Left Lesion Research Articles

Rey-Osterrieth Complex Figure Test in Differentiating Between Left and Right Lesions Caused by Brain Tumors and Stroke

The aim of this study was to examine whether the ROCF qualitative scoring system developed by Loring, Lee and Meador for differentiating complex partial seizures originating from either the right or left temporal lobe is effective in differentiating left-sided and right-sided brain lesions that are the result of cerebrovascular insult or brain tumours. We were also interested in determining whether this scoring system, which was developed for scoring trials with delayed recall, could be applied to trials with immediate recall and copying. The study consisted of 24 participants with lesions of the left hemisphere and 33 participants with right-sided lesions. Participants with right-sided lesions had a significantly greater number of qualitative errors in copying, immediate and delayed recall, and these three variables are the major contributors in distinguishing between groups. Based on these variables and quantitative results on copying, immediate and delayed recall, we were able to correctly classify 78.3 % of participants with left-sided lesions and 66.7 % of participants with right-sided lesions. Given that more than 90 % of participants with left-sided lesions had two or more errors in delayed recall, it is clear that the criterion of two or more errors which was set by Loring, Lee and Meador for patients with a right-sided focus in epilepsy is not applicable to patients with tumours and strokes. These results do not confirm the usefulness of qualitative errors for distinguishing left-sided and right-sided lesions caused by a tumour or stroke, except, perhaps, in cases of very high results (six or more errors) and when one of these errors is error X in immediate and/or delayed recall.

Cognitive Disorders in Patients with Parkinson's Disease

The aim of the study was to identify cognitive disorders in patients with Parkinson's disease
 Material and methods. The study was conducted on the basis of the neurological department of the Regional Clinical Hospital (Odesa) during 2011-2021. 364 patients were diagnosed with Parkinson disease (PD) on the basis of diagnostic criteria of the British Brain Bank. Clinical and demographic data were studied: age, sex, severity according to the UPDRS scale, stage of the disease according to the Hoen-Yahr scale, the presence of cognitive impairment and their nature. MMSE (Mini-Mental State Examination;) and PD-CRS (Parkinson’s Disease-Cognitive Rating Scale) were used to study cognitive functions. Statistical processing was performed by analysis of variance, correlation and factor analysis using Statistica 13.0 software (TIBCO, USA).
 Results.
 At the onset of the disease, left lesions were noted in 126 of 364 patients, ie 34.6%, right - 127 (34.9%), the remaining 111 (30.5%) - bilateral lesions. The structure of the disease was dominated by mixed forms. Akinetic-rigid form was observed in 92 (25.3%) cases, trembling - in 27 (7.4%), mixed rigid-trembling in 157 (43.1%) cases, trembling-rigid in 92 (7.4%). Patients with stage 2 and 3 CP were most often registered in 28.6% and 28.0% of cases, respectively. 31 (8.5%) patients had more severe motor disorders (stages 3.5 and 4). Cognitive impairment was detected in a significant number of patients (238 or 45.2%), the mean score on the MMSE scale was 25.3 ± 0.3. Accordingly, on the PD-CRS scale, the average score was 91.2 ± 3.4 points. Subdemental changes were present in 82 (15.6%) patients. Accordingly, mild dementia was found in 15 (2.8%) patients, moderate dementia - in 18 (3.4%).
 Conclusions:
 
 The frequency of detection of cognitive impairment in patients with CP was 45.2% with a mean score on the MMSE scale of 25.3 ± 0.3, and on the PD-CRS scale - 91.2 ± 3.4 points
 Dementia changes were in 82 (15.6%) patients, mild dementia was found in 15 (2.8%) patients, moderate dementia - in 18 (3.4%)
 There is a direct correlation between the age and severity of intellectual disabilities (r = 0.50).
 Self-care disorders are determined by the severity of both motor and cognitive disorders by 72% (R = 0.851; R2 = 0.723; Adjusted R2 = 0.721; F (2.2) = 309; p <10-4; SE = 4.6 ).
 
 Key words: Parkinson's disease, cognitive impairment, quality of life

P-083 AMYANDS HERNIA WITH RENAL CELL CARCINOMA - A RARE CASE PRESENTATION

Abstract 47 year old gentleman presented to the emergency department with 2 days history of lower abdominal pain and right inguinal swelling which has increased in size during the same duration, he also had one episode of vomiting, bloating and constipation since 2 days. Investigations revealed an inflamed appendix within the right inguinal hernia along with a left renal lesion. The patient underwent emergency open primary repair of inguinal hernia with appendicectomy. Followed up with urology as an outpatient regarding renal lesion and with MDT discussion the patient was subjected for a partial nephrectomy.

Machine-learning-based video analysis of grasping behavior during recovery from cervical spinal cord injury

Comprehensive characterizations of hand grasping behaviors after cervical spinal cord injuries are fundamental for developing rehabilitation strategies to promote recovery in spinal-cord-injured primates. We used the machine-learning-based video analysis software, DeepLabCut, to sensitively quantify kinematic aspects of grasping behavioral deficits in squirrel monkeys with C5-level spinal cord injuries. Three squirrel monkeys were trained to grasp sugar pellets from wells of varying depths before and after a left unilateral lesion of the cervical dorsal column. Using DeepLabCut, we identified post-lesion deficits in kinematic grasping behavior that included changes in digit orientation, increased variance in vertical and horizontal digit movement, and longer time to complete the task. While video-based analyses of grasping behavior demonstrated deficits in fine-scale digit function that persisted through at least 14 weeks post-injury, traditional end-point behavioral analyses showed a recovery of global hand function as evidenced by recovery of the proportion of successful retrievals by approximately 14 weeks post-injury. The combination of traditional end-point and video-based kinematic analyses provides a more comprehensive characterization of grasping behavior and highlights that global grasping performance may recover despite persistent fine-scale kinematic deficits in digit function. Machine-learning-based video analysis of kinematic digit function, in conjunction with traditional end-point behavioral analyses of grasping behavior, provide sensitive and specific indices for monitoring recovery of fine-grained hand sensorimotor behavior after spinal cord injury that can aid future studies that seek to develop targeted therapeutic interventions for improving behavioral outcomes.

Rhino-Orbital-Cerebral Mucormycosis: A Rare Complication of Uncontrolled Diabetes

Introduction Fungal infection of the central nervous system has become more common over the past two decades. It is frequently diagnosed in patients with underlying pathological conditions. We herein report a case of rhino-orbital-cerebral mucormycosis by outlining the clinical presentation, radiological images, histopathological findings, management plan, and its clinical outcome. Case Description. A 47-year-old man, known to have type 2 diabetes mellitus, presented with severe headache involving the left side of the face, numbness along the left V2 trigeminal nerve, ptosis and dryness of the left eye, short-term memory loss, and right hand numbness. He had a social history of being a bee farmer for which he was exposed to bee stings several times in the past. Neuroradiological imaging showed a left temporal ring-enhancing lesion, suggestive of abscess. The patient underwent craniotomy and resection of the lesion. The histopathological evaluation was suggestive of cerebral mucormycosis, fungal sinusitis, and invasive skull base mucormycosis. Conclusion Rhino-orbital-cerebral mucormycosis is a fulminant fungal infection commonly diagnosed in patients with uncontrolled diabetes. Early diagnosis with radiological and histopathological evaluation is required to identify patients at risk of rhino-orbital-cerebral mucormycosis.

Characteristics of cognitive function in patients with cerebellar infarction and its association with lesion location.

Objective: This study aimed to explore the characteristics of cognitive function in patients with cerebellar infarction and its association with lesion location.Methods: Forty-five patients with isolated cerebellar infarction were collected in the Department of Neurology, Beijing Tiantan Hospital. Thirty healthy controls were recruited matched by age and education. Global cognitive function was evaluated by using Addenbrooke’s Cognitive Examination version III (ACE-III). An extensive neuropsychological assessment battery was also tested to evaluate the characteristics of each cognitive domain. 3D slicer software was used to draw the lesion, and evaluate the lesions’ volume, side, and location. Group analysis was used to compare the differences in cognitive performance between patients and healthy controls, and patients with left and right cerebellar hemisphere infarction. Spearman analysis was used to explore the correlation between cognitive function and lesion volume. We also subdivided each patient’s lesions according to the cerebellar atlas to identify the specific cerebellar location related to cognitive decline.Results: Patients with cerebellar infarction had a lower ACE-III score compared with the healthy group (87.9 ± 6.2 vs. 93.7 ± 2.9, p < 0.001), and 22 (48.9%) patients were diagnosed with cognitive impairment. The z-transformed score of attention and executive function in the patients’ group was −0.9 ± 1.4 and −0.8 ± 1.0 respectively, with 19 (43.2%) and 23 (56.4%) patients impaired. Compared with healthy controls, the relative risk ratio with 95% confidence interval (CI) for impairment in attention and executive function were 3.24 (1.22–8.57) and 3.39 (1.45–7.89). However, only 10 (22.1%) patients showed impairment in more than two cognitive domains. Compared with the left lesion group, patients with right cerebellar infarction showed significantly impaired executive function (−1.1 ± 0.3 vs. −0.5 ± 0.2, p = 0.01). And the cerebellar posterior lobe regions, especially lobules VI, VIII, and IX, were explored to have lower cognitive performance. Furthermore, lesion volume was identified to be associated with the ACE-III score (r = −0.37, p = 0.04).Conclusion: We identified that cerebellar involvement in cognition, especially in attention processing and executive function. Cerebellar right-sided lateralization of cognition and functional topography were also revealed in the current study.

Paroxysmal atrial fibrillation ablation with a novel flexible tip radiofrequency catheter incorporating contact force sensing: acute results of the TactiFlex AF IDE trial

Abstract Background Catheter ablation is an established therapy for paroxysmal atrial fibrillation (PAF). The TactiFlex™ Ablation Catheter, Sensor-Enabled™ (TactiFlex SE) is a next-generation radiofrequency ablation catheter incorporating highly accurate fiber optics-based contact force sensing technology with a flexible, laser-cut tip. Purpose To demonstrate that ablation with TactiFlex SE is safe and effective for the treatment of drug refractory, symptomatic PAF. Methods The TactiFlex AF IDE is a prospective, non-randomized, multi-center clinical study which enrolled 355 subjects worldwide. Enrollment in the main study began on June 26, 2020 and completed on June 18, 2021. Subjects underwent de novo Pulmonary Vein Isolation (PVI) and, if indicated, a Cavotricuspid Isthmus ablation (CTI line) for CTI-dependent atrial flutter. Results Subjects were divided into two as treated subgroups: High Standard Power (HSP, n=189), defined as subjects with 100% of left atrial lesions ablated at ≥40 W, and Low Standard Power (LSP, n=119), defined as subjects with at least one left atrial lesion ablated at &amp;lt;40W. First pass success, defined as isolation of all pulmonary veins (PVs) confirmed after a minimum 20 min waiting period was achieved in 93.5% (175/186) and 84.5% (98/116) of HSP and LSP subjects, respectively (p=0.0104). Significant decreases in the HSP versus LSP procedures were also seen in total procedure time (112.0 min [89.0, 139.5] and 149.0 [115.0, 182.0], respectively [p&amp;lt;0.001]), total RF time for PV ablation (14.0 min [11.0, 19.0] and 29.0 [19.0, 41.0], respectively [p&amp;lt;0.0001]), total fluoroscopy time (4.0 min [0.0, 11.0] and 8.0 [3.0, 17.0], respectively [p&amp;lt;0.0001]) and irrigation fluid volume (378.0 mL [310.0, 466.0] and 636.0 [476.0, 829.0], respectively [p&amp;lt;0.0001]) (values given as Median [Q1, Q3]), see Figure 1. Both HSP and LSP subjects had a low rate of repeat procedures (1.6% [3/182] and 4.3% [5/115], respectively [p=0.2684]) and primary safety endpoint events (4.8% [9/189] and 4.2% [5/119], respectively [p=0.8182]) through 90 days post-index procedure. Conclusion The acute data on the TactiFlex SE catheter demonstrates safe and effective treatment of PAF using either a HSP or LSP ablation strategy. Ablation procedures performed using a HSP strategy were shorter and required less irrigation fluid and fluoroscopy. It is anticipated these results will be reflected in the 12-month safety and effectiveness primary endpoints. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Abbott

S1676 Things Are Not Always What They Seem: A Rare Case of Pancreatic Carcinoma Manifesting Through Cutaneous Metastasis

Introduction: Pancreatic cancer is an aggressive disease that commonly metastasizes to the liver, lung, and peritoneum. Cutaneous metastasis is a rare occurrence with an incidence of only 2.0%. We present a case of metastatic pancreatic adenocarcinoma primarily presenting as a cutaneous nodule. Case Description/Methods: A 50-year-old male was undergoing outpatient evaluation for a raised, left scalp lesion along with neck nodules. Associated symptoms included an unintentional 30lb weight loss. Outpatient CT soft tissue neck revealed numerous necrotic lateral neck lymph nodes, lytic lesion with epidural soft tissue extension at C2-4, and occlusion/thrombosis of the left subclavian, brachiocephalic, and left internal jugular veins (Figure). Given these findings, the patient was referred to the Emergency Department (ED). At time of ED arrival, vital signs were stable along with initial laboratory values. CTA PE study showed no pulmonary embolism but revealed numerous pulmonary and bilateral adrenal nodules, multifocal liver and osseous lesions, and widespread lymphadenopathy. Additionally, CT head demonstrated a left scalp soft tissue lesion. Follow up CT abdomen/pelvis revealed a 2.8 x 2.2 x 1.8 cm ill-defined pancreatic lesion and confirmed widespread metastasis including to the muscles. Additional testing revealed elevated cancer markers with Cancer antigen 19-9 (CA 19-9) of 5418 U/mL and carcinoembryonic antigen (CEA) of 63.8 ng/mL. Pathology from initial scalp lesion biopsy showed fragments of necrotic dermis with small foci of poorly differentiated carcinoma. Biopsies of the right and left neck masses revealed poorly differentiated adenocarcinoma of uncertain primary. Therefore, liver biopsy was performed and confirmed non-small cell carcinoma of pancreatobiliary origin. Further imaging to determine treatment course discovered intracranial metastasis and cervical spine disease resulting in cord compression. Ultimately, the patient underwent 4 out of 10 fractions of palliative radiation to the cervical spine but passed away after transitioning to comfort care one month after diagnosis. Discussion: There are less than 25 documented cases of pancreatic cancer with cutaneous involvement; however, it is even more rare that cutaneous involvement prompts initial diagnosis. The umbilicus is the most common site of cutaneous involvement and is referred to as the Sister Mary Joseph Nodule. Involvement of the soft tissue of the scalp and neck is much less common and poorly documented making this case extremely unique.Figure 1.: Axial contrast enhanced CT of the abdomen shows a 2.8 cm ill-defined hypoattenuating mass in the pancreatic tail (A) with multifocal metastatic liver lesions and bilateral adrenal metastasis (B). Axial CT image of the pelvis shows a metastatic lesion in the right rectus femoris muscle (C). On liver biopsy, H&E, 40X,(S21-41666) revealed high grade carcinoma with vesiculated nuclei, prominent nucleoli (D), CA 19-9 IHC 20X diffuse positivity in tumor cells (E) and CK AE1/3 IHC, 20X, diffusely positivee for pancytokeratin in tumor cells confirming carcinoma (F). Axial CT of the head shows a 2.4 cm nodular left parietal scalp soft tissue lesion (G) which was also seen on clinical examination (H). Biopsy of the scalp lesion (H&E, 40X) demonstrated high grade carcinoma with vesiculated nuclei, prominent nucleoli and mitoses (I), histologically similar to liver biopsy findings.

PULMONARY INVOLVEMENT WITH PLEOMORPHIC ADENOMA: 30-YEAR EXPERIENCE WITH THIS RARE ENTITY AT A TERTIARY REFERRAL CENTER

PULMONARY INVOLVEMENT WITH PLEOMORPHIC ADENOMA: 30-YEAR EXPERIENCE WITH THIS RARE ENTITY AT A TERTIARY REFERRAL CENTER

S2783 Strongyloides Reactivation After Initiation of Infliximab Therapy for Severe Crohn’s Colitis

Introduction: Biologic therapies have revolutionized the treatment of patients with inflammatory bowel disease (IBD) and Anti-TNFa inhibitors are the most commonly used agents for patients with moderate to severe disease. Prior to initiation, patients are checked for Tuberculosis (TB) and Hep-B but checking for other latent infections is determined by the Physician. Strongyloides, an endemic South American parasite, is one such potentially latent infection for which no guidelines exist. We present the multi-admission hospital course of a patient with severe Crohn’s Colitis who had reactivation of latent strongyloides after starting Infliximab. Case Description/Methods: A 53 year old Male from South America presented to the ED with hematochezia, fevers, abdominal pain, and a purulent left shin lesion. Past medical history included poorly controlled Crohn’s Colitis refractory to other therapies. Upon arrival the patient was tachycardic, had diffuse abdominal pain, and had multiple bloody bowel movements. A 7 by 4 cm ulcerated lesion with visible necrotic tissue, fibrinous debris and violaceous borders was visualized on his leg. Blood work revealed leukopenia, anemia, an elevated CRP and ESR. Biopsy of the lesion was consistent with Pyoderma Gangrenosum. He was treated with IV corticosteroids with improvement. Serologies for Hepatitis B, C, HIV, latent TB, and a stool test for parasites were negative. Given disease severity therapy with infliximab and 6-mercaptopurine (6MP) was started. The next day he developed worsening pain, and bloody diarrhea. Strongyloides parasites were visible in stool smears and blood work showed eosinophilia. Inflixmab and 6MP were discontinued and ivermectin and a steroid taper were started. Repeat stool studies revealed successful eradication of Strongyloides after which infliximab and 6MP were restarted. The patient had an uncomplicated discharge and is tolerating infliximab well. (Figure) Discussion: Biologics are becoming very common in the medical field in the setting of an increasingly interconnected world and this case shows positive and negative aspects of this. While they may carry an increased risk of severe infection, they are well tolerated and provide dramatic relief. While screening may capture many latent infections there are no recommendations outside of Hep-B and TB. Developing new tools to screen or looking to our International Colleagues for guidance may be necessary as our communities at home become truly international.Figure 1

S2774 Sweet Syndrome as One of the Manifesting Symptoms of Inflammatory Bowel Disease

Introduction: Sweet's syndrome (SS), a subtype of neutrophilic dermatosis (ND), is an uncommon skin disorder characterized by the abrupt appearance of painful erythematous skin lesions, fever, and neutrophilia. Diagnosis of SS is made via biopsy showing a dense neutrophilic infiltrate of the dermis and epidermal sparing. SS is associated with hematologic malignancies or drug reactions and less commonly with inflammatory bowel disease (IBD). Treatment of SS, and other NDs, mirrors treatment of the underlying condition and is typically steroid responsive. Identification is important as SS is an extra systemic manifestation of underlying disease and indicates a poor prognosis. We present an 18 year old male with SS as a manifesting symptom of IBD. Case Description/Methods: An 18 year old male presented with 1 month of abdominal pain, oral ulcerations, hematochezia, and a left lower extremity lesion. He had a diffusely tender abdomen, multiple ulcers bilaterally on his buccal mucosa, cheilitis, and a 1 cm ulcerated lesion on his left leg. He was febrile and blood tests revealed anemia, thrombocytosis, neutrophilia, elevated inflammatory markers, and a positive C-ANCA. His leg and oral lesions were biopsied as well as a cratered esophageal ulcer found during endoscopy. Sigmoidoscopy demonstrated a circular ulceration of the anal mucosa and severe patchy inflammation in the descending and sigmoid colon. He was started on methylprednisolone for empiric treatment of presumed IBD. The skin biopsy showed ND with an interstitial and perivascular inflammatory infiltrate with epidermal necrosis without vasculitis most consistent with SS. He was diagnosed with Crohn’s Disease and has seen improvement of his skin lesions, oral lesions, and abdominal symptoms after a prolonged steroid taper. (Figure) Discussion: While NDs are well described in association with IBD, SS is not a subtype of ND that commonly occurs with less than 100 cases described. Biopsy is the definitive diagnostic study and should be done promptly as ND’s differential includes drug-reaction, malignancy, and the skin lesions may appear similar to infectious lesions. The two former conditions will respond to treatment though may relapse if not identified, and the latter will be exacerbated by immunosuppression. For Physicians treating IBD, knowledge of the appearance of ND can ensure prompt biopsy and initiation, or withdrawal, of appropriate therapies.Figure 1.: Top Row: Mucocutaneous findings in the Mouth and Left Lower Extremity Bottom Row: Perivascular mixed inflammatory infiltrate primarily composed of neutrophils with a few eosinophils present with no evidence of vasculitis. The infiltrate is primarily limited to the dermis.

S2429 A Rare Case of Esophageal Adenocarcinoma Presenting as an Isolated Brain Lesion 6 Years After Treatment

Introduction: Esophageal adenocarcinomas account for ∼1% of all cancers in the U.S. The prevalence of central nervous system (CNS) metastases associated with these cancers is around 1.8%. Response rates to standard of care are poor and prognosis is dismal. Often CNS involvement is associated with widely metastatic disease, herein, we present a case of a solitary brain lesion from esophageal adenocarcinoma at first recurrence. Case Description/Methods: A 72-year-old-male with a 40 pack-year smoking presented with progressive dysphagia in March 2015. Contrast enhanced CT of the chest, abdomen and pelvis revealed a constricting mass at the esophagogastric junction that led to endoscopy guided biopsy revealing esophageal adenocarcinoma. He underwent neoadjuvant chemotherapy (cisplatin/5-fluorouracil) and radiation therapy followed by esophagogastrectomy in July of 2015 where diagnosis of stage IIIBT3N2cM0 esophageal adenocarcinoma was confirmed. Clinical and imaging surveillance for 6 years had not shown any progression of cancer. However, in June of 2021, he presented with altered mental status that led to contrast enhanced brain MRI showing a T2 hyperintense left parietal lobe mass with an 8 mm midline shift and surrounding vasogenic edema (Figure). FDG PET-CT head to toes did not show extracranial recurrence. He underwent left posterior temporal craniotomy for resection of tumor confirming the diagnosis of metastatic esophageal adenocarcinoma. IHC showed positivity of cytokeratin7, CDX2 and SATB2. Whole exome sequencing revealed mutations in ARID1A, FH, and TP53 with variants of unknown significance of ATM and CDH. Tumor displayed proficient mismatch repair protein, a combined positive score of 15 for PD-L1, and negative Her2/Neu. Further sequencing showed tumor mutational burden of 4, no genomic loss of heterozygosity, and stable microsatellite repeats. He received gamma-knife radiation to the solitary left temporal lobe lesion. Patient continues to maintain his quality of life with no evidence of clinical and radiographic recurrence. Discussion: Isolated brain metastasis from esophageal adenocarcinoma is a very rare phenomenon. Limited data suggests that the survival of patients with isolated CNS lesions is < 1 year, however, achieving pathologic complete response after neoadjuvant chemo-radiation therapy has shown to improve survival. These esophageal cancers with isolated CNS metastases may share a unique genomic profile and more research is required to understand their alterations.Figure 1.: MRI of the brain. 1A- Pre-op axial OLEA of L. temporal lobe tumor (06/2021), 1B- Pre-op axial coronal T1 (06/2021), 1C- Follow-up T2 MRI.

P26 Challenging Scenario: Scleroderma/Sjogren overlap with dysautonomia

Introduction/BackgroundScleroderma Overlap conditions are well defined and often behave differently than their limited or diffuse counterparts. The treatment for such patients is usually tailored around the organ system involvement and severity. We present a challenging case of Scleroderma/Sjogren overlap with refractory Raynaud's phenomenon who posed treatment challenges due to severe autonomic dysfunction.Description/Method76-year-old Caucasian lady, non-smoker, who presented in 1990’s with dry eyes, dry mouth and severe Raynaud's phenomenon with recurrent digital ulceration which became infected on multiple occasions. ANA was 1:400 with Extractable nuclear antigen Ro and La positive. Anti DsDNA was negative and C4 was low. Antiphospholipid antibodies and cryoglobulins are negative. She failed calcium channels blockers and phosphodiesterase 5 inhibitors and was intolerant to intravenous (IV) Iloprost which was tried on multiple occasions. IV latanoprost was tried as well. This treatment was complicated when she developed postural hypotension and multiple fall episodes during vasodilator use. This was attributed to autonomic dysfunction secondary to her Sjogren syndrome. She was initiated on Injection Fludrocortisone, however her hypotensive episodes continued. She received monthly intravenous immunoglobulins 20gm (over two days) infusion for a few months for autonomic dysfunction with some response. She eventually developed recurrent diarrhoea and abdominal pain and bloating which was attributed to small bowel overgrowth with rapid bowel transit on a gastric emptying scan. She had a blocked bile duct as well which was unblocked using Endoscopic Retrograde Cholangiopancreatography. Over the next 8 years, she continued struggling with refractory Raynaud’s, having failed IV regional guanethidine blocks and digital sympathectomy. Her postural hypotension decompensated on multiple occasions necessitating plasmapheresis which provided some benefit. In 2020, she was detected to have a PET avid slowly progressing left upper lobe lung lesion. She underwent left video assisted thoracoscopy surgery with upper lobectomy. Histology was suggestive of adenocarcinoma. In 2021, she had another fall episode due to an acute/subacute infarct of left pons. She continues having postural hypotension and requires regular plasmapheresis sessions to manage her symptoms. She is also presently on Bosentan for her raynaud’s phenomenon.Discussion/ResultsThis is a case of overlap of Sjogren syndrome with scleroderma features. Management of Refractory Raynaud’s as part of her scleroderma phenotype was challenging. This case gave us the opportunity to explore all the treatment options available for Raynaud’s phenomenon albeit with poor outcome. She also struggled with autonomic dysfunction leading to postural hypotension and gastrointestinal symptoms which can be seen in upto 50% of patients with Sjogren syndrome. Autonomic failure is often thought to be immune mediated in Sjogren syndrome. This makes way for the use of intravenous immunoglobulin and plasmapheresis to treat these conditions as was done in this case. Increased risk of lung carcinoma with scleroderma is well documented. Autonomic dysfunction can also present as paraneoplastic syndrome with lung carcinoma, however it is more common with small cell lung carcinoma and our patient was diagnosed with Adenocarcinoma. We would have to wait and see if the resection of the tumour has any demonstrable effect on her dysautonomia.Key learning points/ConclusionOverlap connective tissue diseases are often difficult to manage in view of extensive disease heterogeneity. Clinicians need to be aware of challenges in managing Difficult Raynaud’s with Autonomic dysfunction. Treating physicians need to be aware of the high risk of lung malignancy and regular close monitoring is required. This case-based conference gives us the opportunity to discuss further management approaches for her.

Coronary Intravascular Lithotripsy in a Tight Circumferential Calcified Lesion in the Presence of Haematoma Extending into Left Main Coronary Artery After Rotational Atherectomy.

Calcified disease increases procedural challenges and is associated with worse outcomes in percutaneous coronary intervention. Coronary intravascular lithotripsy is a new balloon-based modality for treating calcified disease with deep circumferential calcification. Its main benefit is simplicity and safety compared to atherectomy. However, atherectomy remains the modality of choice in balloon-uncrossable lesions. More than one modality is often needed for treatment of calcified disease. The authors present a case of a balloon-uncrossable calcified ostial left circumflex lesion which was first treated with rotational atherectomy. However, there was haematoma formation in the ostial circumflex extending into left main coronary artery, together with suboptimal preparation of calcified disease. Intravascular coronary lithotripsy was then used to successfully prepare the calcified lesion for stenting without causing extension of the haematoma.

Step Length Asymmetry Predicts Rehabilitation Length in Subacute Post Stroke Patients

Background: During the rehabilitation of individuals post stroke, evaluations are performed in order to discern the patient’s prognosis and optimize the treatment plan. However, these tests do not focus on gait symmetry, which might be a predictor for rehabilitation outcomes. We aimed to correlate gait symmetry measures of subacute post stroke patients with rehabilitation outcome and find the symmetry measure that best predicts the variability of the rehabilitation duration. A secondary aim was to compare these measures between patients with right and left brain lesions. Methods: We recruited 30 subacute post stroke patients (14 with right side lesion). We collected the following measures: National Institutes of Health Stroke Scale (NIHSS), Functional Independence Measure (FIM), the 10 m walk test (10MWT), Functional Ambulation Categories (FAC), spatial-temporal gait measures, and gait symmetry and variability. Results: We found moderate correlations between the step length symmetry and the length of rehabilitation, NIHSS, FIM, FAC and 10MWT. The symmetry index of the step length predicted the length of the rehabilitation period as it explained 32.1% of its variance (p = 0.001). Discussion: We conclude that a simple test of the step length symmetry might be informative in predicting rehabilitation length in subacute post stroke patients.

Multiple cerebral abscess caused by Klebsiella pneumonia on post tumor excision procedure

A cerebral abscess can happen due to a nearby brain infection, other rare body parts spread, head injury and surgery procedures. Intracranial Klebsiella pneumoniae infection rarely happens and usually occurs in immunocompromised patients. We reported a case of a 50 years old immunocompetent woman with prior tumor excision that progressed to a cerebral abscess. The patient came to the ER unconscious with progressive right-side weakness, pus from previous operation scar, fever and headache since few days’ pre-admission. Laboratory findings were leukocyte 13.710, neutrophil 9%, CRP 7.6, and negative HIV test. The contrast CT scan resulted in a multiloculated ring enhancement left frontal lobe lesion sized 5.8x6.9x5.0 cm and perifocal oedema. Open craniotomy managed to evacuate ±40cc. The microbiology culture tested positive for Klebsiella pneumoniae. Despite proper technique and administration of prophylaxis antibiotics, severe infection that requires immediate intervention still develops in a small group of patients. Klebsiella pneumoniae is a common pathogen causing cerebral abscess in both immunocompromised and healthy patients. Pus drainage and immediate antibiotics administration improved all symptoms, including hemiparesis. This case highlights the importance of quick and right therapy.

Endoscopic Ultrasound-Guided Fine-Needle Biopsy versus Fine-Needle Aspiration in the Diagnosis of Focal Liver Lesions: Prospective Head-to-Head Comparison.

Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) or fine-needle aspiration (EUS-FNA) from focal liver lesions are indicated in selected cases, but there has been no previous comparison of needle types of the same size. The aim of our study was to compare the histologic diagnostic accuracy and adequacy of cores obtained with EUS-FNB needles in contrast to those obtained with FNA needles in focal liver lesions. This prospective one-center study included patients with left lobe hepatic focal lesions with contraindications for percutaneous liver biopsy or need for EUS for concomitant lesions. Each patient had one pass of 22G EUS-FNB (Franseen) needle and one pass of 22G EUS-FNA in a crossover manner, without macroscopic on-site evaluation. Each sample was analyzed separately for histologic adequacy and diagnosis. The final diagnosis was based on histology results or on imaging follow-up in the case of negative biopsies. The EUS-FNB samples (n = 30) were found to be more adequate for histologic analysis, with more cellularity and longer tissue aggregates than the EUS-FNA samples (n = 30). The accuracy of EUS-FNB was 100%, whereas that of EUS-FNA was 86.7% (p = 0.039). No post-procedure complications were noted. The 22G EUS-FNB needle proved superior to 22G EUS-FNA in terms of tissue acquisition diagnostic accuracy and histologic adequacy in focal liver lesions.

Tumefactive demyelination-A Rare Presentation of Multiple Sclerosis

Background: Multiple Sclerosis is an inflammatory demyelinating disease having varied manifestations in terms of clinical featuresand radiological features. Rarely it may present as a large demyelinating lesionwith accompanying edema and mass effect, thereby simulating an intracranial tumor, known as Tumefactive Demyelination. Symptoms are usually related to the pressure of a focal mass lesion. When it manifests in a patient without pre-existing MS, it poses a diagnostic challengeas it may mimic a neoplasm, infarct or abscess. Thus, it is essential to recognize this rare clinical entity for proper patient management. Case Presentation: We report here a case of 40 years old female who presented with right sided hemiparesis. The initial brain imaging (CT) suggested left parietal lobe lesion suggestive of glioma. But MRI of the brain showed a cortical based lesion in left parietal lobe in parasaggital location which appeared hyperintense on both T2WI and FLAIR sequences. Further evaluation by MR spectroscopy suggested the lesion to be tumefactive demyelination. She was administered IV Methylprednisolone (1gm daily for 5 days) and responded well to treatment. The characteristic magnetic resonance findings of the patient, its acute onset, and its clinical improvement after corticosteroid therapy finally set the diagnosis of Tumefactive Demyelination. Conclusion: Tumefactive demyelinating lesions pose a unique diagnostic challenge in defining differential diagnosis and management and should always be considered in young patients presenting with tumour like lesions on imaging. Bangladesh Journal of Medical Science Vol. 21 No. 04 October’22 Page : 931-934

P03.10.B A successful case of Histiocytic sarcoma

Abstract Background Histiocytic sarcoma (HS) is an extremely rare malignant neoplasm accounting for less than 1% of all hemato-lymphoid neoplasms. Sixty percent of all cases are metastatic at presentation and the prognosis is really poor. Currently, there are limited treatment options for HS, and no standard treatment can be recommended. Surgery and/or chemotherapy are the most commonly employed treatment modalities for HS, while radiotherapy seems to be an effective option in patients with localized lesions. Material and Methods A 48-year-old woman admitted to our hospital for a drug-resistant neck pain. Her medical record review was relevant for hypothyroidism in replacement therapy, hystero-adnexectomy for fibromatosis (2 years ago), anxiety-depressive syndrome. A Brain and Head-and-Neck Magnetic Resonance Imaging (MRI) showed a left expansive osteolytic occipito-cervical vertebral lesion at level C1-C2, measuring 3.4cm x 2.3 cm x 2.6 cm. The mass was completely resected on July 12,2021 and pathological and immunohistochemical staining confirmed the diagnosis of HS with positive immunohistochemistry for CD163, CD4, CD68, CD14, CD45 / LCA; weak expression of S100 and focal positivity for lysozyme; Ki67 = 45%.On August 10, 2021 a 18F-FDG PET/CT imaging of the total body did not reveal any distal metastases. On August 13, 2021 a bone marrow aspirate showed no neoplastic cells. She underwent to an adjuvant chemotherapy regimen that consisted of ifosfamide administered as an infusion with bolus carboplatin, and etoposide (ICE). On August 28,2021 a concomitant radiotherapy is given, with a total dose of 45 Gy delivered in 15 fractions plus a sequential boost to 54 Gy.Results: VMAT was used to deliver a conformal RT plan. The patient tolerated the entire treatment very well, with a Grade 1 dysphagia immediately after the completion of radiotherapy, with a complete resolution about a week later. At last Brain Head-and-Neck RMN and 18F-FDG PET/CT on March 28, 2022 there is no evidence of recurrent disease. Conclusion The favorable outcome of our patient with combined chemotherapy and radiotherapy should promote future research to explore treatment protocols in patients with localized or favorable subtypes of HS.For patients with a good PS, young age, long life expectancy, advanced RT techniques may be used to customize safe treatment.

One hundred percent utilization of a modified CryoMaze III procedure for atrial fibrillation with mitral surgery

ObjectivesConcomitant atrial fibrillation often goes untreated because of surgeon concerns regarding lesion set complexity and pump times. We describe a new cryoablation procedure to address this. MethodsFrom June 2013 to March 2021, a modified CryoMaze III procedure was used using 3 left atrial ± 3 right atrial cryo-applications creating the key lesions of the Cox Maze III procedure. Since 2018, 3-minute cryo-lesions were used for the left atrial box lesion for total cryoablation times of 8 minutes for the left atrium ± 6 minutes for the right atrium. By using propensity matching, patients undergoing mitral valve surgery with no atrial fibrillation history were compared with CryoMaze III–treated patients. ResultsA total of 100% of the 277 patients with atrial fibrillation requiring mitral valve surgery ± other procedures received the modified CryoMaze III procedure. After propensity score matching (n = 161 each group), the modified CryoMaze III group had mean crossclamp and bypass times 10.5 and 13.4 minutes longer than the control group, respectively. There were no significant differences in 30-day mortality, morbidity, pacemaker use, renal dysfunction, or late survival between groups, but there were less postoperative strokes in the CryoMaze III group. Freedom from atrial fibrillation off antiarrhythmics was 77% (mean follow-up of 3.0 ± 2.1 years). At 12 months, freedom from atrial fibrillation off antiarrhythmics was 90% for the 3-minute ablation group. Late survival was similar to age- and sex-matched Centers for Disease Control and Prevention controls. ConclusionsThe modified CryoMaze III technique is efficient, safe, and effective. Education of the surgical community regarding the late benefits of ablation and the simplicity of this new technique should improve adoption of the Class I Guidelines to treat concomitant atrial fibrillation.