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Background: Percutaneous closure of patent foramen ovale (PFO) and atrial septal defects (ASD) is being more commonly performed due to changes in international guidelines supporting its use. This study was performed to determine the clinical outcomes, safety and cost implications of same-day discharge (SDD) following such procedures and place this in an Australian context. Methods: This was a retrospective, observational study of patients undergoing elective percutaneous PFO or ASD closure at St. George Hospital, Australia between January 2011 and January 2020. Primary outcomes included 30-day major adverse cardiovascular endpoints (MACE) and readmission to hospital within 30 days. Results: Twenty-four patients were included in the primary analysis. Ten (41.7%) patients underwent elective ASD closure while 14 (58.3%) underwent PFO closure. Among the 24 patients who underwent elective percutaneous closure of structural heart disease, 23 patients (95.8%) were managed with SDD. There were no MACE outcomes at 30 days. No patients were re-admitted to hospital at 30 days following these procedures. When compared to overnight admission to hospital post-elective percutaneous structural heart condition closure, SDD yielded a cost saving of AUD 5999 per case. Conclusion: SDD following elective percutaneous closure of ASD and PFO was demonstrated to be a safe and effective strategy for managing patients. With more widespread use, it can lead to significant cost savings for hospitals without compromising patient care.

The importance of the location of the foramen ovale (FO) is particularly evident in external approaches to the skull base. Neighboring structures are of great importance in surgical interventions such as approaches used for trigeminal neuralgia (percutaneous trigeminal rhizotomy), transfacial fine needle aspiration in perineural spread of the tumor, and electroencephalographic analysis for seizures. This study aimed to investigate the morphometry, morphology and anatomical relations of the FO. Eighty hemicraniums of osteological collection of the Department of Anatomy, Faculty of Medicine, Istanbul University, in Turkey were investigated. In the study, the morphological features of the foramen ovale and their distance to the surrounding anatomical structures were measured. Oval (70%), almond (18.75%), slit (6.25%), round (5%) shaped foramen ovale were observed. The average length of foramen ovale on the right side was 7.09+1.07mm and 7.06+1.01mm on the left side, while the width was 4.16+0.79mm and 4.15+0.5mm, right and left respectively. The transverse distance of posterolateral edge of foramen ovale to lateral edge of articular tubercle was 33.06+3.25mm, the transverse and vertical distances of foramen ovale to mastoid proccess were, 17.36+3.09mm and 32.40+3.43mm. Finally, measurements of foramen ovale to the carotid canal, the inferior orbital fissure, and the pterygopalatine fossa were 16.70+1.9mm, 27.94+3.2mm and 14.88+1.91mm, respectively. Regional differences in morphometric and morphological analysis of foramen ovale are of clinical and anatomical significance for medical practitioners in neurosurgical procedures, treatment of trigeminal neuralgia, and diagnostic detection of tumors. [Med-Science 2021; 10(3.000): 1039-46]

Introduction Percutaneous balloon compression (PBC) is an effective and safe option for patients with trigeminal neuralgia. A pear-shaped balloon can be used to identify the proper compression of the Gasserian ganglion during the PBC procedure. The aim of this study was to evaluate the relationship between the foramen ovale (FO) size and intraluminal pressure of the pear-shaped balloon. Methods Thirteen patients that presented with classical trigeminal neuralgia were scheduled to undertake PBC surgery at the Pain Department of the Third Xiangya Hospital, Central South University, from November 2020 to April 2021. Three-dimensional computed tomography reconstruction of the skull base was performed to capture the feature of FO preoperatively. The intraluminal pressure was continuously recorded when a pear-shaped balloon was obtained during the procedure. Correlation analysis was calculated to determine the association of the intraluminal balloon pressure with FO parameter. Results All participants reported complete relief of pain at discharge. The enduring analgesic effect of PBC was maintained in all patients with a median follow-up up to 5.5 months (range, 3–8 months). The average intraluminal balloon pressure was 161.5 ± 29.4 kPa at the initial compression (P1), and 134.8 ± 21.5 kPa at the ending of compression (P2), respectively. P1 was significantly correlated with the length (r = 0.61, P = 0.024) of FO. Similarly, a significant and positive correlation was observed between P2 and the length (r = 0.63, P = 0.022) of FO. Conclusions Preoperative assessment of FO may be a potential predictor of intraluminal pressure to reach a pear-shaped balloon during PBC treatment. Narrow FO is associated lower intraluminal balloon pressure.

Objective : Trigeminal neuralgia is one of the most common causes of facial pain. Our aim is to investigate the efficacy and borders of percutaneous radiofrequency thermocoagulation in the treatment of trigeminal neuralgia.Methods : Between May 2007 and April 2017, 156 patients with trigeminal neuralgia were treated with radiofrequency thermocoagulation. These 156 patients underwent 209 procedures. In our study, we investigated the early and late results of percutaneous radiofrequency thermocoagulation under guiding fluoroscopic imaging in the treatment of trigeminal neuralgia. Barrow Neurological Institute (BNI) pain scale was used for grading the early results. In addition, Kaplan-Meier survival analysis was used to assess long-term outcomes. Of the 156 patients who underwent radiofrequency thermocoagulation for trigeminal neuralgia, 45 had additional disease. Patients with this condition were evaluated with their comorbidities. Early and late results were compared with those without comorbidity.Results : In 193 of 209 interventions BNI pain scale I to III results were obtained. Out of the 193 successful operation 136 patients (65.07%) were discharged as BNI I, 14 (6.70%) as BNI II, 43 (20.58%) as BNI III. Sixteen patients (7.65%) remained uncontrolled (BNI IV and V). While the treatment results of trigeminal neuralgia patients with comorbidity seem more successful in the early period, this difference was not observed in follow-up examinations.Conclusion : Finally, we concluded that percutaneous radiofrequency thermocoagulation of the Gasserian ganglion is a safe and effective method in the treatment of trigeminal neuralgia. However, over time, the effectiveness of the treatment decreases. Neverthless, the reapprability of this intervention gives it a distinct advantage.

OBJECTIVES To investigate the impact of abnormal perinatal loading conditions on cardiac geometry and function in term fetuses and neonates with transposition of the great arteries with intact interventricular septum (simple TGA), and to explore the predictive value of fetal cardiac parameters for an urgent balloon atrial septostomy (BAS) after birth. METHODS This was a prospective longitudinal follow-up study of women delivering at term, including both uncomplicated pregnancies with normal outcome and pregnancies affected by fetal simple TGA. Conventional, spectral-tissue Doppler and speckle-tracking echocardiographic parameters were obtained within 1 week before delivery and within the first few hours after delivery. Neonates with simple TGA that required urgent BAS were assessed after the procedure and before corrective arterial switch surgery. Cardiac parameters were normalized by cardiac cycle length, ventricular end-diastolic length or end-diastolic dimension, as appropriate. Fetal and neonatal cardiac parameters were compared between simple-TGA cases and controls, and perinatal changes in the simple-TGA group were assessed. Receiver-operating-characteristics (ROC)-curve analysis was used to assess the predictive value of fetal cardiac parameters for urgent BAS after birth in the simple-TGA group. RESULTS A total of 67 pregnant women delivering at term were included in the study (54 normal pregnancies and 13 with a diagnosis of fetal simple TGA). Compared with normal term fetuses, term fetuses with simple TGA exhibited more globular hypertrophied ventricles, increased biventricular systolic function and diastolic dysfunction (right ventricular (RV) sphericity index (SI), 0.58 vs 0.54; left ventricular (LV)-SI, 0.55 vs 0.49; combined cardiac output (CCO), 483 vs 406 mL/min/kg; LV torsion, 4.3 vs 3.0 deg/cm; RV isovolumetric relaxation time (IVRT'), 127 vs 102 ms; P

Atrial septal defect (ASD) is the 5th common congenital abnormality at birth. Secundum atrial defect and patent foramen ovale (PFO) are the most common atrial septal defects. In this setting, the anatomical functional characterization of the interatrial septum seems to be of paramount importance not only for device selection but also for therapeutic intervention. This study was carried out to evaluate the morphometric parameters of fossa ovale (FOv) in the human adult cadaveric hearts. For this study, 50 normal cadaveric human hearts available in the department of Anatomy over the period of 3 years were used where size, position, shape, nature of the FOv was noted. The size of the fossa was measured and prominence, location, and extent of the limbus fossa ovalis were observed. The probe patency of foramen ovale (FO) was confirmed. In most specimens, the fossa was oval (80%), the average transverse diameter was 24.21 mm, and the vertical diameter 26.84 mm. In 84% rim was raised. In 56% of cases, the fossa was present at the middle of the interatrial septum. The patency of foramen was observed in 3%. The findings of the present study provide pertinent information on the morphology of the FOv, which may be useful for device selection in treating ASDs and PFO. This would definitely help the clinicians in a deeper understanding of the region as very few cadaveric studies are available in the literature at present.

OBJECTIVES Little is known about cardiac hemodynamics in the fetus with transposition of the great arteries and intact ventricular septum (TGA-IVS). Better understanding of the fetal physiology in TGA-IVS would help to provide insights into specific clinical complications observed after birth, in particular neonatal hypoxia and pulmonary hypertension. The aim of this study was to assess cardiac hemodynamics in fetuses with TGA-IVS by performing systematic longitudinal echocardiographic follow-up from diagnosis to delivery. METHODS This was a longitudinal retrospective study of fetuses referred between 2010 and 2018 to the Sainte-Justine University Hospital Centre. Complete assessment of cardiac hemodynamics was performed in fetuses with TGA-IVS at 18-22, 28-32 and 35-38 weeks' gestation, which were compared with normal fetuses matched for gestational age. The maximum diameter of the foramen ovale was measured using two-dimensional echocardiography under the guidance of color Doppler echocardiography. Fetal cardiac hemodynamics were analyzed according to postnatal preductal transcutaneous oxygen saturation (TcSO2 )

Background: Patent foramen ovale (PFO) has been considered a potential mechanism of embolic stroke of undetermined origin. Objective: The aim of the present study was to identify the features of the right-to-left shunt (RLS) in patients with undetermined embolic ischemic stroke and compare them with those of patients with non-cardioembolic ischemic stroke. Methods: A retrospective study was conducted with 168 patients with stroke and RLS separated into the following two groups: the undetermined embolic stroke group (UES group) and non-cardioembolic stroke group (NCES group). All patients were assessed by transcranial Doppler to evaluate the presence and quantification of microembolic signals (MES) at rest and under Valsalva maneuver. Results: Of all patients evaluated in the current study, 96 were included in the UES group and 72 in the NCES group. In the UES group, 65 patients had RLS with ≥10 MES (67.7%), which was higher than that observed in the NCES group (51.4%, p=0.038). According to the moment of the cardiac cycle, 75 patients (78.1%) in the UES group had a positive test at rest compared to 42 (58.3%) in the NCES group (p=0.007). Conclusions: The current study demonstrated that almost 70% of patients with undetermined embolic stroke and PFO presented a large RLS and more than 75% had RLS at rest. These findings suggest that the size of the shunt should be taken into account when evaluating whether PFO could be a possible mechanism underlying cryptogenic stroke. RESUMO Antecedentes: Uma das potenciais fontes embólicas no acidente vascular cerebral (AVC) de origem indeterminada é o forame oval patente (FOP). Objetivo: O objetivo do presente estudo foi identificar as características do shunt direita-esquerda em paciente com AVC de etiologia indeterminada, presumidamente embólica, e comparar tais características com pacientes apresentando AVC por outras causas não embólicas. Métodos: Trata-se de um estudo retrospectivo com 168 pacientes com AVC e forame oval patente, separados em dois grupos: AVC embólico de etiologia indeterminada e AVC por outras causas não embólicas. Todos os pacientes foram submetidos a Doppler transcraniano, para avaliar a presença de shunt direita-esquerda por meio do teste de embolia paradoxal. Além da quantificação de microbolhas, também foi avaliada a presença de shunt em repouso e sob manobra de Valsalva. Resultado: Do total, 96 pacientes foram incluídos no primeiro grupo (AVC indeterminado) e 72, no segundo grupo (AVC não embólico). No primeiro grupo, 65 pacientes exibiram shunt com passagem de mais de 10 microbolhas (67,5%), enquanto no segundo grupo isso aconteceu em 51,4% (p=0,038) dos casos. Além disso, 75 pacientes (78,1%) do primeiro grupo tiveram teste positivo ao repouso, comparados com 42 pacientes (58,3%) no segundo grupo (p=0,007). Conclusão: O presente estudo demonstrou que até 70% dos pacientes com AVC de etiologia indeterminada e forame oval apresentaram shunts maiores; em mais de 75%, houve passagem de microbolhas ao repouso. Esses achados sugerem que as características do shunt, como quantidade de microbolhas e passagem ao repouso, devem ser levadas em consideração na avaliação do FOP como possível mecanismo subjacente ao AVC.

Background and objectivesAccess through the foramen ovale (FO) is essential in performing trigeminal ganglion injection, glycerol rhizolysis, balloon compression, and radiofrequency thermocoagulation (RFT) to treat idiopathic trigeminal neuralgia (ITN). However, identification of the FO under fluoroscopy can be difficult and time-consuming, and thus exposes patients to increased radiation and procedure risks. Here we present the ‘H-figure’ as a novel fluoroscopic landmark to quickly visualize the FO.MethodsThe H-figure landmark can be recognized as the medial border of the mandible and the lateral edge of the maxilla as the two vertical lines, and thesuperior line ofpetrous ridge oftemporal bone (S-P-T line) as the horizontal line, and the FO fluoroscopic view is then optimized at the center of the H-figure immediately above the S-P-T line. We applied this landmark in a clinical cohort of 136 patients with ITN who underwent fluoroscopy-guided RFT of the trigeminal ganglion. We also compared the H-figure method with the traditional method. The primary outcome was the total number of fluoroscopic images required to visualize the FO (as a proxy of radiation exposure). Secondary measures included the procedure time required to finalize the FO view and the sensory testing voltage for paresthesia.ResultsWith the H-figure approach we were able to view the FO with an average of 4.2 fluoroscopic shots at an average time of 6.8 min. When compared with the non-H-figure traditional technique, the H-figure method required almost half the fluoroscopic shots in nearly half the procedure duration time, and paresthesia was evoked with half of the voltage.ConclusionThe H-figure is an easy fluoroscopic landmark that can help to view the FO with less radiation and procedure time, and the needles placed with this approach can be closer to the target for the RFT treatment of patients with ITN.

Purpose 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. 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. Results 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. Conclusion 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.

Objective Neuromodulation for trigeminal pain syndromes such as trigeminal neuropathic pain (TNP) necessitates accurate localization of foramen ovale (FO). The Hartel-type approach is very well-established and safe, ideal for temporary cannulation of the FO for ablative procedures such as balloon microcompression. A key shortcoming of the Hartel approach for placement of neuromodulation leads is the limited opportunity for secure anchoring. The aim of this study is to introduce a novel surgical approach for the treatment of TNP by investigating key osseous landmarks and their spatial relationships to the FO. Materials and methods Sixteen sides of cadaver heads were dissected to investigate a surgical route of the FO via transoral gingival buccal approach. Alveolar arch of the maxilla and zygomaticomaxillary suture were selected to serve as an osseous landmark for the surgical guidance to the FO. Through the intraoral route, a needle simulating electrode was traversed to aim the FO from the inferior lateral to the superior medial direction to target specific fibers of the aimed division of the nerve. Results Visual identification and access to the trigeminal nerve at the external opening of FO was successful in all 16 hemifacial cadavers. A needle successfully targeted different regions of the trigeminal nerve by changing the angle of the trajectory allowing the needle to reach a specific division of the trigeminal nerve. Conclusions This study provides a novel means of approaching the FO via transoral gingival buccal access.

Antenatal cardiac intervention affords new prospects for hypoplastic left heart syndrome. Its success, however, may come not only from absence of impediments to blood flow but also from a sufficiently developed cardiac wall. Here, we examined the feasibility to perfuse selectively the fetal coronary circulation for treatment with growth promoting agents. Pregnant sheep (94–114 days gestation, term 145 days) were used. An aortic stop-flow procedure was developed for intracoronary access in the nonexposed fetus and human mesenchymal stem cells and their exosomes served as test agents. We found that aortic stop-flow ensures preferential distribution of fluorescent microspheres to the heart. However, intracoronary administration of stem cells or exosomes was detrimental, with fetal demise occurring around surgery or at variable intervals afterwards. Coincidentally, stop-flow caused by itself a marked rise of intraluminal pressure within the occluded aorta along with histological signs of coronary obstruction. We conclude that it is feasible to perfuse selectively the coronary circulation of the preterm fetus, but treatments are not compatible with survival of the animals. The cause for failure is found in the absence of hemodynamic compensation to stop-flow via a left-to-right shunt. This unexpected event is attributed to a largely membranous foramen ovale, characteristic of sheep, that collapses under pressure.

The emissary veins (EVs) passing through the foramen ovale (FO) are not well understood. The aim of this study was to characterize these veins using contrast magnetic resonance imaging (MRI). In total, 85 patients underwent thin-sliced, contrast MRI. Coronal and sagittal images were used for the analysis. The EVs of the FO were well delineated in 100% on sagittal and 97% on coronal images. On the sagittal images, these veins could be classified into the lateral, medial, and perineural types in association with the mandibular division of the trigeminal nerve (V3) segment in the FO. In 22% of the slides, the medial EV was more predominant than lateral one, while in 64% of the slides, the latter was more predominant. On the coronal images, the identified EVs of the FO coursed medially to the V3 in 68% and laterally in 72% of 165 sides. The perineural EVs most frequently coursed along both the lateral and medial surfaces of the V3. On the sagittal images, the angles formed by the midline of the V3 segment in the FO and lower margin of the FO were 81.5 ± 11.9° on the left side and 80.0 ± 12.2° on the right, while on the coronal images, they were 61.5 ± 12.1° on the left side and 64.8 ± 11.3° on the right. The EVs of the FO are structures that may be characterized by a well-developed venous channel in the lateral aspect of the V3 and nearly symmetrical orientation of both V3s lying in the FO.

Objective Develop a high-performing algorithm to detect mesial temporal lobe (mTL) epileptiform discharges on intracranial electrode recordings. Methods An epileptologist annotated 13,959 epileptiform discharges from a dataset of intracranial EEG recordings from 46 epilepsy patients. Using this dataset, we trained a convolutional neural network (CNN) to recognize mTL epileptiform discharges from a single intracranial bipolar channel. The CNN outputs from multiple bipolar channel inputs were averaged to generate the final detector output. Algorithm performance was estimated using a nested 5-fold cross-validation. Results On the receiver-operating characteristic curve, our algorithm achieved an area under the curve (AUC) of 0.996 and a partial AUC (for specificity > 0.9) of 0.981. AUC on a precision-recall curve was 0.807. A sensitivity of 84% was attained at a false positive rate of 1 per minute. 35.9% of the false positive detections corresponded to epileptiform discharges that were missed during expert annotation. Conclusions Using deep learning, we developed a high-performing, patient non-specific algorithm for detection of mTL epileptiform discharges on intracranial electrodes. Significance Our algorithm has many potential applications for understanding the impact of mTL epileptiform discharges in epilepsy and on cognition, and for developing therapies to specifically reduce mTL epileptiform activity.

Resumen: La endocarditis infecciosa es una enfermedad mortal, que a pesar de las mejoras en su manejo sigue estando asociada a gran mortalidad y complicaciones graves. Es una complicación excepcional del cierre percutáneo de foramen oval permeable. Se presenta un caso clínico de un hombre de 52 años intervenido de cierre percutáneo de foramen oval permeable detectado en el estudio etiológico de un ictus. Tres años después, el paciente presentó un cuadro clínico compatible con endocarditis, encontrándose una gran vegetación endocardítica anclada a la vertiente auricular izquierda del dispositivo de cierre de foramen oval permeable. Los hemocultivos fueron positivos para Staphylococcus aureus. Se realizó cirugía con resección del dispositivo. La evolución postoperatoria fue satisfactoria. Abstract: Infective endocarditis is a fatal disease that, despite improvements in its management, is still associated with a high rate of mortality and complications. It is an exceptional complication of percutaneous patent foramen ovale closure. A case report is presented of a 52-year-old man who underwent percutaneous closure of a percutaneous patent foramen ovale diagnosed during the aetiological study of a stroke. Three years after the procedure, the patient presented with symptoms of endocarditis. A large endocarditic growth was found to be anchored to the left atrial surface of the percutaneous patent foramen ovale closure device. Blood cultures were positive for Staphylococcus aureus. Surgery was performed and the device was removed. Postoperative recovery was satisfactory.

Isolated restrictive foramen ovale (rFO) without complex heart defects is a rare pathology. There may be difficulties in managing this situation, which can lead to right heart enlargement, tricuspid regurgitation and hydrops findings in the foetus. We conducted a retrospective analysis of 8451 foetuses. 7883 (93.2%) had a structurally normal heart or minor heart disease, 18 (0.22%) of which had a diagnosis of isolated rFO. Nine patients with neonatal echocardiographic examination were included in the study. In 8 (88.8%) patients, it was stated that a decision to give birth should be made at the time of presentation. Evaluating postpartum echocardiographic examinations, 7 (77.7%) patients had normal or minor defects. The decision of delivery made at the right time during follow-up is critical to determine the prognosis.IMPACT STATEMENTWhat is already known on this subject? The data about the prenatal diagnosis of isolated rFO is limited.What the results of this study add? We conducted a retrospective analysis of 8451 foetuses. 7883 (93.2%) foetuses had a structurally normal heart or minor heart disease, 18 (0.22%) of which had a diagnosis of rFO. Nine patients with foetal and postnatal follow-up and echocardiographic findings were examined in the study. The group's median gestational age at admission was 35.0 weeks (range: 27.0-39.0 weeks). The delivery decision was made in 8 (88.8%) patients at the time of admission. Evaluating postpartum echocardiographic examinations, 7 (77.7%) patients had normal or minor defects. Additionally, one patient was diagnosed with cardiomyopathy, and the other patient was diagnosed with functional pulmonary atresia. No death occurred in any foetus during follow-up.What the implications are of these findings for clinical practice and/or further research? Isolated rFO, a rare condition in the foetus, is generally well-tolerated in foetal life. However, the right heart enlargement, tricuspid regurgitation, or hydrops findings can be seen in patients. The decision of delivery made at the right time during follow-up is critical to determine the prognosis.

BackgroundIn this case report, we describe a very rare case of severe limb ischemia due to an arterial embolus caused by an aneurysm of the oval foramen in a term-born infant that occurred in the first few hours after birth.Case presentationA newborn male Caucasian patient presented on the maternity ward with ischemia of the right foot. Ischemia was treated with nitroglycerin spray and low-molecular-weight heparin in therapeutic dosage. An aneurysm of the oval foramen was found during postnatal echocardiography screening. This was thought to be the source of an embolus causing limb ischemia. At birth and upon follow-up, no clotting disorders were found. A large part of the right forefoot was ischemic, leading to loss of digits 1, 2, and 3. No significant loss of function was found in the first year of life.ConclusionSevere limb ischemia can be caused by an embolus arising from an aneurysm of the oval foramen and can be treated with heparin.

We describe a 3-month-old infant with transposition of great arteries and restrictive foramen ovale who presented with severe cyanosis. Child had a large thrombus causing near-total occlusion of the inferior caval vein. An emergency atrial septoplasty was performed via internal jugular venous access. The case emphasises the technical challenges faced while performing this procedure through jugular approach and plausible solutions to overcome these challenges.

Objective A major challenge that limits understanding and treatment of epileptic events from mesial temporal structures comes from our inability to detect and map interictal networks reproducibly using scalp electrodes. Here, we developed a novel approach to map interictal spike networks and demonstrate their relationships to seizure onset and lesions in patients with foramen ovale electrode implantations. Methods We applied the direct Directed Transfer Function to reveal interictal spike propagation from bilateral foramen ovale electrodes on 10 consecutive patients and co-registered spatially with both seizure onset zones and temporal lobe lesions. Results Highly reproducible, yet unique interictal spike networks were seen for each patient (correlation: 0.93 ± 0.13). Interictal spikes spread in both anterior and posterior directions within each temporal lobe, often reverberating between sites. Spikes propagated to the opposite temporal lobe predominantly through posterior pathways. Patients with structural lesions (N = 4), including tumors and sclerosis, developed reproducible spike networks adjacent to their lesions that were highly lateralized compared to patients without lesions. Only 5% of mesial temporal lobe spikes were time-locked with scalp electrode spikes. Our preliminary observation on two lesional patients suggested that along with lesion location, Interictal spike networks also partially co-registered with seizure onset zones suggesting interrelationship between seizure onset and a subset of spike networks. Conclusions This is the first demonstration of patient-specific, reproducible interictal spike networks in mesial temporal structures that are closely linked to both temporal lobe lesions and seizure onset zones. Significance Interictal spike connectivity is a novel approach to map epileptic networks that could help advance invasive and non-invasive epilepsy treatments.

In patients with severe COVID-19, it has been proposed as mechanism of respiratory failure, intra and extrapulmonary shunt. However, there are no reported or documented cases of this mechanism. Also, there are studies showing this mechanism is not relevant. In this report, we present the case of a patient with severe COVID-19 pneumonia, who after two months, during his rehabilitation period, presented persistent hypoxemia with orthodeoxia. Persistent oval foramen with shunt from right to left was diagnosed. The patient underwent a percutaneous closure of the defect and at 48 hours oxygen therapy could be discontinued and the patient discharged.

Objective: There is a paucity of information regarding the specific anatomy and clinical significance of variations of foramen ovale (FO). The present study was undertaken to define this anatomy in more detail and to review the literature regarding these anatomic variations. Materials and Methods: A total of 124 adult human dry skulls were analyzed for the variations in appearance and number of FO being noted. The length and width of the FO of both sides were determined using digital vernier calipers and area (A) was also calculated and analyzed. Results: Of 82 adult skulls, the values for the right side was 7.64 ± 1.194 mm, 5.128 ± 0.827 mm, and 30.808 ± 7.545 mm2 and for the left side the values was 7.561 ± 1.123 mm, 5.244 ± 0.950 mm, and 31.310 ± 8.262 mm2, respectively, for the mean length, width, and area of the FO. The shape of foramen was typically ovale in most of the skulls (56.70%) with some bony variations such as spine, tubercles, bony bridge/bar, and confluence. Conclusion: Such variants in the FO could interfere with transcutaneous needle placement into the FO or distort anatomic relationships during approaches to the cranial base.

In fetuses, the Eustachian valve directs oxygenated blood returning from the inferior vena cava into the left atrium via the foramen ovale. If too large, the Eustachian valve can restrict right ventricular inflow, as well as induce postnatal cyanosis via an interatrial right-to-left shunt. We report a fetal case of postnatal amelioration of the tricuspid valve and right ventricle hypoplasia, despite significant right ventricular hypoplasia associated with a large Eustachian valve. Application of an appropriate respiratory management regimen to help reduce pulmonary vascular resistance is of particular importance for the reversal of the right-to-left shunt via the foramen ovale and associated increases in right ventricular inflow.

Objective: To assess the intrauterine course and outcome of fetal cardiac intervention (FCI) in fetuses with critical aortic stenosis (CAS), severe mitral regurgitation (MR), severe left atrial dilatation (LAD), and restrictive foramen ovale (RFO) or intact atrial septum. Methods: All fetuses with a prenatal diagnosis of CAS, severe MR, severe LAD, and RFO were retrospectively collected in one tertiary center for fetal medicine over a period of 10 years. Video recordings, pre- and postnatal charts were reviewed for cardiac and extracardiac anomalies, intrauterine course, and postnatal outcome. Results: Nineteen fetuses with CAS, severe MR, severe LAD, and RFO were diagnosed in the study period. In 5 cases, FCI was not considered as the parents either opted for expectative management or for termination. In the remaining 14 fetuses, 21 FCI were performed: 14 balloon valvuloplasties, 2 atrioseptostomies, and 5 fetal atrial stent insertions. Seven of 14 fetuses (50%) had fetal hydrops, 5 of 14 fetuses (36%) presented with intact atrial septum. Procedure-related death occurred in 5 fetuses after aortic valvuloplasty or concomitant atrioseptostomy but in none after fetal atrial stenting. Due to progressive hydrops, two terminations of pregnancy were performed. Among the 7 live births, 3 died in the neonatal period. The remaining 4 received single ventricle palliation, 2 following fetal aortic valvuloplasty and 2 after fetal atrial stent insertion. Conclusions: CAS with severe MR, severe LAD, and RFO has a high overall mortality even in cases undergoing intrauterine intervention. Parameters that accurately predict the intrauterine and postnatal outcome have yet to be defined.

Background: For patients with trigeminal neuralgia who do not respond to medication and for whom surgical approaches are too risky, percutaneous procedures targeting the trigeminal ganglion are the current standard treatment. Percutaneous procedures are performed via the transoval approach under radiologic guidance. Identification of the foramen ovale (FO) under fluoroscopic guidance is an important part of determining the success or failure of the procedures. Objectives: Previous studies have described how to visualize the FO under fluoroscopic guidance, but those methods are limited by poor reproducibility. In this study, we have investigated how to visualize the FO clearly and easily under fluoroscopic guidance. Study Design: Retrospective analysis. Setting: University hospital in Korea. Methods: Seventy-two 3-dimensional facial computed tomography scans without anatomic abnormalities of the skull base were analyzed for verifying the novel method. First, the mandibular angle and the occipital cortical line were overlapped and then turned by 15° oblique rotation using the software package. After these manipulations, the visualization of the FO was graded according to a 4-point scale (0: poor; 1: fair; 2: good; 3: excellent), and the inferior transfacial and oblique angles were measured. Results: This enabled clear visualization of the FO. The mean visual grade of 54 right and 46 left FO (total 100) was 2.74 (0: poor; 1: fair; 2: good; 3: excellent). All recorded FOs had at least grade 2 visibility. Limitations: This study is lacking application in clinical practice and comparative data to the submental view. Conclusions: The mandible angle and the occipital cortex line are obvious anatomic landmarks and are visible even to nonexperienced practitioners. Therefore, our method using these anatomic landmarks can improve the reproducibility and accuracy of FO visualization. Key words: Trigeminal neuralgia, foramen ovale, trigeminal ganglion, 3-dimensional (3D) facial computed tomography (CT) scans

BACKGROUND The classic percutaneous technique used to cannulate the foramen ovale for the treatment of trigeminal neuralgia can place important anatomic structures, such as the distal cervical internal carotid artery, at risk. OBJECTIVE To use fixed anatomic landmarks to safely and reliably locate the foramen ovale on anteroposterior (AP) fluoroscopy. METHODS Locating the foramen ovale was initially tested using AP fluoroscopy on cadaveric skulls in the neurosurgical simulation lab. Fluoroscopic landmarks were identified and utilized to assist in successfully locating the foramen ovale during percutaneous balloon rhizotomy procedures in patients with trigeminal neuralgia. This technique has been successfully used in multiple patients. In this report, we describe our technique in detail. RESULTS The AP fluoroscopy is directed laterally in the coronal plane until a line drawn inferiorly from the lateral orbital rim bisects the inner concavity of the mandibular angle. Fluoroscopy is then directed inferiorly until the top of the petrous ridge bisects the mandibular ramus. The foramen ovale will come into view within the window between the mandibular ramus and hard palate. Two case illustrations are provided. CONCLUSION Balloon rhizotomy is a commonly used treatment option for trigeminal neuralgia. Direct visualization of the foramen ovale can reliably be achieved on AP fluoroscopy using specific anatomic landmarks. This technique can be utilized to increase the accuracy and safety of the procedure.

Background Percutaneous radiofrequency trigeminal rhizotomy (RF-TR) is a well-established treatment for patients suffering from trigeminal neuralgia (TN) as a primary modality or for those refractory to medical treatment. However, few existing studies have identified intraoperative parameter or navigation technique that can be used to predict the rates of short-term or long-term pain relief. In this study, we analyzed patient characteristics, intraoperative parameters and technical factors, and postoperative changes in relation to immediate and long-term pain relief. Method This study included a total 252 patients in which 340 RF-TR were performed under the guidance of intraoperative computed tomography (iCT) alone or with magnetic resonance image (MRI) and iCT fusion imaging. Result The immediate pain relief of RF-TR with iCT alone and iCT with MR image guidance with or without cerebrospinal fluid (CSF) outflow were all above 90.4%. The 2-year pain relief rate of RF-TR using iCT alone and iCT with MR images guidance with or without CSF outflow were 47.8%, 39.8%, 71.7%, and 53.9% respectively. Significant factors for 2-year pain relief were CSF outflow, iCT with MR image fusion, non-recurrent TN, and presence of postoperative facial numbness. Conclusion This preliminary study demonstrated foramen ovale cannulation under the aid of iCT with MR image guidance could improve 2-year pain relief.

Background The occlusion devices used for repair of atrial septal defect and patent foramen ovale commonly contain nitinol, an alloy containing nickel. There are reports of nickel allergy in the context of intracardiac device implantation. Type IV delayed-type reactions likely predominate in intracardiac metal hypersensitivity, but there are potentially other mechanisms such as cytotoxic or innate immunity. Based on available literature to date, the significance of nickel allergy in intracardiac occluders remains unclear. Objective The aim of the study was to investigate nickel allergy management strategies in intracardiac occluders. Methods The American Contact Dermatitis Society facilitated distribution of a survey via e-mail to the members of its association, which included dermatologists and allergists/immunologists. A total of 70 individuals answered the survey. Conclusions There was no consensus regarding the ability of patch testing to accurately determine allergic reactions within cardiac tissue. There was also no agreement on the criteria for patch testing in patients undergoing intracardiac implantation. However, most would inquire about a history of contact sensitivity to previously implanted devices. With a positive patch test, nickel-based intracardiac devices should be avoided, or the decision should be left to the discretion of the cardiologist.

The Pterygospinous Ligament (PSL) extends from the Pterygospinous process of the lateral Pterygoid plate to the spine of the sphenoid bone. Sometimes, it may be ossified forming a bar of bone bounding the pterygospinous foramen to which mandibular nerve and its branches are variably related. Mandibular and chorda tympani nerves may get compressed depicting various clinical symptoms, which in turn depend upon dimensions of the foramen and grades of compression. Therefore, knowledge of the position and extent of ossification of PSL and its relation to the important structures in the deep infratemporal fossa is important for radiologists, neurologists, maxillofacial surgeons, dental surgeons and anesthesiologists during various anesthetic and surgical procedures.

Patent foramen ovale (PFO) is the most common type of inter-atrial shunt, with prevalence as high as 30%. Detection of PFO has implications in patients with stroke, peripheral embolism, decompression illness, and other conditions. Transesophageal echo (TEE) with saline contrast injection is the current standard for PFO detection, but even with TEE, PFOs are sometimes missed. With advances in percutaneous PFO closure therapies and proven long-term benefit of closure, accurate PFO detection takes on cardinal importance. Various provocative maneuvers to enhance PFO detection are in clinical use and have been studied. The Valsalva maneuver has long-held position as the ideal provocation to unmask PFO, but other maneuvers such as cough, sniff, Müller's, and more have gained relevance. In this article, we will examine various maneuvers and discuss their utility in PFO detection.

Background and Aim The foramen ovale is a clinically significant foramen present in the skull base. The mandibular nerve is an important structure traversing this foramen and the trigeminal ganglion is also located just above the foramen ovale in the Meckel's cave. These two structures are targeted by neurosurgeons and pain physicians in patients with trigeminal neuralgia. Clinical procedures for treating trigeminal neuralgia necessitate very precise knowledge about the foramen ovale. Hence, this study was designed to evaluate the morphology and morphometry of foramen ovale and its variations in dry skulls of India. Materials and Methods This study was conducted in 100 adult dry skulls of either sex. The foramen ovale was assessed for morphology and morphometry bilaterally using digital Vernier calipers. The summary data for all the measurements are presented in this study. The statistical analysis was performed using SPSS version 19. Results The most common shape of the foramen ovale was found to be oval. Oval-shaped foramen ovale was present in 72% (right side) and 68% (left side) of dry skulls that were examined. A mean length of 6.62 ± 1.11 mm (right side) and 6.72 ± 1.08 mm (left side) and width of 3.78 ± 0.89 mm (right side) and 3.89 ± 0.73 mm (left side) were observed. The distance between the foramen ovale and the zygomatic point was 35.65 ± 3.24 mm (right side) and 34.91 ± 2.58 mm (left side). The distance between the zygomatic point and the anterior margin of the external auditory meatus was 21.79 ± 3.25 mm (right side) and 18.62 ± 2.37 mm (left side). Conclusion An in-depth knowledge of the morphology and morphometry which include the different metric and nonmetric parameters and the variations in foramen ovale in dry skulls has been studied, which will be helpful to neurosurgeons and pain physicians to plan their clinical procedures which involve the base of skull.

Background Anatomical knowledge of bony bridges around the foramen ovale may be helpful for diagnostic and invasive neurosurgical procedures like electroencephalogram analysis, trigeminal rhizotomy, biopsy of cavernous sinus tumors, and mandibular nerve block.Lateral pterygoid plate forms an important landmark for mandibular anesthesia; therefore, any variation related to lateral pterygoid plate is likely to create confusion during the maneuver of anesthesia. Aims and Objective The aim of the study was to explore any bony obstacle within and around Foramen ovale. Obstacles in form of ossified complete or incomplete ligaments. Additional foramina formed by ligaments or any bony enlargement might disturb the structures passing through the Foramen ovale. Methods Around 530 dried crania (from medical colleges in Uttarakhand and Uttar Pradesh) were observed to find ossified ligaments and foramen formed by them. Crania associated with bilateral enlarged lateral pterygoid plate other than the average width of 1.5 cm were included in this study. Length of ligaments and width of pterygoid plate were measured by digital Vernier calipers. Results Out of 530 crania, unilateral 52 ossified pterygospinous ligament (incomplete 31 and complete 21) were observed. Among them some rare variation was found along with ossified pterygospinous and pterygoalar ligament, one cranium along with unilateral pterygospinous bar was also having bar within foramen ovale, forming an accessory osseous compartment, found to be rare kind of variation. Another unilateral complete pterygospinous bar was enclosing two foramens instead of one. Only single cranium was found to have pterygoalar bar, related medial to foramen ovale. One cranium was associated with bilateral enlarged lateral pterygoid plate (i.e., 2.5 cm) was also found to be obliterating the space, that is, retropharyngeal and parapharyngeal space for surgeons. Conclusion This study would provide the anatomical knowledge of these bony bridges around the foramen ovale and may be helpful for diagnostic and neurosurgical procedure like microvascular decompression by percutaneous trigeminal rhizotomy for trigeminal neuralgia, percuatneous biopsy of cavernous sinus tumor and mandibular nerve block by lateral subzygomatic route. Thus, lateral pterygoid plate forms an important landmark for mandibular anesthesia.