Incidence and long-term follow-up of silent cerebral lesions after pulmonary vein isolation using a remote robotic navigation system as compared with manual ablation.

BACKGROUND: The incidence of silent cerebral lesions (SCL) after atrial fibrillation (AF) ablation is highly variable, depending on the technology used. Recently, an increased risk for SCL has been described for a novel, nonirrigated ablation tool using multielectrode phased radiofrequency (PVAC). The aim of this prospective study was to evaluate the incidence and long-term follow-up of SCL in patients undergoing robotically assisted pulmonary vein isolation (RA-PVI) as compared with manual PVI. METHODS AND RESULTS: Circumferential PVI using irrigated radiofrequency current was performed on 70 patients (41 patients with paroxysmal AF, 59%). Fifty patients underwent RA-PVI and 20 patients underwent a manual approach. Cerebral MRI was performed the day before and the day after the ablation procedure; follow-up MRI was performed on 9 of 12 (75%) patients after a follow-up period of 21 months. SCLs were found in 12 of 70 (17%) patients in this study; the incidence of SCLs was similar in patients undergoing RA-PVI as compared with manually ablated patients (n=9, 18% versus n=3, 15%; probability value=1.0). In 1 patient undergoing manual PVI (1%), an SCL with asymptomatic subarachnoid hemorrhage was detected; the bleeding completely resolved within 1 month. Transient ischemic attack occurred in 1 (1%) patient 2 days after manual PVI. After a median follow-up period of 21 months, no residual SCLs were detected. CONCLUSIONS: The incidence of SCL using the robotic navigation system was 18% in this study. Incidence and size of SCL appears to be similar after RA-PVI as compared with manual PVI. Repeat MRI showed no residual SCLs at long-term follow-up.

Loss of the sense of self-ownership for perceptions of objects in a case of right inferior temporal, parieto-occipital and precentral hypometabolism.

Philosophers define the 'minimal self' as the immediate awareness of being the agent and owner of one's actions and perceptions. Here, we describe a patient with a selective loss of one part of this 'minimal self', namely the immediate sense of self-ownership for perceptions of objects. In contrast, his sense of self-ownership for body perceptions and for self-agency during actions remained intact. 18-Fluorodeoxyglucose positron emission tomography revealed predominantly right inferior temporal hypometabolism in comparison with healthy controls (parahippocampal and fusiform gyri). In addition, dysfunction of the right parieto-occipital junction and precentral cortex were detected. Taken together, we demonstrate selective changes in the quality of the sense of self-ownership for perceptions of objects but not actions and an intact sense of self-agency, which points to anatomically separable systems underpinning different aspects of the 'minimal self'. The associated hypometabolism in inferior temporal, parieto-occipital and motor regions, but not in medial prefrontal areas most consistently associated with self-referential processing, are most parsimoniously explained when self-consciousness is not assumed to be an anatomically localized cognitive function, but instead is conceived as emerging from integration across anatomically distributed networks of regions with different functional specializations, not all of which need to be special for the 'self'.

Patterns of regional brain hypometabolism associated with knowledge of semantic features and categories in Alzheimer's disease.

The study of semantic memory in patients with Alzheimer's disease (AD) has raised important questions about the representation of conceptual knowledge in the human brain. It is still unknown whether semantic memory impairments are caused by localized damage to specialized regions or by diffuse damage to distributed representations within nonspecialized brain areas. To our knowledge, there have been no direct correlations of neuroimaging of in vivo brain function in AD with performance on tasks differentially addressing visual and functional knowledge of living and nonliving concepts. We used a semantic verification task and resting 18-fluorodeoxyglucose positron emission tomography in a group of mild to moderate AD patients to investigate this issue. The four task conditions required semantic knowledge of (1) visual, (2) functional properties of living objects, and (3) visual or (4) functional properties of nonliving objects. Visual property verification of living objects was significantly correlated with left posterior fusiform gyrus metabolism (Brodmann's area [BA] 37/19). Effects of visual and functional property verification for non-living objects largely overlapped in the left anterior temporal (BA 38/20) and bilateral premotor areas (BA 6), with the visual condition extending more into left lateral precentral areas. There were no associations with functional property verification for living concepts. Our results provide strong support for anatomically separable representations of living and nonliving concepts, as well as visual feature knowledge of living objects, and against distributed accounts of semantic memory that view visual and functional features of living and nonliving objects as distributed across a common set of brain areas.

Blood-brain barrier disruption by low-frequency ultrasound.

BACKGROUND AND PURPOSE: A recent study showed a dramatic increase in cerebral hemorrhage comprising atypical locations with low-frequency ultrasound-mediated recombinant tissue plasminogen activator-thrombolysis in humans. Here, we provide a possible explanation for this phenomenon by a side effect observed in a study using the similar ultrasound device. METHODS: The study was originally undertaken to investigate by transcranial Doppler sonography, positron emission tomography and perfusion MRI whether transcranial application of wide-field low-frequency ultrasound (300 kHz) improves cerebral hemodynamics in patients with cerebral small vessel disease. RESULTS: Showing no clear positive effect on cerebral hemodynamics in 4 patients and on cerebral perfusion (positron emission tomography) in 2 patients, the study has been terminated early because of a remarkable side effect in the first patient (a 62 year-old man) undergoing perfusion-MRI: detection of frontoparietal extravasation of Gadolinium contrast agent (applied during MRI perfusion imaging preinsonation) on MRI immediately postinsonation. CONCLUSIONS: Abnormal permeability of the human blood-brain barrier can be induced by wide-field low-frequency insonation. The observed excessive bleeding rate with low-frequency sonothrombolysis might thus be attributable to primary blood-brain barrier disruption by ultrasound.

Mapping of temporal and parietal cortex in progressive nonfluent aphasia and Alzheimer's disease using chemical shift imaging, voxel-based morphometry and positron emission tomography.

Little and controversial evidence is available from neuroimaging studies in progressive nonfluent aphasia (PNA). The goal of this study was to combine information from different imaging modalities in PNA compared with Alzheimer's disease (AD). Chemical shift imaging (CSI), voxel-based morphometry (VBM) and fluorodeoxyglucose positron emission tomography (FDG-PET) were used in 5 PNA, 10 AD patients and 10 normal subjects. Group comparisons revealed left anterior lateral temporal abnormalities (BA20/21) in PNA using CSI, VBM and PET in comparison to normal subjects. AD patients showed more limited hypometabolism within the same area. In addition left lateral parietal (BA40) abnormalities were demonstrated in our PNA as well as our AD group using PET and VBM (AD group only). Combining information from all imaging modalities on a single case basis revealed pathology within the left anterior lateral temporal and lateral parietal lobe both in PNA and AD. PNA and AD patients differed significantly, however, with respect to the frequency of medial temporal lobe and posterior cingulate/precuneus involvement. Although our results might not be generalizable to all subgroups of PNA, we conclude that medial temporal and posterior cingulate/precuneus cortex pathology as assessed by CSI and VBM or PET distinguish PNA from AD, whereas lateral temporal and parietal areas are involved in both conditions.

Posterior cortical atrophy: variant of Alzheimer's disease? A case series with PET findings.

Nine patients with posterior cortical atrophy (PCA), a rare degenerative brain disease of unclear etiology and nosology, were followed over a mean time of 7.4 years. The mean age at onset was low (56.2 years). At onset, eight patients had visuo-spatial and eight had memory impairment. A minority showed early signs of occipital lobe involvement with visual agnosia or hemianopia. Eight patients developed dementia after a mean course of five years. 18F-FDG-PET data of six patients were analysed with statistical parametric mapping. They showed hypometabolism centred on the lateral and medial parietal associative cortex, with variable involvement of the adjacent temporal and occipital associative cortex. A minority showed involvement of the frontal lobes, possibly related to deafferenting of areas related to the control of eye movements. Atrophy and hypometabolism were markedly asymmetric in a subset of cases. Autopsy was performed in one patient. Presenile onset, location, and asymmetry of atrophy suggest that PCA represents a biologically separable variant of Alzheimer's disease.

Hemispheric asymmetries of hypometabolism associated with semantic memory impairment in Alzheimer's disease: a study using positron emission tomography with fluorodeoxyglucose-F18.

Considerable disagreement exists about the neuroanatomical basis of conceptual-semantic impairments observed in a subgroup of patients with Alzheimer's disease (AD) at mild to moderate stages of the disease. Several studies of groups of patients have shown correlations between focal hypometabolism or hypoperfusion in left hemispheric areas and measures of verbal semantic memory impairment in AD patients. The question remains, however, whether left hemispheric hypometabolism is sufficient to produce such impairment in the single case and whether nonverbal semantic knowledge is also affected. We used positron emission tomography (PET) with fluorodeoxyglucose-F18 (FDG), statistical parametric mapping (SPM), and tests of verbal and nonverbal semantic memory in 11 AD patients with a mean score on the Mini-Mental State Examination of 22.6 (+/-2.8). Naming impairment was significantly associated with left hemispheric asymmetry of hypometabolism on a single-case basis. Our correlation analysis showed that metabolism in left anterior temporal, posterior inferior temporal, inferior parietal and medial occipital areas (Brodmann areas: 21/38, 37, 40 and 19) correlated with both verbal and nonverbal semantic performance. We conclude that left hemispheric synaptic dysfunction, as measured by regional glucose hypometabolism, was sufficient to produce semantic impairments in our patients. The majority of areas affected in our patients with semantic impairments were involved in multimodal or supramodal (verbal and nonverbal) semantic knowledge.

Complex visual hallucinations (Charles Bonnet syndrome) in visual field defects following cerebral surgery. Report of four cases.

The development of visual hallucinations after loss of vision is known as the Charles Bonnet syndrome. This phenomenon was first described in 1760 by Charles Bonnet and others during their observations of elderly patients with degeneration of the retina or cornea. To date a clear association between visual hallucinations and neurosurgical procedures has not been reported. Because of their clear demarcation, however, surgical lesions in the cerebrum offer a unique opportunity to determine the pathoanatomical aspects of visual hallucinations. During a 3-year period, 41 consecutive patients who acquired visual field defects after neurosurgery were examined for the occurrence of visual hallucination. Postoperatively, four of these patients experienced visual hallucinations. In two of them an upper quadrantanopia developed after the patients had undergone selective amygdalohippocampectomy. In the other two patients a complete hemianopia developed, in one case after resection of a parietal astrocytoma and in the other after resection of an occipital glioblastoma multiforme. The visual hallucinations were transient and gradually disappeared between 4 days and 6 months postoperatively. The patients were aware of the fact that their hallucinations were fictitious and displayed no psychosis. Electroencephalographic recordings were obtained in only two patients and epileptic discharges were found. Deafferentiation of cortical association areas may lead to the spontaneous generation of complex visual phenomena. In the present series this phenomenon occurred in approximately 10% of patients with postoperative visual field defects. In all four cases the central optic radiation was damaged between the lateral geniculate nucleus and the primary visual cortex. The complex nature of the visual hallucination indicates that they were generated in visual association areas.

Unusual bilateral Tc-99m DPD uptake on bone scan.

A 74-year-old man with prostate cancer was screened for bone metastases. The scan exhibited severe degenerative skeletal changes (especially in the spine and the right knee) and catheter drainage of the bladder, but obviously no bone metastases. Surprisingly, 2 almost symmetric "devil-like"-looking lesions were noted in the frontolateral skull. The patient was treated with bilateral bore hole trepanation because of a subdural hematoma 3 weeks earlier. The lesions can be interpreted as augmented bone metabolism in these regions. Although subdural hematoma is fairly common (incidence, 15:100,000 annually), bilateral trepanation is only performed in approximately 5% of patients.

3D-Cardiac-PET. A Recommendable Clinical Alternative to 2D-Cardiac-PET?

The objective of this study was to test the clinical practicability of a 3D-cardiac-positron emission tomography(PET) procedure. During preoperative viability diagnostics of the myocardium with fluorine-18-fluorodeoxyglucose(18F-FDG)PET, comparative recordings were made in 2D (ECAT Exact) and 3D Mode (Quest). Ten patients (2 women, 8 men, ages 34-72 years) with coronary artery disease and a known myocardial infarction in the history were examined. Both examinations were made on the same day following single FDG injection. In 9 of the 10 cases, 3 independent examiners arrived at the same diagnoses from the 2D and 3D recordings, whereby only one-third the activity used for 2D exposures was required for 3D acquisition. In one case, the 3D recording showed no accumulation around the anterior wall near the apex, in spite of demonstrated, albeit limited, viability in the 2D mode. The cause of this discrepant finding is assumed to lie in equipment/uptake and patient-related differences in the test configuration. In summary, 3D acquisition offers a promising alternative to 2D recordings in the viability diagnostics of the myocardium based on a considerable reduction in radiation exposure for patients and personnel, as well as reduction in the costs for radiopharmaceuticals. Further evaluation of the method in broader studies would appear necessary.