Distal Branches Research Articles

Application of a custom-manufactured directional multibranched stent graft to treat thoracoabdominal aneurysms

OBJECTIVE: The objective of this study was performed to demonstrate the feasibility and effectiveness of a custom-manufactured stent graft (CMSG) with directional multibranches for the treatment of a complex thoracoabdominal aortic aneurysm (TAAA) patient. METHODS: A 73-year-old man presented with Crawford Type V TAAA was treated with a CMSG with four down-going directional branches including two proximal directional branches for the celiac artery and superior mesenteric artery and two distal side directional branches for the bilateral renal arteries. RESULTS: Postoperative course was unremarkable and 6-month follow-up demonstrated sac regression, absence of endoleaks, and all of the visceral branches remained patent. CONCLUSIONS: Total endovascular repair using CMSG with directional multibranches is a suitable alternative in higher risk patients with TAAA who are not suited for open surgery. Longer follow-up is needed to confirm the preliminary results.

Human distal airways contain a multipotent secretory cell that can regenerate alveoli.

The human lung differs substantially from its mouse counterpart, resulting in a distinct distal airway architecture affected by disease pathology in chronic obstructive pulmonary disease. In humans, the distal branches of the airway interweave with the alveolar gas-exchange niche, forming an anatomical structure known as the respiratory bronchioles. Owing to the lack of a counterpartin mouse, the cellular and molecular mechanisms that governrespiratory bronchioles in the human lung remain uncharacterized. Here we show that human respiratory bronchioles contain a unique secretory cell population that is distinct from cells in larger proximal airways. Organoid modelling reveals that these respiratory airway secretory (RAS) cells act as unidirectional progenitors for alveolar type 2 cells, which are essential for maintaining and regenerating the alveolar niche. RAS cell lineage differentiation into alveolar type 2 cells is regulated by Notch and Wnt signalling. In chronic obstructive pulmonary disease, RAS cells are altered transcriptionally, corresponding to abnormal alveolar type 2 cell states, which are associated with smoking exposure in both humans and ferrets. These data identify a distinct progenitor in a region of the human lung that is not found in mouse that has a critical role in maintaining the gas-exchange compartment and is altered in chronic lung disease.

The Axillary Nerve Danger Zone in Percutaneous Fixation in the Pediatric Shoulder: The "1-Mountain-3-Valleys" Principle.

Adult literature cites an axillary nerve danger zone of 5 to 7 cm distal to the acromion tip for open or percutaneous shoulder surgery, but that may not be valid for younger patients. This study sought to quantify the course of the axillary nerve in adolescent patients with reference to easily identifiable intraoperative anatomic and radiographic parameters. A single-institution hospital database was reviewed for shoulder magnetic resonance images (MRIs) in patients 10 to 17 years old. One hundred and one MRIs from patients with a mean age of 15.6 ± 1.2 years (range, 10 to 17 years) were included. Axillary nerve branches were identified in the coronal plane as they passed lateral to the proximal humerus and were measured in relation to identifiable intraoperative surface and radiographic landmarks, including the acromion tip, apex of the humeral head, lateral physis, and central apex of the physis. The physeal apex height (i.e., 1 "mountain") was defined as the vertical distance between the most lateral point of the humeral physis (LPHP) and the central intraosseous apex of the physis. Axillary nerve branches were found in all specimens, adjacent to the lateral cortex of the proximal humerus. A mean of 3.7 branches (range, 2 to 6) were found. The mean distance from the most proximal branch (BR1) to the most distal branch (BR2) was 11.7 mm. The pediatric danger zone for the axillary nerve branches ranged from 6.6 mm proximal to 33.1 mm distal to the LPHP. The danger zone in relation to percent of physeal apex height included from 62% proximal to 242% distal to the LPHP. All branches were found distal to the apex of the physis (1 "mountain" height proximal to the LPHP). Distal to the LPHP, no branches were found beyond a distance of 3 times the physeal apex height (3 "valleys"). In children and adolescents, percutaneous fixation of the proximal humerus should be performed with cortical penetration outside of this range. These parameters serve as readily identifiable intraoperative radiographic landmarks to minimize iatrogenic nerve injury. This study provides valuable landmarks for percutaneous approaches to the proximal humerus. The surgical approach for the placement of percutaneous implants should be adjusted accordingly (i.e., performed at least 1 mountain proximal or 3 valleys distal to the LPHP) in order to prevent iatrogenic injury to the axillary nerve.

NF-κB Signaling-Mediated Activation of WNK-SPAK-NKCC1 Cascade in Worsened Stroke Outcomes of Ang II-Hypertensive Mice.

Worsened stroke outcomes with hypertension comorbidity are insensitive to blood pressure-lowering therapies. In an experimental stroke model with comorbid hypertension, we investigated causal roles of ang II (angiotensin II)-mediated stimulation of the brain WNK (with no lysine [K] kinases)-SPAK (STE20/SPS1-related proline/alanine-rich kinase)-NKCC1 (Na-K-Cl cotransporter) complex in worsened outcomes. Saline- or ang II-infused C57BL/6J male mice underwent stroke induced by permanent occlusion of the distal branches of the middle cerebral artery. Mice were randomly assigned to receive either vehicle dimethyl sulfoxide/PBS (2 mL/kg body weight/day, IP), a novel SPAK inhibitor, 5-chloro-N-(5-chloro-4-((4-chlorophenyl)(cyano)methyl)-2-methylphenyl)-2-hydroxybenzamide (ZT-1a' 5 mg/kg per day, IP) or a NF-κB (nuclear factor-κB) inhibitor TAT-NBD (transactivator of transcription-NEMO-binding domain' 20 mg/kg per day, IP). Activation of brain NF-κB and WNK-SPAK-NKCC1 cascade as well as ischemic stroke outcomes were examined. Stroke triggered a 2- to 5-fold increase of WNK (isoforms 1, 2, 4), SPAK/OSR1 (oxidative stress-responsive kinase 1), and NKCC1 protein in the ang II-infused hypertensive mouse brains at 24 hours after stroke, which was associated with increased nuclear translocation of phospho-NF-κB protein in the cortical neurons (a Pearson correlation r of 0.77, P<0.005). The upregulation of WNK-SPAK-NKCC1 cascade proteins resulted from increased NF-κB recruitment on Wnk1, Wnk2, Wnk4, Spak, and Nkcc1 gene promoters and was attenuated by NF-κB inhibitor TAT-NBD. Poststroke administration of SPAK inhibitor ZT-1a significantly reduced WNK-SPAK-NKCC1 complex activation, brain lesion size, and neurological function deficits in the ang II-hypertensive mice without affecting blood pressure and cerebral blood flow. The ang II-induced stimulation of NF-κB transcriptional activity upregulates brain WNK-SPAK-NKCC1 cascade and contributes to worsened ischemic stroke outcomes, illustrating the brain WNK-SPAK-NKCC1 complex as a therapeutic target for stroke with comorbid hypertension.

Seasonal patterns of increases in stem girth, vessel development, and hydraulic function in deciduous tree species.

The onset of spring growth and vessel formation were examined within three deciduous woody plant species, Acer rubrum, Populus balsamifera ssp. trichocarpa and Quercus rubra. We were broadly interested in the lag between the onset of girth expansion and the formation of mature and hydraulically conductive vessels within the new xylem. Dendrometers were installed on 20 trees (6-7 per species), and expansion of both bole and distal stems was monitored throughout the growing season in a common garden. For each species, four to six distal stems were harvested every other week for anatomical examination of vessel formation. Additionally, for Populus and Quercus, hydraulic conductivity measurements and active xylem staining were completed on all stem samples. For all three species, the timing of girth expansion was similar. Expansion of distal branches occurred 12-37 d earlier than that of the bole. Vessel formation initiated several weeks prior to leaf-out, but no new earlywood vessels were mature at the time of bud break for Acer and Populus and only a few were present in Quercus. Initial stem girth expansion occurred 2 to &gt;6 weeks before the maturation of the first current-year vessels, and there was an additional delay of up to 4 weeks before mature vessels became hydraulically functional. Hydraulic conductivity was strongly correlated with the number and diameter of stained vessels. Bud break and leaf expansion relied predominantly on water supplied by vessels formed during prior seasons. Early-season activity is likely affected by the function of older xylem vessels and the environmental factors that influence their structure and function. Understanding the functional lifespan of vessels and the varying contributions of new and older vessels to conductivity are critical to understanding of the phenology and vascular function of long-lived woody plants in response to changing climates.

Radiological evaluation of maxillary artery and descending palatine artery in the pterygopalatine fossa by 3D rotational angiography.

The aim of this study is to evaluate the branching patterns and topographical features of the third part of the maxillary artery (t-MA) and descending palatine artery (DPA) by 3-Dimensional Rotational Angiography (3DRA) images and to define the radiological classification of their variations, based upon the previous cadaveric studies and a review of the literature. This study was conducted from May 2020 through June 2021. All consecutive adult patients who were examined with 3D-RA were enrolled in the study. The morphological evaluations and measurements of t-MA, DPA and their branches were made on maximum intensity projection images with 10-20mm slice thickness. Eighty-five hemifaces, including 58 females and 45 right sides, were evaluated. The diameter of the t-MA was measured as 1.73 ± 0.30mm. The most common pattern of the t-MA according to its course was loop type (63/85, 74.1%) and according to branching pattern was Type Ib (29/85, 34.1%). The mean diameter of DPA was 1.19 ± 0.20mm. The DPA presented as a single trunk in 11/85 cases. Type II, which was defined as one lesser palatine artery originating from distal-DPA, was the most common morphological variation (51.8%). 3DRA imaging provides valuable information for vascular anatomical studies. The most common morphological variation related to t-MA, DPA is the distal branching pattern.

NMDA receptor antagonist amantadine in treatment of neuropathic orofacial pain

Neuropathic orofacial pain caused by trauma to the distal branches of the trigeminal nerve is most often an iatrogenic complication in the practice of dentists, maxillofacial surgeons, ENT surgeons, cosmetologists and plastic surgeons. The pain is often high-intensity, persistent, and difficult to treat with pain medications. Early signs of spontaneous pain aggravate the course of the disease. There is evidence of the use of N-methyl-d-aspartate (NMDA) receptor antagonists in the treatment of neuropathic pain in the practice of oncologists and diabetologists. The present study was designed to test the efficacy of administration of the NMDA receptor antagonist amantadine (PK-Merz) in the treatment of neuropathic orofacial pain in patients with posttraumatic trigeminal neuropathy (PTN). Our task was to study the effect of amantadine (PK-Merz) on spontaneous burning and evoked types of pain.Objective.To present a treatment protocol using amantadine (PK-Merz) and evaluate the effect of a three-time infusion of the drug on the clinical manifestations of pain in patients with post-traumatic trigeminal neuropathy.Materials and methods.30 patients were examined (22 women, 8 men). The average age is 42.6 years. Patients are experiencing amantadine (PK-Merz, Merz + Co., Germany) – 200 mg (500 ml) intravenously, drip, for 2 hours with a frequency of 1 time per week. A total of three infusions were performed. Spontaneous and evoked pain was measured within 48 hours before treatment, during treatment (after 1 hour), immediately after infusion (after 2 hours), as well as after 7, 14 and 21 days from the start of therapy. The effectiveness of therapy was studied according to the highest criteria: VAS, questionnaires for neuropathic pain DN 4 and Pain DETECT. Spontaneous and induced pain were considered separately. To assess the immediate effects of treatment, spontaneous pain was measured using a visual analog scale (VAS) before, after 1 hour, and at the end of each treatment (after 2 hours), as well as at visits on days 7th, 14th, and 21st. A series of mechanical and thermal stimuli was applied to each patient before, after 1 hour, and at the end of each treatment session to study the pain evoked. Pain caused by these stimuli was also measured using VAS.Results.The patients were divided into two groups, which were formed according to the duration of the disease. Group 1 (n = 12) included patients in the acute period – the time after nerve injury ranged from 5 to 30 days. In group 2, patients were in subacute and chronic periods (time after injury ranged from 30 days to 1.5 years). The mean score of spontaneous pain according to VAS in patients of group 2 was significantly higher than in patients of group 1 (6.1 ± 2.1 vs 4.2 ± 1.6; p = 0.0001). A mean pain reduction of 71 % was reported at the end of amantadine infusion (after 2 hours) in patients in the acute period (Group 1) compared with 29 % in patients in Group 2. The difference in pain reduction between the two patient groups was statistically significant (p = 0.009). Further dynamics of pain also showed the best analgesic result in patients of group 1 – after the completion of treatment with amantadine (PK-Merz), in patients of group 1, a significant decrease in the average score of spontaneous burning pain according to VAS was demonstrated from 4.2 ± 1.6 points to 1.2 ± 1.1 points (p = 0.006; 71 ± 10 % reduction). After treatment of patients in group 2, only a slight and insignificant decrease in VAS was found from 6.1 ± 2.1 to 5.0 ± 1.7 (p = 0.400; 18.0 ± 8.5 %). Symptoms of induced pain were determined mainly among patients of the 2nd group – allodynia (n = 12), hyperalgesia to a needle prick (n = 10), thermal (cold) hyperalgesia (n = 10), "inflated" pain in response to repeated injections (n = 10). A mean decrease in allodynia of 52 % ± 8 % was found at the end of the course of treatment (3.8 ± 1.1 points at the beginning and 1.9 ± 1.1 points at the end; p = 0.006). Indicators of cold hyperalgesia (4.4 ± 1.4 points at the beginning, 2.7 ± 1.4 points at the end; p = 0.004) and ‘inflated’ pain (2.9 ± 1.1 points at the beginning, 1.5 ± 1.2 at the end; p = 0.004) before treatment and at the end of therapy (after 21 days) also differed significantly.Conclusions.We concluded that amantadine (PK-Merz) infusion is a safe and effective treatment for neuropathic pain in the acute period of KITN, and also has a positive effect on the manifestations of induced pain in patients with chronic orofacial pain. Further trials of long-term oral or parenteral treatment with amantadine should be conducted.

Efficacy of LED Photobiomodulation for Functional and Axonal Regeneration After Facial Nerve Section-Suture.

Facial nerve damage can lead to partial or total facial nerve palsy. Photobiomodulation has been reported to improve and accelerate functional recovery following peripheral nerve lesion, depending on the type of lesion and the light exposure parameters used. The aim of this study was to investigate the effects of infrared exposure on functional and axonal regeneration after section-suture of the distal branches of the facial nerve: the buccal and marginal mandibular branches and the distal pes. The animals underwent surgery and were irradiated with infrared light at 850 nm twice daily from day 1 to day 16. The recovery of facial function was then studied at both the behavioral and morphological levels. Behavioral analyses were performed by videoscoring with a high-speed camera and using various devices to assess the recovery of whisker movement on the lesioned side from day 1 to day 30. We also assessed nasal deviation toward the intact side and the ability to close the ipsilateral eyelid completely from day 1 to day 38 and from day 1 to day 50, respectively. For morphological analyses, we assessed the re-establishment of facial motoneuron labeling with Fluorogold®, an immunofluorescent retrograde marker of axonal transport injected into the vibrissae, on D10, D14 and D30. We found that whisker movements recovery was significantly faster in treated than in control mice. A complete disappearance of nasal deviation was observed at 2 weeks in infrared-treated lesioned mice and at 5 weeks in controls. Complete eyelid closure was observed 3 weeks after surgery in treated animals and 6 weeks after surgery in controls. Finally, normal fluorogold labeling of the facial nuclei complex was restored 30 days after surgery in the treated animals, but no such restoration was ever observed in control animals. In conclusion, our data show that IR treatment at a distal site has a significant positive effect on facial nerve recovery. These findings pave the way for the clinical use of infrared photobiomodulation in patients with nerve lesions.

Finite Element Analysis of Soccer Ball-Related Ocular and Retinal Trauma and Comparison with Abusive Head Trauma.

PurposeTrauma to the eye resulting from a soccer ball is a common sports-related injury. Although the types of ocular pathologic features that result from impact have been documented, the underlying pathophysiologic mechanics are not as well studied. The purpose of this study was to evaluate the biomechanical events after the collision of a soccer ball with the eye to better understand the pathophysiology of observed ocular and retinal injuries and to compare them with those observed in abusive head trauma (AHT).DesignComputer simulation study.ParticipantsNone.MethodsA finite element model of the eye was used to investigate the effects of a collision of a soccer ball on the eye.Main Outcome MeasuresIntraocular pressure and stress.ResultsImpact of the soccer ball with the eye generated a pressure wave that traveled through the vitreous, creating transient pockets of high and negative pressure. During the high-frequency phase, pressure in the vitreous near the posterior pole ranged from 39.6 to –30.9 kPa. Stress in ocular tissue was greatest near the point of contact, with a peak of 66.6 kPa. The retina experienced the greatest stress at the vasculature, especially at distal branches, where stress rose to 15.4 kPa. On average, retinal stress was greatest in the subretinal layer, but was highest in the preretinal layer when considering only vascular tissue.ConclusionsThe high intraocular pressure and stress in ocular tissue near the point of soccer ball impact suggest that injuries to the anterior segment of the eye can be attributed to direct transmission of force from the ball. The subsequent propagation of a pressure wave may cause injuries to the posterior segment as the positive and negative pressures exert compressive and tractional forces on the retina. The linear movement of the pressure wave likely accounts for localization of retinal lesions to the posterior pole or superior temporal quadrant. The primarily linear force in soccer ball trauma is the probable cause for the more localized injury profile and lower retinal hemorrhage incidence compared with AHT, in which repetitive angular force is also at play.

Inclusion of quantitative high-density plaque in coronary computed tomographic score system to predict the time of guidewire crossing chronic total occlusion

ObjectiveThis study aimed to establish a new scoring system that includes histological quantitative features derived from coronary computed tomographic angiography (CCTA) to predict the efficiency of chronic total occlusion percutaneous coronary intervention (CTO-PCI).MethodsThis study analyzed clinical, morphological, and histological characteristics of 207 CTO lesions in 201 patients (mean age 60.0 [52.0–65.0] years, 85% male), which were recruited from two centers. The primary endpoint was a guidewire successfully crossing the lesions within 30 m. The new predictive model was generated by factors that were determined by multivariate analysis. The CCTA plaque (CTAP) score that included a quantitative plaque characteristic was developed by assigning an appropriate integer score to each independent predictor, then summing all points. In addition, the CTAP score was compared with other predictive scores based on CCTA.ResultsThe endpoint was achieved in 63% of the lesions. The independent predictors included previous CTO-PCI failure, the proximal blunt stump, proximal side branch, distal side branch, occluded segment bending > 45°, and high-density plaque volume (fibrous volume + calcified volume) ≥ 19.9 mm3. As the score increased from 0 to 5, the success rate of the guidewire crossing within 30 m decreased from 96 to 0%. Comparing the CTAP score with other predictive scores, the CTAP score showed the highest discriminant power (c-statistic = 0.81 versus 0.73–0.77, p value 0.02–0.07). The CTAP score showed similar results for procedural success.ConclusionThe CTAP score efficiently predicted the guidewire crossing efficiency and procedural success.Key Points• An increase in high-density plaque volume (fibrous + dense calcium) was more probable to reduce the efficiency of crossing and lead to procedural failure.• The new prediction scoring system with the addition of the quantitative characteristics of plaques had an improved predictive ability compared with the traditional prediction scoring system.

Mechanical thrombectomy of acute occlusions of individual distal anterior cerebral artery branches

To describe our experience with mechanical thrombectomy (MT) in distal anterior cerebral artery (ACA) occlusions regarding recanalization rates, MT techniques and procedural safety. From a prospectively maintained thrombectomy database all patients with distal ACA occlusions treated with MT between April 2013 and February 2021 were retrospectively identified. Imaging data and angiographic features as well as clinical data were collected. 41 patients were included in the study, including 23 patients (56.1%) with distal main stem occlusions (occlusions distal to the anterior communicating artery but proximal to the origin of the pericallosal and callosomarginal arteries) and 18 patients (46.3%) with distal individual branch occlusions (occlusions of the pericallosal or callosomarginal arteries and their ramifications). A stent retriever mediated technique was applied in 34 patients (82.9%), the ADAPT technique in 7 patients (17.1%). Successful (mTICI 2b/3) and complete recanalization (mTICI 3) rates did not differ for the distal ACA main stem occlusion group (82.6%/56.5%), and the individual branch occlusion group (83.3%/55.6%) (p ≫ 0.05). No severe complications specific to distal MT maneuvers were noted. MT for acute distal individual ACA branch occlusions beyond the common A2/3 trunk appears safe and technically effective in different clinical settings and occlusion patterns with high recanalization rates. However, further studies are required to determine the clinical effectiveness.

A rare coronary anomaly: Left anterior descending artery emerging as a distal branch of the right coronary artery

A rare coronary anomaly: Left anterior descending artery emerging as a distal branch of the right coronary artery

Facial reanimation using nerve transposition

Nerve transposition is an important tool in facial reanimation and is indicated when the proximal end of the facial nerve cannot be grafted but the distal nerve branches and facial muscles are viable. It involves the use of an alternate cranial nerve to reinnervate the distal facial nerve and musculature in order to achieve facial movement, symmetry, and tone. Multiple cranial nerves have been used for nerve substitution; however, none can guarantee complete facial nerve recovery or restoration of normal facial function. The ideal donor nerve depends on the type of nerve injury, time since injury, and patient factors. Nerve transposition can be used for direct motor neurotization, babysitter and double innervation techniques, and innervation of neuromuscular transplants. The most common nerve transposition procedures will be discussed in this article.

Advances and future directions in the care of patients with facial paralysis

Advances and future directions in the care of patients with facial paralysis

Abstract WP148: Magnetically Enhanced Diffusion (MED) Of Intravenous Thrombolytics Decreases Thrombus Leading To Accelerated Reperfusion

Whether systemic fibrinolysis alone or, more recently, combined with thrombectomy are used to re-establish blood flow in cerebral arteries occluded with thrombus, a shower of fragments often plugs more distal arterial branches leading to continued infarction, resulting in some loss of brain function. We hypothesized that magnetite MicroBeads injected intra-arterially near a thrombus and exposed to a rotating magnetic field after IV administration of plasminogen activators (lytics) would accelerate fibrinolysis leading to decreased distal thrombus burden, increased blood flow, and less brain infarction and loss of function. Clots formed in vitro from recalcified citrated rabbit blood were weighed (ave = 100mg) and injected into both common carotid arteries with blood flow occluded at the level of C3/4 in anesthetized male and female rabbits. rtPA (Activase, 1mg/kg, Genentech) was infused IV over 1h or Tenecteplase (TNK, 0.3-0.9mg/kg, Genentech) was injected IV as a bolus. After 30 min, magnetite MicroBeads were injected (300ug) as a bolus every 5 min over 30min (6 doses, 1,800mg) through a 5F angiocatheter placed within 2-3cm of the clot in one carotid, while the other carotid received the lytic alone by diffusion. The clots were removed after 1h and reweighed. MED increased the rate of fibrinolysis of clots leading to &amp;gt95% reduction in clot weight vs 83% with Activase alone (p&amp;lt0.0001 for paired testing, n=8). Clot lysis was also increased with MED + TNK (p&amp;lt0.05, n=6) compared to TNK alone. Thus significant acceleration of lysis and reduction in clot weight occurs after treatment with MicroBeads plus lytic compared to lytic alone. This approach may enhance reperfusion and decrease infarction during stroke treated by either lytic alone or lytic + thrombectomy leading to improved outcomes.

Endovascular coil embolization of inferior mesenteric artery to ileal-conduit fistula: a case report

BackgroundUretero-arterial fistulas (UAFs) are uncommon and pose a diagnostic dilemma, making them life threatening if not recognized and treated expediently. UAFs to small arteries such as a branch of the inferior mesenteric artery (IMA) are very uncommon and present a further diagnostic and treatment challenge. There should be a high index of suspicion for UAFs when intervening on patients with history of treated pelvic cancers and long-standing ureteric stents experiencing hematuria not attributable to another cause.Case presentationWe present a case of a fistula formed between a distal branch of the IMA—superior rectal artery—and an ileal-conduit in a patient with a long-standing reverse nephroureterostomy (Hobbs) catheter presenting with abdominal pain and hematuria through the conduit. During a tube exchange, contrast injection demonstrated a fistula with the superior rectal artery, multiple ileal intraluminal blood clots, and active extravasation. The patient became tachycardic and hypotensive, actively bleeding through the ileal-conduit, prompting a massive transfusion protocol. Successful endovascular coiling of the superior rectal artery was performed with resolution of active extravasation and stabilization of the patient. The patient recovered and was discharged in stable condition 10 days later.ConclusionsAlthough UAFs are uncommon, our case demonstrated key predisposing risk factors to fistula development; pelvic cancer surgery, pelvic radiation, and a prolonged ureteric stent through the ileal-conduit. Typically, UAFs arise from communication with the iliac arterial system, however in this instance we have demonstrated that fistulization to other arterial vessels is also possible. Endovascular management has become the preferred method of therapy, typically involving the placement of covered stents when involving the iliac arterial system. In this instance stent grafting was not possible due to the small caliber vessel and therefore had to be embolized.

Large traumatic middle cerebral artery aneurysm in a Child: case report and review of literature

A 6-year-old girl presented with a very large aneurysm of the distal branch of middle cerebral artery( angular artery). There was a previous history of mild traumatic brain injury. The presentation happened more than 5 weeks after the trauma with an atypical visual complaint. She was successfully treated by embolization and occlusion of the parental vessel. Recognizing pos traumatic aneurysm is a challenging in young child and must be remembered in patients with a recent traumatic event. Endovascular treatment is a good option when the occlusion of the artery is possible in the presence of a good collateral circulation. Key-words: Dissecting aneurysm; middle cerebral artery; endovascular; pediatric aneurysms

Latex-injected, non-decapitated, saturated salt method-embalmed cadaver technique development and application as a head and neck surgery training model.

Published cerebrovascular injection techniques have mostly used decapitated, fresh cadavers or heads embalmed with 10% formaldehyde. There have been no reports using vascular-injected cadavers for head and neck surgical training models or using vascular injections in saturated salt method-embalmed cadavers. Thus, we performed vascular labeling of five saturated salt method-embalmed cadavers without decapitation. Latex mixed with red ink was injected into the common carotid artery via a 3D-printed vascular adapter. The injection force was provided by a peristaltic pump. Thyroidectomy, submandibular gland excision, neck dissection, parotidectomy, and mandibulotomy were performed on both sides of each cadaver (n = 10). The consistency of the cadavers was softer than fresh ones. Subcutaneous tissues were well preserved, and muscles were moist and elastic. Five physicians graded the resemblance of the heads and necks of the latex-injected, saturated salt method-embalmed, non-decapitated of five cadavers compared to living humans using a Likert scale from 0 (no resemblance) to 5 (maximum resemblance). Fifty-two percent of the head and neck region resemblance scale ratings were four or five. Although the cadavers were practical for head and neck surgical simulations, the brain parenchyma was only partially preserved and unsuitable for use. The most distal arterial branches reached by the injected latex were measured. The external caliber of the smallest vessels reached were lacrimal arteries (mean caliber ± SD, 0.04 ± 0.04 mm; 95% CI [0, 0.09]). There were no significant differences in the mean caliber of the smallest vessels reached between the left- and right-sided arterial branches (all p < 0.05).

Ramisyllis kingghidorahi n. sp., a new branching annelid from Japan

Among over 20,000 species of Annelida, only two branching species with a highly modified body-pattern are known until now: the Syllidae Syllis ramosa McIntosh, 1879, and Ramisyllis multicaudata Glasby et al. (Zoological Journal of the Linnean Society, 164, 481–497, 2012). Both have unusual ramified bodies with one head and multiple branches and live inside the canals of host sponges. Using an integrative approach (combining morphology, internal anatomy, ecology, phylogeny, genetic divergence, and the complete mitochondrial genome), we describe a new branching species from Japan, Ramisyllis kingghidorahi n. sp., inhabiting an undescribed species of Petrosia (Porifera: Demospongiae) from shallow waters. We compare the new species with its closest relative, R. multicaudata; emend the diagnosis of Ramisyllis; and discuss previous reports of S. ramosa. This study suggests a much higher diversity of branching syllids than currently known. Finally, we discuss possible explanations for the feeding behaviour in the new species in relation to its highly ciliated wall of the digestive tubes (especially at the distal branches and anus), and provide a hypothesis for the evolution of branching body patterns as the result of an adaptation to the host sponge labyrinthic canal system.

Endovascular embolization of the middle meningeal artery with the SQUID-18 non-adhesive embolic agent as a treatment for recurrent chronic subdural hematoma (a case report)

Objective: to report a case of recurrent chronic subdural hematoma treated using endovascular superselective embolization of the middle meningeal artery with the SQUID-18 non-adhesive embolic agent.Materials and methods. A 73-year-old male patient had an open head injury after own height falling. Multislice computed tomography demonstrated chronic subdural hematoma in the left parietooccipital region. The patient had surgery with a positive effect; however, 1 month postoperatively he developed recurrent hematoma. He was diagnosed with recurrent chronic subdural hematoma and underwent endovascular embolization of the distal branches of the middle meningeal artery with a non-adhesive embolic agent; repeated hematoma drainage was not required.Results. Follow-up multislice computed tomography performed 7 months postoperatively demonstrated total resorption of chronic subdural hematoma.Conclusion. This case illustrates the variety of methods that can be used for the treatment of chronic subdural hematoma and shows that endovascular embolization of the middle meningeal artery is a minimally invasive and effective procedure for such a disorder.