Sex-Specific Patterns of Cerebral Atrophy and Enlarged Perivascular Spaces in Patients with Cerebral Amyloid Angiopathy and Dementia

BACKGROUND AND PURPOSE

Cerebral amyloid angiopathy is characterized by amyloid β deposition in leptomeningeal and superficial cortical vessels. Cognitive impairment is common and may occur independent of concomitant Alzheimer disease neuropathology. It is still unknown which neuroimaging findings are associated with dementia in cerebral amyloid angiopathy and whether they are modulated by sex. This study compared MR imaging markers in patients with cerebral amyloid angiopathy with dementia or mild cognitive impairment or who are cognitively unimpaired and explored sex-specific differences.

MATERIALS AND METHODS

We studied 58 patients with cerebral amyloid angiopathy selected from the cerebrovascular and memory outpatient clinics. Clinical characteristics were collected from clinical records. Cerebral amyloid angiopathy was diagnosed on MR imaging on the basis of the Boston criteria. Visual rating scores for atrophy and other imaging features were independently assessed by 2 senior neuroradiologists.

RESULTS

Medial temporal lobe atrophy was higher for those with cerebral amyloid angiopathy with dementia versus those cognitively unimpaired (P = .015), but not for those with mild cognitive impairment. This effect was mainly driven by higher atrophy in men with dementia, compared with women with and without dementia (P = .034, P = .012; respectively) and with men without dementia (P = .012). Enlarged perivascular spaces in the centrum semiovale were more frequent in women with dementia versus men with and without dementia (P = .021, P = .011; respectively) and women without dementia (P = .011).

CONCLUSIONS

Medial temporal lobe atrophy was more prominent in men with dementia, whereas women showed a higher number of enlarged perivascular spaces in the centrum semiovale. Overall, this finding suggests differential pathophysiologic mechanisms with sex-specific neuroimaging patterns in cerebral amyloid angiopathy.

Causes of Death in Endovascularly Treated Patients with Acute Stroke

BACKGROUND AND PURPOSE

Because stroke therapy has changed with the introduction of endovascular stroke treatment as a standard approach, studies on intrahospital causes of death from stroke are no longer up-to-date. The purpose of this observational study was to present the causes of death during hospitalization of patients with ischemic stroke who received endovascular stroke treatment, with the focus on a differentiation of curative and secondary palliative treatment.

MATERIALS AND METHODS

We studied a total cohort of 1342 patients who received endovascular stroke treatment in a tertiary stroke center (Aachen, Germany) between 2010 and 2020 and analyzed the causes of death in all 326 consecutive deceased patients. We distinguished between curative treatment and a secondary palliative approach and analyzed causes of death and treatment numbers across the years.

RESULTS

In the entire cohort of 326 deceased patients, the most common cause of death was of a cerebrovascular nature (51.5%), followed by pneumonia and sepsis (25.8%) and cardiovascular causes (8.3%). Neurovascular causes constituted 75.8% of reasons for palliation. In the group with a secondary palliative approach, causes of death were neurovascular in 54.0% of patients and pneumonia and sepsis in 26.0% of patients.

CONCLUSIONS

Cerebrovascular causes in patients with stroke play a major role in the intrahospital causes of death and reasons for palliation. Considering the large proportion of secondarily palliative-treated patients, reasons for palliation should be considered instead of causes of death to avoid concealment by, for example, life-terminating measures.

Electrocardiographic imaging a valid tool or an inaccurate toy?

Funding Acknowledgements

Type of funding sources: Private hospital(s). Main funding source(s): Learning Health

Background and aim

Electrocardiographic imaging (ECGI) is capable of performing an activation map with a single beat. However, previous studies using the epicardial-only system, have suggested a bad accuracy for the assessment of the epicardial breakthrough. Recent systems using endo-epicardial analysis have shown promising results. The aim of this study was to assess the accuracy and reproducibility of two endo-epicardial ECGI systems using different cardiac sources one based on the extracellular-potential, and the other on the equivalent double layer model, respectively the AMYCARD (EP Solutions SA, Switzerland) and VIVO (Catheter Precision, NJ USA) systems.

Methods

We studied 11 consecutive patients referred for ablation of frequent idiopathic premature ventricular contractions at our center that had an ECGI performed using both systems on the same day. The AMYCARD system uses a dense array of body-surface electrocardiograms with up to 224 leads and VIVO uses just the 12-leads ECG. Both systems use a patient-specific heart torso geometry obtained with a CT-scan or cardiac magnetic resonance. The localisation of the PVCs based on ECGI was done using a segmental model with 22 segments on the left ventricle, to include the classical 17 segment model plus the aortic cusps and the papillary muscles, and 12 segments on the right ventricle including 4 on the right ventricular outflow tract (RVOT): (anterior, lateral, right septum and left septum). A perfect match was defined as a predicted location within the same anatomic segment, whereas a near match as a predicted location within the same segment or a contiguous one.

Results

The median (Q1-Q3) number of leads used for the AMYCARD was 131 (118-144). Seven patients underwent ablation and in 4 ablation is pending. The predicted locations and the ablation site are depicted on the Table. We found a perfect match between both systems in 73% (Figure) and near match in 91% of cases. In patients that underwent ablation the systems localised the site of origin of the PVCs within the same segment or the contiguous segment in all patients with VIVO and in six out of seven with AMYCARD.

Conclusions

ECGI is an accurate diagnostic tool with reproducible results regardless the cardiac source used for analysis.

P955Non-invasive mapping: what is the minimal number of electrodes needed to obtain a good spatial resolution of the activation map?

Introduction and aims

The 12-lead ECG is highly inaccurate for localization of the site of origin of supraventricular and ventricular arrhythmias.  Non-invasive mapping systems (ECGI) based on a high number of electrodes recording the electrical activity on the surface of the torso have already proven good accuracy for mapping different arrhythmic substrates. The aim of this study was to assess what is the minimal number of leads needed to obtain a precise mapping with the ECGI.

Methods

This study enrolled 14 patients (9 male, median age 50 (44-58) years) referred to our center for catheter ablation of premature ventricular contractions (PVC). Patients underwent pre-procedural ECGI using the epicardial and endocardial mapping system . This system uses the DICOM images from contrast computed tomography of the heart and up to 28 adhesive electrodes with 8 leads each, adding up to 224 body-surface leads. All patients underwent invasive electroanatomical mapping and ablation with the magnetic navigation system. We analysed the number of recording leads used to construct the non-invasive activation map of the PVCs and the accuracy and the spatial resolution of the map when comparing to the invasive map. We then reprocessed the exam, using progressively less leads until we only left the leads placed in the standard 12 lead ECG positions and evaluated the concordance with the invasive map as well as the spatial resolution. We considered an earliest activation site (EAS) area of 1 cm2 a good spatial resolution and using a ROC curve we calculated the minimal number of leads necessary to obtain a good spatial resolution.

Results

The median number of electrodes used for the initial map was 170 (138-177). Concordance between non-invasive and invasive site of origin occurred in 11 out of 14 patients. The results are presented in the Table. The minimal number of electrodes to have a good spatial resolution was 100. The area of EAS was significantly lower when using more than 100 leads, respectively 0.65 (0.5-1) cm2 versus 3 (1.6-5) cm2, p < 0.001.

Conclusions

The minimal number of leads to achieve a good spatial resolution was high.  Reducing the number of leads resulted in a significant decrease in spatial resolution and a lower concordance rate.

ECGI data Number of adhesive electrodes Median number of leads Amycard/Carto concordance Median area of EAS in the ECGI (cm2) Maximal nº electrodes 170 (138-177) 11/14 0.64 (0.5-0.9) 12 electrodes 76 (61-80) 11/14 1.6 (1.4-2.6) 6 electrodes (2 Ant, 2 Lat ,2 Post) 38 (32-44) 9/14 4.3 (3.2-5.4) 12 leads 12 0/14 - Ant anterior; Lat: lateral; Post: posterior; EAS: early activation site.

Abstract Figure. Area of EAS according to the N of leads

P5702Non-invasive epicardial and endocardial mapping in patients with idiopathic right ventricular outflow tract premature ventricular contractions: new insights into arrhythmia substrate

Background

It has been accepted for years that idiopathic premature ventricular contractions (PVCs) with origin in the right ventricular outflow tract (RVOT) are benign. They are thought to result from triggered activity and most studies do not describe abnormal findings during electroanatomical mapping

Dispersion of ventricular repolarization is associated with the susceptibility to ventricular arrhythmias and may indicate the presence of diseased myocardium. The activation recovery interval (ARI) has been used as a surrogate measure of ventricular action potential duration and refractory period.

Purpose

The aim of this study was to use the new non-invasive epicardial and endocardial mapping system (NEES) to study patients with RVOT PVCs in order to evaluate the ARI in the epicardium of RVOT during sinus rhythm (SR).

Methods

Non-invasive mapping was performed with the NEES, based on body surface electrocardiograms of a maximum of 224 electrodes and computed tomography imaging data. Unipolar electrograms were reconstructed on the epicardial and endocardial surfaces. Patients were excluded if they had structural heart disease, previous ablation or conduction abnormalities. ARI was defined as the interval between times of minimum derivative of the QRS and the maximum derivative of the T wave in the unipolar electrograms. We evaluated the ARI map in patients with RVOT PVCs and in a control group of patients without PVCs (Figure). We assessed the maximum value of ARI (Max ARI), the minimum value of ARI (Min ARI) and the difference between the Max ARI and the Min ARI (Diff ARI).

Results

We studied 8 patients with RVOT PVCs and 8 patients without PVCs.

The results are presented in the table.

Demographic and NEES data RVOT PVCs (n=8) Control (n=8) P value* Demographic data   Age in years, median (IQR) 53 (48–65) 59 (52–67) 0.536   Male gender, n (%) 4 (50) 6 (75) 0.608 NEES data   Max ARI in msec, median (IQR) 285 (236–331) 228 (197–298) 0.195   Min ARI in msec, median (IQR) 176 (138–192) 216 (185–255) 0.161   ARI diff in msec, median (IQR) 111 (83–147) 15 (4–34) <0.0001

NEES map

Conclusion

In this group of patients we found a significantly higher dispersion of the ARI measurements through the epicardium of the RVOT in patients with PVCs in comparison with patients without PVCs.

Birds' nesting parameters in four forest types in the Pantanal wetland

We tested the heterogeneity/productivity hypothesis with respect to the abundance and richness of birds and the vegetation density hypothesis with respect to birds' nest predation rates, and determined the relative importance of forested vegetation formations for the conservation of birds in the Pantanal. We estimated the apparent nesting success, and the abundance and richness of nesting birds' in four forest types, by monitoring nests during two reproductive seasons in four forested physiognomies (two high productivity/heterogeneity evergreen forests = Cambará and Landi; two low productivity/heterogeneity dry forests = Cordilheira and Carvoeiro) in the Pantanal wetland in Poconé, State of Mato Grosso, Brazil. We found 381 nests of 46 species (35 Passeriformes and 11 non-Passeriformes) in the four forest types. Of these, we monitored 220 active nests belonging to 44 species, 101 during the reproductive season of 2001 and 119 in 2002. We supported the productivity/heterogeneity hypothesis since the two evergreen forests had higher nest abundance and one of them (Cambará) had higher nesting species richness than the dry forests. The number of nests found in each habitat differed with most nests monitored in the Cambará forest (82%), followed by Landi (9%), Cordilheira (6%) and Carvoeiro (3%) forests. The total number of nests monitored was significantly higher in evergreen forests than in dry forests. Also, more species nested in evergreen (37 species) than in dry (16 species) forests. A Correspondence Analysis revealed that only Carvoeiros had a different nesting bird community. The overall apparent nesting success of 220 nests was 26.8%. We did not support the vegetation density hypothesis since nest predation rates were similar between evergreen (73.5%) and dry (70%) forests, and were higher in the Landi (85%) than in the other three forests (69.2 to 72.2%). Our data indicate that Cambará forests seem to be a key nesting habitat for many bird species of the Pantanal. If this local pattern also occurs in other regions of the Pantanal, the use and management of Cambará forests might prove to be important for the conservation of forest birds of this biome. However, conflicting results with other taxonomic groups show that conservation measures for these forests and land use policies should be based on a more complete biodiversity evaluation of the region.

Diet of the Fuscous Flycatcher Cnemotriccus fuscatus (Wied, 1831) - Aves, Tyrannidae - in three habitats of the northern Pantanal, Mato Grosso, Brazil

The Fuscous Flycatcher (Cnemotriccus fuscatus) is a medium-sized Tyrannidae widespread in South America. Despite its large distribution, there have been very few studies on its diet, especially in different habitats. This study presents data on diet variation in three habitats in the Pantanal wetlands in the state of Mato Grosso, Brazil. The specimens were captured through a mist-netting programme between February 2000 and May 2010, in the Retiro Novo Farm, in the Poconé municipality. Birds were captured in three vegetation types: Landizal, Cambarazal and Cordilheira. Tartar emetic was used to obtain the regurgitation samples identified at order level. We captured 61 individuals (21, 26 and 14 in the above described habitats, respectively). Diet of C. fuscatus differed between the three habitats. Ants and beetles were the most relevant prey items either in numerical frequency (NF) or in frequency of occurrence (OF), in terms of the overall diet (NF = 27.34% and 37.89%; OF = 36.06% and 75.4%, respectively). However, in Cordilheira, seeds and beetles dominated the NF (21.8% and 38.1%, respectively) and OF (28.5% and 85.7%, respectively). Cnemotriccus fuscatus was found to have an omnivorous diet, although in Cambarazal, individuals preyed exclusively on arthropods. The present study provides an important contribution to the knowledge of the diet of a poorly studied Neotropical bird.

Post-stroke acute elation shortly followed by pathologic jealousy - is there a common anatomic substrate?

Both mania and psychotic symptoms are well known to result from vascular brain injury, but their pathophysiology remains largely unknown.

A 69-year-old man with diabetes and hypertension was seen for sudden behaviour disturbance: euphoric, talkative and uninhibited, he continuously shouted he trusted in Medicine, called the doctor the “King of Medicine”, and repeatedly said “I love doctors, I love nurses, I love Hospitals”. He was overcompliant during neurologic exploration, clearly amused with it. Left sensitive hemi-inattention and left homonymous hemianópsia could also be found. MRI showed an acute right temporo-parieto-insular cortical infarction. The following day he was euthymic and embarrassed for what happened. When visited that afternoon by his wife, she noticed he was strangely suspicious, continuously surveilling all her moves. He progressively worsened, believing she was having affairs with several men. This delusion persisted for the following months, even on risperidone 1 mg/day, culminating in Christmas Eve, when the patient shocked his family saying that his wife was having an affair with one of their sons. At this time, risperidone was discontinued and replaced by quetiapine 200 mg/day, resulting in rapid fading of all symptoms.

Both post-stroke mania and psychotic symptoms have been consistently associated with right hemisphere damage, but, to our knowledge, were not previously reported after the same injury. We believe our patient provides evidence that the same anatomic dysfunction, in this case a temporoparietal infarct, can cause both psychiatric phenomena.