We present Stanford\'s experience with patients post-arterial switch operation presenting with chest pain found to have hemodynamically significant myocardial bridging. The evaluation of symptomatic patients post-arterial switch should not only include assessment for coronary ostial patency but also for nonobstructive coronary conditions such as myocardial bridging. (Level of Difficulty: Advanced.).

Lingual thyroid is by far the most common presentation of ectopic thyroid. Though mostly asymptomatic it is associated with congenital hypothyroidism and importantly, absence of orthotopic thyroid making it the only functional thyroid tissue a patient has in many cases. It appears indistinguishable to orthotopic thyroid tissue on imaging, with avid homogeneous enhancement on contrast computed tomography. Here we report clinical presentation and imaging findings of lingual thyroid in a 38-year-old man.

There is a paucity of data on longitudinal seizure outcome of children undergoing epilepsy surgery. All children (n = 132) who underwent resective epilepsy surgery from January 1998 to December 2015 were identified. Relevant clinical, neurophysiological, imaging, surgical and seizure outcome data were extracted. Multivariable logistic regression analysis and Kaplan-Meier survival with Cox proportional hazard modelling were performed. The mean age at surgery was 7.8 years (range 0.2-17.9). 71% were seizure-free at a mean follow up of 5.3 ± 2.7 years. Of those who were seizure-free, 65 patients were able to completely wean off anti- seizure medications successfully. Using survival analysis, the probability of Engel Class I outcome at one year after surgery was 81% (95% confidence interval [CI] 87%-75%). This dropped to 73% at two years (95% CI 81%-65%), 58% at five years (95% CI 67.8%-48%), and 47% at ten years. Proportional hazard modelling showed that the presence of moderate to severe developmental disability (HR 6.5; p = 0.02) and lack of complete resection (HR 0.4; p = 0.02) maintain association as negative predictors of seizure-free outcome. Our study demonstrates favorable long-term seizure control following pediatric epilepsy surgery and highlights important predictors of seizure outcome guiding case selection and counseling of expectations prior to surgery.

A 59-year-old man had angina and an abnormal perfusion scan. Work-up revealed 2 left main coronary arteries: the anomalous artery originated from the right coronary cusp and took an aberrant interventricular septal course; the other artery was atretic. He underwent surgical unroofing, with resolution of symptoms. (Level of Difficulty: Intermediate.).

Infectious SARS-CoV-2 meningitis is rare, especially as the first manifestation of a SARS-CoV-2 infection. Infectious SARS-CoV-2 meningitis can initially manifest with seizures and neuropsychiatric abnormalities, worsen to the point of coma, and occasionally lead to death. Patients with infectious SARS-CoV-2 meningitis require comprehensive evaluation and forced treatment in order to improve the often poor outcome.

Intraoperative functional language mapping is vital to minimize the risks associated with surgical removal of the seizure onset zone in selected patients with epilepsy. In children, this method has been reported extraoperatively by the placement of invasive electrodes to map the language area and monitor epileptic activity. It is difficult from a technical standpoint to perform an awake craniotomy and language mapping in young children under 10 years of age. Here we report a 9-year-old boy suffering from drug-resistant non-lesional epilepsy who underwent extraoperative and intraoperative electrical stimulation with successful identification of Broca\'s language area. Electrocorticography (ECOG) was applied intraoperatively in a continuous manner utilizing grid electrodes before the skin opening. We found that the use of visual digital video games facilitated extraoperative and intraoperative cortical mapping. Cortical language inhibition by electrical stimulation was elicited at an amplitude of 7 mA (100 μs single-phase duration and 50 Hz pulse width). Resection of the seizure onset zone was completed safely. The post-resection ECOG revealed the disappearance of epileptogenic electrographic discharges at the seizure onset contacts and at other involved contacts in the epileptogenic zone. After surgery, the child recovered well with no language deficits and remained seizure-free. The child remembered only the video game test that was performed intraoperatively. This report highlights safety strategies for awake language mapping in pediatrics and the importance of the perioperative use of a visual digital video game and continuous ECOG, in addition to the use of targeted language cortex stimulation to facilitate faster and safer intraoperative language mapping under awake conditions in this age group.

We applied the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR chest pain guidelines to a case of a 76-year-old woman with no known coronary disease presenting to the emergency department with acute chest pain and an intermediate probability of acute coronary syndrome. Her workup per the guidelines involved rapid electrocardiogram, high-sensitivity troponins, nuclear stress testing, and eventually coronary invasive angiography. (Level of Difficulty: Advanced.).

Despite the fact that door-to-balloon times have been greatly reduced, the rates of death and the incidence of heart failure in patients with ST-segment elevation myocardial infarction (MI) have plateaued. There is still an unmet need to further reduce MI size in the reperfusion era. Most adjunctive therapies to enhance myocardial salvage have failed, but some have shown promise. Currently, the only adjunctive therapy in a pivotal trial that has demonstrated reductions in infarct size is localized delivery of supersaturated oxygen (SSO2) therapy. This review provides background on prior infarct size reduction efforts. The authors describe the preclinical data that shows the effectiveness of SSO2 in reducing MI size, improving regional myocardial blood flow and cardiac function, and reducing adverse left ventricular remodeling-presumably by reducing patchy areas of residual ischemia within the reperfused risk zone. Potential mechanisms by which SSO2 is beneficial are described, including the delivery of high levels of dissolved oxygen through plasma to ischemic, but viable, vascular and myocardial cells, thus allowing their survival and function. The authors then describe the SSO2 clinical trials, demonstrating that in patients with anterior ST-segment elevation MI, SSO2 therapy safely and effectively reduces infarct size, improves cardiac function, and reduces adverse left ventricular remodeling.

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