The Borden and Cognard classification systems of DAVM
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DAVM are typically classified by location of the involved sinus or shunt as well as by the pattern of venous drainage. [5] The pattern of venous drainage is a key factor predicting the natural history of these lesions and provides the foundation for the widely adopted Borden [7] and Cognard [8] classification systems. Borden type I DAVM are mostly benign lesions that exhibit normal antegrade flow into a dural sinus. Type II lesions exhibit a degree of AV shunting exceeding the capacity of antegrade outflow from the involved sinus resulting in retrograde venous drainage into cortical veins. Type III lesions drain exclusively into cortical veins or a trapped sinus segment (sinus thrombosis at both ends from high-flow venous congestion). The Cognard classification is a modified version of the Djindjian classification and identifies five types of DAVM based on the pattern of venous outflow. Briefly, type I lesions exhibit normal antegrade flow into a dural sinus. Type II DAVM show retrograde venous drainage into the adjacent sinus segments (type IIa), cortical veins (type IIb) or both (type IIa+b). Types III and IV DAVM drain directly into cortical veins, either with (type IV) or without (type III) venous ectasia. Type V DAVM are typically localized to the tentorium or dural coverings of the posterior fossa and are further characterized by drainage inferiorly into spinal perimedullary veins.
Both classification systems have been validated and appear to correlate well with the risk of intracranial hemorrhage or non-hemorrhagic neurologic deficit (NHND). [9] Borden types II and III DAVM are associated with a more aggressive natural history and when technically feasible are generally treated because of their increased risk of symptomatic presentation. In a study that included 20 patients with Borden type II and III lesions, Duffau et al [10] found that rebleeding within 2 weeks after the first hemorrhage occurred in as many as 35% of patients and noted that rehemorrhage carried a worse prognosis than the initial hemorrhage. The authors recommended complete and early treatment of ruptured DAVM with cortical venous drainage (CVD). On the other hand, Borden type I DAVM generally have a benign natural history. In a study where 68 patients with Borden Type I DAVM were conservatively treated and followed for a mean of 27.9 months, Satomi and colleagues [11] found that only 1 patient suffered an intracranial hemorrhage and noted a benign and tolerable level of disease in 98.5% of cases. However, according to a recent report, the risk of conversion of a Type I lesion to a more aggressive lesion with CVD appears to be higher than previously reported (annual rate of 1%). [12] Any change in patient symptoms should therefore prompt repeat angiographic imaging to rule out the development of alternative drainage routes.
The annual risk of hemorrhage of DAVM varies between 1.8% and 15%. [13-14] The first hemorrhagic episode of a DAVM is associated with >30% mortality or serious disability.
The annual mortality rate for DAVM with CVD may be as high as 10.4% with a combined annual risk of intracranial hemorrhage and NHND of 15%. [15] Recent data suggest that the natural history of DAVM dependents not only on the pattern of venous drainage, but also on the mode of presentation. As such, Soderman et al [16] found that the annual hemorrhage risk of Borden Type II or III DAVM was 7.4% for patients presenting with intracranial hemorrhage compared with only 1.5% for those with non-hemorrhagic presentation. Likewise, in a study by Strom et al [17] that included 28 patients with Borden Type II or III DAVM, the risks of hemorrhage and NHND were 7.6% and 11.4% respectively for lesions with symptomatic CVD versus only 1.4% and 0% for those with asymptomatic CVD. Based upon these data, Zipfel et al [18] proposed the inclusion of the mode of presentation (symptomatic or asymptomatic CVD) into the Borden and Cognard classification systems to allow for more accurate risk stratification in patients with high-grade DAVM.
I | \n\t\t\tDrains directly into venous sinus or meningeal vein | \n\t\t\tNormal antegrade flow into dural sinus | \n\t\t
II | \n\t\t\tDrains into dural sinus or meningeal veins with retrograde drainage into cortical veins | \n\t\t\ta) Retrograde flow into sinus(es) b) Retrograde filling of cortical vein(s) a+b) Retrograde drainage into sinus(es) and cortical vein(s) \n\t\t\t\t \n\t\t\t | \n\t\t
III | \n\t\t\tDrains into cortical veins without dural sinus or meningeal involvement | \n\t\t\tDirect drainage into cortical veins without venous ectasia. | \n\t\t
IV | \n\t\t\t\n\t\t\t | Direct drainage into cortical veins with venous ectasia >5 mm and 3x larger than diameter of draining vein. | \n
V | \n\t\n\t | Drainage to spinal perimedullary veins | \n
The Borden and Cognard classification systems of DAVM
More recently, Geibprasert et al [19] have proposed an ambitious classification, conceptually unifying pathophysiologic consequences of cranial and spinal DAVM on an embryologic basis. The scheme is based on the venous afferent patterns of three epidural spaces: 1) the ventral drainage group derived from the notochord and corresponding sclerotome extending from the base of the sphenoid to the sacrum, 2) the dorsal epidural space derived primarily from the dorsally located intracranial dural sinuses as this space is not well-developed in the spine, and 3) the lateral epidural shunts located where lateral pial emissary bridging veins pierce the dura. By examining 300 patients with DAVM and categorizing their lesions by their respective afferent venous patterns, Geibprasert et al were able to establish some clinical generalizations about each group. Ventral epidural shunts demonstrated a 2.3:1 female predominance and were less likely associated with cortical venous reflux unless there was extensive thrombosis of the epidural drainage or an especially high-flow shunt. Similarly, dorsal epidural shunts were less likely to reflux into the cortical veins unless thrombosis was present. These lesions did not demonstrate sex predominance but did tend to occur in a lower age group (pediatric) and more frequently occur as multiple lesions. The lateral epidural shunts tended to present in older patients and were more common in men. These lateral lesions were always clinically aggressive and demonstrated significant cortical venous reflux.
The clinical features associated with DAVM generally depend on the location of the lesion, the extent of the AV shunting, and associated abnormalities of venous drainage. [20-21] Symptoms may be indistinguishable from those associated with pial brain arteriovenous malformations and may include headache, diplopia, blurred vision, or neurologic dysfunction. Focal neurologic deficits and seizures may develop in relation to disturbances in regional cortical venous drainage resulting from the redirection of venous flow from the shunt into pial veins, potentially congesting venous territory remote from the site of the dural fistula. In patients with severe compromise of the deep venous drainage of the brain or with diffuse intracranial hypertension resulting from the obstruction of both sigmoid sinuses, the clinical presentation may include dementia. [5] Dementia may also develop in patients with superior sagittal sinus DAVM due to venous congestion of bilateral frontal lobes. Closure of the arteriovenous shunts may successfully reverse this state only when there are adequate residual venous channels available for the normal venous drainage of the brain. Rarely, cranial neuropathy or unilateral visual phenomena may arise secondary to arterial steal without evidence of associated venous hypertension. [22] Focal symptomatology may worsen or change as a result of the redirection of venous outflow from a DAVM. For example, progressive thrombosis and occlusion of the inferior and superior petrosal sinuses may be associated with worsening of signs in a patient with a cavernous sinus DAVM draining anteriorly through the ipsilateral ophthalmic veins. If contralateral drainage is available, the venous sinus hypertension may be transmitted to the contralateral cavernous sinus, leading to development of bilateral orbital symptoms.
The signs and symptoms of increased intracranial pressure occasionally complicate cases of DAVM. In certain cases this can be attributed to diminished CSF absorption through the arachnoid villi resulting from the transmission of increased venous pressure throughout the superior sagittal sinus. Patients may present with typical symptoms of normal pressure hydrocephalus, such as progressive dementia, gait disturbance, and urinary incontinence. [23] Alternatively, obstruction of the cerebral aqueduct secondary to compression of the mesencephalon by an ectatic draining vein may occur, leading to obstructive hydrocephalus. [24]Moreover, aneurysmal venous ectasia may unusually cause symptomatic mechanical compression of adjacent neurologic structures, most commonly in DAVM draining into pial veins of the posterior fossa. This is particularly true for type IV DAVM, which not infrequently present with clinical symptoms related to mass effect caused by pronounced venous ectasia. [5]
Approximately 20 to 33 percent of patients with symptomatic DAVM present with an intracranial hemorrhage. This most frequently is encountered in lesions involving the floor of the anterior cranial fossa or the tentorium cerebelli; however, it may occur in any case associated with cortical venous drainage, particularly in the presence of significant cerebral venous ectasia.2 In a recent large study by Bulters et al, [25] DAVM associated with venous ectasia had a 7-fold increase in the incidence of hemorrhage (3.5% no ectasia vs 27% with ectasia). Therefore, patients with venous ectasia may represent a high-risk group that requires rapid intervention.
For those DAVM that present in ways other than hemorrhage, the clinical presentation depends entirely on the grade, location and venous afferent pattern of the fistula. This allows DAVM to be categorized clinicoanatomically into those involving the cavernous sinus, transverse and sigmoid sinuses, superior sagittal sinus, petrosal sinus, torcular, tentorial incisura, and anterior cranial base.
Approximately one-third to one-half of symptomatic intracranial DAVM involve the transverse and sigmoid sinuses. [26] Nearly half present with a subjective bruit as the first clinical manifestation due to proximity of the draining sinus to the middle ear. The tinnitus is synchronized to arterial pulsations and results from increased blood flow into the sigmoid or transverse sinuses. Auscultation over the retroauricular area usually reveals the pulsatile bruit. As with the other DAVM, additional neurologic symptoms and findings generally depend on the pattern of venous drainage encountered in the individual patient. Symptoms may include chronic signs of increased intracranial pressure potentially leading to papilledema and optic atrophy in addition to disturbances related to balance and hearing. Aggressive neurologic symptoms may occur in up to 27% of patients with transverse and sigmoid DAVM. In progressive cases, associated with obstruction of the ipsilateral jugular outflow redirected venous drainage into pial veins of the posterior fossa may result in brain stem or cerebellar dysfunction as well as posterior fossa hemorrhage. Rerouting of drainage into the supratentorial cortical venous compartment may be associated with the development of focal neurologic deficit or seizures as well as increased risk of intracranial hemorrhage. Spontaneous occlusion of transverse and sigmoid DAVM is rare (5%) and generally occurs after hemorrhagic events.
DAVM involving the superior sagittal sinus, tentorial incisura, petrosal sinuses, and anterior cranial base occur less frequently than DAVM involving the transverse, sigmoid, or cavernous sinuses. [5, 27] In these lesions, symptoms typically depend on the route of abnormal venous drainage and associated pattern of venous hypertension, and may include dysphasia, hemiparesis, hemisensory deficits, and abnormal visual phenomena. Several specific features deserve particular attention. (1) Dural fistulas involving the floor of the anterior cranial fossa are usually associated with drainage into ectatic parasagittal cortical veins and often present with intracranial hemorrhage. [27] Moreover, these patients may exhibit unilateral visual loss secondary to arterial steal from the ophthalmic circulation into ethmoidal and recurrent meningeal supplies to the shunt. Although a majority of these lesions are treated with open surgery, embolization through the ophthalmic artery can be undertaken with a reasonably high success rate and low complication risks. [28] (2) DAVM of the petrosal sinuses or tentorial incisura may occasionally drain inferiorly into perimedullary veins of the spinal cord (type V), resulting in progressive myelopathy similar to that encountered in spinal dural AVMs. [26] Assuming the venous sinus drainage of the brain is otherwise unimpaired, these symptoms usually respond well to endovascular or surgical closure of the shunt. Tentorial DAVM drain only via the leptomeningeal-cortical venous system. Consequently, they behave aggressively with severe hemorrhagic and nonhemorrhagic symptoms occurring in 19% and 10% of cases per year. Also, it is not uncommon for such lesions to cause fatal bleeding in the posterior fossa. Therefore, they should be treated aggressively by endovascular and/or surgical means to disconnect the venous drainage system and minimize the risk of hemorrhage and NHND. Superior sagittal sinus DAVM are frequently associated with restrictive change of the superior sagittal sinus and retrograde CVD. Thus, aggressive neurologic symptoms are common and occur in nearly one-half of cases. [29]
DAVM most frequently involve the transverse sinuses. Arterial supply to fistulae of this region predictably derive from identifiable supratentorial and infratentorial sources. The supratentorial group is usually organized around 1) contributors to the basal tentorial arcade, typically including the petrosal and petrosquamosal divisions of the MMA and the lateral division of the meningohypophyseal trunk off the ICA, and, occasionally 2) tranosseous branches of the posterior auricular artery. The infratentorial group commonly involves the jugular division of the ascending pharyngeal artery, transmastoid and more distal transosseous branches of the occipital artery, and the posterior meningeal arteries and artery of the falx cerebelli, either of which can variably arise from the occipital, vertebral or ascending pharyngeal arteries as well as rarely directly from the PICA. With higher flow lesions indirect contribution from contralateral sources may be seen but this usually involves anastomosis with one of the above-mentioned conduits as a final common pathway.
In terms of embolization hazards, the petrosal branch of MMA notably gives rise to a branch which anastomoses with the stylomastoid branch of the occipital or posterior auricular arteries forming an arterial arcade within the facial canal which if aggressively embolized (inadvertently) may result in damage to the facial nerve. In that the petrosal branch of the MMA usually participates in the supply of transverse sinus DAVM through the basal tentorial arcade, its contribution to the lesion commonly can be indirectly devascularized by accessing the basal tentorial arcade posterolaterally through the petrosquamosal division of the MMA avoiding the need for direct catheterization and embolization of the petrosal branch altogether. The basal tentorial arcade is an arterial network extending along the insertion of the tentorium into the petrous ridge from the petroclinoid ligament laterally to the transverse sinus. The jugular division of the APA enters the cranial vault via the jugular foramen supplying CN 9,10,11 before dividing into medial and lateral divisions. The medial division courses along the inferior petrosal sinus where it supplies CN 6 and anastomoses with the medial division of the lateral clival branch of MHT. The lateral division runs superiorly along the sigmoid sinus and vascularizes the dura along the transverse sigmoidal confluence. In very high flow fistulae of the distal transverse sinus or lesions of the sigmoid sinus and foramen magnum, recruitment of supply through the hypoglossal division of the ascending pharyngeal artery may be seen (particularly where this artery gives rise to the ipsilateral posterior meningeal artery. Transarterial embolizations through this division of the APA (particularly with liquid embolic agents) may result in injury to CN 12 leading to ipsilateral paresis of the tongue.
DAVM of the cavernous sinus (CSDAVM) are most commonly seen in female patients and generally associated with orbital signs and symptoms that fluctuate depending on alterations in orbital venous outflow, which develop secondary to thrombosis and changes in head position. Patients typically present with the gradual onset of focal or diffuse chronic eye redness distinguishable from uveitis. Close inspection reveals dilated tortuous conjunctival and epibulbar vessels that exhibit an acute angulation near the ocular limbus. [30-31] These lesions are often associated with an elevation of episcleral venous pressure leading to a persistent rise in intraocular pressure in the affected eye, potentially resulting in the development of glaucoma. If both cavernous sinuses become involved in the venous drainage secondary to a change in the ipsilateral venous outflow of the affected cavernous sinus, the ocular findings may become bilateral. The patient may complain of pulsatile tinnitus, and in 25 percent of cases a bruit can be auscultated over the orbit. [5] Cranial neuropathies, most commonly involving the sixth nerve, frequently lead to ocular motor dysfunction, which also may be exacerbated by orbital venous congestion and proptosis. More important to the planning of embolization are the hypoxic ischemic retinal changes that develop in approximately 15 percent of patients. [21] Rarely, if thrombosis in the cavernous sinus is extensive, abnormal drainage into cerebral veins may occur, increasing the likelihood of an intracranial hemorrhage or venous infarction. [5] Unfortunately, frequently cited classification schemes of intracranial DAVM are deficient in their handling of CSDAVM due to the lack of explicit consideration given to ophthalmic venous drainage and the clinical consequences of orbital venous congestion. Despite the lack of a coherent classification scheme for CSDAVM, the implications of venous outflow from these lesions are similar to DAVM at other locations and the analysis of venous drainage is important in understanding the pathophysiology of the disease at this site. An excellent study of the clinical manifestations in 85 patients with CSDAVM relative to their angiographic characteristics was reported by Stiebel-Kalish et al. [32-33] In this study, the clinical symptoms found in patients with CSDAVM were related to the abnormal venous drainage and could be predicted by analysis of the aberrant venous drainage patterns. Interestingly, central nervous system symptoms or dysfunction, were found in 7 (8%) of these patients, attesting to the potential danger of cortical venous drainage even among patients with CSDAVM. Spontaneous regression of CSDAVM is a well-described phenomenon that is observed in 10%–50% of cases. [29]
The vascular supply to the dura of the cavernous sinus is complex because of extensive regional anastomoses between dural branches of the internal carotid and branches of the internal maxillary artery (middle meningeal, and accessory meningeal arteries, and the artery of the foramen rotundum). Moreover, the ophthalmic artery may participate indirectly via a tentorial branch of the recurrent meningeal artery. From the perspective of angiographic workup and embolization, these lesions may be divided conceptually into two groups: (1) an anterolateral group, arising from the orbital apex and lateral cavernous sinus, and (2) a posterior group, including the posterior cavernous sinus, petroclinoid ligament, and dorsum sella.
The meningeal supply to anterior division lesions may be considered to reflect the hemodynamic balance between branches arising from the horizontal segment of the cavernous internal carotid artery, most notably the inferolateral trunk (ILT) and meningeal branches of the internal maxillary artery. This latter group includes cavernous and recurrent tentorial branches of the MMA, cavernous meningeal branches of the accessory meningeal artery, and the artery of the foramen rotundum. As expected, embolization of these meningeal arteries should be preceded by superselective angiographic analysis to prevent inadvertent embolization into the internal carotid artery or possible damage to the orbit or regional cranial nerves.
The supply to posterior division lesions is derived primarily from medial and lateral clival (meningohypophyseal) branches of the internal carotid artery and their potential anastomotic connections with branches of the ascending pharyngeal and middle meningeal arteries. These most notably include the ascending clival and inferior petrosal arcades, derived from the hypoglossal and jugular divisions of the ascending pharyngeal artery, respectively; the posterior cavernous branches of the MMA; and the basal tentorial arcade supplied by the petrosal and the petrosquamosal branches of the MMA.
Three critical points should be considered before embolization of fistulae involving this territory. (1) The vascular supply to the intrapetrous facial nerve should be determined. This may arise primarily from the petrous branch of the MMA. For this reason, petroclinoid lesions supplied by the basal tentorial arcade should be embolized preferentially from the petrosquamosal branch of the MMA, thereby avoiding the proximal petrosal artery. (2) Potential contributions from the contralateral internal carotid and ascending pharyngeal arteries via transclival anastomoses should be evaluated, particularly in lesions involving the dorsum sellae. (3) Because embolization of upper clival and petroclinoid lesions may involve the hypoglossal or jugular division of the ascending pharyngeal artery, attention must be directed to the possibility of iatrogenic lower cranial neuropathy when using NBCA, Onyx, or ethanol. Midline lesions requiring aggressive embolization of pedicles from both ascending pharyngeal arteries should be performed as a staged procedure on different days, specifically to avoid development of bilateral hypoglossal nerve deficits.
The simplest and most commonly utilized route to access the cavernous sinus is through the inferior petrosal sinus. Guidewire or microcatheter navigation through the sinus may be complicated by vessel rupture. Alternatively, access to the cavernous sinus may be obtained through the facial vein or the superficial temporal vein. Direct operative cannulation of the superior ophthalmic vein is also an acceptable route to the cavernous sinus when other approaches have been exhausted. [34]
Recent advances in both computed tomography (CT) and magnetic resonance imaging (MRI) have significantly contributed to the initial diagnostic evaluation of patients with suspected DAVM. Because CT and MRI findings are nonspecific, however, the diagnosis can be delayed or missed. Routine conventional head CT is the first-line investigation of patients presenting with tinnitus, headache or other neurological symptoms. Its value is limited to identifying intracranial hemorrhage and edema due to venous congestion (area of low density). Focal or generalized atrophy of the brain, possibly accompanied by hydrocephalus, are nonspecific secondary findings that may be appreciated. Although not infrequently diagnostically equivocal, MRI is more helpful than CT because it can reveal dilated vessels, thrombosed venous structures, and prominent vascular enhancement particularly in patients with DAVM associated with CVD. The combination of prominent flow voids on the cortical surface and high-intensity lesions in the deep white matter on T2-weighted images secondary to venous hypertension/congestion is highly suggestive of a DAVM. Despite the presence of these secondary signs that suggest the presence of a DAVM, conventional MRI alone is generally unsuccessful in defining the exact site of fistulization. Any suspicious findings on CT/MRI should prompt catheter angiographic evaluation.
The advent of CT angiography (CTA) and magnetic resonance angiography (MRA) has provided more power to the noninvasive screening of patients with suspected DAVM. In addition to providing anatomic details, these modalities may be coupled with perfusion studies to evaluate the effect of a DAVM on regional blood flow.
CTA aids in the accurate diagnosis and characterization of DAVM by localizing the fistula and demonstrating the pattern of venous drainage and supplying arteries. Overlapping bone structures may make it difficult to demonstrate the detailed vascular pattern of DAVM especially for smaller lesions. The sensitivity of CTA for diagnosis of DAVM is reportedly lower than the sensitivity of MRA (15.4% versus 50%). [35] Lee et al [36] recently introduced a CTA algorithm for bone removal (hybrid CTA) that eliminates bone structures while preserving enhancing transosseous vascular structures. They found that the technique provides valuable information for treatment planning and carries a sensitivity of 93% and a specificity of 98%. In addition, recent studies have shown that 4D CTA with high spatial and temporal resolution are suitable for the diagnosis, classification, treatment planning, and follow-up imaging of DAVM. [37-38]
MRA may be performed using a three-dimensional time-of-flight (3D TOF) technique or MR digital subtraction angiography (MR DSA). [39-42] The presence of multiple high-intensity curvilinear or nodular structures adjacent to a sinus, in conjunction with high-intensity foci within the sinus is considered suspicious for a DAVM; however, the technique still suffers from a high false positive rate, with as many as 14% of otherwise healthy patients incorrectly identified as possibly harboring a DAVM by 3D TOF MRA. Although the current spatial resolution of MR DSA is less than 3D TOF MRA, the benefit of MR DSA would be related to the temporal resolution of the technique and the ability to depict flow within cortical veins, particularly important in those patients with retrograde flow from a DAVM.
Despite the advances in both CTA and MRA, conventional digital subtraction angiography remains paramount in the diagnosis and pretreatment evaluation of intracranial DAVM.
The angiographic evaluation usually includes selective studies of the internal and external carotid arteries bilaterally as well as of both vertebral arteries when evaluating lesions of the posterior fossa or tentorium. The pretherapeutic examination must be tailored to the clinically suspected location of the fistula and must disclose the entire arterial supply, as well as any anastomoses between the supplying vessels and arterial distributions to the orbit, brain, or cranial nerves. This usually requires superselective arterial catheterization and angiography before the use of embolic materials. The venous anatomy must be studied with respect to the pattern of drainage from the fistula, and the adequacy of normal venous drainage of the brain must be assessed.
Because many DAVM regress spontaneously or remain asymptomatic throughout the patient’s life, it is crucial to weigh the risks of treatment against the natural history of these lesions. Management should be tailored to the type of lesion (location, classification, and angiographic features) and individual patient history (age, clinical presentation, and comorbidities) and may include relief of symptoms or complete occlusion of the DAVM. Although spontaneous resolution of clinical signs related to DAVM is not uncommon, most symptomatic lesions require some form of treatment. Treatment options include observation, carotid-jugular compression, transarterial embolization, transvenous embolization, open surgery and stereotactic radiosurgery. In the majority of patients, a multimodality approach with a combination of treatment offers the best chance for success.
Patients with Type I DAVM are at low risk of hemorrhage and should be managed conservatively unless they have disabling clinical symptoms like tinnitus or develop new neurological deficits or CVD at follow-up. Expectant follow-up of asymptomatic lesions should include serial MRI to detect changes in the DAVM anatomy. Angiographic follow-up should also be considered every few years especially for DAVM of the anterior cranial fossa or the tentorial incisura, which commonly develop CVD. Patients with symptomatic type II or III DAVM should be treated aggressively to minimize the risk of hemorrhage and NHND. The management of asymptomatic type II and III lesions should take into consideration the patient’s age, treatment decision and risk of future hemorrhage. Intervention is often favored over observation because of the long-term risk to the patient and the dismal natural history of an intracranial hemorrhage.
Transvenous embolization with metallic coils or detachable balloons has been advocated primarily for the treatment of DAVM involving the transverse, sigmoid or cavernous sinuses. The technique involves a transfemoral or intraoperative approach to the affected venous sinus following which coils, balloons or liquid embolic agents are deposited adjacent to the shunt. Several features are critical in appropriate patient selection for this method of treatment. (1) The segment of sinus to be occluded must be in proximity to the fistula and receive its entire venous drainage. (2) The sinus to be occluded should not be essential to the normal venous drainage of the brain. The cerebral venous drainage must be thoroughly evaluated before embolization to determine the alternate pathways for cerebral venous outflow and avoid potential venous infarction or hemorrhage. (3) The target sinus must be completely occluded throughout the involved segment to avoid diversion of fistulous flow into confluent cerebral veins and worsening of CVD. Such redirection of a high flow shunt into previously uninvolved low capacitance venous channels may precipitate an acute venous infarct or hemorrhage.
Levrier et al developed a novel way to treat DAVM that would preserve the venous sinus. [46] In ten patients including fistulas grade I-IV both with and without sinus stenosis, the researchers used a transvenous approach to angioplasty the involved sinus and then placed stents with high radial force to bridge the ostia of cortical veins draining into the sinus. Their follow-up at 7 months by conventional angiography revealed that four patients had complete DAVM occlusion and four had significantly reduced flow through the fistula. Two subjects refused repeat angiography. At two years, CTA confirmed stent patency in eight out of nine patients imaged. The safety and long-term efficacy of this technique, however, require further investigation.
Transvenous embolization is particularly useful for DAVM with multiple arterial feeders. Typically, involved arteries are small and torturous arterial feeders, which renders selective catheterization extremely challenging or hazardous. Ease of access to the fistulous site and the ability to obliterate the fistula in a single session are important advantages of this approach. Transvenous embolization is associated with a low complication rate and high rates of cure and complete occlusion of the fistula. [47-48] Transvenous embolization, however, is less suited for DAVM involving the superior sagittal sinus. It can also be associated with severe complications, including vessel rupture, sinus venous thrombosis, venous infarction, hemorrhage, and neurological deficits related to disruption of venous drainage. [49] Hemorrhage may be related to vessel injury or to the sacrifice of a dural sinus draining normal brain parenchyma. Additionally, transvenous embolization is rarely associated with the development of de novo DAVM at secondary intracranial sites following occlusion of the primary lesion. While the etiology of these secondary de novo fistulas is unclear, they may arise from angiogenesis induced by venous hypertension secondary to the occlusion of the major dural sinuses targeted by transvenous embolization.
Under some circumstances, transarterial embolization with liquid embolic agents offers advantages over a transvenous approach. Not infrequently, transvenous access to the DAVM is limited by venous sinus occlusion or high-grade stenoses preventing transvenous catheterization. Likewise, high-grade lesions emptying directly into remote small cerebral veins may be inaccessible to uncomplicated venous catheterization. As such, tentorial incisura and anterior cranial fossa DAVM, which frequently behave aggressively, may not be accessed transvenously. Transarterial delivery of a liquid embolic agent capable of permeating the vascular apparatus of the shunt provides the means for discrete definitive occlusion of the fistula site and reduces the likelihood for diversion of shunt flow into more dangerous alternate venous pathways while enabling closure of the fistula without necessarily sacrificing an entire venous conduit that may be critical to the drainage of normal brain parenchyma. Conversely, incomplete occlusion of the fistula by transarterial embolization is usually complicated by recruitment of new collateral vessels that are smaller, more tortuous and less amenable to embolization. Complex fistulas may require a multistaged approach combining transarterial and transvenous techniques to eliminate CVD and occlude the fistula.
Transarterial embolization may be effective in palliating disabling symptoms through occlusion of arterial feeders even without angiographic cure of the DAVM. Transarterial embolization also plays an important role in decreasing flow through DAVM before surgical intervention, transvenous obliteration, and radiosurgery. [50-51]
The transarterial approach requires selective catheterization of individual feeding vessels followed by superselective angiography to evaluate the vascular supply to the fistula, particularly with respect to potential anastomoses with the orbit or cerebral vasculature. It is important to understand that such anastomoses may not be demonstrable on the initial angiograms but may become manifest as progressive embolization produces alterations in flow within the target vascular territory.
Guidewire-directed microcatheters are typically employed in the catheterization of meningeal branches supplying such lesions. The embolic agents commonly used in transarterial embolization of DAVM are liquid cyanoacrylate (NBCA), Onyx, polyvinyl alcohol foam (PVA), or ethanol. Ideally, liquid embolic agents, delivered close to the shunt under wedged-microcatheter induced flow arrest, present the best opportunity for embolotherapeutic cure of the lesion as it enables permeation of the collateral complex supplying the fistula and its immediate venous receptacle thus permanently occluding the shunt. Such a degree of permeation is not possible using particulate agents that characteristically lodge within arterioles of the peri-fistula microcollateral network at a point proximal to the shunt. If not fully permeated, these microcollateral networks will then evolve and reestablish flow through the shunt complex.
Also, the particles degrade within days to weeks, resulting in high recurrence rates of the fistula and possibly in extensive shunting into leptomeningeal veins. Transarterial embolization with PVA is therefore used to relieve symptoms or in combination with other procedures such as radiation, surgery, or transvenous embolization. As with PVA, embolization with coils alone does not provide complete obliteration of DAVM. [52]
Nevertheless, PVA may find use in several situations. First, the initial use of PVA in embolizing the less favorable arterial supplies to a multi-pedicle fistula, may facilitate more complete subsequent embolization of the shunt with liquid embolic agents through a safer conduit. The embolization of competing inflows to the shunt with PVA allows the undiluted permeation of the fistula by the liquid embolic agent without fragmentation of the glue column. PVA may also be useful in reducing flow through low-velocity shunts, thereby facilitating thrombosis in these DAVM. This can be particularly applicable in managing low flow CSDAVM, and may be combined with manual compression in treating lesions also supplied by cavernous segment dural branches of the ipsilateral ICA.
In certain situations, partial embolization of dural fistulas may be performed in an attempt to alleviate disabling symptoms. For example, partial embolization of a cavernous sinus DAVM can reduce intraocular pressure in a patient suffering acute deterioration of visual acuity. Aggressive treatment in such cases may not be needed unless symptoms are particularly disabling or the DAVM is associated with CVD. Partial embolization may also be advocated in patients presenting with new-onset dementia or in those patients with severe tinnitus. Lastly, PVA and liquid embolic agents are used in the preoperative devascularization of dural fistulas prior to surgical excision. In this situation, particulate embolic agents, because of their low morbidity, are generally preferred and should be applied 1 to 2 days before surgery.
NBCA has been widely utilized for transarterial embolization of DAVM with fairly good results. Guedin et al [53] treated 43 patients with Borden Type II or III DAVM using NBCA and reported complete obliteration of the fistula in 34 patients (79%) and occlusion of CVD in all remaining cases. There was no treatment-related mortality or permanent morbidity in the series. Interestingly, they reported post-embolization secondary thrombosis in 5 patients in whom residual flow was noted on the immediate post-treatment angiograms. In a recent large study by Kim et al [54] that included 121 DAVM treated with transarterial glue embolization, immediate cure was achieved in 14.0% of lesions, and progressive complete thrombosis of the residual shunt at follow-up in 15.7% of lesions. Surgical CVD disconnection or transvenous coil embolization was necessary for clinically important residual shunts in as many as 45.2% of all cases. Procedural complications were seen in 7.8% of patients in the series.
However, use of NBCA has some disadvantages. It is an adhesive agent that undergoes rapid polymerization at contact with blood, which may increase the risk of microcatheter retention or avulsion of the feeding artery upon removal of the microcatheter. The injection must be performed quickly and continuously, which may diminish the precision of injection and result in suboptimal penetration into the fistulous site. Use of a wedged microcatheter technique with low-concentration glue may maximize glue penetration into the venous drainage route (Figure 1).
Frontal (A) and lateral (B, C) views of digital subtraction angiography (DSA) in a 50-year-old woman who sustained an intraventricular hemorrhage showing a DAVM fed by posterior branches of the pericallosal artery and draining into the straight sinus. Frontal (D) and lateral (E) views of DSA following embolization with 0.4 mL of NBCA 40% showing complete occlusion of the fistula. Frontal (F) and lateral (G) views of follow-up DSA 7 months later showing durable occlusion of the DAVM.
Recently, the introduction of Onyx has added an important element to the endovascular armamentarium and improved the endovascular treatment of DAVM. Onyx is comprised of ethylene vinyl alcohol copolymer dissolved in DMSO (dimethyl sulfoxide), and suspended micronized tantalum powder to provide contrast for visualization under fluoroscopy. Onyx offers several advantages over NBCA, which allow for safer and more efficient treatment of DAVM. Due to its lava-like flow pattern and its nonadhesive nature, Onyx facilitates longer, slower, and more controlled injections with better penetration of the fistula. It also allows embolization of a substantial portion of the lesion from a single pedicle injection because the agent can efficiently penetrate the depths of the fistulous connection and then flow into adjacent arterial feeders, thereby obviating the need for multiple embolizations. The interventionalist can even discontinue Onyx injection for angiographic assessment of the embolization and evaluation of collateral and en passage feeders that may become evident during the course of embolization. Additionally, Onyx is less adherent to the microcatheter than NBCA with possibly a lower risk of catheter retention and arterial rupture. The middle meningeal artery provides an excellent route for Onyx injection with particularly high curative rates according to several reports. [55-57] The middle meningeal artery is easy to catheterize and its branches are anchored to the dura and calvarium, which facilitates removal of the microcatheter and minimizes the risk of arterial avulsion.
Onyx has some disadvantages compared to NBCA, namely an increase in fluoroscopy time, procedure time, and procedure cost. Cranial nerve injury and DMSO-induced angiotoxicity are additional disadvantages of Onyx. There is also a risk of distal embolization of the embolic material into the venous system and the pulmonary circulation.
Several investigators have reported remarkably high cure rates with this embolic agent, with a high proportion of treatments completed in a single session. [49] Cognard et al enrolled 30 patients in a prospective trial: ten were graded type II, eight type III and twelve type IV fistulas. [55] They reported complete anatomic cure in 24/30 patients with only two complications, including a temporary cranial nerve palsy and post-procedure hemorrhage secondary to venous outlet thrombosis. Lv et al report their experience with 40 patients suffering from DAVM. [27, 58] They report a complete occlusion rate of 25/40 or 62.3%. Nine patients suffered complications including reflexive bradyarrhythmia in 3 patients, hemifacial hypoesthesia in 3, hemifacial palsy in 2, posterior infarction in 2, jaw pain in 1, hallucinations in 1, Onyx migration in 1 and retention of a microcatheter tip in 1. Abud et al [59] treated 44 DAVM with Onyx and achieved occlusion of the shunt in all but 9 patients, 5 of whom were successfully treated by complimentary transvenous embolization with coils and Onyx. In as many as 81% of cases, a cure was obtained in a single session. Six complications were observed including 4 cranial nerve injuries and 2 cases of venous thrombosis post-embolization. In a series of 29 DAVM treated with Onyx embolization, mostly through a transarterial approach, Stiefel et al [56] achieved an angiographic cure in 72% of all lesions, with complications occurring in 9.7% of cases and leading into permanent morbidity in only 2.4%. We have recently reviewed our experience in 39 patients with DAVM treated between 2001 and 2009 at Jefferson Hospital for Neuroscience. We found no major procedure-related complications in the series and achieved an obliteration rate of 75% with elimination of CVD in up to 85% of patients with Onyx embolization (Figure 2-3).
Frontal (A) and lateral (B) views of digital subtraction angiography (DSA) in a 66-year-old woman who sustained a subarachnoid hemorrhage showing an ethmoidal DAVM, fed by the ophthalmic artery and anterior ethmoidal branches, as well as an orbito-frontal branch of the anterior cerebral artery. A small 1 mm aneurysm is seen on the orbito-frontal feeding vessel. The DAVM demonstrates CVD with a draining vein entering the anterior 1/3 of the superior sagittal sinus. (C) Superselective injection through the orbito-frontal pedicle showing the aneurysm and the fistula. The aneurysm and the fistula were embolized with 0.1 ml of Onyx through the orbito-frontal pedicle. Frontal (D) and lateral (E) views of DSA after embolization showing obliteration of the aneurysm and the fistula.
Lateral views of left common carotid artery (A) and left external carotid artery (B) injections of DSA in a 65-year-old woman with severe disabling tinnitus showing a tentorial DAVM draining into the transverse-sigmoid junction with no evidence of CVD. Feeding vessels arise from the superficial temporal artery, middle meningeal artery, occipital artery, and posterior auricular artery. The fistula was treated by embolization with Onyx and PVA through the left occipital artery, left middle meningeal branches, left posterior auricular artery, and superficial temporal arteries. Frontal (C) and lateral (D) views of DSA after embolization showing significant reduction in flow through the fistula.
A few investigators have used Onyx in a transvenous approach to carotid-cavernous fistulas. After an unsuccessful embolization of a C-C fistula using detachable coils and liquid adhesion agents, Arat et al successfully completed the embolization by injecting Onyx into the cavernous sinus forming a cast of the structure. [60-61] Similarly, He et al report their experience in 6 patients using a combination of detachable coils and Onyx via a transvenous approach. [62] Four of the six cases were completely embolized in one attempt, whereas the other two required staged procedures. In these latter two cases the patient suffered minor transient cranial nerve palsies. Suzuki et al report equally good results in three patients with spontaneous C-C fistulas. [63] In all these studies patients experienced rapid relief of their neuro-ophthalmologic symptoms. El Hammady et al [64] treated 12 patients with C-C fistulas using Onyx, 8 through a transvenous route and 4 through a transarterial route. All lesions in their series were obliterated in a single session with resolution of presenting symptoms in 100% of patients by 2 months. Cranial neuropathies, however, were noted in 3 patients likely from post-embolization cavernous sinus thrombosis and swelling or from cranial nerve ischemia/infarction from deep penetration of Onyx. We have recently reported on Onyx embolization of C-C fistulas through a surgical cannulation of the superior ophthalmic vein in a series of 10 patients. [34] We achieved complete obliteration of the fistula in 8 patients and a significant reduction in fistulous flow in 2 patients, with no procedural complications.
With the advent of Onyx, most lesions can now be successfully managed with endovascular therapy. However, surgical treatment of DAVM may still be necessary when endovascular options have failed. Surgery consists of disconnection of draining veins, disconnection of arterial feeders, resection/packing of the dural sinus, and/or direct puncture and embolization of large varices or meningeal arteries. Hoh et al [65] described a technique whereby the draining vein is clipped close to the fistula with extensive dural coagulation.
DAVM of the anterior cranial fossa and the superior sagittal sinus are more suitable for surgical treatment than other types of DAVM. Transarterial embolization plays an important role in decreasing flow through the DAVM prior to surgical intervention and facilitates operative exposure of the involved segment of the dural sinuses, thus affecting the quality and completeness of surgical excision.
Stereotactic radiosurgery is an acceptable option for DAVM not amenable to surgical or endovascular therapies. It is best suited for benign lesions without CVD (type I) and for low-flow cavernous DAVM (which typically do not have CVD). Radiosurgery induces thrombogenic obliteration of DAVM with a latency period of up to two years. This treatment modality is therefore not suitable for DAVM with CVD because such lesions have a malignant natural history and require rapid and definitive treatment via surgical or endovascular means. A recent review of 14 studies found that stereotactic radiosurgery with or without adjunctive embolization results in DAVM obliteration in 71% of cases and post-treatment hemorrhage in 1.6% of cases (4.8% of lesions with CVD). [66] Despite these promising results, experience with radiosurgery in DAVM treatment remains limited and the efficacy of the technique requires more investigation in large prospective studies. Meanwhile, stereotactic radiosurgery should be reserved for lesions that are not amenable to surgical or endovascular interventions.
Recent advances in endovascular therapies and studies of the anatomical and functional properties of DAVM led to a rapid evolution in their diagnosis and management. Onyx embolization through transarterial or transvenous approaches has emerged as safe and highly efficient treatment for even the most complex lesions. However, the decision of which approach and embolic agent to use for treatment of a DAVM must be tailored to each individual case, recognizing that the most effective approach for permanent DAVM treatment, particularly in high-flow shunts, may require a combination of approaches and embolic agents. Treatment of DAVM should be entrusted to a multidisciplinary team with ample expertise in the management of these often challenging lesions.
The publication of Shannon’s fundamental works [1, 2] coincided with the appearance of the first computers and urgent need for the development of fast and reliable channels for digital data transmission. Shannon’s theory led to the almost immediate development of backgrounds of the coding and digital CS theory. The parallel fast development of high-resolution AD-DA converters and digital technologies made digitizing and coding the basic principle of signal transmission.
The side effect of the successes of digital CS was initial lack of interest in CS with feedback channels (FCS) and codeless signals transmission, although this possibility was noted by Shannon in [1, 2]. The first work of Elias [3] in this direction was published seven years later, in 1956. The results of the work showed that ideal feedback channel and proper setting of the modulation gains permit to transmit analog signals without coding in real time with the limit bit rate equal to the capacity of the forward channel—the result unfeasible in digital CS with coding. Moreover, the absence of coders radically simplified the construction of FCS transmitters. Initially not noticed, this work initiated a great cycle of research in the optimization of FCS (see e.g. [4, 5, 6, 7, 8, 9, 10, 11, 12, 13]) carried out in 1960s in MIT, Bell Lab., Stanford University, NASA, and other research centres. The results of these investigations unambiguously confirmed that modulation and feedback enable a development of simple CS transmitting signals and short codes in real time perfectly and with minimal distortion. Moreover, analytical results of the research determined a way to design of the perfect FCS design.
However, since the mid-1970s, interest in the research in the FCS theory sharply declined, and, during subsequent decades, only a small number of academic papers were published. The main reason was the lack of practical results, as well as a pessimistic evaluation of the entire direction of research (“The subject itself seems to be a burned out case” [14], p. 324). It is worth adding that, at that time, short-range transmission was provided by wires, and there was no special need in wireless FCS. At the same time, development of digital technologies, communications and automatics generated a lot of complex theoretical tasks, and the industry required specialists. As a result, most FCS researchers took up these tasks.
The situation changed with the appearance of mobile communications and wireless networks (WN) containing a great number of wireless end nodes (EN), each communicating with the base station (BSt) over forward and feedback channels. This renewed interest in FCS was still, however, strictly academic [15] and without any practical results. Having no alternative, currently, all the channels of WN employ only the coding principle of transmission.
Apart from the traditional requirements for CS (maximal rate, quality, reliability, range of transmission, etc.), battery-supplied or battery-less low-power transmitters of EN should be minimally complex and minimally energy-consuming, and should satisfy a large number of the other, sufficiently rigorous requirements [16] such as maximal energy efficiency of transmission, optimal utilization of the channel bandwidth, reduction of inter-channel interference, security of transmission, and others. The set of these characteristics is now defined by the general term “performance,” and the main task of designers is the improvement of the systems or channels’ performance.
The development of the first generations of WN and corresponding FT did not cause any particular difficulties, but each subsequent generation does pose new, increasingly complex problems. One should stress that the performance of the lower, physical (PHY) layer channels EN-BSt dramatically influences the performance of the overall network regardless of the particularities of the higher layers’ organization.
The design of the PHY layer channels is carried out almost independently from that of the higher layers and software of WN, and requires thorough knowledge of mathematics, signals processing, communication and information theory, and so on. Nevertheless, even among experienced designers, “the task of changing from a cable to wireless is still seen as a daunting prospect; wireless retains its reputation of being close to black magic. For most designers, it is an area where they have very little ability to change anything, other than the output power” [16]. A similar sentiment is expressed in [17].
This is not an isolated opinion. A large number of recent publications question the capability of the modern theory to provide any noticeable improvement in wireless transmission: “Shannon limit is now routinely being approached within 1 dB on AWGN channels… So is coding theory finally dead? …there is little more to be gained in terms of performance [18]”; “Whether research at the physical layer of networks is still relevant to the field of wireless communications? … any improvements are expected to be marginal [19].” Similar evaluations of the state of theory can be found in [20, 21, 22] and other works.
Analysis of the sources of problems showed that the main reason is the lack of efficient theoretical basis permitting one to investigate the behavior of wireless CS in different scenarios and to choose the versions best suited to the goals of the project.
In the following sections of the chapter, we discuss these problems and their solution. To simplify the discussion, apart from CS and FCS, we use the following abbreviations: CSC—communication system with coding and AFCS—adaptive feedback communication system transmitting signals over the forward channels (FT) using analog modulators (AMs) adjusted by the controls formed in BSt and delivered to FT over feedback channels.
Let us clarify the subject of discussion. The term “performance”, relatively new in communications, is broader than the term “quality”. Furthermore, the evaluation of CS performance has its own groups of the criteria used to compare the systems by their general utility characteristics, further called the “performance” criteria. Another, relatively narrow and stable group of “analytical” criteria is used in the research as a tool permitting to improve one or a part of the performance criteria.
The performance criteria determine the required, desired, or real characteristics of the future or existing wireless CS permitting to use these systems for solution of definite tasks in the given conditions, and to evaluate the corresponding benefits, costs, and risks [16]. The main criteria of this group are:
range of reliable transmission
data rate and throughput
latency
frequency range and channel bandwidth
power and energy consumption
security of transmission
interference and coexistence
resistance to industrial disturbances and changes in the environment
possibility of supplying from renewable energy sources
design, production, and deployment costs
size, weight, price, and other characteristics.
These criteria are used for elaboration of standards and have no analytical tools for a prior evaluation of performance. Instead, each of the listed criteria has a fixed numerical evaluation determining the corresponding requirement to CS. Each standard defines a class of CS with a unique combination of performance criterions granting these systems the ability to solve definite tasks under definite conditions better than other systems. For a new system to have better performance, it should pass a certification which confirms the existence of new qualities. Moreover, to become the standard, it should be manufactured at least by three independent firms [16].
Analytical criteria serve a different purpose, and are used to establish conditions that allow the rate, quality, reliability of transmission, and other characteristics of CS to approach their limit or given values in different conditions and under given constraints. These criterions are built on adequate mathematical models of the main components of CS or of the system as a whole, and their values depend on all the basic factors influencing the work of the system. Some of these factors can be regulated by designers who search for their combination that either maximizes the “main” criterion (e.g. the rate of transmission) or minimizes its value (e.g., transmission errors) taking into account existing limitations. The results of research determine the approach to design the best system in a given class under given conditions and limitations.
Analytical evaluations of the quality of transmission are not used in performance criteria but the research results create a rigorous basis for the design of more efficient CSs and for their emergence within new standards. Nevertheless, RF (radio frequency) design “is typically the smallest section of any wireless standard” and “the hardware definition may be less than 5% of the total specification in terms of the number of pages ([16], p. 20).
Currently, the term “improvement of performance” is widely used in communications and pushed out also not strictly defined earlier term “improvement of quality” of the systems, channels, transmission, etc. In this chapter, we use both these terms. It is worth adding that the term “perfect” should be taken literally: the performance of the AFCS discussed below does attain the limits established by information theory. Note that this discussion clarifies not only the terminology, but also the relations between different groups of criteria mutually connected through plural tradeoffs. The analytical results presented below allow for the simultaneous improvement of several performance criteria (to which we will return in the final discussion).
Nowadays, commonly used analytical criteria in CSC performance include the bit rate [bits/s], energy [J/bit], and spectral [bit/s/Hz] efficiencies of transmission, as well as bit error rate (BER). Sets of possible values of energy-spectral efficiencies have upper bounds, and the task of designers is to make the characteristics of the system approach these boundaries under possibly smaller BER. As the basic references, the theory employs limit values of bit rate and efficiencies of the transmission usually computed for linear memory less channels with additive white Gaussian noise (AWGN). So, limit bit rate determines the capacity of the channel (Shannon’s formula) as follows:
where
is the signal-to-noise ratio (SNR) at the channel output.
The energy efficiency of transmission (“energy per bit”)
The spectral (or bandwidth) efficiency
This formula directly follows from (1) and (2) and is convenient for practical applications. Another frequently used but less convenient measure of energy efficiency is defined as
The example of the expression for the BER computed for two orthogonal signals transmitting particular bits over channels with AWGN has the form:
where
These relationships are mutually connected by multiple tradeoffs: power-bandwidth tradeoff; tradeoffs between BER and energy efficiency, deployment efficiency-energy efficiency, and many others (see, e.g. [23, 26]). In these conditions, the development of a regular approach for the optimization of CSC is practically impossible.
The sources of difficulties are:
Impossibility to find, among the infinite set of possible codes, the code minimizing errors of transmission: “The existence of optimal encoding and decoding methods is proved, but there are no methods indicated for the construction or technical realization of these results [27].”
Impossibility to formulate any expressions for current (not only limit) bit rate and energy-spectral efficiencies.
Both the quality of transmission and the results of CSC optimization directly depend on the scenario of the system application (placement of the system, characteristics of the environment, fading, noise, path loss, etc.). Implementation of theoretical results is only possible if there is a possibility of at least partial channels identification but a system optimal in one scenario will not be optimal in another.
The lack of the regular analytical approach to optimization of CSC makes impossible evaluation of the potentially achievable bounds of transmission quality and the search for the most efficient technical solution permitting their achievement.
There are many approaches for the improvement of CSC (e.g., [28, 29, 30]) but their discussion is beyond the scope of the chapter. We will note the fact stressed in the literature (e.g., in [31, 32]): theoretical bounds determined by the existent methods of analysis are unachievable for real systems. As a result, modern CSCs transmit signals with the necessary performance but nobody can assess the efficiency of their energy, spectral, and other resources utilization. The listed reasons, including scenario-dependent performance, make the development of the perfect CSCs optimally and fully utilizing their energy and spectral resources an unrealistic task.
In the next section, we show that modulation and feedback resolve the listed problems and enable elaboration of the FCS transmitting signals perfectly, as well as permit to improve their performance criteria.
The novelty of the topic makes us begin by considering sufficiently general but not complex systems to simplify the explanation of the main ideas, mathematical tools, methods, and results. Below we consider point-to-point FCS (block diagram in Figure 1) assuming that the input signals are Gaussian and channel noises are AWGN, and high quality feedback channel delivers signals from the BSt to the FT with negligibly small errors. One may add that this block diagram, with different formulations of the tasks, was the subject of both early and later research in this field. The material below does not repeat any of these works but summarizes and clarifies their main ideas, approaches to problem-solving, and results to elucidate the difficulties, which had blocked the development of the theory. We also hope that the reader might appreciate the beauty of these works, which came so close to success, but which are now almost forgotten.
General block diagrams of point-to-point AFCS.
The analysis that follows is carried out in discrete time. Samples
Values
For every
where high-frequency (RF) components are omitted;
is routed to the processor of the BSt which computes a new estimate
The variable
The BSt processor stores estimate
All the results of pioneering and later research in FCS optimization were obtained using
Models (6)–(8) are not abstract and describe the sequence of transformations of the signal along its transition over the real units and components of FCS, as well the influence of noises and distortions on the final result of transmission. Moreover, each of these models allows calculation of the changes in the statistical characteristics of signals after each subsequent transformation, and considers the most substantial particularities of this process influencing the work of the system.
Apart from the initially known (given) parameters, these models contain free parameters permitting the designers to regulate the work of particular units and improve the performance of the overall system. For the FCS under consideration, these parameters are
The optimization of FCS begins from the definition of algorithm permitting to compute, using the received data
where
Substitution of (10) into (8) results in algorithm computing optimal Bayesian estimates that takes an extremely simple form
The full transmission-reception algorithm (6)–(8) permits to build a mathematical model of transmission process and to derive the following algorithm for calculation of the mean square error (MSE) of estimates formed by FCS in sequential cycles.
where
Free parameters
Beginning the first works, the most widely used additional condition was (and still remains) a constraint on the instant or average power of emitted signals
Without loss of generality, one may assume that the power of the FT transmitter and the amplitude of emitted signals are connected by the relationship
According to (13), for every
The substitution of (16) into (13) gives the following recurrence equation for the corresponding minimal values of MSE:
where parameter
Formula (17) shows that greater values of modulation index
where
where SNR
Moreover, the optimal transmission-reception algorithm permits us to compute the information characteristics of optimal AFCS prior and posterior entropies, as well as the mean amount of information in estimates
Taking into the account that the amount of information (22) in estimates is achieved in
Similar results were obtained in [4, 6, 9] and other works. However, regardless of their correctness, neither the above nor earlier obtained algorithms of transmission in any of their versions could be implemented in practice. Analysis of the reasons showed that the main reason was the omission of saturation effects in the FT.
Another, not less critical reason, and not counted in all formulations of the optimization tasks, has been noted in Section 2, that is, the local dependence of the quality of transmission on the scenario of FCS application. The presented above results confirm this fact directly: values of optimal parameters
In the following sections, we show that modulation and feedback may resolve or at least substantially reduce these problems and make the perfect FCS feasible.
Signals
However, externally completely correct additional condition (14) does not count possible saturation of the modulators or emitters, if the signals
Static transition characteristic of the transmitter with a finite output range.
In real FT, output range
The probability of the first saturation of FT would appear in the
where
Substitution of formula (18) into (25) gives the following evaluation of the probability of the first saturation in
and the probability of its appearance during first five cycles of transmission attains the value
One should add that MSE of estimates is weakly sensitive to sufficiently rare cases of FT saturation. However, taking into account that each instance of saturation causes a loss of the sample and
The previous section and formula (25) show that saturation of the FT can be almost eliminated if the gains
Under fulfilled condition (25), the probability of the sample saturation has the value
Relationship (26) determines the set of permissible values of the gains
where parameter
reduces
reduces
The structure and form of the basic relationships for the MSE, bit rate, and effectiveness remain the same. Changes in Shannon’s formula (23) for the capacity and in the other relationships affect only the values of amplitude and power of emitted signals (29).
To distinguish the considered systems and the FCS, and to focus on the new systems, in what follows, we use a new abbreviation to refer to these systems: AFCS (adaptive FCS).
Let us remind that these relationships were derived under assumption that the feedback channels are ideal. This is not an unrealistic suggestion: relatively inexpensive modern CSCs provide virtually error-free short-range transmission. If necessary, the quality of the channel can also be improved by increasing the power of transmitters—the BSt have sufficiently large, if not unlimited energy resource.
We should add that the discussed relationships are a particular case of the more general optimal transmission-reception algorithm for the statistically fitted AFCS with noisy feedback [36, 37, 38, 39], see also Table 1 below. It is worth stressing that these algorithms have the same structure and form as those presented in pervious sections. The only but principle difference concerns the expression for the MSE of transmission, which takes the form:
Algorithm | Parameters | |
---|---|---|
Initial values | ||
Signal at the modulator input | ||
Emitted signal | ||
Received signal | ||
Estimate computing | ||
Basic equation for MSE |
Basic relationships for modeling and design of optimal AFCS with non-ideal feedback channel (
where variable
A summary of the relationships sufficient for the development of a MATLAB model of optimal AFCS and simulation experiments is presented in Table 1. Moreover, these seemingly simple relationships were used to design a prototype (demonstrator) of the perfect AFCS, discussed in the next section.
If a relative error of the sample transmission
where
As noted above, the basic criterion for transmission quality is the accuracy (in [1] “fidelity”) of the signals’ recovery. For the CS transmitting analog signals, this is the MSE of their estimates. The importance of MSE is due to several factors. First of all, for arbitrary linear channels with AWGN, which transmit Gaussian signals, MSE
So, if CSs transmit the samples each in
independent of whether the system is optimal or not. This value determines the spectral efficiency of the sample transmission
The iterative principle of transmission permits us to introduce the measure more informative than (33): the
which describes the increment of information in sequentially computed estimates
The general expression for the energy efficiency of transmission can be defined as follows:
which shows that, unlike spectral efficiency, this characteristic of the CS performance depends not only on the MSE, but also on the SNR
Another particularity of the MSE, which is not currently utilized in communications, is its analytical formulations have empirical analogs, as well as well-studied and widely used methods of their evaluation. In our research, the following method is used. However, as it follows from (36), evaluation of the energy efficiency, in the general case, requires additional measurement of SNR
The FT generates and sends to the BSt a testing sequence of M random Gaussian samples
next used for the evaluation of the bit rate (35) and energy-spectral efficiency of AFCS. In practice, it is more convenient to compute these values using the MSE expressed in dB:
as well as normalized root square (relative error of transmission)
The adjusting algorithm uses the “resonance” effect that is increase of MSE, if the values of parameters
Changes of mean relative error of estimates depending on the deviation of the gains
To adjust the parameters, the system utilizes two identical testing sequences of Gaussian samples
In the first cycle, the modulation index
In this cycle, the microcontroller of the FT forms the sequence of signals
The duration and frequency of adjustments depend on the dynamics of scenario changes, processors’ rate, channel bandwidth, requirements for the accuracy of estimates, environmental characteristics, and other factors.
The prototype of AFCS was designed on the basis of the optimal transmission-reception algorithm(6)–(8), using and parameters set to the values (16), (18), (or in Table 1, for
Layout of PCB modules of prototype of perfect AFCS: (a) forward transmitter integrated with sensor; (b) base station.
The transmitter was realized using narrowband adaptive AM modulator followed by the programmable voltage-controlled oscillator VG7050EAN (power 10 dBm, carrier frequency 433.2 MHz). The feedback channel was realized using digital receiver RFM31B-S2 and transmitter RFM23B (power 27 dBm, carrier frequency 868.3 MHz). This ensured virtually ideal feedback transmission of signals in the indoor and outdoor experiments carried out at distances to 100 meters (straight line view, FT with ceramic mini-antennas, BSt with quarter-wave antennas).
At the beginning of every new series of experiments, a self-adjusting algorithm was activated, which set the parameters
The main measured characteristic of the prototype was the
Values
The plots are presented in the decibel scale, and the nearly linear dependence of the measured values
Moreover, plots in Figure 5 allow for a sufficiently accurate evaluation of the characteristics of the system. With this aim, let us rewrite the expression of spectral efficiency (33) in the decibel scale in the form (the confirmed close to perfect transmission permits us to write that
The linear approximation of the plots in Figure 5 in first
Distance (m) | 40 | 50 | 75 |
MSE | −6.25 | −4.4 | −1.4 |
2.07 | 1.46 | 0.465 | |
3.21 | 1.75 | 0.375 | |
1.76 | 1.19 | 0.8 | |
1.85 | 0.76 | −0.92 |
Measured characteristics of the prototype.
Two-dimensional plot presenting values (red points) of the energy-spectral efficiency of optimal AFCS measured at the distances in 40, 50, 75 meters.
The plots in Figure 7a, b illustrate the results of measurements carried out at the fixed distance sequentially, with the time interval in 1–3 minutes.
Dependencies
All the experiments confirmed the existence of the initial interval
It was also noted the growing influence of the external disturbances and noises on the further changes of MSE if it attained sufficiently small values. Since this time, MSE decreased with the growing fluctuations, sometimes regularly but at the smaller rate. This could not be an effect caused by saturations: experiments were carried out under saturation factor
The experiments confirmed the feasibility of the perfect AFCS, as well as the capability of modulation and feedback to ensure the perfect signal transmission.
The chapter gives a brief outlook of the approaches to design of the currently not used class of communication systems which may substantially improve the efficiency and performance of the wireless low-power transmission. The presented results develop excellent but not finished and today almost forgotten research in FCS theory carried out in the years 1960–1970. These investigations were first steps toward the formation of the second direction in information theory: the theory of the systems with feedback channels. However, in the middle of 70s, the research was hampered.
The main reason for the difficulties was the lack of practical results. Another, less obvious source of failures was the omission of possible saturation of modulators or emitters in the forward transmitters. The not less crucial obstacle also was not discussed in the literature which is the dependence of the CS performance on the scenarios of application.
The chapter shows how modulation and feedback permit to resolve these difficulties. The results of research confirm the general conclusion of the pioneering research: FCS may transmit signals without coding perfectly, that is in real time, with a bit rate equal to the capacity of systems, and with the limit accuracy of the signals recovery. Moreover, the only difference between the relationships presented in the chapter and those presented in earlier works is the numerical values of modulation index.
The rapidly developing wireless networks (WN) utilize a great number of short-range low-energy end-node (EN) transmitters. Nowadays, all of them employ the coding and advanced digital technical solutions. The level and number of requirements for EN transmitters grow permanently. However, as noted by many authors, possibilities to improve the performance of the PHY layer of WN are almost exhausted. We discussed this in the beginning of the chapter. Moreover, all networks utilize, on the mass scale, feedback channels.
What can we conclude? Despite its great merits, coding is losing its advantages and is being used in low-power EN transmitters designed for the short-range transmission (“one mile zone” and shorter). The main task of these transmitters is the reliable and secure delivery of relatively small amounts of information to the BSt or master node, if possible, with minimal delay. The great rates (except for rare exclusions) are not necessary: this is the task for BSt which communicate with other BSt or higher level stations.
Today’s problems of the EN transmitters design are prosaic: they should be as less energy-consuming as possible to increase the duration of continuous work (“lifetime”) and to reduce the requirements of the energy sources. They should be resistant to inter-channel disturbances caused by nearby EN, as well as should have minimal complexity to decrease the production and deployment costs. It is also desirable that they have low emission, small size, light units, etc.
Reduction of the energy consumption inevitably causes the reduction of the power of the EN transmitters and that crucially decreases the quality and range of transmission. Compensation of the losses requires application of more efficient correcting codes and more complex coders, as well as the extension of the channel bandwidth. In turn, wide band transmission creates sufficiently powerful inter-channel disturbances in closely placed EN. The result is the appearance of complex technical solutions suppressing these distortions or, vice versa, utilizing them for improvement of the signals recovery. The list of tradeoffs between different requirements of the systems is large, and coding has no efficient answers to these questions.
Having no alternatives, the industry has no other choice but to transfer known principles of long-distance CS with coding (CSC) design and technologies to the design of low-power EN transmitters produced on the scale by the orders greater than powerful CSC transmitters. The not too essential for long-distance communications, constraints on the power of the transmitters, requirements for the bandwidth and other constrains became the crucial considerations in the wireless EN design. From our point of view, the greatest stumbling block is that CSCs do not allow for a development of the systematic approach to their optimization similar to the Bayesian approach described in the chapter. Codes have no parameters permitting their adjustment to the changes of characteristics of the channel, nor allow the formulation of mathematical models accounting for all the transformations of signals as they pass through the transmitter, channel, and receiver. AFCSs do have such possibilities.
Moreover, the signals generated by the transmitters of CSC are discrete, their form is fixed and in no way depends on the input signals. Information is delivered by combinations of the symbols of code. There is no possibility to regulate the quality of the transmission aside from the external regulation of the power of transmitter or switching the codes. Meanwhile, the quality of transmission provided by the adjusted perfect AFCS depends on the scenario of their application, but always attains the limit or close to the limit values.
General evaluation of the future perspectives of AFCS: currently, almost all CS and networks have feedback channels, and AFCS could solve many of the aforementioned and other problems. Below, we attach a summary of possibilities of the perfect AFCS, which have been established and verified in [36, 37, 38, 39, 40, 41] and other works.
Perfect AFCSs provide the most energy-spectral efficient transmission of signals in real time with the limit energy-spectral efficiency, bit rate equal to the capacity of forward channel, and minimal MSE of the signals reception.
The absence of coders allows for the construction of a full mathematical model of transmission, from the source of signals to the BSt processor. This model enables the formulation of a clear analytical criterion (MSE), the application of Bayesian estimation theory, and the derivation of optimal transmission-reception algorithms determining the approach to the perfect AFCS design.
Feedback channel and optimal transmission algorithms enable the development of adaptive algorithms adjusting the parameters of AFCS to the environment changes. This permits the system to maintain the perfect mode of transmission in different, also non-stationary scenarios. De facto, the system regulates its own capacity, adjusting it to the changes of environment.
The side effect of AFCS adjustment is that the BSt computes the on-line estimates of MSE, SNR, and capacity of the system. These data permit to evaluate the current energy-spectral efficiency of transmission and to decrease the losses of energy regulating the number of cycles maintaining the required accuracy of the signal recovered.
The analytical expression for MSE of transmission has an empirical analog, whose values can be measured and used for evaluation of the performance of every CS used for the analog signals transmission. As shown in Section 3, MSE permits us to determine the quality of transmission, bit rate, as well spectral efficiency of every CS. For the perfect AFCS, minimal MSE determines the energy efficiency of transmission.
Signals emitted by the FT have the form of realizations of the (stationary) pulse white Gaussian noise. The amplitudes of each emitted pulse depend on random values of the signals
The absence of coding units simplifies the architecture of the FT, as well as reduces their energy consumption, complexity, and cost, which allow for the development of efficient battery-less AFCS.
The FT transmitters can be realized in analog, digital, and mixed technologies. The results of analysis show that the most preferable form of realization would be the software implementation of the FT. Optimal transmission-reception and adjusting algorithms contain all basic information for the development and implementation of the software (SDR) version of the FT. Moreover, this software can be used for the reconfiguration of transmitters and the extension of possibilities of their utilization and functional possibilities of the EN as a whole.
Preliminary research [42] showed that perfect AFCS can be also used, virtually without modification of transmission scheme and algorithms, for the transmission of short codes. These codes can be parts of the longer code routed to the input of the AFCS or formed by digital sensors. The set of the codes can be converted into the uniform set of analog values, and high accuracy of AFCS transmission will ensure reliable resolution of the received signals.
The designed prototype of AFCS is the first “living” example of the system that transmits signals without coding perfectly, and this was confirmed by the results of experiments.
Most of the listed capabilities of AFCS are not feasible for the CS with coding.
In this chapter, we considered only scalar (point-to-point) AFCS which employ the AM transmission, but the theory allows for the extension to optimization of the multi-channel FCS. Moreover, AM is only one of three types of modulation, and each has its own limited operating range. It would be important to investigate the systems with the FM and PM modulations—this could give a new classes of perfect FCS transmitting signals without abnormal errors and with the limit energy-spectral efficiency. It is also worth noting that statistical fitting condition (26) can be used for the optimization of different classes of estimation, controlling, measurement, and signal processing systems.
In conclusion, let us repeat the questions asked in [19]: “Is the PHY layer dead? … whether the research directions taken in the past have always been the right choice and how lessons learned could influence future policy decisions?”
The author expresses a deep gratitude to the young colleagues Ievgen Zaitsev, Borys Jeleński, and Jan Piekarski, as well as to the colleague Henryk Chaciñski for their active participation in the elaboration of the AFCS prototype and creative engineering thinking.
communication system communication system with coding feedback communication system adaptive feedback communication system wireless network end node forward transmitter base station physical layer of network additive white Gaussian noise signal-to-noise ratio bit error rate mean square error minimal mean square error root mean square
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Plus, rib cartilage can be carved into ideal septal extension and batten grafts that are required.",book:{id:"8616",slug:"contemporary-rhinoplasty",title:"Contemporary Rhinoplasty",fullTitle:"Contemporary Rhinoplasty"},signatures:"Angelo Cuzalina and Ahmed Tamim",authors:[{id:"270232",title:"Dr.",name:"Angelo",middleName:null,surname:"Cuzalina",slug:"angelo-cuzalina",fullName:"Angelo Cuzalina"},{id:"278087",title:"Dr.",name:"Ahmed",middleName:null,surname:"Tamim",slug:"ahmed-tamim",fullName:"Ahmed Tamim"}]},{id:"36339",doi:"10.5772/29345",title:"Cochlear Implant Surgery",slug:"hearing-preservation-in-cochlear-implant-surgery",totalDownloads:6974,totalCrossrefCites:2,totalDimensionsCites:2,abstract:null,book:{id:"652",slug:"cochlear-implant-research-updates",title:"Cochlear Implant Research Updates",fullTitle:"Cochlear Implant Research Updates"},signatures:"Hakan Soken, Sarah E. Mowry and Marlan R. Hansen",authors:[{id:"77409",title:"Dr.",name:"Marlan",middleName:null,surname:"Hansen",slug:"marlan-hansen",fullName:"Marlan Hansen"},{id:"86423",title:"Dr",name:"Hakan",middleName:null,surname:"Soken",slug:"hakan-soken",fullName:"Hakan Soken"},{id:"123447",title:"Dr.",name:"Sarah E",middleName:null,surname:"Mowry",slug:"sarah-e-mowry",fullName:"Sarah E Mowry"}]}],mostDownloadedChaptersLast30Days:[{id:"66026",title:"Alar Rim Grafts",slug:"alar-rim-grafts",totalDownloads:1103,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Alar rim grafts date back to the 1950s for the correction of alar base in cleft lip nose. Cartilage struts under the anterior half of the alae of a pinched nose tip were popularised and the cartilage of the auricular concha became the donor site of choice for nasal procedures. Recently, some surgeons pointed to its potential role in aesthetic cases and added some technical refinements. These grafts are used for open and closed rhinoplasties. They usually consist of a rod of septal or auricular cartilage that we lay as reinforcement inside a pocket along the alar margin. Indications include the following: congenital or traumatic asymmetry, dynamic alar collapse, alar flare, primary retraction or notching, secondary (surgical or traumatic) retraction and malposition of the lateral cartilages (upwards or downwards). Harvesting and implanting techniques as well as the possible drawbacks are discussed.",book:{id:"8616",slug:"contemporary-rhinoplasty",title:"Contemporary Rhinoplasty",fullTitle:"Contemporary Rhinoplasty"},signatures:"Pedro S. Arquero, Wenceslao M. Calonge, Daniel P. Espinoza and Diana Oesch",authors:[{id:"202013",title:"M.D.",name:"Wenceslao M",middleName:null,surname:"Calonge",slug:"wenceslao-m-calonge",fullName:"Wenceslao M Calonge"},{id:"286266",title:"Dr.",name:"Daniel",middleName:null,surname:"Espinoza Kauer",slug:"daniel-espinoza-kauer",fullName:"Daniel Espinoza Kauer"},{id:"286267",title:"Dr.",name:"Diana",middleName:null,surname:"Oesch Ortiz",slug:"diana-oesch-ortiz",fullName:"Diana Oesch Ortiz"},{id:"292634",title:"Dr.",name:"Pedro S.",middleName:null,surname:"Arquero",slug:"pedro-s.-arquero",fullName:"Pedro S. Arquero"}]},{id:"65017",title:"Learning Curve and Septorhinoplasty",slug:"learning-curve-and-septorhinoplasty",totalDownloads:743,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The learning curve as a concept has been considered and discussed in medical education and surgical practice. Rollin Daniel stated that rhinoplasty is the most difficult of all cosmetic operations for three reasons: (a) nasal anatomy is highly variable, (b) the procedure must correct form and function and (c) patients’ expectations. With this in mind, a study was planned on learning curve in septorhinoplasty based on a surgeon questionnaire. The aims of the study were to extract the idea of learning curve from different surgeons across experience about septorhioplasty, to calculate certain parameters of the learning curve in rhinoplasty and to prepare a roadmap for an early rhinoplasty surgeon. The conclusion derived from the study was the concept of the learning curve in rhinoplasty should not be generalised as certain factors, for example, minimum number to achieve proficiency has a wide range. It is thought that each type of rhinoplasty should be dealt with separately and learning curve calculated accordingly. A roadmap for a novice surgeon is hereby charted out.",book:{id:"8616",slug:"contemporary-rhinoplasty",title:"Contemporary Rhinoplasty",fullTitle:"Contemporary Rhinoplasty"},signatures:"Aditya Yeolekar",authors:[{id:"266750",title:"Associate Prof.",name:"Aditya",middleName:null,surname:"Yeolekar",slug:"aditya-yeolekar",fullName:"Aditya Yeolekar"}]},{id:"64668",title:"Cleft Lip and Palate Patient Rhinoplasty",slug:"cleft-lip-and-palate-patient-rhinoplasty",totalDownloads:1793,totalCrossrefCites:0,totalDimensionsCites:2,abstract:"Cleft lip and palate patients represent one of the most difficult groups of patients for septorhinoplasty. Prior surgery at younger ages resulting in severe scar tissue is a major obstacle in most cleft rhinoplasties along with substantial asymmetries especially in the unilateral cleft patient. Replacement of missing and asymmetric cartilages and even bone is a key component for rhinoplasty in the cleft patient. Use of very sturdy cartilage typically from rib is almost always required to adequately resist the fibrotic soft tissues in the noses. Plus, rib cartilage can be carved into ideal septal extension and batten grafts that are required.",book:{id:"8616",slug:"contemporary-rhinoplasty",title:"Contemporary Rhinoplasty",fullTitle:"Contemporary Rhinoplasty"},signatures:"Angelo Cuzalina and Ahmed Tamim",authors:[{id:"270232",title:"Dr.",name:"Angelo",middleName:null,surname:"Cuzalina",slug:"angelo-cuzalina",fullName:"Angelo Cuzalina"},{id:"278087",title:"Dr.",name:"Ahmed",middleName:null,surname:"Tamim",slug:"ahmed-tamim",fullName:"Ahmed Tamim"}]},{id:"64721",title:"Saddle Nose: A Systematic Approach",slug:"saddle-nose-a-systematic-approach",totalDownloads:1054,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The saddle nose deformity is always associated to cartilaginous or bone defects. It could have congenital, traumatic, infectious or iatrogenic origin. Its correction consists not only in a camouflage, but also it is important to reconstruct the missing structure. In this chapter, we will discuss about all aspect of the saddle nose and we will propose a different therapeutical approach (septum, concha or costal grafts) in relation to the severity of the defects (with a personal classification). The classification is also based on the presence or absence of the nasal septum, which is a fundamental aspect that we must take into account when approaching nasal reconstruction. We will discuss the technical aspect of the rib graft harvesting and its use to reconstruct the nasal structure.",book:{id:"8616",slug:"contemporary-rhinoplasty",title:"Contemporary Rhinoplasty",fullTitle:"Contemporary Rhinoplasty"},signatures:"Marianetti Tito Matteo",authors:[{id:"177687",title:"Dr.",name:"Tito",middleName:null,surname:"Marianetti",slug:"tito-marianetti",fullName:"Tito Marianetti"}]},{id:"36343",title:"A Review of Stimulating Strategies for Cochlear Implants",slug:"stimulating-strategies-for-cochlear-implants",totalDownloads:4451,totalCrossrefCites:2,totalDimensionsCites:0,abstract:null,book:{id:"652",slug:"cochlear-implant-research-updates",title:"Cochlear Implant Research Updates",fullTitle:"Cochlear Implant Research Updates"},signatures:"Charles T. M. Choi and Yi-Hsuan Lee",authors:[{id:"107160",title:"Prof.",name:"Charles T. M.",middleName:null,surname:"Choi",slug:"charles-t.-m.-choi",fullName:"Charles T. M. 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His research interests are focused on modern imaging methods used in medicine and pharmacy, including in particular hyperspectral imaging, dynamic thermovision analysis, high-resolution ultrasound, as well as other techniques such as EPR, NMR and hemispheric directional reflectance. Author of over 100 scientific works, patents and industrial designs. Expert of the Polish National Center for Research and Development, Member of the Investment Committee in the Bridge Alfa NCBiR program, expert of the Polish Ministry of Funds and Regional Policy, Polish Medical Research Agency. Editor-in-chief of the journal in the field of aesthetic medicine and dermatology - Aesthetica.",institutionString:null,institution:{name:"Medical University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null},{id:"8",title:"Bioinspired Technology and Biomechanics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",isOpenForSubmission:!0,editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",slug:"adriano-andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",biography:"Dr. Adriano de Oliveira Andrade graduated in Electrical Engineering at the Federal University of Goiás (Brazil) in 1997. He received his MSc and PhD in Biomedical Engineering respectively from the Federal University of Uberlândia (UFU, Brazil) in 2000 and from the University of Reading (UK) in 2005. He completed a one-year Post-Doctoral Fellowship awarded by the DFAIT (Foreign Affairs and International Trade Canada) at the Institute of Biomedical Engineering of the University of New Brunswick (Canada) in 2010. Currently, he is Professor in the Faculty of Electrical Engineering (UFU). He has authored and co-authored more than 200 peer-reviewed publications in Biomedical Engineering. He has been a researcher of The National Council for Scientific and Technological Development (CNPq-Brazil) since 2009. He has served as an ad-hoc consultant for CNPq, CAPES (Coordination for the Improvement of Higher Education Personnel), FINEP (Brazilian Innovation Agency), and other funding bodies on several occasions. He was the Secretary of the Brazilian Society of Biomedical Engineering (SBEB) from 2015 to 2016, President of SBEB (2017-2018) and Vice-President of SBEB (2019-2020). He was the head of the undergraduate program in Biomedical Engineering of the Federal University of Uberlândia (2015 - June/2019) and the head of the Centre for Innovation and Technology Assessment in Health (NIATS/UFU) since 2010. He is the head of the Postgraduate Program in Biomedical Engineering (UFU, July/2019 - to date). He was the secretary of the Parkinson's Disease Association of Uberlândia (2018-2019). Dr. Andrade's primary area of research is focused towards getting information from the neuromuscular system to understand its strategies of organization, adaptation and controlling in the context of motor neuron diseases. His research interests include Biomedical Signal Processing and Modelling, Assistive Technology, Rehabilitation Engineering, Neuroengineering and Parkinson's Disease.",institutionString:null,institution:{name:"Federal University of Uberlândia",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null},{id:"9",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering",coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",isOpenForSubmission:!0,editor:{id:"126286",title:"Dr.",name:"Luis",middleName:"Jesús",surname:"Villarreal-Gómez",slug:"luis-villarreal-gomez",fullName:"Luis Villarreal-Gómez",profilePictureURL:"https://mts.intechopen.com/storage/users/126286/images/system/126286.jpg",biography:"Dr. Luis Villarreal is a research professor from the Facultad de Ciencias de la Ingeniería y Tecnología, Universidad Autónoma de Baja California, Tijuana, Baja California, México. Dr. Villarreal is the editor in chief and founder of the Revista de Ciencias Tecnológicas (RECIT) (https://recit.uabc.mx/) and is a member of several editorial and reviewer boards for numerous international journals. He has published more than thirty international papers and reviewed more than ninety-two manuscripts. His research interests include biomaterials, nanomaterials, bioengineering, biosensors, drug delivery systems, and tissue engineering.",institutionString:null,institution:{name:"Autonomous University of Baja California",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null}]},overviewPageOFChapters:{paginationCount:18,paginationItems:[{id:"81778",title:"Influence of Mechanical Properties of Biomaterials on the Reconstruction of Biomedical Parts via Additive Manufacturing Techniques: An Overview",doi:"10.5772/intechopen.104465",signatures:"Babatunde Olamide Omiyale, Akeem Abiodun Rasheed, Robinson Omoboyode Akinnusi and Temitope Olumide Olugbade",slug:"influence-of-mechanical-properties-of-biomaterials-on-the-reconstruction-of-biomedical-parts-via-add",totalDownloads:2,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering - Annual Volume 2022",coverURL:"https://cdn.intechopen.com/books/images_new/11405.jpg",subseries:{id:"9",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering"}}},{id:"81751",title:"NanoBioSensors: From Electrochemical Sensors Improvement to Theranostic Applications",doi:"10.5772/intechopen.102552",signatures:"Anielle C.A. 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For 20 years, he has studied the analysis and processing of biomedical images, emphasizing the full automation of measurement for a large inter-individual variability of patients. Dr. Koprowski has authored more than a hundred research papers with dozens in impact factor (IF) journals and has authored or co-authored six books. Additionally, he is the author of several national and international patents in the field of biomedical devices and imaging. Since 2011, he has been a reviewer of grants and projects (including EU projects) in biomedical engineering.",institutionString:null,institution:{name:"University of Silesia",institutionURL:null,country:{name:"Poland"}}}]},{type:"book",id:"7218",title:"OCT",subtitle:"Applications in Ophthalmology",coverURL:"https://cdn.intechopen.com/books/images_new/7218.jpg",slug:"oct-applications-in-ophthalmology",publishedDate:"September 19th 2018",editedByType:"Edited by",bookSignature:"Michele Lanza",hash:"e3a3430cdfd6999caccac933e4613885",volumeInSeries:2,fullTitle:"OCT - Applications in Ophthalmology",editors:[{id:"240088",title:"Prof.",name:"Michele",middleName:null,surname:"Lanza",slug:"michele-lanza",fullName:"Michele Lanza",profilePictureURL:"https://mts.intechopen.com/storage/users/240088/images/system/240088.png",biography:"Michele Lanza is Associate Professor of Ophthalmology at Università della Campania, Luigi Vanvitelli, Napoli, Italy. His fields of interest are anterior segment disease, keratoconus, glaucoma, corneal dystrophies, and cataracts. His research topics include\nintraocular lens power calculation, eye modification induced by refractive surgery, glaucoma progression, and validation of new diagnostic devices in ophthalmology. \nHe has published more than 100 papers in international and Italian scientific journals, more than 60 in journals with impact factors, and chapters in international and Italian books. He has also edited two international books and authored more than 150 communications or posters for the most important international and Italian ophthalmology conferences.",institutionString:'University of Campania "Luigi Vanvitelli"',institution:{name:'University of Campania "Luigi Vanvitelli"',institutionURL:null,country:{name:"Italy"}}}]},{type:"book",id:"7560",title:"Non-Invasive Diagnostic Methods",subtitle:"Image Processing",coverURL:"https://cdn.intechopen.com/books/images_new/7560.jpg",slug:"non-invasive-diagnostic-methods-image-processing",publishedDate:"December 19th 2018",editedByType:"Edited by",bookSignature:"Mariusz Marzec and Robert Koprowski",hash:"d92fd8cf5a90a47f2b8a310837a5600e",volumeInSeries:3,fullTitle:"Non-Invasive Diagnostic Methods - Image Processing",editors:[{id:"253468",title:"Dr.",name:"Mariusz",middleName:null,surname:"Marzec",slug:"mariusz-marzec",fullName:"Mariusz Marzec",profilePictureURL:"https://mts.intechopen.com/storage/users/253468/images/system/253468.png",biography:"An assistant professor at Department of Biomedical Computer Systems, at Institute of Computer Science, Silesian University in Katowice. 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Biochemistry examines macromolecules - proteins, nucleic acids, carbohydrates, and lipids – and their building blocks, structures, functions, and interactions. Much of biochemistry is devoted to enzymes, proteins that catalyze chemical reactions, enzyme structures, mechanisms of action and their roles within cells. Biochemistry also studies small signaling molecules, coenzymes, inhibitors, vitamins, and hormones, which play roles in life processes. Biochemical experimentation, besides coopting classical chemistry methods, e.g., chromatography, adopted new techniques, e.g., X-ray diffraction, electron microscopy, NMR, radioisotopes, and developed sophisticated microbial genetic tools, e.g., auxotroph mutants and their revertants, fermentation, etc. More recently, biochemistry embraced the ‘big data’ omics systems. Initial biochemical studies have been exclusively analytic: dissecting, purifying, and examining individual components of a biological system; in the apt words of Efraim Racker (1913 –1991), “Don’t waste clean thinking on dirty enzymes.” Today, however, biochemistry is becoming more agglomerative and comprehensive, setting out to integrate and describe entirely particular biological systems. The ‘big data’ metabolomics can define the complement of small molecules, e.g., in a soil or biofilm sample; proteomics can distinguish all the comprising proteins, e.g., serum; metagenomics can identify all the genes in a complex environment, e.g., the bovine rumen. 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Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}},subseries:[{id:"14",title:"Cell and Molecular Biology",keywords:"Omics (Transcriptomics; Proteomics; Metabolomics), Molecular Biology, Cell Biology, Signal Transduction and Regulation, Cell Growth and Differentiation, Apoptosis, Necroptosis, Ferroptosis, Autophagy, Cell Cycle, Macromolecules and Complexes, Gene Expression",scope:"The Cell and Molecular Biology topic within the IntechOpen Biochemistry Series aims to rapidly publish contributions on all aspects of cell and molecular biology, including aspects related to biochemical and genetic research (not only in humans but all living beings). 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In recent years, the application of chemistry to biological molecules has gained significant interest in medicinal and pharmacological studies. This topic will be devoted to understanding the interplay between biomolecules and chemical compounds, their structure and function, and their potential applications in related fields. Being a part of the biochemistry discipline, the ideas and concepts that have emerged from Chemical Biology have affected other related areas. 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Behind these definitions are hidden all the aspects of normal and pathological functioning of all processes that the topic ‘Metabolism’ will cover within the Biochemistry Series. 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Thus proteomics, an area of research that detects all protein forms expressed in an organism, including splice isoforms and post-translational modifications, is more suitable than genomics for a comprehensive understanding of the biochemical processes that govern life. The most common proteomics applications are currently in the clinical field for the identification, in a variety of biological matrices, of biomarkers for diagnosis and therapeutic intervention of disorders. From the comparison of proteomic profiles of control and disease or different physiological states, which may emerge, changes in protein expression can provide new insights into the roles played by some proteins in human pathologies. Understanding how proteins function and interact with each other is another goal of proteomics that makes this approach even more intriguing. Specialized technology and expertise are required to assess the proteome of any biological sample. Currently, proteomics relies mainly on mass spectrometry (MS) combined with electrophoretic (1 or 2-DE-MS) and/or chromatographic techniques (LC-MS/MS). MS is an excellent tool that has gained popularity in proteomics because of its ability to gather a complex body of information such as cataloging protein expression, identifying protein modification sites, and defining protein interactions. 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