Cerebral Magnetic Resonance Imaging Research Articles

Management of a human immunodeficiency virus case with discordant antiviral drug resistance profiles in cerebrospinal fluid compared with plasma: a case report

BackgroundHuman immunodeficiency virus-1-associated neurocognitive disorder is a known complication in individuals treated with antiretroviral therapy. Cerebrospinal fluid escape, which is defined as discordant higher cerebrospinal fluid viremia than plasma, may occur in antiretroviral therapy-experienced individuals. Different cerebrospinal fluid versus plasma mutation patterns have been observed in individuals with cerebrospinal fluid escape.Case presentationA 46-year-old adult African male with human immunodeficiency virus-1 infection and acquired immunodeficiency syndrome based on cerebral toxoplasmosis and a chronic hepatitis B virus infection developed cerebrospinal fluid escape. A different human immunodeficiency virus-1 genotypic drug resistance profile was observed in plasma compared with cerebrospinal fluid. Brain biopsy and cerebral magnetic resonance imaging indicated the development of human immunodeficiency virus encephalopathy. A discordant protease inhibitor mutation/wild-type T74PT in plasma but not in cerebrospinal fluid indicated poor central nervous system penetration due to the selective pressure of drug therapy. An intensified antiretroviral therapy regimen including dolutegravir with good central nervous system penetration improved conditions.ConclusionsThis case shows the importance of measuring human immunodeficiency virus drug resistance in cerebrospinal fluid, which might differ from resistance detected in plasma samples and target effective antiretroviral therapy treatment accordingly.

Presentation of Congenital Portosystemic Shunts in Children.

Background: Congenital portosystemic shunts (CPSS) are rare vascular anomalies resulting in communications between the portal venous system and the systemic venous circulation, affecting an estimated 30,000 to 50,000 live births. CPSS can present at any age as a multi-system disease of variable severity mimicking both common and rare pediatric conditions. Case presentations: Case A: A vascular malformation was identified in the liver of a 10-year-old girl with tall stature, advanced somatic maturation, insulin resistance with hyperinsulinemia, hyperandrogenemia and transient hematuria. Work-up also suggested elevated pulmonary pressures. Case B: A young girl with trisomy 8 mosaicism with a history of neonatal hypoglycemia, transient neonatal cholestasis and tall stature presented newly increased aminotransferase levels at 6 years of age. Case C: A 3-year-old boy with speech delay, tall stature and abdominal pain underwent abdominal ultrasound (US) showing multiple liver nodules, diagnosed as liver hemangiomas by hepatic magnetic resonance imaging (MRI). Management and outcome: After identification of a venous malformation on liver Doppler US, all three patients were referred to a specialized liver center for further work-up within 12 to 18 months from diagnosis. Angio-computed tomography (CT) scan confirmed the presence of either an intrahepatic or extrahepatic CPSS with multiples liver nodules. All three had a hyperintense signal in the globus pallidus on T1 weighted cerebral MRI. Right heart catheterization confirmed pulmonary hypertension in cases A and C. Shunts were closed either using an endovascular or surgical approach. Liver nodules were either surgically removed if there was a risk of malignant degeneration or closely monitored by serial imaging when benign. Conclusion: These cases illustrate most of the common chief complaints and manifestations of CPSS. Liver Doppler US is the key to diagnosis. Considering portosystemic shunts in the diagnostic work-up of a patient with unexplained endocrine, liver, gastro-intestinal, cardiovascular, hematological, renal or neurocognitive disorder is important as prompt referral to a specialized center may significantly impact patient outcome.

Vertebral artery compression of the medulla oblongata: A benign radiological finding?

Background: To the best of our knowledge, no study has documented the natural history of rostral medullary compression of the vertebral artery (RMCVA) as radiological finding. The aim of this study was to explore it.Methods: A total of 57 patients with RMCVA and not presenting symptoms of medullary compression syndrome were enrolled. These participants underwent cerebral magnetic resonance imaging with contrast, and 19 of them who were followed for 5.7 ± 1.9 years (range: 3.0–10.3 years) were analyzed in detail. For comparison, clinical courses of two other patients with vertebrobasilar dolichoectasia (VBDE) were presented.Results: RMCVA was well delineated in all 57 patients. In the 19 patients analyzed, RMCVA was found in 17 sides on the right and 15 on the left. Moreover, the ventrolateral medulla was the most frequent compression site, and it was found in 69% of cases, with 84.2% presenting as mild compression and 15.8% as considerable compression. During the follow-up period, no patients showed neurological deterioration or radiological progression. In contrast, the two VBDE patients demonstrated both neurological and radiological progressions during the follow-up period.Conclusion: Unlike VBDE, RMCVA seems to be a benign condition without progression, even when with a considerable compression. Degree of the compression in RMCVA may not be relevant to the patient’s neurological status.

Herpetic encephalitis: which treatment for which body weight?

Prognosis of herpetic encephalitis remains severe, with a high proportion of deaths and sequelae. Its treatment is based on acyclovir, but the precise and most effective modalities of this treatment are not established. The objective of this study was to determine them. For this, we carried out a descriptive, retrospective, monocentric study, using the current coding database at Marseille University Hospitals. Cohort was intended to be exhaustive for the disease, from January 2000 to June 2019, including patients hospitalized in intensive care and conventional hospitalization sector. Patients (n = 76) included were at least 16years of age and had a clinical presentation, cerebral Magnetic Resonance Imaging, and/or electroencephalogram abnormalities consistent with herpetic encephalitis confirmed by a positive HSV-PCR in the CSF. Clinical data and treatment, including the doses actually administered to the patient, were compared according to patient's outcome. The mortality rate was 12%, whereas 49% had complete recovery and 39% sequelae impeding independence. Poor outcome was statistically associated with persistence of confusion, aphasia, and impaired consciousness lasting more than 5days, superinfection, status epilepticus, and length of stay in intensive care unit. A statistical decision tree, constructed using the Classification And Regression Tree model, to prioritize treatment management, showed two main factors that influence the outcome: the patient's weight, and the average daily acyclovir dose actually administered. These results suggest to modify acyclovir management in herpetic encephalitis, for low-weight patients (< 79kg) with a minimum dosage of 2550mg/day (850mg/ 8h), when possible.

Dissociative stupor in young adults. Challenges in differential diagnosis and treatment management

Dissociative stupor is a rare psychiatric condition, included in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) among Other Specified Dissociative Disorders, as an acute dissociative reaction to a stressful event. Like other acute pathological dissociative presentations, it is primarily related to traumatic experiences. Aim. This article aims at presenting the case of dissociative stupor in a 21-year-old male who presented firstly with mixed symptoms of tonic seizures and catatonia. Method. Before the present admission, the patient had two previous emergency department presentations, upon which he presented altered consciousness, muscular rigidity, unresponsiveness to external stimuli, alternated with episodes of psychomotor agitation and visual hallucinations, symptoms partially remitted after the administration of propofol, levetiracetam and solumedrol. During the presentation, the patient’s mother revealed that the patient may have seen the dead body of his grandfather, with whom he had a previously close relationship, and found out in this manner that he passed away during the previous night. Urinary tox-screen was positive for tetrahydrocannabinol (THC). Also, complete blood count (CBD), basic metabolic panel (BMP), cerebrospinal fluid (CSF) analysis, cerebral magnetic resonance imaging (MRI), both native and angiographic sequence, and electroencephalogram (EEG) were performed, with results within normal range. The treatment with selective serotonin reuptake inhibitors (SSRI’s; sertraline) and second-generation antipsychotics (SGA; olanzapine) was initiated. Discussion. From a psychiatric point of view, the patient needs to be reevaluated periodically regarding the psychopharmacologic therapy; also, cognitive-behavioral therapy (CBT) or hypnosis may be an option in this case. Conclusions. The diagnosis and therapeutic management of dissociative stupor represents a real challenge due to the need of excluding other psychiatric or somatic conditions and the fact that there are no available data regarding the psychopharmacological treatment. However, there is much ongoing research in the neurobiology of trauma-related altered states of consciousness and the promising results of them are the basis of future psychopharmacological strategies.

A bullous purpura triggered by warming in a newborn with congenital cytomegalovirus infection

A newborn with microcephaly presented hemorrhagic bullous purpura triggered by heat in the 1st h of life. Doppler arterial and venous ultrasound excluded vascular complications. Cytomegalovirus was detected in blood, urine, and serum of the lesions. The final diagnosis was cytomegalovirus congenital infection due to reactivation in an immune mother, with associated purpuric rash, confirmed by cerebral magnetic resonance imaging.

Purpura fulminans, presenting feature of multisystem inflammatory syndrome in children (MIS-C)

Introduction. Coronavirus disease 2019 (COVID-19) has been a worldwide health issue since early 2020, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Even though children do not usually present with se­vere COVID-19 unless the patient has an underlying di­sease, post­in­fectious complications, such as the multisystem in­flam­ma­to­ry syndrome in children (MIS-C), have been a sig­ni­fi­cant cause of child morbidity and mortality during the pan­de­mic. Even more challenging is that MIS-C has a very broad differential diagnosis due to its clinical heterogeneity. Case report. We report the case of a 6-month-old infant with­out another medical history who was brought to the ge­ne­ral practitioner’s office for persistent fever and cough. The symp­toms did not ameliorate under antipyretic and mucolytic treat­ment, so the patient later presented in the emergency room with associated dyspnea, diarrhea, vomiting and rapidly ge­ne­ra­li­zing purpuric skin lesions suggestive of purpura ful­mi­nans. He was admitted into our hospital and received em­pi­ri­cal antibiotic treatment. He also developed neck stif­fness. Meningococcemia was thus suspected; however, all cultures came out negative. Laboratory studies showed an important inflammatory syndrome, thrombocytopenia, se­vere anemia, coagulopathy, low protein C, protein S and an­ti­throm­bin levels, low fibrinogen, high D-dimer levels and hypo­al­bu­mi­ne­mia. Cerebral magnetic resonance imaging (MRI) showed no evidence of brain lesions. SARS-CoV-2 IgG-type antibodies were positive, therefore MIS-C was sus­pec­ted. The laboratory studies were extended and revealed high NT-proBNP, IL-6 and IL-2 soluble antigen levels. Other pos­si­ble diagnoses were excluded, which permitted our team to establish the diagnosis of MIS-C. The specific treatment was initiated with intravenous immunoglobulins (IVIG) and high-dose methylprednisolone associated with enoxaparin, broad-spectrum antibiotics and with symptomatic treatment. The patient rapidly evolved well, with the remission of fe­ver, inflammatory syndrome, coagulopathy and all other clinical and laboratory alterations. The skin lesions ame­lio­ra­ted as well, however, at a slower pace. Conclusions. MIS-C is a potentially life-threatening complication of COVID-19 in children. Therefore, clinicians must maintain a high degree of suspicion in the setting of the ongoing SARS-CoV-2 pandemic. However, the diagnostic criteria should be strictly followed due to the clinical similarities this pathology might have with other known diseases.

Reversible posterior encephalopathy syndrome on malignant hypertension secondary to congenital nephrotic syndrome (case report)

Posterior reversible encephalopathy syndrome (PRES) is a fairly rare complication, and even more so in children. Cerebral magnetic resonance imaging (MRI) is considered the reference examination to evoke this diagnosis. We report the case of a 7-year-old boy presenting with a reversible posterior encephalopathy syndrome secondary to malignant arterial hypertension complicating CKD on congenital nephropathy, which presented with a tonic-clonic seizure and loss of consciousness, with a BP of 190/130mmHg in an apyretic context . Imaging revealed characteristic edema of the white and gray matter in the form of multiple areas of T2 hyper signal and cortico-subcortical cortical temporo-occipital and frontal, of the caudate nucleus and bilateral lenticulars, of the brain stem and cerebellum in relation to the PRES given the clinico radiological context. The course of action was hospitalization in intensive care with stabilization and conditioning, and was put on antihypertensive and anticonvulsant drugs A rigorous monitoring was required in our patient and the evolution was very favorable.

Intra-Sellary Arachniodocele: About a Case at the Medical Clinic “The Stars” of Bamako

Intrasellar arachnoidocele is a herniation of the optochiasmatic cistern through a dehiscence of the sellar diaphragm producing an empty sella turcica, hence its name empty sella turcica syndrome. It is an extremely rare benign malformative pathology. We report a case of intra-sellar arachnoidocele in a 34-year-old woman revealed during an annual control of a sellar mass under dossinex by cerebral magnetic resonance imaging (MRI) which found the cystic formation of liquid signal identical to that of the LCS in hypo signal T1 and hyper signal T2 without enhancement after injection of Gadolinium. The epidemiological, clinical and radiological aspects of arachnoidocele were analyzed. The purpose of this work is to bring the interest of MRI in the management of this pathology.

A case of repeated focal motor seizures as expression of an inflammatory cerebral process with suspected dysimmune etiology.

Autoimmune encephalitis (AE) is a condition of severe brain inflammation with a complex differential diagnosis. The identification of a specific neuronal antibody (NA) is not mandatory to diagnose AE. Moreover, even when a NA is detected, the clinical picture can be inconsequential (i.e., GAD-65) and not disease-specific (i.e., LGI1). Peculiar clinical manifestations and specific alterations of conventional tests as cerebral spinal fluid (CSF) and magnetic resonance imaging (MRI) can be sufficient to confirm the diagnostic suspicion of AE. New-onset seizures may be the first manifestation of AE and require immediate treatment. We report the case of a 19-year-old woman with sudden onset of focal motor seizures with unimpaired awareness, resistant to different intravenous antiseizure medications (ASMs). Ancillary tests (MRI, CSF analysis and electroencephalogram) were pathological and compatible with an autoimmune disorder of the brain. A weak positivity of GluR-3 antibody was detected in low serum dilution along with very high levels of angiotensin-converting enzyme in serum. After administration of high-dose corticosteroids, electro-clinical and neuroradiological pictures progressively normalized. This case report suggests that, even without a definite NA positivity, an inflammatory brain disorder of suspected autoimmune etiology should be considered based on clinical assessment and suggestive ancillary tests.

Leopard spot chorioretinopathy revealing late onset sympathetic ophthalmia

AbstractPurposeTo report a case of a very late onset atypical sympathetic ophthalmia presented as a leopard spot retinopathy.MethodsAn observational case report of a 64‐year‐old patient with a history of penetrating ocular trauma of the right eye (RE) at the age of 3‐year‐old who presented with visual blurring of the left eye (LE). The patient underwent complete ophthalmic examination, autofluorescence imaging, fluorescein angiography, Indocyanine Green (ICG) angiography, swept‐source optical coherence tomography (SS‐OCT).ResultsExamination of the RE showed a phthisis bulbi. Visual acuity of the LE was limited to hand motion. Slit lamp examination revealed +1 cells anterior chamber inflammation, granulomatous keratic precipitates, posterior synechiae, with a mild cataract and +2 vitreous cells. Fundoscopy showed multiple yellowish patchy subretinal lesions. Fluorescein angiography revealed hyperfluorescent nummular areas at early frames without late leakage surrounded by zones of hypofluorescences. Fundus autofluorescence imaging showed a leopard spot pattern with areas of hypoautofluorescence surrounded by hyperautofluorescence. ICG angiography showed no hypofluorescent dark dots. SS‐OCT demonstrated retinal thickening, multiple areas of flat subretinal fluid, irregular hyperreflective spots at the photoreceptor outer segment layer and irregularities of the retinal pigment epithelium. The diagnosis of unilateral diffuse uveal melanocytic proliferation (DUMP) was first made. The patient underwent a systemic workup with full‐body computed tomography scans, cerebral and ocular magnetic resonance imaging and blood tests including tumor markers. All tests were normal. The patient was put on oral prednisone (1 mg/kg/day) during 6 months with a gradual tapering and good initial outcome. Visual acuity increased to 40/200.Two weeks after stopping steroids, he presented with acute granulomatous anterior uveitis and the diagnosis of very late onset sympathetic ophthalmia was made.ConclusionsLeopard retinopathy can be an uncommon clinical presentation of a variety of disorders especially sympathetic ophthalmia. The diagnosis could be challenging in case of atypical presentation and very late onset. Treatment outcome and close follow‐up should be considered for a correct diagnosis.

SUBARACHNOID HAEMORRHAGE ASSOCIATED WITH CEREBRAL SINUS THROMBOSIS – A RARE CASE

Cerebral venous thrombosis is a condition that requires greater clinical and radiological experience due to the significantly wider range of clinical signs and significant radiological variability. When the patient presents with SAH (subarachnoid haemorrhage), the challenge can be great. We present a case of cerebral venous thrombosis that radiologically presented with SAH without initial involvement of the parenchyma, which is why early diagnosis was important. We present a 36-year-old patient, with clinical manifestation of acute headache, elements for SAH on CT (computerised tomography) without initial involvement - haemorrhage of the brain parenchyma. CT angiography and venography using MRI (magnetic resonance imaging) demonstrated extensive thrombosis of the jugular vein, sigmoid and transverse sinus, with no other cause for SAH. Complete recanalization of the venous sinuses and significant improvement of the clinical diagnosis were reached after adequate anticoagulation therapy. The findings indicated that venous sinus thrombosis may initially manifest as unilateral SAH without the involvement of the brain parenchyma. Keywords: cerebral venous thrombosis, subarachnoid haemorrhage, CT and MRI venography, acute headache &nbsp

NOTCH3 Mutations and CADASIL Phenotype in Pulmonary Arterial Hypertension Associated with Congenital Heart Disease

Background: The etiology of pulmonary arterial hypertension associated with congenital heart disease (PAHCHD) is complicated and the phenotype is heterogeneous. Genetic defects of NOTCH3 were associated with cerebral disease and pulmonary hypertension. However, the relationship between NOTCH3 mutations and the clinical phenotype has not been reported in CHD-PAH. Methods: We eventually enrolled 142 PAH-CHD patients from Fuwai Hospital. Whole exome sequencing (WES) was performed to screen the rare deleterious variants of NOTCH3 gene. Results: This PAH-CHD cohort included 43 (30.3%) men and 99 (69.7%) women with the mean age 29.8 ± 10.9 years old. The pathogenic or likely pathogenic mutations of NOTCH3 were identified in five cases. Patients 2, 5, 8 and 11 carried the same NOTCH3 mutation c.1630C > T (pArg544Cys), which is the hot-spot mutation for cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). Patient 3 carried the NOTCH3 mutation p.Arg75Gln that has also been reported to be associated with the CADASIL. Patients 2, 5, 8, 11 took the examination of the cerebral magnetic resonance imaging (MRI) and confirmed the phenotype of CADASIL. Conclusions: We first reported the NOTCH3 rare mutations and CADASIL phenotypes in CHD-PAH patients. The NOTCH3 rare variants were with a relatively high positive rate and CADASIL phenotypes were likely enriched in PAH-CHD patients. The preoperative neurological examination might be recommended for PAH-CHD patients to determine the surgical contraindications and reduce intraoperative neurological complications.

Spinocerebellar Ataxia Type 13: A report of a non-progressive disease

Introduction: Spinocerebellar ataxia type 13 is a rare autosomal dominant disease caused by point mutations in the KCNC3 gene coding for the Kv3.3 voltage-gated potassium channel. This disease can present different neurodevelopmental and neurodegenerative forms. Case report: We present a case of a child who had trunk and appendicular ataxia, exuberant gait ataxia, tremor, dysarthria, and dysrhythmic and scanning speech. She presented a delay and difficulty in acquiring fine motor skills. Cerebral magnetic resonance imaging showed moderate hypoplasia of the cerebellum. A pathogenic variant c1268 G&gt;A p.(Arg423His) in heterozygosity in the KCNC3 gene was detected, allowing the diagnosis of Spinocerebellar Ataxia type 13. Later, the same diagnosis was established in the patient's father. However, he gradually improved his ataxia and motor function throughout his life. Discussion: Unlike most spinocerebellar ataxias, including the other spinocerebellar ataxia type 13 phenotypes, this one does not lead to progressive ataxia. Children with this disease should be follow-up by a multidisciplinary team and referred to an early intervention program. A regular neurologic examination is recommended to evaluate disease progression.

Markers of brain damage in full-term newborns with intrauterine growth retardation

The increase in the number of newborns with intrauterine growth retardation, who are characterized not only by high perinatal morbidity and mortality, but also by neurodevelopmental disorders in later life, has determined a wide search for diagnostic markers of prenatal hypoxia for a timely objective assessment of brain damage and a justification of neuroprotection methods. This article presents literature data on biomarkers and methods of instrumental diagnosis of brain damage that have received evidence of the effectiveness of their use in early neonatal life of newborns with intrauterine growth retardation. It is emphasized that such biomarkers as S100B, NSE, and BDNF proteins are the most reliable and easy to determine non-invasively. However, for their wide application in clinical practice, it is necessary to establish reference values in umbilical cord blood and urine, while taking into account the gestational age, sex, and method of giving birth, and to unify the use of laboratory analysis systems and diagnostic tests for this purpose. The comparison of biomarker indicators with cerebral oximetry, electroencephalogram and magnetic resonance imaging data will allow for developing new approaches to the treatment of perinatal pathology and, largely, preventing adverse consequences in those born with intrauterine growth retardation.

Correlation Between Retinal Microvascular Abnormalities and Total Magnetic Resonance Imaging Burden of Cerebral Small Vessel Disease in Patients With Type 2 Diabetes.

Background and Purpose: Diabetic retinopathy (DR) is one of the common microvascular complications in diabetes. The total magnetic resonance imaging (MRI) burden of cerebral small vessel disease (CSVD) tends to be increased in diabetic patients and is a marker of microvascular disease; however, the relationship between DR and CSVD is unclear. This study aimed to explore the relationship between retinal microvascular abnormalities and the total MRI burden of CSVD in patients with type 2 diabetes.Methods: Data were collected from patients with type 2 diabetes who were hospitalized between December 2019 and November 2020 in Changzhou Second People’s Hospital affiliated to Nanjing Medical University. All patients underwent retinal photography and cerebral MRI. The central retinal artery equivalent (CRAE), the central retinal venous equivalent (CRVE), and arteriole-to-venule ratio (AVR) were calculated using Image J software to determine the retinal vascular calibers for each patient. The total MRI burden score for CSVD was determined, and the relationship between retinal microvascular abnormalities and the total MRI burden of CSVD was analyzed.Results: Of the 151 diabetic patients included in the study, 84 (55.6%) had no diabetic retinopathy (NDR), 27 (17.9%) had mild DR, and 40 (26.5%) had moderate, or severe non-proliferative DR (grouped together for this study as “more than mild DR”). In patients with more than mild DR, the proportion of moderate to severe burden of CSVD was 75%, which was higher than in patients with mild DR (48.1%) or NDR (26.2%). Patients with moderate to severe burden of CSVD were more likely than those with mild burden of CSVD to have narrowed retinal arterioles (105.24 ± 8.42 μm vs. 109.45 ± 7.93 μm), widened retinal venules (201.67 ± 16.25 μm vs. 193.95 ± 13.54 μm), and lower arteriole-to-venule ratio (0.52 ± 0.05 vs. 0.57 ± 0.04) (P < 0.05 for all). The degree of DR (r = 0.465, P < 0.001) and CRVE (r = 0.366, P < 0.001) were positively correlated with the total MRI burden of CSVD. Multivariate logistic regression analysis indicated that, after adjustments were made for age, smoking, alcohol consumption, hypertension, and other factors, more than mild DR (OR, 4.383; P = 0.028), CRAE (OR, 0.490; P = 0.031), and CRVE (OR, 1.475; P = 0.041) were independently associated with moderate to severe burden of CSVD.Conclusion: Retinal microvascular abnormalities in patients with type 2 diabetes are associated with the presence of cerebral small vessel lesions. The degree of DR and retinal vessel changes can be used as predictors of intracranial microcirculation lesions.

Evaluation of atelectasis using electrical impedance tomography during procedural deep sedation for MRI in small children: A prospective observational trial

Study objectiveTo investigate the variation of poorly ventilated lung units (i.e., silent spaces) in children undergoing procedural sedation in a day-hospital setting, until discharge home from the Post-Anesthesia Care Unit (PACU). DesignProspective, single-center, observational cohort trial. SettingThis study was conducted at the radiology department and in PACU at Bern University Hospital (Switzerland), a tertiary care hospital. PatientsWe included 25 children (1–6 years, ASA I-III) scheduled for cerebral magnetic resonance imaging scan, spontaneously breathing under deep sedation. Children planned for tracheal intubation, supraglottic airway insertion, or with contraindication for propofol were excluded. InterventionAfter intravenous or inhaled induction, deep sedation was performed with 10 mg/kg/h Propofol. All children received nasal oxygen 0.3 ml/kg/min. MeasurementsThe proportion of silent spaces and the global inhomogeneity index were determined at each of five procedural points, using electrical impedance tomography: before induction (T1); before (T2) and after (T3) magnetic resonance imaging; at the end of sedation before transport to the PACU (T4); and before hospital discharge (T5). Main resultsThe median [interquartile range (IQR)] proportion of silent spaces at the five analysis points were: T1, 5% [2%–14%]; T2, 10% [7%–14%]; T3, 12% [5%–23%]; T4, 12% [7%–24%]; and T5, 3% [2%–11%]. These defined significant changes in silent spaces over the course of sedation (p = 0.009), but no differences in silent spaces from before induction to before discharge from the PACU (T1 vs. T5; p = 0.29). Median [IQR] global inhomogeneity indices were 0.57 [0.55–0.58], 0.56 [0.53–0.59], 0.56 [0.54–0.59], 0.57 [0.54–0.60] and 0.56 [0.54–0.57], respectively (p = 0.93). None of the children reported anesthesia-related complications. ConclusionDeep sedation results in significantly increased poorly ventilated lung units during sedation. However, this does not significantly affect ventilation homogeneity, which was fully resolved at discharge from the PACU.Trial registration: clinicaltrials.gov, identifier NCT04507581

Left Atrial Remodeling and Cerebrovascular Disease Assessed by Magnetic Resonance Imaging in Continuously Monitored Patients

Background: Atrial remodeling is associated with future atrial fibrillation (AF) and stroke. AF has been associated with cognitive impairment and cerebral white matter lesions. We wished to investigate the possible direct association between atrial remodeling and cerebrovascular disease in patients with and without AF documented by implantable loop recorder (ILR). Methods: Cardiac and cerebral magnetic resonance imaging were acquired in a cross-sectional study, including participants ≥70 years of age with stroke risk factors without known AF. Cerebrovascular disease was visually rated using the Fazekas scale and number of lacunar strokes. Left atrial (LA) and ventricular volumes and function were analyzed. Associations between atrial remodeling and cerebrovascular disease were assessed with logistic regression models. The analyses were stratified according to sinus rhythm or any AF during 3 months of continuous ILR monitoring to account for subclinical AF. Results: Of 200 participants investigated, 87% had a Fazekas score ≥1 and 45% had ≥1 lacunar infarct. Within 3 months of ILR monitoring, AF was detected in 28 (14%) participants. For participants with sinus rhythm (n = 172), lower LA passive emptying fraction was associated with Fazekas score after multivariable adjustment (OR [95% CI]: 0.51 [0.27; 0.86] p = 0.02), and increased LA maximum (OR [95% CI]: 1.38 [1.07; 1.82] p = 0.01) and minimum volumes (OR [95% CI]: 1.48 [1.03; 2.17] p = 0.04) were associated with lacunar infarcts. There were no significant associations in patients with AF. Conclusion: In AF-free patients, as documented by ILR monitoring, we found an independent association between LA passive emptying fraction and Fazekas score and between atrial volumes and lacunar infarcts.

Atrial Fibrillation Ablation Using Robotic Magnetic Navigation Reduces the Incidence of Silent Cerebral Embolism.

Background: The incidence of silent cerebral embolisms (SCEs) has been documented after pulmonary vein isolation using different ablation technologies; however, it is unreported in patients undergoing with atrial fibrillation (AF) ablation using Robotic Magnetic Navigation (RMN). The purpose of this prospective study was to investigate the incidence, risk predictors and probable mechanisms of SCEs in patients with AF ablation and the potential impact of RMN on SCE rates.Methods and Results: We performed a prospective study of 166 patients with paroxysmal or persistent AF who underwent pulmonary vein isolation. Patients were divided into RMN group (n = 104) and manual control (MC) group (n = 62), and analyzed for their demographic, medical, echocardiographic, and risk predictors of SCEs. All patients underwent cerebral magnetic resonance imaging within 48 h before and after the ablation procedure to assess cerebral embolism. The incidence and potential risk factors of SCEs were compared between the two groups. There were 26 total cases of SCEs in this study, including 6 cases in the RMN group and 20 cases in the MC group. The incidences of SCEs in the RMN group and the MC group were 5.77 and 32.26%, respectively (X2 = 20.63 P < 0.05). Univariate logistic regression analysis demonstrated that ablation technology, CHA2DS2-VASc score, history of cerebrovascular accident/transient ischemic attack, and low ejection fraction were significantly associated with SCEs, and multivariate logistic regression analysis showed that MC ablation was the only independent risk factor of SCEs after an AF ablation procedure.Conclusions: Ablation technology, CHA2DS2-VASc score, history of cerebrovascular accident/transient ischemic attack, and low ejection fraction are associated with SCEs. However, ablation technology is the only independent risk factor of SCEs and RMN can significantly reduce the incidence of SCEs resulting from AF ablation.Clinical Trial Registration: ChiCTR2100046505.

Association Between Early Amino Acid Intake and Full-Scale IQ at Age 5 Years Among Infants Born at Less Than 30 Weeks’ Gestation

An international expert committee recently revised its recommendations on amino acid intake for very preterm infants, suggesting that more than 3.50 g/kg/d should be administered only to preterm infants in clinical trials. However, the optimal amino acid intake during the first week after birth in these infants is unknown. To evaluate the association between early amino acid intake and cognitive outcomes at age 5 years. Using the EPIPAGE-2 (Epidemiologic Study on Small-for-Gestational-Age Children-Follow-up at Five and a Half Years) cohort, a nationwide prospective population-based cohort study conducted at 63 neonatal intensive care units in France, a propensity score-matched analysis was performed comparing infants born at less than 30 weeks' gestation who had high amino acid intake (3.51-4.50 g/kg/d) at 7 days after birth with infants who did not. Participants were recruited between April 1 and December 31, 2011, and followed up from September 1, 2016, to December 31, 2017. Full-scale IQ (FSIQ) was assessed at age 5 years. A confirmatory analysis used neonatal intensive care unit preference for high early amino acid intake as an instrumental variable to account for unmeasured confounding. Statistical analysis was performed from January 15 to May 15, 2021. Amino acid intake at 7 days after birth. The primary outcome was an FSIQ score greater than -1 SD (ie, ≥93 points) at age 5 years. A complementary analysis was performed to explore the association between amino acid intake at day 7 as a continuous variable and FSIQ score at age 5 years. Data from cerebral magnetic resonance imaging at term were available for a subgroup of preterm infants who participated in the EPIRMEX (Cerebral Abnormalities Detected by MRI, Realized at the Age of Term and the Emergence of Executive Functions) ancillary study. Among 1789 preterm infants (929 boys [51.9%]; mean [SD] gestational age, 27.17 [1.50] weeks) with data available to determine exposure to amino acid intake of 3.51 to 4.50 g/kg/d at 7 days after birth, 938 infants were exposed, and 851 infants were not; 717 infants from each group could be paired. The primary outcome was known in 396 of 646 exposed infants and 379 of 644 nonexposed infants who were alive at age 5 years and was observed more frequently among exposed vs nonexposed infants (243 infants [61.4%] vs 206 infants [54.4%], respectively; odds ratio [OR], 1.33 [95% CI, 1.00-1.71]; absolute risk increase in events [ie, the likelihood of having an FSIQ score >-1 SD at age 5 years] per 100 infants, 7.01 [95% CI, 0.06-13.87]; P = .048). In the matched cohort, correlation was found between amino acid intake per 1.00 g/kg/d at day 7 and FSIQ score at age 5 years (n = 775; β = 2.43 per 1-point increase in FSIQ; 95% CI, 0.27-4.59; P = .03), white matter area (n = 134; β = 144 per mm2; 95% CI, 3-285 per mm2; P = .045), anisotropy of the corpus callosum (n = 50; β = 0.018; 95% CI, 0.016-0.021; P < .001), left superior longitudinal fasciculus (n = 42; β = 0.018; 95% CI, 0.010-0.025; P < .001), and right superior longitudinal fasciculus (n = 42; β = 0.014 [95% CI, 0.005-0.024; P = .003) based on magnetic resonance imaging at term. Confirmatory and sensitivity analyses confirmed these results. For example, the adjusted OR for the association between the exposure and the primary outcome was 1.30 (95% CI, 1.16-1.46) using the instrumental variable approach among 978 participants in the overall cohort, and the adjusted OR was 1.35 (95% CI, 1.05-1.75) using multiple imputations among 1290 participants in the matched cohort. In this cohort study, high amino acid intake at 7 days after birth was associated with an increased likelihood of an FSIQ score greater than -1 SD at age 5 years. Well-designed randomized studies with long-term follow-up are needed to confirm the benefit of this nutritional approach.