Better 90 Minutes Late than Never: Differential Diagnosis on MRI Scanning in a Case of Hepatic Angiosarcoma.

Primary hepatic angiosarcoma (PHA) is a rare liver malignancy with few studies describing its radiological characteristics. This article aims to assess the imaging features of each of the multiple delayed contrast-enhanced magnetic resonance imaging (MRI) scans, in addition to the conventional MRI protocol, in a patient with PHA. Standard MRI sequences and a liver protocol were used in the examination of a 71 year-old male with pathologically proven PHA after current imaging evaluation. In addition, the patient underwent transversal and coronal MRI T1-weighted scans at 10 min, 20 min and 90 min after intravenous (IV) administration of gadobenatedimeglumine (Gd-BOPTA). The PHA revealed a variable appearance on MRI, with classic imaging being insufficient in making a reliable diagnosis. Lesions have increased vascularity, which translates into increased IV contrast uptake in the MRI arterial phase, showing progressive and globular enhancement in the portal and parenchymatous phases. On delayed scans, at 10 min after IV administration, the lesions maintained no washout, but slightly began to washout at 20 min post-contrast. However, in the hepatobiliary phase (90 min post-contrast injection), on an MRI T1-weighted sequence, PHA lesions were hypointense, suggesting the absence of hepatocytes, thus indicating high-grade malignancy. This approach proved the conclusion that in a patient with PHA, an extra MRI T1-weighted scan at 90 min post-gadobenatedimeglumine injection can provide helpful information in differential diagnosis.

Diagnosis and Management of Cerebral Venous Thrombosis Due to Polycythemia Vera and Genetic Thrombophilia: Case Report and Literature Review.

(1) Background: Cerebral venous and dural sinus thrombosis (CVT) rarely appears in the adult population. It is difficult to diagnosis because of its variable clinical presentation and the overlapping signal intensities of thrombosis and venous flow on conventional MR images and MR venograms. (2) Case presentation: A 41-year-old male patient presented with an acute isolated intracranial hypertension syndrome. The diagnosis of acute thrombosis of the left lateral sinus (both transverse and sigmoid portions), the torcular Herophili, and the bulb of the left internal jugular vein was established by neuroimaging data from head-computed tomography, magnetic resonance imaging (including Contrast-enhanced 3D T1-MPRAGE sequence), and magnetic resonance venography (2D-TOF MR venography). We detected different risk factors (polycythemia vera-PV with JAK2 V617F mutation and inherited low-risk thrombophilia). He was successfully treated with low-molecular-weight heparin, followed by oral anticoagulation. (3) Conclusions: In the case of our patient, polycythemia vera represented a predisposing risk factor for CVT, and the identification of JAK2 V617F mutation was mandatory for the etiology of the disease. Contrast-enhanced 3D T1-MPRAGE sequence proved superior to 2D-TOF MR venography and to conventional SE MR imaging in the diagnosis of acute intracranial dural sinus thrombosis.

Clinical Consideration of Anatomical Variations in the Common Hepatic Arteries: An Analysis Using MDCT Angiography.

PURPOSE: The purpose of this study was to determine the prevalence of normal hepatic vascularization and variations in the common hepatic arteries using multidetector computer tomography angiography. These variants should be acknowledged before any surgery of the upper abdomen. The aim of our work was to analyze the variations in the hepatic arteries and their possible clinical and surgical implications. MATERIALS AND METHODS: This study was carried out on 4192 patients who underwent 64-slice MDCT angiography, from August 2015 to December 2021. We used surface and volume-rendering techniques in order to post-process images of the vascular components in the desired area. RESULTS: We highlighted 76 cases with replaced common hepatic arteries, which are characterized by the origin of the common hepatic artery trunk located outside the classical composition of the celiac trunk. We identified three levels of origin: the abdominal aorta, the superior mesenteric artery and the left gastric artery. We observed six different aspects of the morphological variability of the celiac trunk and the superior mesenteric artery. The trajectory of the artery trunk, between the aortic origin and the hepatic pedicle portion of the hepatic portal vein, is variable and we analyzed the pancreatic trajectory accordingly. CONCLUSIONS: The prevalence of hepatic arterial variants found during this study was similar to that in other specialized studies. We came across variants that have not been described in the well-known classification of Michels and even described extremely rare variations. The study of abnormal hepatic vascularization plays an important role in the surgical planning of hepatic transplantation, liver and pancreatic resection and extrahepatic upper abdominal surgeries.

An Integrated Approach on the Diagnosis of Cerebral Veins and Dural Sinuses Thrombosis (a Narrative Review).

(1) Objective: This review paper aims to discuss multiple aspects of cerebral venous thrombosis (CVT), including epidemiology, etiology, pathophysiology, and clinical presentation. Different neuroimaging methods for diagnosis of CVT, such as computer tomography CT/CT Venography (CTV), and Magnetic Resonance Imaging (MRI)/MR Venography (MRV) will be presented. (2) Methods: A literature analysis using PubMed and the MEDLINE sub-engine was done using the terms: cerebral venous thrombosis, thrombophilia, and imaging. Different studies concerning risk factors, clinical picture, and imaging signs of patients with CVT were examined. (3) Results: At least one risk factor can be identified in 85% of CVT cases. Searching for a thrombophilic state should be realized for patients with CVT who present a high pretest probability of severe thrombophilia. Two pathophysiological mechanisms contribute to their highly variable clinical presentation: augmentation of venular and capillary pressure, and diminution of cerebrospinal fluid absorption. The clinical spectrum of CVT is frequently non-specific and presents a high level of clinical suspicion. Four major syndromes have been described: isolated intracranial hypertension, seizures, focal neurological abnormalities, and encephalopathy. Cavernous sinus thrombosis is the single CVT that presents a characteristic clinical syndrome. Non-enhanced CT (NECT) of the Head is the most frequently performed imaging study in the emergency department. Features of CVT on NECT can be divided into direct signs (demonstration of dense venous clot within a cerebral vein or a cerebral venous sinus), and more frequently indirect signs (such as cerebral edema, or cerebral venous infarct). CVT diagnosis is confirmed with CTV, directly detecting the venous clot as a filling defect, or MRI/MRV, which also realizes a better description of parenchymal abnormalities. (4) Conclusions: CVT is a relatively rare disorder in the general population and is frequently misdiagnosed upon initial examination. The knowledge of wide clinical aspects and imaging signs will be essential in providing a timely diagnosis.

Diagnosis and Management of Mixed Transcortical Aphasia Due to Multiple Predisposing Factors, including Postpartum and Severe Inherited Thrombophilia, Affecting Multiple Cerebral Venous and Dural Sinus Thrombosis: Case Report and Literature Review.

Cerebral venous and dural sinus thrombosis (CVT) is an uncommon disease in the general population, although it is a significant stroke type throughout pregnancy and the puerperium. Studies describing this subtype of CVT are limited. Most pregnancy-associated CVT happen in late pregnancy, or more commonly in the first postpartum weeks, being associated with venous thrombosis outside the nervous system. Case presentation: The current study describes a case of multiple CVT in a 38-year-old woman with multiple risk factors (including severe inherited thrombophilia and being in the puerperium period), presenting mixed transcortical aphasia (a rare type of aphasia) associated with right moderate hemiparesis and intracranial hypertension. The clinical diagnosis of CVT was confirmed by laboratory data and neuroimaging data from head computed tomography, magnetic resonance imaging, and magnetic resonance venography. She was successfully treated with low-molecular-weight heparin (anticoagulation) and osmotic diuretics (mannitol) for increased intracranial pressure and cerebral edema. At discharge, after 15 days of evolution, she presented a partial recovery, with anomic plus aphasia and mild right hemiparesis. Clinical and imaging follow-up was performed at 6 months after discharge; our patient presented normal language and mild right central facial paresis, with chronic left thalamic, caudate nucleus, and internal capsule infarcts and a partial recanalization of the dural sinuses.

Contrast-enhanced ultrasound for the assessment of focal nodular hyperplasia - results of a multicentre study.

AIM: Contrast-enhanced ultrasound (CEUS) has become a relevant imaging method for the evaluation of focal liver le-sions (FLL). The aim of this study was to evaluate the performance of CEUS for the assessment of focal nodular hyperplasia (FNH) in a large study group. MATERIAL AND METHODS: We performed a multicentre prospective observational study, which included successive CEUS examinations from fourteen Romanian centres. CEUS examinations were performed in de novo FLL, using low mechanical index ultrasound, following an intravenous bolus of 2.4 ml SonoVue. CEUS was considered conclusive for FNH if a typical pattern was present following contrast (rapid "spoke-wheel" enhancement during the arterial phase, hyperenhanced lesion during venous phase, hyper- or isoenhanced in the late phase). In all cases a reference method was available (contrast enhanced CT or MRI or biopsy). The trial was registered in clinicaltrials.gov (Identifier NCT01329458). RESULTS: During the 6 years study, 2062 "de novo" FLL were evaluated by CEUS. From this cohort, 94/2062 (4.5%) had a typical enhancing pattern for FNH as described in the EFSUMB guidelines. Contrast enhanced CT/MRI and biopsy diagnosed additional 15 FNH. From the 94 cases diagnosed as FNH by CEUS, in nine the final diagnosis was different (five of them adenomas). CEUS had 85% sensitivity, 99.5% specificity, 90.4% positive predictive value, 99.2% negative predictive value and 98.8% diagnostic accuracy for the diagnosis of FNH. CONCLUSIONS: CEUS is a sensitive and very specific method for the diagnosis of FNH.

A rare cause of biliary obstruction - intraductal neuroendocrine tumor of the right hepatic biliary duct: a case report.

Primary biliary tract neuroendocrine tumors (NETs) are extremely rare tumors that account for 0.2-2% of all gastrointestinal neuroendocrine tumors. The typical presentation is with jaundice and other symptoms related to biliary obstruction.We present a case of right hepatic duct NET in a 27-year-old female patient, asymptomatic, presented for a routine ultrasound examination that revealed moderate dilatation of the intrahepatic biliary ducts and a 20 mm hyperechoic lesion in the right hepatic biliary duct. Additional imaging was performed with the presumptive diagnosis of cholangiocarcinoma. After surgery, the histopathological and immunohistochemical report was conclusive for the diagnosis of G2 well-differentiated NET.

Replaced right hepatic artery originated from splenic artery, in association with gastrosplenic trunk: a case report.

The authors report a case of a 74-year-old woman found to have an extremely rare case highlighted by multidetector computed tomography (MDCT) angiography, with the presence of a replaced right hepatic artery (RRHA) arising from the splenic artery (SA). In this case, the SA arose from a gastrosplenic trunk (GST). The GST had an endoluminal diameter of 9.2 mm at its origin and a length of 9.3 mm. It arose directly from the anterior abdominal aortic wall, at the level of the T12-L1 intervertebral disc. The SA branched off from the GST and travelled in front of the abdominal aorta (AA) for 18.2 mm up to the level of the L1-L2 intervertebral disc. The SA then continued along an upward and tortuous path towards the splenic hilum. The inflection point of the SA trunk was located above the origin of superior mesenteric artery (SMA). The RRHA arose from the right of this inflection point. The RRHA had an endoluminal diameter of 3.0 mm at its origin and a length of 96.0 mm; it had a downward trajectory towards the hepatic hilum. The common hepatic artery (CHA) had an endoluminal diameter of 6.2 mm at origin and arose directly from the anterior wall immediately to the right of the mediosagittal plane of the AA. Knowledge of this rare anatomical variation is important for interventional radiologists, oncologists, hepatic and abdominal surgeons.

Management of an old woman with cavernous sinus thrombosis with two different mechanisms: case report and review of the literature.

Cavernous sinus thrombosis (CST) usually produces a characteristic clinical syndrome. Septic CST represents a sporadic, but severe complication of infection of the cavernous sinuses, which can bring high mortality and morbidity rates if not treated right away. Case presentation: The current research is a case report of a 64-year-old woman with inherited thrombophilia who developed an acute mastoid infection that resulted in septic right CST. The clinical diagnosis was verified by laboratory studies and evidence from high-resolution computed tomography (HRCT), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA). Clinical medical care resulted in the patient being successfully treated with low-molecular-weight heparin and broad-spectrum intravenous antibiotics, which avoided severe complications.

Replaced right hepatic artery arising from inferior pancreaticoduodenal artery, in association with left multiple renal arteries: a case report using MDCT angiography.

The authors illustrate a case of a 61-year-old male who presented an extremely rare association of anatomical variations highlighted by multi-detector computed tomography (MDCT) angiography, with a replaced right hepatic artery (RRHA) arising from inferior pancreaticoduodenal artery (IPDA), in association with left multiple renal arteries (RAs). The celiac trunk (CT) arises from the abdominal aorta (AA), at the level of middle 1∕3 of L1 vertebral body. The superior mesenteric artery (SMA) origin was located at the anterior aspect of AA, at 2.5 mm below the origin of CT, at the level of L1∕L2 intervertebral discs. The SMA has at origin an endoluminal diameter of 11.3 mm. At 22.7 mm from its aortic origin, from the right aspect of the SMA trunk, arises IPDA. At 10.4 mm from its origin in IPDA, arises RRHA with a 78.5 mm artery length and the endoluminal diameter at origin of 2.9 mm. From the arising point, the RRHA is oriented ascending to the right, passing initially posterior to the hepatic portal vein and the head of the pancreas, then lateral to the head of the pancreas and posterior to the hepatic portal vein, after entering the hepatic parenchyma to bifurcate into the anterior and posterior branches. From left aspect of AA arise three RAs: one main, one additional (from AA), and an accessory renal (from left common iliac artery). Knowledge of this hepatic and renal anatomical variation is important for interventional radiologists, vascular experts, oncologists, vascular, hepatic and urologic surgeons.

Hepato-spleno-mesenteric trunk, in association with an accessory left hepatic artery, and common trunk of right and left inferior phrenic arteries, independently arising from left gastric artery: case report using MDCT angiography.

The authors report the case of a 53-year-old male found to have an extremely rare case of a triple anatomical variation highlighted by multidetector computed tomography (MDCT) angiography, with the presence of a hepato-spleno-mesenteric trunk (HSMT) in association with an accessory left hepatic artery (ALHA) and a common trunk origin of right (RIPA) and left (LIPA) inferior phrenic arteries from left gastric artery (LGA) arising independently from the abdominal part of aorta (AA). The HSMT with an endoluminal diameter of 10.9 mm at its origin, and a length of 4 mm arose from the anterior wall of the AA at the level of 1∕2 upper part of the L1 vertebral body. From the distal portion of HSMT, give birth to the hepato-splenic trunk (HST) and to the superior mesenteric artery (SMA). HST, with a diameter at origin of 9.2 mm and 22.3 mm long, has an upward trajectory and done with the anterior face of AA an open angle to the top of 69°. From the distal part of the HST, arise common hepatic artery (CHA) and splenic artery (SA). The LGA, with an endoluminal diameter of 4.2 mm at origin, arose directly from the anterior wall of the AA at the level of the lower 1∕3 of T12 vertebral body, 8.2 mm above the origin of the HSMT. It ran upwards in front of the AA and after 59.5 mm gave rise to an ALHA. At 18.6 mm from its aortic origin, LGA gives birth to an inferior phrenic artery trunk (IPAT), which has at origin an endoluminal diameter of 2.6 mm and a length of 2.4 mm. The RIPA and LIPA have to origin a diameter of 2.3 mm and 1.7 mm, respectively. Knowledge of this anatomical variation is important for anatomists, interventional radiologists, vascular medicine experts, oncologists, vascular, and hepatic surgeons.

Common hepatic artery arising from the left gastric artery: a case report using MDCT angiography and a brief review of the literature.

We report a very rare case of a 67-year-old male with the presence of a common hepatic artery (CHA) arising from the left gastric artery (LGA) in association with a presence of a gastro-splenic trunk (GST), found incidentally on multidetector computed tomography (MDCT) angiography, used to investigate peripheral vascular disease. The GST arises from the anterior aspect of the abdominal aorta (AA), at the level of lower 1∕3 of L1 vertebral body. The GST has a slightly concave trajectory to the right, and ends dividing into splenic artery (SA) and LGA. In the initial part of its trajectory, the SA it is wedged at 180°, pointing to the left, to the splenic hilum. The LGA has two different portions: the first dilated, initially oriented towards the higher, and then aligns to the infero-lateral left and gives birth to the second portion; the narrow portion, oriented initially horizontally, and then lower to the right. Dilated portion of LGA is continued with CHA. The CHA trunk is cuddling in a horizontal plane, at 180°, and is then oriented towards the fissure of the ligamentum venosum for entering in the liver parenchyma. At 51.7 mm from the origin, the CHA gives rise to the left hepatic artery (LHA), and after another 58 mm to the right hepatic artery (RHA), and finally continues with the gastroduodenal artery (GDA). Knowledge of this anatomical variation should be considered in planning and performing vascular surgery in the supramesocolic floor of the abdominal cavity.

An anomalous origin of the gastrosplenic trunk and common hepatic artery arising independently from the abdominal aorta: a case report using MDCT angiography.

The authors describe a case of a 61-year-old female patient, which presented on multidetector computed tomographic (MDCT) angiography a gastrosplenic trunk (GST) and common hepatic artery (CHA) arose independently from abdominal aorta (AA). The GST arose from the anterior wall of the AA, at the level of upper edge of the L1 vertebral body. The left gastric artery (LGA) arose from the superior wall of the GST. The splenic artery (SA) continuous the path of GST. The CHA arose from the anterior wall of the AA, at the level of upper one third of the L1 vertebral body, at 15.3 mm above the origin of superior mesenteric artery (SMA). The incidence and developmental and clinical significance of this vascular variation is discussed with a detailed review of the literature.

Is Contrast Enhanced Ultrasonography a useful tool in a beginner's hand? How much can a Computer Assisted Diagnosis prototype help in characterizing the malignancy of focal liver lesions?

AIM: Contrast enhanced ultrasound (CEUS) improved the characterization of focal liver lesions (FLLs), but is an operatordependent method. The goal of this paper was to test a computer assisted diagnosis (CAD) prototype and to see its benefit in assisting a beginner in the evaluation of FLLs. MATERIAL AND METHOD: Our cohort included 97 good quality CEUS videos[34% hepatocellular carcinomas (HCC), 12.3% hypervascular metastases (HiperM), 11.3% hypovascular metastases (HipoM), 24.7% hemangiomas (HMG), 17.5% focal nodular hyperplasia (FNH)] that were used to develop a CAD prototype based on an algorithm that tested a binary decision based classifier. Two young medical doctors (1 year CEUS experience), two experts and the CAD prototype, reevaluated 50 FLLs CEUS videos (diagnosis of benign vs. malignant) first blinded to clinical data, in order to evaluate the diagnostic gap beginner vs. expert. RESULTS: The CAD classifier managed a 75.2% overall (benign vs. malignant) correct classification rate. The overall classification rates for the evaluators, before and after clinical data were: first beginner-78%; 94%; second beginner-82%; 96%; first expert-94%; 100%; second expert-96%; 98%. For both beginners, the malignant vs. benign diagnosis significantly improved after knowing the clinical data (p=0.005; p=0,008). The expert was better than the beginner (p=0.04) and better than the CAD (p=0.001). CAD in addition to the beginner can reach the expert diagnosis. CONCLUSIONS: The most frequent lesions misdiagnosed at CEUS were FNH and HCC. The CAD prototype is a good comparing tool for a beginner operator that can be developed to assist the diagnosis. In order to increase the classification rate, the CAD system for FLL in CEUS must integrate the clinical data.

Fusiform aneurysm of a persistent primitive trigeminal artery associated with cerebrovascular anatomic variations: a report of two cases.

There are four embryonic anastomoses that exist between the internal carotid artery (ICA) and the vertebrobasilar (VB) system, which may fail to regress postfetal life; one of which is the trigeminal artery. Other persistent anastomoses include those formed by the hypoglossal, otic and proatlantic intersegmental arteries. In addition, other cerebrovascular variations may accompany a persistent primitive trigeminal artery (PPTA); such as arteriovenous malformations, aneurysms, carotid-cavernous fistulas and stenotic cerebral vessels. We present two very rare cases of a left PPTA. In the first case, there was a past medical history significant for cervico-thoraco-lumbar spondylitis and in the second case of an operated occipital astrocytoma. In both cases, the PPTA was associated with a fusiform aneurysm located in the carotidian (lateral) aspect of the PPTA as well as other cerebrovascular anatomic variations. In the first case, the length of the PPTA was 26.0 mm and its endoluminal diameter, at its origin at the ICA, was 1.8 mm; the aneurysm has a length of 8.4 mm. In the second case, the length of the PPTA was 31.0 mm and its endoluminal diameter at its origin at the ICA was 3.0 mm; the aneurysm have a length of 7.6 mm. Identification of these variant vessels should not be ignored before planning and execution of neurosurgeries to prevent possible perioperative risks.

Fenestration of the middle cerebral artery in a patient who presented with transient ischemic attack.

Cerebral artery fenestrations are usually detected incidentally during angiography, have a reported incidence ranging from of 0.03% to 1%, and rarely cause neurological symptoms. They can, however, be associated with aneurysmal dilatation at the proximal or distal end of the fenestration, cerebral arteriovenous malformations, or (rarely) ischemic symptoms. We present a case of a 54-year-old obese woman who presented with a large convex-lens-like fenestration of the right middle cerebral artery (MCA) at the M1 segment (distal to the origin of the temporopolar artery) associated with a transient ischemic attack. The MCA fenestration caused a local change in hemodynamic blood flow, which leads to cerebral ischemia. Magnetic resonance angiography (MRA) also revealed an associated small slit-like fenestration of the basilar artery (BA), hypoplasia of the A1 segment of the right anterior cerebral artery, bilateral fetal posterior cerebral arteries, and bilateral absence of the posterior communicating arteries. To our knowledge, this is the sixth reported case of MCA fenestration with an associated ischemic attack. In our case, fenestrations of the MCA, the BA, and hypoplasia of the A1 segment of ACA were not associated with any aneurysms.

Duplication of the distal end of the left vertebral artery with fenestration of the right posterior cerebral artery.

The vertebrobasilar system (VBS) consists in the intracranial parts of the vertebral arteries (VAs), the basilar artery (BA) and its branches. The presence of a duplication at the level of the intracranial segment of VA (V4) is generally an incidental finding, but may be associated with aneurysms or arteriovenous malformations. We present an extremely rare case of duplication of the distal end of the left vertebral artery, associated with fenestration of the right posterior cerebral artery. The distal end of the left VA was duplicated into two arms (the right with a length of 5.5 mm and a diameter of 2.3 mm that connected with the contralateral VA; and the left with a length of 11.0 mm and a diameter of 1.6 mm, which connected more distally with the BA). The right posterior cerebral artery (PCA) had a fenestration in the posterior segment of the posterior communicating part (P2), with a length of 6.8 mm.

Anomalous pattern of origin of the left gastric, splenic, and common hepatic arteries arising independently from the abdominal aorta.

The celiac trunk is the first unpaired midline branch of the abdominal aorta that usually gives rise to the left gastric artery (LGA), the common hepatic artery (CHA) and the splenic artery (SpA). Despite this classic arrangement, many variations exist. We describe an atypical case of an absent CT and anomalous origin of the LGA, CHA and the SpA from the abdominal aorta using multidetector computed tomography angiography (MDCTA) in a 72-year-old male patient. The LGA arose from the anterior wall of the AA at the level of the T12-L1 intervertebral disk [33.8 mm above the origin of the superior mesenteric artery (SMA)]. The SpA originated directly from the anterolateral wall of the AA at the junction of the upper-third and middle-third of the L1 vertebral body (24.8 mm above the origin of the SMA). The CHA branched directly from the anterior wall of the AA at the level of the middle-third of the L1 vertebral body (17 mm above the origin of the SMA). The 64-slice MDCTA system has become the primary tool for evaluation of abdominal blood vessels. It is important to be aware of such a variation as it can have a significant impact on surgical and clinical practice.

Left crossed fused renal ectopia L-shaped kidney type, with double nutcracker syndrome (anterior and posterior).

Crossed fused renal ectopia (CFRE) is the second most common fusion anomalies (FAs) of the kidneys after horseshoe kidney. Crossed fused renal ectopia (CFRE) results from one kidney crossing over to the opposite side and subsequent fusion of the parenchyma of the two kidneys. We report, by multidetector-row computed tomography (MDCT) angiography, an extremely rare case of a left CFRE (L-shaped kidney type), consisting of multiple renal arteries (one main renal artery for the upper renal parenchyma, and three renal arteries (one main and two additional) for the lower renal parenchyma) and two left renal veins, which produced a double nutcracker syndrome (both anterior and posterior). The L-shaped left kidney has a maximum length of 18.5 cm, a maximum width of 10.2 cm, and a maximum thickness of 5.3 cm. The upper pole of the kidney is located at the level of the lower third of T12 vertebral body (4.6 cm left to the mediosagittal plan); the lower pole is located along the lower half of the L5 vertebral body (1.5 cm left to the mediosagittal plan). The following case will focus on the relevant anatomy, embryology, and the clinical significance of this entity.

An unusual origin of the celiac trunk and the superior mesenteric artery in the thorax.

The authors report a case of a 44-year-old male found to have unusual origins of the celiac trunk (CT) and superior mesernteric artrery (SMA) as revealed by routine multidetector computed tomograph (MDCT) angiography. The CT and SMA originate from the thoracic aorta (TA) 21 mm and 9 mm above the aortic hiatus, respectively. The median arcuate ligament (MAL) is located at the level of the L1-L2 intervertebral disc. The course of the CT descends in the thoracic cavity making a 14° acute downward angle in front of the TA; below the level of the MAL, the CT descends, making an angle of 47°. The course of the SMA descends at both the thoracic and abdominal level making an angle of 17°, and having an aortomesenteric distance of 9 mm at the level of the third part of the duodenum. In the present case, the supradiaphragmatic origin of the CT and the SMA was determined by their incomplete caudal descent, associated with a pronounced apparent descent of the diaphragm. A thoracic origin of the CT and SMA and the acute downward aortomesenteric angle (17°) associated with a reduced aortomesenteric distance at the level of the third part of the duodenum (9 mm), although no clinical signs are present, may predispose the patient to develop simultaneously a triple syndrome: the compression of CT by MAL (celiac axis compression syndrome), the compression of SMA by MAL (superior mesenteric artery compression syndrome), and the compression of the duodenum by the SMA (superior mesenteric artery syndrome).