A Possibility of Vasospastic Angina after mRNA COVID-19 Vaccination

We report a case of vasospastic angina (VSA) following COVID-19 mRNA vaccination. Despite the widespread occurrence of myocarditis, there have been few reports of post-vaccinal VSA. A 41-year-old male patient was referred for chest pain at rest following mRNA vaccination; he had never experienced chest pain prior to vaccination. He was diagnosed by an acetylcholine (Ach) provocation test that showed multivessel vasospasm. After the initiation of treatment with a calcium channel blocker and nitrate, no further exacerbation of chest pain was observed. To our knowledge, this constitutes the first reported case of VSA proven by Ach provocation test after COVID-19 vaccination. The vaccination may increase coronary artery spasticity. VSA should be ruled out in post-vaccine new onset resting chest pain.

Twelve-month safety and effectiveness of TCD-17187 drug-coated balloon for the treatment of atherosclerotic lesions in the superficial femoral and proximal popliteal artery

PURPOSE

The aim of this preapproval trial was to evaluate the 12-month safety and effectiveness of the TCD-17187 drug-coated balloon (DCB) for the treatment of atherosclerotic lesions in the superficial femoral artery (SFA) and/or proximal popliteal artery (PA).

METHODS

This was a prospective, multicenter, core laboratory adjudicated, single-arm trial. From October 2019 to November 2020, a total of 121 symptomatic peripheral artery disease patients with SFA and/or proximal PA lesions were enrolled. The primary effectiveness endpoint was 12-month primary patency defined as freedom from restenosis as determined by duplex ultrasonography in the absence of clinically driven target lesion revascularization (CD-TLR). The safety endpoint was the major adverse event (MAE) rate defined as freedom from a composite of device- and procedure-related death within 30 days, and index limb major amputation and/or CD-TLR through follow-up.

RESULTS

Average age was 74.5 ± 7.3 years and the frequency of diabetes mellitus was 67.5%. Average lesion length and vessel diameter were 106.0 ± 52.6 and 5.2 ± 0.8 mm, respectively. The frequency of chronic total occlusion and bilateral calcification was 17.5% and 50.8% of patients, respectively. The 12-month primary patency rate calculated by Kaplan-Meier analysis was 81.1%, while 12-month freedom from CD-TLR was 95.8%. The MAE rate at 30 days was 1.7% and all events comprised CD-TLR. There were no instances of device- or procedure-related deaths, major amputations, or thrombosis throughout the 12-month evaluation period.

CONCLUSION

This preapproval trial confirmed the safety and effectiveness of TCD-17187 DCB in the treatment of atherosclerotic lesions in the SFA and/or proximal PA.

Gadolinium contrast balloon pulmonary angioplasty for a patient with chronic thromboembolic pulmonary hypertension and severe iodine allergy

Chronic thromboembolic pulmonary hypertension (CTEPH) is group 4 pulmonary hypertension caused by organized thrombi in the pulmonary arteries. Balloon pulmonary angioplasty (BPA) is an emerging treatment option for patients with inoperable CTEPH but needs contrast media. Therefore, management can be very difficult in patients who have severe iodine allergies. We present a case of a 61-year-old female with CTEPH. Right heart catheterization showed that the mean pulmonary arterial pressure (mPAP) was 47 mmHg. Her organized thrombi were not surgically accessible, so we performed BPA to improve her hemodynamic status. One session of BPA was performed, but the second session was halted because of iodine-induced anaphylactic shock. Despite the administration of pulmonary arterial hypertension-specific drugs for 3 months, the patient's mPAP was still 33 mmHg. CTEPH patients with mPAP ≥30 mmHg have a poor prognosis, so we decided to perform BPA using gadolinium contrast media. A total of six sessions of gadolinium contrast BPA (Gd-BPA) improved the patient's mPAP to the normal range. Gadolinium contrast media could also be used for visualizing pulmonary arteries during BPA. Our report is the first successful case of Gd-BPA, which improved the patient's hemodynamic status to the almost normal range. Gd-BPA may be an attractive treatment option for patients with inoperable CTEPH and severe iodine allergy.

Immunohistochemical and ultrastructural study of basophilic inclusions in adult-onset motor neuron disease

We immunohistochemically and ultrastructurally studied basophilic inclusions (BI) in a patient with adult-onset sporadic motor neuron disease (MND). BI were frequently observed not only in degenerated anterior horn cells, such as central chromatolytic neurons, but also in normal-appearing large anterior horn neurons. They had various shapes, round, elliptical or irregular, and occasionally they had distinct basophilic rims. They also varied in size. There were no halos around them nor core in their centers. Immunohistochemically, some BI were immunostained for ubiquitin or SOD1, but BI were not immunoreactive with anti-phosphorylated neurofilament (SMI 31), phosphorylated tau, cystatin C or Golgi (MG-160) antibodies. Ubiquitin-positive skein-like inclusions (SI) were occasionally observed in the somata of anterior horn neurons. Ultrastructurally, BI consisted of filamentous structures associated with granules, which were attached to thick filaments. The thick filaments were straight without constriction or side arms and their diameter was twice that of the neurofilaments. BI occasionally contained tubular structures among the granule-associated filaments. The granulo-filamentous profiles varied from being compactly arranged to being more loosely packed. The structure of BI resembles that of the Lewy body-like hyaline inclusions (LBHI) observed in sporadic MND patients. Bundles of filaments resembling SI, which were composed of compactly packed filaments without fine granules running parallel to the longitudinal axis, were frequently observed inside or at the periphery of BI, and occasionally clustered in the perikarya. Each filament measured approximately 15-25 nm in diameter, and a bundle of these grouped filaments was sometimes surrounded by a unit membrane. We also occasionally observed in-between structures of BI and bundles of filaments resembling SI. These findings suggest a certain relationship between BI, SI and LBHI in the pathomechanism of BI development. Further studies are needed to elucidate whether sporadic adult-onset MND characterized by BI forms a different subtype of MND.

The 3-dimensional representation of EEG distance by use of Shannon-Gelfand-Yaglom information measure during mental arithmetic

EEG relationships in delta, theta, alpha and beta frequency bands as well as the whole frequency range among 12 electrode locations during resting and mental arithmetic were examined by use of Shannon-Gelfand-Yaglom information measure (SGY) in 10 normal subjects. The EEG relationships were represented in a 3-dimensional (3-D) feature space with multidimensional scaling (MDS). MDS resulted in an anterior-posterior, a left-right and an upper-lower axis. In all 5 frequency bands, the 12 electrodes on the anterior-posterior and left-right axes resembled their actual positions on the scalp during resting and mental arithmetic. During mental arithmetic, prominent changes in the 3-D representation of electrode sites were visualized for activity. The isolation of left and right mid-temporal locations, together with greater EEG distances between left and right mid-temporal locations, were notable during mental arithmetic, suggesting the simultaneous activation possibly in dominant and non-dominant hemispheres and contralateral influences from left to right mid-temporal locations.

A new segmentation method of electroencephalograms by use of Akaike's information criterion

Non-stationary EEGs, whose statistical properties change with time, were segmented into stationary segments to closely track the behavior of EEG characteristics. We have developed a new segmentation method of optimizing segmentation parameters by using AIC (Akaike's information criterion) as an objective criterion. We applied the segmentation method to EEGs. The instantaneous power spectra of EEGs estimated with wavelet transform were compared with the segmented EEGs. EEGs were recorded from F3, F4, C3, C4, P3, P4, 01 and 02 in 13 normal subjects. Artifact-free 15-s epochs were taken at each electrode location. Each epoch was divided into stationary segments, consisting of several fixed intervals, by optimizing 2 segmentation parameters (interval length and starting point) so that the sum of AICs for several sequences of segments could be the smallest. The EEG segmentation could represent differences in the power spectra between segments. The average length of segments during relaxed wakefulness was 6.0 +/- 3.8 s. The EEG segmentation during mental arithmetic could detect the start of mental arithmetic.

Inter-site EEG relationships before widespread epileptiform discharges

EEG interactions of the background among locations can start to change just before epileptiform discharges. Such interactions were investigated with relative power contribution analysis based on a multivariate autoregressive model, which permits determination of multiple causal relations of EEGs among locations. EEGs from F3, F4, P3, P4, T3 and T4 were examined in 10 epileptic patients with asymmetric spike and wave complexes (SWCs). A 12.5-s epoch just before SWCs was divided into stationary segments throughout 6 locations with a segmentation method. In segments long before SWCs, most power at each location was generated from its own location. In segments immediately preceding SWCs, contributions from other locations, particularly from the hemisphere with smaller SWCs, increased. Overall EEG relationships among 6 locations were examined by an entropy which measures the uniformness of the spatial distribution of power contribution. The entropy significantly increased gradually toward SWCs. Our findings demonstrated stronger interactions among locations just before epileptiform discharges, suggesting a transitional state from background EEG to epileptiform discharges.

Potential flow of alpha activity in the human electroencephalogram

The movement of potential field of alpha activity was investigated with a potential flow technique, alpha activity was divided into slow, medium and fast subbands. The peak-to-peak amplitude and source density distribution of each subband was also constructed. The potential flow of medium alpha was from medial to lateral in the anterior region, and from lateral to medial in the posterior region. The flow patterns of slow and fast alpha were more complicated. Similar flow directions formed a group. Different groups met or diverged at discontinuous grid points around the local maxima of potential distribution. The discontinuous points of medium alpha were centered in the parieto-occipital region, and those of slow and fast alpha were more equally distributed over the scalp. Against potential gradients, several groups of similar flow directions participated in the formation of potential field. The generation of potential field was assumed to be controlled widely for medium alpha and locally for slow and fast alpha.

Moving potential field of frontal midline theta activity during a mental task

The movement of potential field (potential flow) of frontal midline theta activity (Fm theta) was examined by using optical flow detection techniques in image processing in 6 normal subjects. Electroencephalograms (EEGs) over the fronto-central region were recorded from 13 electrodes around Fz. The potential flow of Fm theta was estimated on a frame which consisted of a square grid of 19 x 19 points in which each of the 13 electrodes was positioned with Fz at the center of grid. The peak-to-trough amplitude distribution was rounded or oval with a maximum just anterior to Fz. In each hemisphere, potential field moved medially in a region anterior to Fz, posteriorly near or at the midline and laterally in a region posterior to Fz. In the temporal sequence of potential field, at each point velocity directions tended to change progressively clockwise or counterclockwise. In the whole frame, a rotary movement of potential flow was found with a center at the middle on each side. Our findings suggested that a potential maximum at the midline may be due to overlapping of fields of opposite direction over the frontal scalp, arising from sources of similar orientation in both hemispheres. It can be assumed that Fm theta propagates in a clockwise direction in the left hemisphere and in a counterclockwise direction in the right hemisphere.

Changes in the fractal dimension of alpha envelope from wakefulness to drowsiness in the human electroencephalogram

Changes in the fractal dimension of the waxing and waning of alpha activity from wakefulness to drowsiness were investigated in 10 normal subjects. The envelope of filtered alpha activity was estimated with the Hilbert transform. A subset time series was constructed from the alpha envelope data taken at an interval (k). The points of the logarithm of interval k vs. the logarithm of the curve length of the subset time series (log L(k)) were fitted by a two-segment curve, consisting of small and long line segments (segments 1 and 2). The fractal dimension was estimated from the slope of straight line for each segment by using Higuchi's method. The mean fractal dimension was 1.16 for segment 1 and 1.95 for segment 2 during wakefulness and 1.15 for segment 1 and 1.89 for segment 2 during drowsiness. The fractal dimension significantly decreased in both segments during drowsiness, thus, indicating decreases in the complexity of alpha envelope.

Increases in the power spectral slope of background electroencephalogram just prior to asymmetric spike and wave complexes in epileptic patients

Moment-to-moment electroencephalogram (EEG) changes just before spike and wave complexes (SWCs) were investigated by using a non-stationary power spectral analysis in 10 epileptic patients with asymmetric SWCs. The instantaneous power spectra of background EEG were estimated for a 10-s period just before SWCs in 10 locations. The spectral shape, showing a l/f amplitude characteristic, was assessed by the negative slope (spectral slope) of a straight line on a plot of log power versus frequency. Spectral slope significantly increased toward SWCs at locations with greater SWCs. This finding suggested structural changes in EEG frequency composition just before SWCs because of an epileptogenic process.

Potential flow of frontal midline theta activity during a mental task in the human electroencephalogram

The movement of potential field (potential flow) of frontal midline theta activity (Fm theta) as well as its potential distribution was examined in 7 subjects by using optical flow detection techniques in image processing. Electroencephalograms (EEGs) over the fronto-central region were recorded from 13 electrodes near the frontal midline (Fz) while the subjects were performing a mental task. The potential flow of Fm theta was estimated on a frame consisting of a square grid with Fz at its center. In regions anterior to Fz, the direction of potential flow was from lateral to medial, whereas it was from medial to lateral in regions posterior to Fz. The peak-to-trough amplitude distribution was round or oval with a maximum just anterior to Fz. The source density distribution showed the greatest potential along the midline in the frontal region and bilaterally symmetric smaller maximum areas mostly in the prefrontal regions. Our findings suggested the presence of 2 different source areas of opposite direction in each hemisphere in spite of a round or oval amplitude distribution.

Half-field sinusoidally modulated light stimulation at subject's alpha frequency

Interhemispheric responses of alpha activity were investigated by use of half-field sinusoidally modulated light (SML) stimulation at the subject's alpha frequency. The left and right visual half-fields as well as full-field were separately stimulated by the SML. The power spectrum of SML responses, averaged with Wiener filtering, was obtained at the left and the right occipital area (O1 and O2) in 11 normal subjects. Power in each hemisphere, phase difference and coherence between O1 and O2 were estimated at an alpha frequency. A laterality index of power was defined as (P(l)-P(r))/(P(l) + P(r)) where P(l) is a power value at O1, and P(r) at O2. In most of the subjects, laterality index decreased in the order: left half-field, full-field and right half-field stimulation. This relationship revealed greater SML responses on the ipsilateral occipital area. There were significant differences in laterality index among 3 visual field conditions, thus showing that full-field responses ranged in lateralization between the left and right half-field responses in most of the subjects. This hemispheric distribution suggests that half-field SML stimulation affected alpha activity selectively in each hemisphere, mostly in the ipsilateral hemisphere.

Abnormality of background EEG determined by the entropy of power spectra in epileptic patients

Relationships between epileptiform discharges and background activity were examined by power spectral entropy (PSE), measuring a degree of EEG irregularity. The EEGs were recorded from 10 electrodes placed at F3, F4, C3, C4, T3, T4, P3, P4, O1 and O2 in 11 epileptic patients with widespread lateralized spike and wave complexes (SWCs). Bipolar records were also made from the antero-posterior derivations. The locations of the maximum PSE coincided with those of the maximum amplitude of SWC in most of the patients. Bipolar derivations with the maximum PSE always included the locations with the maximum PSE obtained from a linked ears reference. Pearson's correlation coefficient between PSE and SWC amplitude was 0.62 +/- 0.14 (mean +/- S.D.) in 11 patients, thus indicating that the scalp distribution of PSE was closely related to that of the amplitude of SWC. These findings suggest that the background EEG is disorganized in or near the epileptogenic focus. A focal background abnormality can therefore be estimated by PSE.

Quantification of EEG irregularity by use of the entropy of the power spectrum

A new method for quantifying irregularity of EEGs is proposed in this study. The entropy, an information measure, determines the uniformity of proportion distribution. The peakedness or flatness of the distribution of the EEG power spectrum, representing EEG rhythmicity, can be measured by the entropy, because the power spectrum consists of proportions of power at each frequency. The irregularity of the EEG was measured by the entropy of the power spectrum, called an irregularity index (II). The II was obtained from the power spectrum at F3, F4, C3, C4, P3, P4, O1 and O2 during rest and mental arithmetic in 10 normal subjects. Relative band powers of delta, theta, alpha and beta bands and alpha peak frequency were also obtained. EEGs during rest were significantly more irregular anteriorly than in the occipital areas. Alpha activity was also more irregular in the anterior region. A greater degree of EEG desynchronization during mental arithmetic was found over the left hemisphere and the right occipital area. The II was more sensitive to such desynchronization than alpha band power and alpha peak frequency. The differences in spectral structures between rest and mental arithmetic conditions, mainly over the left hemisphere, were also confirmed by the Kullback-Leibler information.

Analysis of rapidly changing EEGs before generalized spike and wave complexes

Ten epileptic patients who had absence and tonic-clonic seizures were examined. They showed almost generalized 2-5 Hz spike and wave complexes (SWCs) with maxima at the frontal or central locations. Their EEGs were recorded from F3, F4, C3, C4, P3, P4, O1 and O2. One 15 sec EEG epoch, which included the background activity followed by SWCs, was divided into 20 segments. On the basis of Akaike's information criterion obtained from an AR model fitted to each segment by the least squares method, a distance measure between segments was obtained. The 20 segments were classified according to the distance measure with the combined use of both cluster analysis and multidimensional scaling. The power spectrum was also obtained for each segment. There were 2-6 clusters at some locations, always including the largest amplitude locations of the SWCs (the frontal or central locations). The clusters could be grouped into 3 major types, each forming a period: (1) one large cluster distant from the SWCs (the period of background activity); (2) small clusters just before the SWCs (the period just before the SWCs); (3) small clusters during the SWCs (the period of the SWCs). The period just before the SWCs, which occurred earliest at the largest amplitude location, may be a transition state of the background activity to the SWCs. A few segments remote from the SWCs belonged to the small cluster just before or during the SWCs in some patients, thus suggesting that an EEG event similar to EEG changes just before or during the SWCs occurred. The EEG event buried within the background can be considered as a poorly developed epileptiform discharge. A gradual increase or decrease in alpha frequency before the SWCs was found in most patients; this suggests that changes in the level of vigilance occur before SWCs.