Early Antibiotic Exposure and Adverse Outcomes in Very Preterm Infants at Low Risk of Early-Onset Sepsis: The EPIPAGE-2 Cohort Study.

OBJECTIVE: To assess the association between early empirical antibiotics and neonatal adverse outcomes in very preterm infants without risk factors for early-onset sepsis (EOS). STUDY DESIGN: This is a secondary analysis of the EPIPAGE-2 study, a prospective national population-based cohort that included all liveborn infants at 22-31 completed weeks of gestation in France in 2011. Infants at high risk of EOS (ie, born after preterm labor or preterm premature rupture of membranes or from a mother who had clinical chorioamnionitis or had received antibiotics during the last 72 hours) were excluded. Early antibiotic exposure was defined as antibiotic therapy started at day 0 or day 1 of life, irrespective of the duration and type of antibiotics. We compared treated and untreated patients using inverse probability of treatment weighting based on estimated propensity scores. RESULTS: Among 648 very preterm infants at low risk of EOS, 173 (26.2%) had received early antibiotic treatment. Early antibiotic exposure was not associated with death or late-onset sepsis or necrotizing enterocolitis (OR, 1.04; 95% CI, 0.72-1.50); however, it was associated with higher odds of severe cerebral lesions (OR, 2.71; 95% CI, 1.25-5.86) and moderate-severe bronchopulmonary dysplasia (BPD) (OR, 2.30; 95% CI, 1.21-4.38). CONCLUSIONS: Early empirical antibiotic therapy administrated in very preterm infants at low risk of EOS was associated with a higher risk of severe cerebral lesions and moderate-severe BPD.

Safety of very high-power short-duration radiofrequency ablation for pulmonary vein isolation: a two-centre report with emphasis on silent oesophageal injury.

AIMS: Very high-power short-duration (vHPSD) via temperature-controlled ablation (TCA) is a new modality to perform radiofrequency pulmonary vein isolation (PVI), conceivably at the cost of a narrower safety margin towards the oesophagus. In this two-centre trial, we aimed to determine the safety of vHPSD-based PVI with specific emphasis on silent oesophageal injury. METHODS AND RESULTS: Ninety consecutive patients with atrial fibrillation (AF) underwent vHPSD-PVI (90 W, 3-4 s, TCA) using the QDOT MICRO catheter, in conjunction with the nGEN (Bad Neustadt, n = 45) or nMARQ generator (Bruges, n = 45). All patients underwent post-ablation oesophageal endoscopy. Procedural parameters and complications were recorded. A subgroup of 21 patients from Bad Neustadt underwent cerebral magnetic resonance imaging (cMRI) to detect silent cerebral events (SCEs). Mean age was 67 ± 9 years, 59% patients were male, and 66% patients had paroxysmal AF. Pulmonary vein isolation was obtained in all cases after 96 ± 29 min. No steam pop, cardiac tamponade, stroke, or fistula was reported. None of the 90 patients demonstrated oesophageal ulceration (0%). Charring was not observed in the nMARQ cohort (0% vs. 11% in the nGEN group). In 5 out of 21 patients (24%), cMRI demonstrated SCE (exclusively nGEN cohort). CONCLUSION: Temperature-controlled vHPSD catheter ablation allows straightforward PVI without evidence of oesophageal ulcerations or symptomatic complications. Catheter tip charring and silent cerebral lesions when using the nGEN generator have led to further modification.

The effect of complex vascular anatomy on silent new ischemic cerebral lesions in carotid artery stenting procedures (from the COMPLEX-CAS Trial).

BACKGROUND: Carotid artery stenting is a minimally invasive, durable alternative treatment option, which is an alternative to the reference method, carotid endarterectomy, for patients with carotid artery stenosis; however, silent new ischemic cerebral lesions (SNICLs) after carotid artery stenting remain as a matter of concern. Hence, we aimed to assess the effect of complex vascular anatomy on silent new ischemic cerebral lesions in carotid artery stenting procedures. METHODS: We prospectively evaluated 122 patients (mean age: 69.5 ± 7.1 years, male:83) who underwent carotid artery stenting for carotid artery revascularization. The patients having symptomatic transient ischemic attack or stroke after carotid artery stenting were excluded. The presence of a new hyperintense lesions on diffusion-weighted imaging without any neurological findings was considered as the SNICL. Patients were classified into two groups as DWI-positive and DWI-negative patients. RESULTS: Among the study population, 32 patients (26.2%) had SNICLs. The DWI-positive group had a significantly higher common carotid artery (CCA)-internal carotid artery (ICA) angle, older age, more frequent history of stroke, a higher proportion of type III aortic arch, and longer fluoroscopy time than the DWI-negative group. High CCA-ICA angle was identified as one of the independent predictors of SNICL (OR (odds ratio) = 1.103 95%CI (confidence interval): (1.023-1.596); p = 0.034), and CCA-ICA angle higher than 34.5 degrees predicted SNICL with a sensitivity of 62.5% and a specificity of 62.2% (area under the curve: 0.680; 95% CI: 0.570 to 0.789; p = 0.003). CONCLUSIONS: The higher CCA-ICA angle may predict pre-procedure SNICL risk in carotid artery stenting and may have clinical value in the management of patients with carotid artery stenosis.

Risk factors for silent new ischemic cerebral lesions following carotid artery stenting.

PURPOSE: Silent new ischemic cerebral lesions (sNICL) detected by diffusion-weighted imaging (DWI) are common after carotid artery stenting (CAS). As part of the Revascularization of Extracranial Carotid Artery Stenosis (RECAS) study, this work aimed to determine predictors of sNICL detected by DWI following CAS. METHODS: A total of 694 patients eligible for the RECAS study treated in Xuanwu Hospital, Capital Medical University, with complete imaging data were included in this retrospective study. The patients were asymptomatic after CAS, and those with stroke, transient ischemic attack (TIA), or death were excluded. The RECAS protocol specified that DWI was completed 1-7 days before the procedure and within 3 days after CAS. Several parameters were assessed for associations with sNICL occurrence after CAS in univariate analysis. Finally, multivariate analysis was performed to determine risk factors for sNICL. RESULTS: The rate of post-procedural sNICL in CAS was 51.3% (356/694 patients with sNICL). All patients underwent stenting with embolic protection devices. Univariate analysis showed that diabetes mellitus (P = 0.008), ipsilateral calcified plaques (P = 0.036), ipsilateral ulcerated plaques (P = 0.026), pre-dilatation (P = 0.003), and open-cell stent use (P < 0.001) were significantly associated with sNICL occurrence in CAS. Multivariate analysis revealed that diabetes mellitus (P = 0.006), ipsilateral calcified plaques (P = 0.024), ipsilateral ulcerated plaques (P = 0.021), and open-cell stent use (P < 0.001) were independent risk factors for sNICL. CONCLUSIONS: Patients with diabetes, calcified or ulcerated plaques who undergo CAS with open-cell stent application, are at high risk of sNICL. Large-scale prospective randomized controlled trials are needed to confirm these findings.

Multiple high-grade gliomas: epidemiology, management, and outcome. A systematic review and meta-analysis.

Multiple high-grade gliomas (M-HGGs) are well--separated tumors, differentiated as multifocal (MF) and multicentric (MC) by their MRI features. The authors performed a systematic review and meta-analysis of literature examining epidemiology, clinical and radiological characteristics, management, and the overall survival from M-HGGs. According to PRISMA guidelines, a comprehensive review of studies published between January 1990 and January 2017 was carried out. The authors identified studies that examined the prevalence rate, clinical and radiological characteristics, treatment, and overall survival from M-HGGs in patients with HGG. Data were analyzed using a random-effects meta-analysis model. Finally, we systematically reviewed demographic characteristics, lesion location, and surgical and adjuvant treatments. Twenty-three studies were included in this systematic review. The M-HGGs prevalence rate was 19% (95% CI 13-26%) and the hazard ratio of death from M-HGGs in the HGGs population was 1.71 (95% CI 1.49-1.95, p < 0.0001). The MC prevalence rate was 6% (CI 95% 4-10%), whereas MF prevalence rate was 11% (CI 95% 6-20%) (p < 0.0001). There were no statistically significant differences between MF and MC HGGs in gender, lesion location, histological type, and surgical treatment. Survival analysis of MC tumors showed that surgical resection (gross total resection or subtotal resection) is an independent predictor of improved outcome (HR 7.61 for biopsy subgroup, 95% CI 1.94-29.78, p = 0.004). The prevalence of M-HGGs is approximately 20% of HGGs. The clinical relevance of separating M-HGGs in MF and MC tumors remains questionable and its prognostic significance is unclear. When patient status and lesion characteristics make it safe and feasible, cytoreduction should be attempted in patients with M-HGGs because it improves overall survival.

Fetal Brain Injury Associated with Parvovirus B19 Congenital Infection Requiring Intrauterine Transfusion.

BACKGROUND: Infection with parvovirus B19 (B19V) during pregnancy may cause severe fetal anemia, hydrops, and fe tal death. Furthermore, neurodevelopmental impairment among survivors may occur despite appropriate prenatal management, including intrauterine transfusion (IUT). OBJECTIVES: Our primary objective was to describe cerebral lesions on MRI in fetuses with severe anemia requiring IUT for B19V infection. Our secondary objective was to search for clinical and biological characteristics associated with the occurrence of such lesions. STUDY DESIGN: We performed a retrospective review of data on fetuses infected with B19V and requiring at least one IUT between 2005 and 2016. Fetuses with abnormal cerebral MRI results in the 3rd trimester were compared to those with normal MRI results. RESULTS: Of 34 transfused fetuses, 26 children were born at full term. Five intrauterine fetal deaths, 1 neonatal death, and 2 terminations of pregnancy occurred. Cerebral anomalies were observed in 7/27 fetuses on MRI, including cerebellar hemorrhage or a small cerebellum. Only viral load in fetal blood appeared to be associated with brain lesions (11.5 log10 copies/mL [10.5-12.5] in case of abnormal MRI results vs. 9.5 log10 copies/mL [7.8-10.0]; p = 0.05). CONCLUSIONS: Among the fetuses transfused for B19V infection, 26% presented with prenatal abnormal cerebral imaging results. In our study, viral load in fetal blood appeared to be the only factor associated with fetal brain lesions.

Sonographic Detection of Seizure-Like Activity in Fetuses with Congenital Infection: Report of Three Cases and Review of the Literature.

Fetal seizure is a very rare prenatal finding and associated with an almost invariably poor outcome, the most common causes being hypoxic-ischemic encephalopathy, congenital anomalies of either the central nervous system (CNS) or musculoskeletal system, and metabolic disorders. The prenatal detection of seizure-like activity in fetuses with congenital infection has not been previously reported. In this report, we describe 3 cases of seizures in fetuses with congenital infection including Zika virus (n = 2) and toxoplasmosis (n = 1). All 3 fetuses had associated CNS abnormalities and the perinatal outcome was uniformly poor. This report suggests that for fetuses with proven congenital infections an extended and targeted sonographic examination may be helpful in -detecting associated fetal seizures that may even worsen the neonatal outcome.

[Brain MRI-findings in Ph - negative myeloproliferative disorders].

Myeloproliferative disorders (MPD) are accompanied by a high proportion of thrombotic complications, which may lead to cerebrovascular disease (CVD). AIM: To describe MRI-findings in patients with Ph - negative MPD and evaluate any cerebrovascular disease. MATERIALS AND METHODS: We included 104 patients with Ph - negative MPD (age varied between 20 and 58) with clinical correlates of cerebrovascular pathology. RESULTS: Brain MRI showed post - stroke lesions in 20% of patients (7 hemispheric infarcts due to thrombotic occlusion of one of the large cerebral arteries, 14 - cortical infarcts). 37 patients (36%) had vascular cerebral lesions. Cerebral venous sinus thrombosis occurred in 5 patients - in 7% (n=3) of patients with polycythemia vera and 5% (n=2) - in patients with essential thrombocythemia. The incidence of vascular cerebral lesions was associated with higher levels of the following: erythrocyte, platelet count, fibrinogen, and with the decrease in fibrinolytic activity, as well. CONCLUSION: The pioneering results of the study include the description and analysis of brain MRI-findings in patients with Ph - negative MPD. The underlying mechanisms of cerebrovascular pathology in these patients are associated with certain blood alterations (particularly, hemorheology) which present a major risk factor.

Spectrum Of Brain Abnormalities Detected On Whole Body F-18 FDG PET/CT Scan.

Positron emission tomography (PET) with integrated computed tomography (CT) is a unique modality to noninvasively scan the whole body for diagnosing, staging and assessing response to therapy in various benign and malignant diseases. 18F fluorodeoxyglucose (FDG) is the most commonly used radiotracer for PET/CT imaging in cancer patients. FDG is a glucose analogue which is the predominant substrate for brain metabolism. As the brain cells are obligate glucose consumers, the knowledge of physiologic radiotracer uptake within the brain is imperative for correct interpretation of abnormal sites of metabolism. Over 10,000 PET/CT scans have been performed at our centre in a 5 years' period. A spectrum of brain abnormalities, both benign and malignant, detected in cancer patients undergoing whole body 18F FDG PET/CT imaging has been compiled.

Cerebral Lesions at Fetal Magnetic Resonance Imaging and Neurologic Outcome After Single Fetal Death in Monochorionic Twins.

BACKGROUND: Single fetal death (sFD) in monochorionic twin pregnancies is associated with substantial morbidity and mortality in the survivor. The aim of our study was to evaluate the rate of cerebral lesions detected at fetal Magnetic Resonance Imaging (MRI) and to correlate the results with the neurologic outcome of the survivors of monochorionic twin pregnancies after sFD. METHODS: Between 2005 and 2012, 11 monochorionic twin pregnancies with sFD and subsequent fetal MRI of the survivor were included. All neonates underwent neurologic assessment after birth and 56% of surviving infants underwent long-term neurologic assessment. MRI findings and neurologic outcome of the survivors were evaluated. RESULTS: Gestational age at sFD was 20.9 (±2.9) weeks; 55% (6/11) of survivors of monochorionic twin pregnancies after sFD showed cerebral lesions at fetal MRI; 72% (8/11) of all survivors had normal neonatal neurologic outcome: all survivors with normal fetal MRI and 50% of survivors with cerebral lesions at fetal MRI. Long-term neurologic assessment was normal in all tested patients with normal fetal MRI and in one of three tested patients with cerebral lesions at fetal MRI. CONCLUSION: Survivors of monochorionic twin pregnancies after sFD show a high rate of cerebral lesions at fetal MRI. The importance of cerebral lesions at fetal MRI in survivors after sFD in monochorionic twin pregnancies is uncertain. All tested survivors with normal fetal MRI showed normal neurologic outcome but only one of three survivors with cerebral lesions at fetal MRI showed normal long-term neurologic outcome.

Acute safety and efficacy of a novel multipolar irrigated radiofrequency ablation catheter for pulmonary vein isolation.

INTRODUCTION: "Single shot" ablation devices to treat symptomatic atrial fibrillation have been engineered over the last years. Safety and efficacy also includes subclinical complications only detected with esophageal endoscopy or cerebral MRI in asymptomatic patients. We studied the acute efficacy and safety profile of a novel multipolar irrigated RF ablation catheter (nMARQ™). METHODS AND RESULTS: Forty-three patients underwent pulmonary vein isolation (PVI) using the novel ablation device. Patient baseline and procedural characteristics were documented. Efficacy of PVI was identified using only the nMARQ™ catheter. All patients underwent postablation endoscopic evaluation of the esophagus to document thermal damage and cerebral MRI (diffusion weight imaging, attenuated diffusion coefficient-map) to document incidence and number of silent cerebral lesions (SCL). Effective PVI was achieved in 98% of targeted PVs in a mean procedure time of 133 minutes. A mean of 4.8, 60-second RF applications, per PV was needed for effective PVI. No clinical procedure-associated complications were noted. Esophageal temperature increase >40.5 °C was noted in 22 (51%) patients and 14 of these had thermal esophageal lesions on endoscopic evaluation. A total of 26 SCLs were noted in 14 patients (33%; 1.9/patient; mean diameter of 2.3 mm, 88% of lesions were ≤3 mm). CONCLUSIONS: PVI using the novel irrigated RF multipolar ablation device (nMARQ™) appears to be acutely effective. No clinical complications were identified. A high incidence of SCL (33%) and thermal esophageal lesions (33%) bears caution and further studies on long-term efficacy and safety are needed.

Prose reading in neglect.

Prose reading has been shown to be a very sensitive measure of Unilateral Spatial Neglect. However, little is known about the relationship between prose reading and other measures of neglect and its severity, or between prose reading and single word reading. Thirty participants with a first stroke in the right hemisphere and clear symptoms of spatial neglect in everyday life were assessed with tests of prose reading (text in one column book-like, and in two columns magazine-like), single words reading, and a battery of 13 tests investigating neglect. Seventy percent of these participants omitted words at the beginning of the text (left end), showing Prose Reading Neglect (PRN). The participants showing PRN differed from those not showing PRN only for the overall severity of neglect, and had a lesion centred on the insula, putamen and superior temporal gyrus. Double dissociations emerged between PRN and single word reading neglect, suggesting different cognitive requirements between the two tests: parallel processing in single word reading vs. serial analysis in text reading. Notably, the pattern of neglected text varied dramatically across participants presenting with PRN, including dissociations between reading performance of one and two columns text. Prose reading proved a complex and unique task which should be directly investigated to predict the effects of unilateral neglect. The outcome of this study should also inform clinical assessment and advises given to patients and care-givers.

Cerebral microsporidiosis manifesting as progressive multifocal leukoencephalopathy in an HIV-infected individual - a case report.

Microsporidia have become increasingly recognized as opportunistic pathogens since the genesis of the AIDS epidemic. The incidence of microsporidiosis has decreased with the advent of combination antiretroviral therapy but it is frequently reported in non-HIV immunosuppressed patients and as a latent infection in immunocompetent individuals. Herein, we describe an HIV-infected male (46 years) with suspected progressive multifocal leukoencephalopathy that has not responded to optimal antiretroviral therapy, steroids, or cidofovir. Post-mortem examination revealed cerebral microsporidiosis. No diagnostic clue however, was found when the patient was alive. This report underscores the need for physicians to consider microsporidiosis (potentially affecting the brain) when no other etiology is established both in HIV, non-HIV immunosuppressed patients and in immunocompetent individuals.

Exchanging Catheters Over a Single Transseptal Sheath During Left Atrial Ablation is Associated with a Higher Risk for Silent Cerebral Events.

BACKGROUND: Silent cerebral events (SCE) have been identified on magnetic resonance imaging (MRI) in asymptomatic patients after atrial fibrillation (AF) ablation. Procedural determinants influencing the risk for SCE still remain unclear. OBJECTIVE: Comparing the risk for SCE depending on exchanges of catheters (ExCath) over a single transseptal sheath. METHODS: 88 Patients undergoing pulmonary vein isolation (PVI) only ablation using either single-tip or balloon-based technique underwent pre- and post-ablation cerebral MRI. Ablations were either performed with double transseptal access and without exchanging catheters over the transseptal sheaths (group 1: no ExCath) or after a single transseptal access and exchanges of therapeutic and diagnostic catheters (group 2: ExCath). Differences in regard to SCE rates were analyzed. Multivariate analysis was performed to identify factors related to the risk for SCE. RESULTS: Included patients underwent PVI using single tip irrigated radiofrequency in 41, endoscopic laser balloon in 27 and cryoballoon in 20 cases. Overall SCE were identified in 23 (26%) patients. In group 1 (no ExCath; N=46) 6 patients (13%) and in group 2 (N=42) 17 patients (40%) had documented SCE (p=0.007). The applied ablation technology did not affect SCE rate. In multivariate analysis age (OR 1.1, p=0.03) and catheter exchanges over a single transseptal sheath (OR 12.1, p=0.007) were the only independent predictors of a higher risk for SCE. CONCLUSIONS: Exchanging catheters over a single transseptal access to perform left atrial ablation is associated with a significantly higher incidence of SCE compared to an ablation technique using different transseptal accesses for therapeutic and diagnostic catheters.

Hematological predictors of silent new cerebral ischemic lesions in carotid artery stenting: A retrospective study.

BACKGROUND: Silent new cerebral ischemic lesions (sNCIL) are a common complication of carotid artery stenting (CAS) that can lead to an increase in morbidity and mortality. We aimed to evaluate the impact of hematological parameters on sNCIL in patients undergoing CAS. METHODS: We retrospectively evaluated 103 patients who underwent CAS, with a mean age of 70.5 ± 6.7 years, and 31 (20.1 %) of whom were female. Stents were placed for internal carotid artery revascularization. The presence of new hyperintense lesions on diffusion-weighted imaging (DWI) without neurological symptoms was considered as sNCIL in cases without apparent neurological findings. Patients were categorized into two groups based on DWI results: positive (29) and negative (74). RESULTS: In the study population, sNCIL was observed in 29 patients (28.2 %). The DWI-positive group exhibited significantly higher Plateletcrit (PCT) levels, advanced age, and a lack of embolic protection device usage compared to the DWI-negative group. The Receiver Operating Characteristic (ROC) analysis identified a PCT value of 0.26 as the optimal threshold, detecting the development of sNCIL with a sensitivity of 75.9 % and specificity of 59.1 % (AUC: 0.700; 95 % CI: 0.594-0.806, p = 0.002). CONCLUSION: To be determined by a simple blood parameter, PCT can predict the risk of sNCIL before CAS and holds clinical value in the treatment of patients with carotid artery stenosis.

Cerebral lesions sites in neurosarcoidosis: a lesion mapping study.

BACKGROUND AND PURPOSE: Sarcoidosis is a granulomatous disease of unknown etiology affecting the central nervous system in up to 15% of the patients. Diagnosis of neurosarcoidosis is very challenging due to the heterogeneity of its clinical manifestation. This study intended to evaluate the distribution of cerebral lesion sites and the potential presence of specific lesion clusters in neurosarcoidosis patients using voxel-based lesion symptom mapping (VLSM). METHODS: Patients with neurosarcoidosis were retrospectively identified and included between 2011 and 2022. Cerebral lesion sites were correlated voxel-wise with presence and absence of neurosarcoidosis using non-parametric permutation test. Multiple sclerosis patients served as controls for the VLSM-analysis. RESULTS: Thirty-four patients (mean age 52 ± 15 years) of whom 13 were diagnosed with possible, 19 with probable and 2 with confirmed neurosarcoidosis were identified. Lesion overlap of neurosarcoidosis patients demonstrated a distribution of white matter lesions in all brain areas, with a periventricular predilection similar to multiple sclerosis. In contrast to multiple sclerosis controls, no propensity for lesions in proximity of the corpus callosum was observed. Neurosarcoidosis lesions appeared smaller and lesion volume was lower in the neurosarcoidosis cohort. The VLSM analysis showed minor associations between neurosarcoidosis and damaged voxels in the bilateral frontobasal cortex. CONCLUSIONS: The VLSM analysis yielded significant associations in the bilateral frontal cortex, suggesting that leptomeningeal inflammatory disease with following cortical involvement is a quite specific feature in neurosarcoidosis. Lesion load was lower in neurosarcoidosis than in multiple sclerosis. However, no specific pattern of subcortical white matter lesions in neurosarcoidosis was revealed.

A pediatric case of autoimmune encephalitis with chronologically moving seizure foci and cortical lesions: A case report.

INTRODUCTION: Autoimmune encephalitis (AIE) is a relatively newly described category of immune-mediated diseases involving the central nervous system with a wide spectrum of clinical presentations, ranging from relatively mild or insidious onset of cognitive impairment to more complex forms of encephalopathy with medically refractory seizures. Single or multifocal seizures accompanied by neuropsychiatric symptoms and cognitive or memory impairments are suggestive of clinical features at AIE onset. CASE REPORT: A six-year-old boy presented with repetitive focal seizures, slowly progressive emotional liability, and attention-deficit/hyperactivity disorder-like symptoms. Seizure types varied during the clinical course, sometimes emerging as clusters or statuses. MRI performed during seizure clustering/status revealed moving signal abnormalities. We successfully treated the patient with high-dose intravenous methylprednisolone. Cerebrospinal fluid analysis revealed pleocytosis and marked elevation of antibodies against N-terminals of N-methyl-d-aspartate type glutamate receptor subunits and granzyme B. CONCLUSION: We report a case of moving seizure foci with abnormal MRI findings. Although the onset of psychiatric symptoms slowly progressed to those atypical for AIE, responsiveness to immunotherapy, cerebrospinal fluid pleocytosis, and autoantibodies all indicated AIE. We thus suggest that moving seizure foci and abnormal MRI signals may be findings of AIE.

Cerebral safety after pulsed field ablation for paroxysmal atrial fibrillation.

BACKGROUND: Pulsed field ablation (PFA) is a novel, nonthermal ablation modality that can ablate myocardial tissue with minimal effects on surrounding tissue. Preclinical data show an absence of cerebral emboli after extensive PFA. However, clinical data on silent cerebral lesions (SCLs) and/or silent cerebral events (SCEs) after PFA are lacking. OBJECTIVES: The purpose of this study was to investigate the occurrence of neurological deficits and SCL and/or SCE after PFA in paroxysmal atrial fibrillation (AF) using National Institutes of Health Stroke Scale (NIHSS) scores and magnetic resonance imaging (MRI). METHODS: In patients with symptomatic paroxysmal AF, pulmonary vein isolation (PVI) using PFA was performed. NIHSS scores were assessed before and 2 days and 30 days after PVI. One day after PVI, patients underwent cerebral 1.5-T MRI scanning using diffusion-weighted imaging and fluid-attenuated inversion recovery sequences to document the occurrence of SCL/SCE. RESULTS: PFA was performed in 30 patients (age 63 ± 10 years). No patient showed neurological deficits. All NIHSS scores showed the minimum value of 0. Cerebral MRI scans were normal in 29 of 30 patients (97%). In 1 patient (3%), a single 7-mm cerebellar lesion was observed. Forty days after the procedure, follow-up cerebral MRI scan showed complete regression of the lesion. CONCLUSION: In patients treated with PFA for symptomatic paroxysmal AF, the incidence of MRI-detected asymptomatic thromboembolic cerebral events or lesions was as low as 3%. No neurological deficits occurred in any of the patients.

Plaque morphology effect on periprocedural asymptomatic cerebral embolism in carotid artery stenting using first-generation carotid stents: A diffusion-weighted magnetic resonance imaging study.

BACKGROUND: Silent cerebral embolism with carotid artery stenting (CAS) may contribute to dementia and cognitive decline. Moreover, clinically silent embolism is an important index of peri-procedural stroke risk. AIMS: The purpose of this study was to compare the periprocedural asymptomatic cerebral embolism rates of CAS procedures performed for noncalcified and calcified carotid artery plaques using diffusion-weighted magnetic resonance imaging (DW-MRI). METHODS: Five hundred and seventy clinically uncomplicated patients who underwent CAS at our center from December 2010 to June 2020 (mean [standard deviation, SD] age 69.3 [8.2 years]) were analyzed retrospectively. The patients were divided into 2 groups with noncalcified (268 patients) and calcified (302 patients) plague. Cerebral DW-MRI was performed for the patients before and after CAS and compared. The presence of periprocedural new ipsilateral diffusion limitations detected on cerebral DW-MRI was noted as a significant finding. Ipsilateral diffusion limitations of the non-calcified and calcified plaque groups detected on cerebral DW-MRI were compared. RESULTS: The presence of periprocedural asymptomatic ipsilateral DW-MRI lesions was higher in patients in the noncalcified plaque group (45 [16.8%]) than in patients in the calcified plaque group (31 [10.3%]; P = 0.02). CONCLUSION: This study demonstrated that the rate of ipsilateral asymptomatic cerebral embolism detected on cerebral DW-MRI was higher in the CAS procedures performed for noncalcified carotid artery plaques than in those performed for calcified plaques.

Should we change our carotid stenting technique? Does balloon postdilatation increase periprocedural cranial embolism? A diffusion-weighted magnetic resonance imaging study.

Introduction: Silent cranial embolism has been demonstrated to cause dementia, cognitive decline and even ischemic stroke. Aim: To compare the periprocedural asymptomatic cranial embolism rates of classical carotid artery stenting (CAS) and non-classical CAS methods using cranial diffusion-weighted magnetic resonance imaging (DW-MRI). Material and methods: 367 clinically uncomplicated patients who underwent CAS at our center between December 2010 and June 2020 (mean age: 69.3 ±11.9) were analyzed retrospectively. The patients were divided into 2 groups, classical CAS (130 patients) and non-classical CAS (237 patients). Classical CAS patients were defined as those who received a stent after suboptimal balloon dilatation (with a 3.0-4.0 mm balloon at 8-10 atmosphere (atm)) and underwent balloon postdilatation after stent deployment (with a 5.0-5.5 mm balloon at 8-10 atm). Non-classical CAS patients were defined as those in whom a stent was deployed after optimal balloon dilatation (with a 4.0-5.0 mm balloon at 10-14 atm) and did not undergo balloon postdilatation. Results: Periprocedural asymptomatic ipsilateral microembolism on cranial DW-MRI was detected in 25 (10.5%) patients in the non-classical CAS group and 24 (18.5%) in the classical CAS group. This difference between the two groups was found to be statistically significant (p = 0.033). Conclusions: The rate of ipsilateral asymptomatic cranial embolism detected on cranial DW-MRI was lower in the CAS procedures in which optimal predilatation was performed but postdilatation after stent deployment was not performed compared to the CAS procedures in which suboptimal predilatation and postdilatation after stent deployment were performed.