Right Insular Atrophy in Neurocardiogenic Syncope: A Volumetric MRI Study

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Fig 1.
Statistical parametric maps showing regional differences in GM volume between 32 patients with NCS and 32 controls. Orthogonal images show a reduction of GM volume in the right insula in patients with NCS compared with controls, superimposed on a standard template (P < .05, cluster-level-corrected for multiple comparisons by using family-wise error). The color bar represents the T values. The left side of each image is the left side of brain.
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Fig 2.
An illustration of segmentation and volume measurement of the right insula in a control subject (upper row, volume = 8119 mm³) and a patient (lower row, volume = 7247 mm³). The automatically segmented insular cortex is superimposed on axial (first column) and coronal (second column) GM images, and the third column illustrates a 3D reconstructed image of the right insula. The left side of each image is the right side of brain.
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Fig 3.
The relationship between the volume of the whole right insular cortex and BP changes in patients with NCS. Normalized right insular volume (raw volume/estimated total intracranial volume [eTIV] × 100) was negatively correlated with the extent of drops in systolic BP (SBP) (left panel, r = −.410, P = .020) and diastolic BP (DBP) (right panel, r = −.507, P = .003) during the head-up tilt test (Spearman correlation, P < .05).

Demographic data, clinical characteristics, and regional volumetry of patients with NCS and controls^a

	Patients with NCS (n = 32)	Controls (n = 32)	P Value
Clinical features
Age (yr)	24.1 ± 6.9	24.8 ± 5.2	.655
Male sex (No.) (%)	11 (34.4)	12 (37.5)	.794
Age of onset (yr)	20.8 ± 7.1
Disease duration (yr)	4.3 ± 4.7
No. of total syncope and presyncope attacks	38.4 ± 74.4
Head-up tilt test findings
Baseline systolic BP (mm Hg)	109.5 ± 12.2
Baseline diastolic BP (mm Hg)	62.0 ± 9.6
Baseline mean HR (beats/min)	67.7 ± 10.0
Change in systolic BP (mm Hg)	−40.5 ± 15.3
Change in diastolic BP (mm Hg)	−18.3 ± 10.1
Change in HR (beats/min)	−33.5 ± 15.8
Volume of structure (mm³)
R rostral anterior cingulate	2288 ± 416.3	2461 ± 425.2	.137
R caudal anterior cingulate	2386 ± 555.6	2488 ± 639.3	.498
R insula	7323 ± 689.1	8011 ± 932.5	.002
R amygdala	1755 ± 232.2	1829 ± 184.9	.339
L rostral anterior cingulate	2791 ± 484.6	3141 ± 589.7	.014
L caudal anterior cingulate	1819 ± 494.8	2142 ± 711.5	.063
L insula	7234 ± 649.5	7657 ± 701.0	.018
L amygdala	1770 ± 216.2	1816 ± 229.1	.963

Note:—R indicates right; L, left.
↵a The values are presented as means. An independent t test and χ² test were used to compare between-group differences in age and sex, respectively. MANCOVA adjusting for age,sex, and estimated total intracranial volume was performed to compare regional volumes of each structure between the groups.