Could the Anatomic Variants of the Superior Thalamic Vein (STV) Be Considered a Possible Landmark for Target Identification in Magnetic-Resonance-Guided Focused Ultrasound Procedures? A Pilot Study Using Susceptibility Weighted Imaging Sequences.

During magnetic-resonance-guided focused ultrasound ablation of the ventral intermediate thalamic nucleus (VIM) for essential tremor (ET) and Parkinson's disease (PD), targeting is generally performed using a standard atlas-based stereotactic approach. The purpose of our work is to evaluate the anatomic variations in the venous vasculature of the thalamus in patients treated with MRgFUS, as a possible landmark for targeting. We retrospectively evaluated the relationship between the obtained thalamotomy lesion and the ipsilateral superior thalamic vein (STV). A total of 36 patients (25 ET and 11 PD) who underwent MRgFUS treatment were evaluated, and the STV was studied with susceptibility weighted imaging (SWI) sequences. Based on the axial SWI images, the distance between the STV and the center of the lesion at the presumed site of the VIM was measured in follow-up MRI images one month after treatment. Statistical analysis shows that there is a correlation between the STV and the presumed site of the VIM. The STV visible in SWI could be used as an additional, real-time, and patient-specific anatomical landmark for VIM identification during MR examination and just before and during FUS treatment.

The Role of Treatment-Related Parameters and Brain Morphology in the Lesion Volume of Magnetic-Resonance-Guided Focused Ultrasound Thalamotomy in Patients with Tremor-Dominant Neurological Conditions.

PURPOSE: To determine the best predictor of lesion volume induced by magnetic resonance (MR)-guided focused ultrasound (MRgFUS) thalamotomy in patients with tremor-dominant symptoms in Parkinson's disease (PD) and essential tremor (ET) patients. METHODS: Thirty-six neurological patients with medication-refractory tremor (n°19 PD; n°17 ET) were treated using a commercial MRgFUS brain system (Exablate Neuro 4000, Insightec) integrated with a 1.5 T MRI unit (Sigma HDxt; GE Medical System). Linear regression analysis was used to determine how the demographic, clinical, radiological (Fazekas scale), volumetric (total GM/WM/CSF volume, cortical thickness), and MRgFUS-related parameters [Skull Density Ratio (SDR), n° of transducer elements, n° of sonications, skull area, maximal energy delivered (watt), maximal power delivered (joule), maximal sonication time delivered, maximal mean temperature reached (T°C_max), accumulated thermal dose (ATD)] impact on ventral intermediate (VIM)-thalamotomy-related 3D volumetric lesions of necrosis and edema. RESULTS: The VIM thalamotomy was clinically efficacious in improving the tremor symptoms of all the patients as measured at 1 week after treatment. Multiple regression analysis revealed that T°C_max and n° of transducer elements were the best predictors of the necrosis and edema volumes. Moreover, total WM volume also predicted the size of necrosis. CONCLUSIONS: Our study provides new insights into the clinical MRgFUS procedures that can be used to forecast brain lesion size and improve treatment outcomes.

Changes in cerebral cortex activity during a simple motor task after MRgFUS treatment in patients affected by essential tremor and Parkinson's disease: a pilot study using functional NIRS.

Objective.Magnetic resonance imaging-guided focused ultrasound surgery (MRgFUS) is a non-invasive thermal ablation method that involves high-intensity focused ultrasound surgery (FUS) and Magnetic Resonance Imaging for anatomical imaging and real-time thermal mapping. This technique is widely employed for the treatment of patients affected by essential tremor (ET) and Parkinson's disease (PD). In the current study, functional near-infrared spectroscopy (fNIRS) was used to highlight hemodynamics changes in cerebral cortex activity, during a simple hand motor task, i.e. unimanual left and right finger-tapping, in ET and PD patients.Approach.All patients were evaluated before, one week and one month after MRgFUS treatment.Main results.fNIRS revealed cerebral hemodynamic changes one week and one month after MRgFUS treatment, especially in the ET group, that showed a significant clinical improvement in tremor clinical scores.Significance.To our knowledge, our study is the first that showed the use of fNIRS system to measure the cortical activity changes following unilateral ventral intermediate nucleus thalamotomy after MRgFUS treatment. Our findings showed that therapeutic MRgFUS promoted the remodeling of neuronal networks and changes in cortical activity in association with symptomatic improvements.

MR-Guided Focused Ultrasound for Refractory Epilepsy: Where Are We Now?

Epilepsy is one of the most common neurological diseases in both adults and children. Despite improvements in medical care, 20 to 30% of patients are still resistant to the best medical treatment. The quality of life, neurologic morbidity, and even mortality of patients are significantly impacted by medically intractable epilepsy. Nowadays, conservative therapeutic approaches consist of increasing medication dosage, changing to a different anti-seizure drug as monotherapy, and combining different antiseizure drugs using an add-on strategy. However, such measures may not be sufficient to efficiently control seizure recurrence. Resective surgery, ablative procedures and non-resective neuromodulatory (deep-brain stimulation, vagus nerve stimulation) treatments are the available treatments for these kinds of patients. However, invasive procedures may involve lengthy inpatient stays for the patients, risks of long-term neurological impairment, general anesthesia, and other possible surgery-related complications (i.e., hemorrhage or infection). In the last few years, MR-guided focused ultrasound (MRgFUS) has been proposed as an emerging treatment for neurological diseases because of technological advancements and the goal of minimally invasive neurosurgery. By outlining the current knowledge obtained from both preclinical and clinical studies and discussing the technical opportunities of this therapy for particular epileptic phenotypes, in this perspective review, we explore the various mechanisms and potential applications (thermoablation, blood-brain barrier opening for drug delivery, neuromodulation) of high- and low-intensity ultrasound, highlighting possible novel strategies to treat drug-resistant epileptic patients who are not eligible or do not accept currently established surgical approaches. Taken together, the available studies support a possible role for lesional treatment over the anterior thalamus with high-intensity ultrasound and neuromodulation of the hippocampus via low-intensity ultrasound in refractory epilepsy. However, more studies, likely conceiving epilepsy as a network disorder and bridging together different scales and modalities, are required to make ultrasound delivery strategies meaningful, effective, and safe.

Anti-Atherogenic Effect of 10% Supplementation of Anchovy (Engraulis encrasicolus) Waste Protein Hydrolysates in ApoE-Deficient Mice.

Fish protein consumption exerts beneficial metabolic effects on human health, also correlating with a decreased risk for cardiovascular disease. Fish waste contains high amount of proteins and utilization may offer the opportunity for generating compounds advantageous for human health. Especially, fish waste protein hydrolysates beneficially influence pathways involved in body composition, exerting anti-inflammatory and antioxidant activities, making their potential supplementation in human disorders of increased interest. This study assessed the effect of a 10% (w/w) anchovy waste protein hydrolysate (APH) diet for 12 weeks in reducing atherosclerosis in ApoE-/- mice, through histological and immunohistochemical methods. In addition, monitoring of plaque development was performed, using high-frequency ultrasound and magnetic resonance imaging. Overall, the APH diet attenuated atherosclerotic plaque development, producing a regression of arterial lesions over time (p < 0.05). Twelve weeks on an APH diet had an anti-obesity effect, improving lipid metabolism and reducing hepatic enzyme activity. A significant reduction in plaque size and lipid content was observed in the aortic sinus of APH-fed mice, compared to the control (p < 0.001), whereas no differences in the extracellular matrix and macrophage recruitment were observed. Supplementation of APH significantly attenuates atherosclerosis in ApoE-/- mice, exerting a lipid-lowering activity. The opportunity to use fish waste protein hydrolysates as a nutraceutical in atherosclerosis is worthy of future investigations, representing a low cost, sustainable, and nutritional strategy with minimal environmental impact.

Asymptomatic lymphangioleiomyomatosis: Large cyst mimicking a hydropneumothorax in a healthy patient.

Lymphangioleiomyomatosis (LAM) is a rare, idiopathic, cystic disease that affects lungs of young women at childbearing age. Usually, LAM clinical manifestations are pneumothorax, progressive dyspnea and chylous pleural effusions. In many cases, due to unusual and nonspecific symptoms, LAM is mis-recognized and patients, who are affected by such disease, receive delayed diagnosis. This case report focuses on a 45-year-old woman patient with asymptomatic lymphangioleiomyomatosis who presented a big cyst which makes it looks like hydropneumothorax condition. Although chest radiograph and following CT scan has given an incidental diagnosis of right hydropneumothorax, treatment with drainages and video-assisted thorascopic surgery, instead, has allowed us to formulate correct diagnosis of cysts in LAM.

In Vivo Computed Tomography Direct Volume Rendering of the Anterior Ethmoidal Artery: A Descriptive Anatomical Study

Abstract Introduction The clinical relevance of the anatomy and variations of the anterior ethmoidal artery (AEA) is outstanding, considering its role as a landmark in endoscopic surgery, its importance in the therapy of epistaxis, and the high risks related to iatrogenic injuries. Objective To provide an anatomical description of the course and relationships of the AEA, based on direct computed-tomography (CT)-based 3D volume rendering. Methods Direct volume rendering was performed on 18 subjects who underwent (CT) with contrast medium for suspected cerebral aneurism. Results The topographical location of 36 AEAs was assessed as shown: 10 dehiscent (27.8%), 20 intracanal (55.5%), 6 incomplete canals (16.7%). Distances from important topographic landmarks are reported. Conclusion This work demonstrates that direct 3D volume rendering is a valid imaging technique for a detailed description of the anterior ethmoidal artery thus representing a useful tool for head pre-operatory assessments.

In Vivo Computed Tomography Direct Volume Rendering of the Anterior Ethmoidal Artery: A Descriptive Anatomical Study.

Introduction The clinical relevance of the anatomy and variations of the anterior ethmoidal artery (AEA) is outstanding, considering its role as a landmark in endoscopic surgery, its importance in the therapy of epistaxis, and the high risks related to iatrogenic injuries. Objective To provide an anatomical description of the course and relationships of the AEA, based on direct computed-tomography (CT)-based 3D volume rendering. Methods Direct volume rendering was performed on 18 subjects who underwent (CT) with contrast medium for suspected cerebral aneurism. Results The topographical location of 36 AEAs was assessed as shown: 10 dehiscent (27.8%), 20 intracanal (55.5%), 6 incomplete canals (16.7%). Distances from important topographic landmarks are reported. Conclusion This work demonstrates that direct 3D volume rendering is a valid imaging technique for a detailed description of the anterior ethmoidal artery thus representing a useful tool for head pre-operatory assessments.

Effects of Simvastatin on Fetal Cardiac Impairment in the Diaphragmatic Experimental Hernia Model.

BACKGROUND: Statins and sildenafil have been shown to exert beneficial effects in cardiac injury. We hypothesized that antenatal maternal administration of simvastatin and/or sildenafil might also promote benefits in cardiac remodeling of congenital diaphragmatic hernia (CDH). Therefore, we performed micro-CT image analysis and histology of the heart after antennal treatment in experimental nitrofen-induced CDH. METHODS: At 9.5 days post conception (dpc), pregnant rats were exposed to nitrofen. At 16 and 20 dpc fetuses were treated with simvastatin and/or sildenafil. At 21 dpc postmortem micro-CT and autopsy were performed. RESULTS: All nitrofen-treated fetuses had a lower birth weight compared to controls; in the simvastatin-treated group, a significant improvement in CDH was noted. Impairment of the lung and liver was also noted in CDH. Compared to controls, CDH rats showed lower ventricular mass, with greater left ventricular thickness; simvastatin decreased the ventricular mass and improved wall thickness. CDH rats exhibited myocardial hypotrophy, severe vascular depression in the left ventricle, and intense interstitial edema compared to controls and nitrofen-exposed animals without CDH. In CDH, the cardiac morphology appeared deformed with left ventricular wall verticalization. Simvastatin improved cardiac myocyte appearance and heart morphology. CONCLUSION: The potential to treat CDH with antenatal simvastatin may improve the management of this malformation.

dB/dt Evaluation in MRI Sites: Is ICNIRP Threshold Limit (for Workers) Exceeded?

The Directive 2013/35/EU establishes standards for workers exposed to static and time varying magnetic fields. These limits are based on ICNIRP guidelines expressed in terms of the electric field induced in the body. The complexity of this measurement led to theoretical models being developed. In this study, the experimental evaluation included varying magnetic field exposures for two classes of MRI workers. The measurements are conducted on four different MRI Systems including one 0.35 T, two 1.5 T, and one 3.0 T. Pocket magnetic dosimeters were used and it was carried out during routine conditions, emergency conditions, and cold-head maintenance/substitution. The acquired data has been processed and the corresponding dB/dt curves have been computed as the first time derivative of the dataset. The weighted peak approach was also implemented for the compliance assessment with regulatory limits. The dB/dt peak values have been compared with the reference level (RL) proposed by ICNIRP. The results show that the RL always exceeds during measurements on the 3.0 T scanner and sometimes on 1.5 T. In light of the foregoing, the diffusion of ultra-high field MRI scanners involves the introduction of behavioral rules that could be more useful than a numerical action level.

Calcific left atrium: A rare consequence of endocarditis.

Usually, cardiac calcifications are observed in aortic and mitral valves, atrio-ventricular plane, mitral annulus, coronary arteries, pericaridium (usually causing constrictive pericarditis) and cardiac masses. Calcifications of atrial walls are unusual findings that can be identified only using imaging with high spatial resolution, such as cardiac magnetic resonance and computed tomography. We report a case of a 43-year-old patient with no history of heart disease that underwent cardiac evaluation for mild dyspnoea. The echocardiogram showed a calcific aortic valve and a hyper-echogenic lesion located in atrio-ventricular plane. The patient was submitted to cardiac magnetic resonance and to computed tomography imaging to better characterize the localization of mass. The clinical features and location of calcified lesion suggest an infective aetiology causing an endocarditis involving the aortic valve, atrio-ventricular plane and left atrium. Although we haven't data to support a definite and clear diagnosis, the clinical features and location of the calcified lesion suggest an infective aetiology causing an endocarditis involving the aortic valve, atrio-ventricular plane and left atrium. The patient was followed for 12 mo both clinically and by electrocardiogram and echocardiography without worsening of clinical, electrocardiographic and echocardiographic data. Cardiac magnetic resonance imaging and computed tomography are ideal methods for identifying and following over time patients with calcific degeneration in the heart.

Budd-Chiari syndrome complicating the surgical closure of patent foramen ovale in right minithoracotomy.

We present the case of a 45-year old female operated on for minimally invasive closure of patent foramen ovale, who suffered in the postoperative course of the Budd-Chiari syndrome caused by the thrombotic occlusion of the inferior vena cava. Medical treatment with oral anticoagulants and heparin was promptly established, avoiding a further increase of the thrombus that completely disappeared 3 months later.

MRI of cardiac involvement in transthyretin familial amyloid polyneuropathy.

OBJECTIVE: The purpose of this study was to evaluate cardiac MRI features in a group of patients with transthyretin familial amyloid polyneuropathy (FAP). SUBJECTS AND METHODS: Sixteen patients with transthyretin FAP underwent 2D echocardiography with Doppler examination, cardiac MRI, and (99m)Tc-diphosphonate (DPD) scintigraphy. Four patients had peripheral polyneuropathy, three had carpal tunnel syndrome, one patient had symptoms and signs of heart failure, and eight patients had no symptoms but had a family history of FAP. At MRI, cardiac function parameters and delayed contrast enhancement findings were evaluated. RESULTS: Six patients had cardiac radiotracer uptake at scintigraphy (FAP cardiac group), and 10 patients had no cardiac uptake (FAP noncardiac group). The FAP cardiac group included the four patients with peripheral neuropathy, one patient with carpal tunnel syndrome, and the only patient with heart failure. At MRI, abnormal contrast enhancement was found in all patients with positive scintigraphic findings and in no patient with negative scintigraphic findings. All patients had involvement of the left ventricle and other chambers or structures (atria, right ventricle, tricuspid valve leaflets). Left ventricular contrast enhancement was focal in four patients, subendocardial circumferential in one patient, and diffuse in one patient. The only patient with signs of heart failure had circumferential subendocardial enhancement. CONCLUSION: Cardiac contrast-enhanced MRI can be used to identify cardiac amyloidosis in patients with FAP who do not have clinical signs of heart involvement. In these patients, the typical subendocardial circumferential pattern of contrast enhancement is rare. We observed unusual enhancement patterns as focal or diffuse left ventricular enhancement accompanied by enhancement of the atria, tricuspid valve, or right ventricle.

Myocardial deformation in acute myocarditis with normal left ventricular wall motion--a cardiac magnetic resonance and 2-dimensional strain echocardiographic study.

BACKGROUND: The aim of our study was to assess longitudinal (L), circumferential (C) and radial (R) strain (S) of the left ventricle (LV) in patients with acute myocarditis and preserved LV wall motion. METHODS AND RESULTS: Of the 26 male patients that were enrolled, 13 patients (26+/-8 years) suffered from acute myocarditis and 13 (25+/-2 years) were healthy participants (controls). Both patients and controls underwent cardiac magnetic resonance (CMR) and 2-dimensional S imaging (2D-S) echocardiography on the same day. Myocardial strains (RS, LS and CS) were quantified by 2D-S. In patients with myocarditis, a delayed enhancement (DE) CMR study was performed to identify damaged myocardial segments. In the myocarditis group there was a significant LS reduction compared with controls (-25+/-7 vs -20+/-7, P<0.0001), whereas no difference was found between the 2 groups concerning CS and RS. Subepicardial DE areas were found in 12 of 13 patients. Segments with DE showed a significantly lower LS in comparison with segments without DE (-19+/-4 vs -23+/-6, P<0.0001). In contrast, no difference in CS and RS was found when comparing segments with DE vs segments without DE. CONCLUSIONS: In patients with acute myocarditis, evidence of subepicardial damage and no wall motion abnormalities, longitudinal deformation is diffusely impaired, whereas circumferential impairment is regionally sited in the areas of subepicardial damage.

Lipomatous metaplasia in ischemic cardiomyopathy.

Lipomatous metaplasia is characterized by substitution of muscle fibers with adipose tissue in the context of a myocardial scar. Cardiac magnetic resonance is an accurate cardiac imaging technique with high tissue spatial resolution that can easily characterize scar tissue, adipose tissue and lipomatous metaplasia. We report a case of lipomatous metaplasia in a 68-year-old man with a 14-year history of anterior myocardial infarction admitted to our cardiac department for dyspnea and palpitations.

An unusual presentation of a right atrial Chiari network.

In 1897, the anatomist Chiari described a structure in the right atrium connected to the Eustachian valve identified as the embryological vestige of the right valve of the sinus venosus. The discovery of a mass in the right atrium obliges the clinician to perform a broad differential diagnosis among a tumour, vegetations on the tricuspid valve, an atrial thrombus and Chiari network. We present a case of Chiari network in a 55-year-old Italian woman.

Cerebral transient ischemic attack due to left ventricular thrombus formation in a young patient with silent myocardial infarction and normal coronary arteries.

Among many cardiac diseases related to cerebral stroke, left ventricular thrombus formation due to silent myocardial infarction with normal coronary arteries represents a rare cause of cerebral ischemia. We describe an unusual case of cerebral ischemia due to cardiac thrombus formation in a young patient with silent myocardial infarction and normal coronary arteries in which echocardiography and cardiac MR imaging clearly showed the embolic source.

An integrated imaging approach with magnetic resonance imaging can reveal pitfall pleural effusion at echocardiography.

We report an echocardiographic pitfall, where a hypoecogenic area mimicking a pleural effusion was detected by CMR as an area of normal pulmonary parenchyma between the posterior left atrial wall and the dilated right pulmonary vein.

An unusual diagnosis of atrial shunt defect by magnetic resonance imaging.

Paroxysmal atrial arrhythmias especially atrial fibrillation are frequently encountered in adult patients with atrial septal defect. However, the diagnosis of atrial defect can be difficult. Thransthoracic echocardiography, the mostly utilized cardiac technique, has shown a limited ability to identify small atrial defects. Transesophageal echocardiography has shown high accuracy to identify but it isn't well tolerated of the patients. Recently, the utility of multislice computed tomography in the evaluation of direction, location, and size of shunt flow in congenital heart disease has been demonstrated. Cardiac magnetic resonance imaging (MRI) is a recent imaging technique that permits with high spatial resolution and without ionising radiation an accurate identification of many cardiovascular diseases. We report an unusual detection of an atrial defect by phase-contrast cine MRI in a patient clinically suspected of arrhitmogenic right ventricular displasia.