An [18F]-Positron Emitting Fluorophore Allows Safe Evaluation of Small Molecule Distribution in the CSF, CSF Fistulas, and CNS Device Placement.

The small molecule fluorescein is commonly used to guide the repair of cerebral spinal fluid leaks (CSFLs) in the clinic. We modified fluorescein so that it is also visible by positron emission tomography (PET). This probe was used to quantitatively track the fast distribution of small molecules in the CSF of rats. We tested this probe in models relevant to the clinical diagnosis and treatment of central nervous system (CNS) diseases that affect CSF flow. In this study, fluorescein was radiolabeled with fluorine-18 to produce Fc-AMBF3. [18/19F]-Fc-AMBF3 was introduced at trace quantities (13.2 nmols, 100 µCi) intrathecally (between L5 and L6) in rats to observe the dynamic distribution and clearance of small molecules in the CSF by both [18F]-PET and fluorescence (FL) imaging. Murine models were used to demonstrate the following utilities of Fc-AMBF3: (1) utility in monitoring the spontaneous CSFL repair of a compression fracture of the cribriform plate and (2) utility in quantifying CSF flow velocity during neurosurgical lumboperitoneal shunt placement. Fc-AMBF3 clearly delineated CSF-containing volumes based on noninvasive PET imaging and in ex vivo FL histology. In vivo morbidity (n = 16 rats, <2.7 mg/kg, 77 times the PET dose) was not observed. The clearance of the contrast agent from the CNS was rapid and quantitative (t1/2 = 33.8 ± 0.6 min by FL and t1/2 = 26.0 ± 0.5 min by PET). Fc-AMBF3 was cleared from the CSF through the vasculature and/or lymphatic system that supplies the cribriform plate and the temporal bone. Fc-AMBF3 can be used to diagnose CSFLs, image CSFL repair, and determine the CSF flow velocity in the CNS or through lumboperitoneal shunts by PET/FL imaging. In conclusion, Fc-AMBF3 PET imaging has been demonstrated to safely and dynamically quantitate CSF flow, diagnose fistulas associated with the CSF space, and approximate the clearance of small molecules in the CSF.

Surgical management of sacral meningeal cysts by obstructing the communicating holes with muscle graft.

BACKGROUND: The surgical indication and treatment of sacral meningeal cyst have not been well established and current methods are usually accompanied by complications and recurrence. The aim of this study is to discuss the treatment of symptomatic sacral meningeal cyst, by investigating the surgical results of our surgically treated patients, and minimize the complications and recurrence. METHODS: We retrospectively reviewed all patients with symptomatic sacral meningeal cysts who were surgically treated by a single surgeon in the same institution from 2002 to 2017. All patients underwent the same operation by incising the cyst wall and obstructing the communicating hole with muscle graft, while the cyst wall was left untreated instead of resected or imbricated. The obstruction was verified by doing a Valsalva-like maneuver. The preoperative symptoms and signs, and the outcomes at most recent follow-up were rated and compared by Neurological Scoring System. RESULTS: A total of 18 patients (7 male patients and 11 female patients, average age 42.3 years) were followed up for an average of 51.7 months. All patients had communicating holes linking the cysts and the dural sacs. The average preoperative neurological score was 19.7 ± 2.2, and it was improved to 23.2 ± 2.8 at the most recent follow-up (p < 0.01). CONCLUSIONS: The sacral meningeal cyst originated from the communication with the dural sac. Surgical treatment of symptomatic sacral meningeal cysts can yield a long-term resolution of the appropriately selected patient's symptoms. Obstructing the communicating hole with muscle graft is an effective and simple method to obliterate the cyst. The incised cyst wall can be left untreated instead of resected or imbricated.

Delayed unilateral abducens nerve palsy following contralateral post-traumatic epidural hematoma.

A 26-year-old Asian woman presented with diplopia occurring at 1 week after conservative treatment for left temporal bone fracture and left temporo-occipital epidural hematoma (EDH). At presentation, right abducens nerve palsy was observed with esotropia and abduction limitation in the right eye. Six weeks later, the abducens nerve palsy fully recovered with complete absorption of the EDH.

[Condition and consequences of zinc metabolic disorder in patients with neurosurgical pathology requiring intensive care].

INTRODUCTION: diseases that require neurosurgical intervention for many years constitute the major cause of disability and death in the world. These patients develop the disorder of zinc supply which is a universal bioregulator. The aim of the research is the assessment of zinc metabolism and effects of its disorder in patients with neurosurgical disorders that require intensive care. MATERIALS AND METHODS: observational analytical retrospective research ( « Case control study ¼ type) of zinc exchange status in 60 patients was conducted. Study group included 40 patients of neurosurgical profile who needed intensive care. Control group consisted of 20 conventionally healthy volunteers. Presence of clinical and laboratory signs of zinc deficiency, presence or absence of gastrointestinal failure, level of consciousness, need for mechanical ventilation, and severity of patient's condition were assessed. Statistical analysis of the results was performed using the methods of descriptive statistics, nonparametric comparison of two groups in terms of qualitative and quantitative indicators, establishing correlation relationships. RESULTS AND CONCLUSIONS: in neurosurgical patients requiring intensive care, on the third day of treatment reduction in plasma zinc was observed, causing the clinical signs of zinc deficiency, even without achieving the minimum diagnostically significant threshold of its content in blood of 13 mcM/l. Zinc deficiency contributes to gastrointestinal, cerebral and immune insufficiency, increases the need for artificial lung ventilation and aggravates the severity of patient's condition. At the same time, high mortality of neurosurgical patients requiring intensive care is not directly related to the level of zinc in the blood plasma.

Modeling cognition and disease using human glial chimeric mice.

As new methods for producing and isolating human glial progenitor cells (hGPCs) have been developed, the disorders of myelin have become especially compelling targets for cell-based therapy. Yet as animal modeling of glial progenitor cell-based therapies has progressed, it has become clear that transplanted hGPCs not only engraft and expand within murine hosts, but dynamically outcompete the resident progenitors so as to ultimately dominate the host brain. The engrafted human progenitor cells proceed to generate parenchymal astrocytes, and when faced with a hypomyelinated environment, oligodendrocytes as well. As a result, the recipient brains may become inexorably humanized with regards to their resident glial populations, yielding human glial chimeric mouse brains. These brains provide us a fundamentally new tool by which to assess the species-specific attributes of glia in modulating human cognition and information processing. In addition, the cellular humanization of these brains permits their use in studying glial infectious and inflammatory disorders unique to humans, and the effects of those disorders on the glial contributions to cognition. Perhaps most intriguingly, by pairing our ability to construct human glial chimeras with the production of patient-specific hGPCs derived from pluripotential stem cells, we may now establish mice in which a substantial proportion of resident glia are both human and disease-derived. These mice in particular may provide us new opportunities for studying the human-specific contributions of glia to psychopathology, as well as to higher cognition. As such, the assessment of human glial chimeric mice may provide us new insight into the species-specific contributions of glia to human cognitive evolution, as well as to the pathogenesis of human neurological and neuropsychiatric disease.

Artificial neural networks in neurosurgery.

Artificial neural networks (ANNs) effectively analyze non-linear data sets. The aimed was A review of the relevant published articles that focused on the application of ANNs as a tool for assisting clinical decision-making in neurosurgery. A literature review of all full publications in English biomedical journals (1993-2013) was undertaken. The strategy included a combination of key words 'artificial neural networks', 'prognostic', 'brain', 'tumor tracking', 'head', 'tumor', 'spine', 'classification' and 'back pain' in the title and abstract of the manuscripts using the PubMed search engine. The major findings are summarized, with a focus on the application of ANNs for diagnostic and prognostic purposes. Finally, the future of ANNs in neurosurgery is explored. A total of 1093 citations were identified and screened. In all, 57 citations were found to be relevant. Of these, 50 articles were eligible for inclusion in this review. The synthesis of the data showed several applications of ANN in neurosurgery, including: (1) diagnosis and assessment of disease progression in low back pain, brain tumours and primary epilepsy; (2) enhancing clinically relevant information extraction from radiographic images, intracranial pressure processing, low back pain and real-time tumour tracking; (3) outcome prediction in epilepsy, brain metastases, lumbar spinal stenosis, lumbar disc herniation, childhood hydrocephalus, trauma mortality, and the occurrence of symptomatic cerebral vasospasm in patients with aneurysmal subarachnoid haemorrhage; (4) the use in the biomechanical assessments of spinal disease. ANNs can be effectively employed for diagnosis, prognosis and outcome prediction in neurosurgery.

[A case of intraventricular isolated neurosarcoidosis diagnosed by neuroendoscopic biopsy].

A 76-year-old woman was admitted to our hospital because of dementia, nausea, and speech disturbances. Computed tomography(CT)of her brain showed hydrocephalus and an intra-ventricular mass with a left temporo-parieto-occipital low density area. She underwent emergency ventricular drainage. Thereafter, she was referred to our department: neurosurgery. Gadolinium-enhanced magnetic resonance imaging of the brain showed homonymous enhancement in the left lateral, third, and fourth ventricles. CT of her chest and abdomen showed no abnormal findings. Initially, we performed a neuro-endoscopic biopsy and made a histopathological diagnosis of noncaseating granuloma. However, because we did not detect pulmonary or ocular lesions, we eventually made a diagnosis of isolated neurosarcoidosis. She received a ventricular-peritoneal shunt and steroid pulse therapy, and recovered from all her symptoms. Neurosurgeons should be aware of the possibility of hydrocephalus mimicking an intraventricular tumor and caused by isolated neurosarcoidosis. In this article, we provide a case description and review of the literature.

Meningeal Rosai-Dorfman disease mimicking meningioma.

Rosai-Dorfman disease of the central nervous system is extremely rare and difficult to diagnose also for pathologists. We describe three unusual cases of meningeal Rosai-Dorfman disease and illustrate the difficulties of preoperative and pathological diagnosis. We retrospectively analyzed three patients who underwent surgery for a suspected meningioma for whom the final diagnosis was Rosai-Dorfman disease of the central nervous system. Pathological initial diagnosis was schwannoma, lymphoplasmacyte-rich meningioma, or inflammatory tumor, but final diagnosis in all cases was Rosai-Dorfman disease. These cases underline the preoperative and pathological difficulties of such diagnosis. Pathologists and physicians should be aware of the occurrence of such rare localization of this disease and should think about this differential diagnosis in lymphocyte-rich meningeal tumors mimicking, clinically and radiologically, a meningioma. Communication of significant previous medical history to pathologists and careful examination of slides with appropriate medical history and the use of S100 antibody in the diagnosis of meningeal tumors mimicking Rosai-Dorfman disease could lower the rate of misdiagnosis.

History of cellular grafting for central nervous system repair-A clinical perspective.

As late as in the 1970s, the evidence supporting that brain function might be restored by replacing dead cells by transplantation of new healthy cells was scarce in experimental animals and lacking in humans. Repairing the human brain was regarded as completely unrealistic by clinicians. Fifty years later, the situation is very different, and cellular grafting has reached patient application in several conditions affecting the CNS. The clinical studies performed so far have shown that cellular grafts can survive, grow, and function also in the diseased adult human brain. However, no proven treatment based on cell transplantation is currently available for any brain disorder. Here, the history of cellular grafting is described from a clinical perspective, including some of the preclinical work that has formed the basis for its translation to patient application. The focus is on cell transplantation for Parkinson disease, which in many ways is paving the way for this field of research. The chapter gives an account of the scientific milestones, the ups and downs, as well as the positive and negative reactions from the scientific and clinical community, and how this research field despite many obstacles has continued to move forward over more than four decades.

Unrelated cord blood transplantation for central nervous system relapse in high-risk childhood acute lymphoblastic leukemia.

Few clinical studies have investigated the role of unrelated cord blood transplantation (CBT) for central nervous system (CNS) relapse of childhood acute lymphoblastic leukemia (ALL) patients with high-risk factors. The aim of this report is to identify the potential benefits of unrelated CBT in high-risk childhood ALL with CNS relapse who has been treated on CNS-directed treatment strategies. Eleven childhood ALL patients with CNS relapse who underwent unrelated CBT enrolled in our study between 2001 and 2011, and all of the patients had features associated with poor outcomes, such as high white blood cells at diagnosis, ph + chromosome, or a history of bone marrow relapse. All transplants were performed with myeloablative-conditioning therapy (BU/cyclophosphamide (CY2) or total body irradiation/CY) plus highly CNS-active agents (carmustine or high-dose cytarabine). All patients achieved neutrophil engraftment and platelet engraftment. A total of nine patients (81.8 %) developed pre-engraftment syndrome at a median of 7 days, and three patients developed acute graft-vs-host disease at a median of 21 days. The median follow-up after CBT was 28.5 months. The probability of overall survival at 9 years was 63.6 %, and no patient experienced a CNS relapse. Our experience suggests that unrelated CBT appears to be an effective treatment option for CNS relapse of childhood ALL patients associated with poor outcome features.

70th Birthday symposium of Prof. Dr. Riederer: autologous adult stem cells in ischemic and traumatic CNS disorders.

Ischemic and traumatic insults of the central nervous system both result in definite chronic disability, only to some extent responsive to rehabilitation. Recently, the application of autologous stem cells (fresh bone marrow-derived mononuclear cells including mesenchymal and hematopoietic stem cells) was suggested to provide a strategy to further improve neurological recovery in these disorders. During the acute phase, stem cells act mainly by neuroprotection with prevention of apoptosis, whereas during the chronic situation they provide neurorestoration by transdifferentiation and/or the secretion of neurotrophic factors. To reach these goals, in the acute phase, stem cells (10 million mononuclear cells per kg body weight) might be best applied intravenously, as during the first 7 days after the lesion, the blood-brain barrier permits passage of cells from the blood into the brain or the spinal cord. In the more chronic situation, though, those cells might be applied best intrathecally by lumbar puncture. Based on the reported results so far, it seems justified to develop well-designed clinical double-blind trials in chronic spinal cord injury and ischemic stroke patients, as efficacy and safety concerns might not be answered by preclinical studies.

Juvenile xanthogranulomas of the nervous system: A report of two cases and review of the literature.

Juvenile xanthogranulomas (JXG) are uncommon non-Langerhans cell histiocytic proliferations which arise most often in children. While most cases present as solitary cutaneous lesions, occasional cases involve extracutaneous sites. Rare examples of JXGs have been reported involving all levels of the neuroaxis. We present two cases of JXGs involving the nervous system, and review the literature. The first patient was a 14-year-old female with headaches and a mass involving the left trigeminal nerve; pathologic examination showed a JXG. At 11 months follow-up, after administration of systemic chemotherapy, the patient remained stable with residual tumor. The second patient was a 15-year-old female with leg weakness and numbness, who underwent complete surgical resection of a dural JXG. At eight months follow-up, she showed no evidence of tumor, and was able to walk without difficulty. Review of the literature revealed 38 previously published reports of JXGs involving the nervous system. The CNS was involved in the majority (75%) of cases. The clinical characteristics of JXGs arising in the CNS varied significantly from cases in the peripheral nervous system (PNS); CNS tumors occurred in younger patients, more often males, and were more likely to be associated with concurrent cutaneous and extra-nervous systemic lesions. The clinical outcomes were similar for CNS and PNS lesions, with the caveat that all three lethal JXGs occurred in the CNS. The clinical and radiologic presentation of JXGs is nonspecific, thus necessitating biopsy and pathologic examination to arrive at the diagnosis. The pathologic differential diagnosis includes a heterogeneous group of histiocytic proliferations; immunostaining for histiocytic markers CD68, factor XIIIa, and Fascin, and the absence of Birbeck granules and CD1a immunoexpression suggests the diagnosis of JXG. In many cases, total surgical resection is curative. However, some cases will require additional chemotherapy and/or radiotherapy.

Isolated neurosarcoidosis in the medulla oblongata involving the fourth ventricle: a case report.

We report a 61-year-old woman with definite diagnosis of isolated neurosarcoidosis in the medulla oblongata involving the fourth ventricle. We could not recognize neurosarcoidosis as one of the differential diagnoses of the lesion before biopsy because the brainstem lesion location and periventricular lesion configuration were quite unusual.

[Sural sinus as the main source of postoperative venous thromboembolic complications in neurosurgical patients].

The authors analysed the results of diagnosis and treatment of venous thromboembolic complications in a total of 239 patients presenting with various-aetiology intracranial haemorrhage and tumours of the central system. The total incidence of venous thromboses in the system of the inferior vena cava amounted to 25.1%. Thromboembolism of pulmonary artery complicated the course of the underlying disease in 3.3% of cases. Operative treatment of the underlying disease resulted in an increased incidence rate of thromboses of deep veins from 18.5 to 36.4% (p=0.015) and that of pulmonary artery thromboembolism from 2.7 to 4.5% (p=0.5). The most frequently encountered localization of thromboses in the postoperative period turned out to be the sural veins of the crus. The level of consciousness (p=0.0001), operative treatment (p=0.002), putaminal and thalamic intracranial haematomas (p=0.01), as well as dislocation syndrome (p=0.05) according to the findings of the univariate analysis were the risk factors for the development of venous thromboses in patients with haemorrhagic stroke. Independent predictors of the development of venous thromboembolic complications in patients with haemorrhagic-type acute impairments of cerebral circulation according to the data of the univariate analysis were the level of consciousness by the Glasgow coma scale scoring 4-5 points (p=0.01) and deep-seated localization of the intracerebral haematoma (p=0.01). Patients with intracranial haematoma having endured operative treatment are a cohort of patients running the highest risk for the development of postoperative venous thromboembolic complications.

Successful anesthesia management with inhalation anesthesia in Rosai-Dorfman disease: a case report.

Rosai-Dorfman disease (RDD) is a rare, benign, non-Langerhans cell histiocytic proliferative disease. RDD with central nervous system involvement is extremely rare. Surgical excision is generally regarded as the appropriate treatment of choice for this disease, especially when the lesion causes neurological compression. RDD can be accompanied by systemic symptoms, such as malaise, fever, weight change, leukocytosis, anemia, and hormonal disturbance, which may be challenging during general management. Little is known regarding peri-anesthesia management of this rare disease. We report a case of a patient in his 20s who had recurrent RDD and had general anesthesia with perioperative management. He was obese and hepatic insufficiency. This case report adds to the literature regarding the perioperative anesthetic management of RDD with central nervous system involvement.

Neural stem cell transplantation in central nervous system disorders: from cell replacement to neuroprotection.

PURPOSE OF REVIEW: Transplantation of neural stem/precursor cells (NPCs) has been proposed as a promising therapeutic strategy in almost all neurological disorders characterized by the failure of central nervous system (CNS) endogenous repair mechanisms in restoring the tissue damage and rescuing the lost function. Nevertheless, recent evidence consistently challenges the limited view that transplantation of these cells is solely aimed at protecting the CNS from inflammatory and neurodegenerative damage through cell replacement. RECENT FINDINGS: Recent preclinical data confirmed that transplanted NPCs may also exert a 'bystander' neuroprotective effect and identified a series of molecules - for example, immunomodulatory substances, neurotrophic growth factors, stem cell regulators as well as guidance molecules - whose in-situ secretion by NPCs is temporally and spatially orchestrated by environmental needs. A better understanding of the molecular and cellular mechanisms sustaining this 'therapeutic plasticity' is of pivotal importance for defining crucial aspects of the bench-to-beside translation of neural stem cell therapy, that is route and timing of administration as well as the best cellular source. Further insight into those latter issues is eagerly expected from the ongoing phase I/II clinical trials, while, on the other hand, new cellular sources are being developed, mainly by exploiting the new possibilities offered by cellular reprogramming. SUMMARY: Nowadays, the research on NPC transplantation in neurological disorders is advancing on two different fronts: on one hand, recent preclinical data are uncovering the molecular basis of NPC therapeutic plasticity, offering a more solid rational framework for the design of clinical studies. On the other hand, pilot trials are highlighting the safety and feasibility issues of neural stem cell transplantation that need to be addressed before efficacy could be properly evaluated.

Neural stem cells: therapeutic potential for neurodegenerative diseases.

INTRODUCTION: Neural stem cells (NSCs) from specific brain areas or developed from progenitors of different sources are of therapeutic potential for neurodegenerative diseases. SOURCES OF DATA: Treatment strategies involve the (i) transplantation of exogenous NSCs; (ii) pharmacological modulations of endogenous NSCs and (iii) modulation of endogenous NSCs via the transplantation of exogenous NSCs. AREAS OF AGREEMENT: There is a consensus about the therapeutic potential of transplanted NSCs. The ability of NSCs to home into areas of central nervous system injury allows their delivery by intravenous injection. There is also a general agreement about the neuroprotective mechanisms of NSCs involving a 'bystander effect'. AREAS OF CONTROVERSY: Individual laboratories may be using phenotypically diverse NSCs, since these cells have been differentiated by a variety of neurotrophins and/or cultured on different ECM proteins, therefore differing in the expression of neuronal markers. GROWING POINTS: Optimization of the dose, delivery route, timing of administration of NSCs, their interactions with the immune system and combination therapies in conjunction with tissue engineered neural prostheses are under investigation. AREAS TIMELY FOR DEVELOPING RESEARCH: In-depth understanding of the biological properties of NSCs, including mechanisms of therapy, safety, efficacy and elimination from the organism. These areas are central for further use in cell therapy. CAUTIONARY NOTE: As long as critical safety and efficacy issues are not resolved, we need to be careful in translating NSC therapy from animal models to patients.

Influence of the environment on adult CNS plasticity and repair.

During developmental critical periods, external stimuli are crucial for information processing, acquisition of new functions or functional recovery after CNS damage. These phenomena depend on the capability of neurons to modify their functional properties and/or their connections, generally defined as "plasticity". Although plasticity decreases after the closure of critical periods, the adult CNS retains significant capabilities for structural remodelling and functional adaptation. At the molecular level, structural modifications of neural circuits depend on the balance between intrinsic growth properties of the involved neurons and growth-regulatory cues of the extracellular milieu. Interestingly, experience acts on this balance, so as to create permissive conditions for neuritic remodelling. Here, we present an overview of recent findings concerning the effects of experience on cellular and molecular processes responsible for producing structural plasticity of neural networks or functional recovery after an insult to the adult CNS (e.g. traumatic injury, ischemia or neurodegenerative disease). Understanding experience-dependent mechanisms is crucial for the development of tailored rehabilitative strategies, which can be exploited alone or in combination with specific therapeutic interventions to improve neural repair after damage.

Tracking stem cell differentiation in the setting of automated optogenetic stimulation.

Membrane depolarization has been shown to play an important role in the neural differentiation of stem cells and in the survival and function of mature neurons. Here, we introduce a microbial opsin into ESCs and develop optogenetic technology for stem cell engineering applications, with an automated system for noninvasive modulation of ESC differentiation employing fast optogenetic control of ion flux. Mouse ESCs were stably transduced with channelrhodopsin-2 (ChR2)-yellow fluorescent protein and purified by fluorescence activated cell sorting (FACS). Illumination of resulting ChR2-ESCs with pulses of blue light triggered inward currents. These labeled ESCs retained the capability to differentiate into functional mature neurons, assessed by the presence of voltage-gated sodium currents, action potentials, fast excitatory synaptic transmission, and expression of mature neuronal proteins and neuronal morphology. We designed and tested an apparatus for optically stimulating ChR2-ESCs during chronic neuronal differentiation, with high-speed optical switching on a custom robotic stage with environmental chamber for automated stimulation and imaging over days, with tracking for increased expression of neural and neuronal markers. These data point to potential uses of ChR2 technology for chronic and temporally precise noninvasive optical control of ESCs both in vitro and in vivo, ranging from noninvasive control of stem cell differentiation to causal assessment of the specific contribution of transplanted cells to tissue and network function.

Maturity onset diabetes of the young: clinical characteristics and outcome after kidney and pancreas transplantation in MODY3 and RCAD patients: a single center experience.

The diabetes and renal phenotype of patients with maturity-onset diabetes of the young (MODY) on a transplantation waiting list is not known; neither is their outcome after pancreas (PT) and/or kidney transplantation (KT). Between 2002 and 2009, we screened 50 of 150 patients referred for kidney and pancreas transplantation to the Kremlin-Bicêtre center for HNF1B and HNF1A mutations if one or more of the following criteria was present (i) an atypical history of diabetes (ii) diabetes with at least one affected parent or two affected relatives, (iii) an absence of auto-antibodies at diagnosis (iv) a persistent secretion of fasting C peptide (v) a personal or a family history of renal cysts or dysplasia. Their phenotype and their outcome were analyzed. Four HNF1A (MODY3) and eight HNF1B mutations [renal cysts and diabetes (RCAD)] were identified. All MODY3 patients had diabetic nephropathy, but only 50% of RCAD patients. Four patients underwent a kidney and pancreas transplantation and two a kidney transplant alone. After 4.1 ± 1.1 years of follow-up, 83% of patients still have a functioning kidney and 75% a functioning pancreas. PT can be proposed with good results for MODY3 and RCAD patients.