Silent Lesions Research Articles

Altered Callosal Morphology and Connectivity in Asymptomatic Carotid Stenosis.

Carotid stenosis, even in the clinically asymptomatic stage, causes cognitive impairment, silent lesions, and hemispheric changes. The corpus callosum (CC) is crucial for hemispheric cortical integration and specialization. To examine if CC morphology and connectivity relate to cognitive decline and lesion burden in asymptomatic carotid stenosis (ACS). Retrospective, cross-sectional. 33 patients with unilaterally severe (70%) ACS and 28 demographically and comorbidity-matched controls. A publicly available healthy adult lifespan (ages between 18 and 80; n = 483) MRI dataset was also included. A 3.0 T; T1 MPRAGE and diffusion weighted gradient echo-planar imaging sequences. Structural MRI and multidomain cognitive data were obtained. Midsagittal CC area, circularity, thickness, integrity, and probabilistic tractography were calculated and correlated with cognitive tests and white matter hyperintensity. Fractional anisotropy, mean diffusivity (MD), and radial diffusivity were determined from DTI. Independent two-sample t-tests, χ2 tests, Mann-Whitney U, locally weighted scatterplot smoothing (LOWESS) curve fit, and Pearson correlation. A P value < 0.05 was considered statistically significant. Patients with ACS demonstrated significant reductions in callosal area, circularity, and thickness compared to controls. The callosal atrophy was significantly correlated with white matter hyperintensity size (r = -0.629, P < 0.001). Voxel-wise analysis of diffusion measures in the volumetric CC showed that ACS patients exhibited significantly lower fractional anisotropy and higher MD and radial diffusivity in the genu and splenium of the CC than controls. Further lifespan trajectory analysis showed that although the midsagittal callosal area, circularity, and thickness exhibited age-related decreases, the values in the ACS patients were significantly lower in all age groups. Midsagittal callosal atrophy and connectivity reflect the load of silent lesions and the severity of cognitive decline, respectively, suggesting that CC degeneration has potential to serve as an early marker in ACS. 3 TECHNICAL EFFICACY STAGE: 2.

Patent foramen ovale closure with the Occlutech Figulla flex II device: A long-term (up to 10-years) follow-up

BackgroundPercutaneous closure represents the first line of treatment in patients with cryptogenic stroke and documented patent foramen ovale (PFO). Scarce data report the long-term outcomes of patients undergoing PFO closure with the Figulla Flex II device (Occlutech, Germany). MethodsConsecutive patients undergoing PFO closure with a Figulla Flex II device at a single, high-volume Institution were included. Baseline clinical and procedural features were collected and patients were followed up for up to 10 years. The device's long-term safety was assessed, as well as mortality, recurrent cerebrovascular events, new-onset atrial fibrillation (AF) and residual shunt. ResultsOverall, 442 patients were included. The main indication for PFO closure was cryptogenic stroke/transitory ischemic attack (65.5%), followed by migraine (21.7%), silent lesions at MRI (10.8%), and decompression disease (2.0%). Atrial septal aneurysm was present in 20.8% of cases, Eustachian valve in 9.0%, Chiari network in 19.9%. The most frequently implanted device was the 23/25 mm (49.5% of cases). One procedural failure due to device embolization; in-hospital complications occurred in 15 cases (3.4%; 4 minor access site complications, 11 transient supraventricular tachycardias (SVT)/AF). After a follow-up of 9.2 years, 2 patients suffered recurrent TIA (with no residual R-L shunt detected). A moderate or severe residual shunt was observed in 3 patients after discharge. ConclusionsFigulla Flex II devices for PFO closure are associated with high procedural success and low incidence of adverse events even at long-term follow-up.

PREVALENCE AND DISEASE SPECTRUM OF FIBROMUSCULAR DYSPLASIA IN PATIENTS WITH SPONTANEOUS CEREBROVASCULAR ARTERY DISSECTION

Objective: Spontaneous cervical artery dissection (sCeAD) is the most frequent cause of ischemic stroke in young adults and has been associated to various arteriopathies, such as fibromuscular dysplasia (FMD). The aim of this study was to assess the prevalence of both cervical and extra-cervical FMD in patients with a diagnosis of CeAD. Design and method: All patients discharged from the Stroke Unit of A.O.U. Città della Salute e della Scienza of Turin from 2016 to 2020 with a diagnosis of CeAD underwent a contrast-enhanced CTA from chest to pelvis to look for FMD-related lesions (multifocal stenosis, aneurysms, dissections, arterial tortuosity). FMD diagnosis was assessed in the presence of at least a multifocal stenosis in one of the vascular beds explored. Results: Among 56 patients with spontaneous CeAD, 72.7% were male of middle age (52±8.5 y.o.). According to radiological findings, 43.2% of patients showed extra-cervical arterial lesions, with a prevalence of overall FMD (defined as the presence of at least a multifocal stenosis) reaching 47.3% of the studied sample and affecting carotid (36.4%), renal (18.9%), visceral (16.2%), iliac (22.2%) and coronary arteries (2.7%) respectively. Renal involvement included multifocal renal stenosis (13.5%) and arterial aneurysms (5.4%). Visceral involvement included multifocal stenosis (13.5%), visceral aneurysms (2.7%) and silent mesenteric artery dissection (5.4%). Iliac involvement included multifocal stenosis (2.7%), silent artery dissection (2.7%) and tortuosity (16.7%). Furthermore, two spontaneous dissections, one of the left external iliac artery and the other of the coeliac trunk, clinically asymptomatic, were reported in two males with no multifocal stenosis. Two women suffered also from SCAD. Multivascular extra-cervical involvement was observed in almost one third of the patients (27.0%) with sever lesions (multifocal high degree stenosis and/or arterial dissections) affecting 13.5% of the population. Conclusions: According to our results, we demonstrated that FMD is frequently associated to CeAD and that silent FMD-related lesions, even severe as arterial dissections, may coexist in such patients. Therefore, FMD should always be taken in consideration in the differential diagnosis of spontaneous arterial dissection, especially in young subjects without major cardiovascular risk factors.

Early anticoagulation in patients with stroke and atrial fibrillation is associated with fewer ischaemic lesions at 1 month: the ATTUNE study

BackgroundThe optimal time to commence anticoagulation in patients with atrial fibrillation (AF) after ischaemic stroke or transient ischaemic attack (TIA) is unclear, with guidelines differing in recommendations. A limitation of...

Incidence of silent cerebral lesions after pulmonary vein isolation with a novel radiofrequency balloon

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Speaker fees by Biosense Webster (not specific to this research) Background A novel radiofrequency balloon (RFB) is currently used for pulmonary vein isolation (PVI) in selected centres. The incidence of silent cerebral lesions (SCL) detected by magnetic resonance imaging (MRI) has already been researched for common energy sources such as the cryoballoon and irrigated-tip radiofrequency catheters. Purpose We aimed to investigate the incidence of SCL after RFB ablation. Methods 105 patients were treated with RFB PVI between December 2020 and November 2022. Cerebral MRI was performed in 38 unselected patients after a median of 1 day after the procedure. Neurological symptoms as well as size and location of SCL were assessed. The RFB allows for assessment of real time isolation using a spiral catheter which can be inserted through a central lumen of the balloon. During the investigated period the procedure underwent a streamlining process. Initially a 3D high resolution map of the left atrium (LA) was obtained before and after the ablation. To create this post-ablation map, the RFB had to be exchanged for a circumferential mapping catheter. After the first 50 procedures post-ablation re-mapping was omitted. This reduced the number of necessary catheter exchanges through the transseptal sheath. Results None of the patients developed neurological symptoms after the procedure. SCLs were detected in 28,9% (11) of patients. Analysis of patient baseline characteristics (gender, age, BMI, comorbidities, LA size, LVEF) as well as procedural data (procedure length, LA dwell time, ablation time, number of radiofrequency applications, cardioversion, activated clotting time) showed no significant independent predictor for SCL. We compared procedural data and SCL incidence prior to streamlining of the procedure (non-streamlined, NSL) to those after streamlining (SL). We observed a numerical difference in incidence of SCL between the NSL group (42,1%, 8 of 20) and the SL group (16,7%, 3 of 18), but the difference did not meet criteria for statistical significance (p = 0,159). Procedure time (NSL: 69.4 ± 10.8, SL: 51.1 ± 8.6, p = 0.009) and LA dwell time (NSL: 63.8 ± 10.9, SL: 45.8 ± 8.3, p = 0.009) were significantly shorter in the SL group. Conclusion This is the first report of the incidence and possible predictors of silent cerebral lesions after PVI with a novel radiofrequency balloon. We initially observed a higher-than-expected number of SCL. After streamlining of the procedure and especially reducing the necessary catheter exchanges this incidence dropped. It is now comparable to data of SCL after PVI with other technologies in our centre. This supports our assumption that the number of left atrial catheter exchanges might be an important factor for the development of SCL. Furthermore, this data emphasize the necessity of caution during the initial learning phase with new ablation devices. Further MRI after the procedure could reveal statistically significant predictors of SCL.

Assessment of Preoperative and Postoperative Cognitive Performance in Asymptomatic Patients Undergoing Carotid Endarterectomy: A Pilot Study

The association between vascular cognitive impairment and carotid stenosis and the possible improvements in vascular cognitive impairment favored by the intervention of carotid endarterectomy (CEA) have not yet been clearly defined. The aim of this pilot study was to prospectively evaluate whether cognitive functions can be influenced by carotid endarterectomy performed in patients with asymptomatic severe carotid stenosis. From January to August 2022, 105 consecutive CEAs were performed in patients with severe asymptomatic carotid stenosis at our institution. Of these, 28 provided informed consent for inclusion in the study and were therefore enrolled, representing our study group. The evaluation of the cognitive functions was made by using the Montreal Cognitive Assessment (MoCA), which was administered to the participants at the moment of the preoperative anesthesiologic assessment, usually between 1 and 7 days prior to surgery. Following the intervention and within the third postoperative month, a clinical and instrumental control visit was performed and during that visit the MoCA questionnaire was again administered to the patients. A comparison between the mean corrected pre- and postoperative values of the MoCA questionnaire was performed using Student t test. Multivariate analysis for the factors affecting the lack of postoperative improvement was performed. Patients were more frequently male (18 patients, 64%) with a mean age of 74.4 ± 7.9 years. The mean MoCA test value in the preoperative was 22.68 ± 3.34, thus slightly below the threshold value for identifying the presence of cognitive impairment. The distribution of the values followed a normal pattern. There were nor perioperative deaths neither neurological events. All the patients had their 3-month reevaluation; no neurological events were detected in this period. At the three-month follow-up, the mean MoCA test score was 23.4 ± 3.4, with a statistical trend toward significant improvement (P = .08; 95% confidence interval, −1.8 to 0.34). The most noticeable improvements were found in the visuospatial, language and abstraction domains, while they were less marked in the domains of attention and memory. Multivariate analysis for the factors affecting the lack of postoperative improvement showed a trend toward worse results in diabetic patients, in those with silent ipsilateral brain lesions and in those on neuropsychiatric drug therapy. Our pilot study, consistently with the literature, confirmed a mild cognitive improvement after CEA performed in asymptomatic patients; however, larger studies with a higher number of patients and a longer follow-up are necessary before considering the possibility of suggesting CEA in order to prevent or reverse cognitive decline.

Cerebral Embolic Protection Devices: Current State of the Art.

Transcatheter aortic valve replacement (TAVR) has become a first-line treatment for severe aortic stenosis with intermediate to high-risk population with its use increasingly expanding into younger and low-risk cohorts as well. Cerebrovascular events are one of the most serious consequential complications of TAVR, which increase morbidity and mortality. The most probable origin of such neurological events is embolic in nature and the majority occur in the acute phase after TAVR when embolic events are most frequent. Cerebral embolic protection devices have been designed to capture or deflect these emboli, reducing the risk of peri-procedural ischaemic events. They also carry the potential to diminish the burden of new silent ischemic lesions during TAVR. Our review explores different types of these device systems, their rationale, and the established clinical data.

Ascending colon malignancy presenting as large bowel obstruction: a rare case report

Colorectal cancer is the third most common cancer in both men and women and the fourth most common cause of cancer related deaths. It can be classified as sporadic (70%), inherited (5%) and familial (25%), various genetic pathways are involved. Carcinomas of right colon are known to be relatively silent lesion producing non-specific symptoms like fatigue, weakness, and vague lower abdominal pain. Whereas, left colon carcinomas are frequently more dramatic presenting as altered bowel habits, bloody mucoid stools, and obstruction. Most importantly almost 50% of left sided cancers present as a palpable growth of lower rectum. Emergency right hemicolectomy is the treatment of choice for an obstructing right colon malignancy, options varies from open/lap right hemicolectomy with a primary ileo-transverse anastomosis in a stable patient with or without diverting ileostomy or placement of endoluminal self-expanding metallic stent (SEMS). Here we present a case 47 year old female who presented with abdominal pain and vomiting for 2 days and was diagnosed with mid ascending colon growth with distended caecum and proceeded with emergency laporotomy. Intraoperatively circumferential constrictive growth seen in ascending colon with impending perforation in caecum and was subjected to a right hemicolectomy with end-to-end ileo-transverse anastomosis with an uneventful post-operative period.

Correlation between the Clinical Course of CRMO Lesions and the Imaging Characteristics on Follow-up MRIs

Objective: To evaluate the correlation between the clinical course of chronic recurrent multifocal osteomyelitis (CRMO) lesions and their imaging characteristics on follow-up MRIs. Material and Methods: Two musculoskeletal fellowship-trained radiologists retrospectively reviewed the initial and follow-up MRI images of 9 CRMO patients who were treated in our institution from 2008 to 2018. Evaluation of clinical course was based on symptomatology, lab results and physical examination and was compared to MRI findings, on follow-up MRIs. Results: Thirty-five CRMO lesions in 9 patients were identified. Patient’s ages ranged from 4 to 15 years with a mean age of 10 years (S.D.±3.22). Six of the 9 patients were female. Only 21 of 35 lesions had been longitudinally followed by MRI. Of the 39 follow-up MRI exams, there was clinical improvement 15 times, and 24 times there was no clinical improvement confirmed by the clinician. Three MRI features: 1) bone marrow edema (BME) size, 2) BME signal intensity and 3) periosteal edema, significantly correlated with the clinical course (p-value&lt;0.001). When there was the improvement of all these three findings, the correlation with clinical improvement was high with 80% sensitivity and 100% specificity. The area under the receiver operator characteristic curve was 0.90 (95% confidence interval 0.795-1.005). Fourteen silent clinical lesions were also identified. Conclusion: Bone marrow edema and periosteal edema correlated best with the clinical course of CRMO patients on follow-up MRIs.

Reader Response: Frequency of Asymptomatic Optic Nerve Enhancement in a Large Retrospective Cohort of Patients With Aquaporin-4+ NMOSD.

This study by Shah et al. demonstrated that asymptomatic optic nerve enhancement could occur in optic neuritis (ON) patients.1 For multiple sclerosis, silent lesions on MRI have diagnostic and prognostic values and are used in disease monitoring.2 However, the frequency of new silent lesions (including asymptomatic ON, myelitis, and brain lesions) and their association with future relapse in aquaporin-4 antibody neuromyelitis optica spectrum disorder remain unclear.1,3,4 The authors indicated that optic nerve enhancement at the site of prior attacks with shorter lesion length presumably represented intermittent blood-brain barrier breakdown; however, recurrent ON cannot be completely ruled out, especially when it has been a long time since the last attack. New asymptomatic lesions in 2 scans could be subclinical relapses and often require acute therapeutic intervention.

Editors' Note: Frequency of Asymptomatic Optic Nerve Enhancement in a Large Retrospective Cohort of Patients With Aquaporin-4+ NMOSD.

In “Frequency of Asymptomatic Optic Nerve Enhancement in a Large Retrospective Cohort of Patients With Aquaporin-4+ NMOSD,” Shah et al. reported that 17% of patients with Aquaporin-4+ NMOSD have asymptomatic optic nerve enhancement, predominantly at the site of prior optic neuritis. They suggested that this could represent intermittent blood-brain barrier breakdown or subclinical optic neuritis. Cao et al. noted that it is unclear whether asymptomatic enhancement is associated with an increased risk of relapse, given silent lesions have both diagnostic and prognostic value in multiple sclerosis. Chen and Shah responded that the number of recurrent attacks was the same for both patients with and without asymptomatic optic nerve enhancement, suggesting this is not a risk factor for relapse. They speculated that the varying prognostic value of enhancement of the optic nerve, as compared with the brain and spinal cord, may be attributed to blood-brain barrier differences, but noted additional studies that include imaging of all 3 parts of the neuroaxis are needed to explore this further. The findings of this study suggest that NMOSD may be a more continuous inflammatory disorder than previously thought. In “Frequency of Asymptomatic Optic Nerve Enhancement in a Large Retrospective Cohort of Patients With Aquaporin-4+ NMOSD,” Shah et al. reported that 17% of patients with Aquaporin-4+ NMOSD have asymptomatic optic nerve enhancement, predominantly at the site of prior optic neuritis. They suggested that this could represent intermittent blood-brain barrier breakdown or subclinical optic neuritis. Cao et al. noted that it is unclear whether asymptomatic enhancement is associated with an increased risk of relapse, given silent lesions have both diagnostic and prognostic value in multiple sclerosis. Chen and Shah responded that the number of recurrent attacks was the same for both patients with and without asymptomatic optic nerve enhancement, suggesting this is not a risk factor for relapse. They speculated that the varying prognostic value of enhancement of the optic nerve, as compared with the brain and spinal cord, may be attributed to blood-brain barrier differences, but noted additional studies that include imaging of all 3 parts of the neuroaxis are needed to explore this further. The findings of this study suggest that NMOSD may be a more continuous inflammatory disorder than previously thought.

Asymptomatic carotid stenosis is associated with both edge and network reconfigurations identified by single-subject cortical thickness networks.

Patients with asymptomatic carotid stenosis, even without stroke, are at high risk for cognitive impairment, and the neuroanatomical basis remains unclear. Using a novel edge-centric structural connectivity (eSC) analysis from individualized single-subject cortical thickness networks, we aimed to examine eSC and network measures in severe (> 70%) asymptomatic carotid stenosis (SACS). Twenty-four SACS patients and 24 demographically- and comorbidities-matched controls were included, and structural MRI and multidomain cognitive data were acquired. Individual eSC was estimated via the Manhattan distances of pairwise cortical thickness histograms. In the eSC analysis, SACS patients showed longer interhemispheric but shorter intrahemispheric Manhattan distances seeding from left lateral temporal regions; in network analysis the SACS patients had a decreased system segregation paralleling with white matter hyperintensity burden and recall memory. Further network-based statistic analysis identified several eSC and subgraph features centred around the Perisylvian regions that predicted silent lesion load and cognitive tests. We conclude that SACS exhibits abnormal eSC and a less-optimized trade-off between physical cost and network segregation, providing a reference and perspective for identifying high-risk individuals.

Evaluation of the association between silent ischemic lesions and stent design in carotid stenting applications

Minor ischemic events and silent ischemic lesions are more common in carotid stenting than in endarterectomy. These silent ischemic lesions are also associated with stroke risk and cognitive impairment, so it is important to understand the factors that increase the risk and develop strategies to reduce the risk. We aimed to evaluate the association between carotid stent design and silent ischemic lesion development. The files of the patients who underwent carotid stenting between January 2020 and April 2022 were scanned. Patients with diffusion MR images taken within the postoperative 24 h were included in the study, while those undergoing acute stent placement were excluded. The patients were divided into two groups: those with open-cell stents and those with closed-cell stents. A total of 65 patients, including 39 patients undergoing open-cell stenting and 26 patients undergoing closed-cell stenting, were included in the study. There was no significant difference in demographic data and vascular risk factors between the groups. New ischemic lesions were detected in 29 (74.4%) patients in the open-cell stent group and 10 (38.4%) patients in the closed-cell stent group and were significantly higher in the open-cell group. There was no significant difference between the two groups in terms of major and minor ischemic events and stent restenosis at the 3-month follow-up. The rate of new ischemic lesion development was found to be significantly higher in carotid stent procedures performed with an open-cell Protégé stent than in those performed with a closed-cell Wallstent stent.

Risk Factors for the Occurrence of Asymptomatic Brain Lesions in Patients with β-Thalassemia: a Systematic Review and Meta-Analysis.

Several factors, including increased platelet aggregation, decreased platelet survival, decreased antithrombotic factors cause a hypercoagulable state in thalassemia patients. This is the first meta-analysis designed to summarize the association of age, splenectomy, gender, and serum ferritin and hemoglobin levels with the occurrence of asymptomatic brain lesions in thalassemia patients using MRI. This systematic review and meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. We searched four major databases and included eight articles for this review. The quality of the included studies was assessed based on the Newcastle-Ottawa Scale checklist. Meta-analysis was performed using STATA 13. Odds ratio (OR) and standardized mean difference (SMD) were considered as effect sizes for comparing the categorical and continuous variables, respectively. The pooled OR for splenectomy in patients with brain lesions compared to those without lesions was 2.25 (95% CI 1.22 - 4.17, p = 0.01). The pooled analysis for SMD of age between patients with/without brain lesions was statistically significant, 0.4 (95% CI 0.07 - 0.73, p = 0.017). The pooled OR for the occurrence of silent brain lesions was not statistically significant in males compared to females, 1.08 (95% CI 0.62 - 1.87, p = 0.784). The pooled SMD of Hb and serum ferritin in positive brain lesions compared to negatives were 0.01 (95% CI -0.28, 0.35, p = 0.939) and 0.03 (95% CI -0.28, 0.22, p = 0.817), respectively, which were not statistically significant. Older age and splenectomy are risk factors for developing asymptomatic brain lesions in β-thalassemia patients. Physicians should consider a careful assessment of high-risk patients for starting prophylactic treatment.

Incidence, clinical, and imaging presentation of orbital metastasis over 20 years in a tertiary eye care center in Egypt

Purpose The aim of this study was to review the demographic, clinical, and imaging features of Egyptian patients with orbital metastases. Patients and methods This is a retrospective study of 66 patients with orbital metastatic lesions over the last 20 years (January 2000–December 2019). The ophthalmological reports and radiological images of the included patients were reviewed. Results The study included 66 patients: 34 males and 32 females. The primary tumors were breast carcinoma in 25.8% of the patients, hepatocellular carcinoma in 15.2%, and cutaneous malignant melanoma in 7.6% of the patients. The most common primary tumor in children was neuroblastoma (58.3%). In 22 (33.3%) patients, there was no history of cancer, and the orbital metastatic lesion was the first presentation. Diplopia and limited ocular movements were the presenting feature in 38 (57.6%) patients, proptosis and/or globe displacement in 32 (48.5%) patients, blurred vision in 12 (18.2%) patients, pain in nine (13.6%) patients, enophthalmos in six (9.1%) cases, ptosis in five (7.6%) cases, and inflammatory manifestations in four (6.1%) patients. In 60 (91%) patients, the lesion was unilateral and only six (9%) cases had bilateral lesions. Orbital imaging showed infiltrative lesion in 36.4%, mass lesion in 33.3%, isolated muscle thickening in 10.6%, and bone changes in 39.4% of the patients. The observed incidence of orbital metastasis increased from 13.6% during 2000–2004 to 43.9% in 2015–2019. Conclusion The incidence of orbital metastatic lesions increased dramatically through the last two decades. Moreover, this may be underestimated due to undiagnosed small silent lesions. Breast carcinoma ranked as the first primary tumor followed by hepatocellular carcinoma, probably owing to the high prevalence of hepatitis C virus among the Egyptian population.

A single-center pilot randomized controlled trial of atorvastatin loading for preventing ischemic brain damage after carotid artery stenting.

Carotid artery stenting (CAS) performed perioperatively with high-dose atorvastatin may reduce the incidence of new ischemic brain lesions, but more high-level evidence is needed. Furthermore, the optimal dose and course of perioperative statin therapy remain uncertain. A single-center, prospective, parallel controlled, pilot randomized clinical trial was conducted at Beijing Hospital. The study includes a total of 130 patients with CAS. The patients were randomly assigned to receive a high-dose of 80 mg/day atorvastatin (n = 65) or a standard-dose of 20 mg/day atorvastatin (n = 65) 3 days before and 3 days after planned CAS. The primary endpoint event was the cumulative incidence of silent new ischemic cerebral lesions (sNICL) on post-CAS cerebral diffusion-weighted magnetic resonance imaging (DW-MRI), transient ischemic attack (TIA), or ischemic stroke within 30 days after CAS. Among the 130 patients, 123 completed the study, of which 63 were in the high-dose group and 60 were in the standard-dose group. The incidence of major endpoint events was 69.8% (44 cases) and 78.3% (46 cases) in the high-dose and standard-dose groups, respectively. There was no significant difference between the two groups (HR, 0.705; 95% CI, 0.315-1.576; p = 0.393). According to the stratified analysis results, the sNICL incidence was significantly different between the two groups in the symptomatic patients (HR, 0.263; 95% CI, 0.70-0.984; p = 0.04). Among patients with CAS, a periprocedural high-dose of atorvastatin did not reduce the rate of periprocedural ischemic brain damage. However, high-dose statins can reduce the incidence of sNICL after CAS in patients with symptomatic carotid stenosis. Clinicaltrials.gov, identifier NCT03079115.

A case report on a rare presentation of adrenal myelolipoma with low-impact traumatic haemorrhage and the challenges of conservative management

Adrenal myelolipomas are rare, hormonally silent, adipose and myeloid-containing lesions that are mostly asymptomatic. If they do present it is usually with mass-related flank pain or spontaneous haemorrhage. A 55-year-old female presented with right flank pain after a fall from a static pushbike. Computer tomography identified a large adrenal lesion with surrounding acute retroperitoneal haemorrhage. A conservative approach to treatment was decided on as the patient remained haemodynamically stable. The patient developed a pulmonary embolism during the time of conservative management and therefore had to be anticoagulated with close monitoring. Outpatient surveillance imaging was reassuring, hormonal screening was negative and biopsy confirmed myelolipoma. We report a rare presentation of adrenal myelolipoma with the sequelae of haemorrhage from low-impact trauma and the challenges of conservative management.

Abstract 14123: AF Ablation Using a Novel “Single-Shot” Map-and-Ablate Spherical Array Pulsed Field Ablation Catheter: Impact of Application Repetition on PV Isolation Durability in the PULSE-EU Study

Introduction: Preclinical studies have revealed that pulse field ablation (PFA) lesion dimension increases with consecutive applications at a similar electric field. Whether durability of pulmonary vein isolation (PVI) is predicated on repetitive PFA applications is unknown. In the first-in-human PULSE-EU clinical trial (NCT05164107), the ability of this map-and-ablate PFA catheter to achieve durable PVI was assessed, both with single vs repetitive PFA applications. Methods: Under general anesthesia, paroxysmal AF pts underwent PVI using the spherical array PFA catheter (Globe; Kardium Inc, Canada) delivered with a deflectable 19Fr transeptal sheath and ICE-guidance. Using a custom mapping system, the PFA catheter rendered contact and voltage anatomic maps ( Figure ). The spherical array is positioned at the PV ostium and PFA is performed (1.6-2 kV/lesion, ungated 3s pulses). Follow-up was post-procedure EGD and brain MRI within 1 day, and invasive remapping at ⁓2 months. Results: A total of 21 pts (age 63±11 years; M/F 33%/67%) underwent PVI in 2 groups: Gp1-single PF application/PV, and Gp2-3 PF applications/PV. In Gp1 (n=11 pts) and Gp2 (n=10 pts), PVI was acutely successful in 100% of PVs in both groups. Pulse delivery times and total procedure times were 75.2±7.4 sec/pt vs 24.5±5.5 sec/pt and 73.2±13.7 mins​ vs 93.7±18.5 mins​ in Gp2 vs Gp1. There was no stroke/TIA, pericardial effusion, phrenic nerve injury, or esophageal complications. EGD was normal in all 9/9 pts. Brain MRI showed silent cerebral lesions (DWI+/FLAIR-) in 3/16 (18.8%) pts. PV remapping revealed durable PVI in 25/40 (62.5%) PVs in 10 pts in Gp1, compared with all 34/34 (100%) PVs in 9 pts in Gp2; this translates to all PVs being durably isolated in 27% vs 100% (p&lt;0.05) of pts in Gp1 and Gp2. Conclusion: The “single-shot” map-and-ablate spherical array PFA catheter can safely isolate PVs. Repetitive PFA applications is key for lesion consolidation to improve PVI durability.

Cerebral safety after pulsed field ablation for paroxysmal atrial fibrillation.

Pulsed field ablation (PFA) is a novel, nonthermal ablation modality that can ablate myocardial tissue with minimal effects on surrounding tissue. Preclinical data show an absence of cerebral emboli after extensive PFA. However, clinical data on silent cerebral lesions (SCLs) and/or silent cerebral events (SCEs) after PFA are lacking. The purpose of this study was to investigate the occurrence of neurological deficits and SCL and/or SCE after PFA in paroxysmal atrial fibrillation (AF) using National Institutes of Health Stroke Scale (NIHSS) scores and magnetic resonance imaging (MRI). In patients with symptomatic paroxysmal AF, pulmonary vein isolation (PVI) using PFA was performed. NIHSS scores were assessed before and 2 days and 30 days after PVI. One day after PVI, patients underwent cerebral 1.5-T MRI scanning using diffusion-weighted imaging and fluid-attenuated inversion recovery sequences to document the occurrence of SCL/SCE. PFA was performed in 30 patients (age 63 ± 10 years). No patient showed neurological deficits. All NIHSS scores showed the minimum value of 0. Cerebral MRI scans were normal in 29 of 30 patients (97%). In 1 patient (3%), a single 7-mm cerebellar lesion was observed. Forty days after the procedure, follow-up cerebral MRI scan showed complete regression of the lesion. In patients treated with PFA for symptomatic paroxysmal AF, the incidence of MRI-detected asymptomatic thromboembolic cerebral events or lesions was as low as 3%. No neurological deficits occurred in any of the patients.

Metabolomics detects clinically silent neuroinflammatory lesions earlier than neurofilament-light chain in a focal multiple sclerosis animal model

BackgroundDespite widespread searches, there are currently no validated biofluid markers for the detection of subclinical neuroinflammation in multiple sclerosis (MS). The dynamic nature of human metabolism in response to changes in homeostasis, as measured by metabolomics, may allow early identification of clinically silent neuroinflammation. Using the delayed-type hypersensitivity (DTH) MS rat model, we investigated the serum and cerebrospinal fluid (CSF) metabolomics profiles and neurofilament-light chain (NfL) levels, as a putative marker of neuroaxonal damage, arising from focal, clinically silent neuroinflammatory brain lesions and their discriminatory abilities to distinguish DTH animals from controls.Methods1H nuclear magnetic resonance (NMR) spectroscopy metabolomics and NfL measurements were performed on serum and CSF at days 12, 28 and 60 after DTH lesion initiation. Supervised multivariate analyses were used to determine metabolomics differences between DTH animals and controls. Immunohistochemistry was used to assess the extent of neuroinflammation and tissue damage.ResultsSerum and CSF metabolomics perturbations were detectable in DTH animals (vs. controls) at all time points, with the greatest change occurring at the earliest time point (day 12) when the neuroinflammatory response was most intense (mean predictive accuracy [SD]—serum: 80.6 [10.7]%, p < 0.0001; CSF: 69.3 [13.5]%, p < 0.0001). The top discriminatory metabolites at day 12 (serum: allantoin, cytidine; CSF: glutamine, glucose) were all reduced in DTH animals compared to controls, and correlated with histological markers of neuroinflammation, particularly astrogliosis (Pearson coefficient, r—allantoin: r = − 0.562, p = 0.004; glutamine: r = − 0.528, p = 0.008). Serum and CSF NfL levels did not distinguish DTH animals from controls at day 12, rather, significant differences were observed at day 28 (mean [SEM]—serum: 38.5 [4.8] vs. 17.4 [2.6] pg/mL, p = 0.002; CSF: 1312.0 [379.1] vs. 475.8 [74.7] pg/mL, p = 0.027). Neither serum nor CSF NfL levels correlated with markers of neuroinflammation; serum NfL did, however, correlate strongly with axonal loss (r = 0.641, p = 0.001), but CSF NfL did not (p = 0.137).ConclusionsWhile NfL levels were elevated later in the pathogenesis of the DTH lesion, serum and CSF metabolomics were able to detect early, clinically silent neuroinflammation and are likely to present sensitive biomarkers for the assessment of subclinical disease activity in patients.