Location Of Artery Research Articles

An isolated ruptured spinal aneurysm presents with a thalamic Infarct: case report

BackgroundIsolated spinal artery aneurysms are extremely rare, and their pathogenesis, clinical presentation, and treatment strategies are poorly established. We report only the second case of a patient with an isolated posterior spinal aneurysm and concurrent left thalamic infarct and review the literature to help clarify treatment strategies of isolated spinal aneurysms.Case presentationA 49-year-old patient presented with acute onset walking difficulty followed by diaphoresis, back and abdominal pain, and paraplegia. Imaging was notable for a hemorrhagic spinal lesion with compression at T12 through L4 and an acute left thalamic infarct. Surgical exploration revealed an isolated posterior spinal artery aneurysm. The aneurysm was surgically resected and the patient had partial recovery six months post-operatively.ConclusionsIsolated posterior spinal artery aneurysms of the thoracolumbar region are rare lesions that commonly present with abdominal pain, radiating back pain, and lower extremity weakness. Imaging may not provide a definitive diagnosis. The three primary treatment strategies are conservative management, endovascular treatment, or surgical resection. In patients with symptomatic cord compression, immediate surgical intervention is indicated to preserve neurologic function. In all other cases, the artery size, distal flow, morphology, and location may guide management.

A review of the carotid artery and facial nerve canal systems in extant turtles.

The cranial circulation and innervation systems of turtles have been studied for more than two centuries and extensively used to understand turtle systematics. Although a significant number of studies related to these structures exists, a broader comprehension of variation across the tree has been hindered by poor sampling and a lack of synthetic studies that addressed both systems together. We here provide new insights regarding the carotid circulation and facial nerve innervation systems in a broad set of extant turtles using CT (computed tomography) scans, which allow us to trace the canals these structures form in bone and understand the interaction between both systems. We document that the palatine artery, including the lateral carotid canal, is absent in all pleurodires and carettochelyids and was likely reduced or lost several times independently within Testudinoidea. We also highlight osteological correlates for the location of the mandibular artery. We finally summarize variation regarding the placement of the mandibular artery, location of the geniculate ganglion, placement of the hyomandibular and vidian nerves, and situations where we recommend caution when assessing canals in fossils. A morphometric study confirms that the relative sizes of the carotid canals are correlated with one another. Our results have the potential for building new phylogenetic characters and investigating the circulation systems of fossil taxa, which are expected to shed light on the evolution of the circulation system of turtles and clarify some unresolved relationships between fossil turtle clades.

Irregular pulsation of intracranial unruptured aneurysm detected by four-dimensional CT angiography is associated with increased estimated rupture risk and conventional risk factors

BackgroundIntracranial aneurysms (IAs) are common in the population and current imaging-based rupture risk assessment needs to be refined. We aimed to use four-dimensional CT angiography (4D-CTA) to investigate the associations...

Position of posterior superior alveolar artery in relation to the maxillary sinus using cone beam computed tomography in Indian sub-population

Purpose: To assess the location of posterior superior alveolar artery (PSAA) using CBCT in relevance to sinus lift procedure for implant placement. Patients and Methods: A retrospective study was conducted using the CBCT data of 500 patients (n = 500). Linear measurements were carried out to localize the medio-lateral and vertical position of posterior superior alveolar artery in postero-lateral wall of maxillary sinus and its proximity to the floor of maxillary sinus using CS 3D imaging 3.7.0 software program. The relative position of PSAA was determined as; (a) intra-osseous, (b) below the membrane and (c) outer-cortex of lateral sinus wall. The location of PSAA was assessed in molar region bilaterally by using following radiographic measurement; (1) distance between the lower border of posterior superior alveolar artery and alveolar crest, (2) height from the floor of maxillary sinus to alveolar crest and (3) distance from the posterior superior alveolar artery to medial wall of maxillary sinus. Results: The prevalence of the artery was observed in 99.4% of the sinuses and was mostly intraosseous (84.2%).The mean distance between the lower border of the artery and alveolar crest is significantly higher in males compared to females (P < 0.01). The distribution of artery location did not differ significantly across various age groups (P > 0.05). Discussion/Conclusion: The most common variant of PSAA was identified in the intra-osseous region and the mean distance of the vessel to crest of the residual ridge differs significantly with gender and not with age.

The Sensory Collateral Nerve-Pull Technique: A Viable Maneuver to Aid Harvesting the Pedicle of the Moschella Flap.

Moschella and Cordova originally reported the utility of the reverse dorsoradial flap for thumb soft-tissue reconstruction. To ensure success with this procedure, special attention should be paid not to visualize the dorsoradial digital artery during pedicle dissection because this carries the risk of damaging the tiny perivascular venules.1 As visualizing the vascular anatomy in the pedicle area is not advisable, what anatomical landmark can be used to locate the vascular axis and ensure including these vessels in the flap pedicle, especially when a narrow pedicle is harvested? Although designing the pedicle wide enough can reduce the probability of not harboring these vessels, an excessively bulky pedicle may result in poor aesthetic appearance.2 Alternatively, as described in previous studies, a Doppler probe could be used to identify the dorsoradial digital artery preoperatively. However, this device is generally not available in basic level hospitals, and such a small vessel is not always easily detectable. Previous well-conducted anatomical study has demonstrated that the dorsoradial digital artery runs in close approximation to the dorsal collateral branch of the superficial radial nerve.3 Understanding this anatomy is key to locating the flap pedicle in a different manner and making appropriate adjustments. In this communication, we would like to propose a simple nerve-pull technique for locating the vessels in a pedicle area. Intraoperatively, the incision is initiated along the proximal edge of the flap to dissect the sensory collateral nerve. Once the entire flap is raised, a longitudinal pull is applied gently and repeatedly in line with the nerve enclosed in the flap, and movements of the distal part can be observed. [See Video 1 (online), which demonstrates the sensory collateral nerve-pull technique to locate the vascular axis.] By doing so, the nerve embedded in the pedicle area can be easily and precisely identified; in other words, the vessels are safely “visualized,” while avoiding skeletonizing the pedicle. Then, the pedicle is harvested along this vascular axis with a cuff of the surrounding fatty tissue and the tourniquet is deflated to confirm flap circulation. [See Video 2 (online), which shows robust blood supply immediately after surgery.] {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"This video demonstrates the sensory collateral nerve-pull technique to locate the vascular axis.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_4byrpeg8"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2.","caption":"This video shows robust blood supply immediately after surgery.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_cijotxgl"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} We believe that this nerve-pull technique is extremely helpful in locating the vessels within the pedicle. The most prevalent complication with this flap is venous congestion caused by excessive compression of the pedicle. In our experience, the circumference of the pedicle can be safely narrowed with the precise location of the dorsoradial digital artery, and there has been no evidence that a narrow flap pedicle (<0.9 cm) can result in venous insufficiency. From an aesthetic standpoint, unnecessary width of the flap pedicle may prevent easy primary closure without skin grafts or skin bridge,4 thus producing a less aesthetically pleasing result. In conclusion, the sensory collateral nerve pull technique can be safely and effectively used in harvesting the pedicle of the Moschella flap. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Qualitative and Quantitative Wall Enhancement Analyses in Unruptured Aneurysms Are Associated With an Increased Risk of Aneurysm Instability.

ObjectiveIntracranial aneurysm wall enhancement (AWE) is independently associated with unstable aneurysms. However, a quantitative analysis of wall enhancement is lacking. This study aims to investigate the relationship between qualitative and quantitative wall enhancement indices (WEIs), traditional risk factors for aneurysms, and clinical ELAPSS/PHASES scores in a large cohort of intracranial saccular aneurysms.Materials and MethodsIn this cross-sectional study, a total of 174 patients (mean age 60.4 ± 9.5 years; 53% women) with 248 asymptomatic unruptured intracranial aneurysms underwent pre- and post-contrast black-blood magnetic resonance imaging (MRI). The extent of AWE was defined as non-AWE (pattern 0), focal AWE (pattern 1), or circumferential AWE (pattern 2). WEI was calculated using wall signal intensities on pre- and post-contrast images. Predicted 3- and 5-year growth risk and 5-year rupture risk were obtained from ELAPSS and PHASES scores, respectively. Uni- and multivariate analyses were conducted to explore the relationship between AWE characteristics, risk-related factors, and aneurysm instability.ResultsAneurysm size [odds ratio (OR), 1.3; 95% confidence interval (CI), 1.2–1.4; P < 0.001], non-internal carotid artery/middle cerebral artery location (OR, 1.9; 95% CI, 1.0–3.6; P = 0.045), and irregular shape (OR, 2.4; 95% CI, 1.2–4.5; P = 0.009) were independently associated with AWE. For aneurysms with AWE, the estimated 3- and 5-year growth risk (25.3 ± 13.0% and 38.0 ± 17.4%) and the 5-year rupture risk (3.9 ± 5.2%) were 1.9–3.3 times higher than those for aneurysms without AWE (12.8 ± 9.1%, 20.3 ± 13.0%, and 1.2 ± 1.6%, respectively; all P < 0.001). Larger areas and higher WEIs of enhancement positively correlated with aneurysm size (r = 0.43 and 0.38, respectively), 3- and 5-year growth risk, and 5-year rupture risk (r = 0.49 and 0.40, r = 0.49 and 0.40, r = 0.36 and 0.24, respectively; all P < 0.001). In sum, a larger aneurysm size, non-internal carotid artery/middle cerebral artery location, and irregular shape were independently associated with AWE. Larger areas and higher WEIs were associated with an increased risk of aneurysm growth and rupture. These findings suggest that quantitative AWE metrics should be considered in future large-scale longitudinal studies to evaluate their value in aneurysm risk management.

Mechanism of Stroke According to the Severity and Location of Atherosclerotic Middle Cerebral Artery Disease

Background and purposeStrategy for secondary prevention of ischemic stroke depends on the mechanism of stroke. The aim of this study was to compare the stroke mechanism according to the location and severity of middle cerebral artery (MCA) disease. MethodsWe analyzed acute ischemic stroke patients within 7 days of onset with symptomatic MCA disease. The location of MCA disease was classified into proximal MCA M1 (pMCA) and distal MCA M1/proximal M2 (dMCA). The mechanism of stroke was categorized according to the pattern of ischemic lesion: local branch occlusion, artery-to-artery embolism/hemodynamic infarction, in situ-thrombosis, or a combined mechanism. The mechanism and imaging characteristics of stroke were compared according to the location and severity. The factors associated with the stroke mechanism were also investigated. ResultsA symptomatic MCA disease was observed in 126 patients (74 pMCA and 52 dMCA). The mechanism of stroke differed according to the location (p < 0.001); the combined mechanism was most common in pMCA disease (54.1%), especially in those who presented with MCA occlusion and with a susceptible vessel sign. Artery-to-artery embolism/hemodynamic infarction was most common in dMCA disease (46.2%). A longer length of stenosis was observed in local branch occlusion than in other mechanisms (p = 0.04) and was an independent factor associated with local branch occlusion (OR=1.631, 95% CI=1.161–2.292; p = 0.005). ConclusionsThe mechanism of stroke differed according to the location of MCA disease: occlusion caused by plaque rupture with combined mechanism of stroke type was predominant in pMCA. Longer length of stenosis was associated with local branch occlusion.

Frequency and risk factors for postoperative aneurysm residual after microsurgical clipping

ObjectiveAneurysm residuals after clipping are a well-known problem, but the course of aneurysm remnants in follow-up is not well studied. No standards or follow-up guidelines exist for treatment of aneurysm remnants. The aim of this study was to evaluate the risk factors for postoperative aneurysm remnants and their changes during follow-up.MethodsWe performed a retrospective analysis of 666 aneurysms treated via clipping in our hospital from 2006 to 2016. Postoperative and follow-up angiographic data were analyzed for aneurysm remnants and regrowth. Clinical parameters and aneurysm-specific characteristics were correlated with radiological results.ResultsThe frequency of aneurysm residuals was 12% (78/666). Aneurysms located in the middle cerebral artery (p = 0.02) showed a significantly lower risk for incomplete aneurysm occlusion. Larger aneurysms with a diameter of 11–25 mm (p = 0.005) showed a significantly higher risk for incomplete aneurysm occlusion. Five patients underwent re-clipping during the same hospital stay. Remnants were stratified based on morphological characteristics into “dog ears” (n = 60) and “broad based” (n = 13). The majority of the “dog ears” stayed stable, decreased in size, or vanished during follow-up. Broad-based remnants showed a higher risk of regrowth.ConclusionsA middle cerebral artery location seems to lower the risk for the incomplete clip occlusion of an aneurysm. Greater aneurysm size (11–25 mm) is associated with a postoperative aneurysm remnant. The majority of “dog-ear” remnants appear to remain stable during follow-up. In these cases, unnecessarily frequent angiographic checks could be avoided. By contrast, broad-based residuals show a higher risk of regrowth that requires close imaging controls if retreatment cannot be performed immediately.

Hemodynamic Effects of Ultrasound-Assisted, Catheter-Directed, Very Low-Dose, Short-Time Duration Thrombolysis in Acute Intermediate–High Risk Pulmonary Embolism (from the EKOS-PL Study)

Ultrasound-assisted, catheter-directed, low-dose thrombolysis (USAT) at an average alteplase dose of 20 mg infused over 12 to 24 hours reversed right ventricular disfunction and improved pulmonary hemodynamics in intermediate-high-risk pulmonary embolism patients. As bleeding risk increases with the thrombolytic dose, establishing a minimal effective USAT dosing regimen is of clinical importance. We aimed to investigate hemodynamic effects and safety of a very low-alteplase-dose USAT of 10 mg administered within 5 hours. We included 12 consecutive intermediate-high-risk pulmonary embolism patients with symptoms duration of <14 days and proximal thrombi location in pulmonary arteries. Pulmonary Embolism Response Team decision-based fixed, bilateral ultrasound-assisted alteplase infusions at the rate of 1mg/hour/catheter for 5 hours through EKOS system catheters were made. The primary efficacy measure was the change in invasive systolic and mean pulmonary arteries pressure, and in cardiac index from USAT start to termination. Safety measures were 180-day all-cause death or cardiopulmonary decompensation and bleeding complications. The systolic pulmonary arteries pressure and mean pulmonary arteries pressure decreased from 53 (45.5 to 59) to 37.5 (27.5 to 40.5) mm Hg (p = 0.02) and from 29.5 (27.5 to 32) to 21.5 (15.5 to 25) mm Hg (p = 0.02), respectively. The cardiac index increased from 1.6 (1.5 to 1.8) to 2.2 (1.9 to 2.4) l/min/m2, (p = 0.02). No deaths, decompensations, or need for therapy intensification occurred. There was 1 episode of access-site bleeding, which subsided after conservative management. No intracranial hemorrhages appeared. In conclusion, reduced dose and duration USAT improved pulmonary hemodynamics and cardiac function leading to cardiopulmonary stabilization in intermediate-high risk pulmonary embolism patients at a low periprocedural risk.

Evaluation of length and location of the maxillary sinus intraosseous artery using computerized tomography.

The intraosseous artery is a branch of the posterior superior alveolar artery that supplies the lateral wall of the maxillary sinus. The present study seeks to analyze the location of the intraosseous artery and its site of termination. Cone beam computed tomography was used to evaluate 200 patients making up 400 maxillary sinuses. The following criteria were measured: (1) the distance of the lower border of the intraosseous artery to the floor of the sinus, (2) the average length of the artery, (3) the diameter of the artery, (4) the site at which the artery terminates at, and (5) the distance of the artery from the first premolar, second premolar, first molar, second molar, and third molar. The intraosseous artery was identified in 336 (84.0%) quadrants. The most common site of termination was at the mesial of the second molar (22%), regardless of dental status and right or left quadrant. Its overall mean diameter was 0.91 ± 0.56 mm, with no difference within the dental status. Its overall mean length was 7.40 ± 3.39 mm, with a statistically significant difference between dentate and edentulous quadrants (P < 0.001). Its overall mean distance from the floor was 6.95 ± 6.49 mm, with no difference within the dental status. All parameters showed no difference between right or left quadrants. The chances of encountering the intraosseous artery at the premolar area is <21% during a lateral window sinus floor elevation. The most common (22%) site of termination of the intraosseous artery is at the mesial of the second molar. Understanding of the course, location, and termination of the artery enhances the precision of a clinician when it comes to pre-operative treatment planning.

Doppler Ultrasonographic Anatomy of the Midline Nasal Dorsum.

This study was performed to identify a safe method for filler injection to prevent blood vessel damage, by means of checking the location and depth of the blood vessels on the midline of the nose using Doppler ultrasonographic imaging. Ultrasonographic images of the nasal areas of patients for filler injection rhinoplasty were reviewed. The location and depth of the dorsal nasal arteries and the intercanthal vein in each part on the midline of the nose were checked. The intercanthal vein was detected in the midline of the radix in 22 patients and the midline of the rhinion region in two patients. There were no patients in whom the intercanthal vein was observed in the midline of the supratip region. The dorsal nasal artery was detected in the rhinion region in six patients and in the supratip region in two patients. There were no patients in whom the dorsal nasal artery was observed in the midline of the radix. The dorsal nasal artery was located within 1.2 mm from the perichondrium or periosteum in three patients in whom it was detected in the rhinion. When performing dorsal augmentation, the injection of filler into the preperiosteal layer in the rhinion region should be avoided for the prevention of vascular embolism. During dorsal augmentation in patients with a nasal hump, the filler can be injected into the preperiosteal space in the radix by introducing a needle perpendicular to the periosteum from the skin. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Identification of the high-risk patient in primary percutaneous coronary intervention: development and validation of a novel predictive index

Abstract Background Primary percutaneous coronary intervention (PPCI) is the best treatment for patients with ST elevation myocardial infarction (STEMI). Several risk scores have been created to help risk-stratify these patients but few of these can be calculated in-lab, during the acute event. Development of a score that could be applied during PPCI could aid operators' decisions regarding adjunctive therapies and post-procedural surveillance which could improve patient outcomes. This study aimed to develop a simple, practical risk model that could be applied during PPCI to identify high-risk patients. Methods Demographic, clinical and outcome data were collected for all patients, as part of the HEAT-PPCI trial, who underwent PPCI for suspected STEMI between February 2012 and November 2013 at our hospital. Independent predictors of the composite outcome of 28-day mortality or severe impairment of LV function (ejection fraction ≤35%) were identified using multiple logistic regression. A risk model was fitted and internal validation was performed by bootstrapping. External validation was performed on a separate cohort of patients with STEMI. Results The derivation cohort included 1271 patients, with 131/1271 = 10.3% experiencing the composite outcome of 28-day mortality or poor LV function. Three variables were required to predict the outcome: age (OR:2.07, 95% CI 1.55 to 2.78), location of the culprit artery (OR:6.16, 95% CI 4.00 to 9.47), myocardial blush grade post-PPCI (OR:2.32, 95% CI 1.39 to 3.88). External validation was performed on 324 patients undergoing PPCI from a different centre. The model showed good discrimination on ROC-curve analysis (c statistic 0.79, 95% CI 0.75 to 0.83) and performed well on external validation (c statistic 0.87, 95% CI 0.72 to 0.95). Accuracy of the risk model on the validation data was improved by simple recalibration. The model was used to create a risk prediction chart that can be used in-lab during PPCI (Figure 1). Conclusions We have developed a risk model that accurately predicts 28-day mortality or poor LV function following STEMI using age, culprit location and myocardial blush grade. The model can assist operators in identifying high-risk patients during PPCI. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): National Health Service, UK

CCS patients with polyvascular disease are a high risk but heterogenous subset of patients: insights from the CLARIFY registry

Abstract Introduction Polyvascular disease constitutes a powerful predictor of cardiovascular events, is found in 10 to 15% of chronic coronary syndromes (CCS) patient. Smoking and diabetes mellitus are strongly associated with polyvascular disease. Risk stratification is key to select the most appropriate therapeutic strategy for a given patient. Purpose We aimed to describe 5-year ischaemic risk of CCS patients according to vascular disease phenotype and diabetic or smoking status. Method We analyzed data from 32 703 consecutive CCS outpatients (45 countries) enrolled between November 2009 to June 2010 in the prospective observational CLARIFY registry. Three mutually exclusive groups were compared: Coronary artery disease (CAD) alone, CAD with peripheral artery disease (PAD) or cerebrovascular disease (CVD) (CAD+1), CAD with CVD and PAD (CAD+2). Primary outcome was a composite of cardiovascular death, myocardial infarction or stroke, adjusted on age, sex and geographic origin at 5 years. Results At baseline, 26440 (80.8%) patients were diagnosed with CAD alone, 4967 (15.2%) had CAD+1, 1296 (4%) had CAD+2. Overall, 9501 (29%) patients were diabetics, 19184 (58.7%) were smokers or ex-smokers and only 9220 (28.2%) were free of these two major cardiovascular risk factors. Primary outcome increasing gradually according to the number of arterial diseases locations from 8.4% (95% CI 8.09–8.73) in patients with CAD alone to 17.4% (95% CI 16.95–17.83) of CAD+2 patients (p&amp;lt;0.001). Subgroup analysis according to diabetes or smoking status further enriched risk stratification from 7% (95% CI 6.48–7.59) in non-diabetic, non-smoking CAD alone patients to 20.3% (95% CI 19.08–21.44) in diabetics and smokers CAD+ 2 patients (Figure 1). Diabetic CAD alone patients had a comparable risk to that of non-diabetic and non-smoking polyvascular patients, 9.8% (95% CI 8.82–10.68) vs 10.3% (95% CI 9.61–10.96), p=0.38. Outcome was similar between polyvascular diabetic patients, regardless of the number of arterial diseases, 15.5% (95% CI 14.31–16.60) for CAD+1 and 15.0 (95% CI 13.88–16.13) for CAD+2, p=0.83. Smoking increased 5-year risk proportionally to the number of symptomatic arterial bed, 8.2% (95% CI 7.72–8.68) vs 11.8% (95% CI 11.18–12.31) vs 17.9% (95% CI 17.18–18.54), respectively for CAD alone, CAD+1 and CAD+2. Conclusion CCS patients with polyvascular disease remain at high risk of ischaemic events in the contemporary practice with widespread secondary prevention therapies. Polyvascular is a very heterogenous subset of patients with ischaemic risk varying not only according to the number of vascular bed diseased but also according to smoking and diabetes status, two conditions present in the vast majority of CCS patients. Diabetes confers upfront a maximal increased risk. Identification of higher risk subsets in polyvascular patients can potentially identify those that could derived the greatest benefit from new secondary prevention strategies. Figure 1 Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Assistance Publique-Hôpitaux de Paris

Prevalence of cerebrovascular diseases that can cause hemorrhagic stroke in liver transplantation recipients: a 6-year comparative study with 24,681 healthy adults.

Cerebrovascular diseases are a leading cause of mortality after liver transplantation (LT). The prevalence of potentially hemorrhagic cerebrovascular diseases (HCVDs) that could cause a hemorrhagic stroke in patients with severe liver diseases has not been reported. We aimed to analyze the underlying prevalence of HCVDs that could lead to hemorrhagic strokes in LT recipients compared with that in previously healthy controls. A retrospective study with 1,920 consecutive LT recipients and 24,681 adults who underwent a health checkup during the same period was conducted (January 2011-December 2016). The prevalence of cerebral aneurysms (CA), cerebral arteriovenous malformation (AVM), and cavernous malformation (CM) was evaluated using brain imaging, including computed tomography angiography, magnetic resonance imaging, magnetic resonance angiography, and digital subtraction angiography. The prevalence of CA and CM were 3.1% and 0.5%, respectively, in the LT group and 3.8% and 0.4%, respectively, in the control group. According to the location of the cerebral artery, paraclinoid internal carotid artery aneurysms (odds ratio [OR] 0.440; P = 0.009) had a lower prevalence in LT recipients than in healthy controls. Anterior communicating artery (OR 3.080; P = 0.002) and superior cerebellar artery (OR 8.767; P = 0.017) aneurysms had a higher prevalence in the LT group than in the control. The prevalence of AVM was significantly higher in LT recipients (0.26%) than in healthy controls (0.06%). LT recipients showed a different distribution of CA prevalence according to the locations of the cerebral artery and had a higher overall prevalence of AVM than previously healthy controls.

Targeted Endodontic Microsurgery: Implications of the Greater Palatine Artery

IntroductionTargeted Endodontic Microsurgery (TEMS) combines trephine burs and 3D-printed guides to make flapless maxillary palatal root-end surgery possible. This study assessed the location of the greater palatine artery (GPA), the relationship of the GPA to maxillary molar root ends, and the feasibility of flapless palatal-approach TEMS. MethodsThree endodontists analyzed 250 cone-beam computed tomographic images of maxillary molars for (1) transition morphology between the hard palate and the alveolar process adjacent to first and second molars as an indication of the most likely location of the GPA, (2) the superior-inferior relationship between the GPA and root ends, and (3) the feasibility of palatal-approach TEMS. ResultsPalatal transition morphology included 20% Spine, 72% Bridge, and 8% Smooth. GPA position as related to palatal root ends was classified as 34% superior, 40% adjacent, and 21% inferior. Five percent of classifications were undefined. TEMS was deemed feasible for 47% of maxillary first molars and 52% of second molars, and was significantly more feasible with GPAs superior to palatal root ends. Reasons for infeasibility included GPA proximity and unfavorable resection angle or level. Maxillary first molar palatal roots were 11.13 ± 2.68 mm from the greater palatine foramen (GPF) and 2.37 ± 1.46 mm from the GPA. Second molar palatal roots were 4.94 ± 2.55 mm from the GPF and 2.53 ± 1.77 mm from the GPA. ConclusionsPalatal transition morphology and GPA position adjacent to maxillary molars, as manifested in cone-beam computed tomographic coronal views, suggested maxillary palatal root TEMS could be accomplished with a 2-mm safety margin in 47% of first molars and 52% of second molars. Historical paradigms that do not consider flapless palatal surgical approaches may need to be revised.

Use of the Da Vinci Sensitive Firefly Imaging System for Transperitoneal Visualization in Gynecologic Surgery

Study Objective First, to introduce the use of Sensitive Firefly in robotic surgery. Second, to compare the efficacy of Firefly (currently in use) to Sensitive Firefly Fluorescence Imaging for ureter identification using the IS-001 (IND 124804) investigational contrast agent. Design Prospective, open-label, 2-stage dose escalation clinical trial design. Setting Multi-center; academic and academic affiliated community hospitals. Patients or Participants Women (n=30) between ages 18 and 75 scheduled to undergo robotic gynecological procedures using a da Vinci® Surgical System with Sensitive Firefly® Fluorescent Imaging. Interventions A single IV slow bolus injection of fluorescent dye IS-001 at 2 mg/mL was administered, with intra-operative identification of the ureter compared between white light endoscopy, Firefly®, and Sensitive Firefly Fluorescence Imaging modalities. Measurements and Main Results Visualization of the ureter was evaluated both quantitatively and based on a qualitative surgeon rating score using Firefly, Sensitive Firefly with IS-001 versus white light endoscopy. Ureter visibility was measured at the level of the pelvic brim (PB) with a tissue depth of ∼ 0.5 mm, and at the level of the uterine artery (UA) with an estimated tissue depth of ∼ 2-3 mm; both of which are common sites of ureteral injury during hysterectomy. Measurements were at time intervals of 10, 30, and 60 minutes after IS-001 injection using each modality. Early trial results indicate that Sensitive Firefly's boosted near-infrared sensitivity facilitated clear IS-001 fluorescent ureter detection at both shallow (PB) and deep (UA) locations. Sensitive Firefly offered a 5-fold improvement in ureter visibility at the deeper uterine artery location compared to white light endoscopy and a marked benefit compared to the existing Firefly Fluorescent Imaging system. Conclusion The use of Sensitive Firefly showed improved transperitoneal IS-001 fluorescent visualization and delineation of the ureter at greater tissue depths and for longer periods of time when compared to the current Firefly Fluorescent Imaging System. First, to introduce the use of Sensitive Firefly in robotic surgery. Second, to compare the efficacy of Firefly (currently in use) to Sensitive Firefly Fluorescence Imaging for ureter identification using the IS-001 (IND 124804) investigational contrast agent. Prospective, open-label, 2-stage dose escalation clinical trial design. Multi-center; academic and academic affiliated community hospitals. Women (n=30) between ages 18 and 75 scheduled to undergo robotic gynecological procedures using a da Vinci® Surgical System with Sensitive Firefly® Fluorescent Imaging. A single IV slow bolus injection of fluorescent dye IS-001 at 2 mg/mL was administered, with intra-operative identification of the ureter compared between white light endoscopy, Firefly®, and Sensitive Firefly Fluorescence Imaging modalities. Visualization of the ureter was evaluated both quantitatively and based on a qualitative surgeon rating score using Firefly, Sensitive Firefly with IS-001 versus white light endoscopy. Ureter visibility was measured at the level of the pelvic brim (PB) with a tissue depth of ∼ 0.5 mm, and at the level of the uterine artery (UA) with an estimated tissue depth of ∼ 2-3 mm; both of which are common sites of ureteral injury during hysterectomy. Measurements were at time intervals of 10, 30, and 60 minutes after IS-001 injection using each modality. Early trial results indicate that Sensitive Firefly's boosted near-infrared sensitivity facilitated clear IS-001 fluorescent ureter detection at both shallow (PB) and deep (UA) locations. Sensitive Firefly offered a 5-fold improvement in ureter visibility at the deeper uterine artery location compared to white light endoscopy and a marked benefit compared to the existing Firefly Fluorescent Imaging system. The use of Sensitive Firefly showed improved transperitoneal IS-001 fluorescent visualization and delineation of the ureter at greater tissue depths and for longer periods of time when compared to the current Firefly Fluorescent Imaging System.

Case Report: Limb Salvage after Delayed Brachial Artery Injury with Critical Limb Ischemia

Background ꓽ The superficial location of the brachial artery makes it the most frequently injured artery in the upper extremity; its injury represents approximately 28% of all vascular injuries. The objective of this study is to highlight that prompt revascularization can save the limb even in cases of delayed brachial artery injury with severe vascular compromise. Patients and Methods ꓽ It is a case study of 22-year male patient transferred to our hospital with critical limb ischemia following penetrating injury of his left elbow caused by glass during a fight .He presented to us 9 hours after the injury with hypotension, pallor, severe rest pain, cold and cyanosed extremity with absent distal pulses, and also he had bleeding lacerated wound at the region of left elbow. Diagnosis of brachial artery injury was made with clinical examination with no need for farther diagnostic modalities, and after rapid patient resuscitation, he was taken immediately to the theater and we performed end ̶ to ̶ end anastomosis of the brachial artery and also repair of the associated nerve injuries. Conclusion ꓽ Prompt surgical intervention with appropriate management is essential to save the limb in cases of delayed brachial artery injuries with critical limb ischemia.

Blunt cerebrovascular injury in the geriatric population.

Blunt cerebrovascular injury (BCVI) is associated with high rates of neurological morbidity and mortality. The detection and management of BCVI has improved with advances in imaging and sensitive screening protocols. Few studies have explored how these injuries specifically affect the geriatric population. The purpose of this retrospective analysis was to investigate the presentation and prognosis of BCVI in the elderly population and to assess its clinical implications in the management of these patients. All patients presenting to the University of Cincinnati (UC) level I trauma center between February 2017 and December 2019 were screened for BCVI and entered into the prospectively maintained UC Neurotrauma Registry. Patients with BCVI confirmed by CT angiography underwent retrospective chart reviews to collect information regarding demographics, positive screening criteria, cause of injury, antithrombotic agent, injury location, Denver Grading Scale, hospital and ICU length of stay, and discharge disposition. Patients were divided into geriatric (age ≥ 65 years) and adult (age < 65 years) subgroups. Continuous variables were analyzed using the Student t-test and categorical variables with the Pearson chi-square test. Of 124 patients with BCVI, stratification by age yielded 23 geriatric and 101 adult patients. Injury in the geriatric group was associated with significantly higher mortality (p = 0.0194). The most common cause of injury in the elderly was falls (74%, 17/23; p < 0.0001), whereas motor vehicle accidents were most common in the adult group (38%, 38/100; p = 0.0642). With respect to the location of injury, carotid (p = 0.1171) and vertebral artery (p = 0.6981) injuries did not differ significantly for the geriatric group. The adult population presented more often with Denver grade I injuries (p < 0.0001), whereas the geriatric population presented with grade IV injuries (p = 0.0247). Elderly patients were more likely to be discharged to skilled nursing facilities (p = 0.0403) and adults to home or self-care (p = 0.0148). This study is the first to characterize BCVI to all cervical and intracranial vessels in the geriatric population. Older age at presentation is significantly associated with greater severity, morbidity, and mortality from injury, with no preference for the particular artery injured. These findings carry important clinical implications for adapting practice in an aging population.

INCIDENTAL FINDING OF ONYX EMBOLIZATION OF THE PULMONARY ARTERY: A RARE COMPLICATION OF HIGH FLOW DURAL ARTERIOVENOUS FISTULA REPAIR

SESSION TITLE: Medical Student/Resident Imaging Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Onyx® is a non-adhesive liquid embolic agent used for embolization of brain arteriovenous malformations (bAVMs). We present a case of a 58 year-old woman with shortness of breath found to have a foreign body on chest imaging later determined to be a pulmonary artery Onyx embolus. CASE PRESENTATION: A 58 year-old woman with history of tracheostomy-dependent chronic respiratory failure and dural arteriovenous fistula (DAVF) status post multistage embolic repair presented to the emergency department with shortness of breath, chest tightness, and productive cough for one week. On arrival, she was hypoxic requiring 4L oxygen via tracheostomy mask to maintain an oxygen saturation of 94%. Her exam was remarkable for expiratory wheezes in all lung fields and purulent secretions from her tracheostomy. Chest radiograph revealed a linear radiopaque foreign body overlying the expected location of the right pulmonary artery. A computed tomography of the chest confirmed the finding of a tortuous metallic foreign body within the lower lobe branches of the right pulmonary artery. No lung parenchymal changes were noted in the area supplied by these vessels. Interventional radiology reviewed these images and determined the foreign body to be an irretrievable embolus of the agent used during her DAVF repair, her final treatment having occurred three months prior. This finding was of no significance to the patient’s presentation. She was diagnosed with viral tracheitis and managed symptomatically with complete resolution of symptoms. DISCUSSION: The Onyx liquid embolic agent is made of ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide and suspended micronized tantalum powder to make it radio-opaque. It is designed to harden within five minutes of deployment and available in two different formulations varying in viscosity. The lower viscosity Onyx 18 will travel further from the deployment catheter compared to the higher viscosity Onyx 34. Its non-adhesive nature and ease of use makes it a preferable choice to the cyanoacrylate-based (“glue”) agents for some neurointerventionalists. Common complications include hemorrhage, stroke and vessel perforation. Embolus migration has been rarely reported. It is usually noted incidentally on follow-up imaging, as happened with our patient. Clinical presentations are typically asymptomatic, though there have been reports of acute presentations of hypoxemia and superior vena cava syndrome. Treatment options include conservative measures, retrieval of embolus or medical management of symptoms. CONCLUSIONS: Brain AVMs are increasingly being treated with Onyx embolization. Distal migration to non-targeted vessels can be a complication of this procedure, which may be discovered as a puzzling incidental or less commonly an acute finding. Reference #1: FDA, Access Data - Onyx Liquid Embolic system, Instructions for Use, 2003, Site: https://www.accessdata.fda.gov/cdrh_docs/pdf3/P030004c.pdf Reference #2: Tolly, B. T., Kosky, J. L., Koht, A., & Hemmer, L. B. (2016, August 31). A Case Report of Onyx Pulmonary Arterial Embolism... : A&A Practice. LWW. https://journals.lww.com/aacr/fulltext/2017/02150/A_Case_Report_of_Onyx_Pulmonary_Arterial_Embolism.7.aspx#JCL-P-13 Reference #3: Crusio, R., Ramachandran, K., Ramachandran, K., Kupfer, Y., & Tessler, S. (2011). Superior vena cava syndrome caused by embolisation of liquid Onyx. BMJ case reports, 2011, bcr1120103502. https://doi.org/10.1136/bcr.11.2010.3502 DISCLOSURES: No relevant relationships by Timothy Miett, source=Web Response No relevant relationships by Nishka Shetty, source=Web Response

Central Retinal Artery: A Human Fetal Cadaveric Study with Histological Correlation.

The optic nerve is the second cranial nerve. It is supplied by the central retinal artery. It is said that this artery starts getting incorporated within the optic nerve at around the sixth week of gestation, and by the ninth week it is entirely inside the optic nerve. However, the point of incorporation lies in the intraorbital course of the optic nerve. The present study aimed at identifying the location of the central retinal artery inside the optic nerve, i.e. the peripheral or central position. Human fetuses of second and third trimester were dissected to expose the optic nerve. Morphometric measurements were taken and sectioned in 3 regions. These transverse sections were subjected to histological procedures. The results showed that the central retinal artery, at its entry into the optic nerve, was peripheral and inferior in 3 of 25 optic nerves and peripheral and lateral in the remaining optic nerves. However, the arteries were all centrally placed, close to the posterior pole of the eyeball. These findings are important for the ophthalmologist in identifying certain congenital anomalies of the eyeball in neonates.