Deep Location Research Articles

Tropical Pyomyositis in Immunocompetent Hosts Posing Diagnostic Challenges: A Case Series

Abstract Pyomyositis is an acute pyogenic infection of the muscles and tissues which results in localized pus collections and abscess formation. This entity at times becomes difficult to diagnose due to lack of specific signs and atypical or nonspecific manifestations. This condition is a mimic for a wide range of differential diagnoses due to which the patient often receives many unwarranted antibiotics. Furthermore, the deep location of the muscles makes the clinical signs in apparent leading to misdiagnosis as rarer entities such as inflammatory myositis. In the last 1 year, four such interesting cases were admitted in this tertiary care center with different clinical presentations. All these cases were healthy, immunocompetent individuals who presented to smaller hospitals with clinical presentation of muscle and joint pain with fever. The muscle groups affected were different in all these cases. All four patients were transferred to this hospital due to the diagnostic dilemma between inflammatory and infective myositis. After a thorough workup including imaging and tissue diagnostics, they were labeled pyomyositis. This further stresses the need for physicians to become acquainted with this potentially life-threatening yet curable infective disease entity. The patients were managed with antibiotics for a minimum duration of 3 weeks and a maximum duration of 8 weeks for complete recovery. Pyomyositis in immunocompetent hosts was related to factors affecting the muscles without any strenuous exercise or direct trauma. Comprehensive evaluation of the muscles is facilitated by assessment of fluorodeoxyglucose uptake on positron emission tomography–computed tomography scan. The initial therapy consisting of cephalosporin and teicoplanin was found effective in our patients. The minimum length of in-hospital treatment was 4 weeks. This series further reinforces the fact that tropical pyomyositis is not exclusive to immunocompromised persons.

Prediction of brain tumor recurrence location based on multi-modal fusion and nonlinear correlation learning.

Brain tumor is one of the leading causes of cancer death. The high-grade brain tumors are easier to recurrent even after standard treatment. Therefore, developing a method to predict brain tumor recurrence location plays an important role in the treatment planning and it can potentially prolong patient's survival time. There is still little work to deal with this issue. In this paper, we present a deep learning-based brain tumor recurrence location prediction network. Since the dataset is usually small, we propose to use transfer learning to improve the prediction. We first train a multi-modal brain tumor segmentation network on the public dataset BraTS 2021. Then, the pre-trained encoder is transferred to our private dataset for extracting the rich semantic features. Following that, a multi-scale multi-channel feature fusion model and a nonlinear correlation learning module are developed to learn the effective features. The correlation between multi-channel features is modeled by a nonlinear equation. To measure the similarity between the distributions of original features of one modality and the estimated correlated features of another modality, we propose to use Kullback-Leibler divergence. Based on this divergence, a correlation loss function is designed to maximize the similarity between the two feature distributions. Finally, two decoders are constructed to jointly segment the present brain tumor and predict its future tumor recurrence location. To the best of our knowledge, this is the first work that can segment the present tumor and at the same time predict future tumor recurrence location, making the treatment planning more efficient and precise. The experimental results demonstrated the effectiveness of our proposed method to predict the brain tumor recurrence location from the limited dataset.

Ultrasonographic Localization of Parotid Gland Tumor Relative to the Facial Nerve Using Stensen's Duct Criterion

During the preoperative evaluation of parotid gland tumors, one of the main concerns is to determine the location of the tumors in relation to the facial nerve. This study aims to assess the value of ultrasound for determining the location of parotid gland tumors in relation to the facial nerve using Stensen's duct. This is a retrospective cross-sectional study at a single institute. The subjects who underwent preoperative ultrasound and parotidectomy for parotid gland tumors were included. The subjects with incomplete operative records or no reference standard for the location of parotid gland tumor were excluded. The primary predictor was ultrasound tumor location, which was defined as the location of parotid gland tumors determined by preoperative ultrasound as to whether the tumors were superficial or deep to the facial nerve. The operative records were used as the reference standard for the location of parotid gland tumors. The primary outcome was diagnostic performances of preoperative ultrasound in predicting the location of parotid gland tumors, which were calculated by comparing ultrasound tumor location to the reference standard. Covariates were sex, age, type of surgery, tumor size, and tumor histology. Data analysis involved descriptive and analytic statistics; P<.05 was considered statistically significant. One hundred and two of 140 eligible subjects met inclusion and exclusion criteria. There were 50 male and 52 female, with a mean age of 53.3years. Ultrasound tumor location was classified as deep in 29 subjects, superficial in 50, and indeterminate in 23. The reference standard was deep in 32 subjects and superficial in 70. Indeterminate ultrasound tumor location results were grouped as either deep or superficial to make every possible cross table in which ultrasound tumor location results were presented as a dichotomy. The mean sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the ultrasound to predict the deep location of parotid tumors were 87.5, 82.1, 70.2, 93.6, and 83.8%, respectively. Stensen's duct on ultrasound can be a useful criterion to determine the location of parotid gland tumor relative to the facial nerve.

Deep learning-based burst location with domain adaptation across different sensors in water distribution networks

This study proposes a domain adaption method for pipe burst location based on deep learning. Multi-scale feature extractors are designed to extract pipe burst features, then three classifiers are trained by pipe burst features with different scales, and adversarial training is introduced during the edge domain fusion. Finally, the probability ranking of each pipeline is obtained according to the classification results of the three classifiers. In this study, a Net3 pipe network hydraulic model was used as an example to carry out related research. The pressure monitoring data of three sensors were used to train and test the model, and different scenarios of one, two and three sensors were considered at the same time. The results showed that the overall prediction accuracy of the three scenarios was over 90% when considering the five pipelines with the highest pipe burst probability.

Characteristics and outcomes of catheter ablation of ventricular arrhythmias originating from the left ventricular summit

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Catheter ablation (CA) of the left ventricular summit (LVS) arrhythmias is a challenging procedure due to the inherent complexity anatomy of that region. Different anatomical approaches are usually performed for mapping this area including deep intramural location. The objective of this study is to investigate the procedural outcomes of ablation of LVS arrhythmias. Methods Retrospective analysis of 32 consecutive patients (mean age 58±12 years old) who underwent CA of LVS arrhythmia in a single center. Baseline characteristics, procedural parameters and clinical outcomes were analyzed. Results All LVS arrhythmias had inferior and vertical axis (positive inferior leads with negative aVR and aVL leads). LBBB pattern was found in 25/32 (78%) and RBBB pattern in 7/32 (22%). 14/32 (44%) patients presented a "w" morphology in DI lead. 18/32 (56%) cases showed abrupt V3 transition. 13/32 (41%) patients had a previous failed ablation. Direct mapping of the intramural septum, through the septal perforator veins, was performed using a wire or a multipolar 2Fr catheter in 19 patients (59%). The earliest activation area was recorded in LCC-RCC in 13 patients (41%) followed by a septal perforator vein in 9 patients (28%). Most patients required multisite sequential ablation for achieving success (20 patients, 62%). Acute arrhythmia suppression was achieved in 22 patients (69%) and only 1 patient presented a complication (pericardial tamponade). Late success was noted in 3 patients (9%). During a median follow up of 9,79±8,6 months, 23 patients (72%) maintained a sustained acute success (80% reduction of PVC burden at least) None of the 9 patients without sustained acute success needed to repeat ablation. Conclusions Ablation of LVS arrhythmias is a challenging procedure with frequent previous ablation attempts. The earliest activation area is commonly found between LCC-RCC junction and in the intramural septum. Multisite non-conventional anatomical mapping and ablation steps are required to obtain a sustained success.

Efficient algorithm for directed text detection based on rotation decoupled bounding box.

A more effective directed text detection algorithm is proposed for the problem of low accuracy in detecting text with multiple sources, dense distribution, large aspect ratio and arbitrary alignment direction in the industrial intelligence process. The algorithm is based on the YOLOv5 model architecture, inspired by the idea of DenseNet dense connection, a parallel cross-scale feature fusion method is proposed to overcome the problem of blurring the underlying feature semantic information and deep location information caused by the sequential stacking approach and to improve the multiscale feature information extraction capability. Furthermore, a rotational decoupling border detection module, which decouples the rotational bounding box into horizontal bounding box during positive sample matching, is provided, overcoming the angular instability in the process of matching the rotational bounding box with the horizontal anchor to obtain higher-quality regression samples and improve the precision of directed text detection. The MSRA-TD500 and ICDAR2015 datasets are used to evaluate the method, and results show that the algorithm measured precision and F1-score of 89.2% and 88.1% on the MSRA-TD500 dataset, respectively, and accuracy and F1-score of 90.6% and 89.3% on the ICDAR2015 dataset, respectively. The proposed algorithm has better competitive ability than the SOTA text detection algorithm.

Management of the Uncinate Process in No-Touch Laparoscopic Pancreaticoduodenectomy.

Laparoscopic pancreatoduodenectomy (LPD) is a demanding abdominal operation that necessitates meticulous surgical skills and teamwork. The management of the pancreatic uncinate process is one of the most important and difficult processes in LPD because of its deep anatomical location and difficult exposure. Complete resection of the uncinate process and mesopancreas has become the cornerstone of LPD. In particular, it is even more difficult to avoid positive surgical margins and incomplete lymph node dissection when the tumor is located in the uncinate process. No-touch LPD, which is an ideal oncological operation process fitting the "tumor-free" principle, has been reported by our group previously. This article introduces the management of the uncinate process in no-touch LPD. Based on the multi-angle arterial approach, in this protocol, the median-anterior and left-posterior approaches to the SMA are used to correctly deal with the important vascular structure, the inferior pancreaticoduodenal artery (IPDA), in order to ensure the safe and complete excision of the uncinate process and mesopancreas. For the achievement of the no-touch isolation technique in LPD, the pancreatic head and the blood supply to the duodenal region must be severed at the very early stage of the operation; after that, the tumor can be isolated intact, resection can be performed in situ, and finally, the tissue can be removed en bloc. This paper aims to show the distinctive ways to manage the uncinate process in no-touch LPD and investigate the viability and safety of this approach. Moreover, the technique may increase the R0 resection rate.

Self-Supervised Deep Location and Ranging Error Correction for UWB Localization

In this paper, we propose a self-supervised deep network that mainly applies location and ranging error corrections to a classical UWB localization approach to improve its accuracy. The core of this method is the self-supervised learning strategy which removes the requirement for ground-truth in the training process, and thus reduces the training cost of the method. To this end, we first use an existing classical UWB localization approach to provide an initial tag location, and then build a deep location and ranging error correction (DLRC) network to jointly estimate the tag position corrections and distance corrections. The self-supervised training strategy is built based on these regressed corrections and the initial tag position as well as the fixed anchor positions and raw ranging measurements, through the topological structure of the UWB sensors. Finally, the initial tag location can be corrected by the trained DLRC network. For this proposed method, it makes use of high-level representations of the UWB measurements by the deep network, while the geometric information important for UWB localization is also considered though the self-training strategy and the classical approach. Therefore, it can effectively improve the localization performance compared to the stat-of-the-art classical approach. This improvement is also verified by conducting real-world experiments.

CE-454610-3 VT STORM DUE TO HYPERTROPHIC CARDIOMYOPATHY TREATED WITH ALCOHOL SEPTAL ABLATION

Radiofrequency (RF) ablation is a guideline-recommended therapy for ventricular tachycardia (VT). However, certain locations can be inaccessible through endocardial or epicardial approach. There are several documented unconventional techniques in these cases where VT is either treatment-refractory to RF ablation, or ablation is unlikely to be successful due to deep intramural substrate. N/A N/A A 66-year-old gentleman with a history of coronary artery disease (CAD) presents with four days of palpitations and lightheadedness to the emergency department. An ECG was performed which showed monomorphic VT from a basal septal focus. He was hemodynamically stable and thus started on a lidocaine drip and intermittent metoprolol IV pushes with conversion to sinus rhythm. Given the history of CAD, primary differential concerns were ischemia-mediated or scar-mediated VT. Thus, the patient underwent a coronary angiogram which revealed stable non-obstructive CAD. The patient then underwent a cardiac MRI which revealed severe asymmetric left ventricular hypertrophy measuring up to 18 mm in the mid-basal interventricular septum with mid-myocardial late gadolinium enhancement in the same area. This was most consistent with hypertrophic cardiomyopathy (HCM) as the etiology for the patient’s VT. As the patient continued to have significant ventricular ectopy and recurrent bouts of sustained VT on medical management, options for VT ablation were discussed. Overall, given the deep intramural location of the suspected VT substrate, endocardial and epicardial approaches were thought to have a low probability of success. Transarterial coronary ethanol ablation (TCEA) of the septum was thought to have the highest likelihood of success at controlling the patient’s VT in the setting of HCM. The patient underwent successful TTE guided TCEA of the first septal branch. Left ventricular outflow tract (LVOT) gradient improved from 45 to 17 mmHg. The patient was observed for 24 hours without evidence of VT. An ICD was subsequently implanted for secondary prevention. The patient was discharged in stable condition on an oral beta blocker without any additional anti-arrhythmic medications. In patients with VT due to HCM where there is a deep intramural substrate not amenable to traditional RF catheter ablation, TCEA is a reasonable approach. We describe a case of successful TCEA in both decreasing a patient’s LVOT gradient as well as cessation of the patient’s treatment refractory VT.

Functional and oncological outcome of petroclival chondrosarcoma operated on through an extradural anterior petrosectomy approach. A single center experience

BackgroundManagement of skull base chondrosarcoma (SBC) remains challenging due to its deep location and complex growth pattern. Non-total resection and postoperative residual mass are common features, with controversy regarding the need to offer systematic postoperative radiation therapy or additional surgery. MethodsA single-center retrospective cohort study was conducted on 10 consecutive patients harboring petroclival chondrosarcomas that were operated on between May 2007 and March 2019. After resection, the patients were allocated to a wait-and-rescan policy. ResultsPatients were operated on through an extradural anterior petrosectomy (EAP). Subtotal tumor resection was achieved in all patients. The mean duration of follow-up was 70 months (range 25–137/median 67 months). Clinical outcomes dramatically improved in three (30%) patients, while five patients retained preoperative cranial nerve (CN) disturbances after surgery (50%). Two patients reported transient postoperative worsening of their symptoms (20%). All of the postoperative CN new deficits improved within one year, except in one patient who showed permanent facial nerve palsy. The preoperative median Karnofsky Performance Scale (KPS) score was 80 (range 70–100), and then it became 90 (range 70–100) postoperatively. Patients harboring a tumor residue were included in a wait-and-rescan policy. With this regimen, tumor control was obtained in seven patients (70% of cases until the last follow-up). Three patients (30%) showed progression of the residual; two of them were treated with adjuvant therapy, while an extra cranial growth residue was observed in the third. ConclusionOptimal and reasonable surgical resection of petroclival chondrosarcomas could be achieved with good to excellent functional outcomes through an EAP. In spite of a significant percentage of regrowth, only one patient required additional salvage surgery.

The progress of PET/MRI in clinical management of patients with pancreatic malignant lesions.

Recently, the morbidity and mortality of pancreatic cancer have been increasing year by year. Because of its deep anatomical location and because most presented patients often suffer from abdominal pain or jaundice, it is difficult to diagnose pancreatic cancer at an early stage, leading to late clinical stage and poor prognosis. integrated positron emission tomography/magnetic resonance imaging (PET/MRI) fusion imaging not only has the characteristics of high resolution and multi-parameter imaging of MRI, but also combines the high sensitivity and the semi-quantitative characteristics of PET. In addition, the continuous development of novel MRI imaging and PET imaging biomarkers provide a unique and precise research direction for future pancreatic cancer research. This review summarizes the value of PET/MRI in the diagnosis, staging, efficacy monitoring, and prognosis evaluation of pancreatic cancer, and prognosis for developing emerging imaging agents and artificial intelligence radiomics in pancreatic cancer.

Impaired Kidney Function Small Vessel Disease Markers and Its Association with Periventricular White Matter Hyperintensities (P3-5.016)

<h3>Objective:</h3> We hypothesize that impaired kidney function is differentially associated with brain markers of SVD, and the association is greater with SVD markers restricted to deep, penetrating arteries. <h3>Background:</h3> Small vessel disease (SVD) is a condition associated with aging and vascular risk factors to which the brain and kidney are susceptible. However, whether kidney dysfunction may directly contribute to brain SVD as opposed to both organs being affected as an epiphenomenon of aging is less clear. <h3>Design/Methods:</h3> We leveraged existing data from our institution stroke registry. Odds ratio (OR), estimate, confidence intervals (CI), and p values were calculated. We rated visually the presence an anatomical location of cerebral microbleeds and chronic lacunar infarcts and used the Fazekas scale to semi-quantitate white matter hyperintensities. We created linear regression models adjusted for age, sex, race/ethnicity and vascular risk factors to evaluate the relationship between kidney function (defined as self-reported chronic kidney disease or creatinine on admission). <h3>Results:</h3> We included 973 patients (mean age 65±16 years, 51 % female). The prevalence of self-reported CKD/ESRD was 14% and the mean creatinine on admission was 1.61±2.04 mg/dl. The prevalence of chronic brain infarct was 40%, cerebral microbleeds 24%, and all had some degree of white matter hyperintensity. Calculated OR for deep location CMB in CKD/ESRD patients was 1.83 (p= 0.076). Beta estimate for periventricular WMH was 0.40 (p= 0.031) in CKD/ESRD patients and 0.51 (p= ≤0.01) in relation to the creatinine levels on admission. <h3>Conclusions:</h3> There is association between previous history of CKD-ESRD and creatinine levels on admission with periventricular WMH. These data also hint a possible association between CMB of deep location with history of CKD-ESRD, but a bigger sample is required for significance. <b>Disclosure:</b> Dr. Murguia Fuentes has nothing to disclose. Dr. Khasiyev has nothing to disclose. Dr. Gurel has nothing to disclose. Dr. Spagnolo-Allende has nothing to disclose. Dr. Rahman has nothing to disclose. Dr. Bueno has nothing to disclose. Mr. Murguia Fuentes has nothing to disclose. The institution of Dr. Marshall has received research support from NIH. Dr. Marshall has received publishing royalties from a publication relating to health care. Dr. Elkind has received personal compensation for serving as an employee of American Heart Association. Dr. Elkind has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Atria Academy. The institution of Dr. Elkind has received research support from BMS-Pfizer Alliance for Eliquis. The institution of Dr. Elkind has received research support from Roche. Dr. Elkind has received publishing royalties from a publication relating to health care. Dr. Elkind has a non-compensated relationship as a Officer with American Heart Association that is relevant to AAN interests or activities. Dr. Gutierrez has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Roetzel &amp; Andress, JOHN ASTUNO, JR. L.L.C.. The institution of Dr. Gutierrez has received research support from NIH. Dr. Gutierrez has received publishing royalties from a publication relating to health care. Dr. Gutierrez has received publishing royalties from a publication relating to health care.

Timing and Predictors of T2-Lesion Resolution in MOGAD (P13-5.028)

Timing and Predictors of T2-Lesion Resolution in MOGAD (P13-5.028)

Cerebral Small Vessel Disease Subtypes and Blood Pressure Control after Intracerebral Hemorrhage (P7-5.024)

<h3>Objective:</h3> NA <h3>Background:</h3> Intracerebral hemorrhage (ICH) survivors are at high risk of neurological decline for underlying progressive cerebral small vessel disease (CSVD). Most ICHs are attributable to two common CSVD types: cerebral amyloid angiopathy (CAA) and hypertensive-CSVD (HTN-CSVD). HTN-CSVD includes pure deep or mixed location ICH/microbleeds, the latter more severe. Hypertension control being the most potent intervention delaying CSVD-related ICH progression, we investigated whether more severe forms of HTN-CSVD are related to worse blood pressure (BP) control over time after CSVD-related ICH. <h3>Design/Methods:</h3> We analyzed data from consecutive non-traumatic ICH in-patients between 2011–2020 in a tertiary care center. MRI-based CSVD markers classified ICH patients as CAA-related and HTN-CSVD-related, deep and mixed locations within HTN-CSVD. Validated MRI-based score quantified CSVD burden. Longitudinal BP following ICH obtained via semi-automated electronic health records review. Linear mixed effects models examined association of BP during follow-up with CSVD etiology and severity. <h3>Results:</h3> 796 ICH survivors were followed for a median of 48.8 months (interquartile range [IQR] 41.5 – 60.4). CAA-related (n = 373) displayed lower systolic BP (median 138 mmHg, IQR: 133–142 mmHg) compared to deep hypertensive ICH/microbleeds (n = 222, systolic BP median 141 mmHg, IQR: 136–143 mmHg, p = 0.037 for comparison), and mixed location ICH/microbleeds (n = 201, systolic BP median 142 mmHg, IQR: 135–144 mmHg, p = 0.015 for comparison). In multivariable analysis, mixed location ICH/microbleeds (effect: +3.8 mmHg, Standard Error [SE]: 1.3 mmHg, p = 0.008) and increasing CSVD severity (+1.8 mmHg per score point, SE: 0.8 mmHg, p = 0.032) were independently associated with higher follow-up systolic BP. No associations between CSVD subtype/severity and diastolic BP. <h3>Conclusions:</h3> CSVD severity and subtype predict subsequent hypertension control. We confirm previous findings that mixed location ICH/microbleeds are related to more severe hypertensive disorder. Our findings support incorporating MRI-derived CSVD markers when tailoring hypertension control strategies for ICH survivors. <b>Disclosure:</b> Dr. Mallick has nothing to disclose. Dr. Das has nothing to disclose. Ms. Keins has nothing to disclose. Jessica Abramson has nothing to disclose. Juan Pablo Castello, MD has nothing to disclose. Marco Pasi has nothing to disclose. Dr. Popescu has nothing to disclose. Leidys Gutierrez-Martinez has nothing to disclose. Dr. Mayerhofer has nothing to disclose. Christina Kourkoulis has nothing to disclose. Axana Rodriguez-Torres has nothing to disclose. Andrew d. Warren has nothing to disclose. Mrs. Gokcal has nothing to disclose. Dr. Viswanathan has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Alnylam Pharmaceuticals. Dr. Viswanathan has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Biogen. Dr. Viswanathan has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Roche Pharmaceuticals. Dr. Greenberg has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Eli Lilly. Dr. Greenberg has received personal compensation in the range of $10,000-$49,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Washington University/IQVIA. Dr. Greenberg has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Bayer. Dr. Greenberg has received research support from National Institutes of Health. Dr. Greenberg has received publishing royalties from a publication relating to health care. The institution of Dr. Anderson has received research support from Bayer AG. An immediate family member of Dr. Anderson has received publishing royalties from a publication relating to health care. Dr. Rosand has received personal compensation for serving as an employee of Massachusetts General Hospital. Dr. Rosand has received personal compensation in the range of $50,000-$99,999 for serving as a Consultant for Boehringer Ingelheim. Dr. Rosand has received personal compensation in the range of $0-$499 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Elsevier. Dr. Rosand has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Boehringer Ingelheim. The institution of Dr. Rosand has received research support from NIH. The institution of Dr. Rosand has received research support from OneMind. The institution of Dr. Rosand has received research support from American Heart Association. Dr. Rosand has received personal compensation in the range of $0-$499 for serving as a Peer reviewer with National Institutes of Health. Dr. Rosand has a non-compensated relationship as a Board Member with Columbia University that is relevant to AAN interests or activities. The institution of Dr. Gurol has received research support from NIH/NINDS. The institution of Dr. Gurol has received research support from Boston Scientific Corporation. The institution of Dr. Gurol has received research support from AVID (a wholly owned subsidiary of Eli Lilly). The institution of Dr. Gurol has received research support from Pfizer. Dr. Biffi has nothing to disclose.

Catheter ablation of intramural outflow tract premature ventricular complexes: a multicentre study.

Ablation of outflow tract ventricular arrhythmias may be limited by a deep intramural location of the arrhythmogenic source. This study evaluates the acute and long-term outcomes of patients undergoing ablation of intramural outflow tract premature ventricular complexes (PVCs). This multicenter series included patients with structurally normal heart or nonischemic cardiomyopathy and intramural outflow tract PVCs defined by: (a) ≥ 2 of the following criteria: (1) earliest endocardial or epicardial activation < 20ms pre-QRS; (2) Similar activation in different chambers; (3) no/transient PVC suppression with ablation at earliest endocardial/epicardial site; or (b) earliest ventricular activation recorded in a septal coronary vein. Ninety-two patients were included, with a mean PVC burden of 21.5±10.9%. Twenty-six patients had had previous ablations. All PVCs had inferior axis, with LBBB pattern in 68%. In 29 patients (32%) direct mapping of the intramural septum was performed using an insulated wire or multielectrode catheter, and in 13 of these cases the earliest activation was recorded within a septal vein. Most patients required special ablation techniques (one or more), including sequential unipolar ablation in 73%, low-ionic irrigation in 26%, bipolar ablation in 15% and ethanol ablation in 1%. Acute PVC suppression was achieved in 75% of patients. Following the procedure, the PVC burden was reduced to 5.8±8.4%. The mean follow-up was 15±14 months and 16 patients underwent a repeat ablation. Ablation of intramural PVCs is challenging; acute arrhythmia elimination is achieved in 3/4 patients, and non-conventional approaches are often necessary for success.

Vestibulo-Cochlear Symptoms Revealing Vertebro-Basilar Dolicho-Ectasia

Introduction: Vertebrobasilar dolichoectasia (VBD) are uncommon arteriopathies defined by increased length and caliber of one or more intracranial arteries. The clinical picture is polymorphic. They are most often associated with ischemic or hemorrhagic stroke, but this pathology can also cause symptoms of cranial nerve compression. Objective: We report the case of a vertebro-basilar dolichoectasia collected in the radiology department of Ibn Tofail Hospital in Marrakech, revealed by vestibulo-cochlear symptoms and diagnosed by brain MRI. In the light of this observation, we review this uncommon pathology and the contribution of magnetic resonance imaging in its diagnosis. Case report: The patient was 68 years old and had a history of severe sleep apnea syndrome. He presented with rotatory vertigo, tinnitus and hypoacusis on the left side of the head for 3 months. The neurological examination was normal and the examination of the ENT sphere revealed bilateral sensorineural hearing loss and left hyporeflexia. A cerebral MRI was performed as part of the etiological workup, which revealed elongation and dilation of the vertebral arteries measuring 3.9 mm on the left and 5.2 mm on the right, with loops of which the left crossed the homolateral cochleovestibular nerve 7 mm from its emergence, responsible for a deviation of its path, and the glossopharyngeal nerve 4 mm from its emergence. It also showed an elongation and dilatation of the basilar trunk measuring 6.8 mm, presenting a loop lateralized to the left at the level of its origin (Smoker's Grade 2) with a bifurcation opposite the floor of the V3 (Smoker's Grade 2).Thus, the diagnosis of a DEVB responsible for a vascular-nervous conflict was retained. The indication for surgical management was given but was refused by the patient due to the deep location of the arteriopathy. Discussion and conclusion: DEVB is a rare and progressive condition with cranial nerve compression as a possible complication. Brain MRI is...

Application of the pressure cooker technique for transarterial embolization of brain arteriovenous malformations: Factors affecting obliteration and outcomes.

The typical pressure cooker technique (PCT) and several modifications with similar mechanisms have been introduced to enhance the embolization of brain arteriovenous malformations (bAVMs). This study aimed to assess the effectiveness of transarterial embolization of bAVMs with the PCT. From January 2019 to December 2021, 125 consecutive patients with bAVM managed by transarterial embolization in the prospective database on cerebral vascular diseases of a single center were retrospectively reviewed. Patient data and lesion characteristics were collected. According to the treatment strategy, the patients were assigned to the PCT group (46 patients) and conventional embolization technique (CET) group (79 patients). Baseline patient features were comparable between the two groups. After the first procedure, complete obliteration immediately was observed in 61 and 42% of patients in the PCT and CET groups, respectively. The rate was markedly elevated in the PCT group (p = 0.04). In subgroup analysis, the rate of immediate complete obliteration was starkly increased in PCT group patients with Spetzler-Martin grade I/II bAVM (86 and 53% in the PCT and CET groups, respectively; p = 0.0036). The overall complication rates were similar in the two groups (13 and 10% in the PCT and CET groups, respectively; p = 0.77). In multivariable analysis, nidus size >3 cm (OR = 8.826, 95% CI: 1.250-62.312; p = 0.03) and deep location (OR = 8.576, 95% CI: 1.480-49.690; p = 0.02) were significant factors affecting complete obliteration in the PCT group. The PCT may yield a higher rate of immediate complete obliteration with transarterial embolization of bAVMs, without increasing the rate of procedure-related complications.

A Rare Case of Aspergillus Granuloma in the Cavernous Sinus of an Immunocompetent Patient

Aspergillosis is an invasive fungal disease that commonly infects immunocompromised hosts. Among the Aspergillus group, A. fumigatus is responsible for most cases of invasive Aspergillosis, mostly occurring in immunocompromised individuals, as well as chronic Aspergillosis and allergic syndromes. Prolonged exposure to Aspergillus is said to cause disease even in immunocompetent host.Hereby discussing a case of a 42-year-old male with headache, drooping of right eyelid and right ophthalmoplegia, right facial pain along the V1 and V2 region with features indicative of cranial nerve palsies involved in cavernous sinus syndrome. With radioimaging not giving clues toward the etiology, an open biopsy was done, was suggestive of fungal Aspergillus granuloma. Hence, the patient was started on voriconazole and clinically improved over time. This emphasizes that although rare with diagnostic barriers such as nonspecific clinical manifestations, deep anatomical location, and completely depending on pathological diagnosis, timely intervention saves the patient.

391 Stereotactic Radiosurgery for Intermediate and High-Grade Arteriovenous Malformations: Outcomes Stratified by the Supplemented Spetzler-Martin Grading System

INTRODUCTION: The Supplemented Spetzler-Martin (Supp-SM) grading system is predictive of surgical risk for patients with brain arteriovenous malformations (AVM). METHODS: 219 patients had SRS from 1990 to 2016 for SM III (n = 154) or SM IV-V (n = 65) AVM. The Supp-SM grades were 4 (n = 14, 6%), 5 (n = 36, 16%), 6 (n = 67, 31%), 7 (n = 76, 35%), and 8-9 (n = 26, 12%). 60 patients (27%) had deep AVM (basal ganglia, thalamus, or brainstem). 39 patients (18%) had volume-staged SRS; 41 (19%) underwent repeat SRS. The median follow-up was 69 months for grade III AVM and 113 months for grade IV-V AVM. RESULTS: 163 patients (74%) had obliteration at a median of 38 months after initial SRS. The obliteration rates at 4 and 8 years were 59% and 76%, respectively. 31 patients (14%) had post-SRS deficits from hemorrhage (n = 7, 3%) or radiation injury (n = 24, 11%). 6 patients (3%) died after SRS (hemorrhage, n = 5; radiation injury, n = 1). The rates of neurologic decline or death at 4 and 8 years were 11% and 18%, respectively. Factors predictive of non-obliteration were deep location (HR 0.57, 95% CI 0.39-0.82, p = 0.003) and increasing AVM volume (HR 0.96, 95% CI 0.93-0.99, p = 0.002). Increasing AVM volume was the only factor associated with neurologic decline (HR 1.05, 95% CI 1.02-1.08, p = 0.002). The Supp-SM grading system did not correlate with obliteration (HR 0.94, 95% CI 0.82-1.09, p = 0.43) or neurologic decline (HR 1.15, 95% CI 0.84-1.56, p = 0.38). CONCLUSIONS: The Supp-SM grading system was not predictive of outcomes after SRS of intermediate or high-grade AVM. In a cohort which included a high percentage (47%) of “inoperable” AVM (Supp-SM ≥7), most patients had obliteration after SRS, although the chance of neurologic decline was significant.

350 A Comparison of Incidental and Symptomatic Unruptured Brain Arteriovenous Malformations in Children

INTRODUCTION: Unruptured brain arteriovenous malformations (AVMs) may present with headaches, seizures, and/or neurologic deficits. A smaller number of cases may be discovered incidentally. These lesions remain incompletely understood due to their sparse reporting. METHODS: We performed a retrospective analysis of patients presenting with brain AVMs from 1998 to 2021 at the University of California, San Francisco. Inclusion criteria included age ≤18 at time of presentation with angiographically-proven unruptured AVM diagnosed postnatally. RESULTS: Of 76 children with unruptured AVMs, 66 (86.8%) presented with headaches, seizures, and/or neurologic deficit. Ten (13.1%) were incidentally discovered through unrelated disease workup (50%), cranial trauma (40%), or research study participation (10%). Compared to symptomatic unruptured AVMs, incidental unruptured AVMs possessed smaller mean nidus maximum diameter (2.82 ± 1.1 vs. 3.98 ± 1.52 cm, p = 0.025) and deep venous drainage proportion (20% vs. 61%, p = 0.036). They also presented at earlier ages (10 ± 5.2 vs. 13.5 ± 4 years, p = 0.043) with longer durations to first treatment (541 ± 922 vs. 196 ± 448 days, p = 0.005). During the period of observation, one patient developed recurring headaches and demonstrated AVM nidus growth. Four AVMs greater than 3 centimeters or in deep location were treated with radiosurgery. Six other AVMs were treated with surgical resection with 2 receiving preoperative embolization. Seven AVMs (70%) were obliterated on last follow-up. Postprocedural complications included 2 transient neurologic deficits following resection and 1 delayed seizure development following radiosurgery. The mean follow-up period was 5.1 ± 5.8 years without any hemorrhage episodes. CONCLUSIONS: A substantial proportion of pediatric patients with unruptured AVMs are discovered incidentally. With earlier presentation and more elementary angioarchitecture than symptomatic unruptured AVMs, these incidental lesions provide a snapshot into AVM natural history before symptom development or rupture.