Vascular anomalies: nomenclature, classification, and imaging algorithms.

There is a lot of ambiguity in the usage of correct terminology in the description of vascular malformations and tumors. Hemangioma and arteriovenous malformation (AVM) are the most commonly used terms and are the mostly incorrectly used as well! The aim of this review article was to lay out the correct nomenclature and describe the correct usage for the physicians and radiologists involved in diagnosing and managing these lesions. We describe the various classification systems which have been devised to define the multiple entities included under vascular anomalies. The latest classification system that should be adhered to is per the International Society for the Study of Vascular Anomalies, approved at the 20th ISSVA Workshop held in Melbourne in April 2014, last revised in May 2018. The main features of the latest revision have been highlighted. This classification, however, does not list the diagnostic clinico-radiological features for each entity. In addition, guidelines regarding the appropriate use of available imaging modalities are lacking in the literature. We, hereby, aim to address these pertinent issues in this review article.

Role of Triamcinolone Acetonide in the Maturation of Scars.

Background: Surgeons have tried various measures to achieve a minimum and aesthetically appealing scars after wound healing at surgical sites. Various regimens have been recommended to minimize scars both intraoperatively and postoperatively. Our study aims to assess the outcome of the injection of triamcinolone acetonide used intraoperatively on a normal surgical suture line. Methods: This is a prospective, observational study of 21 patients (divided into test and control groups with a single scar at the same site) treated with or without injection of triamcinolone acetonide, and outcomes were assessed using Vancouver Scar Scale and Stony Brook Scar Evaluation Scale. Results: We found a significant difference (P > 0.05) between the median of vascularity, pigmentation, and total score on the Vancouver Scar Scale, whereas there was significant difference between height, color, and overall appearance according to the Stony Brook Scar Evaluation Scale between the test and the control group. We could not find a significant difference in outcome with varying, increasing doses of triamcinolone acetonide. Conclusion: A low dose of triamcinolone acetonide is an effective drug that tends to improve the outcome of a scar in terms of vascularity, pigmentation, height, and overall appearance of the postoperative surgical scar and helps in the maturation of a normal scar.

Review of Replantation Services from a Level One Trauma Center in India.

The aim of this article is to examine the elements that contribute to effective operation of a specialized replantation center and to provide readers with a general idea of the outcome of replantation services in India. A dedicated high-volume center coupled with a sound referral system is the backbone of replantation services in a country. A retrospective study was done on all patients who visited a level 1 trauma center in India from November 1, 2017, to December 31, 2018, for various amputations. The medical records and digital pictures of these patients were extracted from the records and analyzed. During the study period, 77 replants were performed on 63 patients at our center. Males were 68% of the study, mostly belonging to the 20 to 40 years age group (63%). Thirty-four percent of cases were smokers. Agricultural injuries (49%) were the most common cause of amputation. Finger replantation was the most common type of replantation (82%). The rate of successful replantation was highest for scalp (100%) followed by hand (71%) and thumb (67%). Setting up dedicated replantation services is essential, especially in highly populated areas. Manpower, resources, and a protocol-led approach help in achieving optimum results. A multidisciplinary team approach with round-the-clock availability plays a vital role in intraoperative decision-making and planning postoperative rehabilitation.

The challenges and complications of re-implantation of the penis following amputation.

Amputation of the penis is a rare and devastating injury. The etiologies vary from accidental, self-inflicted to attacks due to sexual jealousy and revenge. In the present era of microvascular surgery, replantation is the standard care. However, replantation of the penis comes with its own set of difficulties and complications. Knowledge of the anatomy and prior knowledge of the possible complications makes the surgeon aware of the course of events after a replantation. It helps in devising strategies to overcome these challenges methodically. We present a case of penile replant with the complications that we encountered, and the measures are taken to counter them on our way to a successful outcome. Funding: No external funding.

Atypical case of arteriovenous malformation invading into a pedicled medial arm flap.

A 54-year-old woman who had previously undergone total excision of an arteriovenous malformation (AVM) of lower lip and chin along with pedicled medial arm flap reconstruction, presented with recurrence of swelling in the same region. The patient reported progressive difficulty in feeding, talking and constant aching pain besides aesthetic concerns. On evaluation, recurrence of AVM with invasion into the flap substance was identified. We performed debulking surgery, which resulted in a considerable reduction in pain and improved lower lip functioning and aesthetic appeal of the face. This case is unique due to the rare presentation of an AVM invading the normal flap tissue. Such a finding has never been reported before for a pedicled flap, along with details of the histopathology and imaging description. There are lacunae in the understanding of the progression of vascular malformations and this additional information will add to the existing literature on AVM.

Kimura Disease: A Case Series and Systematic Review of Clinico-radiological Features.

Kimura disease is a rare chronic inflammatory disorder mostly reported in males in second to third decades from south-east Asia. Head and neck is the most commonly involved region. The usual presentation is painless facial swelling with salivary gland involvement and regional lymphadenopathy. The diagnosis can be suspected on imaging but needs to be proven on histopathology. We describe three histopathology proven cases of Kimura disease and emphasize the specific clinic-radiological findings which can help in early identification of the condition and its differentiation from other diseases with similar presentation. Gray scale Ultrasound, contrast-enhanced ultrasound, and contrast-enhanced Magnetic Resonance Imaging (CE-MRI) were done in all patients and Computed Tomography (CT) was done in one. The salient imaging features were ill-defined solid mass in the subcutaneous location of the facial region which was heteroechoic on Gray scale Ultrasound, heterogeneously hyperintense on T2W MRI and without much diffusion restriction. There was involvement of salivary glands with ipsilateral cervical adenopathy. The lesion showed avid contrast enhancement on contrast-enhanced ultrasound and CE-MRI. We also present a systematic literature review of clinico-radiological features in Kimura disease in the head and neck. The articles with histopathologically proven cases and satisfactory description of imaging findings were included and we have compared the findings in our cases with published literature. In addition, we have included examples of radiological mimics of this disease. Certain imaging findings are highly suggestive and can aid in early diagnosis of Kimura disease which helps in early initiation of treatment with better patient prognosis.

Seed Germination Ecology of Chenopodium album and Chenopodium murale.

Chenopodium album L. and Chenopodium murale L. are two principal weed species, causing substantial damage to numerous winter crops across the globe. For sustainable and resource-efficient management strategies, it is important to understand weeds' germination behaviour under diverse conditions. For the germination investigations, seeds of both species were incubated for 15 days under different temperatures (10−30 °C), salinity (0−260 mM NaCl), osmotic stress (0−1 MPa), pH (4−10), and heating magnitudes (50−200 °C). The results indicate that the germination rates of C. album and C. murale were 54−95% and 63−97%, respectively, under a temperature range of 10 to 30 °C. The salinity levels for a 50% reduction in the maximum germination (GR50) for C. album and C. murale were 139.9 and 146.3 mM NaCl, respectively. Regarding osmotic stress levels, the GR50 values for C. album and C. murale were 0.44 and 0.43 MPa, respectively. The two species showed >95% germination with exposure to an initial temperature of 75 °C for 5 min; however, seeds exposed to 100 °C and higher temperatures did not show any germination. Furthermore, a drastic reduction in germination was observed when the pH was less than 6.0 and greater than 8.0. The study generated information on the germination biology of two major weed species under diverse ecological scenarios, which may be useful in developing efficient weed management tactics for similar species in future agri-food systems.

Imaging of traumatic peripheral nerve injuries.

Nerves are commonly injured in case of blunt or penetrating trauma to the extremities. Patients with nerve injuries have profound consequences and thus a timely decision for operative management is a very important. Conventionally, management decisions have been based on clinical findings, patient course and electrophysiological studies. However, imaging modalities have an enormous role not only in localizing and grading of the nerve injuries but also in the follow-up of the nerve recovery. High-resolution ultrasound (HUS) is the modality of choice for evaluation of peripheral nerves. Magnetic resonance neurography (MRN) plays a complementary role, enabling better assessment of muscle changes and deeper nerves. Corresponding to the injured layer of the cross-section of the nerve, imaging manifestations differ in different grades of injury. Since imaging cannot detect ultrastructural changes at the microscopic level, thus there may be overlap in the imaging findings. Herewith, we discuss the imaging findings in different grades of nerve injury and propose a simple 3-tier grading for imaging (HUS and MRN) assessment of peripheral nerve injuries.

Gastrocnemius Myocutaneous Flap: A Versatile Option to Cover the Defect of Upper and Middle Third Leg.

BACKGROUND: Large soft tissue leg defect involving upper and middle third remains a therapeutic challenge. The objective of this study was to evaluate the effectiveness and versatility gastrocnemius myocutaneous flap cover for post traumatic large defect of upper and middle third of leg. METHODS: This prospective study was conducted from January 2015 to January 2017 on 25 consecutive cases of post-traumatic upper and middle third leg defect who were treated with gastrocnemius myocutaneous flap and the functional and aesthetic outcome were evaluated. RESULTS: There was no case of complete flap failure. Partial skin necrosis occurred in 2 patients (8%). There was no postoperative hematoma while mild discharge was seen in only 4(16%) patients. With regard to the donor site morbidity, no functional deformity was seen in follow up period. The procedure was found to be reliable, technically easy and aesthetically acceptable. CONCLUSION: Post-traumatic large defects of leg extending in upper and middle third were easily covered with the help of regional gastrocnemius myocutaneous flap with excellent outcome and aesthetically acceptable coverage of skin without any major complications or long term morbidity.

Thoracoumbilical Flap: Anatomy, Technique, and Clinical Applications in Upper Limb Reconstruction in the Era of Microvascular Surgery.

PURPOSE: Microvascular reconstruction is the standard of care for salvage of soft tissue defects in complex upper extremity due to their distinct advantages over the pedicled flaps. However, in the era of microsurgery, pedicled flaps have an acceptable significant role for reconstruction of complex soft tissue defects. The authors aim to demonstrate the versatility of pedicled thoracoumbilical flap (TUF) in selected clinical scenarios. PATIENTS AND METHODS: Retrospective analysis of patients who underwent TUF for upper limb posttraumatic reconstruction was performed between January 2016 and October 2017. The demographic details, etiology, wound parameters, clinical circumstances, and complications were recorded. RESULTS: Ten patients were included in the retrospective case series. Out of them, nine of the patients had critical issues, which justified a pedicled TUF over free flap. The critical issues were severe comorbid illnesses ( n = 3), the paucity of recipient vessels ( n = 1), salvage of hand replant and revascularization ( n = 2), circumferential degloving injury to the multiple fingers and palm ( n = 1), coverage for metacarpal hand ( n = 1), and extensive scarring at the surgical site ( n = 1). Mean age was 34.4 years (range: 11-70 years), six of them were males, and four were females. Two patients had infections resulting in wound gaping. One of the patients had flap tip necrosis. CONCLUSION: Pedicled flaps have a significant acceptable role in this era of microsurgery, and a pedicled TUF is a versatile option for coverage of complex soft tissue defects of the forearm, wrist, hand, and fingers. LEVEL OF EVIDENCE: This is a level IV, therapeutic, and retrospective study.

The segmental gastrocnemius muscles' flap: a cadaveric study.

The aim of this study was to evaluate the feasibility of splitting each head of the gastrocnemius muscle into two segments. This prospective study was conducted on 35 fresh cadavers with injection of radio-opaque contrast material in the popliteal artery. Seventy medial gastrocnemius and 70 lateral gastrocnemius muscle specimens were obtained. Gastrocnemius intramuscular arterial anatomy was analysed by using the digital X-ray technique. The most common vascular pattern found in this study was both bellies supplied by individual sural arteries, which shows distal bifurcation. The medial sural artery always showed bifurcation in the medial gastrocnemius muscle in both lower limbs, whereas this bifurcation of the lateral sural artery was present in only 87% cases and 13% of cases showed a single lateral sural artery without bifurcation in the lateral gastrocnemius muscle. The mean pedicle length of the medial sural artery in the right lower limb was 2.1 cm, and in left lower limb 2.3 cm. The mean pedicle length of the lateral sural artery in the right lower limb was 2.44 cm and in the left lower limb 3.21 cm. The segmental vascular pattern of the medial belly of the gastrocnemius is constant, and, thus, it can be divided safely for coverage of multiple wound defects around the knee joint. The short length of the median sural artery allows for high division of the medial gastrocnemius muscle belly. The segmental vascular anatomy is not constant in the lateral belly of the gastrocnemius muscle and, hence, division of the lateral belly is not advocated without prior preoperative colour Doppler.