His bundle pacing capture threshold stability during long-term follow-up and correlation with lead slack

Aims His bundle pacing (HBP) is the most physiologic form of pacing. Long-term HBP capture threshold stability and its relation to lead characteristics at the time of implantation have not been adequately described. The aim of this study was to characterize HB capture threshold in follow-up and to identify potential lead characteristics predictive of lead capture instability. Methods and results Consecutive patients with successful HBP for bradycardia indications were identified from the Geisinger HBP registry. His bundle capture thresholds, baseline comorbidities, and radiographic lead slack characteristics were analysed. An increase in HB capture threshold ≥1 V above implant values at any time during follow-up was tracked. Forty-four of the 294 studied (15%) experienced HB capture threshold increase by ≥ 1 V. Threshold increase was seen early (41% by 8 weeks, 66% by 1 year). Eighteen (6%) patients required lead revision in follow-up. Abnormal slack shape was associated with a trend toward capture threshold increase [hazard ratio (HR) 2.07; 95% confidence interval (CI) 0.9–4.6; P = 0.08]. Non-perpendicular angle of lead insertion on radiography was associated with the capture threshold increase (HR 2.81, 95% CI 1.4–5.8; P < 0.01). Conclusion His bundle capture threshold remains stable in the majority (85%) of patients. Implant characteristics may predict the threshold rise. Further evaluation of the aetiology of threshold increase and design changes in lead and delivery systems may lead to chronically stable capture thresholds.

Targeting Central Mechanisms of Pain to Improve Acupuncture Analgesia in a Humanized Mouse Model of Sickle Cell Disease

Background: Pain is one of the major comorbidities of sickle cell disease (SCD), which largely remains reliant on opioid use for analgesia. Side effects of opioids including, but not limited to fear of addiction, constipation, pruritus and opioid-induced hyperalgesia warrant the need for analgesic therapies devoid of side effects. Non-pharmacological strategies including acupuncture have been effective in pain treatment. A retrospective analysis (n=24 patients) showed that acupuncture reduced pain in a majority (75%) of SCD patients (Lu K et al., Clin J Pain. 2014). In a mouse model of SCD, electroacupuncture (EA) on conscious free-moving mice led to variable analgesic response ranging from high- (nociceptive threshold increase >200%), moderate- (threshold between 100~200%) to non-responders (threshold increase ≤100%) (Wang Y et al., Sci Rep. 2016). Substance P (SP), a proinflammatory vasoactive neuropeptide in the periphery and centrally and spinal activated p38 mitogen activated protein kinase (MAPK), critical mediators of chronic pain were significantly increased in sickle mice with moderate or no response to EA analgesia. Increased circulating SP has been reported in SCD patients at steady state and during chronic pain. We hypothesize that chronic pain in moderate- and non-responders is due to central sensitization mediated by SP-induced p38 MAPK phosphorylation; and that inhibiting the effect of SP and/or downstream p38 MAPK signaling would improve response to EA in moderate and non-responsive sickle mice. Methods: HbSS-BERK sickle mice expressing human sickle hemoglobin without any treatment and those showing moderate- (threshold between 100~200%) and no-response (threshold increase ≤100%); and HbAA-BERK control mice that express normal human hemoglobin A were used. All groups included mice of both genders at 5-7 months of age and were treated daily with 10 mg/kg, i.p. netupitant (antagonist of neurokinin 1 receptor, a receptor for SP), or SB203580, a p38MAPK inhibitor, with or without four sequential EA treatments (every 3rd day, frequency: 4 or 10 Hz, pulse width: 100 microsecond, duration: 30 min) at acupoint GB30. Hyperalgesia was evaluated daily before starting the inhibitor/EA treatment (baseline, BL) and after treatments throughout 12 days by determining the sensitivity to mechanical-, thermal- and deep tissue-stimuli using von Frey filaments, Hargreaves test, cold plate and grip force, respectively. Results: Sickle mice showing no- or moderate responsive to EA did not demonstrate a significant effect of netupitant or SB203580 without EA on hyperalgesia. However, co-treatment with netupitant and EA reduced mechanical, thermal and deep tissue hyperalgesia through the entire treatment, reaching significance at day 9 and/or day 12. Co-treatment with netupitant enhanced analgesia of EA by significantly decreasing mechanical hyperalgesia (p<0.05 vs untreated sickle or moderate-responder + netupitant) and heat sensitivity (p<0.05 vs BL) at day 9, cold sensitivity (p<0.05 vs BL) at day 12 for both moderate- and non-responders. Deep tissue hyperalgesia for co-treated moderate-responders (p<0.05 vs BL) was significantly reduced at day 9, while the reduction observed with co-treated non-responders (p<0.05 vs BL) only reached significance on day 12. These data suggest that SP mediates sustained chronic pain in SCD, which imparts resistance to EA analgesia. Co-treatment with SB203580 and EA together decreased heat sensitivity (p<0.05 vs BL) at day 9, mechanical hyperalgesia (p<0.05 vs BL or moderate-responder + EA) and cold sensitivity (p<0.05 vs BL) at day 12 and deep tissue hyperalgesia for moderate-responders (p<0.05 vs BL) at day 9 and 12 and non-responders (p<0.05 vs BL) at day 12. Therefore, central sensitization with increased p38MAPK phosphorylation perhaps mediated by high SP levels prevents the responsiveness to EA. Conclusion: Increased SP-induced spinal p38MAPK activation may underlie poor responsiveness to EA and perhaps other analgesic therapies in SCD. Therefore, inhibition of SP or p38 MAPK may improve analgesic outcomes with EA. Circulating SP levels may also be predictive of response to EA and/other analgesic therapies. Co-treatment strategies using acupuncture with mechanism-based targets of central sensitization may be potentially beneficial in treating pain and reducing opioid use in SCD. Disclosures Gupta: Tau tona: Consultancy; Novartis: Honoraria.

Comparison of probabilistic and deterministic fiber tracking of cranial nerves

OBJECTIVEThe depiction of cranial nerves (CNs) using diffusion tensor imaging (DTI) is of great interest in skull base tumor surgery and DTI used with deterministic tracking methods has been reported previously. However, there are still no good methods usable for the elimination of noise from the resulting depictions. The authors have hypothesized that probabilistic tracking could lead to more accurate results, because it more efficiently extracts information from the underlying data. Moreover, the authors have adapted a previously described technique for noise elimination using gradual threshold increases to probabilistic tracking. To evaluate the utility of this new approach, a comparison is provided with this work between the gradual threshold increase method in probabilistic and deterministic tracking of CNs.METHODSBoth tracking methods were used to depict CNs II, III, V, and the VII+VIII bundle. Depiction of 240 CNs was attempted with each of the above methods in 30 healthy subjects, which were obtained from 2 public databases: the Kirby repository (KR) and Human Connectome Project (HCP). Elimination of erroneous fibers was attempted by gradually increasing the respective thresholds (fractional anisotropy [FA] and probabilistic index of connectivity [PICo]). The results were compared with predefined ground truth images based on corresponding anatomical scans. Two label overlap measures (false-positive error and Dice similarity coefficient) were used to evaluate the success of both methods in depicting the CN. Moreover, the differences between these parameters obtained from the KR and HCP (with higher angular resolution) databases were evaluated. Additionally, visualization of 10 CNs in 5 clinical cases was attempted with both methods and evaluated by comparing the depictions with intraoperative findings.RESULTSMaximum Dice similarity coefficients were significantly higher with probabilistic tracking (p < 0.001; Wilcoxon signed-rank test). The false-positive error of the last obtained depiction was also significantly lower in probabilistic than in deterministic tracking (p < 0.001). The HCP data yielded significantly better results in terms of the Dice coefficient in probabilistic tracking (p < 0.001, Mann-Whitney U-test) and in deterministic tracking (p = 0.02). The false-positive errors were smaller in HCP data in deterministic tracking (p < 0.001) and showed a strong trend toward significance in probabilistic tracking (p = 0.06). In the clinical cases, the probabilistic method visualized 7 of 10 attempted CNs accurately, compared with 3 correct depictions with deterministic tracking.CONCLUSIONSHigh angular resolution DTI scans are preferable for the DTI-based depiction of the cranial nerves. Probabilistic tracking with a gradual PICo threshold increase is more effective for this task than the previously described deterministic tracking with a gradual FA threshold increase and might represent a method that is useful for depicting cranial nerves with DTI since it eliminates the erroneous fibers without manual intervention.

Detection of Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage Using Motor Evoked Potentials

ABSTRACT BACKGROUND: Early detection of vasospasm (VS) following aneurysmal subarachnoid hemorrhage (aSAH) is vital to trigger therapy and to prevent infarction and subsequent permanent neurological deficit. Although motor evoked potentials (MEPs) are a well-established method for intraoperative detection of cerebral VS and cerebral ischemia during aneurysm surgery, there are no studies investigating the diagnostic value of MEPs for detecting delayed VS following aSAH in an intensive care unit. OBJECTIVE: A prospective study was conceived to assess the diagnostic accuracy of MEPs in comparison with digital subtraction angiography. METHODS: MEP threshold changes were determined in patients both with and without angiographic VS following high-grade aSAHs. Sensitivity, specificity, and the positive and negative predictive values of significant MEP threshold increases, which indicate angiographic VS, were calculated. RESULTS: In all patients experiencing VS of the arteries supplying cerebral motor areas, a minimal MEP threshold increase of 50 mA (mean 66.25 mA) was observed, whereas a maximum MEP threshold increase of 30 mA was observed in patients without VS. Therefore, an increase from a baseline of ≥50 mA was considered significant and resulted in a sensitivity of 0.83, a specificity of 0.92, a positive predictive value of 0.83, and a negative predictive value of 0.92. CONCLUSION: VS following aSAH can be detected accurately by using MEPs. MEPs are a feasible bedside tool for online VS detection in an intensive care unit and, therefore, may complement existing diagnostic tools.