Superior Branch Research Articles

S2118 Angiographic Diagnosis and Treatment of Adult GI Bleeding from Meckel’s Diverticulum

INTRODUCTION: Meckel's diverticulum is the most common gastrointestinal anomaly resulting from a persistent omphalomesenteric duct. It is usually discovered in children when gastrointestinal (GI) bleeding occurs. This case demonstrates the use of provocative angiography for both the diagnosis and treatment of a bleeding Meckel's diverticulum in an adult. CASE DESCRIPTION/METHODS: A 22-year-old woman with no known past medical history presented to the emergency department with a chief complaint of black stool, lightheadedness and weakness. On exam, her abdomen was soft and non-tender. Rectal exam showed black stool with bloody mucus. Labs were significant for a Hgb of 6.1 (MCV 90.1) from 12.1 one week prior. During her hospitalization she underwent several studies to determine the location of her bleed. Esophagogastroduodenoscopy, colonoscopy, tagged red blood cell scan, and Meckel’s Scan were all normal. Video capsule endoscopy visualized blood in the terminal ileum and cecum mixed with stool, however no lesions were identified in these areas on colonoscopy. Magnetic resonance enterography was without evidence of small bowel inflammation. A visceral arteriogram was performed by interventional radiology, which was negative for bleeding until provocation was done using direct intra-arterial thrombolytic infusion (tissue plasminogen activator) that demonstrated active bleeding in an superior mesenteric artery branch which appeared to be serving a Meckel's diverticulum. Successful embolization was performed with a 3 mm coil and no further bleeding episodes occurred during her hospital stay. One month later she returned for surgical resection. Pathology confirmed Meckel's diverticulum with focal ulceration, underlying granulation tissue, and gastric heterotopia. DISCUSSION: Tc-99m pertechnetate scintigraphy (Meckel's Scan) is helpful in diagnosis of a Meckel’s diverticulum as pertechnetate is taken up by mucin-secreting cells of ectopic gastric tissue. This scan has high sensitivity and specificity in children but is drastically lower in adults as hemorrhage due to ectopic gastric mucosa is primarily a pediatric disease. For adults with suspected bleeding from a Meckel's diverticulum with multiple negative imaging modalities including a Meckel's scan, it is important to continue pursuit of the diagnosis using all means available. This case demonstrates the vital importance of provocation angiography in diagnosis of a Meckel's diverticulum that would have otherwise been missed and therefore left untreated.Figure 1.: Negative Meckel’s Scan. No heterotopic gastric mucosa visualized.Figure 2.: Angiogram before tPA administration. Red arrow indicates suspected Meckel diverticulum served by superior mesenteric artery branch.Figure 3.: Angiogram after tPA administration. Red arrow indicates area of extravasation and active bleeding.

Pancreaticoduodenectomy in a patient with intestinal malrotation and distal cholangiocarcinoma: a case report and review of the literature

BackgroundA combination of intestinal malrotation and distal cholangiocarcinoma is considered a rare condition and poses some difficulties in surgical management. We present a case of a patient with asymptomatic nonrotation of the midgut with a concomitant distal cholangiocarcinoma who underwent successful pancreaticoduodenectomy.Case presentationA 52-year-old Sudanese man presented to our hospital with progressive painless jaundice associated with dark urine, pale stool, and itching for the last 2 months. He had no other complaint or significant previous medical history apart from being an ex-smoker. His clinical examination revealed a palpable gallbladder and scratch mark. His other systems were unremarkable. His blood test results showed a normal complete blood count, elevated total bilirubin (mainly direct bilirubin), elevated alkaline phosphatase, and normal cancer antigen 19-9 and carcinoembryonic antigen. Ultrasound, computed tomography of the abdomen, and magnetic resonance cholangiopancreatography showed a dilated intrahepatic and extrahepatic biliary system down to the distal part, where the lumen was obstructed by a periampullary mass measuring 2.4 by 2.1 cm. The patient’s gallbladder was distended. He had no liver metastases or ascites and few lymph nodes. Inversion of the superior mesenteric artery and superior mesenteric vein but no invasion was seen, and malrotation of the bowel was observed with the large bowel on the left side and the small bowel to the right of the abdomen. Endoscopic retrograde cholangiopancreatography showed a fleshy ampulla that was stented. Laparotomy showed malrotation, with the duodenum straight on the right side of the midline, and Ladd’s band crossed the second portion of the duodenum. The vessels were approached from the lateral side meticulously after kocherization of the duodenum and pancreas, dissection along an extended portion of the superior mesenteric artery to assure preservation of the superior mesenteric artery and branches going to the jejunum, Ladd’s procedure, division of the jejunum 10 cm below the uncinate process of pancreas, and modified pancreaticoduodenectomy were performed, and anastomoses were performed in the standard fashion. The patient had an uneventful postoperative course, started oral feeding after 5 days, and discharged to home on day 10 for regular follow-up. Histopathology confirmed distal cholangiocarcinoma, and the patient was referred for further oncological management.ConclusionsPancreaticoduodenectomy can be safely performed in patients with intestinal malrotation with some modifications of the standard approach. Meticulous dissection after preoperative identification of vascular anomaly and a lateral approach are of great help to reduce morbidity.

Duration reproduction in regular and irregular contexts after unilateral brain damage: Evidence from voxel-based lesion-symptom mapping and atlas-based hodological analysis

It has been proposed that not completely overlapping brain networks support interval timing depending on whether or not an external, predictable temporal cue is provided during the task, aiding time estimation. Here we tested this hypothesis in a neuropsychological study, using both a topological approach – through voxel-based lesion-symptom mapping (VLSM), that assesses the relation between continuous behavioral scores and lesion information on a voxel-by-voxel basis – and a hodological approach, using an atlas-based tractography. A group of patients with unilateral focal brain lesions and their matched controls performed a duration reproduction task assessing time processing in two conditions, namely with regularly spaced stimuli during encoding and reproduction (Regular condition), and with irregularly spaced stimuli during the same task (Irregular condition). VLSM analyses showed that scores in the two conditions were associated with lesions involving partly separable clusters of voxels, with lower performance only in the Irregular condition being related to lesions involving the right insular cortex. Performance in both conditions correlated with the probability of disconnection of the right frontal superior longitudinal tract, and of the superior and middle branches of the right superior longitudinal fasciculus. These findings suggest that the dissociation between timing in regular and irregular contexts is not complete, since performance in both conditions relies on the integrity of a common suprasecond timing network. Furthermore, they are consistent with the hypothesis that tracking time without the aid of external cues selectively relies on the integration of psychophysiological changes in the right insula.

The human costal cartilage: Anatomical and radiological study of macro-vascularization and micro-vascularization and its clinical relevance regarding vascularized chondrocostal free flap surgery

IntroductionCartilage repair usually involves in non-vascularized osteochondral or chondral grafts with some drawbacks potentially linked to the lack of vascular supply in those grafts. The aim of this study was to describe a surgical approach for harvesting a vascularized chondrocostal graft, to study the vascular supply to the perichondrium and finally to describe the perichondrium micro-vascularization in order to know how such grafts could be used in cartilage repair surgery. Materials and methodsWe harvested and studied 18 costal cartilages harvested from 12 fresh anatomical subjects. The anatomic pieces were injected with a radio-opaque tracer, analyzed macroscopically, then a plain X-rays and CT scan analysis with three-dimensional rendering was performed in order to evaluate the characteristics of the different patterns of their vascularization. ResultsThe surgical approach to harvest a vascularized 5th chondrocostal graft is explained in detail. All of the cartilages were vascularized by the internal thoracic artery and harvested with a pedicle of an average length of 34mm and diameter of 2.14mm. In all specimens, perichondrium vascularization arises from both superior and inferior intercostal branches. Anastomoses between inferior and superior intercostal branches are always found in all specimens at the level of the epichondrium. ConclusionsThe anatomic approach for harvesting a vascularized chondrocostal graft is simple and only slightly differs from the approach described for harvesting a non-vascularized chondrocostal graft. The vascular supply to the perichondrium of such a vascularized chondrocostal graft is sustained by the internal thoracic vessels which have a sufficient diameter and length to allow easy micro-anastomosis. The organization of the micro-vasculature within the perichondrium allows the graft to be tailored to a large cartilage defects and also to small bipolar cartilage defects.

Sources of off-target effects of vagus nerve stimulation using the helical clinical lead in domestic pigs

ObjectiveClinical data suggest that efficacious vagus nerve stimulation (VNS) is limited by side effects such as cough and dyspnea that have stimulation thresholds lower than those for therapeutic outcomes. VNS side effects are putatively caused by activation of nearby muscles within the neck, via direct muscle activation or activation of nerve fibers innervating those muscles. Our goal was to determine the thresholds at which various VNS-evoked effects occur in the domestic pig—an animal model with vagus anatomy similar to human—using the bipolar helical lead deployed clinically.ApproachIntrafascicular electrodes were placed within the vagus nerve to record electroneurographic (ENG) responses, and needle electrodes were placed in the vagal-innervated neck muscles to record electromyographic (EMG) responses.Main resultsContraction of the cricoarytenoid muscle occurred at low amplitudes (∼0.3 mA) and resulted from activation of motor nerve fibers in the cervical vagus trunk within the electrode cuff which bifurcate into the recurrent laryngeal branch of the vagus. At higher amplitudes (∼1.4 mA), contraction of the cricoarytenoid and cricothyroid muscles was generated by current leakage outside the cuff to activate motor nerve fibers running within the nearby superior laryngeal branch of the vagus. Activation of these muscles generated artifacts in the ENG recordings that may be mistaken for compound action potentials representing slowly conducting Aδ-, B-, and C-fibers.SignificanceOur data resolve conflicting reports of the stimulation amplitudes required for C-fiber activation in large animal studies (>10 mA) and human studies (<250 μA). After removing muscle-generated artifacts, ENG signals with post-stimulus latencies consistent with Aδ- and B-fibers occurred in only a small subset of animals, and these signals had similar thresholds to those that caused bradycardia. By identifying specific neuroanatomical pathways that cause off-target effects and characterizing the stimulation dose-response curves for on- and off-target effects, we hope to guide interpretation and optimization of clinical VNS.

Fetal topography of branches of the cervical and thoracic divisions of the vagus nerves

The study of age and individual anatomical variability of vagus nerves and their branches in different age periods of human ontogenesis causes interest among both morphologists and doctors of different specialties.The aim of the study. To find out the topography of the cervical and thoracic divisions of the vagus nerves in human fetuses aged from 4th to 10th gestational months.Materials and methods. The research was conducted on 75 preparations of human fetuses ranging from 81.0 to375.0 mm in parietal-coccygeal length (PCL) using methods of macro-microscopic dissection and morphometry.Results. In human fetuses, the left vagus nerve is placed anteriorly to the left subclavian artery, then on the lateral surface of the Botallo’s arterial duct and the aortic arch. In the neck region, the superior cardiac branch departs from the left vagus nerve and goes to the anterior surface of the left common carotid artery.In the inferior part of the left common carotid artery, the superior cardiac branch gives off two branches: the middle one reaches the aortic arch wall, and the lateral one runs along the anterior surface of the left common carotid artery. The left recurrent laryngeal nerve departs from the left vagus nerve at the level of the inferior border of the aortic arch. The right vagus nerve passes from the right subclavian artery anteriorly and gives rise to the right recurrent laryngeal nerve, which continues inferiorly and posteriorly around the subclavian artery. The superior cardiac branch originates from the right vagus nerve at the level of the inferior border of the thyroid gland. The inferior cardiac branch departs inferiorly and medially from the right laryngeal nerve and is located on the right anterolateral surface of the trachea.Conclusions. During the fetal period of human ontogenesis, age and individual anatomical variations of the branches of the cervical and thoracic vagus nerves is observed, which is manifested by the variability of the structure, asymmetry of the topography of the recurrent laryngeal nerves, bronchial, esophageal and cardiac branches. The left recurrent laryngeal nerve departs from the left vagus nerve at the level of the inferior border of the aortic arch, the right recurrent laryngeal nerve departs from the right vagus nerve at the level of the right subclavian artery. The esophageal nervous plexus is formed by esophageal branches of the vagus nerves, which then forms mainly the posterior vagal trunk. The anterior vagal trunk is a direct continuation of the left vagus nerve branches. The innervation of the aortic arch involves the common cardiac trunk, which is formed by the superior cardiac branch and the superior cardiac nerve and also anastomoses both with vagus nerve and with recurrent laryngeal nerves.

A Case of Branch Retinal Vein Occlusion with Macular Edema Presenting as Sub-Acute Vision Loss

Branch retinal vein occlusion is the most common retinal vein occlusion. RVO is divided into central (CRVO), hemi (HRVO) and branch retinal vein (BRVO) occlusion. BRVO is venous occlusion at any branch of central retinal vein. Here our case illustrates present a 40 years old gentleman presented with sub-acute vision loss. He was found to have superior temporal branch retinal vein occlusion where hypertension, diabetes mellitus and dyslipidemia were thought to be the main risk factors. Close follow up, tight blood pressure are crucial to prevent the similar scenario in the fellow eye.

PENGARUH BUDAYA ORGANISASI TERHADAP KINERJA KARYAWAN DENGAN KOMITMEN ORGANISASI SEBAGAI VARIABEL MEDIASI (Survei pada karyawan PT. TASPEN (Persero) Kantor Cabang Surakarta)

PT. TASPEN (Persero) Surakarta Branch Office is a State-Owned Enterprise engaged in services in serving participants of Civil Servants and the State Civil Apparatus who manage welfare or old-age social security for employees and their families. PT. Taspen (Persero) Surakarta branch office is committed to improving the performance of the Surakarta branch office to become a superior branch office. The purpose of this study is to (1) analyze the significance of the influence of organizational culture on organizational commitment, (2) analyze the significance of the influence of organizational culture and organizational commitment on employee performance, and (3) analyze whether organizational commitment mediates organizational culture on employee performance.This type of research is a survey of employees of PT. TASPEN (Persero) Surakarta branch office. The type of data uses quantitative and qualitative data. Data sources use primary and secondary data. The research population is all employees of PT. TASPEN (Persero) Surakarta branch office, amounting to 33 employees. The sample of this study was 33 people using the census method. The data analysis techniques using multiple linear test, t test, F test, direct influence test, indirect effect test, path analysis and coefficient of determination. The results show that organizational culture has a significant effect on organizational commitment, organizational culture and organizational commitment have a significant effect on employee performance, and organizational commitment mediates organizational culture on employee performance.

Variant facial artery anatomy revisited: Conventional angiography performed in 284 cases.

A number of studies have evaluated the variable courses of facial artery. However, the results of these differed substantially from each other so not consistent relationships have yet been established. There has also yet to be a relevant study using conventional angiography.We assessed the variant branching pattern of the facial artery and its branches using conventional angiography.Two radiologists retrospectively reviewed 284 cases of angiographies of the external carotid artery in 198 patients. The courses of the facial artery and infraorbital branch of the maxillary artery were classified into 4 types and 2 types, according to the end branch.Among 284 cases of facial artery, type 1 (angular branch) made up 104 cases (36.6%), type 2 (lateral nasal branch) made up 138 cases (48.6%), type 3 (superior labial branch) made up 24 cases (8.5%), and type 4 (inferior labial branch) made up 18 cases (6.3%).Regarding the 284 total cases of maxillary artery, 163 cases (57.4%) had anastomosis with the angular artery or extended to the territory of the angular artery. In addition, 121 cases (42.6%) had nothing done in regard to the angular artery.The results may be helpful for avoiding complications related to facial and maxillary arteries during facial surgeries and cosmetic procedures.

Emborrhoid in patients with portal hypertension and chronic hemorrhoidal bleeding: preliminary results in five cases with a new coiling release fashion "Spaghetti technique".

This manuscript reports on a preliminary experience concerning emborrhoid in patients affected by cirrhotic portal hypertension; furthermore, a novel customized technique of coils release, named "Spaghetti technique," is described. Five patients with chronic anemia due to internal hemorrhoidal bleeding and cirrhotic portal hypertension were treated. Clinics and hemoglobin values were evaluated to objectively assess clinical conditions up to 3months follow-up. Embolizations were performed with fibered coils, oversized, released stretched and not packed. Technical success, intended as occlusion of all superior hemorrhoidal artery branches, was 100%. In two patients, inferior hemorrhoidal arteries were embolized too. No patients reported major or minor complications. At 3-month follow-up, clinical improvement was obtained in four of the five patients; hemoglobin values improved or remained stable in the whole sample. Based on this limited experience, emborrhoid seems to be safe and effective at 3-month follow-up to improve symptoms in patients with cirrhotic portal hypertension and chronic anemia due to hemorroidal bleeding; the stretched fashion to release oversized coils provides effective embolization.

Role of CT imaging in discriminating internal hernia from aspecific abdominal pain following Roux-en-Y gastric bypass: a single high-volume centre experience.

Internal hernia (IH) represents a delayed complication of the laparoscopic Roux-en-Y gastric bypass (LRYGB) and it is historically difficult to identify preoperatively. Numerous CT signs were considered suggestive of IH but none of them is pathognomonic. In this study, we aim to evaluate the accuracy of CT in diagnosing IH, differentiating from non-specific abdominal pain. This can lead to a way of personalized medicine and improve the outcome of anti-obesity treatments. We retrospectively reviewed CT scans of 50 patients previously subjected to LRYGB procedure, with a clinical suspicion of IH. 3 groups of patients were identified: IH group (21 patients with a surgical confirmed IH), negative group (12 patients in whom IH was not confirmed at surgery), and control group (17 patients who were not surgically explored because of low/no suspicion of IH). We divided CT signs into three groups: "bowel loop signs", "vessel signs", and "venous congestion/stasis signs". The accuracy of CT in detecting IH was tested by comparing each sign, either individually or in combination, with the surgical findings. Statistical analysis showed that "vessel signs" (swirl sign, superior mesenteric vein beaking, mesenteric arteries, and veins branches inversion) present the highest distribution in patients with IH demonstrated at surgery, with a higher accuracy in case of simultaneous presence of two or three signs. CT imaging is highly accurate in diagnosing IH. Despite no single sign being pathognomonic, the combination of two or more signs, especially among the "vessels signs", can suggest the IH, even in pauci-symptomatic patients.

SPARC: Neural elements mediating side effects during cervical vagus nerve stimulation in the pig

Vagus nerve stimulation (VNS) is FDA‐approved and CE‐marked for a diverse set of conditions including epilepsy, depression, heart failure, and others. Despite widespread adoption and perceived efficacy, a post‐hoc analysis of patients treated for heart failure using VNS revealed that only 12% of patients showed stimulation evoked heart rate changes one‐year post‐implant. This finding is not unexpected given that A‐type nerve fibers have the lowest activation thresholds, and they innervate neck muscles, causing contractions that patients will not tolerate. Therefore, muscle responses at lower amplitudes may have prevented application of higher amplitudes required to achieve cardiac effects in clinical trials of VNS for heart failure. Understanding therapy‐limiting side effects to VNS and finding ways to mitigate them are critical for optimizing VNS for clinical therapies.We developed a swine model of VNS which closely approximates the size and fascicular organization of the cervical vagus nerve observed in humans. The clinical LivaNova stimulation electrode was used as advised by a practicing neurosurgeon. We hypothesized that neck muscle responses are mediated by somatic branches of the vagus nerve as opposed to direct electrical activation of the muscle fibers. Further, we hypothesized that stimulation evoked responses depend on the location of the stimulation electrode on the vagus nerve. We measured compound nerve action potentials using intrafascicular electrodes placed within the vagus to identify activation of different nerve fiber types by conduction velocity. The downstream effects of nerve fiber activation, i.e. changes in heart rate and neck muscle responses (EMG), were measured using an arterial catheter and intramuscular electrodes, respectively. We then used a neuromuscular junction blocking agent, as well as systematic transection of somatic vagus nerve branches, to specifically identify the pathways causing neck muscle contractions.Two pathways contributed to VNS‐evoked neck muscle responses: activation of nerve fibers in the recurrent laryngeal branch of the cervical vagus nerve at low amplitudes and in the superior laryngeal branch at higher amplitudes. Lesser activation of the superior laryngeal branch could be achieved by moving the stimulation electrode caudally down the length of the vagus. This work represents a step towards mitigating intolerable side effects of VNS, thereby allowing maximization of intended target engagement and therapeutic benefit.Support or Funding InformationThe Defense Advanced Research Projects Agency (DARPA) Biological Technologies Office (BTO) Targeted Neuroplasticity Training Program under the auspices of Doug Weber and Tristan McClure‐Begley through the Space and Naval Warfare Systems Command (SPAWAR) Systems Center with (SSC) Pacific grants no. N66001‐17‐2‐4010, and the NIH SPARC Program Award OT2 OD025340.

Functional vagotopy in the cervical vagus nerve of the domestic pig: implications for the study of vagus nerve stimulation

Objective. Given current clinical interest in vagus nerve stimulation (VNS), there are surprisingly few studies characterizing the anatomy of the vagus nerve in large animal models as it pertains to on-and off-target engagement of local fibers. We sought to address this gap by evaluating vagal anatomy in the pig, whose vagus nerve organization and size approximates the human vagus nerve. Approach. Here we combined microdissection, histology, and immunohistochemistry to provide data on key features across the cervical vagus nerve in a swine model, and compare our results to other animal models (mouse, rat, dog, non-human primate) and humans. Main results. In a swine model we quantified the nerve diameter, number and diameter of fascicles, and distance of fascicles from the epineural surface where stimulating electrodes are placed. We also characterized the relative locations of the superior and recurrent laryngeal branches of the vagus nerve that have been implicated in therapy limiting side effects with common electrode placement. We identified key variants across the cohort that may be important for VNS with respect to changing sympathetic/parasympathetic tone, such as cross-connections to the sympathetic trunk. We discovered that cell bodies of pseudo-unipolar cells aggregate together to form a very distinct grouping within the nodose ganglion. This distinct grouping gives rise to a larger number of smaller fascicles as one moves caudally down the vagus nerve. This often leads to a distinct bimodal organization, or ‘vagotopy’. This vagotopy was supported by immunohistochemistry where approximately half of the fascicles were immunoreactive for choline acetyltransferase, and reactive fascicles were generally grouped in one half of the nerve. Significance. The vagotopy observed via histology may be advantageous to exploit in design of electrodes/stimulation paradigms. We also placed our data in context of historic and recent histology spanning multiple models, thus providing a comprehensive resource to understand similarities and differences across species.

Estudo anatômico do ramo infrapatelar do nervo safeno em humanos

Objective To perform an anatomical study of the location of the infrapatellar branch of the saphenous nerve in relation to the structures of the knee. Methods An anatomical study was performed by dissection of 18 humans knees (9 right and 9 left knees). After exposure of the infrapatellar branch and its direct and indirect branches, they were then measured. We adopted a quadrant in the medial region of the knee delimited by two transversal planes as a parameter of the study. Results In 17 of the 18 knees (94.4%) studied, a single infrapatellar branch was observed. The infrapatellar branch emerged as fibers of the womb of the sartorius muscle in 17 of the 18 knees (94.4%). In relation to the branch, we observed that in 100% of the knees the infrapatellar branch had at least one primary branch, resulting in a superior branch and an inferior branch. In 9 limbs (50% of the cases) this branch occurred outside the proposed quadrant, and, in the remaining limbs, it occurred within the quadrant. Conclusion The infrapatellar saphenous nerve branch was found in all dissected knees, and, in 94.4% of the cases, it was of the penetrating type; in 100% of the cases, it originated two primary direct branches. The direct and indirect branches presented great variability regarding their path.

Do We Have Another Option to Treat Bleeding Hemorrhoids? The Emborrhoid Technique: Experience in 16 Patients.

Hemorrhoidal disease is very common in western countries and rectal bleeding is the main symptom complained by patients. Nowadays the ultimate goal of treatment is to block the bleeding with minimally-invasive techniques to minimize post-procedural pain. The aim of this study is to assess the preliminary results of the emborrhoid technique (embolization of the superior rectal arteries branches) as a new tool for the proctologist to treat severe bleeding hemorrhoids causing anemia. Many categories of patients might benefit from this treatment, such as patients not eligible for conventional surgery, patients not responding to conventional treatment and fit patients with severe bleeding who refused endorectal surgical therapy. From May 2017 to November 2018 a total of 16 patients with chronic rectal bleeding due to hemorrhoids underwent super-selective embolization of the superior rectal arteries at the department of General Surgery in La Spezia, S. Andrea Hospital, Italy. Median age was 59 years. 14 patients were males (87.5%). No post-procedural and short-term complications were observed at maximum follow up (12 months). The reduction of rectal bleeding with improvement of the quality of life was obtained in 14 patients (87.5%). Our study, although small in number, demonstrates that embolization of superior rectal arteries with coils to treat severe bleeding due to hemorrhoids is safe and effective and does not lead to immediate complications.

Application of Superficial Temporal Artery Flap in Wound Repairing After the Resection of Craniofacial Malignant Tumors.

Craniofacial malignant tumors require not only extended resection but also appropriate reconstruction to restore appearance, which remains a major challenge. Here the authors introduced the application of superficial temporal artery (STA) flap in wound repairing after the resection of craniofacial malignant tumors. From January 2015 to December 2018, 16 patients with craniofacial malignant tumors were enrolled into the study, including squamous cell carcinoma (n = 6), basal cell carcinoma (n = 3), melanoma (n = 4), neuroendocrine carcinoma (n = 2), and dermatofibrosarcoma protuberance (n = 1). All of the tumors underwent extended resection. The defects formed were repaired by flaps pedicled with superior or frontal branch of STA. Donor sites were repaired with skin grafts. Patients were followed up for 6 months to 3 years to monitor the recurrence of tumor. All the flaps survived well. Venous congestion occurred in two cases but resolved after blood-letting and application of drugs promoting venous draining. During the follow-up, no recurrence of tumors was observed and the appearance of flaps was satisfying. But flap donor sites suffered from relatively poor appearance or alopecia deformity. The STA flap is reliable for wound repairing after resection of craniofacial malignant tumors. The STA parietal branch flap is preferred for repairing scalp defects, while the STA frontal branch flap is preferred for repairing facial defects. However, the STA flap should be used prudently due to its disadvantage of the deformity in scalp donor sites.

Interventional Radiological Treatment of Paediatric Liver Transplantation Complications.

To assess the efficacy of percutaneous techniques in managing paediatric liver transplantation complications. We carried out 105 paediatric cadaveric donor liver transplantations at our centre from 2001 to 2018. Percutaneous techniques were used to treat 25 cases involving transplantation complications in 23 patients. Biliary complications were treated in 14 cases (13.3%): 10 patients had bile duct obstruction, and 4 had biliary leaks. Vascular complications were treated in 11 cases (10.5%): 5 hepatic artery (HA) stenoses/occlusions, 2 inferior vena cava (IVC) stenoses, and 1 portal vein (PV) stenosis. Other interventions involved embolisation of the superior mesenteric artery branch to manage gastrointestinal bleeding in 2 patients and embolisation of an arteriobiliary fistula in 1 patient. Biliary: We carried out external-internal drainage and balloon dilatation of stenoses in 12 cases. The external-internal drainage catheter was removed after 6-8weeks in 7 patients, with the remaining 5 patients with persisting stenosis assigned for retransplantation. We failed to cross anastomotic occlusions in 2 patients before completing the procedures using external drainage; both individuals subsequently underwent retransplantation. Vascular: We performed PTA/stenting of HA stenoses/occlusions in 4 out of 5 patients. After the procedure, all 4 patients showed liver function normalisation. All 3 cases of embolisation were technically and clinically successful. Both IVC and PV stenoses treated with dilatation/stenting were also successful. Percutaneous techniques used to treat biliary and vascular complications after liver transplantation in paediatric patients are safe and efficient.

Exposure to blast shock waves via the ear canal induces deficits in vestibular afferent function in rats

The ears are air-filled structures that are directly impacted during blast exposure. In addition to hearing loss and tinnitus, blast victims often complain of vertigo, dizziness and unsteady posture, suggesting that blast exposure induces damage to the vestibular end organs in the inner ear. However, the underlying mechanisms remain to be elucidated. In this report, single vestibular afferent activity and the vestibulo-ocular reflex (VOR) were investigated before and after exposure to blast shock waves (∼20 PSI) delivered into the left external ear canals of anesthetized rats. Single vestibular afferent activity was recorded from the superior branch of the left vestibular nerves of the blast-treated and control rats one day after blast exposure. Blast exposure reduced the spontaneous discharge rates of the otolith and canal afferents. Blast exposure also reduced the sensitivity of irregular canal afferents to sinusoidal head rotation at 0.5–2Hz. Blast exposure, however, resulted in few changes in the VOR responses to sinusoidal head rotation and translation. To the best of our knowledge, this is the first study that reports blast exposure-induced damage to vestibular afferents in an animal model. These results provide insights that may be helpful in developing biomarkers for early diagnosis of blast-induced vestibular deficits in military and civilian populations.

Cerebral deep vascular architectures and subcortical infarcts

The lenticulostriate arteries (LSA) supply the lateral half of the head of the caudate nucleus, entire putamen, anterior limb, genu and the superior part of the internal capsule (IC) and a part of the corona radiata. The LSA consists with medial, intermediate and lateral branches. The medial branches perfuse the lateral segment of the globus pallidus, the head of the caudate nucleus and the anterior limb of the IC. The intermediate branches supply the anterior half of the LSA territory, while the lateral branches supply the posterior half. The anterior cerebral artery (ACA) perforators, predominantly Heubner's artery, perfuse the inferomedial part of the caudate head, the anteromedial part of putamen, the anterior part of the lateral segment of the globus pallidus and anterior limb of the internal capsule. Such territories can be represented by the anterior and ventral basal ganglions. The anterior choroidal artery (AChA) gives off three main groups of branches including the lateral branches that supply the medial temporal lobe, the medial branches that supply the cerebral peduncle and the superior branches that supply the internal capsule and the basal ganglia. The superior branches are further discriminated into proximal branches that supply the anterior one third of the posterior limb of internal capsule (PLIC) and the medial segment of the globus pallidus and distal branches that supply the posterior two-third of PLIC, retro-lenticular part of the internal capsule and the lateral thalamic nuclei. The superficial penetrating arteries, i.e. medullary arteries, arise from the cortical branches of the middle cerebral artery (MCA) and supply the deep white matter. Infarcts caused by the medullary artery occlusion are located in the centrum-semiovale and half of them were caused by embolic mechanism. The centrum-semiovale corresponds to cortical border-zone (BZ) while the corona radiate corresponds to internal BZ.

Morphological and morphometrical characteristics of arterial, venous and accessory venous Corona Mortis: Case Report

Corona Mortis (CM) is a variation determined by the arterial and / or venous connection between the anastomotic branches of the obturator artery and the inferior epigastric branch on the superior branch of the pubis. Knowledge about the different morphological and topographic possibilities of MC is relevant and deserves attention because it is an anatomical structure with high potential for lethal risk during pelvic surgical procedures. Thus, the study sought to characterize the CM vessels found in a right hemipelve during a routine dissection. Measurements of length, diameter and distances were measured with a digital caliper. The arterial CM was 4.8 cm long and 0.2 cm in diameter, while the venous CM had 4.1 cm and 0.31 cm, respectively. The presence of an accessory vein (VCMa) was also found. Therefore, the knowledge about such variation is fundamental to minimize the risks of bleeding and possible iatrogenic errors in this region.