A target definition based on electroanatomic maps for stereotactic arrhythmia radioablation.

PURPOSE: Identifying the target region is critical for successfully treating ventricular tachycardia (VT) with single fraction stereotactic arrhythmia radioablation (STAR). We report the feasibility of target definition based on direct co-registration of electroanatomic maps (EAM) and radioablation planning images. MATERIALS AND METHODS: The EAM consists of 3D cardiac anatomy representation with electrical activity at endocardium and is acquired by a cardiac electrophysiologist (CEP) during electrophysiology study. The CEP generates an EAM using a 3D cardiac mapping system anticipating radioablation planning. Our in-house software read these non-DICOM EAMs, registered them to a planning image set, and converted them to DICOM structure files. The EAM based target volume was finalized based on a consensus of CEPs, radiation oncologists and medical physicists, then expanded to ITV and PTV. The simulation, planning, and treatment is performed with a standard STAR technique: a single fraction of 25 Gy using volumetric-modulated arc therapy or dynamic conformal arc therapy depending on the target shape. RESULTS: Seven patients with refractory VT were treated by defining the target based on registering EAMs on the planning images. Dice similarity indices between reference map and reference contours after registration were 0.814 ± 0.053 and 0.575 ± 0.199 for LV and LA/RV, respectively. CONCLUSIONS: The quality of the transferred EAMs on the MR/CT images was sufficient to localize the treatment region. Five of 7 patients demonstrated a dramatic reduction in VT events after 6 weeks. Longer follow-up is required to determine the true safety and efficacy of this therapy using EAM-based direct registration method.

Morgagni Hernia Causing Incarcerated Bowel and Contributing to Cardiac Arrest.

A Morgagni hernia is a congenital diaphragmatic hernia (CDH)-incomplete formation of the diaphragm. Though congenital diaphragmatic hernias (CDHs) are a common class of birth defect, the majority are diagnosed either prenatally or shortly after birth since these patients can present with cardiopulmonary failure due to pulmonary hypoplasia or pulmonary hypertension.1 However, the Morgagni type of CDH predisposes it to go undetected well into adulthood. We describe the case of a 63-year-old male who presented to the emergency room with epigastric pain and emesis. He was found to have incarcerated bowel in his pericardial sac on computed tomography imaging after being resuscitated from cardiac arrest. He then underwent surgical repair of the defect. This case is unique in its presentation with small bowel inside the pericardium, contributing to cardiac tamponade and subsequent cardiac arrest.

CT of viral lower respiratory tract infections in adults: comparison among viral organisms and between viral and bacterial infections.

OBJECTIVE: We retrospectively compared the CT findings of consecutive viral and bacterial lower respiratory tract infections (LRTIs) to determine their imaging appearance and any definable differences among the causative viruses and between the viral and bacterial infections. MATERIALS AND METHODS: Imaging features of LRTI caused by influenza virus, respiratory syncytial virus (RSV), parainfluenza, adenovirus, and bacteria over a 33-month period were reviewed by three radiologists blinded to clinical and diagnostic information. Individual CT features and the dominant pattern of infection were recorded for each examination. Imaging characteristics were compared among the four respiratory viruses and between viral and bacterial infections. RESULTS: One hundred fifteen chest CT scans were analyzed (60 influenza virus, 19 RSV, 10 adenovirus, four parainfluenza virus, and 22 bacterial pneumonia LRTIs). Individual imaging findings and imaging patterns were seen in similar frequencies when we compared viral and bacterial LRTIs, with the exception of the diffuse airspace pattern, which was seen more frequently in bacterial infections. Although there was overlap in the imaging appearance of individual viruses, RSV and adenovirus tended to have characteristic imaging appearances. RSV presented with an airway-centric pattern of disease (13/19 cases [68%]) characterized by varying mixtures of tree-in-bud opacities and bronchial wall thickening, with or without peribronchiolar consolidation. Adenovirus typically appeared as multifocal consolidation or ground-glass opacity without airway inflammatory findings (7/10 cases [70%]). CONCLUSION: There is considerable overlap in the imaging appearance of viral and bacterial respiratory infections. However, some characteristic differences can be seen, especially with RSV and adenovirus infections.

Chest computed tomographic imaging characteristics of viral acute lower respiratory tract illnesses: a case-control study.

OBJECTIVE: This study aimed to determine whether computed tomographic (CT) findings can distinguish viral lower respiratory tract illness (LRTI) from other conditions. METHODS: Three radiologists reviewed CT images of patients with LRTI who underwent testing for respiratory viral infection. Imaging findings in subjects with positive viral assays were compared with subjects with negative assays. RESULTS: Of 334 subjects, 93 were positive for viral LRTI. Tree-in-bud opacities and bronchial wall thickening were observed more often in subjects with viral LRTI (P < 0.05). Multifocal airspace disease occurred with similar frequency in both groups. Diffuse airspace opacification was negatively associated with viral LRTI. Pleural effusion was observed more often among subjects without viral LRTI (P < 0.001). CONCLUSIONS: Airway inflammatory changes such as tree-in-bud opacities, bronchial wall thickening, and peribronchiolar consolidation are associated with community-acquired viral LRTI. Recognition of these findings should prompt testing for viral infection. Multifocal consolidation is commonly found in cases of viral LRTI but is nonspecific.

An uncommon cause of Ortner syndrome.

Ortner syndrome is a rare cause of hoarseness, resulting from compression of the left recurrent laryngeal nerve by a cardiovascular etiology. It was initially described secondary to left atrial enlargement and mitral valve disease. Other causes have now been recently described. We present a case of Ortner syndrome caused by penetrating atherosclerotic ulcers of the thoracic aorta.

Factors mediating powerful voltage attenuation along CA1 pyramidal neuron dendrites.

We performed simultaneous patch-electrode recordings from the soma and apical dendrite of CA1 pyramidal neurons in hippocampal slices, in order to determine the degree of voltage attenuation along CA1 dendrites. Fifty per cent attenuation of steady-state somatic voltage changes occurred at a distance of 238 microm from the soma in control and 409 microm after blocking the hyperpolarization-activated (H) conductance. The morphology of three neurons was reconstructed and used to generate computer models, which were adjusted to fit the somatic and dendritic voltage responses. These models identify several factors contributing to the voltage attenuation along CA1 dendrites, including high axial cytoplasmic resistivity, low membrane resistivity, and large H conductance. In most cells the resting membrane conductances, including the H conductances, were larger in the dendrites than the soma. Simulations suggest that synaptic potentials attenuate enormously as they propagate from the dendrite to the soma, with greater than 100-fold attenuation for synapses on many small, distal dendrites. A prediction of this powerful EPSP attenuation is that distal synaptic inputs are likely only to be effective in the presence of conductance scaling, dendritic excitability, or both.