ESR Essentials: ten steps to cardiac MR-practice recommendations by ESCR.

Cardiovascular MR imaging has become an indispensable noninvasive tool in diagnosing and monitoring a broad range of cardiovascular diseases. Key to its clinical success and efficiency are appropriate clinical indication triage, technical expertise, patient safety, standardized preparation and execution, quality assurance, efficient post-processing, structured reporting, and communication and clinical integration of findings. Technological advancements are driving faster, more accessible, and cost-effective approaches. This ESR Essentials article presents a ten-step guide for implementing a cardiovascular MR program, covering indication assessments, optimized imaging, post-processing, and detailed reporting. Future goals include streamlined protocols, improved tissue characterization, and automation for greater standardization and efficiency. CLINICAL RELEVANCE STATEMENT: The growing clinical role of cardiovascular MR in risk assessment, diagnosis, and treatment planning highlights the necessity for radiologists to achieve expertise in this modality, advancing precision medicine and healthcare efficiency. KEY POINTS: • Cardiovascular MR is essential in diagnosing and monitoring many acute and chronic cardiovascular pathologies. • Features such as technical expertise, quality assurance, patient safety, and optimized tailored imaging protocols, among others, are essential for a successful cardiovascular MR program. • Ongoing technological advances will push rapid multi-parametric cardiovascular MR, thus improving accessibility, patient comfort, and cost-effectiveness. KEY POINTS: • Cardiovascular MR is essential in diagnosing and monitoring a wide array of cardiovascular pathologies (Level of Evidence: High). • A successful cardiovascular MR program depends on standardization (Level of Evidence: Low). • Future developments will increase the efficiency and accessibility of cardiovascular MR (Level of Evidence: Low).

Costotransversectomy in the Surgical Treatment of Mediolateral Thoracic Disk Herniations: Long-Term Results and Recent Minimally Invasive Technical Adjuncts.

Thoracic herniated disks are relatively rare. They account for approximately 2% of all intervertebral herniated disks in large series. Traditional surgery via laminectomy has frequently yielded disappointing results, although the recent literature reports that anterior calcified thoracic herniation was successfully treated with this approach. This issue has encouraged a search for alternatives, such as anterolateral, lateral, and posterolateral approaches to the thoracic spine. From January 2009 to December 2019, we selected 66 patients harboring a symptomatic median-paramedian herniated disk at the level of the thoracic spine, treated at the authors' institutions. The present experience would give further support to the use of costotrasversectomy, along with its "mini-invasive" modifications, as a suitable and safe approach for thoracic disk disease. Although we must admit that endoscopy is likely to become the gold standard of surgical method in the future and that the anterior approach with mini-toracotomy without rib removal will become popular, the future scenario could certainly reserve an important place for the approach we have used in the surgical management of this challenging spinal pathology, mainly because of the approach's versatility and short learning curve.

Retrolabyrinthine approach to the lateral skull base: The value of preoperative temporal bone CT analysis.

PURPOSE: The most used neurosurgical approach to reach cerebellar-pontine angle is the retrosigmoid route. This article describes the presigmoid approach which requires excellent knowledge of the labyrinthine block together with quantitative analysis of temporal bone CT. METHODS: CT-based quantitative measurements were obtained in patients undergoing vestibular neurectomy with a presigmoid approach. Eighteen patients were enrolled, and five measures were taken: Trautmann's area, the petro-clival angle, presigmoid dura length and its angle. The relationship between these measurements and hospitalization days, operating times, and complications was explored. RESULTS: The posterior semicircilar canal (PSC)-sigmoid sinus (SS) distance, presigmoid dura- internal auditory canal (IAC)-PSC angle, and duration of surgery are predictors of complications. Specifically, a PSC-sigmoid sinus distance <11 mm, a dura presig-IAC-PSC angle <14 are associated with the highest risk of complications. CONCLUSION: Preoperative temporal bone CT scan can guide the surgeon through the narrowest areas of the surgical approach. Trautmann's triangle area and petro-clival angle reduction are challenging and can be faced with combined microscopic-endoscopic technique, and with optics angulation-rotation. The retrolabyrinthine approach can enable hearing preservation and minimal cerebellar retraction.

Selective Vestibular Neurectomy through the Presigmoid Retrolabyrinthine Approach in the Treatment of Meniere's Disease.

BACKGROUND: Meniere's disease (MD) is a disabling disease, especially in patients who are refractory to medical therapy. Moreover, selective vestibular neurectomy (VN), in these selected cases, can be considered a surgical alternative which preserves hearing function and facial nerve. METHODS: We retrospectively studied 23 patients with MD diagnosis and history of failed extradural endolymphatic sac surgery (ELSS) who underwent combined micro-endoscopic selective VN, between January 2019 and August 2023, via a presigmoid retrolabyrinthine approach. All patients were stratified according to clinical features, assessing preoperative and postoperative hearing levels and quality of life. RESULTS: At the maximum present follow-up of 2 years, this procedure is characterized by a low rate of complications and about 90% vertigo control after surgery. No definitive facial palsy or hearing loss was described in this series. One patient required reintervention for a CSF fistula. Statistically significant (p = 0.001) difference was found between the preoperative and the postoperative performance in terms of physical, functional, and emotive scales assessed via the DHI questionnaire. CONCLUSIONS: Selective VN via a presigmoid retrolabyrinthine approach is a safe procedure for intractable vertigo associated with MD, when residual hearing function still exists. The use of the endoscope and intraoperative neuromonitoring guaranteed a precise result, saving the cochlear fibers and facial nerve. The approach for VN is a familiar procedure to the otolaryngologist, as is lateral skull base anatomy to the neurosurgeon; therefore, the best results are obtained with multidisciplinary teamwork.

Pre-TAVI imaging: an Italian survey by the CT PRotocol optimization (CT-PRO) group.

PURPOSE: The purpose of this survey was to evaluate the current state-of-art of pre-TAVI imaging in a large radiological professional community. METHODS: Between December 2022 and January 2023 all members of the Italian Society of Medical and Interventional Radiology (SIRM) were invited by the CT PRotocol Optimization group (CT-PRO group) to complete an online 24-item questionnaire about pre-TAVI imaging. RESULTS: 557 SIRM members participated in the survey. The greatest part of respondents were consultant radiologists employed in public hospitals and 84% claimed to routinely perform pre-TAVI imaging at their institutions. The most widespread acquisition protocol consisted of an ECG-gated CT angiography (CTA) scan of the aortic root and heart followed by a non-ECG-synchronized CTA of the thorax, abdomen, and pelvis. Contrast agent administration was generally tailored on the patient's body weight with a preference for using high concentration contrast media. The reports were commonly written by radiologists with expertise in cardiovascular imaging, and included all the measurements suggested by current guidelines for adequate pre-procedural planning. About 60% of the subjects affirmed that the Heart Team is present at their institutions, however only 7% of the respondents regularly attended the multidisciplinary meetings. CONCLUSIONS: This survey defines the current pre-TAVI imaging practice in a large radiological professional community. Interestingly, despite the majority of radiologists follow the current guidelines regarding acquisition and reporting of pre-TAVI imaging studies, there is still a noteworthy absence from multidisciplinary meetings and from the Heart Team.

Microsurgical endoscopy-assisted presigmoid retrolabyrinthine approach as a minimally invasive surgical option for the treatment of medium to large vestibular schwannomas.

BACKGROUND: Treatment of vestibular schwannomas presents many controversial aspects, from the indication to the selection of the best treatment option. In the era of stereotactic radiotherapy, microsurgery has to be competitive in terms of providing the best chances of functional preservation and complete tumor removal. The two most commonly used surgical approaches are the retrosigmoid suboccipital and the presigmoid translabyrinthine. We describe the endoscopy-assisted presigmoid retrolabyrinthine approach (EAPRA) aiming at combining the advantages of the retrosigmoid and translabyrinthine techniques. METHODS: For 2 years (from May 2009 to June 2011), the EAPRA was used to remove medium to large sporadic vestibular schwannomas in ten patients. RESULTS: Complete tumor removal was obtained in eight patients, postoperative transient facial nerve function impairment or worsening was observed in two, and one had hearing deterioration postoperatively. No threatening complications occurred after surgery, and the length of hospitalization was usually less than 10 days. CONCLUSIONS: The EAPRA can provide direct access to the CPA along with labyrinthine complex conservation, allowing hearing function preservation and minimal cerebellar retraction. Endoscopic assistance is a crucial adjunct in the presigmoid retrolabyrinthine approach in order to address the limits imposed by labyrinthine complex preservation. It ensures complete visualization of the intracanalicular portion of the schwannoma, thus improving the rate of a radical tumor resection. The EAPRA could represent a valid surgical option in vestibular schwannoma surgery.

Bifenestral surgical and chemical labyrinthectomy, a new effective ablative surgical approach to intractable vertigo in Ménière disease elderly patients.

INTRODUCTION: In this article, the bi-fenestral surgical chemical labyrinthectomy is introduced as a surgical demolition technique for treating resisting incurable forms of Meniere's disease in patients aged over 70 and/or with low hearing residues refractory to medical treatment. MATERIALS AND METHODS: The results on participants fitting the inclusion criteria (n = 16) were reported using anamnesis (frequency of the crisis), Dizziness Handicap Inventory (DHI) and Functional Level Scale (FLS) before and after the intervention. RESULTS: Vertigo control was achieved in all patients of this case series. A difference of 57 and 3.67 in mean DHI (from 68 (SD 16.7) to 11 (SD 14)) and FLS (from 4.68 (SD 0.7) to 0.1 (SD 0.3)) scores respectively were seen after an average of 16.28 months. Contextually tinnitus was reported to improve in seven patients (43.75%), aggravate in three (18.75%) and remain unchanged in the remaining six (37.5%). CONCLUSION: Bi-fenestral surgical chemical labyrinthectomy appears a safe, immediate, and effective demolition treatment for vertigo control in a restricted class of patients affected by intractable Meniere disease.

Endolymphatic Duct and Sac Decompression: A New Life for an Old Technique.

BACKGROUND: Ménière's disease is an inner ear disorder causing recurrent vertigo, hearing loss, and tinnitus. Diagnosis is based on the variability of the symptoms over time and absence of radiological abnormalities. Medical therapy is effective only in a small percentage of patients. Surgical strategies remain controversial. In this article, we revisit a surgical technique neglected over the years: endolymphatic sac surgery. METHODS: Fifty-four patients affected by Ménière's disease underwent endolymphatic duct and sac decompression. According to the American Academy of Otolaryngology-Head and Neck Surgery criteria, vertigo control was evaluated with follow-up at 6 months, 1 year, and 2 years from the intervention. Hearing results were evaluated before the surgery and at 2 years of follow-up using the pure tone average. The results were compared with similar techniques of endolymphatic sac surgery described in the literature. RESULTS: According to the American Academy of Otolaryngology-Head and Neck Surgery criteria classification, 2 years after surgery, 87% patients achieved complete control of vertigo (class A). The hearing remained stable in 93.5% of patients. The results appear compatible with other publications data regarding endolymphatic sac surgeries. CONCLUSION: The duct and endolymphatic sac decompression allows the control of vertigo and preserves hearing from the pathological effects of Ménière's disease. The revised technique allows the functional restoration of endolymphatic homeostasis.

Microclimate of Grape Bunch and Sunburn of White Grape Berries: Effect on Wine Quality.

This research aimed to evaluate the composition of wines made with white grapes which are particularly susceptible to sunburn symptoms due to the absence of anthocyanin. Sunburn is a complex physiological dysfunction leading to browning or necrosis of berry tissues. In vintage 2021, the canopy of 'Verdeca' grapevines grown in Salento, South Italy, was differently managed by sun exposing or shading the bunches. Micrometeorological conditions were studied at different levels. Grapes were vinified, comparing the winemaking with and without skin maceration. The vegetative-productive balance of plants was not substantially modified. On the contrary, a significant effect was observed on the quality and quantity of grapes produced: smaller berries with sunburn symptoms were found on unshaded bunches. This influenced the percentage distribution among skin, pulp and seeds, causing a decrease in must yield of up to 30%. The pH was significantly higher in macerated wines made using shaded grapes, due to a lower titratable acidity and to significant impacts on the acid profile. Obviously, maceration produced a higher extraction of phenolics in wines, which reached their maximum in wines made with sunburned grapes. The absorbance at 420 nm, index of yellow color, was also significantly higher in sunburned grapes, indicating greater oxidation. Even though excessive grape sun-exposure could negatively affect the perception of white wines made without maceration (resulting in more oxidative character), the sensory quality of orange/amber wines was not significantly impacted by the presence of sunburned grapes. Thus, this winemaking technique could be particularly interesting to set up a production strategy adapted to viticultural regions strongly affected by climate change.

Endolymphatic duct and sac decompression: A new technique for Ménière's disease treatment.

Background: The present article aims to introduce the endolymphatic duct and sac decompression technique (DASD) and to give a spotlight on its benefits in Ménière's disease (MD) treatment. Methods: Eighty-two patients with intractable MD which met the inclusion criteria were recruited and underwent DASD. This technique allows a meningeal decompression of the duct and the sac from the posterior cranial fossa to the labyrinthine block. The authors considered as main outcomes, the change of the dizziness handicap inventory (DHI) results, with the evaluations of the three sub-scales (Functional scale, Physical scale, and Emotional scale); ear fullness and tinnitus change on the perceptions of the patient; and hearing stage with four-Pure Tone Average (500 hz-1000 hz-2000 hz-4000 hz). The differences between the preoperative and the postoperative score were evaluated. A comparison with the literature was conducted. Results: After a 14-month follow-up, patients that underwent DASD reported a remarkable improvement of the symptoms in all three functional scales, confirmed by the total DHI. The difference between preoperative and postoperative scores is statistically significant. The data describe an ear fullness and tinnitus improvement. The multi-frequency tonal average before and after the surgery does not suggest a worsening of the value for any of 82 patients. Conclusion: The modification of sac surgery includes the endolymphatic duct in the decompression area allowing inner ear functional improvement, vertigo control, ear fullness improvement with minimal risk of facial nerve paralysis, and hearing loss. DASD is an improved old surgical technique.

Minimal invasive resurfacing: an innovative technique for the superior semicircular canal dehiscence. A case series.

The superior semicircular canal dehiscence is a vestibular disease recognized condition in recent years, and surgical therapy has been modeling itself over the years to ensure the control of vestibular symptoms and auditory symptoms. In this case series, the authors have experienced an intervention aimed at closing the superior semicircular canal dehiscence through the insertion of bone paté between the meninx and the residual middle cranial fossa bone wall. Seven patients underwent this intervention, they reported an improvement in all vestibular and auditory symptoms, and hearing threshold remained stable. Despite the small sample size, the difference was significant in the control of dizziness and the reduction of pulsatile tinnitus. The technique described in this article allows the control of symptoms in superior semicircular canal dehiscence, and it is a type of surgery familiar to the otosurgeon and easily replicable as it involves a modified mastoidectomy. More data are needed.

The effects of logon versus click on vestibular evoked myogenic potentials.

CONCLUSION: Logon is superior to click to trigger larger and more consistent vestibular evoked myogenic potentials (VEMPs). OBJECTIVES: To record and compare the parameters of VEMPs evoked by bone- and air-conducted logon (l-VEMPs) and click (c-VEMPs). SUBJECTS AND METHODS: Air- and bone-conducted l-VEMPs and c-VEMPs were recorded in 28 normal ears with an Amplaid MK12 (Amplaid, Milan) equipment. RESULTS: VEMPs response rate was 100% with both air-conducted logon and click, while l-VEMPs showed a higher response rate (79%) in comparison with c-VEMPs (21%) with bone-conducted stimuli. A significant (p<0.05) increase of P1, N1 and P1-N1 amplitude and augmented P1 and N1 latencies were noticed in l-VEMPs with respect to c-VEMPs.

Rap2, but not Rap1 GTPase is expressed in human red blood cells and is involved in vesiculation.

Recent studies have suggested that Rap1 and Rap2 small GTP-binding proteins are both expressed in human red blood cells (RBCs). In this work, we carefully examined the expression of Rap proteins in leukocytes- and platelets-depleted RBCs, whose purity was established on the basis of the selective expression of the beta2 subunit of the Na+/K+ -ATPase, as verified according to the recently proposed "beta-profiling test" [J.F. Hoffman, A. Wickrema, O. Potapova, M. Milanick, D.R. Yingst, Na pump isoforms in human erythroid progenitor cells and mature erythrocytes, Proc. Natl. Acad. Sci. U. S. A. 99 (2002) 14572-14577]. In pure RBCs preparations, Rap2, but not Rap1 was detected immunologically. RT-PCR analysis of mRNA extracted from highly purified reticulocytes confirmed the expression of Rap2b, but not Rap2a, Rap2c, Rap1a or Rap1b. In RBCs, Rap2 was membrane-associated and was rapidly activated upon treatment with Ca2+/Ca2+ -ionophore. In addition, Rap2 segregated and was selectively enriched into microvesicles released by Ca2+ -activated RBCs, suggesting a possible role for this GTPase in membrane shedding.

Platelet interaction with CNBr peptides from type II collagen via integrin alpha2beta1.

Adhesion of blood platelets to fibrillar collagens plays a crucial role in haemostasis. Collagen type II is a homotrimeric member of the fibrillar collagen family, whose ability to interact with platelets has been poorly investigated. In this work, we analysed platelet adhesion to the whole collagen type II molecule, as well as to its CNBr peptides. We found that collagen type II is as efficient as collagen type I in supporting platelet adhesion. Platelet binding sites on collagen type II were identified in two different CNBr-derived peptides, CB8 and CB11. The ability of these peptides to support platelet adhesion required the triple helical conformation. Interaction of platelets with CB8 and CB11 peptides was totally dependent on the presence of Mg(2+) ions, and was completely inhibited by the anti-integrin alpha(2)beta(1) antibody P1E6. Upon adhesion to CB8 and CB11, a significant increase in intracellular protein tyrosine phosphorylation was observed. The pattern of tyrosine phosphorylated proteins in CB8- and CB11-adherent platelets was very similar to that observed in platelets adherent to the whole collagen molecule. By immunoprecipitation experiments, we identified two substrates that were tyrosine phosphorylated in adherent platelets as the tyrosine kinase Syk and the PLCgamma2 isozyme. By contrast, platelet adhesion to CB8 and CB11 did not promote tyrosine phosphorylation of FcR gamma-chain. Finally, we found that collagen type II, but not the CNBr-derived peptides, was able to induce cell aggregation associated to protein tyrosine phosphorylation when added to a platelet suspension. These results identify the CNBr peptides from collagen type II CB8 and CB11 as ligands for platelet integrin alpha(2)beta(1), and recognise their ability to support platelet adhesion and activation.

Otosclerosis and stapedoplasty in older adults.

OBJECTIVES: To evaluate the efficacy of stapedoplasty in patients aged 60 and older, based on audiometric data and a questionnaire about quality of life. DESIGN: A retrospective (1994-2000) study. SETTING: People living in southern and central Italy. PARTICIPANTS: Sixty-three patients: 32 consecutive patients aged 60 and older (group 1) and 31 consecutive patients younger than 60 (group 2). MEASUREMENTS: In each patient, we evaluated the pre- and postoperative auditory thresholds. Each patient answered a questionnaire about postoperative quality of life. RESULTS: When comparing the pre- and postoperative air conduction thresholds and air-bone gap in the patients aged 60 and older, a statistically significant (P <.001) improvement at each frequency was observed. When elaborating the answers to the questionnaire about postoperative quality of life, we noticed that the older patients experienced a greater improvement. CONCLUSION: The results show that stapedoplasty offers greater improvement in quality of life for selected adults aged 60 and older than for younger adults. The operation also appears to be as safe for adults aged 60 and older as for younger adults. Stapedoplasty provides subjects with satisfactory social hearing level (hearing capacity sufficient for normal social relations) and slows the progression of otosclerosis. Providing older patients with good auditory functionality improves their state of health, quality of life, and cognitive processes.

Treatment of benign positional vertigo in the elderly: a randomized trial.

OBJECTIVES/HYPOTHESIS: The objective of the study was to evaluate the efficacy of three therapeutic strategies (Semont maneuver, flunarizine, and no treatment) in patients with benign paroxysmal positional vertigo. STUDY DESIGN: Randomized prospective trial. METHODS: One hundred fifty-six consecutive patients older than 60 years of age who were affected by benign paroxysmal positional vertigo of the posterior semicircular canal were enrolled. The diagnosis was made on the basis of the history of recurrent sudden crisis of vertigo and positional-induced typical nystagmus after Dix-Hallpike positioning maneuver. Patients were randomly allocated to receive Semont liberatory maneuver (intended as a statoconia-detachment maneuver), flunarizine, or no treatment. A post-treatment negative Dix-Hallpike test result was considered as a proof of vertigo resolution. RESULTS: Cure rates with Semont maneuver were significantly higher (94.2%) than those obtained with flunarizine (57.7%) and no treatment (36.4%) (P <.001). Within a 6-month follow-up, relapse rates were lower among patients treated with Semont maneuver (3.8%) than those obtained with flunarizine (5.8%) and no treatment (21.1%). All patients with resolution of symptoms and negative Dix-Hallpike test results showed a great improvement in daily activities and quality of life (P <.001). CONCLUSION: Semont liberatory maneuver is the most successful therapy for benign paroxysmal positional vertigo and improves patients' quality of life. Diagnostic and therapeutic maneuvers are easy to perform and should be part of the medical knowledge of every general practitioner and geriatrician.

Stapedoplasty in patients with small air-bone gap: why not?

Otosclerosis is a primary osteodystrophy which affects a localized area within the human temporal bone. Hearing loss is the most functional deficit caused by otosclerosis. However, tinnitus and vestibular disorders are frequently reported by otosclerotic patients, especially in those patients with inner ear involvement. The best therapy in achieving a significant improvement is surgery (stapedoplasty). In most patients if the operation is not carried out for pure middle ear type, the hearing impairment can progress to high-degree hearing loss. Recently, guidelines for the treatment of otosclerosis reported the 20 dbHL threshold as the minimum air-bone gap in performing stapedoplasty. We believe that stapedoplasty is an effective procedure for selected patients affected by otosclerosis with an air-bone gap which is smaller than 20 dbHL. An operation in the earlier phases of the disease can arrest the progression of otosclerosis, preserve inner ear structures and provide a complete auditory recovery, with increased satisfaction of the patient.

Preserved otoacoustic emissions in postparotitis profound unilateral hearing loss: a case report.

We report a case of a profound unilateral sensorineural hearing loss following epidemic parotitis, with good response of otoacoustic emissions. The patient was a 12-year-old girl who had developed a unilateral hearing impairment 2 weeks after the onset of mumps. Pure tone audiometry confirmed a profound left sensorineural hearing loss. The affected ear showed an absence of auditory brain stem responses, whereas transient evoked otoacoustic emissions and distortion product otoacoustic emissions were preserved. Epidemic parotitis virus is likely responsible for an impairment of inner hair cells, primary afferent fibers or their synapses, or a combination of these areas, and it does not seem to have a specific tropism for cochlear outer hair cells. Further follow-up will be necessary to differentiate the present case from auditory neuropathy.

Hearing loss associated with 35delG mutation in Connexin-26 (GJB2) gene: audiogram analysis.

35delG is the most common mutation in the Connexin-26 gene, representing a major cause of autosomal recessive hearing loss. The aim of this study was to evaluate the relationship between the audiological phenotype and the 35delG mutation in 64 Sicilians with non-syndromic deafness. Pure-tone audiometry and a screening for 35delG mutation were performed. Audiograms were evaluated according to the classification of Liu and Xu. Thirteen homozygotes and nine heterozygotes for the investigated mutation were found. Symmetrical hearing loss was significantly (p=0.008) more common in homozygous subjects than in those without the Connexin-26 mutation. Profound-severe hypoacusia was found in 92.3 per cent of 35delG homozygous, 22.3 per cent of heterozygous and 58.7 per cent of 35delG absent patients. Residual shape audiograms were more frequent in homozygotes. A molecular analysis for the 35delG mutation should be performed in cases of symmetric, severe-profound congenital hearing loss, as a genetic cause is probable in such cases.