Perfusion imaging for delayed cerebral ischemia detection in patients following ruptured aneurysmal subarachnoid hemorrhage: Interrater reliability assessment.

BACKGROUND: Delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) is associated with adverse neurological outcomes. Early and accurate diagnosis of DCI is crucial to prevent cerebral infarction. This study aimed to assess the diagnostic accuracy and interrater agreement of the visual assessment of neuroimaging perfusion maps to detect DCI in patients suspected of vasospasm after aSAH. METHODS: In this case-control study, cases were adult aSAH patients with DCI who underwent magnetic resonance perfusion or computed tomography perfusion (CTP) imaging in the 24 h prior to digital subtraction angiography for vasospasm diagnosis. Controls were patients with dizziness and no aSAH on CTP imaging. Three independent raters, blinded to patients' clinical information, other neuroimaging studies, and angiographic results, visually assessed anonymized perfusion color maps to classify patients as either having DCI or not. Tmax delay was classified by symmetry into no delay, unilateral, or bilateral. RESULTS: Perfusion imaging of 54 patients with aSAH and 119 control patients without aSAH was assessed. Sensitivities for DCI diagnosis ranged from 0.65 to 0.78, and specificities ranged from 0.70 to 0.87, with interrater agreement ranging from 0.60 (moderate) to 0.68 (substantial). CONCLUSION: Visual assessment of perfusion color maps demonstrated moderate to substantial accuracy in diagnosing DCI in aSAH patients.

Perfusion-weighted MRI patterns in neuropsychiatric systemic lupus erythematosus: a systematic review and meta-analysis.

BACKGROUND: Neuropsychiatric Systemic Lupus Erythematosus (NPSLE) is a complex manifestation of Systemic Lupus Erythematosus (SLE) characterized by a wide range of neurological and psychiatric symptoms. This study aims to elucidate the patterns of Perfusion-Weighted MRI (PWI) in NPSLE patients compared to SLE patients without neuropsychiatric manifestations (non-NPSLE) and healthy controls (HCs). MATERIAL AND METHODS: A systematic search was conducted in PubMed/Medline, Embase, Web of Science, and Scopus for studies utilizing PWI in NPSLE patients published through April 14, 2024. Cerebral blood flow (CBF) data from NPSLE, non-NPSLE patients, and HCs were extracted for meta-analysis, using standardized mean difference (SMD) as an estimate measure. For studies lacking sufficient data for inclusion, CBF, cerebral blood volume (CBV), and mean transit time (MTT) were reviewed qualitatively. RESULTS: Our review included eight observational studies employing PWI techniques, including dynamic susceptibility contrast (DSC) and arterial spin labeling (ASL). The meta-analysis of NPSLE compared to non-NPSLE incorporated four studies, encompassing 104 NPSLE patients and 90 non-NPSLE patients. The results revealed an SMD of -1.42 (95% CI: -2.85-0.00, I2: 94%) for CBF in NPSLE compared to non-NPSLE. CONCLUSION: PWI reveals informative patterns of cerebral perfusion, showing a significant reduction in mean CBF in NPSLE patients compared to non-NPSLE patients. Our qualitative synthesis highlights these changes, particularly in the frontal and temporal lobes. However, the existing data exhibits considerable heterogeneity and limitations.

Peripheral perfusion index of pulse oximetry in adult patients: a narrative review.

The peripheral perfusion index (PI) is derived from pulse oximetry and is defined as the ratio of the pulse wave of the pulsatile portion (arteries) to the non-pulsatile portion (venous and other tissues). A growing number of clinical studies have supported the use of PI in various clinical scenarios, such as guiding hemodynamic management and serving as an indicator of outcome and organ function. In this review, we will introduce and discuss this traditional but neglected indicator of the peripheral microcirculatory perfusion. Further clinical trials are required to clarify the normal and critical values of PI for different monitoring devices in various clinical conditions, to establish different standards of PI-guided strategies, and to determine the effect of PI-guided therapy on outcome.

Challenges in flap monitoring with indocyanine green angiography in experimental models.

Introduction: Non-invasive angiography with indocyanine green dye facilitates the assessment of flaps. Although ICG angiography has been successfully utilized in clinical settings for human beings, its application in experimental models exhibits certain limitations. This study aimed to address the encountered issues in angiography with different experimental models and introduce a novel modification to the ICG imaging of the McFarlane flap. Materials-methods: Rats were randomly divided into three groups: the first group received an epigastric flap (n = 4), the second group received a deep inferior epigastric perforator flap (n = 4), and the third group received a dorsal flap (n = 8). In the first group, sterile silicone background was placed under two flaps. In the second group, no background was used. In the third group, a sterile silicone or aluminum foil was placed under the flaps. Flap perfusions were assessed using fluorescent imaging after flap adaptations, at postoperative 30th minute and 3., 5. and 7. days. Necrosis calculations were performed using all images obtained from the digital camera and the fluorescent imaging. In the third group, the flow velocities were also calculated. All flaps were sent for histopathological examination. Results: Even with a silicone background, clear perfusion evaluation and determining the threshold value for predicting necrosis rates were challenging. Moreover, a portion of the flaps without background material survived as grafts. Using an aluminum foil background improved image quality by reducing reflection from interior organs. Conclusion: The use of an aluminum foil background is beneficial in non-invasive angiography for assessing flap perfusions accurately and predicting necrosis in experimental animal models.

Risk prediction of postoperative permanent stroke in acute type A aortic dissection patients with severe common carotid artery stenosis using brain CT perfusion.

Rationale and objectives: To explore the feasibility and predictive utility for neurological outcomes of brain computed tomography perfusion (CTP) for surgically treated acute type A aortic dissection patients with severe common carotid artery stenosis. Materials and methods: Consecutive acute type A aortic dissection patients with severe common carotid artery stenosis undergoing preoperative brain computed tomography perfusion and surgery at our center were examined in retrospect. Brain perfusion was assessed using parameters including cerebral blood flow, cerebral blood volume, mean transmit time, time to maximum, penumbra volume and infarct core volume. Univariable and multivariable regression analyses were performed to identify clinical and imaging predictors associated with postoperative permanent stroke. Results: Out of 44 patients included, 19 patients (43.2 %) presented with postoperative permanent stroke. Univariable analysis revealed that internal carotid artery dissection, cerebral blood flow of the affected side, cerebral blood volume of the affected side, and penumbra volume were implicated in postoperative permanent stroke. Multivariable analysis further showed that cerebral blood flow of the affected side was an independent indicator of a permanent stroke following surgery (odds ratio: 0.820, 95 % confidence interval: 0.684-0.982; p = 0.012). The area under the receiver operating characteristic curve was 0.867 (95 % confidence interval: 0.764-0.970), and the optimal cut-off value was 45.6mL/100 mL/min. Conclusion: Cerebral blood flow of the affected side was an independent indicator of permanent stroke following surgery in acute type A aortic dissection patients with severe common carotid artery stenosis. Brain CTP could be a helpful modality for quantitative evaluation of cerebral malperfusion and neurological prognostication.

Evaluation of the gastric conduit perfusion using indocyanine green in thoracoscopic esophagectomy for esophageal cancer.

Objective: Indocyanine green has been used in the assessment of the gastric conduit perfusion in thoracoscopic esophagectomy to prevent malperfusion-associated anastomotic leak. This study aims to evaluate the initial results of investigating the gastric conduit perfusion with indocyanine green in the surgical treatment of esophageal cancer. Patients and methods: This cross-sectional descriptive study was carried out on 54 esophageal cancer patients undergoing thoracoscopic esophagectomy and gastric conduit reconstruction. The blood flow in the gastric conduit was observed using an infrared camera and indocyanine green after completion of the conduit and after tunneling the conduit through the mediastinum to the neck. Results: The gastric conduit width and length were 5.2 ± 0.3 cm, and 31.5 ± 1.6 cm, respectively. The length of the gastric conduit from the junction between the right and left gastroepiploic to the point where the distal end of the gastric conduit still has a vascular pulse was 11.9 ± 4.3 cm. Seventeen patients (31.5%) had poor blood supply at the distal end of the gastric conduit, with indocyanine green appearance time ⩾ 60 s, in whom anastomotic leaks occurred in five patients (9.3%). The lack of connection between the right and left gastroepiploic vessels was associated with poor blood supply of the distal gastric conduit (p = 0.04). Multivariable logistic regression analysis showed association between the time of indocyanine green appearance at the distal gastric conduit and the risk of anastomotic leak (OR = 1.99, 95% CI = 1.10-3.60, p = 0.02). Conclusion: Investigation of gastric conduit perfusion using indocyanine green in gastric conduit reconstruction detected 31.5% of patients with poor blood supply at the distal end of the conduit, in whom 9.3% had anastomotic leak. The longer indocyanine green appearance time in the distal gastric conduit (segment BC), was associated with the higher rate of the anastomotic leak.

Combining cerebrospinal fluid and PI-2620 tau-PET for biomarker-based stratification of Alzheimer's disease and 4R-tauopathies.

INTRODUCTION: Recent advances in biomarker research have improved the diagnosis and monitoring of Alzheimer's disease (AD), but in vivo biomarker-based workflows to assess 4R-tauopathy (4RT) patients are currently missing. We suggest a novel biomarker-based algorithm to characterize AD and 4RTs. METHODS: We cross-sectionally assessed combinations of cerebrospinal fluid measures (CSF p-tau181 and t-tau) and 18F-PI-2620 tau-positron emission tomography (PET) in patients with AD (n = 64), clinically suspected 4RTs (progressive supranuclear palsy or corticobasal syndrome, n = 82) and healthy controls (n = 19). RESULTS: Elevated CSF p-tau181 and cortical 18F-PI-2620 binding was characteristic for AD while normal CSF p-tau181 with elevated subcortical 18F-PI-2620 binding was characteristic for 4RTs. 18F-PI-2620-assessed posterior cortical hypoperfusion could be used as an additional neuronal injury biomarker in AD. DISCUSSION: The specific combination of CSF markers and 18F-PI-2620 tau-PET in disease-specific regions facilitates the biomarker-guided stratification of AD and 4RTs. This has implications for biomarker-aided diagnostic workflows and the advancement in clinical trials. HIGHLIGHTS: Novel biomarker-based algorithm for differentiating AD and 4R-tauopathies. A combination of CSF p-tau181 and 18F-PI-2620 discriminates AD versus 4R tauopathies. Hypoperfusion serves as an additional neuronal injury biomarker in AD.

Performance evaluation of a 4D similarity filter for dynamic CT angiography imaging of the liver.

BACKGROUND: Dynamic computed tomography (CT) angiography of the abdomen provides perfusion information and characteristics of the tissues present in the abdomen. This information could potentially help characterize liver metastases. However, radiation dose has to be relatively low for the patient, causing the images to have very high noise content. Denoising methods are needed to increase image quality. PURPOSE: The purpose of this study was to investigate the performance, limitations, and behavior of a new 4D filtering method, called the 4D Similarity Filter (4DSF), to reduce image noise in temporal CT data. METHODS: The 4DSF averages voxels with similar time-intensity curves (TICs). Each phase is filtered individually using the information of all phases except for the one being filtered. This approach minimizes the bias toward the noise initially present in this phase. Since the 4DSF does not base similarity on spatial proximity, loss of spatial resolution is avoided. The 4DSF was evaluated on a 12-phase liver dynamic CT angiography acquisition of 52 digital anthropomorphic phantoms, each containing one hypervascular 1 cm lesion with a small necrotic core. The metrics used for evaluation were noise reduction, lesion contrast-to-noise ratio (CNR), CT number accuracy using peak-time and peak-intensity of the TICs, and resolution loss. The results were compared to those obtained by the time-intensity profile similarity (TIPS) filter, which uses the whole TIC for determining similarity, and the combination 4DSF followed by TIPS filter (4DSF + TIPS). RESULTS: The 4DSF alone resulted in a median noise reduction by a factor of 6.8, which is lower than that obtained by the TIPS filter at 8.1, and 4DSF + TIPS at 12.2. The 4DSF increased the median CNR from 0. 44 to 1.85, which is less than the TIPS filter at 2.59 and 4DSF + TIPS at 3.12. However, the peak-intensity accuracy in the TICs was superior for the 4DSF, with a median intensity decrease of -34 HU compared to -88 and -50 HU for the hepatic artery when using the TIPS filter and 4DSF + TIPS, respectively. The median peak-time accuracy was inferior for the 4DSF filter and 4DSF + TIPS, with a time shift of -1 phases for the portal vein TIC compared to no shift in time when using the TIPS. The analysis of the full-width-at-half-maximum (FWHM) of a small artery showed significantly less spatial resolution loss for the 4DSF at 3.2 pixels, compared to the TIPS filter at 4.3 pixels, and 3.4 pixels for the 4DSF + TIPS. CONCLUSION: The 4DSF can reduce noise with almost no resolution loss, making the filter very suitable for denoising 4D CT data for detection tasks, even in very low dose, i.e., very high noise level, situations. In combination with the TIPS filter, the noise reduction can be increased even further.

Brain perfusion SPECT in the presurgical evaluation of epilepsy: is additional ictal SPECT required in case of high-confidence lateralization of the seizure onset zone by interictal SPECT and vice versa?

BACKGROUND: Ictal brain perfusion SPECT provides higher sensitivity for the identification of the epileptic seizure onset zone (SOZ) than interictal SPECT. However, ictal SPECT is demanding due to the unpredictable waiting period for the next seizure to allow for ictal tracer injection. Thus, starting with an interictal scan and skipping the ictal scan if the interictal scan provides a SOZ candidate with high confidence could be an efficient approach. The current study estimated the rate of high-confidence SOZ candidates and the false lateralization rate among them for interictal and ictal SPECT. METHODS: 177 patients (48% females, median age 38y, interquartile range 27-48y) with ictal and interictal SPECT acquired with 99mTc-HMPAO (n = 141) or -ECD (n = 36) were included retrospectively. The vast majority of the patients was suspected to have temporal lobe epilepsy. Visual interpretation of the SPECT data was performed independently by 3 readers in 3 settings: "interictal only" (interictal SPECT and statistical hypoperfusion map), "ictal only" (ictal SPECT and hyperperfusion map), and "full" setting (side-by-side interpretation of ictal and interictal SPECT including statistical maps and SISCOM analysis). The readers lateralized the SOZ (right, left, none) and characterized their confidence using a 5-score. A case was considered "lateralizing with high confidence" if all readers lateralized to the same hemisphere with at least 4 of 5 confidence points. Lateralization of the SOZ in the "full" setting was used as reference standard. RESULTS: The proportion of "lateralizing with high confidence" cases was 4.5/31.6/38.4% in the "interictal only"/"ictal only"/"full" setting. One (12.5%) of the 8 cases that were "lateralizing with high confidence" in the "interictal only" setting lateralized to the wrong hemisphere. Among the 56 cases that were "lateralizing with high confidence" in the "ictal only" setting, 54 (96.4%) were also lateralizing in the "full" setting, all to the same hemisphere. CONCLUSIONS: Starting brain perfusion SPECT in the presurgical evaluation of epilepsy with an interictal scan to skip the ictal scan in case of a high-confidence interictal SOZ candidate is not a useful approach. In contrast, starting with an ictal scan to skip the interictal scan in case of a high-confidence ictal SOZ candidate can be recommended.

Cerebral hypoperfusion resulting from improper cannulation positioning during aortic dissection surgery: a case report.

BACKGROUND: Selective antegrade cerebral perfusion (sACP) is a crucial cerebral protection technique employed during aortic dissection surgeries involving cardiopulmonary bypass. However, postoperative neurological complications, particularly those related to cannulation issues and perfusion problems, remain a significant concern. CASE PRESENTATION: This case report details an unusual instance where a 38-year-old male patient with Marfan syndrome experienced cerebral hypoperfusion during emergency surgery for Stanford Type A aortic dissection. Despite following standard protocols, a significant drop in regional cerebral oxygen saturation (rSO2) and abnormal blood pressure fluctuations were observed shortly after initiating sACP via the innominate artery. After initial attempts to optimize perfusion flow proved ineffective, the cannulation position was adjusted, leading to improvements. Nevertheless, the patient subsequently exhibited signs of cerebral hypoperfusion and was found to have suffered a new cerebral infarction. CONCLUSIONS: This case report underscores the importance of precise cannula placement during sACP procedures and the dire consequences that can arise from improper positioning. It emphasizes the need for continuous monitoring and prompt intervention in cases of abnormal cerebral oxygenation and blood pressure, as well as the value of considering cannulation-related issues as potential causes of postoperative neurological complications.

Artificial intelligence for optimum tissue excision with indocyanine green fluorescence angiography for flap reconstructions: Proof of concept.

Background: Indocyanine green fluorescence angiography (ICGFA) is gaining popularity as an intraoperative tool to assess flap perfusion. However, it needs interpretation and there is concern regarding a potential for over-debridement with its use. Here we describe an artificial intelligence (AI) method that indicates the extent of flap trimming required. Methods: Operative ICGFA recordings from ten consenting patients undergoing flap reconstruction without subsequent partial/total necrosis as part of an approved prospective study (NCT04220242, Institutional Review Board Ref:1/378/2092), provided the training-testing datasets. Drawing from prior similar experience with ICGFA intestinal perfusion signal analysis, five fluorescence intensity and time-related features were analysed (MATLAB R2024a) from stabilised ICGFA imagery. Machine learning model training (with ten-fold cross-validation application) was grounded on the actual trimming by a consultant plastic surgeon (S.P.) experienced in ICGFA. MATLAB classification learner app was used to identify the most important feature and generate partial dependence plots for interpretability during training. Testing involved post-hoc application to unseen videos blinded to surgeon ICGFA interpretation. Results: Training:testing datasets comprised 7:3 ICGFA videos with 28 and 3 sampled lines respectively. Validation and testing accuracy were 99.9 % and 99.3 % respectively. Maximum fluorescence intensity identified as the most important predictive curve feature. Partial dependence plotting revealed a threshold of 22.1 grayscale units and regions with maximum intensity less then threshold being more likely to be predicted as "excise". Conclusion: The AI method proved discriminative regarding indicating whether to retain or excise peripheral flap portions. Additional prospective patients and expert references are needed to validate generalisability.

FEVR combined with macular heterotopia in children presenting as pseudo-exotropia: a case report and literature review.

Familial exudative retinopathy (FEVR) is a hereditary disease involving abnormal retinal vascular development in which macular heterotopia (MH) caused by mechanical-like pulling of the vitreous may lead to pseudo-strabismus. We describe the case of a 12-year-old male patient from China who presented to our hospital with a request for surgical correction of exotropia. Examination revealed that the strabismic appearance was due to MH, and dilated pupil examination of the peripheral fundus revealed that the blood vessels of the left eye and the macula were displaced toward the temporal retina by pulling, and further FFA examination was performed to diagnose FEVR. With good binocular vision and stereoscopic distance vision, corrective surgery for strabismus in this patient would have resulted in a hard-to-resolve diplopia. Therefore, it is important to identify FEVR combined with MH in clinical practice to avoid wrong diagnostic and treatment options.

Unmasking of Agenesis of Right Pulmonary Artery with Unilateral Absence of Perfusion on Lung Scintigraphy.

We present a rare finding on lung ventilation-perfusion (V/Q) scintigraphy for a woman with longstanding dyspnea. CT of the chest showed volume loss on the right side, which raised concern about possible bronchiolitis obliterans or Swyer-James-MacLeod syndrome; however, the right pulmonary artery could not be visualized. A subsequent V/Q scan showed absence of perfusion and decreased ventilation to the entire right lung, consistent with agenesis of the right pulmonary artery. The patient's clinical course and imaging features mimicked Swyer-James-MacLeod syndrome, which usually presents with a matched perfusion defect in a single lung or lobe on V/Q scanning. This case highlights the importance of a multimodality imaging approach to achieve a diagnosis.

New Subependymal Enhancement After Radiation Therapy in High-Grade Glioma: Utilizing Morphological Features and DSC Perfusion MRI in Differentiate Progression and Post-Radiation Changes.

BACKGROUND: The specific patterns of subependymal enhancement (SE) that frequently occur as radiation-induced changes in high-grade gliomas following radiotherapy are often overlooked. Perfusion MRI may offer a diagnostic clue. PURPOSE: To distinguish between radiation-induced SE and progression in adult high-grade diffuse gliomas after standard treatment. STUDY TYPE: Retrospective. POPULATION: Ninety-four consecutive high-grade diffuse glioma patients (mean age, 55 ± 14 years; 54 [57.4%] males) with new SE identified in follow-up MRI after completion of surgery plus chemoradiation: progression (N = 74) vs. regression (N = 20). FIELD STRENGTH/SEQUENCE: 3 T, gradient-echo dynamic susceptibility contrast-enhanced MRI, 3D gradient-echo contrast-enhanced T1-weighted imaging. ASSESSMENT: To differentiate between radiation changes and progression in SE evaluation, multivariable logistic regression was performed using significant variables among SE appearance interval, IDH mutation, morphological features, and rCBV. Cox regression was performed to predict the tumor progression. For the added value of the rCBV, a log-rank test was conducted between the multivariable logistic regression models with and without the rCBV. STATISTICAL TESTS: Logistic regression, Cox regression, receiver operating characteristic analysis, log-rank test. RESULTS: 38.3% (36/94) patients had first specific SE (9.2 ± 9.5 months after surgery), which disappeared in 21.3% (20/94) after 5.8 ± 5.8 months after initial appearance on post-radiation MRI. IDH mutation, elongated, small lesions with lower rCBV tended to regress: IDH mutation, elongation, diameter, and rCBV_p95; odds ratio, 0.32, 1.92, 1.70, and 2.47, respectively. Qualitative evaluation of shape revealed that thin and curvilinear-shaped SE tended to regress, indicating a significant correlation with quantitative shape features (r = 0.31). In Cox regression, rCBV and lesion shape were significant (hazard ratio = 1.09 and 0.54, respectively). For sub-centimeter lesions, the rCBV showed added value in predicting outcomes (area under the curve, 0.873 vs. 0.836; log-rank test). DATA CONCLUSION: Smaller, elongated lesions with lower rCBV and IDH mutation are associated with regression when differentiating radiation changes from progression in high-grade glioma with post-radiotherapy SE. EVIDENCE LEVEL: 3 TECHNICAL EFFICACY: Stage 2.

Single-center experience of extended brain-death donor heart preservation with the organ care system.

BACKGROUND: The Organ Care System (OCS) (Transmedics, Andover, MA) reduces cold ischemic time of donor hearts by producing a normothermic beating state during ex vivo perfusion, enabling extended ex situ intervals, which potentially increases donor pool. We aimed to compare outcomes in utilization of OCS and conventional cold storage technique. METHODS: Consecutive heart transplants following brain death at our institution between May 2022 and July 2023 were analyzed. Recipients were divided into those receiving hearts preserved with OCS [N = 15] and those with conventional cold storage (Control, N = 27), with OCS utilization when anticipated ischemic time was more than 4 h. Pre-transplant characteristics and transplant outcomes were compared. RESULTS: OCS utilization allowed a significant increase in distance traveled for heart retrieval (OCS, 624 ± 269 vs. Control, 153 ± 128 miles, p < 0.001), with longer mean total preservation times (6.2 ± 1.1 vs 2.6 ± 0.6 h, p < 0.001). All but one patient displayed a general decrease or plateau in lactate throughout perfusion time by OCS. Both groups experienced similar rates of severe primary graft dysfunction (OCS, 6.7% [N = 1] vs. Control, 11.1% [N = 3], p = 0.63), with 100% in-hospital survival in the OCS group compared to 96.3% in the Control group (p = 0.34). Kaplan-Meier survival analysis showed that estimated one-year survival were comparable (OCS, 93.3 ± 6.4% vs. Control, 88.9 ± 6.0%, p = 0.61). CONCLUSION: With a mean preservation time of around 6 h and distance covered of over 600 miles, our results using OCS indicate a potential to safely increase the quantity and viability of accessible organs, thus broadening the donor pool without negatively affecting outcomes.

Perfusion deficit and vessel wall characteristics to predict recurrent ischemic events in medically treated patients with chronic symptomatic anterior circulation large vessel occlusion.

BACKGROUND: To investigate the association between perfusion deficit, vessel wall characteristics, and risk of recurrent ischemic events in medically treated patients with chronic symptomatic anterior circulation large vessel occlusion. METHODS: We retrospectively reviewed chronic symptomatic patients due to anterior circulation large vessel occlusion in our center. All patients received multiparametric magnetic resonance imaging (including perfusion-weighted imaging and high-resolution vessel wall imaging) within 4 weeks to 3 months after symptom onset. The association between baseline clinical or imaging variables and recurrent ischemic events was assessed in bivariate models and multivariable logistic regression to identify independent predictors of recurrence. RESULTS: Among 71 enrolled patients, 21.1% (15/71) patients had recurrent ischemic events (nine ischemic strokes and six transient ischemic attacks) during a 2-year follow-up. In bivariate models, hypertension, occlusion with hyperintense signals, the presence of intraluminal thrombus, Tmax >4 s volume, Tmax >6 s volume, Tmax >8 s volume, and Tmax >10 s volume were associated with recurrence (all p < 0.05). In multivariate analysis, hypertension (p = 0.039, OR 10.057 (95% CI, 1.123-90.048)), higher deficit volume of Tmax >4 s (p = 0.011, OR 1.012 (95% CI, 1.003-1.021)) and occlusion with hyperintense signal (p = 0.030, OR 6.732 (95% CI, 1.200-37.772)) were still independent predictors of recurrent ischemic events. CONCLUSIONS: Besides hypertension history, higher deficit volume of Tmax >4 s and occlusion with hyperintense signal determined using multiparametric MRI are strongly associated with risk for recurrent ischemic events in medically treated patients with chronic symptomatic anterior circulation large vessel occlusion. Future studies are needed to determine the utility of revascularization strategies in such high-risk patients.

Value of Ischemia and Coronary Anatomy in Prognosis and Guiding Revascularization Among Patients With Stable Ischemic Heart Disease.

BACKGROUND: The value of physiological ischemia versus anatomic severity of disease for prognosis and management of patients with stable coronary artery disease (CAD) is widely debated. METHODS: A total of 1764 patients who had rest-stress cadmium-zinc-telluride single-photon emission computed tomography myocardial perfusion imaging and angiography (invasive or computed tomography) were prospectively enrolled and followed for cardiac death/nonfatal myocardial infarction. The CAD prognostic index (CADPI) was used to quantify the extent and severity of angiographic disease. Prognostic value was assessed using Cox models, adjusted for pretest risk, known CAD, stressor, left ventricular ejection fraction, %ischemia and infarct, CADPI, and early (90-day) revascularization. Incremental prognostic value was evaluated using net reclassification index. RESULTS: The mean age was 69.7±9.5 years, 24.4% were women, and 29.3% had known CAD. Significant ischemia (>10%) was present in 28.4%. Nonobstructive, single, and multivessel disease was present in 256 (14.5%), 772 (43.8%), and 736 (41.7%), respectively. Early revascularization occurred in 579 (32.8%). Cardiac death/myocardial infarction occurred in 148 (8.4%) over a 4.6-year median follow-up. Both %ischemia and CADPI provided independent and incremental prognostic value over pretest clinical risk (P<0.001). In a model containing both ischemia and anatomy, ischemia was prognostic (hazard ratio per 5% ↑, 1.35 [95% CI, 1.11-1.63]; P=0.002) but CADPI was not (hazard ratio per 10-unit ↑, 1.09 [95% CI, 0.99-1.20]; P=0.07). Early revascularization modified the risk associated with %ischemia (interaction P=0.003) but not with CADPI (interaction P=0.6). %Ischemia and single-photon emission computed tomography variables added incremental prognostic value over clinical risk and CADPI (net reclassification index, 20.3% [95% CI, 9%-32%]; P<0.05); however, CADPI was not incrementally prognostic beyond pretest risk, %ischemia, and single-photon emission computed tomography variables (net reclassification index, 3.1% [95% CI, -5% to 15%]; P=0.21). CONCLUSIONS: Ischemic burden provides independent and incremental prognostic value beyond CAD anatomy and identifies patients who benefit from early revascularization. The anatomic extent of disease has independent prognostic value over clinical risk factors but offers limited incremental benefit for prognosis and guiding revascularization beyond physiological severity (ischemia).

Total aortic arch replacement with frozen elephant trunk technique for intramural haematoma of the thoracic aorta.

Presenting this video tutorial, we want to demonstrate a step-by-step surgical approach to acute intramural haematoma of the thoracic aorta without a definite entry tear. Limited by the aortic valve proximally, the intramural haematoma involved the aortic root, ascending aorta, aortic arch, including adjacent parts of supra-aortic branches, and descending aorta extending to the diaphragmatic level. The operative strategy involved urgent total aortic arch replacement with the frozen elephant trunk technique and anatomical reimplantation of the three supra-aortic vessels. The direct open over-the-wire technique was used to cannulate the right axillary artery, and standard venous cannulation was performed while brain protection was achieved with bilateral selective antegrade cerebral perfusion.