Comparative Analysis of Lennox-Gastaut Syndrome With Different Subtypes of Tonic Seizures: A Single-Center Retrospective Cohort Study.

BACKGROUND: Lennox-Gastaut syndrome (LGS) is one of the most severe childhood-onset epileptic encephalopathies, primarily characterized by tonic seizures. In clinical practice, we have identified various subtypes of tonic seizures in LGS. This study aimed to analyze the clinical characteristics, electrographic features, treatment responses, and prognosis across different subtypes of LGS. METHODS: This retrospective cohort study included 46 patients diagnosed with LGS at our center between January 2017 and January 2020. Patients were classified into four groups based on tonic seizure subtypes: Group A (tonic), Group B (spasm-tonic), Group C (myoclonic-tonic), and Group D (combination of spasm-tonic and myoclonic-tonic). Comprehensive clinical data were collected and analyzed. RESULTS: Of the 46 patients, 33 were male. The mean age of onset for Group B (12.38 ± 7.85 months) was significantly less than those of the other three groups (P = 0.02). No significant differences in etiology were found among the groups. Genetic analysis identified mutations in SCN8A, MCCC2, STXBP1, GABRB3, and CACNA1H. After a minimum follow-up of 24 months, the treatment outcomes were more favorable in Groups A and C, whereas psychomotor development was notably poorer in Groups B and D. CONCLUSIONS: The findings of this study suggest that LGS may present with distinct subtypes of tonic seizures, with spasm-tonic seizures presenting at an earlier age. Patients with LGS experiencing spasm-tonic seizures, with or without myoclonic-tonic seizures, exhibited poorer treatment responses and psychomotor development than those with other subtypes.

Optimizing surgical technique in microvascular decompression for hemifacial spasm - Results from a surgical series with contemporary use of neuronavigation and intraoperative neuromonitoring.

Background: Microvascular decompression (MVD) through a retrosigmoid approach is considered the treatment of choice in cases of hemifacial spasm (HFS) due to neurovascular conflict (NVC). Despite the widespread of neuronavigation and intraoperative neuromonitoring (IONM) techniques in neurosurgery, their contemporary application in MVD for HFS has been only anecdotally reported. Methods: Here, we report the results of MVD performed with a combination of neuronavigation and IONM, including lateral spread response (LSR) in 20 HFS patients. HFS clinical outcome and different surgical-related factors, such as craniotomy size, surgical duration, mastoid air cell (MAC) opening, postoperative cerebral spinal fluid (CSF) leakage, sinus injury, and other complications occurrence, and the length of hospitalization (LOS) were studied. Results: Postoperatively, residual spasm persisted only in two patients, but at the latest follow-up (FU) (mean: 12.5 ± 8.98 months), all patients had resolution of symptoms. The mean surgical duration was 103.35 ± 19.36 min, and the mean LOS was 2.21 ± 1.12 days. Craniotomy resulted in 4.21 ± 1.21 cm2 in size. Opening of MAC happened in two cases, whereas no cases of CSF leak were reported as well as no other complications postoperatively and during FU. Conclusion: MVD for HFS is an elective procedure, and for this reason, surgery should integrate all technologies to ensure safety and efficacy. The disappearance of LSR is a crucial factor for identifying the vessel responsible for NVC and for achieving long-term resolution of HFS symptoms. Simultaneously, the benefits of using neuronavigation, including the ability to customize the craniotomy, contribute to reduce the possibility of complications.

Severe cardiac complication as coronary artery spasm during bronchoscopy: a case report.

Background: Bronchoscopy is widely used in clinical diagnosis and treatment of respiratory diseases. Although it is generally safe, cardiac complications such as acute myocardial ischemia and arrhythmia can also occur in patients especially with comorbidities and in elderly ones. Acute malignant coronary vasospasm as a severe cardiac complication can occur during bronchoscopy. It is essential to observe the occurrence of complications and provide early curing. Case Description: We presented a case of a 52-year-old man who experienced chest pain, dyspnea and even shock during bronchoscopy. Electrocardiogram (ECG) showed an acute muti-leads ST-segment elevation and declined to baseline soon after emergent medication treatment including antithrombotic, expansion of coronary artery and fluid replenishment myocardial infarction. Coronary artery spasm was considered according to the clinical symptom and ECG characteristics. Subsequent coronary angiogram which showed normal coronary artery also supported the diagnosis of coronary artery spasm. The symptom of the patient was discovered timely and was treated successfully with good prognosis. Conclusions: Bronchoscopy is the main and important method of diagnosis and treatment for respiratory diseases. Coronary artery spasm as a serious cardiac complication should be paid more attention during bronchoscopy. Timely and appropriate treatment may lead to better clinical results. Multidisciplinary cooperation plays a key role in the whole therapy. The potential triggers of coronary artery spasm during bronchoscopy mainly include low oxygen, hypersensitivity reactions and chronic inflammatory.

Two distinct stages and mechanisms of ST-elevation during cryothermal cavotricuspid isthmus ablation guided by intracardiac echocardiography: A case report.

Radiofrequency (RF) catheter ablation is the primary treatment for cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL), with cryothermal energy as an alternative. While cryoablation offers comparable effectiveness and safety to RF ablation, it poses a risk of coronary artery spasm leading to ST-elevation. This case report presents a 65-year-old man with drug-refractory atrial fibrillation (AF) and AFL undergoing cryothermal CTI ablation guided by intracardiac echocardiography (ICE). During the procedure, two distinct ST-elevation episodes were observed. The first episode coincided with the pull-down of the cryoablation catheter, potentially resulting in coronary compression, as indicated by ICE, and was rapidly resolved by discontinuing the freezing process. The second episode, occurring without active freezing, was attributed to coronary artery spasm and resolved with intracoronary nitroglycerin administration. During the second episode, emergent right coronary angiography confirmed total occlusion in the segment 4 AV adjacent to the region where cryoablation was performed, which fully resolved post-nitroglycerin. This report underscores the dual mechanisms of ST-elevation-coronary artery compression and spasm-during cryothermal CTI ablation, highlighting the critical role of ICE in enhancing procedural safety.

A Case Report of an Atypical Presentation of Morvan Syndrome.

Morvan syndrome, also known as Morvan's fibrillary chorea, is a rare paraneoplastic neurological syndrome presenting with central nervous system (CNS) symptoms, peripheral nerve hyperexcitability, and autonomic nervous system (ANS) manifestations. The etiology and severity of the disease are not well understood. An adult female presented with a sudden onset of chest pain, unilateral extremity weakness, blepharospasms, and muscle spasms, with positive voltage-gated potassium channel (VGKC) antibody and positive neuronal antibody (amphiphysin) in serum. Morvan syndrome can be diagnosed in patients with myokymia, positive VGKC antibody, and neuropsychiatric symptoms with a high clinical index of suspicion. This atypical presentation of Morvan syndrome in a female identifies a novel association of amphiphysin positivity in this rare disease.

Clinical analysis of abnormal muscle response monitoring for hemifacial spasm during microvascular decompression: a retrospective study.

BACKGROUND: Microvascular decompression (MVD) is a widely recognized therapeutic approach for the treatment of hemifacial spasm (HFS). Abnormal muscle response (AMR) is a distinctive electromyographic finding exclusively in patients with HFS. The purpose of our investigation was to determine the correlation between changes in intraoperative AMR and surgical efficacy, as well as the incidence of postoperative complications in patients with HFS after undergoing MVD. METHODS: In this retrospective study, we evaluated 145 patients with HFSs treated with MVD, which was maintained for 1 year postoperatively. The subjects were divided into two groups based on the persistence or disappearance of AMR. Continuous monitoring of AMR during surgery provided data on persistence. All patients were followed up 1 day, 30 days, and 1 year after MVD. A range of potential predictive factors, such as patient demographics, symptom duration, and morphology and latency of AMR, were analyzed using binary logistic regression to assess their relationship with postoperative non-cure and delayed cure rates. RESULTS: The 1 day postoperative cure rate was 77.9%, with a 1 year postoperative cure rate of 94.59% and 1 day postoperative relief rate of 87.6%. A marked distinction was noted between preoperative and 1 year postoperative Cohen grades (P < 0.05). Moreover, 1 day after surgery, the outcome demonstrated significant variability, as shown by the binary logistic regression model (χ2 = 62.913, P < 0.05). The results suggested that factors such as age, symptom duration, disappearance of AMR, and preoperative carbamazepine treatment markedly influence outcomes 1 day after surgery. The binary logistic regression model for delayed cure at 1 year showed significant variability (χ2 = 54.883, P < 0.05). Furthermore, analysis using generalized estimating equations revealed that the duration of postoperative follow-up significantly impacted Cohen grades, as did the disappearance of AMR, with the grade of AMR disappearance being only 10% of that of non-AMR disappearance (P < 0.05). CONCLUSION: Our findings suggest that MVD is an effective intervention for HFS. Our findings also indicate that factors such as patient age, duration of symptoms, disappearance of AMR, and preoperative carbamazepine therapy are significant predictors of 1 day postoperative cure rate. Major predictors for delayed cure at 1 year include age, symptom duration, AMR disappearance, preoperative carbamazepine and botulinum neurotoxin administration, single morphology AMR, and offending vertebral artery.

Altered Brain Structure in Hemifacial Spasm Patients: A Multimodal Brain Structure Study.

Objective: Hemifacial spasm (HFS) is a clinical neurosurgical disease, which brain structural alterations caused by HFS remain a topic of debate. We evaluated changes in brain microstructure associated with HFS and observed their relevance to clinical characteristics. Methods: We enrolled 72 participants. T1-weighted structural and diffusion tensor images were collected from all participants using 3.0T magnetic resonance equipment. Voxel-based morphometry (VBM) and tract-based spatial statistics (TBSS) were used to identify changes in gray matter volume (GMV) and disruptions in white matter (WM) integrity. The severity of the spasms was graded using the Cohn scale. Results: VBM analysis revealed that the GMV was significantly reduced in the left Thalamus and increased GMV in the right Cerebellum IV-V of the HFS group. TBSS analysis showed that FA in the left superior longitudinal fasciculus (SLF) of the HFS group was significantly increased. GMV in the thalamus showed a negative correlation with disease duration and Cohn grade, while FA in the left SLF had a positive correlation with both the disease duration and Cohn grade. Conclusion: We identified regions with altered GMV in HFS patients. Additionally, we determined that FA in the left SLF might serve as a significant neural indicator of HFS.

A Review of the Role of Tests of Coronary Reactivity in Clinical Practice.

Vasoreactivity testing is used by cardiologists in the diagnosis of coronary spasm endotypes, such as epicardial and microvascular spasm. Intracoronary injection of acetylcholine and ergonovine is defined as a standard class I method according to the Coronary Vasomotion Disorder (COVADIS) Group. Because single vasoreactivity testing may have some clinical limitations in detecting the presence of coronary spasm, supplementary or sequential vasoreactivity testing should be reconsidered. The majority of cardiologists do not consider pseudonegative results when performing these vasoreactivity tests. Vasoreactivity testing may have some limitations when it comes to documenting clinical spasm. In the future, cardiologists around the world should use multiple vasoreactivity tests to verify the presence or absence of epicardial and microvascular spasms in the cardiac catheterisation laboratory.

New evidence supports RYR3 as a candidate gene for developmental and epileptic encephalopathy.

Background: The ryanodine receptor 3 (RYR3) is involved in skeletal muscle contraction by releasing calcium from the sarcoplasmic reticulum and subsequent T-tubule depolarization. It is also expressed in the brain, and variants in the RYR3 gene can lead to congenital myopathy type 20 (MIM: #620310). Methods: We retrospectively analyzed the clinical characteristics and prognosis of a case of West syndrome, developmental and epileptic encephalopathy (DEE) caused by a missense variant in the RYR3 gene. We also reviewed and summarized the literature on epilepsy cases caused by RYR3 gene variants. Results: A 10-month-old female child with delayed psychomotor development and recurrent spasm-like seizures was diagnosed with infantile spasm syndrome and DEE. Treatment with various antiepileptic drugs resulted in initial improvement but ultimately failed to control the seizures. Whole-exome sequencing revealed a novel heterozygous variant c.10943C > T/p.T3648M in the RYR3 gene, and genome-wide sequencing ruled out other potentially pathogenic variants. Three previous reports have described RYR3 variants causing DEE, two of which were attributed to de novo heterozygous variants, and one was a compound heterozygote. Conclusion: The present case of DEE caused by a RYR3 heterozygous variant is consistent with previous rare cases of epilepsy caused by RYR3 gene variants in terms of pathogenesis and clinical features, but significantly different from congenital myopathy type 20. Our findings provide important evidence for the diagnosis of RYR3-related DEE, and we hypothesize that RYR3 gain-of-function variants resulting in "leaky" Ca2+ release channels may be a molecular genetic feature leading to DEE rather than myopathy.

Movement disorders of the stomatognathic system: A blind spot between dentistry and medicine.

Movement disorders of the stomatognathic system include oromandibular dystonia (OMD), oral dyskinesia, sleep/awake bruxism, functional (psychogenic) stomatognathic movement disorders (FSMDs), tremors, and hemimasticatory spasm (HMS). Most patients first consult dentists or oral surgeons. The differential diagnoses of these involuntary movements require both neurological and dental knowledge and experience, and some of these movement disorders are likely to be diagnosed as bruxism or temporomandibular disorders (TMDs) by dental professionals. However, excepting movement disorder specialists, neurologists may find it difficult to differentially diagnose these disorders. Patients may visit numerous medical and dental specialties for several years until a diagnosis is made. Therefore, movement disorders of the oral region may represent a blind spot between dentistry and medicine.The present narrative review aimed to describe the clinical characteristics and differential diagnoses of some movement disorders, as well as the problems bridging dentistry and medicine. Movement disorders have the following characteristic clinical features: OMD - task specificity, sensory tricks and the morning benefit; FSMDs - inconsistent and incongruous symptoms, spreading to multiple sites and the lack of sensory tricks; and HMS - the paroxysmal contraction of unilateral jaw-closing muscles, the persistence of symptoms during sleep and the loss of a silent period. A careful differential diagnosis is essential for the adequate and effective treatment of each involuntary movement. Refining the latest definition of bruxism may be necessary to prevent the misdiagnosis of involuntary movements as bruxism.Both dental and medical professionals should take an interest in the movement disorders of the stomatognathic system, and these disorders should be diagnosed and treated by a multidisciplinary team.

Comparative effects of fascial distortion model with and without neuromuscular inhibition technique on pain, range of motion and quality of life in patients with piriformis syndrome.

PURPOSE: This study aimed to compare the effects of the fascial distortion model (FDM) with and without neuromuscular inhibition technique (NIT) on pain, range of motion and quality of life in patients with piriformis syndrome. METHODS: The study was a randomized controlled trial and 54 participants were randomly allocated by lottery method into two groups. Group A (27 participants) received the FDM with NIT and Group B (27 participants) received the FDM alone. The patients were treated for six weeks, three sessions each week on alternate days. Outcome measurements were taken before the first treatment session and after the last (sixth week) session. Numeric Pain Rating Scale, Sciatica Bothersomeness Index (SBI), and Goniometer were used as outcome measures. SPSS version 25 was used for statistical analysis. RESULTS: Data was normally distributed by the Shapiro-Wilk Test. Statistically significant improvements (p < 0.05) were observed in the FDM with NIT than in FDM alone. Both groups show significant results in all outcome measures with paired sample t-tests (p < 0.05). CONCLUSION: This study concluded that participants with piriformis syndrome show more improvement in the FDM with NIT than the FDM group alone. TRIAL REGISTRATION NUMBER: NCT05404607.

This study provides the evidence-based result of the Fascial Distortion Model in patients with piriformis syndrome.The combined effects of both treatment techniques; Fascial Distortion Model and Neuromuscular Inhibition Technique can provide more effective results for piriformis syndrome.

The value of multimodal imaging fusion in preoperative visualization assessment of neurovascular relationship in hemifacial spasm: a single-center retrospective study.

BACKGROUND: The neurovascular conflict (NVC) at the brainstem exit zone of the facial nerve is considered the primary etiology of primary hemifacial spasm (HFS). Therefore, microvascular decompression (MVD) has become the preferred treatment for HFS. Successful neurovascular decompression can achieve significant therapeutic effects, and accurately identifying the site of compression is crucial for the success of this surgery. Detailed diagnostic neuroimaging plays an important role in accurately identifying the site of compression.The purpose of this study is to explore the feasibility and predictive value of preoperative visualization assessment of the neurovascular relationship in HFS using 3D Slicer software based on multimodal imaging fusion. This aims to reduce the omission of responsible vessels and lower the incidence of postoperative complications, thereby potentially improving the efficacy and safety of the surgery. METHODS: This study retrospectively analyzed 80 patients with HFS who underwent MVD surgery. All patients underwent preoperative cranial MRI scans, including the 3D-FIESTA and the 3D-TOF MRA sequences. Three-dimensional models were reconstructed from the multimodal MRI images using 3D Slicer software. Independent observers, who were blinded to the surgical outcomes, evaluated the neurovascular relationships using both the three-dimensional models and multimodal MRI images. The assessment results were compared with intraoperative findings, and statistical analysis was conducted using SPSS 22.0 software. RESULTS: The agreement between preoperative assessment using the 3D-TOF MRA sequence combined with the 3D-FIESTA sequence and intraoperative findings was represented by a Kappa value of 0.343, while the Kappa value for agreement between three-dimensional reconstruction and intraoperative findings was 0.637. There was a statistically significant difference between the two methods ( X2 = 18.852, P = 0.001 ). The sensitivity and specificity of the 3D-TOF MRA sequence combined with the 3D-FIESTA sequence for evaluating neurovascular relationships were 92.4% and 100%, respectively, while for three-dimensional reconstruction, both were 100%. The Kappa value for agreement between preoperative the 3D-TOF MRA sequence combined with the 3D-FIESTA sequence prediction of offending vessels and intraoperative findings was 0.625, while the Kappa value for agreement between three-dimensional reconstruction and intraoperative findings was 0.938, showing a statistically significant difference ( X2 = 317.798, P = 0.000 ). The Kappa value for agreement between preoperative the 3D-TOF MRA sequence combined with the 3D-FIESTA sequence assessment of the anatomical location of facial nerve involvement in neurovascular compression and intraoperative findings was 0.608, while the Kappa value for agreement between three-dimensional reconstruction and intraoperative findings was 0.918, also showing a statistically significant difference ( X2 = 504.647, P = 0.000 ). CONCLUSIONS: The preoperative visualization assessment of neurovascular relationships in HFS using 3D Slicer software based on multimodal imaging fusion has been demonstrated to be reliable. It is more accurate than combining the 3D-TOF MRA sequence with the 3D-FIESTA sequence and shows higher consistency with intraoperative findings. This method provides guidance for surgical procedures and thereby potentially enhances the efficacy and safety of surgeries to a certain extent.

Optimized microvascular decompression surgery for improving the results of hemifacial spasm: an analysis of reoperations.

Microvascular decompression (MVD) surgery is an effective curative treatment for hemifacial spasm (HFS). This study aims to establish techniques that may lead to favorable outcomes by analyzing reoperations in patients with persistent or recurrent HFS.Patients who exhibited persistent or recurrent HFS symptoms after prior MVD surgery were identified as candidates for reoperation. Information regarding the reoperations was collected by tracing the entire surgical procedures and peri-operative management. Clinical manifestations and follow-up data were obtained from the hospital records and subsequent visits.Twenty-six patients underwent repeat MVD surgery. Among them, multi-culprit neurovascular compression (NVC) was identified as the primary cause of failure to response to the previous operation in 73.08% of cases. Pure tissue adhesion accounted for 38.46% of cases, while shredded Teflon pledget (STP) shifting was observed in 7.69% of cases. Postoperative outcomes were assessed through revisits and categorized into four groups: excellent (76.92%), good (15.38%), fair (7.69%), and poor (0%). The longest follow-up period exceeded 65 moths.The trans-lateral suboccipital infra-floccular approach provides a better visual field. Examination of entire length of the facial nerve is essential. STP with gelatin sponge implantation is a suitable material for facilitating nerve and vascular positioning and reducing adhesion.

Evaluation of the effect of botulinum toxin A on the physical and mental health of patients with hemifacial spasm.

BACKGROUND: Hemifacial spasm (HFS) is a debilitating disease characterized by involuntary tonic and clonic contractions of muscles innervated by the facial nerve. Botulinum toxin A (BTX-A) is the first-line option and the most effective medical treatment for HFS. The objective of this study was to evaluate the effect of BTX-A therapy on the physical and mental health of HFS patients. METHODS: Participants included 65 HFS patients and 65 matched healthy controls in the study. Cornell Medical Index (CMI) self-assessment questionnaire was used to detect the psychological health of all participants. Local injection of BTX-A was applied, and the Cohen hierarchical criteria were employed to stratify the degree of spasticity, further evaluating the efficacy of BTX-A before and two months after treatment in HFS patients. The HFS patients at two months post-treatment were re-evaluated by CMI self-assessment questionnaire, and the evaluated factors of these patients were compared with those of patients before treatment. RESULTS: The scores of somatization, depression, anxiety, inadaptation, sensitivity, anger, tension, M-R, and total scores in the HFS group were significantly higher than those in the control group (all P<0.05). Two months post-treatment, among 65 HFS patients who received with BTX-A treatment, 42 (64.6%) were completely relieved, 16 (24.6%) were significantly relieved, 7 (10.8%) were partially relieved, and 0 (0%) cases were invalid, and the total effective rate was 89.2%. Two months after BTX-A treatment, the scores of somatization, tension, anxiety, depression, sensitivity, M-R and total scores of patients with HFS were lower than those before treatment (all P<0.05). CONCLUSIONS: Patients with HFS are often accompanied by somatization, anger, inadaptation, sensitivity, anxiety, depression, and tension. BTX-A can not only alleviate the symptoms of HFS, but also improve the somatization, tension, anxiety, depression, and sensitivity.

Enhancing surgical precision: a novel electromyography finding for confident identification of the root exit zone during microvascular decompression surgery.

OBJECTIVE: The lateral spread response (LSR) is an important electrophysiological sign that predicts successful decompression in patients undergoing microvascular decompression (MVD) for hemifacial spasm (HFS). However, LSRs do not consistently correlate with clinical outcomes, and there are cases in which LSRs are absent. In this study, the authors identified a unique pattern on facial nerve electromyography (EMG) when the root exit zone (REZ) is touched. This distinctive EMG pattern, which the authors coined the "Sang-ku sign" (SKS), could aid in identifying the offending vessel on the REZ, even in the absence of LSRs. METHODS: Between November 2022 and August 2023, the authors analyzed EMG findings from 185 patients undergoing MVD for HFS. Bipolar stimulation electrodes were placed at the marginal mandibular branch, and recordings were obtained from the frontalis and orbicularis oris muscles. Additionally, stimulation electrodes were placed at the temporal branch, and recordings were obtained from the oris and mentalis muscles. The authors statistically analyzed the presence of SKS and its association with demographic, surgical, clinical outcomes, and anatomical factors. RESULTS: The authors observed a brief, burst-like wave pattern arising from all recorded muscle branches when Teflon felt was placed between the REZ and the facial nerve. This EMG pattern, the SKS, was found in 164 patients (88.6%). Among the factors analyzed, only patient age showed a significant association with the presence of the SKS in univariate analysis (p = 0.007). The presence of the SKS was significantly associated with predicting the disappearance of LSRs (p = 0.045). Clinical outcomes were favorable (99% at the last follow-up) in all cases; thus, no positive correlation was observed in the existence of the SKS and LSRs. CONCLUSIONS: The SKS could serve as an excellent guide for the facial nerve REZ during surgery. Given that HFS results from abnormal vascular contact on the REZ, this finding plays a crucial role in ensuring surgical success. Alongside LSRs, the SKS could provide valuable insights for neurosurgeons.

Distal esophageal spasm and gastroesophageal reflux disease: re-examining the association.

Distal esophageal spasm (DES) is a rare motility disorder presenting with dysphagia or chest pain. Although studies suggest a link between DES and gastroesophageal reflux disease (GERD), data supporting a distinct GERD-related phenotype are limited. This study aims to investigate demographic, symptomatic, and physiologic differences between DES subjects with and without GERD. A retrospective cohort analysis of DES patients determined by high resolution manometry (HRM) was conducted between February 2020 and January 2023. Demographics, medications, symptoms, and quantitative reflux testing data were collected. DES subjects with reflux (R-DES) were defined by presence of Los Angeles Grade B/C/D esophagitis, Barrett's metaplasia, or abnormal pH testing. DES subjects without reflux (NR-DES) had normal parameters. Statistical analysis employed two-sided or Wilcoxon Rank-Sum, Chi-squared, or Fisher's exact tests, and multivariate logistic regression. Of 69 DES subjects, 32 (46.3%) had GERD. R-DES and NR-DES patients had similar demographic variables except for higher BMI in R-DES (30.41 vs. 26.88, P = 0.01). R-DES and NR-DES shared similar symptom profiles (heartburn P = 0.67, dysphagia P = 0.448, chest pain P = 0.32). Proton pump inhibitor use was similar between groups (78.1% vs. 91.9%, P = 0.202). HRM metrics were comparable except for basal LES tone (20.7 mmHg vs. 32.99 mmHg, P = 0.03) and median IRP 11.82 mmHg versus 17.20 mmHg, P = 0.017). This study found no distinguishing clinical or physiologic differences between DES patients with and without GERD, challenging the historical emphasis of GERD in DES pathogenesis. The impact of GERD management on the natural history of DES remains uncertain.

A case report describing myocardial ischaemia as a side effect of carbamazepine overdose.

Background: Overdoses of carbamazepine may occur due to various reasons. The summary of product characteristics of carbamazepine includes information about the possibility of side effects after taking this drug. However, the symptoms described do not include coronary vasospasm, which occurred in the case described. Making such a diagnosis is a key element in therapeutic management, as it changes further clinical decisions. Case summary: A 46-year-old patient was admitted to the hospital for disorders of consciousness following an overdose of carbamazepine. On the second day, the patient exhibited respiratory distress. Subsequently, the patient was transferred to the intensive care unit, intubated, and placed on mechanical ventilation. On the same day, the patient experienced recurrent cardiac arrhythmias in the form of pulseless ventricular tachycardia and ventricular fibrillation; the patient was resuscitated and defibrillated eight times. Due to a rapid decline in cardiac output coupled with persistent electrocardiographic changes and haemodynamic instability, the patient underwent urgent coronary angiography. The procedure revealed a spasm in the initial segment of the circumflex branch of the left coronary artery, which subsequently resolved following nitroglycerin administration. Subsequent to the implementation of this therapeutic approach, a reduction in the demand for norepinephrine and dobutamine was achieved. In the following days, the patient's general condition improved. The patient was discharged home while maintaining full cognitive capacity and cardiovascular and respiratory fitness. Discussion: In the case described, the expeditious performance of a cardiological diagnostic evaluation played a pivotal role in achieving therapeutic success, enabling the prompt initiation of appropriate treatment.

Impact of microvascular decompression on wall shear stress in responsible arteries in trigeminal neuralgia and hemifacial spasm.

Microvascular decompression (MVD) has proven efficacy in trigeminal neuralgia (TN) and hemifacial spasm (HFS). This study utilized computational fluid dynamics (CFD) to investigate the impact of MVD on wall shear stress (WSS) of responsible arteries (RAs) at the neurovascular contact (NVC). A total of 21 cases (10 TN, 11 HFS) were analyzed, involving RAs at NVC validated through intraoperative photographs. Hemodynamic parameters (WSS, vessel diameter, flow rate, pressure drop) was calculated using CFD for the RAs based on 3D silent-magnetic resonance angiograms. The NVC was segmented into NVC-proximal, NVC-site, and NVC-distal portions using simulated 3D CFD images that correlated with surgical observations. WSS ratios of NVC-site to NVC-proximal (NVC-site/proximal) was calculated both before and after MVD. Prior to MVD, WSS in the RA at the NVC displayed a peaked curve with a maximum at NVC-site; however, post MVD, it presented a smooth curve without peaks. The WSS ratio exhibited a significant decrease after MVD. The impact of MVD on WSS of RAs at NVC was evaluated in both TN and HFS cases. Analyzing the hemodynamics of RAs through CFD and identifying WSS peaks at NVC portions before MVD provided a more detailed and localized understanding of the morphologically depicted NVC.