Local sleep-like cortical reactivity in the awake brain after focal injury.

The functional consequences of focal brain injury are thought to be contingent on neuronal alterations extending beyond the area of structural damage. This phenomenon, also known as diaschisis, has clinical and metabolic correlates but lacks a clear electrophysiological counterpart, except for the long-standing evidence of a relative EEG slowing over the injured hemisphere. Here, we aim at testing whether this EEG slowing is linked to the pathological intrusion of sleep-like cortical dynamics within an awake brain. We used a combination of transcranial magnetic stimulation and electroencephalography (TMS/EEG) to study cortical reactivity in a cohort of 30 conscious awake patients with chronic focal and multifocal brain injuries of ischaemic, haemorrhagic and traumatic aetiology. We found that different patterns of cortical reactivity typically associated with different brain states (coma, sleep, wakefulness) can coexist within the same brain. Specifically, we detected the occurrence of prominent sleep-like TMS-evoked slow waves and off-periods-reflecting transient suppressions of neuronal activity-in the area surrounding focal cortical injuries. These perilesional sleep-like responses were associated with a local disruption of signal complexity whereas complex responses typical of the awake brain were present when stimulating the contralesional hemisphere. These results shed light on the electrophysiological properties of the tissue surrounding focal brain injuries in humans. Perilesional sleep-like off-periods can disrupt network activity but are potentially reversible, thus representing a principled read-out for the neurophysiological assessment of stroke patients, as well as an interesting target for rehabilitation.

Italian registry of cardiac magnetic resonance.

OBJECTIVES: Forty sites were involved in this multicenter and multivendor registry, which sought to evaluate indications, spectrum of protocols, impact on clinical decision making and safety profile of cardiac magnetic resonance (CMR). MATERIALS AND METHODS: Data were prospectively collected on a 6-month period and included 3376 patients (47.2 ± 19 years; range 1-92 years). Recruited centers were asked to complete a preliminary general report followed by a single form/patient. Referral physicians were not required to exhibit any specific certificate of competency in CMR imaging. RESULTS: Exams were performed with 1.5T scanners in 96% of cases followed by 3T (3%) and 1T (1%) magnets and contrast was administered in 84% of cases. The majority of cases were performed for the workup of inflammatory heart disease/cardiomyopathies representing overall 55.7% of exams followed by the assessment of myocardial viability and acute infarction (respectively 6.9% and 5.9% of patients). In 49% of cases the final diagnosis provided was considered relevant and with impact on patient's clinical/therapeutic management. Safety evaluation revealed 30 (0.88%) clinical events, most of which due to patient's preexisting conditions. Radiological reporting was recorded in 73% of exams. CONCLUSIONS: CMR is performed in a large number of centers in Italy with relevant impact on clinical decision making and high safety profile.

Segmentation of cardiac cine MR images of left and right ventricles: interactive semiautomated methods and manual contouring by two readers with different education and experience.

PURPOSE: To test interactive semiautomated methods (ISAM) vs. manual contouring (MC) in segmenting cardiac cine MR images. MATERIALS AND METHODS: Short-axis images of 10 consecutive patients (1.5-81.5 years of age) were evaluated by a trained radiologist (R1) and a low-trained engineer (R2). Each of them performed four independent reading sessions: two using ISAM and two using MC. Left ventricle (LV) myocardial mass (LVMM), LV ejection fraction (LVEF), and right ventricle (RV) ejection fraction (RVEF) were obtained. Bland-Altman analysis and Wilcoxon test were used. RESULTS: The bias +/- 2 standard deviations (SD) of ISAM vs. MC for LVMM (g) was -5.7 +/- 13.4 (R1) and -5.5 +/- 26.3 (R2); for LVEF (%) it was -1.4 +/- 13.0 and -2.9 +/- and 6.8; for RVEF (%) it was 2.6 +/- 17.0 and 1.0 +/- 16.7. Considering both readers/methods, intraobserver bias +/- 2 SD ranged from 0.3 +/- 25.3 to -6.8 +/- 23.0, from 0.2 +/- 8.0 to -4.4 +/- 15.8, and from -0.0 +/- 26.4 to -4.6 +/- 27.8, respectively. Interobserver bias +/- 2 SD was -25.9 +/- 46.0 (ISAM) and 26.1 +/- 36.4 (MC), -1.4 +/- 8.6 (ISAM) and 0.1 +/- 17.9 (MC), and 0.7 +/- 23.3 and 2.3 +/- 29.8, respectively. Larger SDs were systematically found for RVEF vs. LVEF. Segmentation times: five minutes for LV with ISAM (both readers); for LV with MC, six (R1) vs. nine minutes (R2) (P < 0.001); five to six minutes for RV (both methods /readers). R2 significantly reduced LV segmentation times from nine (MC) to five minutes (ISAM) (P < 0.001). CONCLUSION: A highly reproducible LV segmentation was performed in a short time by R1. The advantage of ISAM vs. MC for LV segmentation was a time saving only for R2. For RVEF, a lower reproducibility was observed for both methods and readers.

Successful conservative management of benign gastro-bronchial fistula after intrathoracic esophagogastrostomy.

Benign gastro-bronchial fistula is a rare and devastating complication of esophagectomy with gastric replacement. The most likely cause is a leak from the esophagogastric anastomosis with subsequent mediastinal abscess and rupture into the posterior wall of the tracheobronchial tree. The clinical presentation includes cough upon swallowing, fever, and recurrent pneumonia. Early surgical treatment is the standard of care. A unique case of chronic gastro-bronchial fistula is reported in this article. The patient, a 57-year-old woman, was referred from another hospital after 6 months of symptomatic therapy and total enteral nutrition. A self-expanding esophageal metal stent allowed exclusion of the fistula with symptom relief and return to oral alimentation.

Thrombolytic therapy followed by stenting for renal artery dissection secondary to blunt trauma.

A 18-year-old man presented at our clinic with pain in the right flank following a motorbike accident. The diagnosis of renal artery dissection followed by thrombosis was made by computed tomography and confirmed by angiography. Successful revascularization was performed by means of repeated transcatheter injection of small doses of thrombolytic agents within the vessel, followed by deployment of a self-expandable stent. There were no complications, and the patient recovered well. Six months after stent placement, a selective renal angiogram showed excellent flow through the stented portion of the artery and normal parenchyma enhancement in the right kidney.

How many medical requests for US, body CT, and musculoskeletal MR exams in outpatients are inadequate?

PURPOSE: Our aim was to evaluate how many medical requests for US, CT and MR outpatients exams are inadequate. MATERIALS AND METHODS: We evaluated three series of consecutive requests for outpatients exams, distinguishing firstly the adequate from the inadequate requests. The inadequate requests were classified as: (A) absence of real indication; (B) lacking or vague clinical query; (C) absence of important information on patient's status. US requests concerned 282 patients for 300 body segments, as follows: neck (n=50); upper abdomen (n=95); lower abdomen (n=12); upper and lower abdomen (n=84); musculoskeletal (n=32); other body segments (n=27). CT requests concerned 280 patients for 300 body segments, as follows: chest (n=67); abdomen (n=77); musculoskeletal (n=94); other body segments (n=62). MR musculoskeletal requests concerned 138 patients for 150 body segments, as follows: knee (n=87); ankle (n=13); shoulder (n=28) , other body segments (n=22). RESULTS: A total of 228/300 US requests (76%) were inadequate, ranging from 66% (musculoskeletal) to 86% (neck), classified as: A, 21/228 (9%); B, 130/228 (57%); C, 77/228 (34%). A total of 231/300 (77%) body CT requests were inadequate, ranging from 72% (chest) to 86% (musculoskeletal), classified as: A, 22/231(10%); B, 88/231(38%); C, 121/231(52%). A total of 124/150 (83%) MR musculoskeletal requests were inadequate, ranging from 69% (ankle) to 89% (knee), classified as: A, 12/124(10%); B, 50/124(40%); C, 62/124 (50%). No significant difference was found among the levels of inadequacy for the three techniques and among the body segments for each of the three techniques. CONCLUSIONS: The majority of the medical requests for outpatient exams turned out to be inadequate. A large communication gap between referring physicians and radiologists needs to be filled.