Urgent Endovascular Aortic Repair Requiring Coverage of the Left Subclavian Artery.

BACKGROUND: Evaluation of the optimal left subclavian artery (LSA) management during thoracic endovascular aortic repair (TEVAR) involving the distal aortic arch in an urgent setting. METHODS: A total of 52 patients with acute aortic syndromes underwent TEVAR (March 2017 to May 2021) requiring proximal landing in the distal aortic arch. Decision for partial or complete LSA ostial endograft coverage, with or without additional bypassing, was made depending upon the aortic pathology and vascular anatomy. We focused on the patency of the circle of Willis and the unilateral dominance of one carotid or a vertebral artery: 35% underwent complete (complete LSA group) and 17% partial LSA coverage (partial LSA group), whereas in 48% the LSA was reached only by the bare springs of the endograft (control group). A total of 22% of the complete LSA group underwent LSA bypass before TEVAR, whereas 11% underwent cerebrospinal fluid drainage. Endpoints were 30-day and 1-year mortality, stroke, spinal cord ischemia (SCI), and malperfusion. RESULTS: Technical success was achieved in 96%. The endograft length was 171 ± 34 (complete LSA group) versus 151 ± 22 (partial LSA group) versus 181 ± 52 mm (control group), covering 6 ± 2 versus 5 ± 1 versus 7 ± 2 intercostal arteries. The 30-day mortality, stroke and SCI rates did not differ. One patient with arm malperfusion underwent LSA bypass post-TEVAR. After 1 year, aortic interventions occurred in 6 (complete LSA group) versus 22 (partial LSA group) versus 13% (control group). One-year mortality (0 vs. 0 vs. 8%), stroke (6 vs. 0 vs. 4%), and SCI (0 vs. 0 vs. 4%) were similar between groups. CONCLUSION: With an adequate analysis of vascular anatomy, coverage of the LSA for TEVAR is safe and may offer results similar to TEVAR starting distal to the LSA.

Instability and results after non-operative treatment of large anterior glenoid rim fractures: is there a correlation between fragment size or displacement and recurrence?

INTRODUCTION: There is little data available on non-operative treatment of anterior glenoid rim fractures (GRF). Nothing is known about fracture size and displacement in comparison to clinical outcomes and instability in a mainly middle-aged patient population. The aim of this study was to demonstrate the results of non-operative treatment in anterior glenoid rim fractures with the special focus on potential instability/recurrence. METHODS: The inclusion criteria were non-operatively treated anterior GRF of at least ≥ 5 mm width using the age- and gender-matched Constant/Murley score (a.-/g.-CMS) and the Western Ontario Instability Index (WOSI). Radiographic parameters (fracture morphology, displacement, major tuberosity fractures and Hill-Sachs lesion using initial CT and radiographs) and the proportion of the fractured glenoid were detected (2D-CT-circle-method) and osteoarthritis (A.P. and axial radiographs) was classified according to Samilson/Prieto. Proportion of fractured glenoid and medial displacement were correlated with the recurrence rate and the clinical scores. RESULTS: N = 36 patients could be followed-up after a mean of 4.4 years [12-140 month, average age: 58 (± 13, 33-86) years]. The a.-/g.-CMS was 93 (± 11, 61-100) points, and the WOSI was 81% (± 22%, 35-100%) on average. The mean intraarticular displacement was 4 mm (± 3 mm; 0-14 mm). The 2D-circle-method showed a mean glenoid fracture involvement of 21% (± 11, 10-52%). Two cases of frozen shoulders and one case with biceps pathology were associated with the trauma. Within the followed-up patient group re-instability has occurred in n = 2 patients (6%) within the first two weeks after trauma. Osteoarthritis was found in n = 11 cases. There was no correlation between the scores and the fracture size/displacement [(a.-/g.-CMS vs. displacement: r = - 0.08; p = 0.6; vs. size: r = - 0.29; p = 0.2); (WOSI vs. displacement: r = - 0.14; p = 0.4; vs. size: r = - 0.37; p = 0.06)], but very large (≥ 21%) fractures with displacement ≥ 4 mm showed slightly worse results without significant difference (a.-/g.-CMS p = 0.2; WOSI p = 0.2). The apprehension test was negative in all patients at final follow-up. CONCLUSION: Non-operative treatment of anterior GRF was associated with overall good results within a mainly middle-aged larger patient group. Re-instability is rare and is not associated with fragment size but can occur in the first weeks after trauma. Size and dislocation of the fracture is not a criterion for the prognosis of potential instability. LEVEL OF EVIDENCE: Level IV, retrospective case series.

A Highly Reliable Convolutional Neural Network Based Soft Tissue Sarcoma Metastasis Detection from Chest X-ray Images: A Retrospective Cohort Study.

INTRODUCTION: soft tissue sarcomas are a subset of malignant tumors that are relatively rare and make up 1% of all malignant tumors in adulthood. Due to the rarity of these tumors, there are significant differences in quality in the diagnosis and treatment of these tumors. One paramount aspect is the diagnosis of hematogenous metastases in the lungs. Guidelines recommend routine lung imaging by means of X-rays. With the ever advancing AI-based diagnostic support, there has so far been no implementation for sarcomas. The aim of the study was to utilize AI to obtain analyzes regarding metastasis on lung X-rays in the most possible sensitive and specific manner in sarcoma patients. METHODS: a Python script was created and trained using a set of lung X-rays with sarcoma metastases from a high-volume German-speaking sarcoma center. 26 patients with lung metastasis were included. For all patients chest X-ray with corresponding lung CT scans, and histological biopsies were available. The number of trainable images were expanded to 600. In order to evaluate the biological sensitivity and specificity, the script was tested on lung X-rays with a lung CT as control. RESULTS: in this study we present a new type of convolutional neural network-based system with a precision of 71.2%, specificity of 90.5%, sensitivity of 94%, recall of 94% and accuracy of 91.2%. A good detection of even small findings was determined. DISCUSSION: the created script establishes the option to check lung X-rays for metastases at a safe level, especially given this rare tumor entity.

Appearance of recurrent dermatofibrosarcoma protuberans in postoperative MRI follow-up.

PURPOSE: To analyze the appearance of recurrent dermatofibrosarcoma protuberans (DFSP) in postoperative MRI follow-up and to assess the occurrence of postoperative soft tissue changes detected in MRI. METHODS: A total of 464 MRI follow-up scans of 32 patients with histologically proven diagnosis of DFSP were analyzed. MR imaging was performed using a 1.5T MRI system. Recurrent DFSP was examined for signal intensity, contrast behavior, appearance, and extent in MRI. RESULTS: The mean age of the patients was 44,5±17,1 years. Recurrences of DFSP occurred 26±23.3 months after primary tumor resection in the mean (Min.: 9, Max.: 60). In 25% of the patients (n = 8), recurrences of DFSP were detected. Recurrent DFSP most often showed a nodular and homogeneous configuration with well-defined borders and marked contrast enhancement, and a hyperintense signal in PD-weighted and turbo inversion recovery magnitude sequences. All recurrences were well detected in the follow-up MRIs regardless of the performed plastic surgery procedure. Lateral and depth margins had no significant impact on the local recurrence rate. In all, 88% of the patients developed subcutaneous tissue edema (p < 0.01), followed by muscle edema (34%, p = 0.02), and postoperative seroma (22%). CONCLUSION: Recurrent DFSP mainly appear uniform and clearly delimitable on MRI as nodular, homogeneous, and well-defined lesions with marked contrast enhancement. Therefore, MRI is a valuable tool for postsurgical follow-up. Nearly all patients develop subcutaneous edema after the resection of DFSP.

Clinical and Radiological Outcomes After Surgical Treatment of Lower Limb Fractures in Patients With Spinal Cord Injury.

STUDY DESIGN: Retrospective observational study. OBJECTIVES: To analyze the clinical and radiological outcomes of lower limb fractures following surgical treatment in patients with chronic spinal cord injury (SCI). METHODS: Between January 2003 and December 2015, 102 chronic SCI patients with a lower limb fracture were surgically treated at our hospital. A total of 58 patients met the inclusion criteria and were recruited for final analysis. Patients with 2-stage procedure or incomplete clinical records with lost-to-follow-up were excluded from the study. Patients were divided into 2 groups (group 1= internal fixation; group 2 = external fixation). Primary outcome measures were to identify the number of nonunions via Kaplan-Meier analysis and the time to bone consolidation. The diagnosis of a pseudarthrosis was made after more than 180 days of consolidation time. Considering the Kaplan-Meier analysis, pseudarthrosis was interpreted as treatment failure. Secondary outcome measure was to evaluate the complication rate with special focus on heterotopic ossification. RESULTS: A total of 58 chronic SCI patients with closed bone fractures were included in this study. Fifty-two fractures (88%) were simple and 7 (12%) were complex (type C) fractures according to AO classification. The majority of patients (34 cases, 59%) developed femur fractures followed by 24 tibial fractures (41%). Seventeen patients received an external (29%) and 41 an internal fixation (71%). Bone consolidation was reported in 31 patients (53%) with a mean time interval of bone consolidation after 97 days (range from 45 to 160 days; SD = 30). The reported nonunion (pseudarthrosis) rate was 47%. Comparing the internal group (n = 15 patients) versus the external group (n = 14), we could not find any significant difference (P = .939) concerning the bone consolidation time. The Kaplan-Meier analysis showed a 75% cumulative survivorship at 120 days (internal group) versus 111 days (external group). Most common postoperative complications occurred in the internal fixation group with Wound infections being predominantly observed (10%), followed by heterotopic ossifications (8%). CONCLUSIONS: Our results show that surgical treatment of lower limb fractures in chronic SCI patients is a challenging treatment with a high pseudarthrosis rate in both groups. The complication rate seems to be lower in the patients treated with external fixation. As a clinical recommendation, longer implants should be used for a stable osteosynthesis since SCI patients seem to have a higher load on the osteosynthesis material due to missing sensomotoric feedback.

Configuration of Primary and Recurrent Aggressive Fibromatosis on Contrast-Enhanced MRI with an Evaluation of Potential Risk Factors for Recurrences in MRI Follow-Up.

PURPOSE: To analyze the appearance of primary and recurrent aggressive fibromatosis (AF) on MRI with a focus on configuration and to determine potential risk factors for recurrences detected on MRI follow-up scans. METHODS: From 79 consecutive patients with histologically proven diagnosis of AF, 39 patients underwent a minimum of four 1.5 T MRI follow-up scans after resection of primary AF between 2008 and 2018. The primary and recurrent tumors were radiographically examined for configuration, limitation and extent on MRI. Epidemiological data and loco-regional subcutaneous edema, muscle edema and post-operative seroma were included. RESULTS: The mean age of the patients was 39 ±â€Š2.6 years. Primary and recurrent AF most often occurred in the thigh. The main appearance of primary AF was significantly most often fascicular (p = 0.001-0.01) with heterogeneous and marked contrast enhancement. 21 % (n = 8) of the patients developed recurrences of AF. A fascicular configuration with homogeneous/heterogeneous contrast enhancement was the main appearance of recurrent AF, but recurrent AF appeared nodular, polycyclic, ovoid or streaky/flat as well. Recurrent AF significantly most often occurred within the first 9 months after primary tumor resection (p = 0.009), especially in patients up to 25 years of age (RR = 6.1; 95 % CI: 1.8-20.9; p = 0.004). The cases of recurrent AF were altogether significantly smaller than the primary tumors (p = 0.001). Post-treatment subcutaneous and muscle edema were present in 77 % and 56 %, respectively. Patients with muscle edema after primary tumor resection had a significantly higher risk for AF recurrences (relative risk ratio (RR) = 1.8; 95 % CI: 1.16-2.8; p = 0.0096). There was no significant difference detected in patients with complete or incomplete resection of the primary tumor. CONCLUSION: Primary and recurrent aggressive fibromatosis has a mostly fascicular configuration, but may appear ovoid, nodular, streaky/flat or polycyclic as well. High risks for tumor recurrences are detected for patients up to 25 years of age, patients within the first 9 post-operative months and patients with muscle edema after primary tumor resection. KEY POINTS: · Primary aggressive fibromatosis mostly has a fascicular configuration with heterogeneous contrast enhancement. · Recurrent aggressive fibromatosis usually has a fascicular configuration with heterogeneous/homogeneous contrast enhancement. · Patients within the first 9 post-operative months and up to 25 years of age have a significantly higher risk for recurrences. · Muscle edema after resection of primary aggressive fibromatosis is associated with a significantly higher risk for recurrences. CITATION FORMAT: · Sedaghat S, Surov A, Krohn S et al. Configuration of Primary and Recurrent Aggressive Fibromatosis on Contrast-Enhanced MRI with an Evaluation of Potential Risk Factors for Recurrences in MRI Follow-Up. Fortschr Röntgenstr 2020; 192: 448 - 457.

Body mass index and abdominal wall thickness correlate with perforator caliber in free abdominal tissue transfer for breast reconstruction.

INTRODUCTION: The aim of the study was to investigate the relationship of BMI and abdominal wall thickness (AWT) with the diameter of the dominant deep inferior epigastric artery perforator (DIEP) as well as DIEA branching pattern in preoperatively performed computed tomography angiography (CTA). PATIENTS AND METHODS: We conducted a retrospective study including all patients undergoing DIEP flap breast reconstruction with available CTAs from November 2013 to April 2018 in our department. The caliber-strongest DIEP was detected after passage of the rectus fascia as well as the superficial inferior epigastric artery (SIEA) and correlated with the AWT 5 cm above and below the umbilicus, lateral at the level of the umbilicus and at the level of the anterior superior iliac spine (ASIS), and with BMI. RESULTS: Seventy-seven patients met the inclusion criteria (age: 47.3 ± 8.9 years). We observed a significant relationship (p < 0.05) between DIEP (mean ∅ = 2.98 mm) and BMI (r = 0.353), the AWT supra- and infraumbilical (r ≥ 0.32), and the AWT lateral at the level of the umbilicus and ASIS (r ≥ 0.25). In addition, there was a highly significant correlation (p < 0.01) between SIEA and BMI (r = 0.389) and between the AWT lateral at the level of ASIS (r ≥ 0.41). CONCLUSION: We demonstrated a correlation of the diameter of the dominant DIEP with both BMI and AWT. Focusing on the diameter, in patients with a high AWT at the level of the ASIS, the SIEA, if present, may represent an alternative therapeutic option.

Steroid Profiling as an Additional Tool to Confirm One-Sided Hormone Overproduction in Primary Aldosteronism: A Case Report.

Primary aldosteronism (PA) is the leading cause of secondary hypertension. The source of aldosterone hypersecretion is often due to a unilateral aldosterone-producing adenoma, and unilateral laparoscopic adrenalectomy is recommended in such patients. Before surgery, confirmation of unilateral hypersecretion is necessary. This is optimally performed by adrenal venous sampling (AVS). However, AVS is not always successful e.g., due to difficulties in the cannulation of the right adrenal vein. Here we present the case of a 53-year-old female patient with primary aldosteronism, a left-sided adrenal mass and an inconspicuous right adrenal. AVS was performed, but cannulation of the right adrenal vein failed. Therefore, aldosterone hypersecretion also of the right adrenal could not be excluded despite higher aldosterone concentrations in the left renal and adrenal vein. To increase the certainty that the left sided adrenal mass was the source of aldosterone hypersecretion, steroid profiling was performed in a sample from the inferior vena cava. This revealed markedly elevated levels of 18-oxocortisol, 18-hydroxycortisol, 11-deoxycorticosterone, and 11-deoxycortisol, a steroid profile that strongly suggested that the left sided adrenal mass was an aldosterone producing adenoma, most likely due to a somatic KCNJ5 mutation. Following unilateral adrenalectomy, CYP11B2 immunohistochemistry, and genetics analysis of the resected adrenal confirmed a solitary aldosterone-producing adenoma with intense aldosterone synthase expression, which harbored a previously described KCNJ5 Phe154Cys mutation. Biochemical and clinical cure was confirmed 6 months postoperatively.

Feasibility of Transfemoral Aortic Valve Implantation in Patients With Aortic Disease and Simultaneous or Sequential Endovascular Aortic Repair.

OBJECTIVES: The transfemoral approach for transcatheter aortic valve implantation (TF-TAVI) is associated with a significant survival benefit for intermediate and high-risk patients. Due to the increased procedural risk, many operators avoid TF-TAVI in patients with aortic disease. Moreover, significant peri-interventional device interaction may occur in patients with previous endovascular aortic repair (EVAR). We evaluated the feasibility of TF-TAVI in patients with aortic disease in combination with simultaneous or sequential EVAR. METHODS: Data from 15 TF-TAVI patients with concomitant aortic disease treated between 2009 and 2019 in three German heart centers representing 4410 TAVI procedures were analyzed. RESULTS: Two patients with progressive penetrating atherosclerotic ulcers (PAUs) in the descending thoracic aorta underwent sequential and simultaneous thoracic EVAR (TEVAR), respectively. One patient with stable PAU and 4 patients with not yet relevant abdominal aortic aneurysm (AAA) underwent isolated TF-TAVI. One patient with relevant AAA underwent TF-TAVI and sequential EVAR. Seven patients with previous EVAR due to an AAA underwent TF-TAVI (5 with a bifurcated graft and 2 with a straight graft). TF-TAVI and sequential or simultaneous TEVAR were technically successful in all patients. Vascular complications occurred in 1 patient. One patient died within 30 days and 2 patients died within 12 months. CONCLUSION: TF-TAVI can be performed successfully in patients with aortic disease or previous endovascular aortoiliac intervention. Simultaneous and sequential (T)EVAR is feasible.

Use of a self-contained vacuum-assisted biopsy system in the assessment of soft tissue tumors.

BACKGROUND AND OBJECTIVE: This is the first study to compare the safety and efficacy of vacuum-assisted biopsy (VAB) using a self-contained hand-held system compared to those of ultrasound-guided and computed tomography-guided core needle biopsy (US-CNB and CT-CNB) and to incisional biopsy (IB). METHODS: VAB was performed in an outpatient setting under local anesthesia. Safety, diagnostic accuracy, time, and cost expenditures of biopsy were compared between VAB, US-CNB, CT-CNB, and IB in 211 consecutive patients. RESULTS: VAB was applied in 78 patients, US-CNB in 51, CT-CNB in 45, and IB in 37. Patient characteristics did not differ between groups. Sample volume of VAB was 392.5 mm3 , 4062 mm 3 for IB, and 25.1 to 34.5 mm 3 for CNB, P < .001. VAB discriminated between malignant and benign lesions with the highest accuracy of 96% and determined sarcoma grading accurately in 95%. VAB and CNB had no complications vs 5% for IB. Duration of VAB was 5 ± 2 minutes, equal to US-CNB and shorter than CT-CNB and IB. Expenditures for VAB were higher than for US-CNB and lower than CT-CNB and IB. CONCLUSION: VAB is an accurate, safe, cost-effective, and time-saving outpatient diagnostic procedure for patients with soft-tissue tumors and presents a viable alternative to IB.

Simulation of personalised haemodynamics by various mounting positions of a prosthetic valve using computational fluid dynamics.

Diseases of the cardiovascular system account for nearly 42% of all deaths in the European Union. In Germany, approximately 12,000 patients receive surgical replacement of the aortic valve due to heart valve disease alone each year. A three-dimensional (3D) numerical model based on patient-specific anatomy derived from four-dimensional (4D) magnetic resonance imaging (MRI) data was developed to investigate preoperatively the flow-induced impact of mounting positions of aortic prosthetic valves to select the best orientation for individual patients. Systematic steady-state analysis of blood flow for different rotational mounting positions of the valve is only possible using a virtual patient model. A maximum velocity of 1 m/s was used as an inlet boundary condition, because the opening angle of the valve is at its largest at this velocity. For a comparative serial examination, it is important to define the standardised general requirements to avoid impacts other than the rotated implantation of the prosthetic aortic valve. In this study, a uniform velocity profile at the inlet for the inflow of the aortic valve and the real aortic anatomy were chosen for all simulations. An iterative process, with the weighted parameters flow resistance (1), shear stress (2) and velocity (3), was necessary to determine the best rotated orientation. Blood flow was optimal at a 45° rotation from the standard implantation orientation, which will offer a supply to the coronary arteries.

Creeping Fat Assessed by Small Bowel MRI Is Linked to Bowel Damage and Abdominal Surgery in Crohn's Disease.

BACKGROUND: Crohn's disease (CD) leads to bowel damage and surgery in a significant proportion of patients. AIMS: The aim of the study was to evaluate the predictive value of creeping fat assessed by small bowel MRI in CD patients. METHODS: CD patients undergoing small bowel MRI were included in a retrospective observational cohort study. Clinical findings were extracted and correlated with radiological outcome measures. Logistic regression analysis was performed to assess predictors associated with a complicated course and surgery within 2 years and long-term follow-up. RESULTS: Ninety patients (49% female, median follow-up 93 months) were included. Creeping fat was identified in 21.1%. Of these patients, 68% and 79% developed bowel damage (p < .05) and 42% and 63% of patients revealing creeping fat underwent surgery within 2 years following MRI and total follow-up, respectively. The presence of creeping fat [odds ratio (OR) 4.0], inflammatory stenosis (OR 3.7), multisegmental (small) bowel (OR 4.5 and 3.8), and proximal small bowel inflammation (OR 5.0) were associated with inferior outcome (p < .05) in a univariate analysis. Creeping fat was independently associated with a disabling course, bowel damage, and surgery (OR 3.5 each, p < .05) in a multivariate analysis model. CONCLUSION: Creeping fat identified by small bowel MRI is associated with a complicated course and abdominal surgery in CD. Our data adds evidence that small bowel MRI facilitates risk stratification in order to define a patient at risk of disease-related complications in CD. [DRKS00011727, www.germanctr.de/ ].

A complementary role of intracortical inhibition in age-related tactile degradation and its remodelling in humans.

Many attempts are currently underway to restore age-related degraded perception, however, the link between restored perception and remodeled brain function remains elusive. To understand remodeling of age-related cortical reorganization we combined functional magnetic resonance imaging (fMRI) with assessments of tactile acuity, perceptual learning, and computational modeling. We show that aging leads to tactile degradation parallel to enhanced activity in somatosensory cortex. Using a neural field model we reconciled the empirical age-effects by weakening of cortical lateral inhibition. Using perceptual learning, we were able to partially restore tactile acuity, which however was not accompanied by the expected attenuation of cortical activity, but by a further enhancement. The neural field model reproduced these learning effects solely through a weakening of the amplitude of inhibition. These findings suggest that the restoration of age-related degraded tactile acuity on the cortical level is not achieved by re-strengthening lateral inhibition but by further weakening intracortical inhibition.

Impact of Small Bowel MRI in Routine Clinical Practice on Staging of Crohn's Disease.

BACKGROUND AND AIMS: Small bowel visualisation is a complex diagnostic approach, but mandatory for risk stratification and stage-adjusted therapy in Crohn's disease. Current guidelines favour transabdominal ultrasound and small bowel MRI as methods of choice, although their clinical impact in daily practice remains controversial. The aim of this study was to evaluate the diagnostic benefit of small bowel MRI in Crohn's disease according to Montreal Classification, in routine practice. METHODS: Patients who underwent MR-enterography [MRE] or MR-enteroclysis [MRY] were included in a retrospective single-centre study. MRI findings were correlated with results from clinical work-up and evaluated in terms of [1] diagnostic yield, [2] significant additional information, and [3] alterations in the assessment of disease behaviour and location according to Montreal Classification. RESULTS: A total of 347 small bowel MRI examinations were analysed [MRE: 49 / MRY: 298]. MRI had an average sensitivity/specificity of 82.5% and 99.9% [positive predictive value: 99.8% / negative predictive value: 91.1%] respectively. In every second patient, new relevant diagnostic information was provided. Incorporation of the MRI results caused significant shifts in Montreal Classification, specifically higher L-levels [+21.2%; p < 0.05] and higher B-levels: [+24.6%; p < 0.05]. CONCLUSIONS: Even in routine practice, small bowel MRI is a powerful and reliable technique in small bowel work-up. Since MRE and MRY presented high diagnostic yields, often detected significant additional information, and significantly caused shifts in Montreal Classification, both techniques are confirmed to be excellent tools in diagnosing and monitoring Crohn's disease in its daily course.

Second degree AV block and severely impaired contractility in cardiac myxedema: a case report.

The heart is a major target organ for thyroid hormone action. Severe overt hypothyroidism can result in diastolic hypertension, lowered cardiac output, impaired left ventricular contractility and diastolic relaxation, pericardial effusion and bradycardia. However, the function of the atrial pacemaker is usually normal and the degree by which the heart rate slows down is often modest. Here we report the case of a 20 year old male Caucasian with severe overt hypothyroidism. He presented with syncopation due to second degree atrioventricular block type Mobitz 2 and heart failure with reduced ejection fraction (38 %). Laboratory testing revealed a severe overt hypothyroidism with markedly elevated TSH (>100 mIU/L) and reduced fT3 and fT4 levels. The condition was caused by hypothyroid Graves' disease (Graves' disease with Hashimoto component). Although magnetic resonance imaging of the heart demonstrated decreased cardiac contractility and pericardial effusion, suggesting peri-myocarditis, plasma levels for BNP and troponin I were low. A possible infectious cause was unlikely, since testing for cardiotropic viruses was negative. The patient was treated with intravenous levothyroxine and after peripheral euthyroidism had been achieved, left ventricular ejection fraction returned to normal and pericardial effusion dissolved. Additionally, bradycardiac episodes abated, although intermittent second degree AV block was still occasionally present during the night. In conclusion, overt hypothyroidism may be associated by cardiac myxedema affecting both electrophysiology and contractility, observations that underscore the necessity of thyroid testing in different phenotypes of heart failure.

Alterations of monetary reward and punishment processing in chronic cannabis users: an FMRI study.

Alterations in reward and punishment processing have been reported in adults suffering from long-term cannabis use. However, previous findings regarding the chronic effects of cannabis on reward and punishment processing have been inconsistent. In the present study, we used functional magnetic resonance imaging (fMRI) to reveal the neural correlates of reward and punishment processing in long-term cannabis users (n = 15) and in healthy control subjects (n = 15) with no history of drug abuse. For this purpose, we used the well-established Monetary Incentive Delay (MID) task, a reliable experimental paradigm that allows the differentiation between anticipatory and consummatory aspects of reward and punishment processing. Regarding the gain anticipation period, no significant group differences were observed. In the left caudate and the left inferior frontal gyrus, cannabis users were - in contrast to healthy controls - not able to differentiate between the conditions feedback of reward and control. In addition, cannabis users showed stronger activations in the left caudate and the bilateral inferior frontal gyrus following feedback of no punishment as compared to healthy controls. We interpreted these deficits in dorsal striatal functioning as altered stimulus-reward or action-contingent learning in cannabis users. In addition, the enhanced lateral prefrontal activation in cannabis users that is related to non-punishing feedback may reflect a deficit in emotion regulation or cognitive reappraisal in these subjects.

Anxiety of patients undergoing CT imaging-an underestimated problem?

RATIONALE AND OBJECTIVES: Prospective evaluation of anxiety in patients undergoing computed tomography (CT) imaging using a standardized state-trait anxiety inventory (STAI-S) and identification of possible risk factors. MATERIAL AND METHODS: During a 9-month interval, patients undergoing CT were questioned using STAI-S. Additionally, 10 questions concerning specific procedure-related features (claustrophobia, radiation, administration of contrast, and so forth) were added. Moreover, sex, age, admitting subspecialty, organ region, reason for imaging, and prior imaging studies were recorded. Statistical analysis was performed using the Student t test and linear regression analysis; significance level was set to 5%. RESULTS: Of 6122 patients, 825 patients undergoing CT (14%) were included (67% men; average age, 54 ± 17 years). Average STAI was 42 ± 10 with women (45 ± 11 vs. 41 ± 10; P < .001) and patients who received intravenous contrast (43 ± 10 vs. 42 ± 11; P = .021) showing significantly higher anxiety levels compared to those without contrast. Patients with investigations of their extremities (41 ± 11 vs. 43 ± 10; P = .020) and trauma patients (41 ± 11 vs. 43 ± 10; P = .006) revealed significantly lower STAI results. Patients who had never received a CT scan before showed significantly greater STAI-S values than those with repeat studies (42 ± 10 vs. 41 ± 11; P = .036). Females had greater fears concerning examination results (P < .001), radiation exposure (P = .032), administration of contrast (P = .014), and claustrophobia (P < .001). Patients with known malignancies had a significantly higher level of anxiety concerning their CT results (P = .002). CONCLUSIONS: Anxiety does not only occur before MRI but also occur before CT. Its sources are manifold and include communication of CT results, administration of contrast agents, radiation exposure, and claustrophobia. In this setting, women seemed to be more receptive than men.

Muscle imaging data in late-onset Pompe disease reveal a correlation between the pre-existing degree of lipomatous muscle alterations and the efficacy of long-term enzyme replacement therapy.

BACKGROUND: Late-onset Pompe disease (LOPD) is a metabolic myopathy caused by mutations in GAA and characterized by proximal muscle weakness and respiratory insufficiency. There is evidence from clinical studies that enzyme replacement therapy (ERT) with human recombinant alpha-glucosidase improves motor performance and respiratory function in LOPD. OBJECTIVE: We analyzed quantitative muscle MRI data of lower limbs to evaluate the effects of long-term ERT on muscle parameters. METHODS: Three symptomatic LOPD patients who received ERT for five years and four untreated presymptomatic LOPD patients were included in the study. T1-weighted MRI images were used to determine volumes of thigh and lower leg muscles. In addition, mean gray values of eight individual thigh muscles were calculated to assess the degree of lipomatous muscle alterations. RESULTS: We detected a decrease in thigh muscle volume of 6.7% (p < 0.001) and an increase in lower leg muscle volume of 8.2% (p = 0.049) after five years of ERT. Analysis of individual thigh muscles revealed a positive correlation between the degree of lipomatous muscle alterations at baseline and the increase of gray values after five years of ERT (R(2) = 0.68, p < 0.001). Muscle imaging in presymptomatic patients showed in one case pronounced lipomatous alteration of the adductor magnus muscle and mild to moderate changes in further thigh muscles. CONCLUSIONS: The results demonstrate that fatty muscle degeneration can occur before clinical manifestation of muscle weakness and suggest that mildly affected muscles may respond better to ERT treatment than severely involved muscles. If these findings can be validated by further studies, it should be discussed if muscle alterations detected by muscle MRI may be an objective sign of disease manifestation justifying an early start of ERT in clinically asymptomatic patients in order to improve the long-term outcome.

Local anesthetic sympathectomy restores fMRI cortical maps in CRPS I after upper extremity stellate blockade: a prospective case study.

BACKGROUND: Patients with complex regional pain syndrome type I (CRPS I) show a cortical reorganization with contralateral shrinkage of cortical maps in S1. The relevance of pain and disuse for the development and the maintenance of this shrinkage is unclear. OBJECTIVE: Aim of the study was to assess whether short-term pain relief induces changes in the cortical representation of the affected hand in patients with CRPS type I. STUDY DESIGN: Case series analysis of prospectively collected data. METHODS: We enrolled a case series of 5 consecutive patients with CRPS type I (disease duration 3 - 36 months) of the non-dominant upper-limb and previously diagnosed sympathetically maintained pain (SMP) by reduction of the pain intensity of more than > 30% after prior diagnostic sympathetic block. We performed fMRI for analysis of the cortical representation of the affected hand immediately before as well as one hour after isolated sympathetic block of the stellate ganglion on the affected side. STATISTICS: Wilcoxon-Test, paired t-test, P < 0.05. RESULTS: Pain decrease after isolated sympathetic block (pain intensity on the numerical rating scale (0 - 10) before block: 6.8 ± 1.9, afterwards: 3.8 ± 1.3) was accompanied by an increase in the blood oxygenation level dependent (BOLD) response of cortical representational maps only of the affected hand which had been reduced before the block, despite the fact that clinical and neurophysiological assessment revealed no changes in the sensorimotor function. LIMITATIONS: The interpretation of the present results is partly limited due to the small number of included patients and the missing control group with placebo injection. CONCLUSIONS: The association between recovery of the cortical representation and pain relief supports the hypothesis that pain could be a relevant factor for changes of somatosensory cortical maps in CRPS, and that these are rapidly reversible.