think Martin is ready. Yeah, Mahesh is here. Wonderful. Hi. Yeah. All loud and clear. Yeah, I am just trying to, um, share my slides. So if you can just give me a minute, I'm sorry guys, I had to but pros uh, try them. Are you guys able to see the screen? Yeah. Yeah, it's, it's on right. Um, I guess you guys, uh, if you guys give me a call, so I, I'll begin. Ok. So welcome off to today's session on the British Radiology Channel Club. It's wonderful to see you here and we like to see the commitment that you're putting in. So, as we all know, radiology is at the forefront of medical diagnostics and patient care. And we need to critically make some inputs and studies in the advancing field of radiology. Our aim is to have further discussions um on the field of radiology, including all the innovative research that's coming on. We hope to have two presentations per session to allow us to cover a wider range of topics and foster a rich discussion. Hopefully. And we aim to have a presentation every month on the last week of the month to provide the opportunity for more people to participate and to get more insight in this field. We would like to remind everyone to follow us on our social media, stay informed, subscribe to our newsletter and get all the relevant in we have today, Martin and Mahesh with very beautiful topics and I'm sure we are going to learn a lot so we, you can go straight in. Uh I think Martin is due to go first whenever you are ready. Martin. Thank you, Hamid. Um And the team uh for, you know, providing platform to kind of explore our interests um in radiology. Um Just a bit about myself. I'm a, a foundation year one doctor. Um I studied in, studied in the University of Birmingham and um just finishing off my fy one year in um Warsaw. So um today I'll be presenting a um review article published in the British Journal of Radiology in 2024. Um The title is Imaging in acute ischemic stroke, assessing findings in light of evolving therapies. So why this topic? Um stroke is a leading, leading cause of death and long term disability, as you guys all know. Um and this review article specifically focuses on the most prevalent type of stroke which is ischemic strokes and stroke is one of those um conditions that is very um heavily tied in with radiology, especially um CT head, which is the most common scan performed in the hospital. Um I did an audit in um April time um about on all CT scans performed in my hospital and 20% of all of them wore CT heads. So you can see um how prevalent CT head is and most of the CT head hits are, you know, to rule out or investigate for it um bleed into the brain. So the questions to explore today, um you know, reviewing this article is what imaging modalities are used for stroke. Um And why are they used because this this heavily ties into the treatment um options and how does the future look for us? Um So b before jumping into um the treatment options, um I would appreciate if any of you guys can kind of shout out any treatment that they know of about um strokes. Yeah. Clopidogrel, which we give. Yeah. Uh It's I think 300 mg followed by 775. Mhm. Anything else? And for secondary prevention, we do give some statins and um I'm not quite sure about the dual antiplatelet. Ok. Um sorry, I, I'm not able to see who's speaking, who's just speaking my. Yeah, my hi, thanks. Um Yeah, so the treatment options that you, the treatment, um options that you mentioned are kind of the antithrombotic um treatment options that we use to prevent further strokes. Um Does anyone know of any treatment that is used to um, treat the initial stroke? The current stroke that the patient would be experiencing, has anybody heard of? Out of place? Yeah. Yeah. Yeah. I think you were just about to mention that. Um So yeah, the um clopidogrel and aspirin, those are um what we call antithrombotic agents and they don't actually break up the clot. Um They are uh used to prevent recurrent strokes and recurrent strokes are actually more common than first time strokes. So that's why they're very important um in terms of, you know, treating the initial stroke, um there are mainly two treatment options. So first is IV thrombolysis. Um This was first showed um this first, this was first shown to be effective in improving clinical outcomes in a 1995 MS study where they used um TPA um and administering T ta within three hours of um symptom onset has was shown to improve clinical outcomes. And then there are studies um published a few years down the line which showed that um this window could be extended to 4.5 hours of the patient's last well-known time. And then um 20 years later, um mechanical thrombectomy was um shown to be effective in a mister clean trial um carried out in the Netherlands. And this is basically endovascular treatment where we physically go and retrieve the club. Um and it's needs to meet a specific criteria which is that there needs to be tissue downstream, which is salvageable and it needs to be um a large vessel occlusion in the anterior circulation. And it needs to be within six hours of the last well known time. But since then, um we are able to extend treatment windows of uh up to 24 hours or more. And this is this was possible um because perfusion imaging has allowed us to clinicians to more accurately identify salvageable tissue. And if you have uh many questions during um the presentation, feel free to uh jump in and more of the recent advances is um first of all, for posterior circulation strokes. So, traditionally, mechanical thrombectomy was only for anterior circulation strokes. And this was because posterior strokes are uh tend to have poor prognosis. One of the reasons which is that um if the there the posterior circulation in a um supplies the more crucial crucial uh parts of the brain like the brain stem and the cerebellum. But in 2022 a study was published showing that mechanical thrombectomy is beneficial for um basit artery strokes. Number two is for large core infarcts. So traditionally, again, mechanical thrombectomy was only for large vessel occlusions with salvageable tissue. Um But recent advances have shown that actually larger infarcts with um a aspect score of 3 to 5, um we can use a mechanical thrombectomy aspect score is a score um that that clinicians would uh measure based on the first um ct scan that that the patients receive and that kind of gives um the initial impression of how much infarct varies. Um And I'll talk more about that, but um the takeaway is that larger infarcts with um less salvageable tissue. Um as you know, we are treating these patients um with, you know, mechanical thrombectomy. And then number three is for distal vessel occlusions. So like smaller vessels um that are more distal their current trials um being run to explore the efficacy of mechanical thrombectomy in these patients. Um So, looking at the imaging techniques and their roles, as you all know, um the noncontrast CT scan is the first line scan and its main role is to rule out hemorrhagic strokes. And once we do that, you know, we administer aspirin 300 mg to prevent further strokes. Um And then what clinicians um do is um measure the aspect score um which is used to quantify the extent of early ischemic changes and it's a scale from 0 to 1010 being that there is no to minimal um ischemic change and it makes sense that um you would go for thrombolysis um or mechanical thrombectomy if there is salvageable, salvageable tissue. So, traditionally, a score of six or more um would be eligible for thrombolysis. Whereas um a score of less than six, the clinicians would say, oh, this is too much damage it wouldn't be worth um thrombosing. However, recently, um a score of three or more has been shown to um still be beneficial when receiving thrombolysis. Um Number two is CT angiography. Um It's used to visualize the blood vessels. Um mainly is used to identify where the occlusion is and um test for collateral flow, which is a crucial consideration um for when considering for mechanical thrombectomy, uh moving on to more of the advanced emission techniques. Um We we usually talk about perfusion imaging and it's a guide for it. Got it's a useful um technique for um extending therapy to go in for mechanical thrombectomy. So I'm not sure if you guys have come across the term penumbra, but that basically means salvageable tissue. So, a CT perfusion scan is used to assess brain tissue perfusion and it allows us to differentiate between the damaged um infarct core and the potentially salvageable penumbra. Um An MRI scan which is um usually less available is slightly better than a CT perfusion scan for identifying um the infarct and the penumbra. So this is um a CT perfusion scan. Um On the left hand side, you can see um an ischemic cord and ACB V. So what does a CBB stand for? It stands for cerebral blood volume. So you can see the scale that runs from um purple to red. So red, meaning it has the greatest b blood flow and purple, meaning it has that uh or nonexistent blood flow. And you can see um by using a contrast, um you can see which part of the brain has a good cerebral blo blood volume and which has bad um blood volume. The areas highlighted in red and yellow are um tissue areas that's well perfused. Whereas blue areas we would say it's an ischemic core. So potentially it's um already did on the right hand side, you can see um that the scan is a penumbra scan. So TMAX is the um time taken for the contrast to reach its peak concentration in the tissue. So a red or yellow, which um mean that the contrast was very quick in reaching its um peak concentration, which would indicate that blood volume, blood flow is very good. Whereas um blue or purple would mean that the it took very long for um the contrast to reach its um maximum concentration. So you can see that um apart from a small area on the right um side of the brain with red and yellow highlights highlighted areas, um most of the brain is green. So this indicates that the green areas have a relatively um worse blood blood flow, um so less um the tissues are less well perfused. So this um indicates that these areas of the brain are potentially salvageable. But um given that we intervene within the correct time frame. So as you can see this kind of detailed scan provides a much more detailed um idea of the brain and how well it's um perfused rather compared to a traditional um noncontrast CT scan. So what are the limitations and what are the implications? So, it seems like advanced techniques are challenging traditional protocols for guiding intervention. Traditionally, um time was used as a proxy of perceived damage. So any patient that would present six hours after their last well-known time would be treated medically. Um They wouldn't be treated with thrombolysis or thrombectomies and we would monitor them for any complications that of the rise of a stroke, but we wouldn't treat them aggressively. Whereas now we ha with these um new imaging techniques available, we are actually able to assess the anatomy and the actual um damage that is being that is happening in real time. So we would we are able to um uh actually look at what is going on rather than just using time as a very rough measure. Um The limitation of using such scans is that an ischemic Coron imaging does not always equal actual infarction. Um So there is room for potentially very um fast intervention to um rescue these uh penumbra, what we need to think about is because stroke is such a time sensitive um diagnosis and prognosis depends heavily on how quickly there um intervenes the availability of these scans and how fast they can be performed would um be a very important factor in determining how um well, we can, how fast we can intervene on these patients. Um CT perfusion is being increasingly um widely available in the UK MRI less so, but um it seems like we are moving in that direction of uh implementing a lot of these techniques more um as a standard procedure. So what's my one line impression? Um It is that advanced imaging techniques are expanding the time horizon for reperfusion therapies by providing a more detailed individual assessment of an acute ischemic stroke. That's the end of my presentation. Um Thank you all for listening on this Saturday evening. If you have any questions, let us know. Right. Thank you so much Martin. Um Quite an insightful one. It's probably something I'm here for the first time. CT reperfusion because parts of the world have different resources and that limits how much you can do. And we have generally relied more on CT imaging. Sometimes MRI. Uh the availability is uh questionable. Um and the time to get it done before the 3 to 4 hour window is not always uh possible. Well, that's, that's from our side of the world. If anyone has any inputs or comments, questions on the discussion, we'll be happy to have them now before we take our next presentation, but otherwise a brilliant one well summarized too. Thank you. Thanks very much. You can feel free to send in any comments or questions in the chat box and we will take up those discussions or you can unmute and speak if you want to just indicate and we give you a chance to do that. Mahesh. Are you preparing? Gearing up for the next presentation? Yes, wonderful. You could share your screen if that's possible. Uh Can you, can you see? Yeah. Is it visible? Yy, it is. Ok. Uh Can I go? Yeah, feel free? Ok. So I'm Doctor Mahesh, I'm an senior house officer from India. Um I'm currently working in a neurodevelopmental unit which is actually correlating with, with my topic today. Um It, the topic for today is white matter by diffusion MRI following methylphenidate treatment, which is one of the treatment for ADHD. It is a randomized controlled trial. It was done in uh especially in the male population who had ADHD. This was a study done in Netherlands and they have evaluated it using MRI as a modality. Uh I thank the British Radiology General Club for giving me this opportunity to present. So I'll be going ahead with what are my takeaways? So I'll be going um Would you be able to put on your camera? Yeah. Sure. Yeah. Can you, can you see? Yes. But then we lost your slides. Yeah. Yes. Yeah. Yeah. The slide should be visible now. Yeah, it is. Yeah. So I'll be going through step by step. Uh I have divided it into three parts, uh an introduction to the study. Then I'll be um discussing what goes in the imaging, that is the type of imaging they've used. And I wanted to s uh see where this research will take us in the future. So I've divided into three categories, I'll be discussing that. So the study, the main objective was that to see whether the methylphenidate, which is the, which is a treatment for ADHD had an effect on the white matter microstructure uh in the brain of males. So, the age group which uh the study was done on was um a uh teens adolescents and between thirties to forties, uh slightly older men. And they wanted to check um uh check a parameter called as fractional and isotropy. It's a fancy term, but I can simplify it for you in the further slides. And uh this was done for 16 weeks of either uh taking methylphenidate or being placed on a placebo. So this is how it was structured then. Um the participants were the first time uh treatment, takers, boys who were between the teenage group and who were diagnosed with AD HD in, in AD HD clinics in Netherlands Amsterdam. And there were 49 young adult men who were also diagnosed with adhd. So they were randomly assigned to either receive a placebo like AAA pill with no effects or treatment with Metyl ate. So they had an inclusion criteria that it was if uh the, the boys who were aged between 10 to 12, uh they were treatment naive, meaning to say they didn't take methylphenidate before. And uh they were young men aged between 2323 to 40 they were diagnosed with ADHD. So as I said before, uh they were recruited from the adhd outpatient clinics. And if anyone had any psychiatric disorders like schizophrenia or any mood disorders, they were excluded. And there are certain contraindicate contraindications for MRI. Um Can I have from the audience, one or two contraindications that um you may think of for the MRI any metallic fragments in the body? Thank you. Uh Also pacemakers, there are certain pacemakers which we uh avoid, you know, metallic fragments. That's correct like any implants and sometimes pacemakers right now, we do have even um MRI friendly pacemakers, but sometimes the older pacemakers are not MRI friendly. So we should um always make sure that when an MRI is conducted, there are no contraindications. So the study was a randomized double blind placebo controlled trial. And uh the objective was to determine whether the white ma there were any alterations in the white matter microstructure in an age dependent manner. So, when they had concluded with the study, the results were that in, in boys, uh there was an increased white matter fractional and isotropy after 16 weeks of methylphenidate treatment. But whereas in adult men, there was, there wasn't any um noticeable changes in the fractional anisotropy. And this was as as usual the there there wasn't any structural change in their brains. So I wanted to go a deep, a little bit deep into the terminology. So with regards to M MRI, there is a recent technique known as diffusion tensor imaging DTI. So what it essentially does is along with the traditional MRI, it aims to me uh you measure the directional movement of water molecules on the brain surface. So it it, it is um following the principle of um Brownian movement uh which we have read in physics like you know the light response to the B brown brown in movement. And um this magnetic field from the MRI, this influence the water molecules to move in different directions. So that there is an algorithm which you can see on the picture uh to see how the uh white matter tract fibers are there. So could you readjust your slides? We are not able to see it move, it's still on content. OK. Yeah. Sorry, sorry for that. Yeah. Uh Yeah. Can you see now? Yeah. Yeah. So I'll uh start. Should I begin from the where I left it? Just a very quick summary. Yeah. So the summary is that uh it had an effect uh methylphenidate had an effect on boys uh who were treatment naive, naive, which showed some white matter changes on the MRI. Uh But with related to men of the say uh of uh who had a ad HD there wasn't any effect on the white matter of the brain. So that's, that's the summary of the the results. Then I was talking about the modality which is diffusion MRI. So diffusion MRI um uses a technology called called as diffusion tensor imaging. So it measures the water molecules uh moving on the brain. So it it follows the principle of Brownian motion. And uh so basically the the there is um the picture here I've illustrated is a tractography. So when the MRI is done, it uses like a 3d image to represent the nerve tracts, the cortical uh cerebellar tracts and rubrospinal tracts, everything. So it's it's uh represented, you know, uh like this seen on the image. So, and then there are some metrics which they assigned to this fractional isotropy indicates uh how which direction the water diffusion is happening. And if at all that uh this reflects that whether the white matter is um integral or not or are are there any changes corresponding to the white matter? So mean diffusivity overall, all the white matter, um it measures the water molecular movement to see if the tissue, the brain tissue is having any density and cellularity over the old age. Maybe we might see that the density and cellularity might change So how useful is this in Adhd? Uh basically in Adhd, the the diffusion MRI can be helpful in identifying some microstructural changes in the white matter. There are few other studies which I came across while preparing the slides that um MRI might become a useful marker in the future to see or to screen people for ADHD. So and sometimes it can uh you know, help us in monitoring the treatment effects on the brain structure to see how the signals of uh are conducted across the nerve tracts. OK. I know it's a very complex topic, but I tried to break it down. It has been very complex for me to read and understand as well. I would, I would love to explain it again if anybody has had any doubt on it. So, regarding the study methodology and findings. So um basically, the imaging technique was deficient 10 tensor imaging which I discussed earlier and it was used to measure fractional and isotropy going back again. Fractional isotropy is to uh see the degree of directional water diffusion to see to reflect if the white matter of the brain is um you know, is integral or it's intact. OK. So after analyzing the results, they found out that there is time by medication by age. So 16 weeks for the age group of adolescents, there were um significant effects observed in several brain tracts specifically in the left hemisphere there. Uh that is the most sensitive region for methylphenidate effects for boys with ADHD for men. Again, there hasn't been much change. So the findings are categorized into pretreatment and post treatment. So, pretreatment versus um post treatment, there was an increase in fractional isotropy in the treatment group. That is those who received methylphenidate, which is th those who didn't. And the regions of which show which were affected due to the methylphenidate was corpus callosum cum and frontal white matter. So this suggests that the white matter integrity was improved and there was neural con connectivity, which meant if we could have correlated it with the symptoms. Um by asking the uh parents or, you know, uh looking at the, looking at them to see if there we did, there are any changes in concentration or anything. It would have had a much um it would have added much scope to the research. And regarding mean diffusivity, there was a decrease in the mean diffusivity values in the treatment group. Um So the regions affected for mean diffusivity were corpus callosum and frontal white matter. So this indicates that there's a reduced water diffusion and uh there was a healthy white matter there. So the reason of interest uh was that uh fractional anisotropy yielded no main, yielded no main effect of time. Uh It doesn't know how, how long we had the boys were put on the treatment. There was there was no um effect with time. Then Voxel based analysis uh significant interaction effects were observed in specific brain region which I discussed uh before. So there were some limitations of the study. The main limitation is that it had only participants who were males. So uh there weren't any female participants or uh any other uh age group which were included in the um study, which were included in the study. So, regarding the statistical power, uh there were some confounding factors. So in the future, uh you know, the methylphenidate treatment can modulate white matter development in an age dependent manner, particularly in the adolescent age group. And uh we need to explore the treatment effects in females and in other age groups as well, much younger age groups. So let me discuss about the uh mechanism. So, myelination and connectivity, white matter changes in adhd can describe the myelination of the nerve fibers. So that's why we are uh using the deficient tensor imaging, fractional and isotropy uh to see how the nerve tract fibers are, how is the neural communication. So these are affect the brain functions like, you know, attention and impulse, which are one of the key, which are the key symptoms of uh ADHD. So any changes in the white matter, uh e especially the frontostriatal have been linked to ADHD symptoms. So there is few other evidences which I looked at. So, ADHD is mainly associated with changes in white white matter and it showed reduced fractional anisotropy. Whereas here it was uh increased So which, which we, which we come to a conclusion that we can use them as biomarkers for having uh you know, much precision. Sometimes we can maybe uh decide on the dosage. For example, if somebody started on, um you know, adolescent boys are started on a certain dose and there's no improvement we can do an M Ria functional MRI and see uh how much we can add on. OK. So the, the research evidence ma mainly shows that Adhd treatment may impact the white matter. So understanding this can help us uh decide on deciding on treatment option for different age groups as well. All right. So I would like to uh come to the final section about the research, its implication and future direction. So, one of the key key takeaways of the research was that methylphenidate affects uh the brain development, especially the white matter and there should be age considerations uh when taken into consideration. And in, in terms of medical education, it enhances our understanding that Adhd medication has effect on brain development. So we need to tailor the medications for different age groups and for gender based on future resources and which the methylphenidate has been uh off. Recent ADHD has been over diagnosed. We've, I've been into psychiatric practice in UK where people used to come in with self diagnosed adhd or maybe they consulted with a psychologist online and they wanted to start methylphenidate. So when starting someone on a methylphenidate without um actually screening them. Uh since it's having long term effects, it would be better to see if we can uh push the research and direction of screening uh people with adhd with um the diffusion tensor imaging MRI. So I would like the sample size was very um small and it didn't included both the sexes. So if we could have had both the sexes, then we could have a generalisability and it, the, the entire longitudinal study was for 16 weeks, it would be better to see if we had a study for one or two year duration. And we, um the study sh should have been ideally had females as well and it can be better to integrate functional MRI or pet scan and in, in and to have a wholesome picture of the brain so that we can comprehensively study about the treatment and its effect. And like the behavior, uh also could have been studied like, you know, the psychological assessment done after starting the methylphenidate to see if there's any improvement in symptoms. And we haven't co you know, the, the study hasn't compared other ADHD medications to see how ef efficient the other medications are and to see how safe the other medications are and what effect lasting effects they have on the white matter. So the study mo mainly focuses on the age dependent effects of methylphenidate and on the white matter microstructure. So, thank you. Uh, if anybody has any questions? I'd be glad to answer them. Right. Thank you. Thank you so much. Mahesh. I'm just wondering on this study, how were they able to ensure compliance? Because it's just my thoughts, younger kids will be under from their parents and maybe compelled to take their meds. But the older males, you may not be able to have that kind of check on them. So, how was that done? Maybe they have a, a system called as follow up every three weeks or four weeks when they come in for a psychological assessment. Adhd clinics is where they recruited them from. So they would have had ideally a screening questionnaire to see, uh, what is the degree of adhd based on the questionnaire? And then they would have started them on treatment and also the symptoms, how long they would have been there based on that? Uh, they would have, you, they would have started the medication regarding the compliance. I think it's a follow up appointment. Right. Right. That's quite clear enough. Thank you. Um, any further questions from the house, you could type in any questions on the chat box. You could. Yeah, I had, I had, um, one question. So were the, um, were, were the studies measuring fractional and these ecography? Yeah. And, uh, yeah. And MD was it? Yeah, fractional anisotropy and mean diffusivity. Can you just reexplain what, what they were? Sorry? Yes, definitely. It took a while for me to understand that yesterday. So I'll put on the slides again. Thanks. So, so the imaging technique is called as deficient tensor imaging. It, it is measuring the movement of the water molecules across the brain surface. Mm That's what the MRI is trying to capture. OK. So it the there is something a phenomenon called as Brownian move Brownian movement or at effect if you have read it in your uh physics. So the fact that the water keeps on moving across the brain surface, the MRI tries to measure it across different gradients and the water molecules when they're moving, they are influenced by the mag magnetic field. Mm OK. So the fractional anisotropy is measuring for the degree of directional water diffusion. So there is diffusion of water molecules happening and whatever direction they are going in the MRI is trying to measure. So this is done to see whether the m white matter is integral or intact. If it is not, for example, if the white matter is not dense or then there wouldn't be much movement, then mean diffusivity. I think they're using a calculation to calculate the overall movement of the molecules to see um how dense the brain tissue is. And if there is any cellularity. So these are the two metrics which they have used for the study. Uh Was it um You, thank you. Um I was wondering because you mentioned that um it seems effective in changing the white matter in um you know, others, whereas it's not as effective in adults. Yeah. In, in males for this study. Yeah. Um, so would you say because obviously methylphenidates, um, abused among a lot of people as like a brain enhancing medication? No. TRX. Yeah. Yeah. So, would you say that because it has an increased white matter, uh, in adults that it wouldn't, it may be like a pro effect or it wouldn't actually, what I would, what I would say is that in uh adults, the white white matter is actually formed. Whereas in Children, it is continued to evolve into, you know, the final structural changes. So it, it can, it can uh keep the structure integral. Whereas in adults, it wouldn't have much of an effect which you uh termed it as placebo. But what I also came to know is that females are more uh underdiagnosed, like uh uh the ADHD symptoms are much more difficult to catch up in female population. Now, wherever it has been, wherever it is studied in the UK or uh E elsewhere. So there is a bias in the gender as well. And among the age groups, I think we need much better uh studies to see if the doses can be increased, to make it more available at the blood brain barrier or something to. So to see if further studies are required at the white matter level. Hm Are there, are there any side effects to, you know, abusing methylphenidate if you know. No, uh I haven't looked into it, uh, quite in detail. There, there can be, I, I'm ve very much, uh, sure that a lot of countries, uh, I've seen on online forums where people are carrying methylphenidate from other countries where, uh, it's easily available, especially for exam duration. So, when you do abuse it, I think after you, um, after you stop using the medication, there should be some effects on the white matter. Right. Um, just want to find out after how long did they do the DTI for the patients who were in the study? I think it was, uh, I haven't got exactly looked up at the detail when they took it up. Uh, so it was a 16 week study. So, initially after, uh, two weeks to three weeks. Ok. Mm. Right. I'm just thinking, would that be enough time for any such changes on the medication or would it be due to the age of the participants purely in terms of their brain structure? Yeah. So, in elderly people, I think they weren't testing people who were started on methylphenidate the first time. That is participants who are above 30 but for younger Children they were on methyl for the very first time. Ok. Ok. That's true. So, maybe the treatment is more, uh, susceptible in the younger population, right. But did you come across any other studies that compared medications that seem to be more effective in the older population. No, not yet. Uh Maybe there were some studies on functional MRI but these were taken after long term follow up. Ok. All right. Hopefully we get something on that in our subsequent series. But thank you. Thank you so much. It's been an absolutely wonderful discussion on methylphenidate and uh stroke with uh CT reperfusion scans. We've gone close to 50 minutes and if we do not have any further questions, we may be happy to close today's session and get back again next month. Uh We usually meet at the last week of every month. The dates will be communicated, feel free to subscribe to our newsletters. We will share our socials, you can follow us, you can share feedback you can offer to present and we will be happy to have you. Do you have any final comment from anyone interested? Now present us, how did you find today's session? Um I learned a lot, you know, for uh preparing um the presentations. Um And yeah, you can gain a deeper understanding of stroke imaging. Right. Right. That's, that's wonderful. Um Mahesh any final comments from you before we run into this session? Yeah. Yeah. Usually I work in a setup which has child and adolescent mental health. So I see them on day to day basis like ADHD and autism. So I know only the treatment um uh you know how the treatment progresses, how the follow ups are done. I have never looked into imaging as you know, as into the treatment modality. But it is very interesting to see how uh deeper the structures are getting affected. And I think the parents also should be, you know, there should be some awareness among the pa parents and I would like to take the same topic uh in my department so that they can be educated as well. It was very good learning for me. All right. All right. Thank you so much. So, just like that, um our goal is not just to discuss the journals but to properly appraise them and have insightful um comments coming in so we can learn from each other. Um Please, active participation is really encouraged if you want to find out more or get any clarification, you can always use a chat box and we hope to see you all again. Same time next month. Have a wonderful evening and great, great job from the presenters. Nice to meet you. Thank you, doctor. Thank you. I thank you. Ok. Thank you. All right. Have a and bye.