Left-sided Lesions Research Articles

Focal chest wall protuberance due to forked ribs or cartilages: An analysis of 12 cases

Objective: The purpose of this article is to describe and summarize the clinical manifestations and radiographic features of focal bulging of chest walls in children using plain chest radiography and computed tomography (CT) scans. Methods: From 2008 to 2014, we identified 12 patients with forked ribs younger than 18 years of age. These patients received plain chest radiography and computed tomographic scans of the chest for focal anterior chest wall protrusion at the outpatient chest clinic of a children's facility. Results: A total of 12 patients (5 girls and 7 boys; age range, 2–12 years; median, 5 years) were enrolled in this study. Six patients had right-sided costal lesions, four had left-sided lesions, and two had anomalies on both sides. The most common rib involved was the 4th rib. Two patients with forked cartilages and one patient with forked rib were not detected in frontal radiograph but seen by CT scans only. Up to the time of this writing, the follow-up of patients revealed no progression of focal bulging. Conclusion: In otherwise healthy children with asymptomatic focal anterior chest wall bulging, forked ribs is a common cause of variation. The chest radiographs may be normal. Chest CT scans demonstrated forked ribs/cartilage as the cause of focal bulging of the chest wall unequivocally in such instances.

The Effect of Balloon Angioplasty of Nonthrombotic Iliac Vein Lesions

Iliac vein stenting of nonthrombotic iliac vein lesions is an evolving treatment option for venous insufficiency. To characterize these lesions, we examined our experience treating these lesions with balloon venoplasty before stenting. After failed conservative therapy, we performed 1021 venograms with venoplasty and stenting of iliac veins on 713 patients from February 2013 to July 2016. The average age of the patients was 64.88 years (range, 21-99; standard deviation [SD], ±14.57), with 451 female and 262 male patients. Intravascular ultrasound was used to measure the area of stenotic iliofemoral veins before and after balloon angioplasty. If >50% cross-sectional area or diameter reduction was found, the stenotic area was treated with balloon angioplasty, sized to the nonstenotic distal vein segment (range, 10 × 40 mm to 16 × 60 mm). Before angioplasty, the average cross-sectional stenotic area was 67.97 mm2 (range, 6-318; SD, ±34.87). After balloon angioplasty, the average stenotic area was 78.80 mm2 (range, 6-334; SD, ±44.50; >10% of baseline before venoplasty), decreased (2; SD, ±32.80), and postvenoplasty average of 96.52 mm2 (SD, ±49.85). In 294 (28.8%) limbs, the area decreased (average, 28.90%), with prevenoplasty average area of 76.43 mm2 (SD, ±38.80) and postvenoplasty average of 53.22 mm2 (SD, ±26.61); 227 (22.2%) patients had the same area before and after venoplasty. Left-sided lesions had a greater increase in area than right-sided lesions (51.3% to 46.2%; P = .048). No significant correlation was found in area response compared with age; clinical, etiologic, anatomic, and pathophysiologic (CEAP) classification scores (2-6); gender; and lesion location. Our data show that there is a highly variable response after venoplasty in treating the stenotic area of nonthrombotic iliac vein lesions. Balloon venoplasty showed greater improvement in increasing the area of stenotic left-sided lesions. However, stenting of the lesions should be routine because of recoil and spasm in lesions.

Insulin Aspart–Induced Lipoatrophy Treated Successfully With Glucocorticoid Injection

ABSTRACT Objective: To evaluate the management of insulin-induced lipoatrophic areas with local subcutaneous glucocorticoid injection. Methods: A 42-year-old woman with type 2 diabetes mellitus, who was taking biphasic insulin aspart for the last 3 years, presented with two areas of lipoatrophy of insulin injection sites on the anterior abdominal wall. It was associated with erratic glycemic control. We administered glucocorticoid injections (betamethasone) subcutaneously without mixing with insulin on the right-sided lipoatrophic area of the abdomen. The left-sided lesion served as a control. Results: After 6 weeks of treatment, lipoatrophy on the right side of the abdomen showed significant improvement in comparison to the left side, which was also documented by magnetic resonance imaging. Glycemic status was also improved. Conclusion: We observed significant improvement of lipoatrophy with glucocorticoid injection. Contrary to previous observations, betamethasone did not adversely affect the glycemic s...

Myxofibrosarcoma of the maxillary sinus.

Background:Myxofibrosarcoma (MFS) is a common sarcoma in the extremities of older individuals but is extremely uncommon in the head and neck region. Diagnosis may be challenging but is critical to the management of the patient. We discuss the radiographic and histopathologic characteristics of this destructive tumor. The distinguishing features of MFS and its differential diagnosis are reviewed to familiarize the managing otolaryngologist with this rare entity.Methods:A 61-year-old woman presents with a 6-week history of severe left facial pain and left eye pain. Imaging demonstrates significant right and left-sided maxillary sinus opacification with destruction of the left maxillary sinus as well as the left medial and inferior orbital walls.Results:Histopathologic examination revealed spindle and stellate tumor cells of variable cellularity in myxoid stroma with cellular pleomorphism consistent with MFS of intermediate-to high grade. The patient underwent resection of the left-sided lesion with orbital exenteration and repair of the defect with microvascular free flap followed by postoperative radiotherapy.Conclusion:MFS must be differentiated from other lesions with myxoid qualities. Histopathologic examination is required for definitive diagnosis. Management includes complete tumor excision with adequate tumor margins. Adjuvant postoperative radiotherapy should be considered for larger tumors with positive resection margins or lesions of intermediate-to-high grade.

Diagnostic accuracy of faecal biomarkers in detecting colorectal cancer and adenoma in symptomatic patients.

The diagnosis of colorectal cancer (CRC) can be difficult as symptoms are variable with poor specificity. Thus, there is a quest for simple, non-invasive testing that can help streamline those with significant colonic pathology. To assess using faecal immunochemical test for haemoglobin (FIT) or faecal calprotectin (FCP) to detect CRC and adenoma in symptomatic patients referred from primary care. A total of 799 referred for urgent lower gastrointestinal investigations were prospectively recruited. Of these, 430 completed colonic investigations and returned stool samples, and were included in the final statistical analysis. Faecal immunochemical test for haemoglobin was performed on HM-JACKarc analyser (Kyowa Medex, Tokyo, Japan), and FCP by the EliA Calprotectin immunoassay (Thermo Fisher Scientific, Waltham, United States). The negative predictive value (NPV) using FIT alone or both markers (FIT and FCP) in combination was similar at 99% for CRC, with a sensitivity and specificity of 84% and 93%, respectively. FIT measurements were significantly higher in left-sided colonic lesions compared with the right side; 713 vs. 94; P = 0.0203). For adenoma, the NPV using FIT alone, or both markers (FIT and FCP) in combination, was similar at 94% with a sensitivity and specificity of 69% and 56%, respectively. Undetectable faecal immunochemical test for haemoglobin is sufficiently sensitive to exclude colorectal cancer, with higher values in left-sided lesions. FCP in combination does not appear to provide additional diagnostic information. Further studies to determine the health economic benefits of implementing faecal immunochemical test for haemoglobin in primary care are required.

Incidence, morphology, and progression of bicuspid aortic valve in pediatric and young adult subjects with coexisting congenital heart defects.

Bicuspid aortic valve (BAV) occurs both as an isolated cardiac lesion and in association with congenital heart defects (CHD). Their aim was to identify the incidence and morphology of BAV in patients with coexisting CHD and compare their disease progression to patients with isolated BAV. The Mayo Clinic echocardiography database was retrospectively analyzed to identify pediatric and young adult patients (≤22 years) who were diagnosed with BAV from 1990 to 2015. The morphology of BAV was determined from the echocardiographic studies before any intervention. Overall, 1010 patients with BAV were identified, 619 (61%) with isolated BAV and 391 (39%) with BAV and coexisting CHD. The incidence of BAV was highest in patients with coarctation of the aorta (36%) and interrupted aortic arch (36%). In comparison to patients with isolated BAV, patients with BAV and left-sided obstructive lesions more frequently had right-left cusp fusion (P = .0001). BAV in patients with right-sided obstructive lesions was rare, but they more frequently had right-noncoronary or left-noncoronary cusp fusion (P = .01). No significant progression of aortic stenosis or regurgitation was observed in patients with BAV and coexisting CHD; however in patients with isolated BAV the severity of aortic regurgitation increased with age. In patients with isolated BAV, the ascending aorta diameter (z-score) increased with age, peaked around 8-9 years of age, and was larger in comparison to patients with BAV and coexisting CHD. The sinus of Valsalva diameter (z-score) in patients with BAV and ventricular septal defect was larger than isolated BAV patients after 18 years (P < .04). The morphology of BAV, the pattern and progression of aortic dilatation, and the severity of aortic valve disease vary in pediatric and young adult patients with BAV and coexisting CHD. However, there was no significant BAV disease progression when associated with these CHD.

Effect of Right Insular Involvement on Death and Functional Outcome After Acute Ischemic Stroke in the IST-3 Trial (Third International Stroke Trial).

In patients with acute ischemic stroke, whether involvement of the insular cortex influences outcome is controversial. Much of the apparent adverse outcome may relate to such strokes usually being severe. We examined the influence of right and left insular involvement on stroke outcomes among patients from the IST-3 study (Third International Stroke Trial) who had visible ischemic stroke on neuroimaging. We used multiple logistic regression to compare outcomes of left versus right insular and noninsular strokes across strata of stroke severity, on death, proportion dead or dependent, and level of disability (ordinalized Oxford Handicap Score) at 6 months, with adjustment for the effects of age, lesion size, and presence of atrial fibrillation. Of 3035 patients recruited, 2099 had visible ischemic strokes limited to a single hemisphere on computed tomography/magnetic resonance scans. Of these, 566 and 714 had infarction of right and left insula. Six months after randomization, right insular involvement was associated with increased odds of death when compared with noninsular strokes on the left side (adjusted odds ratio, 1.83; 95% confidence interval, 1.33-2.52), whereas the adjusted odds ratio comparing mortality after insular versus noninsular strokes on the left side was not significant. Among mild/moderate strokes, outcomes for right insular involvement were worse than for left insular, but among more severe strokes, the difference in outcomes was less substantial. We found an association between right insular involvement and higher odds of death and worse functional outcome. The difference between right- and left-sided insular lesions on outcomes seemed to be most evident for mild/moderate strokes. URL: http://www.isrctn.com. Unique identifier: ISRCTN25765518.

Sex differences in the functional lateralization of emotion and decision making in the human brain.

Dating back to the case of Phineas Gage, decades of neuropsychological research have shown that the ventromedial prefrontal cortex (vmPFC) is crucial to both real-world social functioning and abstract decision making in the laboratory (see, e.g., Stuss et al., ; Bechara et al., 1994; Damasio et al., ). Previous research has shown that the relationship between the laterality of individuals' vmPFC lesions and neuropsychological performance is moderated by their sex, whereby there are more severe social, emotional, and decision-making impairments in men with right-side vmPFC lesions and in women with left-side vmPFC lesions (Tranel et al., 2005; Sutterer et al., 2015). We conducted a selective review of studies examining the effect of vmPFC lesions on emotion and decision making and found further evidence of sex-related differences in the lateralization of function not only in the vmPFC but also in other neurological structures associated with decision making and emotion. This Mini-Review suggests that both sex and laterality effects warrant more careful consideration in the scientific literature. © 2016 Wiley Periodicals, Inc.

Design and Implementation of a Prospective Adult Congenital Heart Disease Biobank.

Adults with congenital heart disease (ACHD) comprise a growing, increasingly complex population. The Boston Adult Congenital Heart Disease Biobank is a program for the collection and storage of biospecimens to provide a sustainable resource for scientific biomarker investigation in ACHD. We describe a protocol to collect, process, and store biospecimens for ACHD or associated diagnoses developed based on existing literature and consultation with cardiovascular biomarker epidemiologists. The protocol involves collecting urine and ∼48.5 mL of blood. A subset of the blood and urine undergoes immediate clinically relevant testing. The remaining biospecimens are processed soon after collection and stored at -80°C as aliquots of ethylenediaminetetraacetic acid (EDTA) and lithium heparin plasma, serum, red cell and buffy coat pellet, and urine supernatant. Including tubes with diverse anticoagulant and clot accelerator contents will enable flexible downstream use. Demographic and clinical data are entered into a database; data on biospecimen collection, processing, and storage are managed by an enterprise laboratory information management system. Since implementation in 2012, we have enrolled more than 650 unique participants (aged 18-80 years, 53.3% women); the Biobank contains over 11,000 biospecimen aliquots. The most common primary CHD diagnoses are single ventricle status-post Fontan procedure (18.8%), repaired tetralogy of Fallot with pulmonary stenosis or atresia (17.6%), and left-sided obstructive lesions (17.5%). We describe the design and implementation of biospecimen collection, handling, and storage protocols with multiple levels of quality assurance. These protocols are feasible and reflect the size and goals of the Boston ACHD Biobank.

Resection of highly language-eloquent brain lesions based purely on rTMS language mapping without awake surgery.

The resection of left-sided perisylvian brain lesions harbours the risk of postoperative language impairment. Therefore the individual patient's language distribution is investigated by intraoperative direct cortical stimulation (DCS) during awake surgery. Yet, not all patients qualify for awake surgery. Non-invasive language mapping by repetitive navigated transcranial magnetic stimulation (rTMS) has frequently shown a high correlation in comparison with the results of DCS language mapping in terms of language-negative brain regions. The present study analyses the extent of resection (EOR) and functional outcome of patients who underwent left-sided perisylvian resection of brain lesions based purely on rTMS language mapping. Four patients with left-sided perisylvian brain lesions (two gliomas WHO III, one glioblastoma, one cavernous angioma) underwent rTMS language mapping prior to surgery. Data from rTMS language mapping and rTMS-based diffusion tensor imaging fibre tracking (DTI-FT) were transferred to the intraoperative neuronavigation system. Preoperatively, 5days after surgery (POD5), and 3months after surgery (POM3) clinical follow-up examinations were performed. No patient suffered from a new surgery-related aphasia at POM3. Three patients underwent complete resection immediately, while one patient required a second rTMS-based resection some days later to achieve the final, complete resection. The present study shows for the first time the feasibility of successfully resecting language-eloquent brain lesions based purely on the results of negative language maps provided by rTMS language mapping and rTMS-based DTI-FT. In very select cases, this technique can provide a rescue strategy with an optimal functional outcome and EOR when awake surgery is not feasible.

Autosomal and X chromosome structural variants are associated with congenital heart defects in Turner syndrome: The NHLBI GenTAC registry.

Turner Syndrome (TS) is a developmental disorder caused by partial or complete loss of one sex chromosome. Bicuspid aortic valve and other left-sided congenital heart lesions (LSL), including thoracic aortic aneurysms and acute aortic dissections, are 30-50 times more frequent in TS than in the general population. In 454 TS subjects, we found that LSL are significantly associated with reduced dosage of Xp genes and increased dosage of Xq genes. We also showed that genome-wide copy number variation is increased in TS and identify a common copy number variant (CNV) in chromosome 12p13.31 that is associated with LSL with an odds ratio of 3.7. This CNV contains three protein-coding genes (SLC2A3, SLC2A14, and NANOGP1) and was previously implicated in congenital heart defects in the 22q11 deletion syndrome. In addition, we identified a subset of rare and recurrent CNVs that are also enriched in non-syndromic BAV cases. These observations support our hypothesis that X chromosome and autosomal variants affecting cardiac developmental genes may interact to cause the increased prevalence of LSL in TS. © 2016 Wiley Periodicals, Inc.

Central Nervous System and Cardiovascular Diseases

ABSTRACT Children with congenital heart diseases (CHD) are at increased risk of neurodevelopmental delay (NDD). In fetuses with CHD, blood streaming in the brain may be partially deoxygenated. Signs of cerebrovascular autoregulation comparable to the “brain-sparing effect” in growth-restricted fetuses may be shown in fetuses with CHD depending on the type of heart disease. This effect appears to be predominantly present in fetuses with left-side obstructive lesions (LSOL). During prenatal counseling, it is recommended to mention the possibility of an increased risk of NDD. The severity of this impairment varies from the type of CHD, being highest up to 40 to 45% in lesions with univentricular heart hemodynamics, such as hypoplastic left heart syndrome (HLHS). The prenatal life plays an important role in determining postnatal neurodevelopmental functions, but the severity of NDD in fetuses with CHD cannot be predicted prenatally. How to cite this article Arduini M. Central Nervous System and Cardiovascular Diseases. Donald School J Ultrasound Obstet Gynecol 2017;11(4):362-366.

EP 22. A sleep surgery of language eloquent brain lesions purely based on rTMS language mapping

Objective The resection of left-sided perisylvian brain lesions harbors the risk of postoperative language impairment. Hence, neurosurgeons determine the individual patient’s language distribution by using intraoperative direct cortical stimulation (DCS) during awake surgery. Yet, not all patients qualify for awake surgery. Since non-invasive language mapping by repetitive navigated transcranial magnetic stimulation (rTMS) has frequently shown a high correlation in comparison with the results of DCS language mapping in terms of language-negative brain regions, the present study analyzes oncological and functional outcome of patients who underwent left-sided perisylvian resection of brain lesions purely based on the results of rTMS language mapping. Methods Four patients (astrocytoma WHO grade III of the superior temporal gyrus, astrocytoma WHO grade III of the middle and inferior temporal gyrus, glioblastoma WHO IV of the opercular part of the frontal gyrus, and cavernoma of the insular lobe) underwent rTMS language mapping prior to surgery and data of rTMS language mapping were transferred to the intraoperative neuronavigation system. Preoperatively, 5 days after surgery (=POD5), and 3 months after surgery (=POM3) clinical follow-up was performed. Results No patient suffered from a new surgery-related aphasia. Three patients underwent complete resection immediately, while one patient required a second resection some days later. Conclusion Despite only presenting 4 patients, we could show the feasibility of successfully resecting language-eloquent brain lesions purely based on rTMS language mapping data as a rescue strategy in selected cases in which awake surgery is impossible. No patient was harmed and the extent of resection was oncologically optimal.

Hemispheric language dominance measured by repetitive navigated transcranial magnetic stimulation and postoperative course of language function in brain tumor patients

ObjectThe resection of left-sided perisylvian brain lesions harbors the risk of postoperative aphasia. Because it is known that language function can shift between hemispheres in brain tumor patients, the preoperative knowledge of the patient's language dominance could be helpful. We therefore investigated the hemispheric language dominance by repetitive navigated transcranial magnetic stimulation (rTMS) and surgery-related deficits of language function. MethodsWe pooled the bicentric language mapping data of 80 patients undergoing the resection of left-sided perisylvian brain lesions in our two university neurosurgical departments. We calculated error rates (ERs; ER = errors per stimulations) for both hemispheres and defined the hemispheric dominance ratio (HDR) as the quotient of the left- and right-sided ER (HDR >1= left dominant; HDR <1= right dominant). The course of the patient's language function was evaluated and correlated with the preoperative HDR. ResultsOnly three of 80 patients (4%) presented with permanent surgery-related aphasia and 24 patients (30%) with transient surgery-related aphasia. The mean HDR (± standard deviation) of patients with new aphasia after five days was significantly higher (1.68±1.07) than the HDR of patients with no new language deficit (1.37±1.08) (p=0.0482). With a predefined cut-off value of 0.5 for HDR, we achieved a sensitivity for predicting new aphasia of 100%. ConclusionA higher preoperative HDR significantly correlates with an increased risk for transient aphasia. Moreover, the intensive preoperative workup in this study led to a considerably low rate of permanent aphasia.

A single robotic session that guides or increases movement error in survivors post-chronic stroke: which intervention is best to boost the learning of a timing task?

Purpose: Timing deficits can have a negative impact on the lives of survivors post-chronic stroke. Studies evaluating ways to improve timing post stroke are scarce. The goal of the study was to evaluate the impact of a single session of haptic guidance (HG) and error amplification (EA) robotic training interventions on the improvement of post-stroke timing accuracy.Materials and methods: Thirty-four survivors post-chronic stroke were randomly assigned to HG or EA. Participants played a computerized pinball-like game with their affected hand positioned in a robot that either helped them perform better (HG) or worse (EA) during the task. A baseline and retention phase preceded and followed HG and EA, respectively, in order to assess their efficiency at improving absolute timing errors. The impact of the side of the stroke lesion on the participants’ performance during the timing task was also explored for each training group.Results: An improvement in timing performance was only noted following HG (8.9 ± 4.9 ms versus 7.8 ± 5.3 ms, p = 0.032). Moreover, for the EA group only, participants with a left-sided stroke lesion showed a worsening in performance as compared to those with a right-sided stroke lesion (p = 0.001).Conclusion: Helping survivors post-chronic stroke perform a timing-based task is beneficial to learning. Future studies should explore longer and more frequent HG training sessions in order to further promote post stroke motor recovery.Implications for RehabilitationTiming is crucial for the accomplishment of daily tasks.The number of studies dedicated to improving timing is scarce in the literature, even though timing deficits are common post stroke.This innovative study evaluated the impact of a single session of haptic guidance-HG and error amplification-EA robotic training interventions on improvements in timing accuracy among survivors post chronic stroke.HG robotic training improves timing accuracy more than EA among survivors post chronic stroke.

Clinical and Echocardiographic Factors Associated With In-Hospital Mortality in Patients With Infective Endocarditis Affecting the Native Tricuspid Valve

Infective endocarditis (IE) is a highly morbid disease, for which most outcomes data come from patients with left-sided valvular lesions. Echocardiographic findings such as vegetation size and prosthetic valve involvement have been identified as important predictors of mortality in left-sided IE, but predictors of outcomes in right-sided IE are less well characterized. Therefore, the aim of this study was to identify clinical and echocardiographic findings predictive of mortality in tricuspid valve (TV) IE. We retrospectively reviewed all echocardiograms showing TV vegetations that were performed at the Massachusetts General Hospital from January 1, 2003, to December 31, 2013. We identified 105 patients who had echocardiographic evidence of TV vegetations and a definite clinical diagnosis of IE based on the modified Duke's criteria but did not have intracardiac device-associated vegetations. Of the 105 patients, 88 survived until discharge. Clinical and echocardiographic factors that positively correlated with in-hospital mortality included age (p= 0.002), immunosuppression status (p= 0.016), blood urea nitrogen level (p= 0.029), Candida causative organism (p= 0.025), left ventricular ejection fraction <40% (p= 0.027), right ventricular (RV) systolic dysfunction (p= 0.009), and estimated RV systolic pressure >40mm Hg (p= 0.040). Of these factors, immunosuppression status, blood urea nitrogen level, and RV systolic dysfunction were independently associated with increased in-hospital mortality. In conclusion, RV systolic dysfunction may serve as an echocardiographic marker to aid clinicians in identifying high-risk patients with right-sided IE for more aggressive therapy.

Mania secondary to focal brain lesions: implications for understanding the functional neuroanatomy of bipolar disorder.

Approximately 3.5 million Americans will experience a manic episode during their lifetimes. The most common causes are psychiatric illnesses such as bipolar I disorder and schizoaffective disorder, but mania can also occur secondary to neurological illnesses, brain injury, or neurosurgical procedures. For this narrative review, we searched Medline for articles on the association of mania with stroke, brain tumors, traumatic brain injury, multiple sclerosis, neurodegenerative disorders, epilepsy, and neurosurgical interventions. We discuss the epidemiology, features, and treatment of these cases. We also review the anatomy of the lesions, in light of what is known about the neurobiology of bipolar disorder. The prevalence of mania in patients with brain lesions varies widely by condition, from <2% in stroke to 31% in basal ganglia calcification. Mania occurs most commonly with lesions affecting frontal, temporal, and subcortical limbic brain areas. Right-sided lesions causing hypo-functionality or disconnection (e.g., stroke; neoplasms) and left-sided excitatory lesions (e.g., epileptogenic foci) are frequently observed. Secondary mania should be suspected in patients with neurological deficits, histories atypical for classic bipolar disorder, and first manic episodes after the age of 40 years. Treatment with antimanic medications, along with specific treatment for the underlying neurologic condition, is typically required. Typical lesion locations fit with current models of bipolar disorder, which implicate hyperactivity of left-hemisphere reward-processing brain areas and hypoactivity of bilateral prefrontal emotion-modulating regions. Lesion studies complement these models by suggesting that right-hemisphere limbic-brain hypoactivity, or a left/right imbalance, may be relevant to the pathophysiology of mania.

The Predictive Value of Motor-Evoked Potentials and the Silent Period on Patient Outcome after Acute Cerebral Infarction

The predictive value of neurophysiologic assessment on patients' outcome after acute cerebral infarction is poorly understood. The aim of this study was to investigate the prognostic value of motor-evoked potentials (MEPs) and the silent period (SP) on clinical outcome. A total of 202 patients with acute cerebral infarction were prospectively recruited. MEP and SP were recorded from the abductor pollicis brevis of the affected side within 10 days after stroke onset. Patient outcome was measured as the dependency rate. Cortical MEP was induced in 78 patients whereas it was absent in 82 patients. The initial NIHSS (National Institutes of Health Stroke Scale) score was significantly lower in patients with MEP than in those without MEP (P < .001). Regression analysis demonstrated that a left-sided lesion (OR = .391, 95% CI .178-.858, P = .019), NIHSS at admission (OR = .826, 95% CI .744-.917, P < .001), and presence of MEP (OR = 3.918, 95% CI 1.770-8.672, P < .001) were independent predictors of outcome 3 months after stroke. Among patients with MEP, only the contralateral cortical SP value was significantly shorter in the good outcome subgroup (t = 2.541, P = .013). Receiver operating characteristic curve analysis demonstrated that SP was able to predict patients at higher risk of unfavorable outcome 3 months after stroke onset (area under the curve .721, 95% CI .58-.86, P = .008). These data suggested that MEP and SP were useful tools to predict patients' acute outcomes following cerebral infarction.

Feasibility of nTMS-based DTI fiber tracking of language pathways in neurosurgical patients using a fractional anisotropy threshold

BackgroundNavigated transcranial magnetic stimulation (nTMS) provides language maps in brain tumor patients. Yet, corresponding data on the visualization of language-related subcortical pathways is lacking. Therefore, this study evaluates the feasibility of nTMS-based diffusion tensor imaging fiber tracking (DTI FT) for subcortical language pathways by a fractional anisotropy (FA) protocol. New methodDTI FT was performed in 37 patients suffering from left-sided perisylvian brain lesions based on nTMS data exclusively, using the FA-based protocol originally established for the corticospinal tract (CST) by Frey et al. (2012): minimum fiber length was 110mm and the highest individual FA value leading to visualization of white matter tracts was determined as the FA threshold (FAT). Then, deterministic DTI FT using an FA value of 100%, 75%, 50%, and 25% of the individual FAT (with 25% as an additional setting to the original protocol) was performed. ResultsOur approach visualized 9 language-related subcortical white matter pathways. By using 100% FAT, the mean percentage of visualized tracts was 13.5%, whereas DTI FT performed with 75%, 50%, and 25% FAT detected 30.6%, 61.3%, and 93.7% of language-related fiber tracts, respectively. Comparison with existing methodsnTMS language mapping alone is not able to visualize subcortical language-related pathways. ConclusionsThis study shows that nTMS language maps are feasible for DTI FT of language-related pathways within the scope of a FAT-based protocol. Although this approach is novel and might be helpful during scientific neuroimaging and tumor resection, intraoperative validation is needed to go beyond the level of feasibility.

Synchronous Metastatic Skull Base Chordoma to the Breast: Case Report and Literature Review

During routine staging work-up for a left breast mass, a 68-year-old woman complained of dysphagia and dysphonia. During further investigations, a left-sided lesion at the foramen magnum was observed on brain imaging. Both lesions were biopsied and showed a classical chordoma. The skull-base lesion and the breast lesion were surgically resected, and adjuvant radiotherapy was given. Chordoma is a rare primary central nervous system tumour that seldom metastasizes. The lung is the most common site of metastasis. Synchronous breast metastasis from a skull-base chordoma is very rare, and a safe management option includes a maximum resection followed by adjuvant radiotherapy.