Patient-tailored risk assessment of obstructive coronary artery disease using Rubidium-82 PET-based myocardial flow quantification with visual interpretation.

INTRODUCTION: Our aim was to estimate the probability of obstructive CAD (oCAD) for an individual patient as a function of the myocardial flow reserve (MFR) measured with Rubidium-82 (Rb-82) PET in patients with a visually normal or abnormal scan. MATERIALS AND METHODS: We included 1519 consecutive patients without a prior history of CAD referred for rest-stress Rb-82 PET/CT. All images were visually assessed by two experts and classified as normal or abnormal. We estimated the probability of oCAD for visually normal scans and scans with small (5%-10%) or larger defects (> 10%) as function of MFR. The primary endpoint was oCAD on invasive coronary angiography, when available. RESULTS: 1259 scans were classified as normal, 136 with a small defect and 136 with a larger defect. For the normal scans, the probability of oCAD increased exponentially from 1% to 10% when segmental MFR decreased from 2.1 to 1.3. For scans with small defects, the probability increased from 13% to 40% and for larger defects from 45% to > 70% when segmental MFR decreased from 2.1 to 0.7. CONCLUSION: Patients with > 10% risk of oCAD can be distinguished from patients with < 10% risk based on visual PET interpretation only. However, there is a strong dependence of MFR on patient's individual risk of oCAD. Hence, combining both visual interpretation and MFR results in a better individual risk assessment which may impact treatment strategy.

Machine learning based model to diagnose obstructive coronary artery disease using calcium scoring, PET imaging, and clinical data.

INTRODUCTION: Accurate risk stratification in patients with suspected stable coronary artery disease is essential for choosing an appropriate treatment strategy. Our aim was to develop and validate a machine learning (ML) based model to diagnose obstructive CAD (oCAD). METHOD: We retrospectively have included 1007 patients without a prior history of CAD who underwent CT-based calcium scoring (CACS) and a Rubidium-82 PET scan. The entire dataset was split 4:1 into a training and test dataset. An ML model was developed on the training set using fivefold stratified cross-validation. The test dataset was used to compare the performance of expert readers to the model. The primary endpoint was oCAD on invasive coronary angiography (ICA). RESULTS: ROC curve analysis showed an AUC of 0.92 (95% CI 0.90-0.94) for the training dataset and 0.89 (95% CI 0.84-0.93) for the test dataset. The ML model showed no significant differences as compared to the expert readers (p ≥ 0.03) in accuracy (89% vs. 88%), sensitivity (68% vs. 69%), and specificity (92% vs. 90%). CONCLUSION: The ML model resulted in a similar diagnostic performance as compared to expert readers, and may be deployed as a risk stratification tool for obstructive CAD. This study showed that utilization of ML is promising in the diagnosis of obstructive CAD.

Semi-quantitative assessment of ischemia with rubidium-82 PET myocardial perfusion imaging.

PURPOSE: Semi-quantitative scores can be used as an adjunct to visual assessment in rubidium-82 positron emission tomography (82Rb PET). The semi-quantitative cut-off values used in 82Rb PET are derived from single-photon emission computed tomography (SPECT). It is unknown whether these cut-off values can be extrapolated to 82Rb PET. We compared the semi-quantitative with the visual assessment of ischemia and determined which summed difference score (SDS) score predicts ischemia best. METHODS: We included 108 patients who underwent 82Rb PET imaging and performed visual and semi-quantitative assessment. A scan with a SDS ≥ 2 and a summed stress score (SSS) ≥ 4 was considered to demonstrate ischemia. We compared the semi-quantitative with the visual assessment. RESULTS: 41 (38%) Normal scans, and 67 (62%) scans with ischemia and/or an irreversible defect were included. The semi-quantitative assessment showed ischemia more often than the visual assessment (51% vs 29%, P < .001). Patients with a low or intermediate pre-test probability of coronary artery disease (CAD) and a SDS < 4 did not demonstrate ischemia by visual assessment. CONCLUSION: Semi-quantitative assessment in 82Rb PET imaging clearly demonstrates the presence of ischemia. Ischemia is unlikely in patients with low and intermediate pre-test probability of CAD and a SDS < 4.

Value of SiPM PET in myocardial perfusion imaging using Rubidium-82.

BACKGROUND: PET scanners using silicon photomultipliers with digital readout (SiPM PET) have an improved temporal and spatial resolution compared to PET scanners using conventional photomultiplier tubes (PMT PET). However, the effect on image quality and visibility of perfusion defects in myocardial perfusion imaging (MPI) is unknown. Our aim was to determine the value of a SiPM PET scanner in MPI. METHODS: We prospectively included 30 patients who underwent rest and regadenoson-induced stress Rubidium-82 (Rb-82) MPI on the D690 PMT PET (GE Healthcare) and within three weeks on the Vereos SiPM PET (Philips Healthcare). Two expert readers scored the image quality and assessed the existence of possible defects. In addition, interpreter's confidence, myocardial blood flow (MBF), and myocardial flow reserve (MFR) values were compared. RESULTS: Image quality improved (P = 0.03) using the Vereos as compared to the D690. Image quality of the Vereos and the D690 was graded fair in 20% and 10%, good in 60% and 50%, and excellent in 20% and 40%, respectively. Defect interpretation and interpreter's confidence did not differ between the D690 and the Vereos (P > 0.50). There were no significant differences in rest MBF (P ≥ 0.29), stress MBF (P ≥ 0.11), and MFR (P ≥ 0.51). CONCLUSION: SiPM PET provides an improved image quality in comparison with PMT PET. Defect interpretation, interpreter's confidence, and absolute blood flow measurements were comparable between both systems. SiPM PET is therefore a reliable technique for MPI using Rb-82. TRIAL REGISTRATION: ToetsingOnline NL63853.075.17. Registered 13 November, 2017.

Effect of temporal sampling protocols on myocardial blood flow measurements using Rubidium-82 PET.

BACKGROUND: A variety of temporal sampling protocols is used worldwide to measure myocardial blood flow (MBF). Both the length and number of time frames in these protocols may alter MBF and myocardial flow reserve (MFR) measurements. We aimed to assess the effect of different clinically used temporal sampling protocols on MBF and MFR quantification in Rubidium-82 (Rb-82) PET imaging. METHODS: We retrospectively included 20 patients referred for myocardial perfusion imaging using Rb-82 PET. A literature search was performed to identify appropriate sampling protocols. PET data were reconstructed using 14 selected temporal sampling protocols with time frames of 5-10 seconds in the first-pass phase and 30-120 seconds in the tissue phase. Rest and stress MBF and MFR were calculated for all protocols and compared to the reference protocol with 26 time frames. RESULTS: MBF measurements differed (P ≤ 0.003) in six (43%) protocols in comparison to the reference protocol, with mean absolute relative differences up to 16% (range 5%-31%). Statistically significant differences were most frequently found for protocols with tissue phase time frames < 90 seconds. MFR did not differ (P ≥ 0.11) for any of the protocols. CONCLUSIONS: Various temporal sampling protocols result in different MBF values using Rb-82 PET. MFR measurements were more robust to different temporal sampling protocols.

Added value of coronary artery calcium score in the reporting of SPECT versus PET myocardial perfusion imaging.

BACKGROUND: Knowledge of coronary artery calcium score (CACS) influences the interpretation of myocardial perfusion imaging (MPI) with SPECT; however, the impact on PET interpretation remains unclear. We compared the added value of CACS to reporting MPI using SPECT vs PET. METHODS: We retrospectively included 412 patients. 206 patients who underwent Rb-82 PET were propensity-based matched to a cohort of 4018 patients who underwent cadmium-zinc-telluride SPECT MPI to obtain a comparable group of 206 SPECT patients. Next, we created four image sets: SPECT MPI-only, PET-only, SPECT + CACS, and PET + CACS. Two physicians interpreted the 824 images as normal, equivocal, or abnormal for ischemia or irreversible defects. Additionally, event rates were compared between PET and SPECT groups during 30-month follow-up. RESULTS: PET yielded more scans interpreted as normal than SPECT (88% vs 80%, respectively, P = 0.015). Adding CACS to SPECT increased the percentage of normal scans to 86% (P = 0.014), whereas this effect was absent for PET (90%, P = 0.77). Annualized event rates for images interpreted as normal did not differ and varied between 0.7 and 2.0% (P > 0.084). CONCLUSION: Adding CACS correctly increased the percentage of normal scans for SPECT MPI but not for PET, possibly limiting the effect of adding CACS to reporting PET.

Body weight-dependent Rubidium-82 activity results in constant image quality in myocardial perfusion imaging with PET.

BACKGROUND: Clinical practice shows degrading image quality in heavier patients who undergo myocardial perfusion imaging (MPI) with Rubidium-82 (Rb-82) PET when using a fixed tracer activity. Our aim was to derive and validate a patient-specific activity protocol resulting in a constant image quality in PET MPI. METHODS: We included 251 patients who underwent rest MPI with Rb-82 PET (Discovery 670, GE Healthcare). 132 patients were included retrospectively and were scanned using a fixed activity of 740 MBq. The total number of measured prompts was normalized to activity and correlated to body weight, mass per body length and body mass index to find the best predicting parameter. Next, a patient-specific activity was derived and subsequently validated in 119 additional patients. Image quality was scored by three experts on a four-point scale. RESULTS: Both image quality and prompts decreased in heavier patients when using a fixed activity (p < .005). Body weight was used to derive a new activity formula: Activity = 8.3 MBq/kg. When applying this formula, both measured prompts and scored image quality became independent of body weight (p > .60). CONCLUSION: Administrating a Rb-82 activity that linearly depends on body weight resulted in a constant image quality across all patients and is recommended.

Minimal rest activity for SPECT myocardial perfusion imaging in a one-day stress-first protocol.

PURPOSE: Guidelines propose different rest-stress activity ratios (RSAR) for one-day stress-first SPECT myocardial perfusion imaging (MPI), but evidence is limited. Our aim was to determine and validate the minimal RSAR resulting in the same diagnostic outcome in one-day stress-first SPECT MPI. METHODS: Forty-seven patients referred for rest after stress CZT-SPECT/CT MPI were prospectively included. Rest acquisitions were performed 3 h after stress. In addition to the stress and rest acquisitions, the first 22 patients underwent an additional acquisition prior to the rest injection to determine the remaining stress activity. Next, we simulated six RSARs varying from 1.0 to 3.5 in both patients and a phantom and compared the images to those using the reference RSAR of 4.0. Differences in summed difference score (SDS) >2 or ischemic defect interpretation were considered to significantly influence diagnostic outcome. After deriving the minimal RSAR, it was validated in 25 additional patients by comparing it to a RSAR of 4.0. RESULTS: After 3 h only 26% of the stress activity was still present in the myocardium. SDS differences >2 were found in one (4%) patient using RSAR of 3.5, 2.5 and 2.0, in three (12%) using 1.5 and in five (20%) using SRAR of 1.0. These results were consistent with the phantom study showing SDS differences >2 for RSARs ≤1.5 and with the visual interpretation which showed an increased number of deviating scans for RSAR 1.0. Validating the RSAR of 2.0 resulted in a different SDS in one patient (SDS of 30 versus 11). Moreover, two scans were interpreted as ischemic instead of normal when using RSAR 2.0 and in two other scans the opposite was the case. CONCLUSIONS: A RSAR of 2.0 in one-day stress-first MPI SPECT seems sufficient to obtain accurate diagnostic outcomes and is therefore recommended to reduce radiation exposure.

Predictors of severe stenosis at invasive coronary angiography in patients with normal myocardial perfusion imaging.

PURPOSE: Normal myocardial perfusion imaging (MPI) is associated with excellent prognosis. However, in patients with persisting symptoms, it may be difficult to determine the patients in whom invasive angiography is justified to rule out false negative MPI. We evaluated predictors for severe stenosis at invasive angiography in patients with persisting symptoms after normal MPI. METHODS: 229 consecutive patients with normal MPI, without previous bypass surgery, underwent invasive angiography within 6 months. Older age was defined as >65 years. Multivariable analyses were performed to adjust for differences in baseline variables. RESULTS: Mean age was 62 ± 11 years, 48% were women. Severe stenosis was observed in 34%, and of these patients 60% had single-vessel disease (not left main coronary artery disease). After adjusting for several variables, including diabetes, smoking status, hypertension and hypercholesterolaemia, predictors of severe stenosis were male gender, odds ratio (OR) 2.7 (95% confidence interval (CI) 1.5-4.9), older age, OR 1.9 (95% CI 1.02-3.54) previous PCI, OR 2.0 (95% CI 1.0-4.3) and typical angina, OR 2.5 (95% CI 1.4-4.6). CONCLUSIONS: Increasing age, male gender, previous PCI and typical symptoms are predictors of severe stenosis at invasive coronary angiography in patients with normal MPI. The majority of these patients have single-vessel disease.

Effect of a patient-specific minimum activity in stress myocardial perfusion imaging using CZT-SPECT: Prognostic value, radiation dose, and scan outcome.

BACKGROUND: SPECT Myocardial perfusion imaging (MPI) is associated with a relatively high radiation burden and decreasing image quality in heavy patients. Patient-specific low-activity protocols (PLAPs) are suggested but follow-up data is lacking. Our aim was to compare the use of a standard fixed-activity protocol (FAP) with a PLAP in cadmium zinc telluride (CZT)-SPECT MPI. METHODS: We retrospectively included 1255 consecutive patients who underwent CZT-SPECT stress-optional rest MPI. 668 Patients were scanned using FAP (370 MBq) and 587 patients using PLAP (2.25 MBq·kg-1). Percentage of scans interpreted as normal, radiation dose, and 1-year follow-up including hard event rates (all-cause death or non-fatal myocardial infarction) were collected and compared. RESULTS: The percentage of scans interpreted as normal was 67% in FAP and 70% in PLAP groups (P = .29). The annualized hard event rates in these patients were 1.0% in the FAP and 0.9% in the PLAP group (P = .86). However, the mean radiation dose decreased by 23% for stress-only and by 15% to 2.6 mSv for stress-optional rest MPI after introduction of the PLAP (p<0.001). CONCLUSIONS: Introduction of a patient-specific low-activity protocol does not affect the percentage of scans interpreted as normal or prognosis but significantly lowers the radiation dose for CZT-SPECT MPI.

Value of attenuation correction in stress-only myocardial perfusion imaging using CZT-SPECT.

BACKGROUND: Attenuation correction (AC) improves the diagnostic outcome of stress-only myocardial perfusion imaging (MPI) using conventional SPECT. Our aim was to determine the value of AC using a cadmium zinc telluride-based (CZT)-SPECT camera. METHODS AND RESULTS: We retrospectively included 107 consecutive patients who underwent stress-optional rest MPI CZT-SPECT/CT. Next, we created three types of images for each patient; (1) only displaying reconstructed data without the CT-based AC (NC), (2) only displaying AC, and (3) with both NC and AC (NC + AC). Next, two experienced physicians visually interpreted these 321 randomized images as normal, equivocal, or abnormal. Image outcome was compared with all hard events over a mean follow-up time of 47.7 ± 9.8 months. The percentage of images interpreted as normal increased from 45% using the NC images to 72% using AC and to 67% using NC + AC images (P < .001). Hard event hazard ratios for images interpreted as normal were not different between using NC and AC (1.01, P = .99), or NC and NC + AC images (0.97, P = .97). CONCLUSIONS: AC lowers the need for additional rest imaging in stress-first MPI using CZT-SPECT, while long-term patient outcome remained identical. Use of AC reduces the need for additional rest imaging, decreasing the mean effective dose by up to 1.2 mSv.

Visual estimation of coronary calcium on computed tomography for attenuation correction.

BACKGROUND: The coronary calcium score (CCS) provides independent diagnostic and prognostic information on top of myocardial perfusion imaging (MPI) in patients suspected for coronary artery disease, but requires an additional computed tomography (CT) scan. OBJECTIVE: We investigated the accuracy and inter-reader reproducibility of visual estimation of the CCS on the CT used for attenuation correction. METHODS: 250 patients undergoing single photon emission computed tomography MPI and Agatston CCS were included. The CCS was also visually estimated on the CT for attenuation correction by two separate readers blinded to the Agatston CCS, and was categorized into a six-point scale (0, 1-10, 11-100, 101-400, 401-1000 and > 1000). RESULTS: The median Agatston CCS was 82 [25th-75th percentile: 0-562], with a range from 0 to 7287. Of the visually estimated CCS, 60% (reader 1) and 65% (reader 2) were classified correctly into the 6 categories. 93% (reader 1) and 88% (reader 2) of the visually estimated CCS did not vary by more than one category from the Agatston CCS. The intraclass correlation coefficient for agreement between the Agatston CCS and the visually estimated CCS was 0.95 for reader 1 and 0.94 for reader 2. The intraclass correlation coefficient for inter-reader reproducibility of the visually estimated CCS was 0.96. CONCLUSION: The CCS can be accurately estimated on the CT for attenuation correction, as high agreement is demonstrated with the Agatston CCS and inter-reader reproducibility is excellent. If no traditional Agatston CCS is performed, the degree of atherosclerosis should be assessed by means of estimating CCS on the CT for attenuation correction.

Zero coronary calcium in the presence of three-vessel and left main coronary artery disease in a Hodgkin lymphoma survivor.

We describe a 45-year-old male survivor of Hodgkin lymphoma, treated with mediastinal radiation therapy, referred for single-photon emission computed tomography (SPECT) myocardial perfusion imaging in combination with coronary artery calcium (CAC) scoring. SPECT demonstrated a reversible moderate-sized lateral perfusion defect, and the CAC score was zero. A calcium score of zero markedly reduces the probability of having coronary artery disease (CAD) and is associated with a very low risk of future cardiovascular events. However, a CAC score of zero does not completely rule out obstructive CAD. In this case, invasive coronary angiography revealed three-vessel CAD with left main involvement. Whether mediastinal radiation therapy in general is associated with CAD without accompanying CAC is yet unclear.

El regadenosón como nuevo agente de estrés para la adquisición de imágenes SPECT de perfusión miocárdica. Experiencia inicial en Holanda / Regadenoson as a new stress agent in myocardial perfusion imaging. Initial experience in The Netherlands

Objetivo. El regadenosón es un agonista selectivo para los receptores adenosínicos-2A recién aprobado para inducir estrés farmacológico con una sola inyección en bolo para la adquisición de imágenes SPECT de perfusión miocárdica (IPM). Material y Métodos. Se incluyeron 123 pacientes sucesivos referidos para IPM por sospecha de enfermedad arterial coronaria (EAC). A 66 pacientes se les hizo una prueba de estrés con regadenosón y a 57 con adenosina, ambas seguidas por SPECT de manera estándar. A los técnicos, médicos y los pacientes mismos se les pidió que reportaran sus experiencias mediante cuestionarios. Resultados. En comparación con la adenosina, el regadenosón no produjo ningún bloqueo auriculoventricular (frente al 10% tras adenosina), pero produjo una taquicardia menor y cambios de la presión arterial pequeños. Todos los síntomas tras el regadenosón fueron más leves y de duración más corta. Hubo menos pacientes que tenían síntomas graves tras el regadenosón (17% vs. 32%, p < 0,01). El efecto secundario reportado más frecuentemente fue la disnea, seguido por rubefacción y angina, pero todos estos efectos se resolvieron rápidamente. La puntuación global de los síntomas, que incluye tanto la severidad como la duración, fue significativamente más baja después del regadenosón que después de la adenosina (6,7 ± 6,3 vs. 10,0 ± 7,9, respectivamente, p < 0,01). Las imágenes SPECT fueron similares. El procedimiento con el regadenosón fue más rápido y práctico. Conclusión. El regadenosón es un nuevo agente de estrés conveniente para IPM con un perfil muy favorable para los pacientes y los departamentos de cardiología nuclear (AU)

Objective. Regadenoson is a recently approved selective adenosine-2A receptor agonist to induce pharmacological stress in myocardial perfusion imaging (MPI) procedures using a single bolus injection. Material and Methods. We included 123 patients referred for MPI because of suspected coronary arterial disease (CAD). Of these, 66 patients underwent a regadenoson stress test and 57 patients underwent an adenosine stress test preceding standard myocardial SPECT imaging. Technicians, physicians and patients were asked to report their experience using questionnaires. Results. As compared to adenosine, regadenoson did not produce any atrio-ventricular block (0 vs. 10% with adenosine), but did produce minor tachycardia and minimal blood pressure changes while all other side effects were milder and shorter. There were fewer patients with severe complaints after taking regadenoson than adenosine (17% vs. 32%, respectively, p < 0.01). The most frequent complaint reported was dyspnea, followed by flushing and chest pain. However, when they did occur, they usually disappeared rapidly. The overall symptom score, including severity and duration of side effects, was significantly lower after regadenoson than after adenosine (6.7 ± 6.3 vs. 10.0 ± 7.9, respectively; p < 0.01.) SPECT imaging results were similar. The regadenoson procedure was faster and more practical. Conclusion. Regadenoson, the new selective adenosine-2A receptor agonist, is a stress agent for MPI with a patient- and department friendly profile (AU)

Development and validation of a patient-tailored dose regime in myocardial perfusion imaging using CZT-SPECT.

BACKGROUND: Guidelines for SPECT myocardial perfusion imaging (MPI) traditionally recommend a fixed tracer dose. Yet, clinical practice shows degraded image quality in heavier patients. The aim was to optimize and validate the tracer dose and scan time to obtain a constant image quality less dependent on patients' physical characteristics. METHODS: 125 patients underwent Cadmium Zinc Telluride (CZT)-SPECT stress MPI using a fixed Tc-99m-tetrofosmin tracer dose. Image quality was scored by three physicians on a 4-point grading scale and related to the number of photon counts normalized to tracer dose and scan time. Counts were correlated with various patient-specific parameters dealing with patient size and weight to find the best predicting parameter. From these data, a formula to provide constant image quality was derived, and subsequently tested in 92 new patients. RESULTS: Degradation in image quality and photon counts was observed for heavier patients for all patients' specific parameters (P < .01). We found body weight to be the best-predicting parameter for image quality and derived a new dose formula. After applying this new body weight-depended tracer dose and scan time in a new group, image quality was found to be constant (P > .19) in all patients. CONCLUSIONS: Also in CZT SPECT image quality decreases with weight. The use of a tracer dose and scan time that depends linearly on patient's body weight corrected for the varying image quality in CZT-SPECT MPI. This leads to better radiation exposure justification.

[Regadenoson as a new stress agent in myocardial perfusion imaging. Initial experience in The Netherlands]. / El regadenosón como nuevo agente de estrés para la adquisición de imágenes SPECT de perfusión miocárdica. Experiencia inicial en Holanda.

OBJECTIVE: Regadenoson is a recently approved selective adenosine-2A receptor agonist to induce pharmacological stress in myocardial perfusion imaging (MPI) procedures using a single bolus injection. MATERIAL AND METHODS: We included 123 patients referred for MPI because of suspected coronary arterial disease (CAD). Of these, 66 patients underwent a regadenoson stress test and 57 patients underwent an adenosine stress test preceding standard myocardial SPECT imaging. Technicians, physicians and patients were asked to report their experience using questionnaires. RESULTS: As compared to adenosine, regadenoson did not produce any atrio-ventricular block (0 vs. 10% with adenosine), but did produce minor tachycardia and minimal blood pressure changes while all other side effects were milder and shorter. There were fewer patients with severe complaints after taking regadenoson than adenosine (17% vs. 32%, respectively, p<0.01). The most frequent complaint reported was dyspnea, followed by flushing and chest pain. However, when they did occur, they usually disappeared rapidly. The overall symptom score, including severity and duration of side effects, was significantly lower after regadenoson than after adenosine (6.7±6.3 vs. 10.0±7.9, respectively; p<0.01.) SPECT imaging results were similar. The regadenoson procedure was faster and more practical. CONCLUSION: Regadenoson, the new selective adenosine-2A receptor agonist, is a stress agent for MPI with a patient- and department friendly profile.

[Striatopallidodentate calcinosis, hypoparathyroidism and neurological features: a case series study]. / Calcinose striatopallidodentelée, hypoparathyroïdie et atteinte neurologique: étude de série.

INTRODUCTION: The respective roles of hypocalcemia and intracerebral calcifications in the occurrence of various neurological manifestations in hypoparathyroidism is not entirely clear. Nevertheless, therapeutic and prognostic implications are important. OBJECTIVES: We analyze the neurological clinical aspects observed in hypoparathyroidism and correlate them to the biological calcium abnormality and radiological CT scan findings. We also compare these results with data reported in the idiopathic form of striatopallidodentate calcinosis. PATIENTS: The neurological clinical, CT scan findings and outcome have been retrospectively studied in patients recruited during 13 years (2000-2012) for neurological features associated with hypoparathyroidism or pseudohypoparathyroidism. RESULTS: Twelve patients with primary hypoparathyroidism (n=5), secondary to thyroidectomy (n=4) and pseudohypoparathyroidism (n=3) were studied. The sex-ratio was 1 and mean age was 39 years. All patients had a tetany, 60% had epilepsy, associated in one patient with "benign" intracranial hypertension; 50% had behavioral changes. Response to calcium therapy was excellent for all these events. Moderate cognitive deficit was noted in three patients (25%), parkinsonism in two patients and hyperkinetic movement disorders in one other. These events were not responsive to calcium therapy and were more common in cases of extensive brain calcifications and in patients who had pseudohypoparathroidism. COMMENTS: This study suggests that, in patients with hypoparathyroidism, epilepsy and psychiatric disorders are induced by hypocalcemia and reversible after its correction. Cognitive and extrapyramidal impairment seem to be related to the progressive extension of intracerebral calcification, particularly in patients with a late diagnosis. In patients with pseudohypoparathyroidism, this finding is different because of the contribution of other factors, specific to this disease.

Prevalence and predictors of bridging of coronary arteries in a large Indonesian population, as detected by 64-slice computed tomography scan.

BACKGROUND: Multislice computed tomography (MSCT) can be used to detect myocardial bridging (MB) of coronary arteries. However, most published studies included small cohorts and did not collect data about predictors. We investigated prevalence and predictors of MB in an Indonesian population. METHODS: All patients who had MSCT at Cinere Hospital, Jakarta, Indonesia between 2006 and 2009 were included in a prospective registry. MB was defined when at least half of the coronary artery was imbedded within the myocardium with a normal epicardial course of the proximal and distal portion. RESULTS: Of the 934 patients (mean age 53 years, 37.8 % female), MB could be observed in 152 patients (16.3 %). Patients with MB were younger compared with those without MB. Coronary risk factors were not different between the two groups. Coronary calcifications and moderate to severe coronary stenoses were less prevalent in patients with MB, also after adjusting for differences in age. At the time of diagnosis, only a few patients with MB were treated with beta-blockers (35 %) or calcium channel blockers (13 %). CONCLUSIONS: Prevalence of myocardial bridging as detected by MSCT is relatively high. Patients with MB were younger and had a lower prevalence of coronary sclerosis. MB could be the cause of their unexplained symptoms. Follow-up studies are necessary to assess the symptoms of these patients, their response to treatment and the incidence of (coronary) events. MSCT can be used to identify patients for potential new treatment strategies.

[Meningeal febrile syndrome and hemiplegia revealing infectious endocarditis: the story of a catheter-related infection]. / Syndrome méningé fébrile et hémiplégie compliquant une endocardite infectieuse : histoire d'une infection liée aux cathéters.

INTRODUCTION: We report the case of a 48-years patient who is under chimotherapy because of a breast cancer. She was initially found at her place in coma with hyperthermia and neurological deficiency signs. The clinic history and the paraclinical investigations have enabled to detect a catheter-related infection (CRI) as soon as the diagnosis of disseminated infectious endocarditis was made. The resonance imaging confirmed the cerebral blow when it found suspicious images of septic embolus. EXEGESIS: The CRI are usually detected at an early stage and if the classical association CRI-infectious endocarditis-systemical embolus is well known, the discovery on a CRI not treated at the stade of a febril coma is exceptional. CONCLUSION: More than ever the taking care of infectious endocarditis, still delicate and sometimes perilous, requires a global taking care of the patient.