Left Stroke Research Articles

The effect of virtual reality on left and right middle cerebral artery chronic stroke patients

There is a considerable body of evidence around the use of non-immersive virtual reality as a therapeutic modality in stroke rehabilitation. Studies report its use in isolation, and as an adjunct to traditional physical therapy approaches. Very little is known about what effect the location of lesion and the participants’ stage of recovery can have on the efficacy of VR interventions. We present a study using non-immersive VR in two groups consisting of right-middle or left-middle cerebral artery stroke survivors in the chronic stage. Seventeen chronic stroke patients participated in this study. Participants performed 30 sessions of therapy with a Virtual Reality system supervised by a physiotherapist. A series of cognitive (MMSE), ADL (FIM and Barthel), motor (MAS, FMA upper an lower limb and MRC), gait (6MWT, Tineti), spasticity (Asworth), balance (Berg and Tinetti EQ) and depression (GDS) scales were administered to each group of right middle cerebral artery or left middle cerebral artery stroke survivors. Participants with lesions in the left middle cerebral artery had significant improvements when compared with pre- and post-scores in the Barthel, FMA lower an upper, Berg and Tinetti. Participants with right cerebral artery lesions showed significant improvements on the Barthel Index and Fugl-Meyer (lower extremity). We suggest that lateralization may be influencing the different outcomes reported between the right and left cerebral artery stroke groups in this study. We conclude that future VR motor rehabilitation strategies should consider the location of the lesion when designing interventions and call for additional research on this topic.

The Effect of Anterior Cingulate Cortex Direct Current Stimulation on Speech Monitoring Ability in Individuals with Aphasia: A Randomized, Double-Blinded Study

Background: Aphasia is characterized by language comprehension and production deficits and it also reduces the ability to spontaneously monitor speech errors. Recent concepts stress the role of medial frontal areas, especially the anterior cingulate cortex (ACC) in self-monitoring of speech. The current study mainly aimed at examining the effect of transcranial direct current stimulation (tDCS) over the ACC on speech monitoring abilities in individuals with aphasia. Methods: A randomized, sham-controlled, double-blind, within-subject study was designed to explore the involvement of ACC in individuals with non-fluent aphasia. Participants will be 20 patients with a left unilateral stroke for at least six months post onset of lesion classified as aphasic based on brain imaging reports, neurological exams, and the results of a Persian aphasia screening test. They are expected to be fluent in Farsi speaking before the stroke and be able to produce single words now. During four separate sessions, participants will perform four 108-item picture naming tasks in either the normal or noised-masked auditory conditions during anodal (20 minutes, 2 mA) or sham tDCS over the ACC. The interval between sessions will be at least seven days. Performance accuracy and the amount of self-monitoring behaviors will serve as primary outcome measures. Discussion: This will be the first study which explores the effects of tDCS over the ACC on the ability of individuals with aphasia to detect and repair error responses in both overt and inner speech situations. Results will be discussed in relation to recent self-monitoring concepts in speech production and available data about monitoring skills in aphasia.

Pulmonary arteriovenous malformations: endovascular therapy.

Pulmonary arteriovenous malformations (PAVM) are abnormal direct communications between the branches of pulmonary arteries and veins, and are often seen in patients with hereditary hemorrhagic telangiectasia (HHT). If untreated, the right to left shunt can result in symptoms of hypoxemia, paradoxical emboli to the left side circulation, stroke and intracranial abscess. Endovascular therapy is a minimally invasive outpatient based treatment wherein the feeding artery to the PAVM is occluded with coils or plugs or a combination of both and is associated with minimal morbidity and no mortality. In this manuscript, we will review the indications and contraindications for endovascular therapy, pre-procedural work up, procedure technique and variations, complications, and outcomes.

P.097 Subarachnoid hemorrhage associated with a thromboembolic ischemic stroke- an unexpected observation

Atherosclerosis is a significant risk factor for ischemic stroke, and is a frequent cause for extra- and intra-cranial vessels stenosis. Here, we present an unusual case of ischemic stroke associated with intra-cranial vessel stenosis and subarachnoid hemorrhage (SAH) secondary to carotid artery atheroma. A 64-year old female known for hypertension and dyslipidemia presented with a three-day history of three transient episodes (< 30 minutes) of dysarthria and right hand weakness. An initial brain CT scan revealed left frontal SAH. She was admitted to our Stroke Unit for observation and management. CT-angiogram revealed 90% ICAs stenosis bilaterally with several short focal stenotic lesions, involving several left MCA branches. Brain MRI revealed acute infarcts in the left insula, external capsule and inferior frontal gyrus. The clinical picture was attributed to a thromboembolic left MCA ischemic stroke. She was managed with maximum medical therapy, and later underwent successful left carotid endarterectomy. The presence of SAH on our patient’s presenting CT scan lead to an initial radiological diagnosis of RCVS. However, subsequent imaging studies indicated that SAH had occurred in association with a thromboembolic ischemic stroke. Despite its rarity, this clinical association is important to recognize to avoid diagnostic confusion and guide appropriate management.

Laterality of Poststroke Cortical Motor Activity during Action Observation Is Related to Hemispheric Dominance.

Background Increased activity in the lesioned hemisphere has been related to improved poststroke motor recovery. However, the role of the dominant hemisphere—and its relationship to activity in the lesioned hemisphere—has not been widely explored. Objective Here, we examined whether the dominant hemisphere drives the lateralization of brain activity after stroke and whether this changes based on if the lesioned hemisphere is the dominant hemisphere or not. Methods We used fMRI to compare cortical motor activity in the action observation network (AON), motor-related regions that are active both during the observation and execution of an action, in 36 left hemisphere dominant individuals. Twelve individuals had nondominant, right hemisphere stroke, twelve had dominant, left-hemisphere stroke, and twelve were healthy age-matched controls. We previously found that individuals with left dominant stroke show greater ipsilesional activity during action observation. Here, we examined if individuals with nondominant, right hemisphere stroke also showed greater lateralized activity in the ipsilesional, right hemisphere or in the dominant, left hemisphere and compared these results with those of individuals with dominant, left hemisphere stroke. Results We found that individuals with right hemisphere stroke showed greater activity in the dominant, left hemisphere, rather than the ipsilesional, right hemisphere. This left-lateralized pattern matched that of individuals with left, dominant hemisphere stroke, and both stroke groups differed from the age-matched control group. Conclusions These findings suggest that action observation is lateralized to the dominant, rather than ipsilesional, hemisphere, which may reflect an interaction between the lesioned hemisphere and the dominant hemisphere in driving lateralization of brain activity after stroke. Hemispheric dominance and laterality should be carefully considered when characterizing poststroke neural activity.

Differences in swallow physiology in patients with left and right hemispheric strokes.

We sought to determine the impact of lesion lateralization and lesion volume on swallow impairment on group-level by comparing patients with left and right hemisphere strokes and on patient-level by analyzing patients individually. We performed a retrospective, observational, cross-sectional study of 46 patients with unilateral (22 left, 24 right), acute, first-ever, ischemic strokes who received a diffusion weighted MRI (DW-MRI) and modified barium swallow study (MBSS) during their acute hospital stay. We determined lesion side on the DW-MRI and measured swallow physiology using the Modified Barium Swallow Impairment Profile (MBSImP™©), Penetration-Aspiration Scale (PAS), swallow timing, distance, area, and speed measures. We performed Pearson's Chi-Square and Wilcoxon Rank-Sum tests to compare patients with left and right hemisphere strokes, and Pearson or Spearman correlation, simple logistic regression, linear, and logistic multivariable regression modeling to assess the relationship between variables. At the group-level, there were no differences in MBSImP oral swallow impairment scores between patients with left and right hemisphere stroke. In adjusted analyses, patients with right hemisphere strokes showed significantly worse MBSImP pharyngeal total scores (p = 0.02), worse MBSImP component specific scores for laryngeal vestibular closure (Bonferroni adjusted alpha p ≤ 0.0029), and worse PAS scores (p = 0.03). Patients with right hemisphere strokes showed worse timing, distance, area, and speed measures. Lesion volume was significantly associated with MBSImP pharyngeal residue (p = 0.03) and pharyngeal total scores (p = 0.04). At the patient-level, 24% of patients (4 left, 7 right) showed opposite patterns of MBSImP oral and pharyngeal swallow impairment than seen at group-level. Our study showed differences in swallow physiology between patients with right and left unilateral strokes with patients with right hemisphere strokes showing worse pharyngeal impairment. Lesion lateralization seems to be a valuable marker for the severity of swallowing impairment at the group-level but less informative at the patient-level.

Influence of large hiatus hernia on cardiac volumes. A prospective observational cohort study by cardiovascular magnetic resonance

BackgroundLarge hiatus hernia (LHH) is often associated with post-prandial dyspnea, palpitations or chest discomfort, but its effect on cardiac volumes and performance is still debated. Methods and resultsBefore and 3-months after laparoscopic repair, 35 patients underwent cardiovascular magnetic resonance (CMR) in the fasting state and after a standardized meal. Preoperatively, LHH size increased significantly after meal (p < 0.010). Compared to the fasting state, a systematic trend of volume reduction of the cardiac chambers was observed. In addition, both the left ventricle stroke volume (p = 0.012) and the ejection fraction (p = 0.010) were significantly reduced. At 3-months after surgery there was a statistically significant increase in left atrial volume (p = 0.029), overall left ventricle volume (p < 0.05) and right ventricle end-systolic volume (p = 0.046). Both FEV1 (Forced expiratory volume) (p = 0.02) and FVC (Forced Vital Capacity) (p = 0.01) values significantly improved after surgery. Cardiorespiratory symptoms significantly improved compared to pre-operative values (p < 0.01). ConclusionsThe global heart function was significantly impaired by a standardized meal in the presence of a LHH. Restoration of the cardiac physiological status and improvement of clinical symptoms were noted after surgery. A multidisciplinary evaluation and CMR with a challenge meal may be added to routine pre-operative testing to select symptomatic patients for surgical hernia repair.

Tu1374 - Reduced Left Ventricular End-Diastolic Volume (LVEDV) and Stroke Volume (SV) but not Ejection Fraction (Ef) Seem Like Very Early Predictors of Severe Alcoholic Pancreatitis

Tu1374 - Reduced Left Ventricular End-Diastolic Volume (LVEDV) and Stroke Volume (SV) but not Ejection Fraction (Ef) Seem Like Very Early Predictors of Severe Alcoholic Pancreatitis

S72. Case of acute stroke after high-risk carotid surgery: Visual and quantitative EEG analysis

EEG monitoring in the intensive care unit (ICU) has multiple potential uses outside of seizure detection by providing a continuous noninvasive assessment of neurologic function. Since the early 1990s, EEG has been widely employed intraoperatively during carotid endarterectomy to evaluate for cerebral ischemia. Its utility in the ICU, however, is contingent on access to frequent review by an expert neurophysiologist. Several studies found that quantitative EEG (QEEG), particularly a decrease in the alpha/delta ratio (ADR), can be sensitive in screening for delayed cerebral ischemia after subarachnoid hemorrhage. QEEG monitoring may be useful in other situations during which monitoring for ischemia is critical. The EEG for this case was reviewed by three neurophysiologists. QEEG analysis was performed retrospectively with Persyst InsightII software. A 56-year-old right-handed man presented with acute expressive aphasia. Imaging revealed a left frontal stroke and >70% left internal carotid artery stenosis. Six weeks later, he underwent left carotid endarterectomy, complicated by a diseased vessel wall necessitating complete ligation of the artery. Post-operative neurologic exam was non-focal. He was sedated and placed on normothermia protocol in the ICU to prevent cerebral infarction. Visual EEG review initially showed gradually increasing intermittent left temporal slowing. Approximately 90 min later, acute persistent left hemispheric attenuation was seen, most prominent over the centro-posterior region, followed by a gradual increase in left hemispheric delta slowing. Subsequent neurologic exam off sedation revealed a new right hemiparesis; brain MRI showed an acute left middle cerebral artery infarct. QEEG showed immediate prominent and persistent decreases in delta, theta, and alpha power, as well as large reductions in the amplitude-integrated EEG (aEEG) over the left hemisphere. There was also a slight decline in beta power over the left. A delayed decrease in the ADR over the left side was seen approximately 20 min later. Visual EEG inspection in this case revealed acute lasting focal left hemispheric attenuation, with subsequent increased slowing after the time of presumed infarct. Interestingly, QEEG analysis showed simultaneous decreases in absolute power values and aEEG prior to change in the ADR. An automatic alarm system monitoring multiple QEEG parameters could therefore be helpful in monitoring for cerebral ischemia in the ICU, particularly when a trained neurophysiologist is not available.

Altered intra- and inter-network functional coupling of resting-state networks associated with motor dysfunction in stroke.

Motor functions are supported through functional integration across the extended motor system network. Individuals following stroke often show deficits on motor performance requiring coordination of multiple brain networks; however, the assessment of connectivity patterns after stroke was still unclear. This study aimed to investigate the changes in intra- and inter-network functional connectivity (FC) of multiple networks following stroke and further correlate FC with motor performance. Thirty-three left subcortical chronic stroke patients and 34 healthy controls underwent resting-state functional magnetic resonance imaging. Eleven resting-state networks were identified via independent component analysis (ICA). Compared with healthy controls, the stroke group showed abnormal FC within the motor network (MN), visual network (VN), dorsal attention network (DAN), and executive control network (ECN). Additionally, the FC values of the ipsilesional inferior parietal lobule (IPL) within the ECN were negatively correlated with the Fugl-Meyer Assessment (FMA) scores (hand + wrist). With respect to inter-network interactions, the ipsilesional frontoparietal network (FPN) decreased FC with the MN and DAN; the contralesional FPN decreased FC with the ECN, but it increased FC with the default mode network (DMN); and the posterior DMN decreased FC with the VN. In sum, this study demonstrated the coexistence of intra- and inter-network alterations associated with motor-visual attention and high-order cognitive control function in chronic stroke, which might provide insights into brain network plasticity following stroke.

Atypical ipsilateral Dejerine Roussy syndrome following a left thalamic ischemic stroke (P3.249)

Atypical ipsilateral Dejerine Roussy syndrome following a left thalamic ischemic stroke (P3.249)

Longitudinal layer-specific strain assessment of left ventricular systolic function of patients with coronary chronic total occlusion before and after revascularization

Objective To evaluate the longitudinal layer-specific strain of patients with coronary chronic total occlusion (CTO) before and 1 day after the percutaneous coronary intervention (PCI) by two-dimensional speckle tracking imaging (2D-STI), and then to explore the clinical value of PCI for patients with CTO. Methods A total of 30 patients diagnosed with CTO through coronary angiography and successfully taken the PCI procedure were enrolled in this study. Twenty-nine healthy volunteers were set as the control group. All patients were assigned to take echocardiography 1 day before and 1 day after PCI. The apical four-chamber (4CH), apical two-chamber (2CH) and the apical long-axis (APLAX) echocardiographic images of all subjects were acquired. Left ventricular end-diastolic volume (LVEDV), end-systolic volume (LVESV), ejection fraction (LVEF) and stroke volume (LVSV) were measured. The mitral annular lateral S′, septal S′ and average S′ by tissue Doppler imaging (TDI) were also measured. The longitudinal layer-specific strain was analysed by 2D-STI. Results Compared to the control group, CTO group showed a decreased endocardial, midcardial and epicardial longitudinal strain of 4CH, 2CH and APLAX (P 0.05). All the other measures showed no significant difference among the three groups (P>0.05). Conclusions The longitudinal strain of patients with CTO is decreased compared to that of healthy people and increased after PCI. Key words: Echocardiography; Coronary occlusion; Speckle tracking imaging; Ventricular function, left

Ischemic stroke induced myocardial dysfunction associated with nitro-oxidative stress and sympathetic overactivity

Complex interactions exist between cerebro- and cardiovascular diseases: while cardiac diseases are risk factors for cerebral ischemia, ischemic stroke may reciprocally induce heart dysfunctions. The aim of this study was to evaluate how prior cerebrovascular lesions may affect myocardial function and which signals are involved in these processes. Cerebral embolization was performed in adult Wistar male rats by the injection of microspheres into the left or right common carotid artery. Two or 24 hours after stroke or sham embolization, hearts were isolated and perfused ex vivo in the Langendorff mode. Two hours after stroke, the baseline left ventricular developed pressure of hearts from both stroke groups was diminished [106.6 ± 4.4 (left), 106.2 ± 4.7 (right) vs. 129.9 ± 2.7 (sham)] and 24 hours after surgery, the same alteration was observed [91.8 ± 3.7 (left), 104.0 ± 5.3 (right) vs. 120.9 ± 5.1 (sham)]. Echocardiographic measurements showed that left ventricular fractional shortening was altered from both stroke groups 2 hours [38.4 ± 0.4 (left), 38.1 ± 0.4 (right) vs. 41.5 ± 0.6 (sham)] and 7 days after surgery [38.2 ± 0.7 (left), 36.0 ± 0.7 (right) vs. 42.0 ± 0.5 (sham)]. Epinephrine, norepinephrine and growth differentiation factor 15 (GDF15) plasma levels were increased, 2 h after surgery, in rats from both stroke groups, as compared with sham operated. 24 h after surgery, catecholamine levels was also increased and GDF15 only for left stroke rats. Additionally, an increased expression of nitric oxide synthase-3 gene and protein was observed in hearts of stroke rats. Glutathione peroxidase-1 gene overexpression was also observed. To conclude, this study highlighted the deleterious consequences of stroke on cardiac function at different stroke time both ex vivo, in the isolated heart, and in vivo. The molecular mechanisms involved in these processes need to be further investigated in so far as they may involve the sympathetic nervous system and nitro-oxidative stress.

Cardiac voltage-gated sodium channel mutations associated with left atrial dysfunction and stroke in children

Cardiac atrial arrhythmias are the most common type of heart rhythm disorders. Its genetic elucidation remains challenging with poor understanding of cellular and molecular processes. These arrhythmias usually affect elderly population but in rare cases, young children may also suffer from such electrical diseases. Severe complications, including stroke, are commonly age related. This study aims to identify a genetic link between electro-mechanic atrial dysfunction and stroke in children. In two unrelated boys of 11 and 14 years with both stroke and atrial arrhythmias, the clinical phenotype was determined through a complete physical examination, electrocardiogram (ECG), Holter ECG, and computed tomography. The genetic testing was performed on a large 95 genes panel implicated in myocardial electrical imbalance, using the next generation sequencing method. The panel also includes the genes usually associated with the development of cardiomyopathies. In one child, a left atrial dilation was observed. The 2nd boy suffered from atrial standstill. Both suffered from atrial bradycardia, flutter, and fibrillation. The complete genetic testing revealed the SCN5A c.3823G>A (p.D1275N) mutation in the first family, c.1141-2A>G and c.3157G>A (p.E1053K) mutations in the second family. Our results strengthen the association between Nav1.5 mutations and the occurrence of stroke in young patients. It emphasizes the need to look for atrial myopathy in the decision process for anticoagulation in young patients with atrial arrhythmic events.

Efficacy of corrected left ventricular ejection time and stroke volume in guiding volume therapy during single lung transplantation: transesophageal Doppler monitoring

Objective To evaluate the efficacy of corrected left ventricular ejection time (LVETc) and stroke volume (SV) monitored by transesophageal Doppler in guiding volume therapy during single lung transplantation. Methods Twenty-six American Society of Anesthesiologists physical status Ⅲ or Ⅳ patients, aged 32-55 yr, with body mass index of 18.0-24.6 kg/m2, scheduled for elective single lung transplantation, were divided into 2 groups (n=13 each) using a random number table: control group (group C) and LVETc plus SV group (group LS). After implanting double lumen endobronchial tube, a transesophageal probe was inserted to monitor LVETc and SV in group LS, and Swan-Ganz catheter was inserted via the right internal jugular vein puncture to monitor CVP in group C. Fluid infusion was given according to CVP, and CVP was maintained at 6-12 cmH2O in group C. In group LS, fluid infusion was given according to LVETc and SV, LVETc was maintained at 0.35-0.40 s, and the fluctuation of SV was less than 10% of the baseline before fluid replacement.At 5 min before one-lung ventilation, 30 min of one-lung ventilation, 30 min of pulmonary artery occlusion and 30 min of pulmonary artery unclamping and at the end of operation, blood samples were collected from the radial artery for blood gas analysis, blood lactate levels were recorded, and oxygenation index was calculated.The liquid intake and output volume was recorded before pulmonary artery occlusion (from the end of one-lung ventilation until the time point before pulmonary artery occlusion), during pulmonary artery occlusion and during pulmonary artery unclamping (from removal of atrial clamp until the end of operation). The consumption of intraoperative furosemide and metaraminol was recorded.The development of pharyngeal mucosal membrane injury, esophageal perforation, hemorrhage or local hematoma was recorded after operation. Results Compared with group C, the oxygenation index was significantly increased and blood lactate concentrations were decreased at 30 min of pulmonary artery occlusion, 30 min of pulmonary artery unclamping and at the end of operation, the amount of crystalloid and colloid solution infused was increased before and during pulmonary artery occlusion and reduced during pulmonary artery unclamping, the urine output was increased in each period, and the consumption of intraoperative metaraminol was reduced in group LS (P<0.05). No postoperative esophageal perforation, bleeding or local hematoma was found in two groups, and only one patient had pharyngeal mucous membrane injury after operation in group LS. Conclusion LVETc and SV monitored by transesophageal Doppler can not only keep circulation capacity and tissue perfusion effective, but also maintain hemodynamics relatively stable during operation for patients undergoing single lung transplantation. Key words: Lung transplantation; Ventricular function, left; Stroke volume; Fluid therapy; Transesophageal, Doppler

Cardiorespiratory interactions in humans and animals: rhythms for life.

The cardiorespiratory system exhibits oscillations from a range of sources. One of the most studied oscillations is heart rate variability, which is thought to be beneficial and can serve as an index of a healthy cardiovascular system. Heart rate variability is dampened in many diseases including depression, autoimmune diseases, hypertension, and heart failure. Thus, understanding the interactions that lead to heart rate variability, and its physiological role, could help with prevention, diagnosis, and treatment of cardiovascular diseases. In this review, we consider three types of cardiorespiratory interactions: respiratory sinus arrhythmia (variability in heart rate at the frequency of breathing), cardioventilatory coupling (synchronization between the heart beat and the onset of inspiration), and respiratory stroke volume synchronization (the constant phase difference between the right and the left stroke volumes over one respiratory cycle). While the exact physiological role of these oscillations continues to be debated, the redundancies in the mechanisms responsible for its generation and its strong evolutionary conservation point to the importance of cardiorespiratory interactions. The putative mechanisms driving cardiorespiratory oscillations as well as the physiological significance of these oscillations will be reviewed. We suggest that cardiorespiratory interactions have the capacity to both dampen the variability in systemic blood flow as well as improve the efficiency of work done by the heart while maintaining physiological levels of arterial CO2. Given that reduction in variability is a prognostic indicator of disease, we argue that restoration of this variability via pharmaceutical or device-based approaches may be beneficial in prolonging life.

Depressed left and right ventricular cardiac output in fetuses of diabetic mothers

Introduction We compared right and left ventricular cardiac output (RVCO and LVCO) in fetuses of diabetic mothers (FDM) with a large normal cohort.Methods: We prospectively enrolled 264 normal fetuses and 30 FDM. Fetal CO parameters such as semilunar valve velocity time integrals (AVVTI, PVVTI), ventricular outflow diameters (LVOTD, RVOTD) and stroke volumes (AVSV, PVSV) were measured, and LVCO and RVCO were calculated. These were normalized using non-linear regression to estimated fetal weight (EFW) to provide means and standard deviations. Among FDMs, mean Z scores and 95% confidence limits (CL) were calculated and compared to zero.Results: LVCO, RVCO and parameters they were calculated from, increased predictably and non-linearly with increasing EFW. In FDM, LVCO was depressed (mean Z −1.679, 95% CL −2.404, −0.955, P < 0.001), and AVVTI, LVOTD and AVSV were significantly lower than normal. Similarly, RVCO (mean Z = −1.119, CL −1.839, −0.400, P = 0.003), RVOTD (mean −2.085, CL −3.077, −1.093, P < 0.001) and PVSV (mean −1.184, CL −1.921, −0.446, P = 0.003) were lower than normal, however, PVVTI was not different (mean Z 0.078, CL −0.552, +0.707, P = 0.803).Conclusion: Normal biventricular stroke volumes and outputs follow a non-linear regression with EFW. FDM have significantly lower right and left heart stroke volumes and outputs for weight than do normal fetuses.

Utility of Left Atrial Expansion Index and Stroke Volume in Management of Chronic Systolic Heart Failure

Titration of evidence-based medications, important for treating heart failure (HF), is often underdosed by symptom-guided treatment. The aim of this study was to investigate, using echocardiographic parameters, stroke volume and left ventricular (LV) filling pressure to guide up-titration of medications, increasing prognostic benefits. A total of 765 patients with chronic HF and severely reduced LV ejection fractions (<35%), referred from 2008 to 2016, were prospectively studied. Echocardiographic guidance was performed in 149 patients. LV filling pressure was assessed by left atrial expansion index, and stroke volume was estimated from diameter and time-velocity integral in the LV outflow tract. Up-titration of evidence-based medications and adjustment for side effects or worsening clinical conditions according to those parameters were performed. Propensity score matching was used to match pairs of patients with (n=110) or without (n=110) echocardiographic guidance. End points were 4-year frequencies of HF hospitalization and all-cause mortality. During a mean follow-up time of 4.1years, rates of adverse events were 58 (52.7%) with no echocardiographic guidance and 36 (32.7%) with echocardiographic guidance (P<.0001). Echocardiography provided effective guidance to reduce prescribing frequency and dose of diuretics and to promote evidence-based medication prescription. It reduced HF rehospitalization and all-cause mortality. By multivariate analysis, prognostic improvement was associated with up-titration of medications with echocardiographic guidance. There was a statistically significant difference in long-term prognosis between propensity score-matched pairs of patients with chronic severe HF with and without echocardiographic guidance. These findings need further validation in large prospective clinical trials.

Re-emergence of modular brain networks in stroke recovery

Studies of stroke have identified local reorganization in perilesional tissue. However, because the brain is highly networked, strokes also broadly alter the brain's global network organization. Here, we assess brain network structure longitudinally in adult stroke patients using resting state fMRI. The topology and boundaries of cortical regions remain grossly unchanged across recovery. In contrast, the modularity of brain systems i.e. the degree of integration within and segregation between networks, was significantly reduced sub-acutely (n = 107), but partially recovered by 3 months (n = 85), and 1 year (n = 67). Importantly, network recovery correlated with recovery from language, spatial memory, and attention deficits, but not motor or visual deficits. Finally, in-depth single subject analyses were conducted using tools for visualization of changes in brain networks over time. This exploration indicated that changes in modularity during successful recovery reflect specific alterations in the relationships between different networks. For example, in a patient with left temporo-parietal stroke and severe aphasia, sub-acute loss of modularity reflected loss of association between frontal and temporo-parietal regions bi-hemispherically across multiple modules. These long-distance connections then returned over time, paralleling aphasia recovery. This work establishes the potential importance of normalization of large-scale modular brain systems in stroke recovery.

Quantification of the left atrium applying cardiovascular magnetic resonance in clinical routine

Objectives. In recent years the impact of the left atrium (LA) has become more evident in different cardiovascular pathologies. We aim to provide LA parameters in healthy volunteers for cardiovascular magnetic resonance (CMR) using a fast approach. Design. We analyzed 203 healthy volunteers (mean age 44.6 years (y), range 19y–76y) at 1.5 and 3.0 Tesla (T) using steady-state free precession (SSFP) cine in routine long axis view. Left atrial enddiastolic volume (LA-EDV), endsystolic volume (LA-ESV), stroke volume (LA-SV) and ejection fraction (LA-EF) were quantified and indexed to body-surface-area (BSA). Dependency on age and sex was analyzed. Results. 21 subjects had to be excluded. In the remaining, there was no significant difference between 1.5 T and 3.0 T. Absolut LA-EDV and LA-ESV were larger in men than in women (LA-EDV: male 70 ± 19 ml vs. female 61 ± 16 ml (p = .001); LA-ESV: male 24 ± 9 ml vs. female 21 ± 8 ml (p = .01)). These differences disappeared after indexing to BSA (LA-EDV/BSA: male 34 ± 10 ml/m2 vs. female 33 ± 9 ml/m2 (p = .65) and LA-ESV/BSA: male 12 ± 4 ml/m2 vs. female 11 ± 4 ml/m2 (p = .71)). LA-EDV/BSA decreased with older age. Conclusions. Reference values for LA size and function based on a fast approach are provided. LA size decreases with older age. Normalization to body size overcomes sex-dependency. Reports should be related to body size.