Vertebral artery injury in a patient with fractured C4 vertebra.

Vertebral artery injuries due to cervical spine trauma, although rarely described in the literature, are relatively common. While most of them will remain asymptomatic, a small percentage of patients may suffer life threatening complications. We report a case of the right vertebral artery injury in a patient with fracture of C4 vertebra, successfully treated with endovascular approach. A 78-year-old male patient was hospitalized for cervical spine injury caused by falling off the tractor. Radiological assessment revealed fracture of C4 vertebra with proximal two-thirds of C4 body dislocated five millimeters dorsally. Significant swelling of soft prevertebral tissues distally of C2 segment was also present. During emergency surgery using standard anterior approach for cervical spine, excessive bleeding started from the injured right vertebral artery. Bleeding was stopped by tamponade with oxidized regenerated cellulose sheet and C4-C5 anterior fixation; then partial reduction of displacement was done. Fifteen days later, after angiography, endovascular repair of the right vertebral artery was performed using percutaneous stent graft. Follow up computed tomography scan angiography showed valid stent patency without contrast extravasation. In cases of cervical spine trauma, surgeon should always be prepared to manage injury of vertebral artery. Bleeding can primarily be stopped by hemostatic packing, and definitive repair can be successfully achieved by endovascular approach using percutaneous stent graft.

Pancreatic endocrine tumor of uncertain behavior: a case report.

Pancreatic endocrine tumors are rare, and among them large non-functioning tumors of uncertain behavior are extremely infrequent. Non-functioning pancreatic endocrine tumors originate from the endocrine part of the pancreas but are not associated with a distinct hormonal syndrome. A rare case is presented of a 49-year-old woman with a well-differentiated endocrine tumor of uncertain behavior that presented with intermittent pain in the epigastrium radiating to the right subcostal region. Computed tomography showed a well-defined and circumscribed solid mass in the pancreas head. The pancreatic mass was surgically removed and submitted for histopathologic analysis. Microscopically, the tumor had relatively uniform cells with oval nuclei that coated trabecular and pseudoglandular structures, which also showed 1 mitosis per 10 VVP and proliferation activity measured with Ki67 of less than 2%. A focus of intravascular invasion was seen on one slide. Immunohistochemical analyses for NSE, chromogranin and synapthophysin were positive, which along with its size (over 2 cm in diameter) and reported angioinvasion indicated the diagnosis of pancreatic endocrine tumor of uncertain behavior. Although mostly considered as malignant, large non-functioning pancreatic endocrine tumors can sometimes express benign or uncertain behavior; therefore, a large number of factors should always be considered when determining the biological nature of these tumors.