Outcomes of patients with continuous flow left ventricular assist device undergoing emergency endovascular treatment for atraumatic bleeding

Introduction

Severe spontaneous bleeding is a significant complication in patients with continuous flow left ventricular assist devices; there is little evidence on endovascular treatment to support its use.

Materials and methods

We observed seven patients (five men, two women, age 43–67 years) with continuous flow left ventricular assist devices on antiaggregant/coagulant therapy, admitted to our hospital for uncorrectable symptomatic anemia; CT-angiography and diagnostic angiography confirmed the presence of atraumatic arterious bleeding from the gastrointestinal tract (six patients), from the intercostal artery and from the bronchial tree (one patient).

Results

All patients where successfully treated via an endovascular approach with superselective embolization of the involved arterial branches with coils and particles.

Conclusion

Spontaneous atraumatic bleeding is a frequent complication in patients with continuous flow left ventricular assist devices; endovascular treatment represents a promising alternative to the surgical approach as it is less invasive, easily repeatable and associated to a reduced procedural risk.

Radiological Assessment of Paediatric Fungal Infections: A Pictorial Review With Focus on PET/MRI

Paediatric invasive fungal infections have significantly increased over the past few decades, in particular among the immunocompromised population. Candida and Aspergillus spp. are still the most commonly isolated organisms. Image-based assessment of fungal infections can indeed be challenging especially in oncological patients where the differential diagnosis relative to other infections and neoplastic lesions cannot be often obvious. Therefore, the knowledge of the main radiological features associated with fungal infections is crucial to achieve an early correct diagnosis and address the most appropriate therapeutic approach. Thus, our aim was to review the main radiological features of paediatric fungal infections with particular focus on positron emission tomography/magnetic resonance imaging (PET/MRI), referring to the experience of our tertiary level hospital.

Fully integrated 18F-FDG PET/MR in large vessel vasculitis

BACKGROUND

To evaluate the usefulness of [18F] fluorodeoxyglucose (FDG) positron emission tomography (PET)/magnetic resonance (MR) in large vessels vasculitis (LVV) patients.

METHODS

We performed an observational retrospective study based on our records. Images were acquired on a PET/MR scanner using 18F-FDG-PET whole body imaging. For each PET scan, a qualitative analysis and a semi-quantitative measure using the maximum of the standardized uptake value (SUVMax) were performed. SUVMax measurements normalized to the liver uptake were categorized using a grading scale. Vessel's wall thickness (WT) was measured at five fixed points (inferior margin of T5, T9, T12, L3, thickest area-max WT).

RESULTS

23 LVV patients were included, 56.5% giant cells arteritis, 34.8% Takayasu's arteritis and 8.7% isolated aortitis, all Caucasian, mostly females (82%). We considered 32 PET scans for the LVV group (from min. 1 to max. 3 scans/patient) mainly during follow-up (29/32 scans), and 23 PET scans from a control group of non-metastatic malignancies patients. We found higher SUVMax compared to controls, in all sites, irrespective of clinical disease activity. Mean WT resulted higher in patients than in controls but was not correlated to SUVMax. Mean WT positively correlated with age in both cohorts, inversely correlated to disease duration, while no correlation with SUVMax was observed. The concordance between clinically active disease and PET hypermetabolism was poor (K Cohen 0.33).

CONCLUSIONS

PET/MR is a safe imaging technique capable of detecting inflammation in aortic wall. Low radiological exposure of PET/MR should be considered especially in young women receiving follow-up studies.

FGF signaling deregulation is associated with early developmental skeletal defects in animal models for mucopolysaccharidosis type II (MPSII)

Skeletal abnormalities represent a major clinical burden in patients affected by the lysosomal storage disorder mucopolysaccharidosis type II (MPSII, OMIM #309900). While extensive research has emphasized the detrimental role of stored glycosaminoglycans (GAGs) in the bone marrow (BM), a limited understanding of primary cellular mechanisms underlying bone defects in MPSII has hampered the development of bone-targeted therapeutic strategies beyond enzyme replacement therapy (ERT). We here investigated the involvement of key signaling pathways related to the loss of iduronate-2-sulfatase activity in two different MPSII animal models, D. rerio and M. musculus. We found that FGF pathway activity is impaired during early stages of bone development in IDS knockout mice and in a newly generated Ids mutant fish. In both models the FGF signaling deregulation anticipated a slow but progressive defect in bone differentiation, regardless of any extensive GAGs storage. We also show that MPSII patient fibroblasts harboring different mutations spanning the IDS gene exhibit perturbed FGF signaling-related markers expression. Our work opens a new venue to discover possible druggable novel key targets in MPSII.

Are panels of clinical, laboratory, radiological, and microbiological variables of prognostic value in deep neck infections? An analysis of 301 consecutive cases

BACKGROUND

Deep neck infections (DNIs) are often clinically challenging, and may be life-threatening.

OBJECTIVE

The present retrospective study aimed to identify panels of clinical, laboratory, radiological, and microbiological parameters that could identify patients with DNIs at higher risk of complications or long-term hospitalization.

MATERIALS AND METHODS

The investigation concerned 301 consecutive patients with DNIs treated at our institution between 2000 and 2014.

RESULTS

The discriminatory power of a combination of two variables (unknown origin of the infection and the need for surgical treatment) in terms of deep neck infection complications occurrence featured an AUC (ROC) of 0.6701. The power of a panel of four variables (age, leukocyte count, need for surgical treatment, days elapsing from hospitalization to surgical procedure) to identify DNIs necessitating long-term hospitalization featured an AUC (ROC) of 0.7929.

CONCLUSION

Using the scale proposed by Hosmer and Lemeshow, the four-variable panel showed an amply acceptable, nearly excellent discriminatory power for long-term hospitalization.

SIGNIFICANCE

Although this panel achieved promising results for prognostic purposes, other parameters potentially capable of predicting the outcome of DNIs and orienting treatment decisions need to be investigated.

Muscle MRI in patients with dysferlinopathy: pattern recognition and implications for clinical trials

BACKGROUND AND OBJECTIVE

Dysferlinopathies are a group of muscle disorders caused by mutations in the DYSF gene. Previous muscle imaging studies describe a selective pattern of muscle involvement in smaller patient cohorts, but a large imaging study across the entire spectrum of the dysferlinopathies had not been performed and previous imaging findings were not correlated with functional tests.

METHODS

We present cross-sectional T1-weighted muscle MRI data from 182 patients with genetically confirmed dysferlinopathies. We have analysed the pattern of muscles involved in the disease using hierarchical analysis and presented it as heatmaps. Results of the MRI scans have been correlated with relevant functional tests for each region of the body analysed.

RESULTS

In 181 of the 182 patients scanned, we observed muscle pathology on T1-weighted images, with the gastrocnemius medialis and the soleus being the most commonly affected muscles. A similar pattern of involvement was identified in most patients regardless of their clinical presentation. Increased muscle pathology on MRI correlated positively with disease duration and functional impairment.

CONCLUSIONS

The information generated by this study is of high diagnostic value and important for clinical trial development. We have been able to describe a pattern that can be considered as characteristic of dysferlinopathy. We have defined the natural history of the disease from a radiological point of view. These results enabled the identification of the most relevant regions of interest for quantitative MRI in longitudinal studies, such as clinical trials.

CLINICAL TRIAL REGISTRATION

NCT01676077.

The clinical spectrum of CASQ1-related myopathy

OBJECTIVE

To identify and characterize patients with calsequestrin 1 (CASQ1)-related myopathy.

METHODS

Patients selected according to histopathologic features underwent CASQ1 genetic screening. CASQ1-mutated patients were clinically evaluated and underwent muscle MRI. Vacuole morphology and vacuolated fiber type were characterized.

RESULTS

Twenty-two CASQ1-mutated patients (12 families) were identified, 21 sharing the previously described founder mutation (p.Asp244Gly) and 1 with the p.Gly103Asp mutation. Patients usually presented in the sixth decade with exercise intolerance and myalgias and later developed mild to moderate, slowly progressive proximal weakness with quadriceps atrophy and scapular winging. Muscle MRI (n = 11) showed a recurrent fibrofatty substitution pattern. Three patients presented subclinical cardiac abnormalities. Muscle histopathology in patients with p.Asp244Gly showed vacuoles in type II fibers appearing empty in hematoxylin-eosin, Gomori, and nicotinamide adenine dinucleotide (NADH) tetrazolium reductase stains but strongly positive for sarcoplasmic reticulum proteins. The muscle histopathology of p.Gly103Asp mutation was different, showing also NADH-positive accumulation consistent with tubular aggregates.

CONCLUSIONS

We report the clinical and molecular details of the largest cohort of CASQ1-mutated patients. A possible heart involvement is presented, further expanding the phenotype of the disease. One mutation is common due to a founder effect, but other mutations are possible. Because of a paucity of symptoms, it is likely that CASQ1 mutations may remain undiagnosed if a muscle biopsy is not performed.

Non Lipomatous Benign Lesions Mimicking Soft-tissue Sarcomas: A Pictorial Essay

The incidental finding of soft tissue masses is a challenge for the radiologist. Benign and malignant lesions can be differentiated relying on patient history, symptoms and mostly with the help of imaging. Ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) become fundamental in order to distinguish these lesions but the radiologist needs to know the main characteristics of benign soft tissue masses and sarcomas. Herein, we present a pictorial review of lesions mimicking soft tissue sarcomas features.

Magnetic Resonance Imaging Assessment of Lipomatous Soft-tissue Tumors

AIM

To establish the accuracy of magnetic resonance imaging (MRI) in distinguishing between benign and malignant lipomatous tumors; to evaluate the reproducibility of the MRI interpretation assessing the agreement between judgments of two radiologists with the same experience in soft-tissue sarcomas; to identify an association among MRI findings (size, depth, septa, nodules, signal homogeneity) and nature of the lesion.

MATERIALS AND METHODS

A total of 54 patients (28 men and 26 women), with a mean age of 56 (range=27-84) were included years. All subjects followed-up by the Multidisciplinary Sarcoma Group. The following MRI findings were judged in a blind study by two radiologists: size, localization, septa, nodules and signal homogeneity. A diagnostic indication was then given from among lipoma, atypical lipomatous tumour (ALT) and liposarcoma. Accuracy in distinguishing between benign and malignant lesions, and between lipoma and ALT (Fisher's exact test), inter-operator agreement (Cohen's kappa), association of MRI findings and malignancy of the lesion (Fisher's exact test and odds ratio) were evaluated.

RESULTS

The inter-operator agreement was complete (100%). The agreement between diagnostic hypothesis and histological diagnosis was statistically significant (p<0.05). Among the radiological findings taken into account, only septa and signal homogeneity were significantly associated with the malignancy of the lesion (p<0.05).

CONCLUSION

MRI could be helpful in distinguishing lipomatous tumors, allowing biopsy to be avoided in some cases (negative predictive value=100%).

Bayesian Quantification of Contrast-Enhanced Ultrasound Images With Adaptive Inclusion of an Irreversible Component

Contrast Enhanced Ultrasound (CEUS) is a sensitive imaging technique to assess tissue vascularity and it can be particularly useful in early detection and grading of arthritis. In a recent study we have shown that a Gamma-variate can accurately quantify synovial perfusion and it is flexible enough to describe many heterogeneous patterns. However, in some cases the heterogeneity of the kinetics can be such that even the Gamma model does not properly describe the curve, with a high number of outliers. In this work we apply to CEUS data the single compartment recirculation model (SCR) which takes explicitly into account the trapping of the microbubbles contrast agent by adding to the single Gamma-variate model its integral. The SCR model, originally proposed for dynamic-susceptibility magnetic resonance imaging, is solved here at pixel level within a Bayesian framework using Variational Bayes (VB). We also include the automatic relevant determination (ARD) algorithm to automatically infer the model complexity (SCR vs. Gamma model) from the data. We demonstrate that the inclusion of trapping best describes the CEUS patterns in 50% of the pixels, with the other 50% best fitted by a single Gamma. Such results highlight the necessity of the use ARD, to automatically exclude the irreversible component where not supported by the data. VB with ARD returns precise estimates in the majority of the kinetics (88% of total percentage of pixels) in a limited computational time (on average, 3.6 min per subject). Moreover, the impact of the additional trapping component has been evaluated for the differentiation of rheumatoid and non-rheumatoid patients, by means of a support vector machine classifier with backward feature selection. The results show that the trapping parameter is always present in the selected feature set, and improves the classification.

Radiologic Response Assessment in Pediatric Soft Tissue Sarcoma: Computed-Assisted Volume Evaluation

OBJECTIVES

To compare 3 methods of dimensional assessment, with particular attention to a new software assisted method of volume calculation, in soft tissue sarcoma, and to investigate the interobserver agreement and the intermethod agreement in chemotherapy response classification and resultant clinical repercussions.

STUDY DESIGN

We studied 34 pediatric patients with nonmetastatic soft tissue sarcoma who had undergone only diagnostic biopsy. Tumor size was measured both at diagnosis and after induction chemotherapy by 3 observers and using 3 measurement methods: maximum axis (1 diameter), estimated volume (3 diameters), and computed volume (software-assisted volume calculation). We used overall concordance correlation coefficient and Bland-Altman statistical methods to assess interobserver agreement and overall concordance correlation coefficient and the κ Cohen coefficient to assess intermethod agreement.

RESULTS

According to overall concordance correlation coefficient, the interobserver agreement was very high for each method, with a slight superiority of the software assisted method; this agreement was not confirmed in Bland-Altman plots for maximum axis and estimated volume methods. According to kappa coefficients, the intermethod agreement in chemotherapy response evaluation was poor.

CONCLUSIONS

Computed volume was the most accurate method in soft tissue sarcoma tumor size assessment. One- and 3-dimensional methods are not concordant in chemotherapy response classification. In particular, the maximum axis method underestimates chemotherapy response and can lead to switching the chemotherapy regimen erroneously.

Desmoid Fibromatosis of the Abdominal Wall: Surgical Resection and Reconstruction with Biological Matrix Egis®

Desmoid tumor is a rare monoclonal fibroblast proliferation that is regarded as benign. The clinical management of desmoid tumors is very complex and requires a multidisciplinary approach because of the unpredictable disease course. For those cases localized in the anterior abdominal wall, symptomatic and unresponsive to medical treatment, radical resection and reconstruction with a prosthetic device are indicated. We present here a case of desmoid fibromatosis of the left anterolateral abdominal wall with a marked increase of the mass that required a large excision followed by reconstruction with biological matrix. The fact that it can be incorporated in patient tissue without a fibrotic response and that it can resist future infections, together with a very competetive price, made the new collagen matrix Egis^® our first choice.

Prospective evaluation of Quasistatic Ultrasound Elastography (USE) compared with Baseline US for parotid gland lesions: preliminary results of elasticity contrast index (ECI) evaluation

AIMS

To assess the diagnostic value of elasticity contrast index (ECI) elastography, in comparison with conventional ultrasound for the differentiation of benign and malignant parotid lesions.

MATERIAL AND METHODS

Sixty-three consecutive patients with parotid gland tumors, treated surgically at a single tertiary center were enrolled. Ultrasound evaluation consisted of B-mode, color-Doppler and quasistatic ultrasound elastography (USE), conducted with the ECI technique. For each lesion the echogenicity, margins, vascularization, and capsulation were considered to determine benign or malignant lesions. Histology was considered the gold standard.

RESULTS

Using conventional parameters, the observer suggested malignant lesions in 20 cases and benign lesions in 43 cases (accuracy: 61.8%). ECI>3.5 alone was the most accurate parameter (accuracy: 90.5%), with sensitivity of 93.7% and specificity of 89.4%. However, when combined with the other US criteria, no statistically significant diagnostic accuracy improvement was achieved.

CONCLUSIONS

Our results show that USE with ECI index measurement can help to discriminate preoperatively benign from malignant lesions, with the exception of pleomorphic adenoma which is stiff. We suggest that USE can be used as an additional tool to conventional US evaluation of salivary gland lesions.

A genuine pediatric parapharyngeal abscess a year after uneventful adenotonsillectomy

Brescia G, Pedruzzi B, Stramare R, Pendolino AL, Martini A, Marioni G. A genuine pediatric parapharyngeal abscess a year after uneventful adenotonsillectomy. Turk J Pediatr 2017; 59: 715-718. It is unusual for a parapharyngeal abscess (PA) to occur late after an adenotonsillectomy. We report herein a 13-year-old female patient who developed a PA a year after an uneventful adenotonsillectomy. The patient underwent 2 surgical explorations and was given intravenous antibiotic treatment. She was discharged in good general condition after spending 7 days in hospital. The potential pathophysiological mechanisms behind PA formation late after tonsillectomy or adenotonsillectomy, and rational treatments for PA are critically discussed.

A Case of "en bloc" Excision of a Chest Wall Leiomyosarcoma and Closure of the Defect with Non-Cross-Linked Collagen Matrix (Egis®)

Sarcomas arising from the chest wall account for less than 20% of all soft tissue sarcomas, and at this site, primitive tumors are the most frequent to occur. Leiomyosarcoma is a malignant smooth muscle tumor and the best outcomes are achieved with wide surgical excision. Although advancements have been made in treatment protocols, leiomyosarcoma remains one of the more difficult soft tissue sarcoma to treat. Currently, general local control is obtained with surgical treatment with wide negative margins. We describe the case of a 50-year-old man who underwent a chest wall resection involving a wide portion of the pectoralis major and minor muscle, the serratus and part of the second, third and fourth ribs of the left side. The full-thickness chest wall defect of 10 × 8 cm was closed using a non-cross-linked acellular dermal matrix (Egis^®) placed in two layers, beneath the rib plane and over it. A successful repair was achieved with no incisional herniation and with complete tissue regeneration, allowing natural respiratory movements. No complications were observed in the postoperative course. Biological non-cross-linked matrix, derived from porcine dermis, behaves like a scaffold supporting tissue regeneration; it can be successfully used as an alternative to synthetic mesh for chest wall reconstruction.

Core needle biopsy of soft tissue tumors, CEUS vs US guided: a pilot study

PURPOSE

The purpose of this study was to evaluate the usefulness of contrast-enhanced ultrasonography (CEUS) in the bioptic sampling of soft tissue tumors (STT) compared with unenhanced ultrasonography alone.

METHODS

This is a prospective longitudinal study of 40 patients subjected to ultrasonography (US)-guided core needle biopsy (CNB) to characterize a suspected STT. Three series of bioptic samplings were carried out on each patient, respectively using unenhanced US alone and CEUS in both the areas of the tumor enhanced or not by the contrast medium. All bioptic samples underwent a histological evaluation and the results were analyzed by comparing the histology of the biopsy with the definitive diagnosis in 15 surgically excised samples.

RESULTS

27 (67.5 %) of the 40 patients completed the entire study procedure; in 19 cases (70.3 %) the three bioptic samplings gave unanimous results, also when compared to the surgical specimen; in seven cases (25.9 %) use of CEUS allowed to obtain additional or more accurate information about the mass in question, compared to simple US guidance without contrast; in one patient (3.7 %) sampling obtained using unenhanced ultrasonography guidance and in the areas enhanced by the contrast agent had precisely the same results of the surgical specimen.

CONCLUSIONS

CEUS, due to its ability to evaluate microvascular areas, has proven to be a promising method in guiding bioptic sampling of soft tissue tumor, directing the needle to the most significant areas of the tumor. Given the small number of patients evaluated in our study, to achieve statistically significant results, it would be appropriate to obtain a larger sample size, since the very first results seem to be encouraging and to justify the increase of the population.

Clinical and molecular study in a long-surviving patient with MLASA syndrome due to novel PUS1 mutations

Myopathy-lactic acidosis-sideroblastic anemia (MLASA) syndrome is a rare autosomal recessive disease. We studied a 43-year-old female presenting since childhood with mild cognitive impairment and sideroblastic anemia. She later developed hepatopathy, cardiomyopathy, and insulin-dependent diabetes. Muscle weakness appeared in adolescence and, at age 43, she was unable to walk. Two novel different mutations in the PUS1 gene were identified: c.487delA (p.I163Lfs*4) and c.884 G>A (p.R295Q). Quantitative analysis of DNA from skeletal muscle biopsies showed a significant increase in mitochondrial DNA (mtDNA) content in the patient compared to controls. Clinical and molecular findings of this patient widen the genotype-phenotype spectrum in MLASA syndrome.

Pixel-based approach to assess contrast-enhanced ultrasound kinetics parameters for differential diagnosis of rheumatoid arthritis

Inflammatory rheumatic diseases are the leading causes of disability and constitute a frequent medical disorder, leading to inability to work, high comorbidity, and increased mortality. The standard for diagnosing and differentiating arthritis is based on clinical examination, laboratory exams, and imaging findings, such as synovitis, bone edema, or joint erosions. Contrast-enhanced ultrasound (CEUS) examination of the small joints is emerging as a sensitive tool for assessing vascularization and disease activity. Quantitative assessment is mostly performed at the region of interest level, where the mean intensity curve is fitted with an exponential function. We showed that using a more physiologically motivated perfusion curve, and by estimating the kinetic parameters separately pixel by pixel, the quantitative information gathered is able to more effectively characterize the different perfusion patterns. In particular, we demonstrated that a random forest classifier based on pixelwise quantification of the kinetic contrast agent perfusion features can discriminate rheumatoid arthritis from different arthritis forms (psoriatic arthritis, spondyloarthritis, and arthritis in connective tissue disease) with an average accuracy of 97%. On the contrary, clinical evaluation (DAS28), semiquantitative CEUS assessment, serological markers, or region-based parameters do not allow such a high diagnostic accuracy.

Role of Radiologic Imaging in Genetic and Acquired Neuromuscular Disorders

Great technologic and clinical progress have been made in the last two decades in identifying genetic defects of several neuromuscular diseases, as Spinal Muscular Atrophy, genetic muscular dystrophies and other genetic myopathies. The diagnosis is usually challenging, due to great variability in genetic abnormalities and clinical phenotypes and the poor specificity of complementary analyses, i.e., serum creatine kinase (CK) and electrophysiology. Muscle biopsy represents the gold standard for the diagnosis of genetic neuromuscular diseases, but clinical imaging of muscle tissue is an important diagnostic tool to identify and quantifyies muscle damage. Radiologic imaging is, indeed, increasingly used as a diagnostic tool to describe patterns and the extent of muscle involvement, thanks to modern techniques that enable to definethe definition of degrees of muscle atrophy and changes in connective tissue. They usually grade the severity of the disease process with greater accuracy than clinical scores. Clinical imaging is more than complementary to perform muscle biopsy, especially as ultrasound scans are often mandatory to identify the muscle to be biopsied. We will here detail and provideWe will herein provide detailed examples of the radiologic methods that can be used in genetic and acquired neuromuscular disorders, stressing pros and cons.

KEY WORDS

Muscle Imaging, MRI, CT, genetic muscle disorders, myopathies, dystrophies.

Persistent Muscle Fiber Regeneration in Long Term Denervation. Past, Present, Future

Despite the ravages of long term denervation there is structural and ultrastructural evidence for survival of muscle fibers in mammals, with some fibers surviving at least ten months in rodents and 3-6 years in humans. Further, in rodents there is evidence that muscle fibers may regenerate even after repeated damage in the absence of the nerve, and that this potential is maintained for several months after denervation. While in animal models permanently denervated muscle sooner or later loses the ability to contract, the muscles may maintain their size and ability to function if electrically stimulated soon after denervation. Whether in mammals, humans included, this is a result of persistent de novo formation of muscle fibers is an open issue we would like to explore in this review. During the past decade, we have studied muscle biopsies from the quadriceps muscle of Spinal Cord Injury (SCI) patients suffering with Conus and Cauda Equina syndrome, a condition that fully and irreversibly disconnects skeletal muscle fibers from their damaged innervating motor neurons. We have demonstrated that human denervated muscle fibers survive years of denervation and can be rescued from severe atrophy by home-based Functional Electrical Stimulation (h-bFES). Using immunohistochemistry with both non-stimulated and the h-bFES stimulated human muscle biopsies, we have observed the persistent presence of muscle fibers which are positive to labeling by an antibody which specifically recognizes the embryonic myosin heavy chain (MHCemb). Relative to the total number of fibers present, only a small percentage of these MHCemb positive fibers are detected, suggesting that they are regenerating muscle fibers and not pre-existing myofibers re-expressing embryonic isoforms. Although embryonic isoforms of acetylcholine receptors are known to be re-expressed and to spread from the end-plate to the sarcolemma of muscle fibers in early phases of muscle denervation, we suggest that the MHCemb positive muscle fibers we observe result from the activation, proliferation and fusion of satellite cells, the myogenic precursors present under the basal lamina of the muscle fibers. Using morphological features and molecular biomarkers, we show that severely atrophic muscle fibers, with a peculiar cluster reorganization of myonuclei, are present in rodent muscle seven-months after neurectomy and in human muscles 30-months after complete Conus-Cauda Equina Syndrome and that these are structurally distinct from early myotubes. Beyond reviewing evidence from rodent and human studies, we add some ultrastructural evidence of muscle fiber regeneration in long-term denervated human muscles and discuss the options to substantially increase the regenerative potential of severely denervated human muscles not having been treated with h-bFES. Some of the mandatory procedures, are ready to be translated from animal experiments to clinical studies to meet the needs of persons with long-term irreversible muscle denervation. An European Project, the trial Rise4EU (Rise for You, a personalized treatment for recovery of function of denervated muscle in long-term stable SCI) will hopefully follow.