Left-sided Lesions Research Articles

An observational study of vascular endothelial growth factor inhibitors as second-line treatment for metastatic colorectal cancer treated with bevacizumab plus FOLFIRI beyond progression: the association with RAS mutation and tumor sidedness

Background: The BRiTE and ARIES studies suggested that the continued use of bevacizumab beyond progression (BBP) was beneficial. This study investigated the efficacy and safety of the vascular endothelial growth factor inhibitors (VEGFis) bevacizumab and aflibercept as second-line treatments for patients with metastatic colorectal cancer (mCRC) that progressed following the application of bevacizumab-containing chemotherapy as a first-line treatment. Methods: This observational cohort study (OCS) analyzed the medical records of 73 patients with mCRC divided into a no-VEGFi group (n=48) and a VEGFi group (n=25). Progression-free survival (PFS) was the primary endpoint, and the overall survival (OS), objective response rate (ORR), disease control rate (DCR), and safety were secondary endpoints. Results: The results revealed that the PFS, ORR, and DCR of the VEGFi group were significantly superior to those of the no-VEGFi group, even in those with wild-type and mutant-type RAS or left-sided mCRC (all P 0.05). Patients with primary left-sided lesions and continued use of VEGFi exhibited the most marked effect on PFS (P=0.001). No significant differences were observed in the incidence of grade 3 or 4 adverse events (AEs) between the two groups (P=0.133). Conclusions: These results support the use of VEGFi as a second-line treatment after bevacizumab beyond the initial progression in this OCS. Bevacizumab or aflibercept combined with second-line chemotherapy in mCRC has an acceptable safety profile and is relatively active. Regardless of the RAS gene type, VEGFi plus FOLOFX6 exhibited superior PFS to that of FLFOX6 as a second-line treatment, and a greater improvement in PFS was obtained for the left-sided lesions than for the right-sided lesions.

1416. Nocardia beijingensis: A Rare and Unusual Cause of Intracranial Abscess

BackgroundNocardia species are thin, aerobic, filamentous, gram-positive bacilli that are ubiquitous in soil worldwide. Nocardia infections are divided into three main categories: pulmonary nocardiosis, disseminated nocardiosis, and cutaneous nocardiosis.MethodsWe present a case of cerebral nocardiosis in an immunocompetent patient caused by Nocardia beijingensis (NB).ResultsA 60-year-old Caucasian lady from Florida with type 2 diabetes mellitus, hypertension, hyperlipidemia, presented to the emergency room with complaints of altered mentation. Per husband, she was having episodes of emesis and diarrhea 3 days prior to admission that resolved however, her mentation significantly deteriorated to where she was unable to perform simple chores around the house. Pertinently she had resection of lung mass 2 months prior to admission which found to be benign. Vital sign at admission was stable and on examination, the patient was alert and oriented, however, lethargic appearing. Neurological examination was pertinent for expressive aphasia; however, cranial nerves II-XII were grossly intact. The patient was also found to have a 3 cm by 4 cm, tender, cystic lesion on the left-sided occipital scalp. The remainder of the physical examination was unremarkable. Admission laboratories were remarkable for leukocytosis and hyperglycemia. MRI of the brain was completed that showed multiple areas of vasogenic edema and multiple nodules with the largest being 1.8 cm suggestive of abscesses. She was started empirically on vancomycin, ceftriaxone, metronidazole, and ampicillin. Cerebral spinal fluid showed neutrophilic pleocytosis, low glucose, and high protein. Initial cultures including CSF were negative. Left-sided occipital scalp lesion was excised and sent for pathology and culture. Initial cultures showed gram-positive bacilli, so antibiotics were de-escalated to sulfamethoxazole/trimethoprim and ceftriaxone. Repeat imaging showed improving abscess, and final cultures resulted in NB.ConclusionNB is believed to have originated in Southeast Asia. NB has been associated mainly with infections in immunocompromised. In the United States, the two only other cases of NB described in immunocompetent hosts were interestingly from Florida as well. Disclosures All authors: No reported disclosures.

An observational study of vascular endothelial growth factor inhibitors as second-line treatment for metastatic colorectal cancer treated with bevacizumab plus FOLFIRI beyond progression: the association with RAS mutation and tumor sidedness.

BackgroundThe BRiTE and ARIES studies suggested that the continued use of bevacizumab beyond progression (BBP) was beneficial. This study investigated the efficacy and safety of the vascular endothelial growth factor inhibitors (VEGFis) bevacizumab and aflibercept as second-line treatments for patients with metastatic colorectal cancer (mCRC) that progressed following the application of bevacizumab-containing chemotherapy as a first-line treatment.MethodsThis observational cohort study (OCS) analyzed the medical records of 73 patients with mCRC divided into a no-VEGFi group (n=48) and a VEGFi group (n=25). Progression-free survival (PFS) was the primary endpoint, and the overall survival (OS), objective response rate (ORR), disease control rate (DCR), and safety were secondary endpoints.ResultsThe results revealed that the PFS, ORR, and DCR of the VEGFi group were significantly superior to those of the no-VEGFi group, even in those with wild-type and mutant-type RAS or left-sided mCRC (all P<0.05); however, OS did not differ significantly between the two groups (all P>0.05). Patients with primary left-sided lesions and continued use of VEGFi exhibited the most marked effect on PFS (P=0.001). No significant differences were observed in the incidence of grade 3 or 4 adverse events (AEs) between the two groups (P=0.133).ConclusionsThese results support the use of VEGFi as a second-line treatment after bevacizumab beyond the initial progression in this OCS. Bevacizumab or aflibercept combined with second-line chemotherapy in mCRC has an acceptable safety profile and is relatively active. Regardless of the RAS gene type, VEGFi plus FOLOFX6 exhibited superior PFS to that of FLFOX6 as a second-line treatment, and a greater improvement in PFS was obtained for the left-sided lesions than for the right-sided lesions.

Hemispheric tumor location and the impact on health-related quality of life, symptomatology, and functional performance outcomes in patients with glioma: an exploratory cross-sectional study

Purpose To inform high-quality rehabilitation services, this study investigates if patients with glioma located in the right- or left-hemisphere present with different health-related quality of life, symptomatology, and functional performance in the early disease state. Material and methods Between 2013 and 2017, 81 adult patients were assessed during the first week of chemo-radiation, following resection. Patients were stratified into two groups depending on a right- or left-hemispheric lesion. Independent t-tests analyzed potential differences regarding health-related quality of life, symptomatology, and functional performance. Results Forty-five patients (56%) had a tumor located in the right hemisphere, whereas 36 patients (44%) had a tumor in the left hemisphere. Except for more patients with tumors in the left hemisphere having their tumor located in eloquent brain areas, the groups were well matched. No group differences were found in health-related quality of life. Group differences were found in communication deficits (Δ-10.9, 95%CI −19.1; −2.3, p = 0.01), which were more frequent in patients with left-sided lesions, and of headaches (Δ13.9, 95%CI 1.8; 25.9, p = 0.02), which were more frequent in patients with right-hemispheric lesions, who also had significantly greater difficulties with process-skills when performing everyday life tasks (Δ-0.3, 95%CI −0.5; −0.1, p < 0.01). Also, weak evidence suggests that patients with Glioblastoma Multiforme located in the right hemisphere are more affected by fatigue compared to their left-hemispheric comparisons (Δ14.6, 95%CI 0.19; 29.0, p < 0.05). Conclusions The hemispheric location of a glial-cell brain tumor has no consequence for health-related quality of life at the beginning of chemo-radiation treatments. However, findings of tumor-location dependent conditions of communication, headache, patients’ ability to perform executive functions, and fatigue should be considered in rehabilitation situations when designing an intervention to potentially improve executive functions and relieve the symptoms. Implications for rehabilitation It is unclear if laterality impact glioma patients health-related quality of life and functional performance, which might implicate differentiated rehabilitation interventions. The hemispheric location of a glial-cell brain tumor has no consequence for the health-related quality of life at the beginning of chemo-radiation, following surgery. Tumor-location dependent conditions of communication, headache, fatigue, and patients’ ability to perform executive functions should be considered when designing an intervention to improve executive functions and symptom-relieve. In rehabilitation interventions, tumor laterality is not a factor that needs to be considered before recommending aerobic training to improve the functional capacity of patients with glioma.

Is There Currently a Place for Combined Mitral and Aortic Transcatheter Interventions?

The goal was to evaluate published data on the incidence, diagnosis, and management of symptomatic combined mitral and aortic valvular disease. Furthermore, to identify the role of treatment using contemporary transcatheter techniques. Up to a quarter of symptomatic adult valvular disease is caused by multiple left-sided valvular lesions. The etiologic spectrum of this combined disease has shifted from rheumatic to degenerative. Both presentation and diagnosis of lesions are modified compared with isolated disease. Based upon narrative review, there are only limited observational experiences, insufficient to provide robust guidance. These data, however, indicate the feasibility of interventions such as transcatheter aortic valve replacement and edge-to-edge mitral valve repair to treat such disease and mitigate the risks of open surgery. Combined aortic and mitral valve disease is commonly encountered. There is a role for transcatheter interventions based on limited data; however, more research is needed.

“Cerebellar lesions after low-grade tumor resection can induce memory impairment in children, similar to that observed in patients with frontal lesions”

ABSTRACTThe aim of the present study was to specify if cerebellar lesions cause memory impairment in children. The study sample consisted of 44 children with low-grade cerebellar astrocytoma, who underwent surgical treatment and 30 healthy controls, matched with regard to age and sex. Memory was tested using the Rey Auditory Verbal Learning Test AVLT, Corsi Block-Tapping Test, Digit Span, Digit Backwards and Information Subtests from the Wechsler Intelligence Scale for Children-Revised WISC-R (PL). Patients with cerebellar lesions demonstrated memory impairments, similar to those typical for patients with frontal lesions, with auditory and visuospatial working memory deficits, a disorganized learning process without mnemonic strategy (executive dysfunctions) and problems with recalling new material from long-term memory storage, while maintaining good recognition of previously learned material, preserved semantic knowledge and short-term auditory-verbal memory (digit span). Obtained results showed that memory deficits would vary according to the side of the cerebellar lesion, with more pronounced impairment of visuospatial memory tasks accompanying the left-sided cerebellar lesions and worse performance of verbal memory task, observed in the group of patients with right-sided cerebellar lesions. Although the presence of hydrocephalus significantly worsens the memory performance of the children studied, patients with cerebellar lesions without hydrocephalus still present significantly lower memory indicators in the profile described, compared to the control group of healthy children. It confirms the hypothesis that cerebellar lesion alone could result in memory dysfunctions in children.

Impact of Left-sided Lesions in Pediatric Patients Having Surgery for Ebstein Anomaly

Purpose: Pediatric patients undergoing tricuspid valve intervention for Ebstein anomaly (EA) are at risk for post-operative morbidity and mortality. The impact of left-sided abnormalities (LSA), including left ventricular non-compaction (LVNC) as well as abnormalities of the mitral and aortic valves, on early cardiac post-operative outcomes is unknown. We sought to determine factors that impact early post-operative outcomes in pediatric patients undergoing cone repair (CR) for EA. Methods: We performed a retrospective review …

Impact of Left-sided Lesions in Pediatric Patients Having Surgery for Ebstein Anomaly

Impact of Left-sided Lesions in Pediatric Patients Having Surgery for Ebstein Anomaly

A-37 Effects of Atypical Language Representation in Populations Suffering From Intractable Epilepsy

Abstract Objective Atypical language laterality, secondary to refractory epilepsy, presents complications to surgical planning/cognitive outcomes. Extant research shows the non-dominant hemisphere reallocates neural resources for language compensation in response to left-sided lesions (resulting in decreased visuoperceptual/visual memory). The present study examined relationships between 1) lesion location and atypical language organization and 2) lesion location/language laterality on performance on memory (California Verbal Memory Test 2nd-edition (CVLT; Delayed Recall), and visuoperceptual (Rey-Osterrieth Complex Figure Test, ROCFT; Copy) tests in relation to lesion location in a sample of patients with intractable epilepsy. Method Retrospective data was compiled on patients with refractory epilepsy undergoing interdisciplinary pre-surgical workup (N = 101), mean age of 37.2 (SD = 11.9) and mean education of 12.3 (SD = 3.7). The sample was then stratified by non-lesional (n = 48), left (n = 26), right (n = 21) or bilateral (n = 6) mesial temporal sclerosis (MTL); and, language laterality was confirmed by neuroradiologists via functional Magnetic Resonance Imaging (fMRI) scans. Results Analyses showed patients with left MTS were more likely to have atypical language organization, X2 (1, N = 47) = 6.6, p = .01. Moreover, significant differences on T-scores for CVLT, F (3,15) = 3.81, p = .04, 95% Cl [-1.73, -.08] and ROCFT, F(4,28) = 2.85, p = .046 95% Cl [31.62, 46.17] were found between groups stratified by lesion location/language laterality, respectively. Conclusions Organization of language in epileptic populations presents atypically in conjunction with left-sided lesions. Additionally, cognitive processes such as verbal memory and visuoperceptual abilities suffer based on lesion presence/location and language laterality in this fMRI confirmed sample.

Fetal Echocardiographic Parameters and Surgical Outcomes in Congenital Left-Sided Cardiac Lesions.

This study aimed to evaluate fetal echocardiographic parameters associated with neonatal intervention and single-ventricle palliation (SVP) in fetuses with suspected left-sided cardiac lesions. Initial fetal echocardiograms (1/2002-1/2017) were interpreted by the contemporary fetal cardiologist as coarctation of the aorta (COA), left heart hypoplasia (LHH), hypoplastic left heart syndrome (HLHS), mitral valve hypoplasia (MVH) ± stenosis, and aortic valve hypoplasia ± stenosis (AS). The cohort comprised 68 fetuses with suspected left-sided cardiac lesions (COA n = 15, LHH n = 9, HLHS n = 39, MVH n = 1, and AS n = 4). Smaller left ventricular (LV) length Z score, aortic valve Z score, ascending aorta Z score, and aorta/pulmonary artery ratio; left-to-right shunting at the foramen ovale; and retrograde flow in the aortic arch were associated with the need for neonatal intervention (p = 0.005-0.04). Smaller mitral valve (MV) Z score, LV length Z score, aortic valve Z score, ascending aorta Z score, aorta/pulmonary artery ratio, and LV ejection fraction, as well as higher tricuspid valve-to-MV (TV/MV) ratio, right ventricular-to-LV (RV/LV) length ratio, left-to-right shunting at the foramen ovale, abnormal pulmonary vein Doppler, absence of prograde aortic flow, and retrograde flow in the aortic arch were associated with SVP (p < 0.001-0.008). The strongest independent variable associated with SVP was RV/LV length ratio (stepwise logistical regression, p = 0.03); an RV/LV length ratio > 1.28 was associated with SVP with a sensitivity of 76% and specificity of 96% (AUC 0.90, p < 0.001). A fetal RV/LV length ratio of > 1.28 may be a useful threshold for identifying fetuses requiring SVP.

Congenital Heart Surgery Outcomes in Turner Syndrome: The Society of Thoracic Surgeons Database Analysis

Turner syndrome (TS) is a genetic syndrome characterized by monosomy X (45,XO) in phenotypic females and is commonly associated with congenital heart disease. We sought to describe the distribution, mortality, and morbidity of congenital heart surgery in TS and compare outcomes to individuals without genetic syndromes. The Society of Thoracic Surgeons Congenital Heart Surgery Database was used to evaluate index cardiovascular operations performed from 2000 to 2017 in pediatric patients (aged 0-18 years) with and without TS. Analyses were stratified by the most common operations, including coarctation repair, aortic arch repair, partial anomalous pulmonary venous return repair, Norwood, superior cavopulmonary anastomosis (Glenn), and Fontan. Included were 780 operations in TS and 62,659 operations in controls. The most common TS operations were coarctation repair in 274 (35%), aortic arch repair in 116 (15%), and Norwood in 59 (8%). Compared with controls, TS patients had lower weight-for-age Z-scores across all operations (P < .01 for all); however, operative mortality rates did not differ significantly. The chylothorax rate was higher in TS after coarctation repair (8.8% vs 2.8%, P < .001) and Norwood (22% vs 8.1%, P< .001). The median (interquartile range) postoperative length of stay was longer in TS for coarctation repair (6.5 [5.0-15.5] days vs 5.0 [4.0-9.0] days, P < .001), aortic arch repair (15.0 [8.0-27.5] days vs 11.0 [7.0-21.0] days, P= .004), and Glenn (9.0 [6.0-16.0] days vs 6.0 [5.0-11.0] days, P= .013). Turner syndrome patients most commonly underwent operations for left-sided obstructive lesions. Despite increased morbidity for select operations, TS was not associated with increased operative mortality.

Comparison of intralesional triamcinolone acetonide, botulinum toxin type A, and their combination for the treatment of keloid lesions

Objective: Despite the myriad options available, there is no universally the accepted treatment for keloids. Our objective was to compare three regiments and establish superiority in terms of objective and subjective outcomes.Approach: In this intervention study, 50 patients were enrolled. The Group I: included 26 patients with at least two keloid lesions subjected to intralesional triamcinolone acetonide in left-sided lesions and intralesional botulinum toxin type A in right-sided lesions. While group II included 24 patients subjected to a combination of both intralesional TAC and BTX-A. Injections were done for a total of three sessions 4 weeks apart. Color Doppler ultrasound (CDU) was done before and one month after treatment.Results: In terms of thickness and surface area the keloids responded significantly better to combined TCA and BTX versus TCA alone or BTX alone (p .0001). Also improvement in transverse and longitudinal axis was significantly higher in combined therapy (p < .0001 and .004, respectively). Conclusion: Combined injection of intralesional steroids with BTX-A appears to be superior to either therapy alone and offer the best benefit of safer and more efficacious response with lesser side effects.

Efficacy of balloon venoplasty alone in the correction of nonthrombotic iliac vein lesions

ObjectiveIliac vein stenting of nonthrombotic iliac vein lesions is an evolving treatment course for management of chronic venous insufficiency. To characterize these lesions, we examined our experience treating these lesions with balloon venoplasty before stenting. MethodsA retrospective analysis was performed to study all patients who underwent venograms with venoplasty and stenting of iliac veins from February 2013 to July 2016. All patients included in the study were treated with a trial conservative management for 3 consecutive months before venogram and, if indicated, venoplasty was performed. If a greater than 50% reduction in cross-sectional area or diameter was observed on intravascular ultrasound examination, the stenotic area was treated with balloon angioplasty, sized to nonstenotic distal vein segment (range, 10 × 40 mm to 16 × 60 mm). Intravascular ultrasound examination was also used to measure the area of stenotic iliofemoral veins before and after balloon angioplasty. ResultsA total of 1021 venograms with venoplasty and stenting of iliac veins were performed in 713 patients from February 2013 to July 2016. The mean age of the study population age was 64.88 years (range, 21-99 years; standard deviation [SD], 14.57), with 451 female and 262 male patients. Before angioplasty, the mean cross-sectional stenotic area was 67.97 mm2 (range, 6-318 mm2; SD, 34.87). After balloon angioplasty, the mean stenotic area increased to 78.80 (range, 6-334 mm2; SD, 44.50; P < .001). The targeted stenotic areas were categorized into three categories: group A, increased (>10% of baseline before venoplasty); group B, decreased (<10% of baseline), and group C, no area change (±10% of baseline). In 500 limbs (48.9%), the stenotic areas improved after venoplasty (average 36.99%), with a prevenoplasty average area of 60.81 mm2 (SD, 32.80 mm2) and a postvenoplasty average of 96.52 mm2 (SD, 49.85 mm2). In 294 limbs (28.8%), the area decreased (average 28.90%), with a prevenoplasty average area of 76.43 mm2 (SD, 38.80 mm2) and a postvenoplasty average of 53.22 mm2 (SD, 26.61 mm2). There were 227 patients (22.2%) who had the same area before and after venoplasty. Left-sided lesions had a greater increase in area than right-sided lesions (51.3% vs 46.2%, respectively; P = .048). No significant correlation of stenotic area response with age, presenting symptoms of Clinical, Etiology, Anatomy, and Pathophysiology (C2-C6), gender, or location of targeted lesion was observed. ConclusionsOur data show there is a highly variable response after venoplasty of stenotic area of nonthrombotic iliac vein lesions. Balloon venoplasty showed greater improvement in improving the area of stenotic left-sided lesions. However, stenting of the lesions should be performed routinely owing to recoil and spasm in lesions.

Mechanics of the Tricuspid Valve-From Clinical Diagnosis/Treatment, In-Vivo and In-Vitro Investigations, to Patient-Specific Biomechanical Modeling.

Proper tricuspid valve (TV) function is essential to unidirectional blood flow through the right side of the heart. Alterations to the tricuspid valvular components, such as the TV annulus, may lead to functional tricuspid regurgitation (FTR), where the valve is unable to prevent undesired backflow of blood from the right ventricle into the right atrium during systole. Various treatment options are currently available for FTR; however, research for the tricuspid heart valve, functional tricuspid regurgitation, and the relevant treatment methodologies are limited due to the pervasive expectation among cardiac surgeons and cardiologists that FTR will naturally regress after repair of left-sided heart valve lesions. Recent studies have focused on (i) understanding the function of the TV and the initiation or progression of FTR using both in-vivo and in-vitro methods, (ii) quantifying the biomechanical properties of the tricuspid valve apparatus as well as its surrounding heart tissue, and (iii) performing computational modeling of the TV to provide new insight into its biomechanical and physiological function. This review paper focuses on these advances and summarizes recent research relevant to the TV within the scope of FTR. Moreover, this review also provides future perspectives and extensions critical to enhancing the current understanding of the functioning and remodeling tricuspid valve in both the healthy and pathophysiological states.

Alterations in Cortical Morphology after Neonatal Stroke: Compensation in the Contralesional Hemisphere?

Although neonatal arterial ischemic stroke is now well-studied, its complex consequences on long-term cortical brain development has not yet been solved. In order to understand the brain development after focal early brain lesion, brain morphometry needs to be evaluated using structural parameters. In this work, our aim was to study and analyze the changes in morphometry of ipsi- and contralesional hemispheres in seven-year-old children following neonatal stroke. Therefore, we used surface-based morphometry in order to examine the cortical thickness, surface area, cortical volume, and local gyrification index in two groups of children that suffered from neonatal stroke in the left (n=19) and right hemispheres (n=15) and a group of healthy controls (n=30). Reduced cortical thickness, surface area, and cortical volumes were observed in the ipsilesional hemispheres for both groups in comparison with controls. For the group with left-sided lesions, higher gyrification of the contralesional hemisphere was observed primarily in the occipital region along with higher surface area and cortical volume. As for the group with right-sided lesions, higher gyrification was detected in two separate clusters also in the occipital lobe of the contralesional hemisphere, without a significant change in cortical thickness, surface area, or cortical volume. This is the first time that alterations of structural parameters are detected in the "healthy" hemisphere after unilateral neonatal stroke indicative of a compensatory phenomenon. Moreover, findings presented in this work suggest that lesion lateralization might have an influence on brain development and maturation.

Synchronous colorectal carcinoma by Chin et al.

Synchronous colon cancer at initial index presentation is reported in at least 5% of patients. Risk factors for synchronous cancer include male sex, advanced age, and hereditary colorectal neoplastic conditions. However, the impact of synchronous cancers has yet to be determined. Chin et al. 1 herein report on over 17 000 colorectal cancer patients, of which 5.6% had a synchronous colorectal cancer, and describe synchronous lesions to be an independent risk factor for poor survival in stages I–III of colorectal cancer. While over half of patients had synchronous lesions found in the same segment of colon as the primary cancer, up to 45% were found in two to three segments. These findings, together, underscore the importance of completion colonoscopy prior to surgical intervention, when able to not miss undiagnosed lesions at the time of surgery. Their study is particularly relevant in that only 0.2% of patients were lost to follow up, and the study spanned 1995–2016, encompassing years in which novel treatment modifications were introduced. There were no differences over time with respect to synchronous colon cancer continuing to be an independent risk factor for poor survival. Why synchronous colon cancer is associated with worse survival remains uncertain. Are lesions missed due to failure to perform completion colonoscopy? In those patients who had obstructing left-sided lesions, only 9.4% had a complete colonoscopy prior to surgery. It is thus imperative that these patients are getting scoped at least within 6 months of the date of their surgery. It could also be that while a distal, locally advanced tumor is being treated, a concurrent tumor is flourishing. Last, those with synchronous lesions have a more aggressive tumor biology in general, so their underlying malignancy responds differently to systemic treatment. Regardless, complete colonoscopy prior to surgical intervention remains imperative.

GENETIC ASSOCIATION BETWEEN HYPOPLASTIC LEFT HEART SYNDROME AND CARDIOMYOPATHIES VIA THE MYBPC3 GENE

Hypoplastic left heart syndrome (HLHS) has been shown to exhibit familial clustering with other congenital heart lesions, such as bicuspid aortic valve and other left-sided lesions. This study demonstrates inheritance of cardiomyopathies in family members of patients with HLHS, a previously

WP1-21 Maximum safe resection of large medial temporal intrinsic tumours: does the outcome justify the risk?

ObjectivesTo analyse on the long-term outcomes in patients undergoing maximum safe resection (MSR) for large intrinsic temporal tumours.DesignCase seriesSubjectsAll patients undergoing MSR of large medial temporal intrinsic tumours between May 2006 and February 2012 at a tertiary neurosurgical centre with a minimum follow up of 6 years.MethodsRetrospective review of hospital records.ResultsFifty-one patients underwent MSR (28 male, 23 female); age range 20–80 years (mean age 55.3). There was no difference in laterality, although dysphasia was a feature in 32% of left-sided lesions. Presenting features in general included seizures (46%), headaches (27%), hemiparesis (12%) and visual field defects (6%). Surgery was generally well tolerated (median post-operative Karnofsky score 92.5). No patients developed new dysphasia or weakness, but there was transient worsening of existing hemiparesis (n=4) and dysphasia (n=2). Other complications included CSF leak/pseudomeningocoele (n=2), oculomotor palsy (n=1) and wound infection (n=1). Histopathological casemix was GBM (50%), WHO 3 gliomas (14%), WHO 2 gliomas (10%) and metastases (4%). In total, 57% of patients received radiotherapy and 35% received chemotherapy. Survival correlated with pathology; in glioblastoma patients it ranged from 2–19 months (mean 10.4 months). Survival in grade 3 tumours ranged from 10–38 months (mean 24.4 months). 60% of patients with Grade 2 tumours are surviving symptom free with no histological upscale at 8–10 years follow-up. No patient required a second debulking procedure.ConclusionsMSR did not result in survival benefit in glioblastoma. MSR is justified in lesions with pre-operative radiological features of Grade 2 glioma.

The Influence of Stroke Location on Cognitive and Mood Impairment. A Voxel-Based Lesion-Symptom Mapping Study

Background and purpose: The role of stroke location as a determinant of mood and cognitive symptoms is still a matter of debate. The aim of this study was to identify the predictive value of ischemic stroke location, on a voxel basis, for mood and cognitive outcome. Materials and methods: A prospective monocentric study including patients with a supratentorial ischemic stroke was conducted. A 3 Tesla brain MRI was performed at baseline. Mood and cognition were assessed using Hospital Anxiety and Depression scale (HAD), apathy inventory (AI), and Montreal Cognitive Assessment scale subscores, performed at 3 months poststroke. Statistical maps of ischemic stroke location associated with 3 months mood and cognitive scores were obtained using a voxel-based lesion-symptom mapping approach (Brunner and Munzel test). Significant voxels (false discovery rate [FDR] corrected-P < .01) were identified using the standard Montreal Neurological Institute-152 space template. Results: Two hundred and sixty-five nonsevere stroke patients were included (64% men, mean age 66 ± 14, median National Institute of Health Stroke Score 3, interquartile range 2-6). Ischemic stroke location was not associated with HAD or AI scores. Language, abstraction, and delayed recall performances were mainly associated with left-side hemispheric lesions. Lesions in both hemispheres were associated with lower performances in visuospatial and executive functions, naming, attention, and orientation. Conclusion: Ischemic stroke location does not predict mood outcome at 3 months but is a determinant of cognitive outcome in specific domains.

A Case of an Isolated Parachute Mitral Valve: The Importance of Multimodal Imaging in Distinguishing Cardiac Abnormalities Within the Shone's Complex

Few cases of isolated parachute mitral valve lesions have been documented. The presence of a parachute mitral valve generally coexists with three other left-sided obstructive lesions (supramitral valvular ring, subaortic stenosis, and aortic coarctation).1 Collectively, these abnormalities are termed the Shone's complex.1 Differentiation of isolated cases of parachute mitral valves, and those cases of congenital mitral stenosis occurring due to a partial or complete Shone's complex is crucial for proper patient management. As the degree of mitral stenosis worsens (because of the presence of other left-sided obstructive lesions) surgical interventions need to be appropriately tailored.2 The presence of additional cardiac abnormalities has the potential to impact the timing and approach of surgical intervention.3 Failure to document all other cardiac abnormalities can increase the chances of pulmonary hypertension after surgery and can adversely impact long-term surgical outcomes.4 Therefore, a careful routine echocardiographic examination should rule out any/all obstructive lesions that may impact surgical outcomes (particularly those related to the Shone's complex). A multimodality imaging approach is also recommended to ensure all diagnoses are made (especially in cases of technically difficult transthoracic images).