Multidisciplinary management of posterior fossa dural arteriovenous fistula: A single-center experience.

PURPOSE: The management of posterior fossa dural arteriovenous fistulas (pfDAVFs) is challenging. Here, we show how multidisciplinarity leads to their successful management, even in complex cases. METHODS: All pfDAVFs managed from 2010 to 2019 at our center were reviewed. The preoperative clinical and radiological characteristics, their management and the occlusion rate were retrieved. The radiological and functional outcomes were retrieved at discharge and last follow-up (FU). RESULTS: n=27 patients were included (6 females, mean age: 61-years-old, mean FU: 22.5 months). n=8 patients presented with cerebral hemorrhage. Among patients with ruptured pfDAVFs, n=7 had headache, n=4 had ataxia, and n=2 had impaired level of consciousness. In the unruptured group N (n=19), n=7 patients had headache, n=6 patients had focal neurological deficit, n=4 patients had tinnitus, n=3 (had ataxia, and one presented with seizure. n=24 patients were treated by endovascular therapy (EVT), n=2 patients were treated by microsurgery (MS) and n=1 patient was managed with a combined approach. Re-treatment was necessary in n=6 patients. n=24 patients showed total exclusion at last FU. n=2 patients died during the first 30 days; n=1 patient died during FU. CONCLUSIONS: While EVT should be advocated as the first line therapy whenever possible, MS should not be banned from the treatment armamentarium. Neurosurgeons must be able to achieve direct surgical occlusion when the angioarchitecture speaks against EVT.

Apathy in depression: An arterial spin labeling perfusion MRI study.

INTRODUCTION: Apathy, as defined as a deficit in goal-directed behaviors, is a critical clinical dimension in depression associated with chronic impairment. Little is known about its cerebral perfusion specificities in depression. To explore neurovascular mechanisms underpinning apathy in depression by pseudo-continuous arterial spin labeling (pCASL) magnetic resonance imaging (MRI). METHODS: Perfusion imaging analysis was performed on 90 depressed patients included in a prospective study between November 2014 and February 2017. Imaging data included anatomical 3D T1-weighted and perfusion pCASL sequences. A multiple regression analysis relating the quantified cerebral blood flow (CBF) in different regions of interest defined from the FreeSurfer atlas, to the Apathy Evaluation Scale (AES) total score was conducted. RESULTS: After confound adjustment (demographics, disease and clinical characteristics) and correction for multiple comparisons, we observed a strong negative relationship between the CBF in the left anterior cingulate cortex (ACC) and the AES score (standardized beta = -0.74, corrected p value = 0.0008). CONCLUSION: Our results emphasized the left ACC as a key region involved in apathy severity in a population of depressed participants. Perfusion correlates of apathy in depression evidenced in this study may contribute to characterize different phenotypes of depression.

Prevalencia preoperatoria de portadores asintomáticos de COVID-19 en hospitales de Cataluña durante la primera ola tras el reinicio de la actividad quirúrgica / Pre-operative prevalence of asymptomatic carriers of COVID-19 in hospitals in Catalonia during the first wave after the resumption of surgical activity

Introducción La pandemia producida por COVID-19 ocasionó la cancelación de los procedimientos quirúrgicos no esenciales en marzo de 2020. Con el reinicio de la actividad quirúrgica, los pacientes que se sometían a una cirugía fueron uno de los primeros grupos poblacionales a los que se realizó test PCR de forma sistemática. El objetivo de este estudio fue determinar la prevalencia de portadores asintomáticos de SARS-CoV-2 tras el reinicio de la actividad quirúrgica no esencial. Métodos Estudio observacional multicéntrico retrospectivo de los pacientes programados para cirugía o que se sometieron a cirugía urgente en Cataluña entre el 20 de abril y el 31 de mayo de 2020. Se revisaron los resultados microbiológicos de los test PCR preoperatorios, las historias clínicas y se realizó una encuesta epidemiológica a los pacientes con PCR positiva para SARS-CoV-2. Resultados Un total de 10.838 pacientes programados para una intervención quirúrgica o a los que se realizó una cirugía urgente fueron sometidos a cribado para COVID-19. Ciento dieciocho pacientes (1,09%) fueron positivos para SARS-CoV-2 en las 72h previas a la cirugía. La prevalencia de portadores asintomáticos fue del 0,7% (IC95%: 0,6-0,9%). La primera semana del estudio presentó la prevalencia más alta de portadores asintomáticos [1,9% (IC95%: 1,1-3,2%)]. Conclusiones Los bajos niveles de portadores asintomáticos de infección por COVID-19 obtenidos en la población quirúrgica de los hospitales de Cataluña tras el reinicio de la actividad quirúrgica muestran que la mayoría de pacientes se pudieron someter a procedimientos quirúrgicos sin los riesgos de las complicaciones asociadas al COVID-19 en el periodo perioperatorio (AU)

Introduction The COVID-19 pandemic led to the cancellation of non-essential surgical procedures in March 2020. With the resumption of surgical activity, patients undergoing surgery were one of the first population groups to be systematically tested for PCR. The aim of this study was to determine the prevalence of asymptomatic SARS-CoV-2 carriers after the resumption of non-essential surgical activity. Methods Retrospective multicenter observational study of patients scheduled for surgery or undergoing emergency surgery in Catalonia between 20 April and 31 May 2020. The microbiological results of preoperative PCR tests and clinical records were reviewed, and an epidemiological survey was conducted on patients with positive PCR for SARS-CoV-2. Results A total of 10,838 patients scheduled for surgery or who underwent emergency surgery were screened for COVID-19. One hundred and eighteen patients (1.09%) were positive for SARS-CoV-2 in the 72hours prior to surgery. The prevalence of asymptomatic carriers was 0.7% (95%CI: 0.6% - 0.9%). The first week of the study presented the highest prevalence of asymptomatic carriers [1.9% (95%CI: 1.1%-3.2%)]. Conclusions The low levels of asymptomatic carriers of COVID-19 infection obtained in the surgical population of hospitals in Catalonia after the resumption of surgical activity, shows that most patients were able to undergo surgical procedures without the risks of COVID-19 associated complications in the perioperative period (AU)

Ex vivo porcine model for eye, eyelid, and orbit movement analysis of 4-mm ferromagnetic foreign bodies in MRI.

PURPOSE: Ferromagnetic foreign bodies (FFB) present during magnetic resonance imaging (MRI) explorations can lead to tissue injury due to movement, especially in and around the eyes. Ferromagnetic foreign bodies located in the intraocular area, eyelids, and orbit are thus prohibited from undergoing MRI. The aim of the study was to analyze movement of 4-mm ferromagnetic foreign bodies in MRI in the eye, eyelid, and orbit using computed tomography (CT) scan. METHOD: We developed a porcine model using 12 quarters of fresh porcine heads. Each porcine head included one whole orbit with the ocular globe, orbital fat, muscles, and eyelids. Four-millimeter FFB were implanted in the eye within 2 days post-slaughter, and images were acquired within 5 days post-slaughter. Four-millimeter FFB movement was analyzed after 1.5-Tesla (T) MRI. Four locations were tested: intravitreous, suprachoroidal, intraorbital fat, and intrapalpebral. Movement analysis was assessed using computed tomography (CT) scan. RESULTS: The intravitreous ferromagnetic ball moved 14.0 ± 8.8 mm (p < 0.01), the suprachoroidal ball moved 16.8 ± 5.4 mm (p < 0.01), the intraorbital fat ball moved 5.8 ± 0.9 mm (p > 0.05), and the intrapalpebral ball moved 2.0 ± 0.4 mm (p > 0.05). CONCLUSION: The ex vivo porcine model was able to study FFB movement. The 4-mm ferromagnetic balls moved in intravitreous and in suprachoroidal locations after MRI.

Primary total hip arthroplasty with a fully porous-coated uncemented stem: up to twenty-eight years. Retrospective cohort study.

PURPOSE: The use of cementless prosthesis has increased in the last 30 years with the aim of improving the long-term results of total hip arthroplasties in young and active patients. Encouraging results have recently been reported for cementless titanium and cobalt chromium stems. However, there are few studies with long-term follow-up, and the majority have analysed several models of uncemented stems due to their modifications over the years. Therefore, the aim was to assess the long-term survival rate of the Mittelmeier Mark III or Autophor 900-S stem. METHODS: A retrospective cohort study of both gender patients under 70 years old with at least one implanted Mittelmeier Mark III uncemented stem was performed. Survival rate was defined as the proportion of stems that did not need a surgical revision from any cause. Clinical status was evaluated using the Merle d'Aubigne scale modified by Matta (excellent/good/fair/poor). RESULTS: Between 1990 and 1999, 73 stems were implanted. The mean (SD) age at surgical time was 49.3 (9.9) years, and the median (range) of follow-up was 22 (1-28) years. The overall survival rate was 93% (68/73, 95%CI: 85-97%). The stem revisions were due to stem breakage (n = 2), to aseptic loosening (n = 2) and to septic loosening (n = 1). Clinical results were: excellent 84%, good 15% and fair 1.5%. CONCLUSIONS: The Mittelmeier Mark III stem had an excellent survival rate with a stable long-term fixation and excellent clinical outcomes.

Multimodal MRI cerebral correlates of verbal fluency switching and its impairment in women with depression.

BACKGROUND: The search of biomarkers in the field of depression requires easy implementable tests that are biologically rooted. Qualitative analysis of verbal fluency tests (VFT) are good candidates, but its cerebral correlates are unknown. METHODS: We collected qualitative semantic and phonemic VFT scores along with grey and white matter anatomical MRI of depressed (n = 26) and healthy controls (HC, n = 25) women. Qualitative VFT variables are the "clustering score" (i.e. the ability to produce words within subcategories) and the "switching score" (i.e. the ability to switch between clusters). The clustering and switching scores were automatically calculated using a data-driven approach. Brain measures were cortical thickness (CT) and fractional anisotropy (FA). We tested for associations between CT, FA and qualitative VFT variables within each group. RESULTS: Patients had reduced switching VFT scores compared to HC. Thicker cortex was associated with better switching score in semantic VFT bilaterally in the frontal (superior, rostral middle and inferior gyri), parietal (inferior parietal lobule including the supramarginal gyri), temporal (transverse and fusiform gyri) and occipital (lingual gyri) lobes in the depressed group. Positive association between FA and the switching score in semantic VFT was retrieved in depressed patients within the corpus callosum, right inferior fronto-occipital fasciculus, right superior longitudinal fasciculus extending to the anterior thalamic radiation (all p < 0.05, corrected). CONCLUSION: Together, these results suggest that automatic qualitative VFT scores are associated with brain anatomy and reinforce its potential use as a surrogate for depression cerebral bases.

Assessment of 4D MR Angiography at 3T Compared with DSA for the Follow-up of Embolized Brain Dural Arteriovenous Fistula: A Dual-Center Study.

BACKGROUND AND PURPOSE: 4D contrast-enhanced MRA in the follow-up of treated dural arteriovenous fistulas has rarely been evaluated. Our aim was to evaluate its diagnostic performance at 3T in the follow-up of embolized dural arteriovenous fistulas using DSA as the standard of reference. MATERIALS AND METHODS: Patients treated for dural arteriovenous fistulas in 2 centers between 2008 and 2019 were included if they met the following criteria: 1) dural arteriovenous fistula embolization, and 2) follow-up imaging with <6 months between DSA and 4D contrast-enhanced MRA. Two readers reviewed the 4D contrast-enhanced MRA images, first independently, then in consensus to detect any residual/recurrent dural arteriovenous fistula and to grade cases according to the Cognard classification system. Interobserver and intermodality agreement for the detection of a residual dural arteriovenous fistula and stratification of bleeding risk (0-I-IIa; IIb-IIa+b-III-IV-V) was calculated using κ coefficients. RESULTS: A total of 51 pairs of examinations for 44 patients (median age, 65 years; range, 25-81 years) were analyzed. Interobserver agreement for the detection and stratification of bleeding risk was, respectively, κ = 0.8 (95% CI, 0.6-1) and κ = 0.8 (95% CI, 0.5-1). After consensus review, the sensitivity and specificity of 4D contrast-enhanced MRA for the detection of residual/recurrent dural arteriovenous fistula was 63.6% (95% CI, 40.7%-82.8%) and 96.6% (95% CI, 82.2%-99.9%), respectively. The positive and negative predictive values of 4D contrast-enhanced MRA were 93.3% (95% CI, 68.1%-99.8%) and 77.8% (95% CI, 60.8%-89.9%). Intermodality agreement for the detection and stratification of bleeding risk was good, with κ = 0.60 (95% CI, 0.3-0.8). CONCLUSIONS: 4D contrast-enhanced MRA at 3T is of interest in the follow-up of treated dural arteriovenous fistulas but lacks the sensitivity to replace arteriography.

Implicación en Cataluña de los Servicios de Anestesiología y Reanimación en la pandemia por SARS-CoV-2. Una solución real coste-efectiva para una crisis sanitaria sin precedentes / Involvement in Catalonia of the Anaesthesiology and Resuscitation Services in the SARS-CoV-2 pandemic. A real, cost-effective solution to an unprecedented health crisis

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DWI-Based Algorithm to Predict Disability in Patients Treated with Thrombectomy for Acute Stroke.

BACKGROUND AND PURPOSE: The reasons for poor clinical outcome after thrombectomy for acute stroke, concerning around half of all patients, are misunderstood. We developed a hierarchic algorithm based on DWI to better identify patients at high risk of disability. MATERIALS AND METHODS: Our single-center, retrospective study included consecutive patients with acute ischemic stroke who underwent thrombectomy for large anterior artery occlusion and underwent pretreatment DWI. The primary outcome was the mRS at 3 months after stroke onset. Multivariable regression was used to identify independent clinical and imaging predictors of poor prognosis (mRS > 2) at 3 months, and a hierarchic algorithm predictive of disability was developed. RESULTS: A total of 149 patients were analyzed. In decreasing importance, DWI lesion volume of >80 mL, baseline NIHSS score of >14, age older than 75 years, and time from stroke onset to groin puncture of >4 hours were independent predictors of poor prognosis. The predictive hierarchic algorithm developed from the multivariate analysis predicted the risk of disability at 3 months for up to 100% of patients with a high predictive value. The area under the receiver operating characteristic curve was 0.87. CONCLUSIONS: The DWI-based hierarchic algorithm we developed is highly predictive of disability at 3 months after thrombectomy and is easy to use in routine practice.

Multi T1-weighted contrast MRI with fluid and white matter suppression at 1.5 T.

INTRODUCTION: The fluid and white matter suppression sequence (FLAWS) provides two T1-weighted co-registered datasets: a white matter (WM) suppressed contrast (FLAWS1) and a cerebrospinal fluid (CSF) suppressed contrast (FLAWS2). FLAWS has the potential to improve the contrast of the subcortical brain regions that are important for Deep Brain Stimulation surgery planning. However, to date FLAWS has not been optimized for 1.5 T. In this study, the FLAWS sequence was optimized for use at 1.5 T. In addition, the contrast-enhancement properties of FLAWS image combinations were investigated using two voxel-wise FLAWS combined images: the division (FLAWS-div) and the high contrast (FLAWS-hc) image. METHODS: FLAWS sequence parameters were optimized for 1.5 T imaging using an approach based on the use of a profit function under constraints for brain tissue signal and contrast maximization. MR experiments were performed on eleven healthy volunteers (age 18-30). Contrast (CN) and contrast to noise ratio (CNR) between brain tissues were measured in each volunteer. Furthermore, a qualitative assessment was performed to ensure that the separation between the internal globus pallidus (GPi) and the external globus pallidus (GPe) is identifiable in FLAWS1. RESULTS: The optimized set of sequence parameters for FLAWS at 1.5 T provided contrasts similar to those obtained in a previous study at 3 T. The separation between the GPi and the GPe was clearly identified in FLAWS1. The CN of FLAWS-hc was higher than that of FLAWS1 and FLAWS2, but was not different from the CN of FLAWS-div. The CNR of FLAWS-hc was higher than that of FLAWS-div. CONCLUSION: Both qualitative and quantitative assessments validated the optimization of the FLAWS sequence at 1.5 T. Quantitative assessments also showed that FLAWS-hc provides an enhanced contrast compared to FLAWS1 and FLAWS2, with a higher CNR than FLAWS-div.

Critical amino acids for the insecticidal activity of Vip3Af from Bacillus thuringiensis: Inference on structural aspects.

Vip3 vegetative insecticidal proteins from Bacillus thuringiensis are an important tool for crop protection against caterpillar pests in IPM strategies. While there is wide consensus on their general mode of action, the details of their mode of action are not completely elucidated and their structure remains unknown. In this work the alanine scanning technique was performed on 558 out of the total of 788 amino acids of the Vip3Af1 protein. From the 558 residue substitutions, 19 impaired protein expression and other 19 substitutions severely compromised the insecticidal activity against Spodoptera frugiperda. The latter 19 substitutions mainly clustered in two regions of the protein sequence (amino acids 167-272 and amino acids 689-741). Most of these substitutions also decreased the activity to Agrotis segetum. The characterisation of the sensitivity to proteases of the mutant proteins displaying decreased insecticidal activity revealed 6 different band patterns as evaluated by SDS-PAGE. The study of the intrinsic fluorescence of most selected mutants revealed only slight shifts in the emission peak, likely indicating only minor changes in the tertiary structure. An in silico modelled 3D structure of Vip3Af1 is proposed for the first time.

Multicenter initial experience with the EmboTrap device in acute anterior ischemic stroke.

BACKGROUND AND PURPOSE: Mechanical thrombectomy predominantly using stent retrievers effectively restores cerebral blood flow and improves functional outcomes in patients with acute ischemic stroke. We sought to determine the safety and efficacy of mechanical thrombectomy using the EmboTrap device. MATERIALS AND METHODS: We identified 80 consecutive patients from 4 centers with acute ischemic stroke treated with EmboTrap from June 2015 to December 2016. All patients had confirmed large vessel occlusions in the anterior circulation using CT or MR angiography with salvageable tissue. We assessed baseline characteristics and treatment related parameters including onset-to-treatment time, recanalization success (mTICI 2b or greater), complications, and good clinical outcome (mRS 0 to 2). RESULTS: Successful recanalization was achieved in 72 patients (90%). When considering the use of a second thrombectomy device as failure, the EmboTrap successfully recanalized 65 patients (81%), with complete (mTICI 3) recanalization in 40 patients (50%) within 1 or 2 passes. Median procedure time (groin to recanalization) was 35 minutes (8-161 minutes). During the procedure, distal emboli in previously unaffected territories were found in 5 (6%) patients. There were 3 vasospasms (4%) and no vessel perforations. Intracranial hemorrhage on CT at day 1 was found in 18 17 (2321%) patients, none with subarachnoid hemorrhages, and 5 were symptomatic (6%). Good clinical outcome occurred in 4749/68 78 patients (6963%). CONCLUSIONS: In this multicenter retrospective study, the EmboTrap device achieved high recanalization rates, good clinical outcomes and was safe in treating acute stroke patients with large vessel occlusions.

The learning curve effect on embolization of cerebral dural arteriovenous fistula single-center experience in 48 consecutive patients.

BACKGROUND: Cerebral dural arteriovenous fistulas (DAVFs) are rare intracranial vascular lesions but can cause significant morbidity and mortality. OBJECTIVES: To analyze the effect of the center's experience on DAVF embolization efficacy and safety. METHODS: From May 2008 to October 2014, 57 embolization procedures were attempted on 48 patients (37 men and 11 women; median age: 63.9 years) for DAVF in a single center. DAVF presented with cortical venous reflux in 44/48 cases (91.7%) and hemorrhagic manifestation in 21/48 cases (43.75%). Angiographic occlusion quality, whether complete or incomplete (efficacy), and neurological complications (safety) were recorded. The patient population was divided into four consecutive quartiles during the inclusion period to assess the progress profile. Efficacy and safety outcomes were compared with Fisher's test. RESULTS: A logistic regression was performed to explore a learning curve phenomenon, showing a significant association between the chronological rank in the cohort and embolization efficacy (P=0.007). Significant differences were found between first and last quarter (P=0.036). The endovascular technique involved an arterial injection of Onyx® in 36/48 cases (75%), administered via the middle meningeal artery in 25/36 cases (69.5%). The complete occlusion rate improved significantly from 33.3% for the first quartile of the population, to 75.0% for the 2nd and 3rd quartiles and 83.3% for the last quartile. Neurological complications were found in 7/48 patients (14.6%), the rate decreased by 41.7% to 16.7%, without statistically difference. CONCLUSION: The efficacy and safety of DAVF embolization improved with the experience gained at the center, suggesting the existence of a learning curve.

Brain Perfusion Imaging in Neonates: An Overview.

The development of cognitive function in children has been related to a regional metabolic increase and an increase in regional brain perfusion. Moreover, brain perfusion plays an important role in the pathogenesis of brain damage in high-risk neonates, both preterm and full-term asphyxiated infants. In this article, we will review and discuss several existing imaging techniques for assessing neonatal brain perfusion.

Arterial spin labeling in clinical pediatric imaging.

Arterial spin labeling (ASL) perfusion-weighted magnetic resonance imaging is the only approach that enables direct and non-invasive quantitative measurement of cerebral blood flow in the brain regions without administration of contrast material and without radiation. ASL is thus a promising perfusion imaging method for assessing cerebral blood flow in the pediatric population. Concerning newborns, there are current limitations because of their smaller brain size and lower brain perfusion. This article reviews and illustrates the use of ASL in pediatric clinical practice and discusses emerging cerebral perfusion imaging applications for children due to the highly convenient implementation of the ASL sequence.

Inter- and Intrarater Agreement on the Outcome of Endovascular Treatment of Aneurysms Using MRA.

BACKGROUND AND PURPOSE: Patients treated with coiling are often followed by MR angiography. Our objective was to assess the inter- and intraobserver agreement in diagnosing aneurysm remnants and recurrences by using multimodality imaging, including TOF MRA. MATERIALS AND METHODS: A portfolio composed of 120 selected images from 56 patients was sent to 15 neuroradiologists from 10 institutions. For each case, raters were asked to classify angiographic results (3 classes) of 2 studies (32 MRA-MRA and 24 DSA-MRA pairs) and to provide a final judgment regarding the presence of a recurrence (no, minor, major). Six raters were asked to independently review the portfolio twice. A second study, restricted to 4 raters having full access to all images, was designed to validate the results of the electronic survey. RESULTS: The proportion of cases judged to have a major recurrence varied between 16.1% and 71.4% (mean, 35.0% ± 12.7%). There was moderate agreement overall (κ = 0.474 ± 0.009), increasing to nearly substantial (κ = 0.581 ± 0.014) when the judgment was dichotomized (presence or absence of a major recurrence). Agreement on cases followed-up by MRA-MRA was similarly substantial (κ = 0.601 ± 0.018). The intrarater agreement varied between fair (κ = 0.257 ± 0.093) and substantial (κ= 0.699 ± 0.084), improving with a dichotomized judgment concerning MRA-MRA comparisons. Agreement was no better when raters had access to all images. CONCLUSIONS: There is an important variability in the assessment of angiographic outcomes of endovascular treatments. Agreement on the presence of a major recurrence when comparing 2 MRA studies or the MRA with the last catheter angiographic study can be substantial.

Chikungunya outbreak in Montpellier, France, September to October 2014.

In October 2014, an outbreak of 12 autochthonous chikungunya cases, 11 confirmed and 1 probable, was detected in a district of Montpellier, a town in the south of France colonised by the vector Aedes albopictus since 2010. A case returning from Cameroon living in the affected district was identified as the primary case. The epidemiological investigations and the repeated vector control treatments performed in the area and around places frequented by cases helped to contain the outbreak. In 2014, the chikungunya and dengue surveillance system in mainland France was challenged by numerous imported cases due to the chikungunya epidemic ongoing in the Caribbean Islands. This first significant outbreak of chikungunya in Europe since the 2007 Italian epidemic, however, was due to an East Central South African (ECSA) strain, imported by a traveller returning from West Africa. Important lessons were learned from this episode, which reminds us that the threat of a chikungunya epidemic in southern Europe is real.