Intradural extramedullary primary hydatid cyst of the spine: a case report and review of literature.

Primary intradural extramedullary hydatid cyst is a rare form of parasitic infection, causing focal neurological signs, commonly observed in sheep-raising areas of the world. We report a rare case of intradural, extramedullary spinal cyst, which we had misdiagnosis in the first surgery, because of rarity of the case. A 55-year-old man presented to our hospital in August 2008. He was admitted to our clinic because of lumbar pain of increasing severity and progressive difficulty with walking and stiffness of both lower limbs, which had lasted for 1 month. On the basis of imaging results, arachnoid cyst of the lumbar spine was diagnosed. Due to rapid progression of the patient's symptoms toward spastic paraplegia, he underwent an emergency surgical decompression procedure. The patient underwent exploratory surgery using a posterior approach. A L1-L2 laminectomy was performed. After opening the dura, an intradural extramedullary cystic mass was determined. The surgical specimen measured 6 × 2 cm and was described as a whitish, pearl-like, semitranslucent, cystic material, which was thought to be parasitic. Surgery has to be followed by albendazole therapy.

A review of the tragal pointer: anatomy and its importance as a landmark in surgical procedures.

The tragal pointer has long been used as a surgical landmark for the identification of the facial nerve trunk and the maxillary artery in such procedures as parotidectomy, internal fixation of subcondylar and condylar fractures, mandibular osteotomy, temporomandibular joint arthroplasty, and percutaneous blocks of branches of the trigeminal nerve and pterygopalatine ganglion. Aside from its use as an external landmark, it has also been implicated as a contributor to crease formation in the presence of peripheral arterial disease. This article will review the available literature on the tragal pointer's use as an external landmark.

An interrupted inferior vena cava in a situs inversus. Case report and review of the literature.

Situs inversus with interrupted inferior vena cava is an uncommon anatomic variant found in the abdominal and thoracic viscera. In this report, we present a 59-year-old woman with this variation, found during gross anatomical dissection. While this type of variation has been variable, in the present case the hepatic veins drained directly into a very short (2.2 cm) inferior vena cava. The infrarenal component of the inferior vena cava was present and drained into the azygos and hemiazygos veins. Clinical considerations of this variant anatomy are of interest, as they may present in patients as pathology on cross sectional imaging.

Anatomy of the reflected ligament of the inguinal region.

BACKGROUND: There is a paucity in the literature regarding the reflected ligament. Therefore, the present study was performed in order to further elucidate this anatomy. MATERIAL AND METHODS: Eighteen formalin-fixed adult cadavers (35 sides) underwent dissection of the medial inguinal region. The reflected ligament was observed for and when identified, its dimensions were measured. RESULTS: 83% of sides were found to have a reflected ligament. These were identified in 16 male and 13 female bodies. The size and shape for the reflected ligaments were variable but overall, triangular in nature. In general, the reflected ligament was found to extend from the lacunar and medial inguinal ligaments and extended obliquely toward the midline at an approximate 45 degrees angle to insert near the linea alba. Two ligaments (6.9 %) were identified that interdigitated with the contralateral reflected ligament. The medial and lateral lengths of the ligament had a mean measurement of 2.28 and 2.58 cm. The base of the reflected ligament had a mean of 2.52 cm and the height of this ligament was found to have a mean of 2.56 cm. The mean area of the reflected ligament was calculated as 2.93 cm(2). There was no statistically significant difference between right or left sides or between genders. CONCLUSIONS: The reflected ligament was identified in the majority of our specimens and this structure usually contributed to the formation of the posteromedial wall of the external inguinal ring. Therefore, this fact should be included in future descriptions of this ligament.

The costoclavicular ligament revisited: a functional and anatomical study.

INTRODUCTION: The sternoclavicular joint is of clinical importance. However, there is scant information in the literature regarding one ligament of this area, the costoclavicular ligament (CCL). MATERIAL AND METHODS: In order to further elucidate this structure, 10 adult formalin-fixed cadavers (17 sides) underwent dissection of the CCL. Once the CCL was identified, measurements were made of its dimensions and observations made of its anatomy. Next, ranges of motion were performed of the upper extremity and the CCL observed for tension or laxity. RESULTS: Of the 17 sternoclavicular regions examined 16 (94%) were found to possess a CCL. The average medial and lateral lengths, width and thickness were 1, 2, 1.2, 0.340 cm, respectively. The width of the CCL was statistically smaller in women that in men. The majority of ligaments were single structures traveling from the inferior surface of the medial clavicle just lateral and sometimes-fused (12.5%) to the lateral edge of the sternoclavicular joint. These fibers then terminated on the medial end of the first rib and first costal cartilage (75%) or exclusively onto the first costal cartilage (25%). Most ligaments were single and not composed of two parts. Arm abduction resulted in tautness of the ligament and increased as the degree of abduction increased. Internal rotation of the arm translated into medial shift of the clavicle, raising the clavicle away from the first rib creating tension on the CCL. Moderate degrees of external rotation were required before the CCL became taut and even began to pull the first rib laterally. Small amounts of protraction and retraction of the scapula both put the CCL under tension. CONCLUSIONS: The CCL is a constant structure found just lateral to the sternoclavicular joint. This ligament was a single band in the majority of our specimens and limited most ranges of motion of the proximal upper limb thus stabilizing the sternoclavicular region.

Postrenal transplant hemophagocytic lymphohistiocytosis and thrombotic microangiopathy associated with parvovirus b19 infection.

Persistent anemia is a known consequence of Parvovirus B19 (B19) infection following renal transplantation. However, to date, no description of B19-related hemophagocytic lymphohistiocytosis (HLH) exists in renal transplant recipients. We report a 24-year-old male kidney recipient, who presented with fever, severe anemia and allograft dysfunction two years following transplantation. Hyperferritinemia, hypertriglyceridemia, elevated serum lactate dehydrogenase, pancytopenia and fragmented red blood cells on the peripheral blood were also noted. Bone marrow examination revealed giant pronormoblasts and frequent histiocytes with intracellular hematopoietic elements, consistent with HLH. Renal allograft biopsy revealed closure of the lumen of glomerular capillaries and thickening of the capillary walls compatible with thrombotic microangiopathy. The presence of anti-B19 IgM antibody and viral DNA in the patient's serum (detected by real-time PCR) confirmed an acute B19 infection. Following high-dose intravenous immunoglobulin therapy, the anemia gradually resolved and renal function improved. As far as we know, this is the first report of B19-associated HLH and thrombotic microangiopathy in a renal transplant recipient.

Mucormycotic pseudoaneurysm of the common carotid artery with tracheal involvement.

Mucormycosis is an emerging and fatal fungal infection. A high index of suspicion and the knowledge of its potential manifestations are essential for early diagnosis. We describe a patient with acute lymphoblastic leukaemia (L2 subtype) who developed a neck mass following a course of induction chemotherapy. Doppler ultrasonography and angiography of the neck revealed a pseudoaneurysm of the right common carotid artery. The patient then developed haemoptysis. Surgical exploration revealed a necrotic right common carotid artery with anteromedial pseudoaneurysm and adjacent tracheal wall perforation. Local debridement and tracheal repair were performed. Nonseptate hypheal invasion (mucormycosis) was found on the microscopic examination of the excised arterial wall. A subsequent recurrence of pseudoaneurysm was treated with local surgical debridement and intravenous amphotericin B (Fungizone) administration. Although rare, clinicians should be aware of these possible presenting features of mucormycosis as early diagnosis and treatment may potentially improve the survival.

The clinical anatomy of the triangle of Grynfeltt.

Dorsal lumbar hernias are rare pathologies of the abdominal wall. Such hernias may manifest within the superior lumbar triangle of Grynfeltt (TG) or the triangle of Petit. The aim of our study was to identify and describe variations in the size and anatomy of the TG. The triangle was studied in 50 adult human cadavers, and dimensions and surface area were measured. The TG was identified in 82% of cases. Based on surface area parameters, we were able to classify the triangles into four distinct types. Type I (50%), or small triangles, had a surface area of <5 cm(2). Type II (22%, n=22) were defined as triangles intermediate in size with surface areas of 5-15 cm(2). Type III (10%, 10) were large triangles with surface areas of >15 cm(2). Finally, Type 0 (18%, 18) did not exhibit a triangle; instead, the aponeurosis of the transversus abdominis was enclosed by the external abdominal oblique muscle and the sacrospinalis muscle. We present these data with the hope that after further investigation in a clinical setting, they may serve practitioners in predicting which morphometric variations of the TG most predispose patients to posterior wall herniation.

Do mechanical fluid laws dictate the branching pattern of the renal artery?

INTRODUCTION: Anatomy of the renal artery is an important issue in the renal transplantation era. Multi-detector computed tomography angiography (MDCTA) is an accurate modality for the preoperative assessment of live renal donors, and it provides excellent details of donor arterial anatomy. We studied the relationship between the angle of emergence of the renal artery from the aorta and its branching pattern. METHODS: In this study, the MDCTA images obtained from the 138 kidneys of 77 potential renal transplant donors were studied. The courses of the right and left renal arteries from the aorta to the kidney hilus were delineated. The branching angle of the renal artery from the aorta (beta, angle) and the length of the renal artery from the aorta until its first division were measured (Delta, distance). The renal artery deviation from the perpendicular plane of the aorta (D, factor of deviation) was calculated by the following formula: D = (1 - sin [beta]). The cosine of this angle (cos [beta]) was also calculated. Statistical analyses were performed with Pearson correlation tests. The P value was set at .05. RESULTS: The mean age of patients was 28.7 +/- 4.3 with a male to female ratio of 63:14. The mean Delta distance and small de, Cyrillic diameter were 34.37 +/- 10.68 mm (range, 10-58) and 6.13 +/- 1.37 mm (range, 2.8-9.9), respectively. The mean beta angle, factor of deviation, and cos (beta) were 62.19 degrees +/- 16.44, 0.15 +/- 0.14, and 0.45 +/- 0.25, respectively. Significant negative correlations were found between the beta angle, and Delta distance (r = -0.308; P < .001), and small de, Cyrillic diameter (r = -0.303; P = .003). Factor of deviation and cos (beta) were directly associated Delta distance and small de, Cyrillic diameter. CONCLUSION: These findings indicated that with the main renal artery axis deviating from the perpendicular plane of the aorta or with a smaller branching angle, this artery had a greater diameter and underwent late branching. This study suggested that the renal artery diameter and branching pattern might be determined by the mechanical fluid laws.

Effect of prophylaxis with low-dose anti-thymocyte globulin on prevention of acute kidney allograft rejection.

INTRODUCTION: During kidney transplantation, the first contact between the recipient's immune system and the donor organ takes place immediately following the arterial anastomosis. The aim of this study was to evaluate the efficacy of a single, low-dose anti-thymocyte globulin (ATG) prophylaxis in the reduction of early acute rejection in renal allograft recipients. METHODS: In a randomized, controlled clinical trial, we studied the rate of acute rejection within the first month of kidney transplantation in patients who had received their transplant at a single center between the years 2004 and 2007. The patients were divided into 2 groups: group 1 (n = 37) received cyclosporine, mycophenolate mofetil or azathioprine, and prednisolone; group 2 (n = 31) received the above-mentioned agents plus a single ATG bolus (Thymoglobulin; SangStat, Lyon, France; 4-5 mg/kg) the night before the transplantation ( approximately 12 hours before the operation). Blood urea and serum creatinine levels were measured regularly in the posttransplantation period. Acute allograft rejection was justified clinically and/or pathologically. Statistical analysis was performed by SPSS 13.0 using Student t test and Fisher exact test. A P value < or = .05 was considered to indicate statistical significance. RESULTS: There were no significant differences regarding the age and gender ratio between the 2 groups. Acute allograft rejection was found in 32.4% (n = 12) of group 1 patients, and was reduced to 12.9% (n = 4) in group 2 (P = .05). Hence, the first-month acute rejection episodes decreased by approximately 60% with ATG prophylaxis in renal transplant recipients. CONCLUSION: Prophylactic administration of a single and low-dose ATG the night before kidney transplantation could reduce the risk of acute allograft rejection in renal transplant recipients. However, further studies with a greater number of patients should be conducted to confirm these results.

Levator claviculae: a case report and review of the literature.

The levator claviculae is an uncommon anatomical variant found in the posterior cervical triangle. In this report we present a 78-year-old man with this muscular variation, which was found during gross anatomical dissection. While sites of insertion and origin have been variable, in the present case the muscle originated from the left transverse processes of C3 and C4, and inserted onto the lateral third of the ipsilateral clavicle. Clinical considerations of this variant anatomy are of interest, as they may present in patients as a supraclavicular mass and may also mimic pathology on cross-sectional imaging.

The ansa subclavia: a review of the literature.

The ansa subclavia, subclavian loop, Vieussens' ansa or Vieussens' loop is a nerve cord that connects the middle cervical and inferior cervical sympathetic ganglia, forming a loop around the subclavian artery. The structure of the ansa subclavia is evolutionarily conserved from rats, guinea pigs, the porcine species and dogs to humans. A common application in physiological studies is to electrically stimulate the ansa subclavia in animal models as a robust protocol to modulate stimulatory cardiac sympathetic input. Despite a large number of physiological studies utilizing the ansa subclavia, only very brief descriptions have been devoted to it in standard anatomy texts. An extensive search found only one report in the English language literature concerning the anatomy of the ansa subclavia. The aim of this report, therefore, was to provide a comprehensive review of the clinical anatomy of the ansa subclavia and to discuss its potential physiological functions.

Intraluminal septation of the basilar artery: incidence and potential clinical significance.

Variations in the cerebrovascular tree can increase surgical or interventional morbidity. To date, only scant comments are to be found in the literature regarding intraluminal variations of the basilar artery. To further elucidate such anatomy, a cadaveric study was performed. One hundred and fifty human brains were evaluated for the present study. The basilar artery was identified in each and sectioned longitudinally to observe for the presence of intraluminal septa. One specimen (0.67%) was identified that harbored an intraluminal septum of the basilar artery. This wall was within the proximal basilar artery and measured 3 mm by 1.5 mm. No specimen was found to have other anomalies of the basilar artery and in the single specimen with an intraluminal septum no signs of intracranial pathology were seen. Although seemingly rare, septation of the basilar artery can be found. Knowledge of such an intraluminal vascular variation may be important during invasive and minimally invasive procedures.

Screening for thoracoabdominal aortic aneurysms in patients with aortoiliac atherosclerosis: a preliminary study.

Thoracoabdominal aortic aneurysms (TAAs) usually present with rupture and carry a high morbidity and mortality rate. Early detection of TAAs with screening methods and elective surgical repair could potentially diminish these complications. The present study was aimed at screening for TAA in patients with angiography-proven aortoiliac atherosclerosis (n=43). A group of patients without aortoiliac atherosclerosis was used as controls (n=15). Age, sex and aortic diameter at the level of the T12 vertebra were recorded. The subjects were divided into two age categories, the first made up of those aged less than 65 years and the second those aged 65 years or more. A T12 aortic diameter greater than 35 mm was used to indicate TAA. Statistical analyses were performed by independent t-test and general linear model with age category, sex and atherosclerosis as factors. The mean T12 aortic diameters were greater in patients with atherosclerosis than in the control group (25.2+/-5.0 vs. 22.9+/-2.4 mm; p=0.034). Two out of 43 patients (4.7%) with aortoiliac atherosclerosis had TAA, while no one in the control group had TAA. A general linear model showed that the interaction of age category and sex significantly affected the T12 aortic diameter [F (1.49)=4.044, p=0.050]. Post hoc (LSD) tests revealed that male patients aged over 65 had greater T12 aortic diameters than other patients. We conclude that patients with aortoiliac atherosclerosis may be at greater risk for developing TAA. Ageing and male sex may also be associated with thoracoabdominal aortic enlargement.

Retained hand function following transection of the ulnar nerve.

Generally, complete transection of a peripheral nerve results in cessation of function of the muscles innervated by such a nerve. We report a case of a child with a traumatically transected ulnar nerve who retained complete hand function. The authors believe this retention of hand function was due to a Martin-Grüber anastomosis, which is an interneural communication between the ulnar and median nerve in the forearm. Such neural variations should be considered when evaluating injuries to the nerves of the upper extremity (Fig. 2, Ref. 5).

The venous circle of Trolard.

A venous anastomotic network is occasionally found at the base of the brain, which closely resembles the vicinal arterial circle of Willis. When present, this venous polygon is composed of the anterior cerebral and communicating veins, the basal vein of Rosenthal and the posterior communicating and lateral mesencephalic veins. We propose that this anastomotic ring be termed the venous circle of Trolard. This venous circle might cause bleeding with such procedures as an endoscopic third ventriculostomy. We believe that information regarding this venous circle may be useful to neuroradiologists or neurosurgeons operating at the base of the brain (Fig. 1, Ref. 10). Full Text (Free, PDF) www.bmj.sk.

Indirect inguinal hernia of the urinary bladder through a persistent canal of Nuck: case report.

We report a 79-year-old female cadaver found to harbor an indirect inguinal hernia involving the urinary bladder. Further investigation revealed a patent canal of Nuck. The authors describe this rare finding in an adult and review the pertinent literature regarding such herniation. We believe this to be the first report of an indirect inguinal hernia involving the urinary bladder in a cadaver. This also seems to be the first description of such a hernia via a patent canal of Nuck in an adult.

A correlation between direct and indirect Doppler ultrasonographic measures in transplant renal artery stenosis.

Screening for transplant renal artery stenosis (TRAS) with Doppler ultrasonography (DUS) is increasingly used in the era of kidney transplantation. Direct Doppler study of the stenotic site is a time- consuming and difficult method that requires an angle of interrogation parallel to the vessel. The aim of this study was to assess the correlation between the direct-PSVs (peak systolic velocity at the stenotic site), PSVs/PSVi (PSVi, peak systolic velocity of the adjacent iliac artery)-and indirect-intrarenal arterial resistive index (RI), perfusion index (PI), acceleration time (AT)-DUS findings in the kidney transplant recipients with TRAS. We performed 26 DUS studies of both intrarenal and main renal arteries in 19 TRAS patients (who had PSVs > 150 cm/s, PSVs/PSVi > 2). The mean values of PSVs and PSVs/PSVi were 212 +/- 44.19 cm/s and 2.77 +/- 0.77, respectively. The mean intrarenal RI, PI, and AT were 0.48 +/- 0.065, 0.70 +/- 0.12, and 177.8 +/- 54.6 msec, respectively. A significant negative correlation was found between PSVs and intrarenal RI (Pearson correlation coefficient (r) = -0.4, two-tailed P = .043). No correlation was found between intrarenal PI or AT and the direct DUS findings (P > .05). With a cutoff level of 0.55 for intrarenal resistive index, the sensitivity of this parameter to detect proximal renal arterial stenosis was about 85%. Conclusively, PSVs and intrarenal RI were negatively correlated. Intrarenal resistive index can be used as an screening measure for detection of TRAS.

Time-dependent variations in urine output after renal transplantation.

INTRODUCTION: Diuresis begins soon after renal transplantation. Although controversial, early post kidney transplant urine volume may correlate with favorable short- and long-term allograft survival. The aim of the present study was to examine the potential changes in urine volume within the first 6 months after renal transplantation. METHODS: In a prospective study, the first month serum creatinine level and daily urine volume were measured at 24 and 48 hours, and at 1 month after renal transplantation in patients with stable kidney function without the evidence of allograft rejection (n = 54). Fifteen patients were also followed for their urine output at least 6 months post kidney transplantation. Data are expressed in mean values +/- SD. Statistical analysis was performed by SPSS version 13.0 using ANOVA. Correlation between continuous variables was performed using the Pearson test. The P value was set at .05. RESULTS: The mean age of the renal allograft recipients was 35.5 +/- 12.1 years with a male to female ratio of approximately 1.3. The mean first month serum creatinine was 1.26 +/- 0.4 mg/dL. The mean urine outputs were 10.06 +/- 5.89, 5.45 +/- 3.05, and 3.44 +/- 1.25 L at 24 and 48 hours and 1 month post renal transplantation. Those patients who were followed for 6 months post transplant (n=15) were observed to have a mean urine volume of 3.20 +/- 1.24 L at the end of this period. This trend showed that urine volume steadily decreased from 24 and 48 hours to 1 month after renal transplantation (P<.05). However, urine volumes were rather comparable at one month and 6 months after transplantation (P>.05). A positive correlation was found between the first-month serum creatinine and the urine volume at one month (r=0.302 and P=.035). CONCLUSION: Although urine volume showed considerable variation early after renal transplantation, it stabilized by 1 month after transplantation, which was also positively correlated with the first-month serum creatinine. Moreover, we concluded that in stable patients, the final urine output was related to early graft function.

Calcitriol started in the donor, expands the population of CD4+CD25+ T cells in renal transplant recipients.

OBJECTIVES: Alloreactive T cells recognize antigens via direct and indirect pathways. The competency of costimulatory molecules on antigen-presenting cells (APC) is important. An active form of vitamin D (1,25(OH)(2)D(3), calcitriol) inhibits APC cell maturation and expression of costimulatory molecules. Herein we studied the immunosuppressive effects of calcitriol, which was started in the donors and continued in the kidney recipients. METHODS: In this prospective study, candidates for living donor renal transplantation were randomly assigned into two groups: the treatment group were prescribed calcitriol (0.5 microg/day) started in the donor 6 days before donation and continued in recipient side for 6 months after transplantation. The control group received the conventional immunosuppressive regimen, namely, cyclosporine/mycophenolate mofetil and prednisolone. In each group, a recipient blood sample was obtained before and 6 months after transplantation. Diagnostic study of the T-cell markers-CD3, CD4, and CD25-were performed with a flow cytometry technique. RESULTS: The mean values of CD3(+)CD4(+)CD25(+) T cells in the treatment group (four women and five men; 40.8 +/- 8.5 years) and the control group (four women and six men; 37.2 +/- 10 years) were at 14.2 +/- 4.2% and 15.4 +/- 4.5% of total peripheral lymphocytes. Six months after transplantation, these percentages increased to 29 +/- 6.3% in the treatment group and decreased to 12.1 +/- 4.5% in the controls (P<.0001). No clinical rejection was detected in either group during the study period. CONCLUSION: Calcitriol started in the donors and continued in the kidney allograft recipients lead to expansion of CD4(+)CD25(+) regulatory T cells in recipients. We speculated that costimulatory deficient APC for both direct and in-direct pathways may play a role.