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Introducing a preoperative image simulation technique to streamline the visualization of the foramen ovale in percutaneous microcompression. Twenty-five trigeminal neuralgia patients were included in the study. Preoperative cranial computed tomography scans were processed with 3D Slicer software to create simulated fluoroscopic skulls. The angulations required for precise visualization of the foramen ovale were established via simulated anteroposterior imaging. These simulations informed the C-arm's angulations for foramen ovale targeting during surgery. The preoperative simulations accurately forecasted skull rotation angulations, aligning closely with intraoperative observations with negligible discrepancies (0–2 degrees). In 17 patients, the foramen ovale was distinctly visible, while in 8 patients, it was partially obscured yet discernible using the simulated angles. Nonvisible of the foramen ovale did not occur. Postoperative pain relief and complications were recorded. Based on our initial findings, the application of preoperative image simulation shows significant referential value in achieving accurate visualization of the foramen ovale in percutaneous microcompression for trigeminal neuralgia. [ABSTRACT FROM AUTHOR]

• 3D-CT calculates the angle of PBC puncture. • 3D-CT calculates the depth of PBC puncture. • 3D-CT can help to adjust the pear-shaped balloon. • PBC assisted by 3D-CT can achieve good surgical results. To study the value of three-dimensional CT (3D-CT) reconstruction by comparing the surgical effects of C-arm and 3D-CT in the treatment of trigeminal neuralgia (TN) by percutaneous balloon compression (PBC). A total of 136 patients were included from May 2018 to February 2019. Among them, 65 patients underwent PBC treatment with 3D-CT and others with C-arm. During 3D-CT-guided operation, 3D-CT reconstruction software was used to analyze and measure the distances from the internal orifice of Foramen ovale (FO-I) and the external orifice of Foramen ovale (FO-E) to the top of the balloon (BT) and the petrous bone ridge (PR). The data, including the angle between the puncture needle direction and the zygomatic arch, petrous bone ridge, and slope, were used to assist the puncture and balloon plasty. Postoperative follow-up for more than five years was performed to evaluate the efficacy and pain recurrence. The distance from FO-E to PR was (2.10 ± 0.16)cm, the average distance from FO-I to BT was (2.39 ± 0.07)cm, and the average angles between the puncture needle and zygomatic arch, slope, and petrous bone ridge were (56.19 ± 5.59)°, (69.12 ± 6.92)°, and (104.49 ± 6.46)°, respectively. One (1.5 %) patient in the 3D-CT group and three (4.2 %) patients in the C-arm group failed to receive PBC treatment because of failure of FO puncture (P = 0.032).In terms of postoperative pain improvement, 3D-CT group achieved better results than the C-arm group (P = 0.043). There were no significant differences in the rates of major complications and short-term recurrence (P = 0.926) between the two groups after surgery, but the five-year recurrence rate in the 3D-CT group was lower than that in the C-arm group (P = 0.032). By guiding the angle and depth of puncture, the intraoperative application of 3D-CT reconstruction technology can improve the accuracy of foramen ovale puncture and alleviate postoperative pain, and also maintain long-term postoperative pain relief, which can be used as a potentially better guidance method to improve the surgical efficacy of PBC. [ABSTRACT FROM AUTHOR]

Trigeminal neuralgia may be treated via percutaneous access to the foramen ovale (FO). Vascular complications associated with the needle trajectory can result in serious morbidity and mortality. This study aimed to correlate the vascular relationships of the FO at the skull base via cadaveric dissections and computed tomography (CT). Two fresh cadaver heads were injected with red and blue latex to delineate arteries and veins. Neck and infratemporal fossa dissections were carried out to delineate the vascular relationships of the FO. High-resolution head CT images of adult patients undergoing neurosurgical evaluations or procedures were analyzed for distances and sizes of skull base foramina in the infratemporal fossa. Three infratemporal fossa dissections (2 cadaveric specimens) were performed. Mean distance of FO to internal carotid artery was 2.4 ± 0.12 cm, and mean distance of FO to middle meningeal artery was 0.8 ± 0.16 cm. Head CT images of 52 patients (104 sides) with 1-mm axial slice thickness were analyzed. Area of the FO was 31.1 ± 9.6 mm2. Distance of FO to internal carotid artery was 1.70 ± 0.31 cm, and distance of FO to middle meningeal artery was 0.73 ± 0.61 cm. Cadaveric delineation of vascular structures in the infratemporal fossa correlates with head CT imaging and may be used to accurately plan percutaneous access to the FO. Inadvertent puncture of the extracranial internal carotid artery is nearly impossible with good technique. The most likely source of percutaneous vascular injury is the middle meningeal artery and distal branches of the maxillary artery. [ABSTRACT FROM AUTHOR]

• This paper introduced an excellent foramen ovale puncture system for TN treatment. • This puncture system significantly reduced the difficulties of FO puncture. • This system is easy to be generalized, and the audience of the article can be wide. • Other previously reported puncture methods were also reviewed in this paper. To introduce a tooth-supported personalized template-assisted foramen ovale (FO) puncture system for trigeminal neuralgia (TN) treatment, analyze its advantages, and review other previously reported methods. Sixty-seven patients were included. According to the preoperative digital design, the personalized puncture path was determined. Then, a tooth-supported personalized template was designed and manufactured. Finally, surgery (radiofrequency thermocoagulation or balloon compression) was carried out with the assistance of the template. The puncture effect and puncture-associated complications were evaluated, and the related literature was reviewed. The FO was successfully punctured in one attempt in all patients. The procedure was completed in 15 s in 35 (52.24%) patients and in 15–30 s in 28 (41.79%) patients. The required position was accurately reached in all patients, and the center point error range was within 1 mm. No complications associated with puncture occurred. The tooth-supported personalized template-assisted FO puncture system reported in this paper is an exceedingly simple, highly effective and safe FO puncture method that is worth popularizing. [ABSTRACT FROM AUTHOR]

We have been using computed tomography (CT) guidance for percutaneous glycerol rhizotomy (PGR) for the last 7 years. As a quality improvement exercise, we recently began using general anesthesia (GA) with the use of a laryngeal mask airway (LMA) because of our perception that the procedure went faster and that there was less radiation exposure because of less patient movement. We aim to compare PGR radiation exposure and procedural time between patients receiving local anesthetic with sedation and those receiving GA/LMA. A single-center historical cohort study was performed using patients treated with PGR between 2017 and 2019. Ninety-two surgeries were conducted during the study period: 64 surgeries had local anesthetic with intravenous sedation, and 28 surgeries had deeper anesthetic with LMA. Data analyzed included the number of CT sequences obtained, needle placement time, and total radiation dose. Use of GA/LMA resulted in a 23% decrease in mean radiation dose (565.5 vs. 436.1 μGy × cm, P = 0.014), number of CT sequences required (7.4 vs. 5.7, P = 0.003), and needle placement time (12.8 vs. 9.8 minutes, P = 0.006). Additionally, 10 patients underwent multiple glycerol rhizotomies during the collection period with both anesthetic types being used at least once. Seven of 10 patients (70.0%) had a reduction in total radiation dose, number of CT sequences obtained, and needle placement time when GA/LMA was used. There were no procedure- or anesthetic-related complications in this patient cohort. The use of GA/LMA during PGR is associated with decreased radiation exposure without increased anesthetic complications. [ABSTRACT FROM AUTHOR]

The most characteristic symptom of trigeminal neuralgia (TN) is paroxysmal and lancinating pain along the sensory distribution of the trigeminal nerve. Notably, a proportion of TN patients also experience persistent throbbing or burning in the same territory as their paroxysmal pain, termed concomitant continuous pain (CCP). The neurovascular compression (NVC) theory has been regarded as the primary cause of paroxysmal pain in TN. In contrast, the mechanisms underlying CCP can hardly be explained by NVC and have yet to be clearly elucidated. Both the foramen rotundum (FR) and foramen ovale (FO) are substantial bony apertures in the middle cranial fossa, through which the second (V2) and third divisions (V3) of the trigeminal nerve pass, respectively. Prior studies have proposed that a narrow FR and FO on the right side may result in a greater incidence of right-sided symptoms and be involved in the development of TN. However, given the nature of CCP and certain anatomical findings, we postulate that secondary compression of V2 and V3 by narrow foramina is more likely to be the primary cause of the persistent pain instead of the paroxysmal pain in cases of TN with CCP. TN with CCP may be the combination of trigeminal neuralgia induced by NVC and trigeminal neuropathic pain resulting from constant entrapment of V2 and V3. Therefore, considering that microvascular decompression cannot resolve all causes of TN with CCP, percutaneous ablative procedures and stereotactic radiosurgery may be more appropriate for patients with narrow foramina. [ABSTRACT FROM AUTHOR]

Background A wide variety of lesions may develop in the cavernous sinus region, including tumors or pseudotumors of inflammatory origin. Sometimes imaging is insufficient to ascertain a pathologic diagnosis. Percutaneous biopsy performed through the foramen ovale route may aid therapeutic decision making, avoiding unnecessary open surgery when lesions are confirmed to be nonsurgical or unresectable. We conducted a systematic review to determine the efficacy of percutaneous biopsy of cavernous sinus lesions. Method A systematic search in PubMed, LILACS, Web of Science, and Scopus yielded 4495 potentially eligible abstracts. Fourteen studies describing 75 biopsy procedures for lesions in the cavernous sinus region were reviewed. The primary outcome measure was diagnostic success. Data were analyzed according to standard systemic review techniques. Results A diagnosis was obtained in 65 of the 75 cases described in the literature. Among all series, only 3 patients had permanent deficits. No individual studies reported mortality. The histopathologic evaluation revealed neoplastic diseases in 58 lesions. Meningiomas were found in 26 biopsy samples. Nonneoplastic diseases, originating from infectious, inflammatory, or deposition diseases, accounted for 6 biopsy samples. Conclusions Percutaneous biopsy of cavernous sinus lesions is effective for diagnosis. Biopsy can be performed in patients with cavernous sinus masses, especially when neuroimaging fails to provide sufficient histopathologic data. [ABSTRACT FROM AUTHOR]

Background Identification and protection of the cochlea during anterior petrosectomy is key to prevent hearing loss. Currently, there is no optimal method to infer the position of the cochlea in relation to the Kawase quadrangle; therefore, damage to the cochlea during anterior petrosectomy remains a substantial risk. Objectives To identify and define landmarks available during anterior petrosectomy to locate the cochlea and prevent its damage. Methods The Kawase approach was simulated in 11 cadaveric specimens. After a subtemporal craniotomy, foramen spinosum and ovale were identified. Anterior petrosectomy was performed, and the upper dural transitional fold (UDTF) was identified. Two virtual lines, from foramen spinosum (line A), and the lateral rim of the foramen ovale (line B), were projected to intersect the UDTF perpendicularly. The cochlea was exposed, and the distances between lines A and B and the closest point of the outer rim and membranous part of the cochlea were measured. Results The average distance between line A to the bony and membranous edges of the anteromedial cochlea was −0.62 ± 1.38 mm and 0.38 ± 1.63 mm, respectively. The average distance between line B to the bony and membranous edges of the cochlea was 1.82 ± 0.99 mm and 2.78 ± 1.29 mm, respectively. Line B (cochlear safety line) never intersected the cochlea. Conclusions The cochlear safety line is a reliable landmark to avoid the cochlea during the Kawase approach. When expanding the anterior petrosectomy posteriorly, the cochlear safety line can be used as a reliable landmark to prevent exposure of the cochlea, thus preventing hearing loss. [ABSTRACT FROM AUTHOR]

Trigeminal nerve balloon compression (TNBC) 1-3 can provide immediate therapeutic relief to patients suffering from trigeminal neuralgia. This is a particularly effective treatment option for patients who are not eligible for surgical procedures (i.e., elderly patients or patients with multiple comorbidities) or for patients who have had an insufficient response to microvascular decompression. TNBC can also be used as a bridge treatment before stereotactic radiosurgery. Use of intraoperative computed tomography−like images using a C-arm system (DYNA-CT) imaging facilitates the TNBC procedure. 4,5 Three-dimensional DYNA-CT imaging with needle guidance allows for precise needle advancement and insertion through the foramen ovale. DYNA-CT enables the direct visualization and avoidance of vascular structures such as the carotid or internal maxillary arteries and results in decreased procedure times and complications. The authors present a step-by-step video demonstrating the use of intraoperative DYNA-CT needle guidance for TNBC (Video 1). A Siemens Artis Zee Biplane system is used for the procedure. A comprehensive description of all elements of the procedure is provided including balloon preparation, needle trajectory planning, needle advancement, 3-dimensional confirmation of the needle's depth and path, balloon placement, balloon inflation, and balloon removal. Tips and optimal strategies are presented. Advantages of using DYNA-CT for needle guidance include the reduction of fluoroscopy dose and fluoroscopy time. The average dose area product during conventional percutaneous balloon compression in prior studies was 1137 mGycm2, with a mean fluoroscopic time of 62 seconds. 6 In our experience, the mean fluoroscopy dose is 274 mGycm2 and the total fluoroscopic time is about 45 seconds. Furthermore, during the DYNA-CT acquisition, the neurointerventional team stays outside the room during the DYNA-CT, which reduces the cumulative radiation to the operator. DYNA-CT needle guidance facilitates precise advancement of the needle into the foramen ovale and positioning of the balloon in the Meckel cave during TNBC. It is a safe and feasible technique that allows for the visualization and avoidance of important structures such as the internal carotid artery or the internal maxillary artery, resulting in decreased procedure times and complications. [ABSTRACT FROM AUTHOR]

Patients with drug-resistant focal epilepsy may benefit from ablative or resective surgery. In presurgical work-up, intracranial EEG markers have been shown to be useful in identification of the seizure onset zone and prediction of post-surgical seizure freedom. However, in most cases, implantation of depth or subdural electrodes is performed, exposing patients to increased risks of complications. We analysed EEG data recorded from a minimally invasive approach utilizing foramen ovale (FO) and epidural peg electrodes using a supervised machine learning approach to predict post-surgical seizure freedom. Power-spectral EEG features were incorporated in a logistic regression model predicting one-year post-surgical seizure freedom. The prediction model was validated using repeated 5-fold cross-validation and compared to outcome prediction based on clinical and scalp EEG variables. Forty-seven patients (26 patients with post-surgical 1-year seizure freedom) were included in the study, with 31 having FO and 27 patients having peg onset seizures. The area under the receiver-operating curve for post-surgical seizure freedom (Engel 1A) prediction in patients with FO onset seizures was 0.74 ± 0.23 using electrophysiology features, compared to 0.66 ± 0.22 for predictions based on clinical and scalp EEG variables (p < 0.001). The most important features for prediction were spectral power in the gamma and high gamma ranges. EEG data from peg electrodes was not informative in predicting post-surgical outcomes. In this hypothesis-generating study, a data-driven approach based on EEG features derived from FO electrodes recordings outperformed the predictive ability based solely on clinical and scalp EEG variables. Pending validation in future studies, this method may provide valuable post-surgical prognostic information while minimizing risks of more invasive diagnostic approaches. • We analyzed EEG data recorded from foramen ovale and epidural peg electrodes to predict post-surgical seizure freedom. • For patients with seizure onset on foramen ovale electrodes, a computational approach is helpful in outcome prediction. • Our model based on EEG data from bilateral mesial temporal regions outperformed prediction based on clinical and scalp EEG. • The most important features for outcome prediction were spectral power in the gamma and high gamma range. • Machine learning based surgical outcome prediction is possible with data from a minimally invasive EEG diagnostic modality. [ABSTRACT FROM AUTHOR]

Background: We evaluated Carto 3, transoesophageal echocardiography (TOE) and contact force (CF) sensing catheter in atrial fibrillation (AF) ablation.Methods: Unselected consecutive ablations performed under general anaesthesia (GA) were studied with modified protocol (cases, n=11) and compared to retrospective consecutive controls (n=10). Patent foramen ovale (PFO) or single transseptal puncture enabled left atrial (LA) access; ablation strategy was stepwise approach. Modified protocol utilised right atrial (RA) electrograms, CF and TOE to localise SmartTouch and create RA and CS electroanatomic map (EAM) without fluoroscopy. Transseptal puncture was performed with fluoroscopy in absence of PFO. Fluoroless pulmonary vein and LA EAM was created using TOE to locate circular-mapping catheter.Results: Mean age of cases was 57±11 years with 64% male compared with 60±11 (70% male) for controls. Patent foramen ovale was identified in four cases (36%) and two controls (20%). No early complications occurred. Shorter fluoroscopy time (median 36 vs 390seconds; p=0.038) and trend to lower radiation dose (median 17 vs 165 cGym2; p=0.053) was seen in cases, with no increase in total procedure time (p=0.438).Conclusions: General anaesthesia, TOE and CF mapping catheters facilitate minimised fluoroscopy for catheter ablation of LA arrhythmias. Zero fluoroscopy is possible in a majority of cases with PFO. [ABSTRACT FROM AUTHOR]

Résumé Introduction L’hypoxémie est une diminution de la pression partielle artérielle en oxygène (PaO 2 ). L’objectif de ce travail est de présenter une conduite à tenir devant un patient adulte présentant une hypoxémie « nue », au repos ou à l’effort, définie par une absence de dyspnée au repos, de signe clinique ou d’anomalie radiographique évidents. État des connaissances Les outils diagnostiques à la disposition du clinicien sont l’interrogatoire, l’examen clinique, l’angioscanner thoracique, les échocardiographies, le test d’hyperoxie, le doppler transcranien et la scintigraphie pulmonaire. Ce travail propose une démarche diagnostique pragmatique, centrée autour de la réalisation d’un angioscanner thoracique. Perspectives Des travaux sont en cours pour déterminer plus précisément la place de l’échocardiographie pour le diagnostic des shunts intra- ou extracardiaques. Conclusions La constatation d’une hypoxémie « nue » nécessite une démarche diagnostique rigoureuse pour écarter rapidement les causes potentiellement graves et ne pas méconnaître les causes rares. Introduction Hypoxemia is a decrease in blood oxygen partial pressure. This work aims at presenting a practical conduct for patients with a lonely hypoxemia at rest or during exercise, defined by the absence of dyspnea at rest, obvious clinical or radiographic abnormality. State of the art Diagnostic tools available to the clinician are clinical examination, CT scan, echocardiography, hyperoxia test, trans cranial ultrasound and lung scintigraphy. This work proposes a practical diagnostic approach, with a main role of chest CT. Perspectives Work is underway to determine more precisely the place of echocardiography for the diagnosis of intra or extra cardiac shunts. Conclusions The finding of a lonely hypoxemia requires careful diagnostic approach to quickly rule out potentially serious causes and not to disregard the rare causes. [ABSTRACT FROM AUTHOR]

Résumé Le syndrome platypnée-orthodéoxie est une entité clinique rare qui doit être évoquée dans le diagnostic différentiel de malaises en position debout ou d’une dyspnée majorée par l’orthostatisme. Ce syndrome est le plus souvent associé à un foramen ovale perméable (FOP). La physiopathologie n’est pas univoque et la conjonction de plusieurs facteurs anatomiques semble nécessaire. L’échocardiographie de contraste en permet le diagnostic, et la fermeture du FOP par cathétérisme interventionnel est aujourd’hui la méthode thérapeutique de choix. L’amélioration clinique de cette fermeture est souvent spectaculaire et durable. Platypnea-orthodeoxia is a rare clinical condition which must be examined as a differential diagnosis for any bout of faintness occurring during standing or dyspnea that is exacerbated by standing. This syndrome is often associated with a patent foramen ovale. Its physiopathology is not univocal and the association of many anatomical criteria seems to be mandatory. Contrast echocardiography confirms diagnosis and closure of the patent foramen ovale during interventional catheterization and is currently the therapeutic method of choice. After closure of the foramen ovale, clinical improvement is spectacular and durable. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To compare magnetic resonance imaging (MRI) brain feature in cryptogenic stroke patients with patent foramen ovale (PFO), cryptogenic stroke patients without PFO and patients with cardioembolic stroke. Materials and methods: The ethics committee required neither institutional review board approval nor informed patient consent for retrospective analyses of the patients’ medical records and imaging data. The patients’ medical files were retrospectively reviewed in accordance with human subject research protocols. Ninety-two patients under 60 years of age were included: 15 with cardioembolic stroke, 32 with cryptogenic stroke with PFO and 45 with cryptogenic stroke without PFO. Diffusion-weighted imaging of brain MRI was performed by a radiologist blinded to clinical data. Univariate, Fischer's exact test for qualitative data and non-parametric Wilcoxon test for quantitative data were used. Results: There was no statistically significant difference found between MRI features of patients with PFO and those with cardioembolic stroke (p <.05). Patients without PFO present more corticosubcortical single lesions (p <.05) than patients with PFO. Patients with PFO have more often subcortical single lesions larger than 15mm, involvement of posterior cerebral arterial territory and intracranial occlusion (p <.05) than patients with cryptogenic stroke without PFO. Conclusion: Our study suggests a cardioembolic mechanism in ischemic stroke with PFO. [Copyright &y& Elsevier]

Abstract: During amniotic vertebrate development, the embryo and fetus employ a number of cardiovascular shunts. These shunts provide a right-to-left shunt of blood and are essential components of embryonic life ensuring proper blood circulation to developing organs and fetal gas exchanger, as well as bypassing the pulmonary circuit and the unventilated, fluid filled lungs. In this review we examine and compare the embryonic shunts available for fetal mammals and embryonic reptiles, including lizards, crocodilians, and birds. These groups have either a single ductus arteriosus (mammals) or paired ductus arteriosi that provide a right-to-left shunt of right ventricular output away from the unventilated lungs. The mammalian foramen ovale and the avian atrial foramina function as a right-to-left shunt of blood between the atria. The presence of atrial shunts in non-avian reptiles is unknown. Mammals have a venous shunt, the ductus venosus that diverts umbilical venous return away from the liver and towards the inferior vena cava and foramen ovale. Reptiles do not have a ductus venosus during the latter two thirds of development. While the fetal shunts are well characterized in numerous mammalian species, much less is known about the developmental physiology of the reptilian embryonic shunts. In the last years, the reactivity and the process of closure of the ductus arteriosus have been characterized in the chicken and the emu. In contrast, much less is known about embryonic shunts in the non-avian reptiles. It is possible that the single ventricle found in lizards, snakes, and turtles and the origin of the left aorta in the crocodilians play a significant role in the right-to-left embryonic shunt in these species. [Copyright &y& Elsevier]

Copyright of Archives of Cardiovascular Diseases is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Résumé L’embolie paradoxale est une entité rarement démontrée, souvent évoquée, et le diagnostic est présomptif dans la plupart des cas. Le foramen ovale perméable (FOP) est un facteur anatomique prédisposant important pour une telle complication. Nous décrivons le cas d’une patiente ayant un volumineux thrombus enclavé dans le FOP diagnostiqué par l’échocardiographie incluant la modalité 3D, dans un contexte d’embolie pulmonaire aiguë massive. Le traitement n’est pas codifié dans ce contexte, et le thrombus a été extrait avec succès par chirurgie associé à la fermeture du FOP et l’anticoagulation efficace. Paradoxical embolism is rarely demonstrated, often suggested, and the diagnosis has been largely presumptive in most cases. The patent foramen ovale (PFO) is an important predisposing anatomic factor for such a complication. We describe a case where a voluminous thrombus straddling the PFO was diagnosed by echocardiography including the 3D modality, in the setting of acute massive pulmonary embolism. The treatment is not codified in this setting, and the thrombus was successfully removed by surgery, associated with PFO closure, and anticoagulation. [ABSTRACT FROM AUTHOR]

Abstract: In the human sleep literature there is much controversy regarding the existence and the characteristics of hippocampal rhythmic slow activity (RSA). Generally the human RSA is believed to occur in short bursts of theta activity. An earlier study, however, reported mesiotemporal RSA during rapid-eye-movement (REM) sleep that instead of theta fell in the delta frequency band. We conjectured that if this RSA activity is indeed a human analogue of the animal hippocampal theta then characteristics associated with the animal theta should also be reflected in the human recordings. Here our aim was to examine possible phase coupling between mesiotemporal RSA and gamma activity during REM sleep. The study relied on nine epilepsy surgery candidates implanted with foramen ovale electrodes. Positive half-waves of the 1.5–3 Hz RSA were identified by an automatic algorithm during REM sleep. High-frequency activity was assessed for 11 consecutive 20 Hz–wide frequency bands between 20 and 240 Hz. Increase in high frequency activity was phase coupled with RSA in most frequency bands and patients. Such a phase coupling closely resembles that seen between theta and gamma in rodents. We consider this commonality to be an additional reason for regarding delta rather than theta as the human analogue of RSA in animals. [Copyright &y& Elsevier]

Summary: Objective: To determine fluoroscopy time (FT) and radiation dose (RD) applied in percutaneous closure of interatrial septal communications (IAC). Background: Percutaneous closure of IAC, namely patent foramen ovale (PFO) and atrial septal defect (ASD) is increasingly performed. In this often young population in full reproductive age, radiation dosage should be an important issue, yet consistent data on applied radiation dose have not been available to date. Methods: A single center observational cohort study in 50 consecutive patients undergoing closure of a PFO or ASD. RD and FT as recorded by the cardiac catheter laboratory were determined to be the main outcome measures. Secondary outcome measures were determined to be major adverse events. Results: FT averaged 6.3 (±4, 1.4–21.1)min, whereas RD measured as dose area product averaged 325.5 (±271.1; 11.6–1103.4)dGray×cm2. The latter is equivalent to an effective dose of 6.5milliSievert (0.24–22mSv). Conclusion: Whereas closure of IAC can be associated with a low radiation exposure of 0.24mSv, sometimes appreciably higher doses are applied, mandating more careful consideration of radiation safety issues in this patient population, especially the subset younger than 45 years. Analogous to data and recommendations published for radiation dose in coronary angiography, there is a need for binding reference values which would serve as guidelines for closure of IAC. [Copyright &y& Elsevier]

Abstract: Background: Patent foramen ovale (PFO) is an independent risk factor for cerebral infarction. Since ~25% of the population have a PFO, the simple association of PFO with stroke is not enough to establish the diagnosis of paradoxical embolism. We evaluated possible clinical clues to the diagnosis of paradoxical embolism. Methods: Among patients with cryptogenic ischemic stroke (CS) who were investigated for a right-to-left shunt (RLS), we compared clinical, coagulation and biochemical parameters in patients with PFO versus without PFO. Results: Among 1689 new patients referred for TIA/non-disabling stroke between 2001 and 2007, 175 with cryptogenic stroke (CS) were investigated for RLS by transcranial Doppler (TCD) bubble studies; 89 (5.5%) with positive TCD had a PFO confirmed by TEE. In multivariate logistic regression, a history of DVT or pulmonary embolism (OR, 4.39; 95% CI, 1.23–15.69; p =0.023), prolonged travel (OR, 8.77; 95% CI, 1.775–43.3; p =0.008) , migraine (OR, 2.30: 95% CI, 1.07–4.92; p =0.031), a Valsalva maneuver preceding the onset of focal neurological symptoms (OR, 3.33; 95% CI, 1.15–9.64; p =0.026) and waking up with stroke/TIA (OR, 4.53, 95% CI, 1.26–16.2; p =0.018) were independently associated with PFO-associated cerebrovascular events. Patients with PFO had higher plasma total homocysteine levels than patients without PFO (8.9±3 versus 7.9±2.6 µmol/L respectively; p =0.021). Conclusions: A history of DVT or pulmonary embolism, migraine, recent prolonged travel, sleep apnea, waking up with TIA or stroke or a Valsalva maneuver preceding the event are clinical clues to the diagnosis of paradoxical embolism among patients with CS. [Copyright &y& Elsevier]

Copyright of Archives of Cardiovascular Diseases is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract: We aim to evaluate the mechanisms responsible for complications during trigeminal rhizotomy via foramen ovale puncture. Ten dry skulls and 10 skull-base specimens were investigated in the present study. In cadaveric skull-base specimens, the anatomical relationships between the foramen ovale, mandibular nerve and Gasserian ganglion and the surrounding neurovascular structures were investigated intradurally. The distance between the foramen ovale and Gasserian ganglion was measured as 6 mm. The abducent nerve, adjacent to the anterior tail of the petrolingual ligament, was observed passing along the lateral wall of the cavernous sinus. Advancement of the catheter more than 10 mm from the foramen ovale is likely to damage the internal carotid artery and the abducent nerve at the medial side of the petrolingual ligament. Thermocoagulation of the lateral wall of the cavernous sinus may damage the cranial nerves by heat, giving rise to pareses. [Copyright &y& Elsevier]

Summary: Our understanding of fetal circulatory physiology is based on experimental animal data, and this continues to be an important source of new insight into developmental mechanisms. A growing number of human studies have investigated the human physiology, with results that are similar but not identical to those from animal studies. It is time to appreciate these differences and base more of our clinical approach on human physiology. Accordingly, the present review focuses on distributional patterns and adaptational mechanisms that were mainly discovered by human studies. These include cardiac output, pulmonary and placental circulation, fetal brain and liver, venous return to the heart, and the fetal shunts (ductus venosus, foramen ovale and ductus arteriosus). Placental compromise induces a set of adaptational and compensational mechanisms reflecting the plasticity of the developing circulation, with both short- and long-term implications. Some of these aspects have become part of the clinical physiology of today with consequences for surveillance and treatment. [Copyright &y& Elsevier]

In particular clinical scenarios, transthoracic and transoesophageal echocardiography (TEE) have limitations. This study sought to test if intracardiac and intraluminal echocardiography (ICLE), including 2-D, M-mode and Doppler analysis with a miniaturised, multiple-frequency transducer-tipped catheter, is suitable for assessing distinct cardiac and vascular disorders. ICLE was employed in 10 animals using 6 standard approaches. In 12 patients undergoing device closure of patent foramina ovalia (PFO) (n = 6) or atrial septal defects (ASD) (n = 3), or aortic stent implantation (n = 3), interventional procedures were guided by ICLE and, for comparison, also by TEE. ICLE provided enhanced diagnostic information on the aorta, cardiac valves, main pulmonary vessels and both atria and, therefore, added to the diagnostic spectrum of TEE. Especially for guiding interventional procedures (e.g., device closure of atrial septal defects and patent foramina ovalia), ICLE was shown to be helpful. Compared with the conventional approach, the technique reduced fluoroscopy time for device closure procedures: 6.5 min vs. 8.9 min, p < 0.0011. With the patient in a supine position, ICLE was better tolerated than TEE. Complications did not occur, either with ICLE or with TEE. In conclusion, ICLE adds to conventional echocardiography and promises to become a clinical alternative for guiding interventional procedures. (E-mail: thomas.bartel@uni-essen.de) [Copyright &y& Elsevier]

Objectives: To test if a method for real-time detection of epileptic seizures based on electroencephalographic (EEG) analysis with simulated neuronal cell models can be modified to identify pre-seizure changes.Methods: Our EEG analysis method consists of two simulated leaky integrate and fire units (LIFU) connected to a signal preprocessing stage that marks parts of the EEG signals with slopes larger than a preset threshold Hth with unit pulses. The LIFUs change their spiking frequency depending on the rate and the synchrony of the impinging pulse trains. Here, we use our method in a high-sensitivity mode by setting Hth to low values, which causes the LIFUs to continuously spike during the interictal state. We test if the LIFUs spiking rates change before seizure onset.Results: We used 9 long-term EEGs (16±7 h) of 7 patients with drug resistant epilepsy. Fifteen seizures were analyzed and all were preceded by an increase of the time-averaged spiking rates SRav of the LIFUs. We defined a function FSz, which quantifies the changes of SRav. FSz increased and stayed above an individually set and fixed threshold 83±91 min (range: 4–330 min) before EEG seizure onset. Only two false alarms occurred.Conclusions: We conclude that EEG analysis with simulated neuronal cell models may be used to detect pre-seizure changes with high sensitivity and specificity. [Copyright &y& Elsevier]

Ossification of the pterygospinous and pterygoalar ligaments has been well documented forming pterygospinous and pterygoalar bars. However, the actual ligaments have been rarely shown in the existing literature. Therefore, this study aimed to reveal the anatomy of the pterygoalar ligament/bar and pterygospinous ligament/bar, and its relationship with the branches of the mandibular nerve. Thirty sides from fifteen Caucasian fresh frozen cadaveric heads were used in this study. The branches of the mandibular nerve and any ligaments or bony bridges between the lateral plate of the pterygoid process and spine of the sphenoid were observed. A pterygospinous ligament/bar and pterygoalar ligament/bar were defined based on the relationship with the branches of the mandibular nerve. The pterygoalar ligament/bar was further classified into two types. Twenty-seven sides (90%) had at least one pterygoalar ligament/bar or pterygospinous ligament/bar. A pterygospinous ligament/bar was found on 15 sides (50.0%). A pterygoalar ligament/bar was found on 16 sides (53.3%), and a type I on 11 sides and type II on 5 sides. This finding and classification are simple to understand and easy to apply for future studies, and have important implications regarding the clinical anatomy of trigeminal neuralgia and facial pain. [ABSTRACT FROM AUTHOR]

Abstract: We report the case of a man admitted for massive pulmonary embolism. Transthoracic echocardiography showed a serpentine thrombus in the right atrium across the foramen oval. Because of an acute worsening of the circulatory insufficiency, an intravenous thrombolysis was prescribed and the patient recovered progressively. An early control echocardiography showed the disappearing of the intracardiac thrombus and no evidence of abnormality of interatrial septum. While there was no evidence of venous thrombosis in legs, a renal cancer was diagnosed by echography. Silent stroke were highlighted at the scanner. This clinical case leads to discuss the origin of thrombus (in situ formation or thrombus migration) as well as the treatment (heparinotherapy, thrombolysis, surgical embolectomy, definitive closure of the foramen oval). [Copyright &y& Elsevier]

Objective The aim of this study was to describe the anatomic trajectory of the extracranial needle for percutaneous rhizotomy and correlate this with structures at risk during such a procedure. Methods Six sides from 3 frozen fresh Caucasian heads were used in this study. Hartel anatomic landmarks for percutaneous trigeminal rhizotomy procedures were used. A free hand technique was then used, and intraprocedural visualization of the needle was performed with fluoroscopy. When the procedure was completed, the face was dissected along with the needle pathway up to the foramen ovale in order to evaluate for any damaged structures. Results On all sides, the needle passed lateral to the buccinator muscle and near the parotid duct to then pierce the superior head of the lateral pterygoid muscle to enter the infratemporal fossa. This placed the needle near the buccal nerve on all sides, although no direct injury was noted. Although very near, no branches of the facial nerve or artery were damaged. On 1 side, the maxillary artery was pierced. Conclusions To our knowledge, this is the first study to describe the detailed extracranial anatomic needle pathway using the Hartel approach. Such data might help surgeons better recognize potential complications from such procedures. [ABSTRACT FROM AUTHOR]

Abstract: Operations to the face and skull can obscure the landmarks that are required to locate the position of the foramen ovale. We describe the use of three-dimensional computed tomography (3D-CT) to guide the approach to the foramen ovale to block the mandibular nerve in a patient with a mandibular deformity that had been caused by segmental mandiblectomy. Successful blockage of the mandibular nerve controlled the pain, contributed to the relief of physical and mental stress, and avoided the side effects of analgesics and pain from inserting the blocking needle. [Copyright &y& Elsevier]

Abstract: We report the case of a 57-year-old man who underwent orthotopic heart transplantation because of prior myocardial infarction and cardiogenic shock. The patient developed refractory hypoxemia 7 months after transplantation, secondary to a right to left shunt across a patent foramen ovale related to severe tricuspid regurgitation resulting from repeated control biopsies. Percutaneous closure of the foramen ovale was performed. [Copyright &y& Elsevier]

Summary: Fat embolism (FE) and fat embolism syndrome (FES) are controversial topics, particularly regarding their clinical relevance and their independency as a clinical syndrome. FE describes the presence of fat globules within the microcirculation. FES on the other hand, is a clinical syndrome characterized by the presence of FE with the manifestation of an identifiable clinical pattern of signs and symptoms. Both experimental and clinical studies have demonstrated the occurrence and the possible harmful effects of FE. For instance, FE involving the lungs can result in adult respiratory distress syndrome (ARDS). The effects of FE are certainly mechanical, leading to capillary congestion, but are also highly likely to be of a proinflammatory and prothrombotic nature. The demarcation of FES against ARDS is mainly demonstrated by the single organ involvement of ARDS, exclusively influencing the lungs, whereas FES has a multiorgan effect with pulmonary, skin and, neurological manifestations. This article is a review of the pathophysiological mechanisms of FE and the clinical occurrence and influence of FE and FES. [Copyright &y& Elsevier]

Abstract: This article describes the fetal circulation with its three shunts: the ductus venosus; the foramen ovale between the right and left atria; and the ductus arteriosus, which links the descending aorta with the pulmonary trunk. These shunts form an ingenious mechanism, which ensures that oxygenated blood returning to the fetus in the left umbilical vein (the right having regressed early in fetal life) is shunted preferentially into the aortic root, to supply the heart muscle via the coronary arteries, and the cerebral tissues via the vertebral and carotid arteries. At birth, the foramen ovale closes leaving as its relic the fossa ovalis (though this remains probe patent in 10% of patients), the ductus venosus closes and remains as the ligamentum venosum of the adult, while the ductus arteriosus fibroses into the ligamentum arteriosum. [Copyright &y& Elsevier]