Anterior Lesions Research Articles

Hemodynamic assessment of intracranial atherosclerotic stenosis: comparison between invasive non-hyperemic pressure ratio and angiography-derived quantitative flow ratio

ObjectivesTo evaluate the diagnostic accuracy of the quantitative flow ratio (QFR) for hemodynamic exploration of intracranial atherosclerotic stenosis, using the invasive cerebrovascular pressure ratio (CVPR) and resting full-cycle ratio (RFR) as reference standards.Materials and methodsPatients with symptomatic unifocal intracranial atherosclerotic stenosis were included. The CVPR was defined as the ratio of the proximal and distal pressures. All patients underwent angioplasty under general anesthesia. The QFR was calculated based on digital subtraction angiography. Using the CVPR as a reference, we compared its correlation with the QFR across different degrees and locations of stenosis.ResultsThe CVPR and QFR were measured in 34 vessels of 32 patients. The QFR demonstrated a high correlation and excellent agreement(r = 0.8227, p < 0.001) with the CVPR in distal stenosis before intervention. In the subgroup with diameter stenosis >80%, the QFR showed a high correlation (r = 0.8812, p < 0.001) with the CVPR. In the anterior circulation subgroup, the QFR showed an excellent correlation (r = 0.9066, p < 0.001) with the CVPR. In the posterior circulation subgroup, the QFR showed a high correlation with the CVPR (r = 0.7706, p < 0.001). Diameter stenosis rates showed a moderate negative correlation with the CVPR.ConclusionThere was a strong correlation between the QFR and wire-based CVPR, especially for anterior circulation lesions before intervention. The QFR may serve as a predictive factor for evaluating hemodynamic changes in intracranial atherosclerotic stenosis.

Contemporary Outcomes of Degenerative Mitral Valve Surgery in a Regional Tertiary Care Center

Objective: As percutaneous mitral valve techniques become more prevalent, it is important to evaluate the contemporary outcomes of surgical mitral valve interventions. This study assessed the current results and procedural trends of mitral valve surgery for degenerative mitral regurgitation (DMR) at a regional tertiary care center. Methods: Data were analyzed from 693 consecutive DMR patients who underwent isolated mitral valve operations, with or without tricuspid valve repair and atrial fibrillation ablation between 2017 and 2024. The outcomes were defined according to MVARC criteria. The study endpoints included successful mitral valve repair, in-hospital results, and operative and long-term mortality. Logistic regression was applied to assess the impact of valve lesions and patient risk factors on the probability of valve repair. Survival was analyzed using Kaplan–Meier methodology. The follow up was 100% complete. Results: Mitral valve repair was performed in 90.9% of cases, with only 0.9% requiring the conversion to replacement due to unsuccessful repair. Posterior leaflet lesions had the highest success rate (93.4%), while anterior leaflet lesions had a lower rate (86.2%), with anterior pathology being a negative predictor of repair (OR 2.57, p = 0.02). The type of lesion (prolapse vs. flail), the commissural involvement, and the increased risk for SAM had no statistically significant impact on valve repair outcome. Less invasive transaxillary access was used in 63.2% of patients, and its adoption increased significantly (from 50.9% to 67.4% p = 0.03) over time, resulting in more frequent fast-track extubation and home discharges. The rate of in-hospital mortality was 0.6%, while the rate of 5-year survival was 95.5%. Conclusions: Contemporary surgical techniques for DMR lead to high repair rates and excellent recovery outcomes. Despite the rise in transcatheter options, our findings confirm that surgery remains the gold standard for most DMR patients.

Endovascular Treatment of Patients With Acute Ischemic Stroke With Tandem Lesions Presenting With Low Alberta Stroke Program Early Computed Tomography Score.

Recent trials confirmed the efficacy and safety of endovascular thrombectomy in patients with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS); however, evidence in tandem lesions is limited. This study evaluates endovascular thrombectomy safety and efficacy in patients with acute large-vessel occlusion with tandem lesions, stratified by baseline ASPECTS. We conducted a retrospective analysis of data from 16 centers. Inclusion criteria included the following: age ≥18 years, anterior circulation tandem lesions, endovascular thrombectomy <24 hours of symptom onset, and ≥70% internal carotid artery stenosis/occlusion. Patients were categorized into low (0-5) and high (6-10) ASPECTS. Inverse probability of treatment weighting matching was used to balance the groups. Primary outcomes included the following: 90-day modified Rankin Scale (mRS) score 0 to 2 and symptomatic intracranial hemorrhage. Secondary outcomes included the following: ordinal mRS, mRS 0 to 3, modified Thrombolysis in Cerebral Infarction ≥2b and 2c-3, petechial hemorrhage, parenchymal hematoma (1/2), early neurologic improvement, and mortality. Of 691 patients, 44 had ASPECTS 0 to 5 and 505 had ASPECTS 6 to 10. Patients with low ASPECTS had lower odds of 90-day mRS 0 to 2 (adjusted odds ratio [OR], 0.48; P=0.036) and higher odds of symptomatic intracranial hemorrhage (adjusted OR, 3.78; P=0.014). Additional significant differences were found in mRS shift, mRS 0 to 3, parenchymal hematoma 2, and mortality. In interaction analysis, the association between low ASPECTS and functional outcome persisted only in the internal carotid artery occlusion subgroup, with no significant interaction indicating no reason to suppose a difference between the effect of both subgroups. Endovascular thrombectomy in patients with tandem lesions with low ASPECTS is associated with reduced odds of functional recovery and increased symptomatic intracranial hemorrhage risk, when compared with patients with high ASPECTS. However, 30% of patients with low ASPECTS achieved 90-day functional independence, suggesting potential benefit for a nonnegligible proportion of patients.

The Sternocleidomastoid Muscle Reverse Pad: A “Safety Net” in Catastrophic Tracheal Surgery Situation

Background: This paper presents the outcomes of employing the inferiorly based rotated sternocleidomastoid muscle flap in complex tracheal reconstruction/repair scenarios, focusing on the key objectives of ensuring stable airway, functional digestive tract and patient survival. Methods: A retrospective analysis was performed for patients treated at two medical centers (A.O. San Camillo Forlanini, Rome, and A.O.U. Careggi, Florence) from 2011 to 2023, in which the sternocleidomastoid muscle (SCM) flap, detached from the mastoid and basicranium, was rotated on the lower pivot directly onto the repair site and pedicled to the sternal origin to ensure the continuity of the airway. Average postoperative hospital stay, follow-up period and patient survival were analyzed. Follow-up assessments encompassed bronchoscopies and CT scans conducted at intervals of 15 and 28 days, and subsequently at 3 and 9 months. Results: A total of five patients were enrolled in this study. These cases included one patient with anterior tracheal wall lesions with abundant tissue loss, one patient with an anterior wall necrosis due to descending cervical mediastinitis and three patients with extra-long tracheoesophageal fistulas (TEFs) (greater than 4.5 cm or &gt;30% of the total tracheal length). In the case of the direct repair of a TEF with a proximal tracheal stenosis, the sternocleidomastoid muscle was used to reconstruct the tissue deficit caused by extensive loss of substance in the left lateral side of the tracheal wall. In case of repair through exclusion of the TEF, the sternocleidomastoid muscle was interposed between the visceral sutures after exclusion of the TEF by an endomechanical device, in one case even substituting the membranous part of the tracheal wall. Our technique allows rotation on the sternal head of the sternocleidomastoid muscle with the lowest rotation radius, pedicled to the sternal origin, detached from the mastoid process and superior nuchal line, thus providing optimal vascularization from the superior thyroid artery/external carotid artery and accessory vasculature from the suprascapular artery. Patients exhibited uneventful postoperative recovery concerning airway and digestive patency. The mean postoperative hospitalization duration was 41 days. The follow-up assessments were negative for postoperative complications. Conclusions: The use of sternocleidomastoid muscle flap was proposed to ensure repair and protection of the suture margin or to constitute a portion, as a scaffold, of the wall by leveraging the muscle’s vascularization and thickness. This technique may be considered a leading component in managing complex situations in tracheal surgery.

Altered callosal morphology in post-stroke cognitive impairment

Stroke is the second leading cause of death and cognitive impairment. Post-stroke cognitive impairment (PSCI) is one of the most common sequelae among stroke survivors, yet its underlying neural mechanisms remain largely unclear. The corpus callosum (CC) plays a crucial role in interhemispheric integration and hemispheric segregation, with changes in CC morphology potentially overlapping with the spectrum of PSCI. This study aimed to investigate the morphological changes in the CC and their diagnostic value in PSCI patients. Structural MRI, neurobehavioral, and clinical data were collected from 104 PSCI patients and 54 demographically matched healthy controls. Significant reductions in CC area, circularity, and genu thickness were observed in PSCI patients, with these changes strongly correlating with global cognitive function. Subgroup analysis revealed that CC circularity significantly decreased when lesions were located in the posterior circulation, while both CC area and circularity markedly decreased with anterior circulation lesions. Receiver Operating Characteristic analyses identified the midbody areas of the CC as having high diagnostic value, with area under the curve values of 0.748 and 0.746, respectively. Further validation analyses suggest that the transcallosal fibers in these CC subregions are connected to the premotor, dorsal attention, and frontoparietal system. These findings show that areal CC atrophy in PSCI patients, particularly in regions with transcallosal connections to the premotor cortex and frontoparietal network, parallels global cognitive impairment. This suggests that CC morphology may serve as a potential imaging marker for the diagnosis and prognosis of PSCI.

Failure of early neurological improvement can predict futile recanalization after successful interventional recanalization of anterior circulation tandem lesions

PurposeTo explore whether the failure of early neurological improvement can predict futile recanalization after successful interventional recanalization of anterior circulation tandem lesions. Patients and methodsA retrospective analysis was conducted on the clinical data of patients who received successful interventional recanalization treatment of anterior circulation tandem lesions from January 2019 to November 2023. The failure of early neurological improvement is defined as a decrease of less than 4 points in NIHSS score compared to preoperative score at 24 h after surgery. Statistical analysis was conducted using SPSS 26.0 software, and a forest plot and Receiver Operating Characteristic curve related to futile recanalization were drawn. ResultsA total of 120 patients received successful interventional recanalization of anterior circulation tandems lesion were included, including 68 cases of futile recanalization (56.67 %) and 52 cases of effective recanalization (43.33 %). The rate of failure of early neurological improvement in the futile recanalization group was higher than that in the effective recanalization group (94.12 % vs 34.62 %, P < 0.001). After adjusting for confounding factors, the rate of failure of early neurological improvement in the futile recanalization group was higher than that in the effective recanalization group (adjusted OR: 39.925; 95 % CI: 4.110–387.864; P = 0.001). The area under the Receiver Operating Characteristic curve using failure of neurological improvement for predicting futile recanalization was 0.800. ConclusionFailure of early neurological improvement is an effective indicator for predicting futile recanalization after successful interventional recanalization in anterior circulation tandem lesions.

Prostate cancer lesions in transition zone exhibit a higher propensity for pathological upgrading in radical prostatectomy.

The varying malignancy and lethality of different grades of prostate cancer (PCa) highlight the importance of accurate diagnosis. This study aims to evaluate the upgrading of transition zone (TZ) prostate cancer biopsies and identify factors to improve TZ biopsy accuracy. This retrospective study included 217 patients who underwent laparoscopic radical prostatectomy after 12 + X cores transperineal transrectal ultrasound-magnetic resonance imaging (MRI)-guided targeted prostate biopsy from 2018 to 2021 in our center. Patients with TZ lesions showed a higher incidence of International Society of Urological Pathology (ISUP) grade upgrading from 1 to higher grade compared to peripheral zone lesions (16.9% vs. 5.0%, p = 0.005). Multivariate analysis confirmed TZ lesions as an independent risk factor (OR: 4.594, 97.5% CI: 1.569-15.238, p = 0.008) for upgrading from 1 to higher. Additionally, the number of positive biopsy cores (OR: 0.586, 97.5% CI: 0.336-0.891, p = 0.029) and anterior TZ lesion location (OR: 10.797, 97.5% CI: 1.503-248.727, p = 0.048) were independent factors for the upgrading in TZ patients. This study found that PCa lesions located in the TZ, particularly the anterior TZ, have a higher risk of ISUP grade upgrading. This elevated risk arises from the insufficient distribution of biopsy cores around the TZ lesion. The findings underscore the importance of having an adequate number of biopsy cores around the lesion area to improve the accuracy of ISUP grade assessments.

Anterior Rotator Interval Lesion (ARIL), its association with glenoid labrum pathology in patients with anterior shoulder pain and surgical outcome of Arthroscopic Rotator Interval Closure (ARIC)

BackgroundAnterior rotator interval lesions (ARIL) have been associated with shoulder instability. However, a paucity of data exists on its association with labrum pathology as a source for persistent anterior shoulder pain. This study primarily aims to describe pathoanatomy of ARIL and the parameters we used that aid in the diagnosis of ARIL. Secondly, the objective is to describe and report the prevalence of ARIL in combination with labrum injuries presenting as anterior shoulder pain with mild or no instability. Lastly, we intend to present a cohort of patients with combined labrum injury and ARIL and report on the clinical results after labrum repair with Arthroscopic Rotator Interval Closure (ARIC). MethodsConsecutive patients at a single center in United States treated for labrum tears were included by retrospective chart-review. Patients presenting with anterior shoulder pain with mild or no instability were included. Patients with recurrent dislocations, moderate to severe instability and those with bony lesions were excluded. Besides history and physical examination, Magnetic Resonance Arthrography (MRA) was used to aid the diagnosis. Labrum tears with ARIL were treated with an additional ARIC procedure along with arthroscopic labrum repair. ResultsOut of two hundred fourty patients with a labrum tear, 114 had associated ARIL. The prevalence of ARIL ranged from 71 % with reverse Bankart tears to 46 % with anterior Bankart and 36 % in Type II SLAP tears. The success rate after labrum tear repair with ARIC performed in patients with ARIL with labrum pathology was 94.7 % at a 2-year follow-up in terms of relief from anterior shoulder pain. ConclusionAlmost half (47.5 %) of our patients presented with anterior shoulder pain with labrum tears were associated with ARIL. We recommend keeping a high index of suspicion for ARIL in labrum injuries presenting mainly with anterior shoulder pain for better treatment planning. Level of evidenceLevel IV (Retrospective case series without a comparision group)

Surgical Management of 2,350 Pediatric Dermoid Cysts.

We examined operative and pathologic findings of a large series of dermoid cysts at a high-volume pediatric hospital over 23 years. A retrospective review was performed of all dermoid cysts excised from 2000 to 2023 at the Children's Hospital of Philadelphia. Lesions were classified by location. Depth was stratified into Type 1, superficial; Type 2, subperiosteal or containing a stalk to a cranial suture; Type 3, intraosseous or intracartilaginous; Type 4, intracranial extradural; and Type 5, intracranial intradural. Of 2,350 lesions, 2,237 (95.2%) were in the head and neck. Most common locations were lateral brow and orbit, 892 (38%); anterior neck, 303 (12.9%); and frontal, 253 (10.8%). Among the series, 67.9% were Type 1, 10.1% were Type 2, 16.5% were Type 3, 2.3% were Type 4, and 3.2% were Type 5. Older age at surgery correlated with depth among locations demonstrating intracranial extension (r=.061, p=.016). Anterior fontanelle (59.1%), nasal (16.2%), occipital (5.6%), and temporal (4.7%) lesions had the highest intracranial extension rates. Temporal (49.4%), frontal (32.8%), nasal (29.9%), and occipital (22.2%) lesions had higher rates of osseous/cartilaginous involvement. On histopathologic examination, 403 (17.1%) were ruptured. Ruptured lesions were associated with giant cell reaction (46.4 versus 5.7%, p<.001). Anterior fontanelle, nasal, occipital, and temporal lesions are at higher risk of intracranial extension and may require preoperative imaging. Frontal and parietal lesions have a lower risk of intracranial involvement. Lateral brow and orbit, periauricular, and anterior neck lesions demonstrate a higher rate of osseous involvement without intracranial tracking.

Upfront Thoracic Magnetic Resonance Imaging for the Evaluation of Thymic Lesions to Reduce Non-Therapeutic Diagnostic Thymectomy: A Narrative Review.

Background: Thymic pathologies represent the most common lesions of the anterior mediastinum. They may be classified as malignant or benign. Current diagnostic pathways recommend an initial assessment with computed tomography (CT) imaging to delineate potentially malignant thymic lesions. Despite this, high rates of non-therapeutic thymectomy continue to be observed. This carries with it significant anaesthetic, operative, and post-operative risks, in addition to healthcare costs. Consequently, there is a growing interest in magnetic resonance imaging (MRI) as a primary diagnostic modality for lesions of the anterior mediastinum. This narrative review outlines the current approaches to the evaluation of thymic lesions, with a discussion of the strengths and limitations of CT and MRI imaging modalities. It also evaluates the current discourse on the use of upfront MRI for thymic and anterior mediastinal lesion assessment. Methods: A narrative review was performed following a search on the Medline database. Articles that were evaluated had explored the role of MRI on the evaluation of thymic and anterior mediastinal lesions. Results: Current work-up for thymic and anterior mediastinal lesions are highly variable and centre around the use of CT. Upfront MRI demonstrates a similar accuracy to CT for various thymic and anterior mediastinal pathologies; however, the efforts to integrate this approach into routine practice remain in their infancy, with no standardised guidelines that exist. Conclusions: This narrative review demonstrates that there is a paucity of evidence relating to the sensitivity and specificity of MRI compared to CT for thymic lesion analysis and their subsequent relationship with non-therapeutic thymectomy. Future prospective trials to assess the role of MRI in thymic lesion determination are required to understand whether MRI can more accurately characterise these lesions to reduce non-therapeutic thymectomy. Additionally, further research efforts are required to characterise best-practice methods for integrating MRI into diagnostic pathways for these lesions in a cost-effective and resource-conscious manner.

The 2024 Richardson Lecture: Prosopagnosia - A Classic Neurologic Deficit Meets the Modern Era.

Acquired prosopagnosia is a rare disorder, but it serves as a model for impairments in expert-level visual processing. This review discusses five key observations made over the past 30 years. First, there are variants, an apperceptive type linked to damage to the inferior occipitotemporal cortex and an amnestic type associated with anterior temporal lesions, both either right or bilateral. Second, these variants are clustered in syndromes with other perceptual deficits, the apperceptive type with field defects, dyschromatopsia and topographagnosia, and the amnestic type with topographagnosia and the auditory disorders of phonagnosia and acquired amusia. Third, extensive testing often shows additional problems with recognizing exemplars of other objects, especially when degrees of expertise are taken into account. Fourth, the prosopagnosic impairment does not affect all facial information. For example, the perception of expression and lip-reading likely depends on other neural substrates than those for processing facial identity. Last, face perception in prosopagnosia is not immutable but can improve with extensive training, though as yet this does not represent a cure for the condition. Continuing work with neural networks and animal models will enhance our understanding of this intriguing condition and what it tells us about how our brains process vision.

Is Trochlear Dysplasia Associated with a High Prevalence of Repaired Anterior Medial Portal Lesions in Anterior Cruciate Ligament-Deficient Knees?

Abstract Introduction Meniscal tears, especially in the medial meniscus, are common in anterior cruciate ligament (ACL) injuries. Repaired anterior medial portal (RAMP) lesions, specific meniscal injuries associated with ACL ruptures, affect the peripheral attachment of the posterior horn of the medial meniscus. While the relationship between femoral trochlear morphology and ACL tears is established, its association with RAMP lesions remains unexplored. This study investigates the association between femoral trochlear morphology and RAMP lesions in ACL-deficient knees using magnetic resonance imaging (MRI) and evaluates MRI's accuracy against arthroscopy. Methods This hospital-based, cross-sectional observational study was conducted in a tertiary care center over 18 months. It included 126 adult patients who underwent arthroscopic ACL reconstruction and had preoperative MRI. Variables included age, gender, body mass index, trauma nature, and various MRI parameters, including femoral trochlear morphology and presence of RAMP lesions. MRI findings were compared to arthroscopic findings to evaluate diagnostic accuracy. Results RAMP lesions were detected in 21 participants (16.7%) via MRI and 28 participants (22.2%) via arthroscopy. MRI showed 71.4% sensitivity and 99.0% specificity for detecting RAMP lesions. No significant association was found between femoral trochlear morphology and RAMP lesions. However, medial tibial slope (TS) and posterior medial tibial bone edema (PMTBE) were significantly associated with RAMP lesions. The agreement between MRI and arthroscopy was high (Cohen's kappa = 0.773, p &lt; 0.001). Conclusion This study found no significant association between femoral trochlear morphology and RAMP lesions in ACL-deficient knees. Instead, medial TS and PMTBE were significant predictors. MRI proved to have high specificity but moderate sensitivity compared to arthroscopy.

12450 Beyond the Surface: A Deep Dive into Pancreatic Insulinoma

Abstract Disclosure: S. Bhandari: None. R. Elhag: None. J. Singh: None. N. Rastogi: None. Background: Pancreatic neuroendocrine tumors (NET) are rare lesions that are typically sporadic, solitary and usually &amp;lt;2cm in diameter, with reported incidence of 4 cases per 1 million patients per year[1]. The most common hormone secreting NET are insulinomas. The hallmark of insulinomas is hypersecretion of insulin, leading to neuroglycopenic symptoms and uncontrolled sympathoadrenal activity. Clinical case: 51 years old female with no significant past medical history was referred to endocrine clinic by her primary care physician for hypoglycemia with a blood glucose level of 48 mg/dl. She reported an increased frequency of headaches and dizziness which began with intermittent fasting (10-12 hours) for past 6 months. These symptoms improved upon increasing meal frequency. Initial laboratory investigations revealed glucose of 54 mg/dl, normal HbA1c, and negative sulfonylurea panel. The patient had normal liver and kidney function with no malnutrition or malabsorption issues. Further work up showed C-peptide level 1.56 ng/ml (n 0.80-3.85ng/ml), insulin level 7.9 uIU/mL (n &amp;lt;18.4 uIU/mL), pro-insulin level significantly elevated at 77.6 pmol/L (n &amp;lt;/= 18.8pmol/L) and beta hydroxybutyrate of 0.12 mmol/l (n 0.02-0.27mmol/l). Insulin like growth factor was normal. Insulin antibodies were negative, and pituitary hormones were within normal limits. Pancreatic ultrasound was normal. CT abdomen/pelvis showed a 0.8x1.1 cm homogenously hypervascular anterior pancreatic body soft tissue lesion consistent with NET. Patient was started on diazoxide and continuous glucose monitoring (CGM). She was referred to general surgery and underwent successful tumor resection. Insulinoma is suggested by Whipple's triad, which is presence of hypoglycemic symptoms, documented hypoglycemia and resolution of hypoglycemic symptoms after glucose administration. As clinical manifestations are non-specific, diagnosing an insulinoma is challenging and depends on collateral history and a high index of suspicion. The gold standard of diagnosis is supervised 72-hour fasting test with plasma glucose, insulin, C-peptide, and proinsulin level measurements. Medical management of insulinoma includes the use of diazoxide, calcium channel blockers, propranolol, and glucocorticoids. Surgery is definitive treatment for insulinomas, with cure rates ranging from 77 to 100%. Conclusion: Insulinomas are benign and curable in most cases but can be fatal if misdiagnosed. Incidental findings of hypoglycemia should warrant thorough diagnostic workup to facilitate timely diagnosis and management.

Transrectal versus transperineal prostate fusion biopsy: a pair-matched analysis to evaluate accuracy and complications

PurposeTo evaluate biopsy-related complications and detection rates of any PCa and clinically significant PCa (csPCa, intended as grade group ≥ 2) between MRI-targeted TP fusion biopsies (TPBx) and TR ones (TRBx).MethodsWe performed a multicentric study on 4841 patients who underwent fusion biopsy between 2016 and 2023. A case–control matching was performed to find comparable cohorts of 646 TPBx and 646 TRBx. Mean T test and Pearson chi-square tests were used to compare continuous and categorical variables.ResultsBaseline characteristics were comparable between the cohorts, except for target location with a higher rate of anterior lesions in TPBx group. Complications were rare and no difference was found between the groups, with similar rates of infections after TRBx and TPBx (N = 5 (0.8%) vs N = 2 (0.3%), p 0.45). All patients in TRBx and 90.1% in TPBx group received antibiotic prophylaxis. A higher csPCa detection rate was found in TPBx over the group (50.5% vs 36.2%, p < 0.001). On average, positive targeted cores were increased in TPBx group, for any PCa (1.6 vs 1.4, p 0.04) and csPCa (1.0 vs 0.8, p 0.02). Among the limitations of study, we acknowledge the retrospective design and the possible under-reporting of complications.ConclusionsMRI-targeted fusion TPBx achieves a significantly higher csPCa detection than TRBx, with a diagnostic advantage for apical and anterior lesions. No significant differences were found in terms of complications that were rare in both groups, considering a widespread adoption of antibiotic prophylaxis.

Impact of Complex Anatomy and Patient Risk Profile in Minimally Invasive Mitral Valve Surgery

BackgroundWe aimed to assess the impact of complex mitral valve disease and patient risk profile on operative outcomes in the large cohort of the Mini-Mitral International Registry. MethodsPatients were assigned to categories of complex degenerative mitral valve regurgitation (DMR; bileaflet or anterior mitral leaflet prolapse/flail) and simple DMR (posterior mitral leaflet prolapse/flail). Subgroup analyses was performed in low-risk (EuroSCORE II <8%) and high-risk (EuroSCORE II >8%) cohorts. A logistic regression model was applied to investigate the impact of valve anatomy and patient risk factors on valve repair rate and operative risk. ResultsThe study cohort consisted of 4524 patients with DMR (complex DMR, 1296; simple DMR, 3228). Valve repair rate was 87.3% and 91% in complex DMR and simple DMR, respectively. Predictors of valve replacement were anterior leaflet prolapse/flail, bileaflet flail, female sex, age, and reoperation, whereas Barlow disease was protective. Clinical results were comparable between complex DMR and simple DMR. On subgroup analyses, high-risk patients showed less satisfactory outcomes with respect to both the valve repair and operative mortality rates. ConclusionsOur findings suggest that complex DMR can be satisfactorily addressed by minimally invasive techniques. However, whereas complex disease was associated with low operative risk, anterior leaflet lesions and bileaflet flail remain negative predictors of successful valve repair. Conversely, valve repair rate was less satisfactory in high-risk patients, regardless of DMR complexity.

Anterior Labrum Periosteal Sleeve Avulsion Lesions of the Shoulder: A Scoping Review.

Anterior labrum periosteal sleeve avulsion (ALPSA) lesion of the shoulder is defined as a labral avulsion with an intact periosteum of the glenoid neck resulting in medial malattachment of the labrum, which is both nonanatomic and nonfunctional. It is relatively rare compared with Bankart lesions, and its results are usually reported in combination with other anterior labroligamentous lesions in the literature. To (1) assess the size and scope of the literature on ALPSA lesions, (2) highlight the importance of this lesion, and (3) distinguish between ALPSA and Bankart lesions in diagnostic and treatment strategies. Scoping review; Level of evidence, 4. The PubMed, Scopus, Embase, and Google Scholar databases were searched with the keywords "ALPSA,""anterior labrum periosteal sleeve avulsion,""anterior labral periosteal sleeve avulsion," and "anterior labroligamentous periosteal sleeve avulsion" lesion. Duplicate articles and those that did not meet the inclusion criteria were excluded, resulting in the identification of 42 relevant articles. Their references were analyzed for further data curation. This scoping review demonstrated that ALPSA lesions are difficult to clinically identify. Magnetic resonance angiography in the adduction internal rotation position is the most sensitive and specific imaging modality for identification. Optimal views are the anterosuperior portal for accurate identification and the anteroinferior portal for surgical repair during arthroscopy. Treatment begins with correctly identifying the labrum, in contradistinction to dense reactive fibrous tissue, and reattaching the labrum to the correct anatomic glenoid footprint. Chronic lesions with bone loss require either bone block or soft tissue augmentation procedures. There is paucity of exclusive literature on ALPSA lesions. It is important to distinguish this lesion from the Bankart lesion as it is associated with worse outcomes. The higher failure rates of ALPSA lesion repair indicate that the current repair techniques require further refinement to improve the outcomes to the standard of Bankart lesions.

Anterior cingulate cortex lesions impair multiple facets of task engagement not mediated by dorsomedial striatum neuron firing.

The anterior cingulate cortex (ACC) has been implicated across multiple highly specialized cognitive functions-including task engagement, motivation, error detection, attention allocation, value processing, and action selection. Here, we ask if ACC lesions disrupt task performance and firing in dorsomedial striatum (DMS) during the performance of a reward-guided decision-making task that engages many of these cognitive functions. We found that ACC lesions impacted several facets of task performance-including decreasing the initiation and completion of trials, slowing reaction times, and resulting in suboptimal and inaccurate action selection. Reductions in movement times towards the end of behavioral sessions further suggested attenuations in motivation, which paralleled reductions in directional action selection signals in the DMS that were observed later in recording sessions. Surprisingly, however, beyond altered action signals late in sessions-neural correlates in the DMS were largely unaffected, even though behavior was disrupted at multiple levels. We conclude that ACC lesions result in overall deficits in task engagement that impact multiple facets of task performance during our reward-guided decision-making task, which-beyond impacting motivated action signals-arise from dysregulated attentional signals in the ACC and are mediated via downstream targets other than DMS.

Long head of the biceps tendon plays a role in stress absorption and humeral head restriction during the late cocking and deceleration phases of overhead throwing: a finite element study

BackgroundEmerging evidence suggests that the long head of the biceps (LHBT) may play a role in stabilizing the glenohumeral joint, and this has led to controversy around the efficacy of biceps tenotomy for superior labral anterior and posterior (SLAP) lesions. Therefore, the aim of this finite element analysis (FEA) study was to determine the stress absorption and humeral head translation restriction effects of the LHBT within the glenohumeral joint during the late cocking and deceleration phases of overhead throwing with a view to resolving the controversy around tenotomy. MethodsEight FEA models were created using computed tomography and magnetic resonance imaging data from normal glenohumeral joints. The models represented four LHBT conditions: uninjured, subpectoral tenodesis, tenotomy, and type II SLAP lesions. The late cocking and deceleration phases of the overhead throwing were simulated for each model. The impacts of the four LHBT conditions on glenohumeral joint stress absorption and humeral head displacement restriction were studied based on 1) stress and related distributions on the cartilage, labrum, capsule, and LHBT and 2) humeral head translation variation. ResultsThe FEA analysis showed that the magnitude of the contact stress on the articular cartilage, labrum, and capsule was the lowest in the uninjured models, followed by the subpectoral tenodesis, tenotomy, and type II SLAP lesion models. Humeral head translation was the most restricted in the subpectoral tenodesis models, followed by the tenotomy and type II SLAP lesion models. ConclusionFinite element analysis demonstrated that the LHBT plays a significant role in stress absorption and displacement restriction in the late cocking and deceleration phases of overhead throwing. Subpectoral tenodesis of the LHBT exhibited lesser amount of stress and humeral head translation than those of tenotomy, thereby making it a better option for patients who engage in overhead throwing.

Clinical descriptive and long-term outcome of melanocytic uveal lesions in young dogs: 40 cases (45 eyes) including 13 cases of sector iridectomy.

To describe the clinical features surgical technique, early and long-term outcome with or without surgery, and histopathological findings of melanocytic anterior uveal lesions in young dogs. Medical records of dogs at a guide dog facility removed from training due to a pigmented iris lesion were reviewed from 2014 to 2021. Selected dogs had surgical iridectomies performed. Iridal melanocytic lesions were characterized as well-delineated, pigmented, and flat (nevus) or raised (mass) lesions of the iris. Forty dogs (18 Labrador retrievers, 18 German shepherd dogs, 1 Golden retriever, 3 Labrador/Golden mixes) ranging from 0.5 to 3.1 years of age were affected unilaterally (n = 35) or bilaterally (n = 5). Sector iridectomy was performed in 13 dogs with prominent and well-isolated mass lesion and enucleation was carried out in 2 dogs with extensive lesions, while all other cases were monitored without surgical intervention. Postoperative complications included dyscoria (13/13), focal posterior synechia (9/13) and focal nonprogressive cataract (8/13). All eyes remained visual and comfortable up to 6.2 years post-iridectomy with no clinically identifiable local recurrence. Histopathology was consistent with uveal melanocytoma in all samples obtained surgically. All cases that did not undergo surgery remained free of complications up to 4.5 year post diagnosis. Melanocytic anterior uveal lesions may be overrepresented in certain lineages of breeds and be present at a young age. While none of the eyes developed complications when monitored without surgery, early surgical excision of the mass by sector iridectomy yields noteworthy functional outcome and retention of a comfortable globe.

Feasibility, efficacy, and safety of mechanical thrombectomy via sheathless transradial access as a first-line strategy: A case series

ObjectiveAlthough mechanical thrombectomy (MT) is primarily performed via transfemoral access (TFA), transradial access (TRA) is a potential alternative in older patients or those with tortuous vessels. However, the small radial artery diameter restricts the use of large-bore balloon guides and aspiration catheters, a limitation that may be overcome using the sheathless technique. Thus, we aimed to explore the feasibility, efficacy, and safety of sheathless TRA-MT as a first-line treatment approach for acute ischemic stroke. MethodsThis single-center retrospective case series included patients who underwent TRA-MT as first-line treatment between September 2020 and June 2023. Per our MT protocol, TRA was not the first-line approach in cases of left anterior circulation lesions with a type 3 aortic arch. We evaluated treatment effectiveness based on the successful recanalization rate, puncture-to-recanalization time, and modified first-pass effect; access route effectiveness based on the puncture-to-first-pass time and switch-to-TFA rate; and procedure safety based on procedure-related and severe puncture site complications. ResultsSheathless 8-F guide catheters were used in 68 % and large-bore aspiration catheters in 70 % of the procedures. Successful recanalization was achieved in 98 % of the patients, with a modified first-pass effect in 54 % of them. The median puncture-to-first-pass and puncture-to-recanalization times were 20.5 and 33 min, respectively. The rate of procedure-related complications was low (4 %), with no severe puncture site complications. ConclusionSheathless TRA-MT enabled the use of large-bore guide and aspiration catheters, providing a swift approach to the target and satisfactory outcomes, and might be an effective first-line treatment for acute ischemic stroke.