Distal Branches Research Articles

Accelerating TOF-MRA: The impact of the combined use of compressed sensitivity encoding and spiral imaging

PurposeTo evaluate the image quality of the combined technique of compressed sensitivity encoding (CS) and spiral imaging in time-of-flight magnetic resonance angiography (TOF-MRA), which is approximately 2.5 times faster than conventional methods. MethodsTwenty volunteers underwent four TOF-MRA sequences: sensitivity encoding (SENSE) with acceleration factor of 4 (acquisition time: 4:55 min), CS with acceleration factor of 10.9, and spiral and CS-spiral (both 1:55 min). A quantitative image analysis (signal-to-noise ratio [SNR], contrast, and full width at half maximum [FWHM] edge criterion measurements) was performed on four TOF sequences. For qualitative image analysis, two board-certified radiologists evaluated the overall depiction of the proximal, intermediate, and distal branches in CS, spiral, and CS-spiral images using SENSE as a reference. ResultsThe SNR of BA in spiral and CS-spiral imaging was significantly lower than that in SENSE (p = 0.009). The contrasts of ACA and BA in CS-spiral were significantly higher and those in spiral were significantly lower than those in SENSE (p < 0.001). The FWHM in the CS image was significantly higher than that of SENSE; however, no significant differences were observed between the spiral or CS-spiral and SENSE. In qualitative analysis, the depiction of proximal vascular branches was significantly impaired in spiral than in others and that of distal vascular branches was significantly impaired in CS than in others (p < 0.001). ConclusionsIn TOF-MRA, which is approximately 2.5 times faster than conventional methods, the combined use of CS and spiral imaging demonstrated an improvement in image quality compared to either CS or spiral imaging alone. Summary statementThe image quality of Compressed SENSE and spiral imaging is particularly poor in the proximal and distal vascular branches, respectively at an extremely high acceleration factor; however, CS-spiral provided stable image quality in all regions as compared with the SENSE technique.

Transplantation of hESCs-Derived Neural Progenitor Cells Alleviates Secondary Damage of Thalamus After Focal Cerebral Infarction in Rats.

Human embryonic stem cells-derived neural progenitor cells (hESCs-NPCs) transplantation holds great potential to treat stroke. We previously reported that delayed secondary degeneration occurs in the ventroposterior nucleus (VPN) of ipsilateral thalamus after distal branch of middle cerebral artery occlusion (dMCAO) in adult male Sprague-Dawley (SD) rats. In this study, we investigate whether hESCs-NPCs would benefit the neural recovery of the secondary damage in the VPN after focal cerebral infarction. Permanent dMCAO was performed with electrocoagulation. Rats were randomized into Sham, dMCAO groups with or without hESCs-NPCs treatment. HESCs-NPCs were engrafted into the peri-infarct regions of rats at 48 h after dMCAO. The transplanted hESCs-NPCs survive and partially differentiate into mature neurons after dMCAO. Notably, hESCs-NPCs transplantation attenuated secondary damage of ipsilateral VPN and improved neurological functions of rats after dMCAO. Moreover, hESCs-NPCs transplantation significantly enhanced the expression of BDNF and TrkB and their interaction in ipsilateral VPN after dMCAO, which was reversed by the knockdown of TrkB. Transplantated hESCs-NPCs reconstituted thalamocortical connection and promoted the formation of synapses in ipsilateral VPN post-dMCAO. These results suggest that hESCs-NPCs transplantation attenuates secondary damage of ipsilateral thalamus after cortical infarction, possibly through activating BDNF/TrkB pathway, enhancing thalamocortical projection, and promoting synaptic formation. It provides a promising therapeutic strategy for secondary degeneration in the ipsilateral thalamus post-dMCAO.

Facial Nerve High-Resolution Microanatomy Analysis of the Distal Intratemporal to Extracranial Pes Segment: Reconstructive Implications.

Current knowledge of facial nerve topography between the stylomastoid foramen to the pes anserinus is very limited. Elucidating this segment's intraneural microanatomy may be advantageous in certain clinical settings: the planning of nerve grafts for gaps extending from the proximal facial nerve trunk to distal branches or in determining coaptation sites for hypoglossal jump grafts to provide selective upper and lower facial tone. This study is the first to provide high-definition intraneural topography of the aforementioned segment to optimize reconstructive outcomes. Sixteen facial nerves extending from the second genu to the pes anserinus were harvested from eight cadavers en bloc to preserve orientation. Specimens were imaged by micro-computed tomography using a serial 6-μm protocol and digitally reconstructed three-dimensionally to be analyzed using bioinformatic tools. No clinically significant fascicular separation was noted between 14.4 mm proximal to the stylomastoid foramen until 4.4 mm distal to the foramen. Fascicles remained separate throughout the remainder of the specimen and were found to undergo a mean rotation of 45.5 degrees ( P = 0.0002) between 8.9 and 13.7 mm distal to the stylomastoid foramen. This reliable clockwise rotation in left nerves and counterclockwise rotation in right nerves resulted in superficially oriented fascicles entering the upper division of the pes anserinus, whereas deep-oriented fascicles entered the lower division. Intraneural facial nerve topography and rotation are consistent from 4 to 14 mm distal to the stylomastoid foramen, enabling surgeons to accurately place grafts targeted to either the upper or lower face, thus optimizing functional accuracy and minimizing synkinesis.

Pulmonary cement embolism: a complication following vertebroplasty - a case report with brief review of literature

BackgroundA minimally invasive treatment for vertebral compression fractures is vertebroplasty. In spite of its relative safety, complications have been reported. It is a relatively uncommon complication among these that patients experience massive cement pulmonary embolism. Polymethyl methacrylate (PMMA) can cause embolization in the pulmonary arteries. One of the most common cements used in vertebroplasty is PMMA, a type of acrylic cement. Pulmonary cement embolism can occur if cement leaks into the perivertebral veins and then the pulmonary arteries (Barbero et al., Radiol Med 113:101–13, 2008). Occasionally, the patient will show no symptoms at all, while other times they will experience dyspnea, chest pain, or acute respiratory distress syndrome. A 54-year-old male who underwent vertebroplasty developed pulmonary cement embolism is the patient in our case report.Case presentationA 54-year-old male had complaints of breathlessness for 1 week and left lower limb and lower back pain associated with swelling of the lower limbs for 20 days. The patient is an operated case of osteoporotic compression fractures of D6, D11, L1, L3, and L5 vertebroplasty 3 years back. Subsequently, computed tomography pulmonary angiography was performed and diagnosed with partial embolization of the distal peripheral branches of the bilateral pulmonary arteries by the vertebroplasty material.ConclusionVertebroplasty and kyphoplasty are the most prevalent procedures used to inject bone cement (PMMA) into the vertebral column in order to treat osteoporosis. With vertebroplasty, the possibility of embolization increases. In vertebral osteoporosis, the primary advantage is a reduction in pain and vertebral body collapse. Pulmonary cement embolization causes chest discomfort and shortness of breath. Sometimes, acute respiratory distress syndrome is present (Yoo et al., Spine (Phila Pa 1976) 29:E294–7, 2004). After the operation, these symptoms rarely arise. Symptoms often appear weeks, months, or years after the surgery (Habib et al., Heart Lung 41:509-11, 2012). Through this case report, we discuss the complication following vertebroplasty and their management guidelines.

Nerve to the zygomaticus major muscle: An anatomical study and surgical application to smile reconstruction.

Smile reconstruction using the branches that supply the zygomaticus major muscle as a motor source is an established procedure in facial reanimation surgery for facial paralysis. However, the anatomy of the nerve to the muscle remains unclear. Therefore, we herein examined the topographical anatomy of the nerve to the zygomaticus major muscle to obtain more detailed information on donor nerve anatomy. Preserved cadaver dissection was performed under a microscope on 13 hemifaces of 8 specimens. The branches that innervate the zygomaticus major muscle and their peripheral routes medial to the muscle were traced and examined. A median of four (ranges 2-4) branches innervated the zygomaticus major muscle. The proximal two branches (near the muscle origin) arose from the zygomatic branch, the second of which was the major branch. The distal branches (near the oral commissure) arose from the buccal branch or zygomaticobuccal plexus. The vertical distance from the caudal margin of the zygomatic arch to the major branch intersecting point was 19 ± 4.0 mm, while the horizontal distance parallel to the Frankfort plane was 29 ± 5.2 mm. The proximal two branches innervating the zygomaticus major muscle were detected in the majority of specimens. The anatomical findings obtained herein on the nerve to the zygomaticus major muscle will allow for more reliable donor selection in facial reanimation surgery.

Evaluation and comparison of patch materials used for pulmonary arterioplasty in pediatric congenital heart surgery

ObjectiveTo evaluate the long-term performance of the patch materials we have used to augment the pulmonary arterial tree across a wide spectrum of diagnoses and anatomical locations. MethodsRetrospective, single-center review of 217 consecutive pediatric patients at a tertiary referral center from 1993 to 2020 who underwent patch arterioplasty of the pulmonary arterial tree from the pulmonary bifurcation to the distal pulmonary arterial branches. Reintervention data were collected and analyzed. Lesion-specific anatomy and other variables were analyzed as risk factors for reintervention. ResultsThere were 280 total operations performed (217 initial operations and 63 reoperations) and 313 patches used. The patches used were autologous pericardium (166, 53.0%), pulmonary homograft (126, 40.3%), and a heterogeneous group of other materials (21, 6.7%). Overall patient survival was 86.2%, freedom from reoperation was 81.0% and freedom from reintervention (FFR) was 70.6%, with a median follow-up of 13.8 years (interquartile range, 6.3-17.9 years). For all patches, 10-, 20-, and 27-year FFR was 76.6%, 70.6%, and 70.6%, respectively. FFR was similar among all 3 patch type groups (P = .29). Multivariable Cox regression analysis showed that diagnoses of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries and hypoplastic left heart syndrome, patches placed at initial cardiac operation, and increasing number of cardiac operations were risk factors for reintervention. ConclusionsAutologous pericardium and pulmonary homograft patches performed similarly. Although patch type conferred no difference in need for reintervention, other risk factors did exist. Namely, diagnoses of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries and hypoplastic left heart syndrome, patch placement at a patient's first cardiac operation, and increasing number of cardiac operations were risk factors for reintervention.

Formation and branching patterns of deep palmar arch

Objective: The present study is to document and provide information about both normal and variable morphology of the deep palmar&#x0D; arch (DPA) in adult human cadavers by the dissection method.&#x0D; Materials and Methods: We examined 12 upper extremities (6 cadavers). After the classification of the vascular patterns of DPA and&#x0D; its branches, measurements of the vessel diameters were carried out using a digital compass.&#x0D; Results: Deep palmar arch was found as a completed arch (100%) in all cases. The anastomosis between the distal deep palmar branch&#x0D; of the ulnar artery (DPBUA) and the terminal branch of the radial artery (RA) was the most common type in our study. The incidence&#x0D; of the DPA was reported as a complete arch ranging from 54.9% to 100%. Palmar metacarpal arteries (MPAs) originating from the&#x0D; DPA were divided into four branches (25%) in three cases and three branches (75%) in nine cases. The mean diameter of the MPAs at&#x0D; the point of origin at the DPA was between 0.3 mm and 0.6 mm.&#x0D; Conclusion: A comprehensive understanding of the DPA branching diameters in the hand will facilitate surgical and radiological&#x0D; approaches and contribute to a constantly expanding knowledge base in literature.

Ophthalmic artery arising from the external carotid artery system: the middle meningeal artery in South African patients

BackgroundThe ophthalmic artery is the first branch of the internal carotid artery. It arises from the supraclinoid segment of the internal carotid artery within the subarachnoid space and enters the orbit via the optic canal. However, due to complex embryogenesis, the ophthalmic artery can arise from different parts of the internal carotid artery or the distal branches of the external carotid artery. This is usually associated with a variation in the course of the ophthalmic artery through the superior orbital fissure instead of coursing through the optic canal. The ophthalmic artery and its branches vascularise the eyeball and its contents. Consequently, information about its morphologic variation is essential for treating clinical conditions such as central retinal artery occlusion, retinoblastoma chemoembolization, and ophthalmic artery aneurysm.Case presentationWe report on two cases of the ophthalmic artery arising from the middle meningeal artery in one adult (33-year-old Indian female) and one pediatric (2-year-old African male) South African patient examined by digital subtraction angiography. The patients were diagnosed with arteriovenous malformations and bilateral retinoblastoma, respectively.ConclusionsThe ophthalmic artery plays a vital role in vision generation. Thus, its anatomy is of clinical interest to neurosurgeons, ophthalmologists, and interventional radiologists.

Sural communicating nerve for application as a vascularized nerve graft: A microneurovascular anatomic study in cadavers.

Sural nerve harvest causes paraesthesia to the lateral heel of the foot, which can debilitate those with already compromised proprioception. To circumvent this, we investigated an alternative donor nerve, branch of the lateral sural nerve complex called the sural communicating nerve (SCoNe), for its harvest and use as a vascularized nerve graft, in cadaver. The SCoNe was visualized by dissection in 15 legs from 8 human cadavers and the relationship of the SCoNe to the overall sural nerve complex was documented. The surface markings, dimensions, and the micro-neurovascular anatomy in the super-microsurgery range (up to 0.30 mm) of the SCoNe was recorded and analyzed. SCoNe graft surface marking was confined within a triangle drawn between the fibular head laterally, the popliteal vertical midline medially and the tip of the lateral malleolus inferiorly. The proximal end of the SCoNe was situated at a mean intersection distance of 5 cm from both the fibular head and popliteal midline respectively. The mean length of the SCoNe was 226 ± 43 mm with a mean proximal diameter of 0.82 mm and mean distal diameter of 0.93 mm. In 53% of the cadavers, an arterial input was present in the proximal third of the SCoNe and veins were predominantly (87%) present in the distal third. In 46% and 20% of the 15 legs respectively, there was a nutrient artery and vein perfusing the SCoNe in its central segment. The external mean diameter of this artery was 0.60 ± 0.30 mm, while the vein was slightly larger with a mean diameter of 0.90 ± 0.50 mm. SCoNe graft may preserve lateral heel sensation, compared to sural nerve harvest, pending clinical studies. It may have wide applications as a vascularized nerve graft, including being ideal as a vascularized cross-facial nerve graft because its nerve diameter is similar to the distal facial nerve branches. The accompanying artery is a good anastomotic match to the superior labial artery.

(439) Penile Revascularization Utilizing The Lateral Femoral Circumflex Artery After Pelvic Fracture Urethral Injury

Abstract Introduction Pelvic fracture urethral injury (PFUI) is associated with erectile dysfunction (ED) in up to 62% of patients, often due to decreased arterial inflow. For select healthy patients with isolated arterial insufficiency, penile revascularization utilizing the inferior epigastric artery to either the cavernosal or dorsal penile artery has been shown to be an effective treatment ED. The patient originally presented with a PFUI after a motor vehicle collision. He underwent suprapubic tube placement and selective embolization of a right internal pudendal artery pseudoaneurysm. Four months later, he underwent a posterior urethroplasty with corporal splitting and inferior pubectomy. During follow-up, he reported no erectile function following his initial trauma with no prior history of erectile dysfunction. He was trialed on PDE5is which were ineffective and ICI which was discontinued due to pain and minimal efficacy. Penile Doppler ultrasound with ICI showed bilateral arterial insufficiency with peak systolic velocities of 11.3 and 18.8 cm/second and no evidence of veno-occlusive dysfunction with end-diastolic flows of 2.85 and 4.66 cm/second of the cavernosal arteries (Figure 1). Bilateral inferior epigastric arteriography demonstrated 20-30% ostial stenosis with left traumatic occlusion of the internal pudendal and complete occlusion of the right internal pudendal artery post-embolization. The dorsal penile arteries filled in a delayed fashion via small-caliber collaterals. Objective We present this case to demonstrate use of an alternative arterial donor vessel for penile revascularization. Methods An infrapubic incision was made to expose the right dorsal penile artery. Another incision was made from the right anterior superior iliac spine to just above the patella tendon. The rectus femoris and vastus lateralis were atraumatically split and the descending branch of the lateral femoral circumflex artery was exposed. Small branches were clipped (Figure 2). The most distal branch to the rectus femoris was divided to become the donor vessel, leaving the proximal branch to maintain muscular perfusion. The donor branch was mobilized and passed via a subcutaneous tunnel into the infrapubic incision (Figure 3). Using an operating microscope the dorsal penile artery was ligated and the distal end was anastomosed to the donor artery and an end-to-end fashion using 8-0 nylon interrupted sutures. A drain was placed in the thigh wound, and both wounds were closed in two layers. Results The patient was started on 325mg of daily aspirin and remained on bed rest for two days. He was discharged on postoperative day two and his thigh drain remained in place for two weeks. He was restricted to less than 30-degree abduction of the right thigh for four weeks. Four months postoperatively the patient was achieving erections with 7/10 rigidity using only 5mg of tadalafil as needed. His SHIM was 17. At six months postoperatively he had increased his tadalafil dose to 20mg and was achieving erections with 8/10 rigidity from his pre-injury baseline. Conclusions This case demonstrates an excellent result from penile revascularization utilizing the lateral femoral circumflex artery. This artery can be considered an alternate donor for penile revascularization procedures following pelvic fracture urethral injury when there is a contraindication to the use of the inferior epigastric artery. Disclosure No

PO-04-029 TRIANGULATING THE LV SUMMIT: A NOVEL BIPOLAR RADIOFREQUENCY CATHETER ABLATION STRATEGY

Bipolar radiofrequency catheter ablation (RFCA) is an off-label strategy used to target ventricular arrhythmias (VA) from difficult substrates such as the LV summit. To achieve greater transmural RFCA lesions in challenging anatomy with a novel bipolar RFCA strategy. N/A A 51-year-old male with familial HCM and prior catheter ablation for persistent AF presented with pallor and palpitations in the setting of wide complex tachycardia of 210 BPM (Figure A). The patient was given a bolus of IV amiodarone and externally cardioverted. Amiodarone was discontinued given his history of amiodarone-induced hyperthyroidism. During the hospitalization, he had recurrences of sustained VAs that were suppressed with lidocaine. Cardiac MRI was obtained, which showed LVEF 42% and an extensive LGE in the LV (Figure B). The patient was brought to the EP lab for VT ablation. Extensive mapping in the RVOT, distal CS, and peri-aortic area was performed. The best pacemap was achieved with the 2F EPstar catheter (Baylis Medical) in the AIV. The ablation catheter was not able to be advanced into the distal branch in the coronary sinus. A total of 17 unipolar RFCA lesions were delivered from endocardial LV but the clinical VA remained easily inducible. A second ablation catheter was advanced to the posteroseptal RVOT on the opposite side of the septum for bipolar RFCA. The 2F EPstar catheter was positioned in the AIV near the region of best pacemap for tripolar effect (Figure C). A significant difference in the ablation impedance decline was noted between unipolar and bipolar ablations utilizing this novel strategy (Figure D top - unipolar, D bottom - bipolar). Following five bipolar RCFA lesions, the clinical VA was no longer inducible. The patient tolerated the procedure well with no further recurrence of VAs. Bipolar RFCA with a mapping catheter triangulating the target may help achieve deeper lesions.

Different clinical phenotypes of a pair of siblings with familial hypercholesterolemia: a case report and literature review

BackgroundFamilial hypercholesterolemia (FH) leads to high plasma low-density lipoprotein cholesterol (LDL-C) levels and early cardiovascular morbidity and mortality. We treated a pair of siblings with FH. The cardiovascular manifestations in the proband were more severe than those in his elder sister, although they had almost similar LDL-C levels, ages, and lifestyles. Herein, we report the cases of this family to explore the possible causes of clinical phenotypic differences within the same genetic background.Case presentationWe treated a 27-year-old male patient and his 30-year-old sister, both with FH. The coronary angiogram in the male patient revealed 80, 70, and 100% stenosis of the initial, distal right coronary artery branch, and left anterior descending branch, respectively, whereas his sister had almost no coronary stenosis. We treated them accordingly and performed family screening. We found that the LDL-C/particle discordance of the proband is much greater than that of his elder sister. In addition, the average size of LDL-C particle in the proband was smaller than that in his sister.ConclusionsPatients with FH have a much higher risk of premature atherosclerotic cardiovascular disease, but the clinical manifestations are heterogeneous. The smaller LDL particle size may be the underlying cause for different clinical outcomes in this pair of FH cases and be a potential novel indicator for predicting the prognosis of FH.

Comparison of anti-inflammatory influences of the splanchnic sympathetic nerve with those of the hypothalamic-pituitary-adrenal (HPA) axis during systemic inflammation

Branches of the splanchnic sympathetic nerve, that supply several abdominal organs including adrenals, provide the efferent neural pathway for reflex dampening of systemic inflammation (SI). In response to SI, the splanchnic nerves not only suppress secretion of the pro-inflammatory cytokine tumour necrosis factor-α (TNF) but drive release of the anti-inflammatory cytokine interleukin-10 (IL-10) (1,2,3). Recently we showed that the adrenal branch plays a major role in driving IL-10 secretion (3), while distal branches to other organs (e.g. spleen) suppress TNF secretion from immune cells (2,3). Glucocorticoid secretion resulting from activation of the HPA axis during SI is also anti-inflammatory. The present study compares the anti-inflammatory role of the adrenal cortex with that of the splanchnic nerve and adrenal medulla following i.v. lipopolysaccharide (LPS; 60 μg/kg) in urethane-anesthetized male rats. Plasma TNF and IL-10 levels sampled at 90 min after LPS injection were measured by ELISA. We hypothesized that the anti-inflammatory action of the splanchnic nerve differs from that of adrenal corticosteroids during SI. Gender differences were not investigated. We compared effects on endotoxin stimulated IL-10 and TNF secretion of cutting bilaterally (i) adrenal nerves, n=6, (ii) splanchnic nerves, n = 5, (iii) bilateral adrenalectomy, n = 8, (iv) combined adrenalectomy and splanchnic nerve cuts, n = 7, and (v) sham surgery, n = 5. As expected, TNF levels in response to LPS increased after cutting splanchnic (17.1 ± 2.5 ng/ml, mean ± SEM, p &lt; 0.001) or adrenal (12.9 ± 3.8 ng/ml, p &lt; 0.05) nerves compared with sham operated rats (3.9 ± 1.3 ng/ml). Adrenalectomy which reduces circulating adrenaline as well as corticosterone levels, resulted in greater plasma [TNF] (36.4 ± 5.2 ng/ml, p &lt; 0.001), while combined splanchnic denervation and adrenalectomy further increased the TNF level to 61.3 ± 12. 4 ng/ml. Regarding plasma IL-10 levels, cutting either splanchnic or adrenal nerves alone reduced LPS-induced plasma IL-10 from 0.9 ± 0.2 ng/ml (sham) to 0.2 ± 0.1 and 0.3 ± 0.1 ng/ml respectively (both p &lt; 0.05), whereas bilateral adrenalectomy alone (1.1 ± 0.1 ng/ml) or combined with splanchnic denervation (0.6 ± 0.1 ng/ml) did not. We conclude that glucocorticoids strongly suppress both pro- and anti-inflammatory cytokines. However, splanchnic sympathetic nerves are more selective, enhancing release of the anti-inflammatory cytokine IL-10, via adrenaline release, while suppressing pro-inflammatory cytokines such as TNF. References. (1) Martelli, D. et al., J Physiol. 592: 1677-86, 2014. (2) Martelli, D. et al., Am J Physiol Regul Integr Comp Physiol. 316: R235-242, 2019. (3) McKinley, M.J. et al., J Physiol. 600: 4521-36, 2022. NHMRC of Australia This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Exploring the role of polyunsaturated fatty acid ratios in modulating neuroinflammation in LPS-induced microglia: A comprehensive in vitro analysis

The study investigated the effect of different omega (ω)− 3 and omega (ω)− 6 polyunsaturated fatty acid (PUFA) ratios on cytokine secretion, cell viability, and microglial cell shape in lipopolysaccharide (LPS)-induced microglia. The addition of PUFAs at different ratios, especially ω-3 and ratios of 7/1 and 2/1 ω-6/ω-3, resulted in a significant increase in the ameboid form of microglial cells, as well as more branching of their distal branches. Microglial cells were treated with varying ratios of PUFAs, and their cytokine secretion was measured. The results showed that all PUFA ratios had lower tumor necrosis factor (TNF)-α secretion than the control group, higher interleukin (IL)− 4 secretion in the ω-6 group, and less IL-10 secretion most down IL-6 secretion in the 7/1 ratio group. The study suggests that determining the appropriate ω-6/ω-3 consumption ratio, especially the 7/1 and 2/1 ratios, may help manage neuroinflammation, develop dietary models in immune-mediated neurodegenerative diseases, and open up new treatment possibilities.

Multidisciplinary management in the treatment of intrahepatic cholangiocarcinoma.

Multidisciplinary management in the treatment of intrahepatic cholangiocarcinoma.

Lower Facial Nerve Nomenclature Clarification: Cervical Branch Controls Smile-Associated Lower Lip Depression and Dental Display.

In head and neck ablative surgery, traditional teaching is that the key facial nerve branch to preserve along the plane of the lower border of the mandible is the marginal mandibular branch (MMb), which is considered to control all lower lip musculature. The depressor labii inferioris (DLI) is the muscle responsible for pleasing lower lip displacement and lower dental display during natural emotive smiling. To understand the structure/function relationships of the distal lower facial nerve branches and lower lip musculature. In vivo extensive facial nerve dissections under general anesthesia. Intraoperative mapping was performed in 60 cases, using branch stimulation and simultaneous movement videography. In nearly all cases, the MMb innervated the depressor anguli oris, lower orbicularis oris, and mentalis muscles. The nerve branches controlling DLI function were identified 2 ± 0.5 cm below the angle of the mandible, originating from a cervical branch, separately and inferior to MMb. In half of the cases, we identified at least 2 independent branches activating the DLI, both within the cervical region. An appreciation of this anatomical finding may help prevent lower lip weakness following neck surgery. Avoiding the functional and cosmetic consequences that accompany loss of DLI function would have a significant impact on the burden of potentially preventable sequelae that the head and neck surgical patient frequently carries.

Computer-Assisted Surgical Anatomical Mapping of the Antebrachial Cutaneous Nerves: An Anatomical Study with a Proposition for Alternative, Cutaneous Nerve-Sparing Anterior Elbow Incisions.

The lateral antebrachial cutaneous nerve (LABCN) and medial antebrachial cutaneous nerve (MABCN) were identified in the coronal plane around the elbow joint in 10 fresh-frozen human arm specimens. Marked photographs of the specimens were analyzed using computer-assisted surgical anatomical mapping (CASAM). Common anterior surgical approaches to the elbow joint and the distal humerus were then compared with merged images, and nerve-sparing alternatives are proposed. The arm was divided longitudinally, from medial to lateral in the coronal plane, into 4 quarters. The LABCN crossed the central-lateral quarter of the interepicondylar line (i.e., was somewhat lateral to the midline at the level of the elbow crease) in 9 of 10 specimens. The MABCN ran medial to the basilic vein and crossed the most medial quarter of the interepicondylar line. Thus, 2 of the quarters were either free of cutaneous nerves (the most lateral quarter) or contained a distal cutaneous branch in only 1 of 10 specimens (the central-medial quarter). The Boyd-Anderson approach, which is often used to access anteromedial structures of the elbow, should be placed slightly further medially than traditionally advised. The distal part of the Henry approach should deviate laterally, so that it runs over the mobile wad. In distal biceps tendon surgery, the risk of cutaneous nerve injury may be reduced if a single distal incision is placed slightly more laterally (in the most lateral quarter), as in the modified Henry approach. If proximal extension is required, LABCN injury may be prevented by using the modified Boyd-Anderson incision, which runs in the central-medial quarter. Cutaneous nerve injury may be prevented by slightly altering the commonly used skin incisions around the elbow on the basis of the safe zones that were identified by depicting the cumulative course of the MABCN and LABCN using CASAM.

Middle Meningeal Artery Embolization in the Management of Chronic Subdural Hematoma: a Comprehensive Review of Current Literature

Chronic subdural hematoma (cSDH) is a common intracranial hemorrhagic disorder with a high incidence rate among the elderly. While small, asymptomatic cSDH may resolve spontaneously, surgical intervention has been the treatment of choice for larger, symptomatic cases. Surgical evacuation of cSDH may be associated with high rates of recurrence, and even asymptomatic cSDH cases tend to progress. Over the last few years, middle meningeal artery (MMA) embolization has proven to be a safe non-invasive treatment of choice with favorable outcomes and a low recurrence rate. The ensuing paper discusses current treatment modalities for cSDH and reviews existing literature on the anatomy of MMA and its embolization as a treatment option for cSDH. Recent studies show that traumatic head injury leading to subdural hemorrhage can induce neovascularization that may initiate a cycle of recurrent subdural hematoma. Distal branches of MMA supply blood to the dural layers. Several studies have revealed that embolization of the MMA can stop the neovascularization process and blood flow. In addition, patients who underwent MMA embolization had a significantly quicker brain re-expansion and lower recurrence rate. Although the management of cSDH is still very much a dilemma, recent research findings bring MMA embolization to light as a promising treatment alternative and adjunctive therapy.

Model of small-focal ischemic cerebral infarction as a basis for the development of new methods of stroke therapy

Background. Among the existing experimental models of cerebral stroke in large animals, there is no possibility to create a focal brain infarction of limited volume, which would provide an opportunity to evaluate both the endogenous potential of neuroregeneration and to establish the effectiveness of new drugs on postischemic brain remodeling.&#x0D; Aim. Development of a method for modeling small-focal ischemic infarction of the cerebral cortex in a mini-pig.&#x0D; Material and methods. The study used mature female mini-pigs of the Vietnamese fold-bellied breed. Two-level occlusion of the great vessels was performed by ligation of the right common carotid artery and subsequent cauterization of the distal branches of the middle cerebral artery. In the postoperative period, the survival rate of animals and neurological deficit were assessed. On the 7th day, the animals were taken out of the experiment, the brain was isolated from the cranial box. Macroscopic and microscopic examinations included analysis of the localization and area of cerebral infarction, as well as morphological changes in the infarcted and peri-infarcted areas of the cerebral cortex.&#x0D; Results. With a 100% survival rate of experimental animals on the 3rd day after the operation, a neurological examination revealed violations of skin sensitivity and muscle tone in the hind and fore limbs, which partially recovered a week after the onset of ischemic stroke. Macroscopic examination of the brain on the 7th day after the operation visually revealed a small-focal ischemic cerebral infarction in the parietal lobe of the left hemisphere. Histological analysis of the cerebral cortex revealed a wedge-shaped necrotic focus of ischemic injury. In the peri-infarction region of the brain, reactive tissue changes with preserved nerve cells, mostly without visible damage, were found.&#x0D; Conclusion. The developed two-level method of stroke modeling in a mini pig induces ischemic cerebral infarction of limited volume in the parietal lobe; non-critical histological changes in the peri-infarct area and a slight neurological deficit suggest the possibility of using this model to develop new methods of stroke therapy.

Revisiting a Telencephalic Extent of the Ascending Reticular Activating System.

Is the cerebrum involved in its own activation to states of attention or arousal? "Telencephalon" is a term borrowed from embryology to identify not only the cerebral hemispheres of the forebrain, but also the basal forebrain. We review a generally undercited literature that describes nucleus basalis of Meynert, located within the substantia innominata of the ventrobasal forebrain, as a telencephalic extension of the ascending reticular activating formation. Although that formation's precise anatomical definition and localization have proven elusive over more than 70years, a careful reading of sources reveals that there are histological features common to certain brainstem neurons and those of the nucleus basalis, and that a largely common dendritic architecture may be a morphological aspect that helps to define non-telencephalic structures of the ascending reticular activating formation (e.g., in brainstem) as well as those parts of the formation that are telencephalic and themselves responsible for cortical activation. We draw attention to a pattern of dendritic arborization described as "isodendritic," a uniform (isos-) branching in which distal dendrite branches are significantly longer than proximal ones. Isodendritic neurons also differ from other morphological types based on their heterogeneous, rather than specific afferentation. References reviewed here are consistent in their descriptions of histology, particularly in studies of locales rich in cholinergic neurons. We discuss the therapeutic implications of a basal forebrain site that may activate cortex. Interventions that specifically target nucleus basalis and, especially, the survival of its constituent neurons may benefit afflictions in which higher cortical function is compromised due to disturbed arousal or attentiveness, including not only coma and related syndromes, but also conditions colloquially described as states of cognitive "fog" or of "long-haul" mental compromise.