Sensing, Feeling, and Regulating: Investigating the Association of Focal Brain Damage with Voluntary Respiratory and Motor Control

Breathing is a complex, vital function that can be modulated to influence physical and mental well-being. However, the role of cortical and subcortical brain regions in voluntary control of human respiration is underexplored. Here we investigated the influence of damage to human frontal, temporal, or limbic regions on the sensation and regulation of breathing patterns. Participants performed a respiratory regulation task across regular and irregular frequencies ranging from 6 to 60 breaths per minute (bpm), with a counterbalanced hand motor control task. Interoceptive and affective states induced by each condition were assessed via questionnaire and autonomic signals were indexed via skin conductance. Participants with focal lesions to the bilateral frontal lobe, right insula/basal ganglia, and left medial temporal lobe showed reduced performance than individually matched healthy comparisons during the breathing and motor tasks. They also reported significantly higher anxiety during the 60-bpm regular and irregular breathing trials, with anxiety correlating with difficulty in rapid breathing specifically within this group. This study demonstrates that damage to frontal, temporal, or limbic regions is associated with abnormal voluntary respiratory and motor regulation and tachypnea-related anxiety, highlighting the role of the forebrain in affective and motor responses during breathing.

Highlights

Impaired human respiratory regulation is associated with cortical/subcortical brain lesionsFrontolimbic/temporal regions contribute to rhythmic breathing and hand motor controlFrontolimbic/temporal damage is associated with anxiety during tachypnea/irregular breathingThe human forebrain is vital for affective and interoceptive experiences during breathing.

Distribution of multiunit pitch responses recorded intracranially from human auditory cortex

The perception of pitch is a fundamental percept, which is mediated by the auditory system, requiring the abstraction of stimulus properties related to the spectro-temporal structure of sound. Despite its importance, there is still debate as to the precise areas responsible for its encoding, which may be due to species differences or differences in the recording measures and choices of stimuli used in previous studies. Moreover, it was unknown whether the human brain contains pitch neurons and how distributed such neurons might be. Here, we present the first study to measure multiunit neural activity in response to pitch stimuli in the auditory cortex of intracranially implanted humans. The stimulus sets were regular-interval noise with a pitch strength that is related to the temporal regularity and a pitch value determined by the repetition rate and harmonic complexes. Specifically, we demonstrate reliable responses to these different pitch-inducing paradigms that are distributed throughout Heschl's gyrus, rather than being localized to a particular region, and this finding was evident regardless of the stimulus presented. These data provide a bridge across animal and human studies and aid our understanding of the processing of a critical percept associated with acoustic stimuli.

Outcomes of Stented vs Nonstented Femoropopliteal Lesions Treated With Drug-Coated Balloon Angioplasty

PURPOSE

Drug-coated balloon (DCB) angioplasty has been increasingly used for the treatment of lower limb peripheral artery disease (PAD). However, bail-out stenting may be necessary in cases of suboptimal angioplasty. This study investigated the outcomes of femoropopliteal disease treated with DCB with/without bail-out stenting.

MATERIALS AND METHODS

This was a single-center retrospective study enrolling 166 consecutive patients (DCB+stent: n=81 vs DCB: n=85) with 253 femoropopliteal lesions (DCB+stent: n=99 vs DCB: n=154) treated with DCB with/without stenting. Bail-out stenting was performed at the operator discretion for postangioplasty dissections or otherwise suboptimal angiographic result (>30% residual stenosis). Cox regression analysis was performed to examine the outcomes of DCB with/without stenting during 2-year follow-up.

RESULTS

The baseline clinical characteristics were similar between the 2 groups. About half of the patients presented with critical limb ischemia, with most of the lesions located at the superficial femoral artery. The overall mean lesion length was 147±67 mm. The most frequent bail-out stent types were bare metal stents (BMS) (53.5%) followed by drug-eluting stents (DES) (41.4%). Lesions requiring bail-out stenting were on average longer (177±67 mm vs 127±59 mm; p<0.01) and on average had higher prevalence of flow-limiting postangioplasty dissections. The overall procedural success rate was 94% without any differences between the 2 groups. Both the stented and nonstented treatment modalities were effective and safe, demonstrating similar rates of 2-year freedom from major adverse limb event (stented: 71.3% vs nonstented: 64.4%) and 2-year freedom from target lesion revascularization (stented: 77.1% vs nonstented: 72.3%) during following up. The use of DES as bail-out therapy was associated with a lower risk of 2-year death compared with the use of BMS (DES: 97.2% vs BMS: 75.8%; p=0.01).

CONCLUSION

Drug-coated balloon with bail-out stenting is a viable treatment option for cases of suboptimal DCB results, promising similar efficacy with DCB-alone procedures. However, as the patency of stents at the femoropopliteal segment may be a challenge due to the biomechanical stress of the artery, the efficacy of DCB+bail-out stenting should be further evaluated. In addition, future studies are needed to determine which grades of post-DCB dissections should be treated and optimize current bail-out strategies.

Association of Postangioplasty Femoropopliteal Dissections With Outcomes After Drug-Coated Balloon Angioplasty in the Femoropopliteal Arteries

PURPOSE

Balloon angioplasty for the treatment of femoropopliteal lesions is often complicated by postangioplasty dissections. While dissections are known to affect patency and reintervention after balloon angioplasty, the association between dissections and major adverse limb event (MALE) after drug-coated balloon (DCB) angioplasty remains uncertain. Thus, the postangioplasty dissection and bailout stenting patterns were investigated.

MATERIALS AND METHODS

This was a single-center retrospective study enrolling patients with de novo femoropopliteal lesions treated with DCB with/without stenting. Postangioplasty target vessel dissection was graded based to the coronary artery classification grades A-F, with grade C-F considered "severe." Cox regression analysis was performed to examine the association of dissection severity with outcomes during 2-year follow up, among nonstented cases.

RESULTS

In 85.3% of the cases (N=203/238) a postangioplasty dissection was observed. The average dissection length was 55.57 mm (SD 36.71 mm), with 1 dissection present in 91.8% (N=180/196) and 2 or more dissections present in 8.2% (N=16/196). Dissection severity was grade A (19.8%), B (20.6%), C (23.1%), D (10.9%), E (10.1%), and F (0.8%). Bailout stenting was required in 40.4% of the patients, being more prevalent among grade C and grade E cases. Among 142 nonstented cases, dissections were present in 85.2%. A total of 75 (52.8%) of these dissections were grade A and B, while 46 (32.4%) were grade C to F. Among nonstented cases, grade C (hazard ratio [HR] 5.83; 95% CI 1.25 to 27.31; p=0.025) and grade D (HR 6.32; 95% CI 1.39 to 28.86; p=0.017) vs grade A dissections were associated with a higher risk for 2-year MALE. Multivariate analysis adjusting for several lesion characteristics demonstrated a statistically significant higher risk for 2-year MALE among the severe dissection group (HR 2.94; 95% CI 1.27 to 6.79; p = 0.012). Interestingly, the risks of limb loss (HR 1.30; 95% CI 0.22 to 7.79; p=0.774) and repeat revascularization (HR 0.95; 95% CI 0.40 to 2.26; p=0.905) during follow-up were similar between the 2 groups.

CONCLUSION

This study indicated that nonstented moderate and severe postangioplasty dissections after DCB angioplasty were associated with higher risk for MALE. Future studies are needed to validate our results and determine other dissection characteristics (eg, total dissection length, lumen area, total number of dissections) that may affect the efficacy of DCB.

Transcatheter Mitral Valve Repair in Cardiogenic Shock and Mitral Regurgitation: A Patient-Level, Multicenter Analysis

OBJECTIVES

The aim of this study was to evaluate the outcome of transcatheter mitral valve repair (TMVr) in patients with cardiogenic shock and significant mitral regurgitation (MR).

BACKGROUND

Patients in cardiogenic shock with severe MR have a poor prognosis in the setting of conventional medical therapy. Because of its favorable safety profile, TMVr is being increasingly used as an acute therapy in this population, though its efficacy remains unknown.

METHODS

A multicenter, collaborative, patient-level analysis was conducted. Patients with cardiogenic shock and moderate to severe (3+) or severe (4+) MR who were not surgical candidates were treated with TMVr. The primary outcome was in-hospital mortality. Secondary outcomes included 90-day mortality, heart failure (HF) hospitalization, and the combined event rate of 90-day mortality and HF hospitalization following dichotomization by TMVr device success.

RESULTS

Between January 2011 and February 2019, 141 patients across 14 institutions met the inclusion criteria. In-hospital mortality occurred in 22 patients (15.6%), at 90 days in 38 patients (29.5%), and at one year in 55 patients (42.6%). Median length of hospital stay following TMVr was 10 days (interquartile range: 6 to 20 days). HF hospitalization occurred in 26 patients (18.4%) at a median of 73 days (interquartile range: 26 to 546 days). When stratified by TMVr procedural results, successful TMVr reduced rates of in-hospital mortality (hazard ratio [HR]: 0.36; 95% confidence interval [CI]: 0.13 to 0.98; p = 0.04), 90-day mortality (HR: 0.36; 95% CI: 0.16 to 0.78; p = 0.01), and the composite of 90-day mortality and HF hospitalization (HR: 0.41; 95% CI: 0.19 to 0.90; p = 0.03).

CONCLUSIONS

TMVr may improve short- and intermediate-term mortality in high-risk patients with cardiogenic shock and moderate to severe MR. Randomized studies are needed to definitively establish MR as a therapeutic target in patients with cardiogenic shock.

Management of Out-of-Hospital Cardiac Arrest Complicating Acute Coronary Syndromes

PURPOSE OF THE REVIEW

Out-of-hospital cardiac arrest (OHCA) complicating acute coronary syndromes (ACS) continues to carry a high rate of morbidity and mortality despite significant advances in EMS and interventional cardiology services. In this review, we discuss an evidence-based approach to the initial care and management of patients with OHCA complicating ACS from the pre-hospital response and initial resuscitation strategy, to advanced therapies such as coronary angiography, targeted-temperature management, neuro-prognostication, and care of the post-arrest patient.

RECENT FINDINGS

Early recognition of cardiac arrest and prompt initiation of bystander CPR are the most important factors associated with improved survival. A comprehensive and coordinated approach to in-hospital management, including PCI, targeted temperature management, critical care, and hemodynamic support represents a significant critical link in the chain of survival. OHCA complicated by ACS continues to be one of the most challenging disease states facing healthcare practitioners and maintains a high mortality rate despite substantial advancements in healthcare delivery. A comprehensive approach to in-hospital management and further exploration of novel interventions, including ECMO, may yield opportunities to optimize care and improve outcomes for cardiac arrest patients.

Precision surgery of rolandic glioma and insights from extended functional mapping

OBJECTIVES

Electrical cortical stimulation mapping (ECSM) is the current gold standard functional mapping technique; however, it is burdened by several limitations. Our objective in this study is to show that extended functional mapping modalities can (1) allow neurosurgeons to map and preserve eloquent regions that are inaccessible by the traditional ECSM technique and (2) factor into the operative decision-making process and surgical trajectory during resection of Rolandic brain tumors.

PATIENTS AND METHODS

A 55year old patient having a right Rolandic glioblastoma underwent subdural grid implantation followed by surgical resection. Multimodal functional mapping including electrical stimulation, high gamma power mapping, functional magnetic resonance imaging, and diffusion tensor imaging were performed to define the location of the patient's eloquent cortex and white matter tracts in relation to the tumor and determine the optimal surgical trajectory prior to resection.

RESULTS

The patient tolerated a safe surgical resection without any new postoperative deficits. ECSM mapping successfully delineated safe areas for resection as well as eloquent areas related to motor control and speech production. High gamma power analysis successfully mapped areas involved in arm reach. Functional MRI showed the regions related to finger tapping. DTI demonstrated the corticospinal tract and its relation to the hand motor cortex and the tumor.

CONCLUSION

Adjunct mapping techniques used to supplement the data offered by ECSM can help advance the field of functional mapping and Rolandic surgery via broadening our accessibility to the human brain and providing a comprehensive map of eloquent grey and white matter structures and their relation to the tumor.

Rethinking the Magnetic Resonance Imaging Findings in Early Rasmussen Encephalitis: A Case Report and Review of the Literature

OBJECTIVE

We present a child with Rasmussen encephalitis and highlight the pitfalls of diagnosis when magnetic resonance imaging (MRI) is negative for atrophy. We review the literature regarding this issue, introduce the FreeSurfer software as a potential means of noninvasive diagnosis, and discuss methods for prompt and definitive treatment.

METHODS

In addition to the patient description, we review the English language literature regarding pathologic diagnosis of Rasmussen encephalitis using the key words Rasmussen encephalitis, focal lesions, MRI, atrophy, epilepsia partialis continua and hemiparesis in PubMed. We conducted a retrospective, volumetric analysis of our patient's MRIs using FreeSurfer.

RESULTS

Unlike the majority of patients in the literature with Rasmussen encephalitis, our patient's initial MRI was normal and later showed only a small area of T2 and fluid-attenuated inversion recovery high signal despite the presence of epilepsia partialis continua and a rapidly deteriorating clinical course. She did not meet the Rasmussen encephalitis diagnostic criteria until biopsy was obtained but is now seizure-free after functional hemispherotomy performed six months after her initial seizure. FreeSurfer analysis did not show cortical atrophy.

CONCLUSION

The Bien criteria have poor sensitivity for the diagnosis of Rasmussen encephalitis when the MRI is negative for atrophy. Tissue diagnosis is essential in such instances. We suggest a high clinical index of suspicion and multidisciplinary collaboration between radiology, pathology, and neurosurgery to facilitate a greater emphasis on biopsy followed by hemispherotomy as definitive therapy for individuals with early Rasmussen encephalitis.

Frequency flows and the time-frequency dynamics of multivariate phase synchronization in brain signals

The quantification of phase synchrony between brain signals is of crucial importance for the study of large-scale interactions in the brain. Current methods are based on the estimation of the stability of the phase difference between pairs of signals over a time window, within successive frequency bands. This paper introduces a new approach to study the dynamics of brain synchronies, Frequency Flows Analysis (FFA). It allows direct tracking and characterization of the nonstationary time-frequency dynamics of phase synchrony among groups of signals. It is based on the use of the one-to-one relationship between frequency locking and phase synchrony, which applies when the concept of phase synchrony is not taken in an extended 'statistical' sense of a bias in the distribution of phase differences, but in the sense of a continuous phase difference conservation during a short period of time. In such a case, phase synchrony implies identical instantaneous frequencies among synchronized signals, with possible time varying frequencies of synchronization. In this framework, synchronous groups of signals or neural assemblies can be identified as belonging to common frequency flows, and the problem of studying synchronization becomes the problem of tracking frequency flows. We use the ridges of the analytic wavelet transforms of the signals of interest in order to estimate maps of instantaneous frequencies and reveal sustained periods of common instantaneous frequency among groups of signal. FFA is shown to track complex dynamics of synchrony in coupled oscillator models, reveal the time-frequency and spatial dynamics of synchrony convergence and divergence in epileptic seizures, and in MEG data the large-scale ongoing dynamics of synchrony correlated with conscious perception during binocular rivalry.

Analysis of Single-Unit Responses to Emotional Scenes in Human Ventromedial Prefrontal Cortex

Lesion and functional imaging studies in humans have shown that the ventral and medial prefrontal cortex is critically involved in the processing of emotional stimuli, but both of these methods have limited spatiotemporal resolution. Conversely, neurophysiological studies of emotion in nonhuman primates typically rely on stimuli that do not require elaborate cognitive processing. To begin bridging this gap, we recorded from a total of 267 neurons in the left and right orbital and anterior cingulate cortices of four patients who had chronically implanted depth electrodes for monitoring epilepsy. Peristimulus activity was recorded to standardized, complex visual scenes depicting neutral, pleasant, or aversive content. Recording locations were verified with postoperative magnetic resonance imaging. Using a conservative, multistep statistical evaluation, we found significant responses in 56 neurons; 16 of these were selective for only one emotion class, most often aversive. The findings suggest sparse and widely distributed processing of emotional value in the prefrontal cortex, with a predominance of responses to aversive stimuli.

A Functional Connection Between Inferior Frontal Gyrus and Orofacial Motor Cortex in Human

The inferior frontal gyrus (IFG) of humans is known to play a critical role in speech production. The IFG is a highly convoluted and cytoarchitectonically diverse structure, classically forming 3 subgyri. It is reasonable to speculate that during speaking the IFG, or some portion of it, influences by corticocortical connections the orofacial representational area of primary motor cortex. To test the hypothesis that such corticocortical connections exist, electrical-stimulation tract tracing experiments were performed intraoperatively on 14 human subjects undergoing surgical treatment of medically intractable epilepsy. Bipolar electrical stimulation was applied to sites on the IFG, while the resulting evoked potentials were recorded from orofacial motor cortex, using a multichannel recording array. Stimulation of the IFG evoked polyphasic waveforms on motor cortex of both language-dominant and -nondominant hemispheres. The evoked waveforms had consistent features across subjects. The responses were seen in discrete regions on precentral cortex. Stimulation of motor cortex also evoked responses on portions of IFG. The data provide evidence for a functional connection between the human IFG and orofacial motor cortex.

Coherent light scattering by nanostructured collagen arrays in the caruncles of the malagasy asities (Eurylaimidae: aves)

We investigated the anatomy, nanostructure and biophysics of the structurally coloured facial caruncles of three species in a clade of birds endemic to Madagascar (Philepittinae, Eurylaimidae: Aves). Caruncle tissues of all species had reflectance spectra with prominent, peak hues between 403 and 528 nm. Dark blue Neodrepanis tissues had substantial reflectance in the near ultraviolet (320–400 nm), which is visible to birds but not to humans, providing the first evidence of ultraviolet skin colours in birds and the first indications of the possible function of ultraviolet skin colours in avian communication. These structural colours are produced by coherent scattering from arrays of parallel collagen fibres in the dermis. Tissues of Philepitta castanea were organized into hexagonal, crystal-like arrays, whereas Neodrepanis tissues were quasiordered. Predictions of the peak hues of reflectance (λ (max)) using Bragg's law were relatively accurate, but Bragg's law requires physical assumptions that are obviously violated by these structures. A two-dimensional discrete Fourier analysis of the spatial variation in refractive index within the tissues documented that all the tissues are substantially nanostructured at the appropriate spatial scale to scatter visible light coherently. Predicted reflectance spectra based on the two-dimensional Fourier power spectra are relatively accurate at predicting the hue and shape of the reflectance spectra of the tissues. These results confirm that the nanostructure of the collagen arrays determines the colours that are coherently scattered by these tissues. The evolution of the anatomy and nanostructure of asity caruncles is discussed.

Reminiscence: exploring the origins, processes, and consequences

Empirical investigation of reminiscence as a naturally occurring process and as a therapeutic nursing intervention has been hampered by the lack of a theoretical framework that can integrate diverse viewpoints and account for existing data. This article presents a preliminary model of reminiscence that can guide future research efforts and assist clinicians in understanding the functions of the reminiscence process. The model proposes that reminiscence is a source of self-referent knowledge, which influences a person's self-worth. It views reminiscence as a process of acquiring personal existential meaning and as a mechanism for adapting to stress.

The use of 99mtechnetium in the diagnosis of patent processus vaginalis

We report 2 cases of scrotal swelling after placement of peritoneal catheters. 99mTechnetium intraperitoneal scanning was used to identify a patent processus vaginalis in each case. This simple, rapid, and nontoxic method can be used routinely to screen patients for a subclinical hernia before institution of intraperitoneal therapy.