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.

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.

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/ ].

An fMRI study of "theory of mind" in at-risk states of psychosis: comparison with manifest schizophrenia and healthy controls.

OBJECTIVE: Poor social functioning is a hallmark of schizophrenia and may precede the onset of illness. One of the most robust predictors of social impairment is a deficit in the ability to appreciate the mental states of others ("theory of mind"; ToM). We therefore examined ToM in subjects at risk of developing psychosis using an fMRI paradigm and compared brain activations with those of patients with manifest schizophrenia and healthy controls. METHOD: Ten subjects with at-risk ("prodromal") states of psychosis, 22 schizophrenia patients and 26 healthy controls were recruited. During fMRI scanning, participants were shown a series of cartoons. The task was to infer the mental states of the cartoon characters in terms of beliefs, states of knowledge and intentions. RESULTS: Subjects at risk of psychosis activated the ToM neural network comprising the prefrontal cortex, the posterior cingulate cortex, and the temporoparietal cortex more strongly than patients with manifest schizophrenia, and, in part, also more strongly than healthy controls. Manifest schizophrenia patients and controls activated the ToM neural network differently with little overlap of activated regions, where overall, controls showed stronger activations than schizophrenia patients. CONCLUSIONS: Individuals with at-risk states of schizophrenia activate the ToM neural network differently, and in part, more strongly compared to patients with schizophrenia and controls. This could suggest a compensatory overactivation of brain regions critical for empathic responses during mental state attribution in at-risk subjects for schizophrenia.

Multidetector-CT angiography in pulmonary embolism-can image parameters predict clinical outcome?

OBJECTIVE: To assess if pulmonary CT angiography (CTA) can predict outcome in patients with pulmonary embolism (PE). METHODS: Retrospective analysis of CTA studies of patients with PE and documentation of pulmonary artery (PA)/aorta ratio, right ventricular (RV)/left ventricular (LV) ratio, superior vena cava (SVC) diameter, pulmonary obstruction index (POI), ventricular septal bowing (VSB), venous contrast reflux (VCR), pulmonary infarction and pleural effusion. Furthermore, duration of total hospital stay, necessity for/duration of ICU therapy, necessity for mechanical ventilation and mortality were recorded. Comparison was performed by logistic/linear regression analysis with significance at 5%. RESULTS: 152 patients were investigated. Mean duration of hospital stay was 21 ± 24 days. 66 patients were admitted to the ICU; 20 received mechanical ventilation. Mean duration of ICU therapy was 3 ± 8 days. Mortality rate was 8%. Significant positive associations of POI, VCR and pulmonary infarction with necessity for ICU therapy were shown. VCR was significantly associated with necessity for mechanical ventilation and duration of ICU treatment. Pleural effusions were significantly associated with duration of total hospital stay whereas the RV/LV ratio correlated with mortality. CONCLUSION: Selected CTA findings showed significant associations with the clinical course of PE and may thus be used as predictive parameters.

Intra-individual, randomised comparison of the MRI contrast agents gadobutrol and gadoterate in imaging the distal lower limb of patients with known or suspected osteomyelitis, evaluated in an off-site blinded read.

OBJECTIVE: To prove that 1.0 M gadobutrol provides superior contrast enhancement in suspicion of osteomyelitis of the feet compared with 0.5 M gadoterate. METHODS: MRI of feet was performed on 2 separate occasions. Independent injections of 1.0 M gadobutrol and 0.5 M gadoterate at doses of 0.1 mmol Gd/kg body weight were administered per patient. The interval between the two MR examinations was between 24 h and 7 days. Evaluation was performed in an off-site blinded read. RESULTS: 41 patients were eligible for efficacy analysis. Results of secondary efficacy variables did not show statistically significant differences. For the primary efficacy variable, a trend in favour of gadobutrol was seen in the full analysis set (ITT) population resulting in at least non-inferiority. In the per protocol (PP) analysis set gadobutrol had better contrast than gadoterate (Wilcoxon signed rank test, p = 0.0466). CONCLUSION: Imaging of the distal lower limb in this special patient population requires a large number of patients to obtain enough comparative images where non-contrast-agent-dependent factors do not disturb contrast agent efficacy. The ITT analysis showed at least non-inferiority of gadobutrol in comparison to gadoterate. The avoidance of imaging artefacts demonstrates a better outcome for gadobutrol.

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.

Cumulative effective dose associated with radiography and CT of adolescents with spinal injuries.

OBJECTIVE: The purpose of this study was to analyze the quantity and distribution of cumulative effective doses in diagnostic imaging of adolescents with spinal injuries. MATERIAL AND METHODS: At a level 1 trauma center from July 2003 through June 2009, imaging procedures during initial evaluation and hospitalization and after discharge of all patients 10-20 years old with spinal fractures were retrospectively analyzed. The cumulative effective doses for all imaging studies were calculated, and the doses to patients with spinal injuries who had multiple traumatic injuries were compared with the doses to patients with spinal injuries but without multiple injuries. The significance level was set at 5%. RESULTS: Imaging studies of 72 patients (32 with multiple injuries; average age, 17.5 years) entailed a median cumulative effective dose of 18.89 mSv. Patients with multiple injuries had a significantly higher total cumulative effective dose (29.70 versus 10.86 mSv, p < 0.001) mainly owing to the significantly higher CT-related cumulative effective dose to multiple injury patients during the initial evaluation (18.39 versus 2.83 mSv, p < 0.001). Overall, CT accounted for 86% of the total cumulative effective dose. CONCLUSION: Adolescents with spinal injuries receive a cumulative effective dose equal to that of adult trauma patients and nearly three times that of pediatric trauma patients. Areas of focus in lowering cumulative effective dose should be appropriate initial estimation of trauma severity and careful selection of CT scan parameters.

MRI in lipid-lowering agent-associated myopathy: a retrospective review of 21 cases.

OBJECTIVE: The objective of our study was to identify disease-specific patterns of myopathic changes in patients with lipid-lowering agent (LLA)-associated myopathy using a dedicated MRI protocol. MATERIALS AND METHODS: Axial T1- and T2-weighted STIR images were obtained for the detection of lipomatosis and edema, respectively, of the thighs and legs. Information about patient age, sex, duration of dyslipidemia and of medication use, latency of symptom onset, maximum creatine kinase (CK) level, presence of myalgia and muscle weakness, and LLA or LLAs used was collected. RESULTS: Significant correlations resulted for the radiologic diagnosis of LLA-associated myopathy and maximum CK level; the presence of edema and maximum CK level; edema and weakness in the ventral thigh muscle group, thigh adductors, or deep dorsal muscle group of the legs; and lipomatosis and weakness of the deep dorsal muscle group of the legs and peroneal muscle group, respectively. CONCLUSION: MRI is a method that helps detect active pathologic processes in patients with suspected LLA-associated myopathy but does not reveal disease-specific patterns.

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.

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.

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.

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.

A fatal case of spinal tuberculosis mistaken for metastatic lung cancer: recalling ancient Pott's disease.

BACKGROUND: Tuberculous spondylitis (Pott's disease) is an ancient human disease. Because it is rare in high-income, tuberculosis (TB) low incidence countries, misdiagnoses occur as sufficient clinical experience is lacking. CASE PRESENTATION: We describe a fatal case of a patient with spinal TB, who was mistakenly irradiated for suspected metastatic lung cancer of the spine in the presence of a solitary pulmonary nodule of the left upper lobe. Subsequently, the patient progressed to central nervous system TB, and finally, disseminated TB before the accurate diagnosis was established. Isolation and antimycobacterial chemotherapy were initiated after an in-hospital course of approximately three months including numerous health care related contacts and procedures. CONCLUSION: The rapid diagnosis of spinal TB demands a high index of suspicion and expertise regarding the appropriate diagnostic procedures. Due to the devastating consequences of a missed diagnosis, Mycobacterium tuberculosis should be considered early in every case of spondylitis, intraspinal or paravertebral abscess. The presence of certain alarm signals like a prolonged history of progressive back pain, constitutional symptoms or pulmonary nodules on a chest radiograph, particularly in the upper lobes, may guide the clinical suspicion.

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.

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.

Functional imaging of perceptual learning in human primary and secondary somatosensory cortex.

Cellular mechanisms underlying synaptic plasticity are in line with the Hebbian concept. In contrast, data linking Hebbian learning to altered perception are rare. Combining functional magnetic resonance imaging with psychophysical tests, we studied cortical reorganization in primary and secondary somatosensory cortex (SI and SII) and the resulting changes of tactile perception before and after tactile coactivation, a simple type of Hebbian learning. Coactivation on the right index finger (IF) for 3 hr lowered its spatial discrimination threshold. In parallel, blood-oxygen level-dependent (BOLD) signals from the right IF representation in SI and SII enlarged. The individual threshold reduction was linearly correlated with the enlargement in SI, implying a close relation between altered discrimination and cortical reorganization. Controls consisting of a single-site stimulation did not affect thresholds and cortical maps. Accordingly, changes within distributed cortical networks based on Hebbian mechanisms alter the individual percept.

An fMRI study of theory of mind in schizophrenic patients with "passivity" symptoms.

Several studies have shown that patients with schizophrenia underactivate brain regions involved in theory of mind relative to controls during functional brain imaging. However, in most studies the samples were fairly heterogeneous in terms of clinical symptomatology. We examined a group of nine patients with first episode or recurrent episodes, who clinically presented with predominant "passivity" symptoms such as third-person auditory hallucinations or delusion of control, using a cartoon-based theory of mind task and compared activation patterns with a group of 13 healthy controls. All patients responded well to antipsychotic treatment and were only mildly symptomatic at the time of testing. The patient group showed significantly less activation of the right anterior cingulate cortex (ACC) and right insula compared with controls, but greater activation in dorsal areas of the medial prefrontal cortex, right temporal areas and left temporo-parietal junction. Patients with schizophrenia with predominant "passivity" symptoms and good response to antipsychotic treatment show a markedly diverging pattern of brain activation during theory of mind task performance compared with healthy controls. These findings suggest abnormal activation of those brain areas involved in the evaluation of self-reference during mental state attribution.