Left Thyrocervical Trunk Research Articles

Abstract Number ‐ 91: A Case of Complex Giant Neck Arteriovenous Malformation Treated with Endovascular Embolization

Introduction Arteriovenous malformations (AVM) of the head and neck are vascular malformations composed of a cluster of connecting arteries and veins that form a central nidus without an intervening capillary network1. They make up 1.5% of vascular malformations and more than 90% of AVMs are located intracranially1. Extracranial AVMs are predominantly located in the head and neck and can manifest with pain, ulcerations, fatal hemorrhage, airway compromise, and cosmetic aberrations1,2. Methods We present a case of a 21 year old female with a medical history of multiple suspected neck hemangiomas status post microsurgical and laser resections, with a surrounding port wine stain, who presented to the hospital with growth of one of her posterior neck hemangiomas during and after pregnancy. In the postpartum period she reported increasing neck pain and persistent bleeding from the site. Initially, she was hemodynamically stable and her neurologic exam did not show any focal deficits. She underwent computed tomography angiogram of her neck which showed an extensive dorsal neck AVM with multiple arterial supplies frombranches of the bilateral subclavian, vertebral, and external carotid arteries.Her lesion continued to bleed with a precipitous drop in hemoglobin requiring blood transfusions. Subsequently, she underwent urgentpercutaneousN‐butyl‐2‐cyanoacrylate (n‐BCA) embolizationand endovascular onyx embolization of a left thyrocervical trunk branch.The procedure was completed without complications. Months later, she developed skin exfoliation and underwent successful elective embolization involving vertebral artery branches. This, to reduce profuse venous shunting in the paravertebral venous plexus, avoiding long term spinal cord injury. Results The management of complex head and neck AVMs is both challenging and complex. They may pose significant bleeding risk and can become infiltrative within surrounding tissue3. AVMs may be classified as either focal or diffuse. Focal lesions may be curable with resection, whereas diffuse lesions pose a significant challenge, with relapse in 90% of cases3. Head and neck AVMs require expert management and a multidisciplinary approach. The team may consist of neurosurgery, neuro‐endovascular,plastic surgery, and dermatology services. Treatment options include medical management, surgical resection, endovascular and percutaneous embolization. Percutaenous n‐BCA embolization is employed to prevent hemorrhage during surgical resection, or stabilization in acute hemorrhage4,5. This holds especially true when an endovascular approach is difficult; typically due to tortuous vasculature5. Treatment may require a staged target approach, with endovascular or percutaneous embolization prior to surgical excision. Conclusions This case highlights the complexities of AVM management and the multidisciplinary approach necessary, to provide optimal care. In this case, we believe that pregnancy could have contributed to the overall change in aggressive nature of the AVM. The patient underwent emergent percutaneous and endovascular embolization to prevent life threatening hemorrhage followed by palliative embolization to avoid long term cervical spinal cord injury due to venous hypertension.

THE ROLE OF CHEST CT ANGIOGRAPHY AS A DIAGNOSTIC TOOL AND ROAD MAP FOR THE MANAGEMENT OF RASMUSSEN’S ANEURYSM: A CASE REPORT

Rasmussen’s aneurysm is a pulmonary artery pseudoaneurysm, secondary to the invasion of granular tissues to the pulmonary artery wall, causing massive hemoptysis. A 39-year-old male, with a history of pulmonary TB presented with massive hemoptysis, persistent cough, and dyspnea. Chest X-ray and Chest CT depicted active pulmonary tuberculosis and a co-infection with aspergillosis in the form of aspergilloma. Chest CT angiography (CTA) showed narrow-necked Rasmussen’s aneurysm with the feeding artery coming from the pulmonary artery of the apicoposterior segment and the systemic artery from the left thyrocervical trunk branch and left bronchial artery. Fluoroscopy-guided transarterial embolization with polyvinyl alcohol (PVA) and gel foam was performed from the left bronchial artery and thyrocervical trunk branch followed by transcatheter embolization with glue insertion via the pulmonary artery in the aneurysmal site. After the procedures the embolic agent completely filled the aneurysm and there were no complaints of hemoptysis during the follow-up. Appropriate chest CT angiography procedures can help diagnose Rasmussen’s aneurysm and become a road map for embolization. Transarterial catheter embolization from bronchial or non-bronchial systemic artery and pulmonary artery can be used as the treatment modality of choice for Rasmussen’s aneurysm in pulmonary tuberculosis with aspergillosis co-infection in the form of aspergilloma.

A rare origin of the internal thoracic artery on the left thyro-cervical trunk

A rare origin of the internal thoracic artery on the left thyro-cervical trunk

Doppler Study of the Left Common Carotid Artery With Preocclusive Stenosis

Preocclusive stenosis of the common carotid artery is a rare and potentially life-threatening entity, and the early recognition of associated internal and external carotid artery patency is important for the management plan. The patient in this case report was sent for a thyroid ultrasound for complaints of neck pain, voice change, and dysphagia, and a preocclusive stenosis of the left common carotid artery was found. Multiple collateral pathways had developed to supply blood flow to the left internal carotid artery, and there was retrograde flow in the external carotid artery and antegrade flow in the internal carotid artery. Collaterals from the left thyrocervical trunk were supplying the superior thyroid artery which supplied the external carotid artery and finally the internal carotid artery through the carotid bulb. Doppler ultrasound is valuable in the identification of preocclusive common carotid artery stenosis and mapping of collateral pathways.

Coronary Collateralization of a Tumor Located in the Aortopulmonary Window

A 67-year-old woman presented with a paresis of the left hand and a spontaneous bleeding in the left frontal hemisphere. The diagnostic workup showed a heavily vascularized, solid tumor (∗) located in the aortopulmonary window (Figure 1). The left thyrocervical trunk, left internal thoracic artery, descending aorta, and all 3 major coronary arteries contributed to the tumor's blood supply (collaterals are marked with arrows in Figures 1, 2). A transbronchial biopsy specimen revealed no histologic diagnosis.

Posterior C2-6 Laminoplasty for Resection of Arteriovenous Malformation: 2-Dimensional Operative Video.

Large extramedullary-intramedullary arteriovenous malformations (AVMs) within the spinal cord provide a unique management opportunity, compared with the cranial counterpart, in that the surgical morbidity can be minimized and surgical cure can still be achieved by resecting the extramedullary segment and leaving the intramedullary segment without invading the parenchyma. This management strategy minimizes morbidity and provides an excellent chance of surgical cure. This patient had a history of longstanding left hemiparesis since birth that progressed, prompting imaging evaluation that demonstrated a large cervical AVM with bilateral vertebral artery, anterior spinal artery, and left thyrocervical trunk feeding vessels. The AVM had both extramedullary and intramedullary components, making this a challenging lesion for microsurgical obliteration and preservation of neurological function. Preoperative embolization was utilized through the right vertebral artery pedicle. Microdissection was performed to isolate the extramedullary from the intramedullary component. Surgical cure was attempted for this patient by removing the extramedullary component and leaving the intramedullary segment. Indocyanine green fluoroscopy was used to isolate the feeding pedicle and guide surgical resection. Postoperative imaging demonstrated a small residual from the thyrocervical injection, which was obliterated with embolization. The patient improved neurologically within the postoperative period and regained ambulatory status during long-term follow-up. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Common trunk of left internal thoracic artery and thyrocervical trunk arising from the ipsilateral vertebral artery

The sites of origin of the branches of the subclavian artery depict numerous anatomical variations. However, a common trunk of the internal thoracic artery (ITA) and thycocervical trunk (TCT) arising from the vertebral artery is a rare anatomical finding. Herein, we present the first case in which the common trunk of the left ITA and TCT arose from the ipsilateral proximal vertebral artery as discovered on pre-therapeutic evaluation by multidetector-row computed tomography and clearly confirmed by selective angiography. It is important to recognize such anatomic variations for surgical, diagnostic, and interventional radiologic procedures in the head, neck, thorax, and abdomen.

Embolization of craniofacial arteriovenous malformations after the ligation of external carotid artery

To introduce the method of retrograde embolization through the superficial temporal artery (STA) after the ligation of external carotid artery (ECA) for the treatment of craniofacial arterio-venous malformations (AVM). Seven cases of craniofacial AVM were included in the study. After the ligation of ECA, the STA was surgically accessed and a 4F (1F = 0.333 mm) sheath introduced into the artery, and N-butyl-2-cyanoacrylate (NBCA) was selected as the permanent embolization material. The angiogram was successfully carried out in these cases, which showed that some collateral branches from the ophthalmic artery of left internal carotid artery, vertebral artery and thyrocervical trunk provided the blood supply to the AVM nidus. The retrograde embolization with NBCA was completed. The vascular architecture of craniofacial AVM after the ligated ECA was better demonstrated in angiogram of vertebral artery. The retrograde embolization through STA was an effective method for the treatment of craniofacial AVM.

Cervical Perimedullary Arteriovenous Fistula in an Infant Presenting With Subarachnoid Hemorrhage -Case Report-

A 9-month-old boy was transferred to our institute after suffering sudden seizure and loss of consciousness followed by cardiopulmonary arrest. Neurological examination on admission revealed deep coma and tetraparesis. Brain computed tomography revealed diffuse intracranial subarachnoid hemorrhage (SAH), whereas brain magnetic resonance (MR) angiography showed no intracranial abnormalities. MR imaging of the spine demonstrated a remarkable flow void extending from C3 to T1. Digital subtraction angiography revealed a perimedullary arteriovenous fistula (AVF) fed by the left thyrocervical trunk, associated with a varix and a dilated perimedullary vein. He had hypoxic encephalopathy due to transient cardiopulmonary arrest, and remained in the intensive care unit for 2 months. Thereafter, he was transferred to the pediatric ward, where his general condition improved, and after 7 months underwent embolization of the AVF to prevent further SAH. The perimedullary AVF was successfully interrupted by transarterial embolization with n-butyl-2-cyanoacrylate and platinum coils, and no additional neurological deficits developed. Post-embolization MR imaging showed loss of the flow void. The favorable outcome demonstrates the importance of spinal cord imaging in infants with SAH without other intracranial abnormalities to detect the presence of perimedullary AVF. Perimedullary AVFs in children are often associated with huge fistulas and varices, so are good candidates for endovascular surgery.

Massive haemoptysis from an aberrant bronchial artery in a patient with cavitary pulmonary tuberculosis

Summary Massive haemoptysis is a life-threatening emergency requiring prompt and highly specialized intervention to identify the site of haemorrhage, protect the airways and stop bleeding. A wide variety of lung diseases may cause haemoptysis, including tuberculosis. The most common sources of pulmonary bleeding are bronchial (90%) and non-bronchial systemic arteries (5%). Aberrant bronchial vessels have also been described. We report the case of a patient affected by cavitary pulmonary tuberculosis who presented with massive haemoptysis from an aberrant bronchial artery originating from the sovrascapular branch of the left thyrocervical trunk. Successful embolization was performed by means of superselective arteriography.

Anomalous origin of bronchial arteries in patients with cystic fibrosis: therapeutic implications for embolisation

Bronchial artery embolisation (BAE) is an accepted method of controlling haemoptysis in patients with cystic fibrosis. However, anomalous origin of the bronchial arteries, documented in anatomical and angiographic studies, makes the procedure more difficult and increases the number of recurrences. Clinical records and films from three patients affected by cystic fibrosis with haemoptysis, in which the origin of the bleeding vessels was considered anomalous, out of a total of seven patients who underwent BAE, were reviewed. In two patients the source of bleeding was identified from, respectively, the left and the right internal mammary artery and in one from the left thyrocervical trunk. All the vessels considered to be the possible source of haemoptysis were embolised; immediate control of haemoptysis after embolisation was achieved in all patients, but minor haemoptysis recurred in two patients who were conservatively treated. In haemoptysis in patients with cystic fibrosis the possibility of anomalous origin of the bronchial arteries should be considered. This frequency may be higher than in other pulmonary diseases that cause haemoptysis, so a search for anomalous bronchial arteries is mandatory to achieve accurate embolisation and reduce the rate of recurrence.

A CASE OF PSEUDOANEURYSM OF THE NECK ASSOCIATED WITH VON RECKLINGHAUSEN DISEASE

This paper deals with a case of pseudoaneurysm of the neck associated with von Recklinghausen disease. A 60-year-old man seen at the emergency clinic in our hospital because of left shoulder pain and a swelling on the left side of the neck. Close examinations revealed spontaneous rupture of a branch from the left subclavian artery and a pseudoaneurysm of the neck. An emergency operation was performed. At operation, the left thyrocervical trunk was almost dissected at its root and a formation of pseudoaneurysm at the site was observed. The thyrocervical trunk was ligated at the root which led to a successful hemostasis. Postoperative course was uneventful. There has been no re-bleeding for 2 years and 2 months after the operation. Sometimes von Recklinghausen disease is associated with vascular lesions, however, it rarely causes aneurysms or spontaneous rupture of arteries. So far, only 17 cases of aneurysm and 18 cases of spontaneous rupture of arteries have been reported in the Japanese literature.

The sternoclavicular joint: variants of the discus articularis

Objective. To study the anatomy of the sternoclavicular joint, its discus and its variations. Design. Anatomical study (macroscopic dissection). Background. Textbooks on manual therapy give different descriptions of the movements of this joint. These apparent contradictions could be due to poor understanding of the anatomy of this joint resulting in ignoring specific movement patterns under particular conditions. Methods. Macroscopic dissection of 22 embalmed sternoclavicular joints. Results. The sternoclavicular and the costoclavicular parts of the discus always were quite distinct in orientation, thickness, surface and consistency. The sternoclavicular part was attached to the dorso-cranial part of the extremitas sternalis claviculae by a broad insertion in which several small blood vessels are visible. This part is grossly vertical, thicker than the lateral part and has a fibrous aspect. The costoclavicular part of the discus is always thinner than the sternoclavicular part. Sometimes it is reduced to a fine translucent pellet or is perforated. Subsynovial vascular arcades run along the insertion of the discus on the joint capsule, both on sternal and on clavicular sides. The costosternal articular surface can be divided into a sternal and a costal segment, separated by a vascular zone. Conclusions. Findings suggest different functions of the distinct parts of the joint. The smooth aspect of the lateral segment of the costosternal articular surface and of the costoclavicular part of the discus could be an argument to consider a functionally distinct costoclavicular compartment. The insertion of the discus on the clavicula strongly suggests that small movements take place between clavicula and discus and that the discus itself is moved only when the increasing amplitude stretches this insertion. We hypothesise that all midrange movements take place between the convex inferior edge of the clavicula and the costoclavicular part of he discus and that larger elevation depression and pro- and retraction movement take place, respectively, between clavicula and discus or discus and sternum. In three specimens we observed a previously not described arterial ramus articularis originating from the left thyrocervical trunk. Relevance These findings might explain differences of the arthrokinematic behaviour of this joint between midrange and full range motions.

Hemothorax in type I neurofibromatosis

We report a case of life-threatening hemothorax caused by rupture of a left thyrocervical trunk aneurysm and arteriovenous fistula in a patient with type I neurofibromatosis. This lesion was treated with endovascular coil embolization.

Case report: Thyrocervical arterial supply to an intracranial dural arteriovenous malformation

An intracranial dural arteriovenous malformation (DAVM) is presented, which received some of its blood supply from the left thyrocervical trunk. Since arterial supply from the thyrocervical trunk is not revealed by routine four vessel cerebral angiography, opacification of the ipsilateral thyrocervical trunk is advocated in patients with posterior fossa DAVMs for whom endovascular treatment is being considered.

Duplicated origin of right vertebral artery with rudimentary and accessory left vertebral arteries

We observed a rare cerebrovascular anomaly in a patient with brain-stem infarction. Two right vertebral arteries arose from the subclavian artery and communicated directly with each other under the transverse foramen of the fourth cervical vertebra. The left vertebral artery consisted of a rudimentary artery that arose from the left subclavian artery, ran through the transverse foramen of the sixth cervical vertebra and then tapered down to disappear at the fourth/fifth cervical vertebrae, plus a second, accessory artery that arose from a branch of the left thyrocervical trunk, ran through the transverse foramen of the fifth cervical vertebra and tapered off to disappear at the first/second cervical vertebrae.

Neurofibromatosis with Extracranial Vertebral Arteriovenous Fistulae

A 38-year-old female was hospitalized complaining of left cervical pain. On physical examination, bruits were audible in the painful region. Plain X-rays of the cervical spine showed widening of intervertebral foramina and scalloping of the vertebral bodies at C2-C5. Left vertebral angiography disclosed aneurysmal dilatation and arteriovenous fistulae at the C3 and C4-C5 levels of the artery. The right vertebral artery, bilateral occipital arteries, left thyrocervical trunk, and costocervical trunk were associated with the fistulae as collateral pathways to the left vertebral artery. In a sequential procedure, the left vertebral artery was clipped just proximal to the posterior inferior cerebellar artery, the lower fistula was occluded by a detachable balloon, and muscle was packed to the abnormal vessel close to the upper fistula. After treatment the bruits diminished and the radiculomyelopathy abated. Arteriovenous fistulae should arouse suspicion of neurofibromatosis. Auscultation of the neck and angiography are recommended for patients with neurofibromatosis presenting with radiculomyelopathy. Intravascular surgery with a detachable balloon is considered very effective for extracranial vertebral arteriovenous fistulae.

Anomalous Origin of the Left Thyrocervical Trunk as a Cause of Residual Pain after Myocardial Revascularization with Internal Mammary Artery

A patient with successful implantation of an internal mammary artery graft in the left anterior descending coronary artery complained of residual but different anginal pain after operation. Ischemia was demonstrated during a manual stress test. Angiography revealed anomalous origin of the thyrocervical trunk from the internal mammary artery. Angina and ischemia disappeared after the trunk was ligated.