Vertebral artery variations revised: origin, course, branches and embryonic development.

BACKGROUND: The vertebral artery originates from the subclavian artery and is divided into four segments. The aim of this study is to investigate the anatomical variations in the course and branches of the vertebral artery. MATERIALS AND METHODS: A research was performed via PubMed database, using the terms: "variations of vertebral artery AND cadaveric study", "variations of vertebral artery AND cadavers" and "anomalies of vertebral artery AND cadavers". RESULTS: A total of 24 articles met the inclusion criteria, 13 of them referring to variations of the origin of the vertebral artery, 9 to variations of the course and 3 to variations of its branches. On a total sample of 1192 cadavers of different populations, origin of the left vertebral artery directly from the aortic arch was observed at 6.7%. In addition, among 311 cadavers, 17.4% were found with partially or fully ossified foramen of the atlas for the passage of the vertebral artery, while the bibliographic review also showed variants at the exit site of the artery from the transverse foramen of the axis. CONCLUSIONS: Despite the fact that variations of both the course and the branches of vertebral artery are in most cases asymptomatic, good knowledge of anatomy and its variants is of particular importance for the prevention of vascular complications during surgical and radiological procedures in the cervix area.

Insights in clinical examination and diagnosis of Athletic Pubalgia.

Athletic pubalgia presents with groin and/or pubic pain mainly in athletes. The purpose of this review is to analyze, by evaluating current literature, the clinical examination and differential diagnosis of athletic pubalgia, in an effort to better understand this clinical entity. Diagnosis is challenging due to the anatomical complexity of the groin area, the biomechanics of the pubic Romasymphysis region and the large number of potential sources of groin pain. Clinical examination and medical history are of utmost importance. Differential diagnosis includes intra-and-extra-articular hip and intra-abdominal pathology, as well as non-myoskeletal disorders, such as femoroacetabular impingement (FAI), acetabular labral tears, osteitis pubis, adductor muscles injuries and true inguinal hernia. A thorough clinical examination should be performed in such cases, including the "Resisted sit-up" and the "Single or Bilateral Resisted Leg Adduction" test. Regarding imaging, Magnetic resonance imaging (MRI) should be performed when athletic pubalgia is suspected, especially in athletes. Other imaging techniques, such as plain radiographs and ultrasonography may add to the diagnostic process.

Complex anatomic variation in the brachial region.

Authors describe a case of a complex anatomic variation discovered during dissection of the humeral region. On the right side, brachial artery followed a superficial course. Musculocutaneous nerve did not pierce coracobrachialis muscle but instead passed below the muscle before continuing in the forearm. On the left side, a communication between musculocutaneous and median nerve was dissected. Those variations are analytically presented with a brief review on their anatomic and clinical implications. Considerations on their embryological origin are attempted.

The more allergens an atopic patient is exposed to, the easier and quicker anaphylactic shock and Kounis syndrome appear: Clinical and therapeutic paradoxes.

Kounis syndrome is a condition that combines allergic, hypersensitivity, anaphylactic or anaphylactoid reactions with acute coronary syndromes including vasospastic angina, acute myocardial infarction and stent thrombosis. This syndrome is a ubiquitous disease affecting patients of any age, involving numerous and continuously increasing causes, with broadening clinical manifestations and covering a wide spectrum of mast cell activation disorders. Drugs, environmental exposures and various conditions are the main offenders. Clinical and therapeutic paradoxes concerning Kounis syndrome therapy, pathophysiology, clinical course and causality have been encountered during its clinical course. Drugs that counteract allergy, such as H2-antihistamines, can induce allergy and Kounis syndrome. The more drugs an atopic patient is exposed to, the easier and quicker anaphylaxis and Kounis syndrome can occur. Every anesthetized patient is under the risk of multiple drugs and substances that can induce anaphylactic reaction and Kounis syndrome. The heart and the coronary arteries seem to be the primary target in severe anaphylaxis manifesting as Kounis syndrome. Commercially available adrenaline saves lives in anaphylaxis but it contains as preservative sodium metabisulfite and should be avoided in the sulfite allergic patients. Thus, careful patient past history and consideration for drug side effects and allergy should be taken into account before use. The decision to prescribe a drug where there is a history of previous adverse reactions requires careful assessment of the risks and potential benefits.

Is hypertension a manifestation of the nutcracker phenomenon/syndrome? Case report and brief review of the literature.

Hypertension has been rarely reported in patients with the nutcracker phenomenon/syndrome. We describe a young male adult where a computed tomography angiography provided evidence of left renal vein dilatation, probably due to its compression through the angle between the aorta and the superior mesenteric artery, during the evaluation for secondary hypertension. As there were no other signs for secondary hypertension, we proceeded with a venography of the inferior vena cava and the renal veins that revealed mild anatomical findings compatible with the so called nutcracker phenomenon/syndrome. Blood levels of renin and aldosterone and renocaval pressure gradient from these sites were between normal limits. As there were coexisting anatomical and clinical findings (hypertension), nutcracker syndrome might have been claimed. However, no causal links could be established and these findings should be considered only as a coincidence.

Hormonal responses to marathon running in non-elite athletes.

BACKGROUND: Exercise is known to be a powerful stimulus for the endocrine system. The hormonal response to exercise is dependent on several factors including the intensity, duration, mode of exercise (endurance versus resistance), and training status of the subject. The aim of the present study was to determine the steroid hormonal response (immediately after a race and 1 week later) to endurance exercise under the real conditions of the classic Athens marathon in a group of well-trained, middle-aged, non-elite athletes. METHODS: Blood samples were drawn 1 week before the race, directly after completion of the race, and 1 week later. RESULTS: Serum cortisol and prolactin showed distinct rises 1 h after the race and returned to baseline 1 week later. Androstenedione and dehydroepiandrosterone sulphate did not show any changes. Total testosterone as well as free testosterone dropped significantly 1 h after the race but returned to baseline 1 week later. CONCLUSION: In this particular group of non-elite, middle-aged marathon runners, the race resulted in an acute increase in serum cortisol and prolactin levels and in a concomitant decline in testosterone level. The aforementioned changes returned to baseline 1 week later.

Usefulness of reperfusion ventricular arrhythmias in non-invasive prediction of early reperfusion and sustained coronary artery patency in acute myocardial infarction.

BACKGROUND: Established tenets of occurrence of reperfusion ventricular arrhythmias in acute myocardial infarction (AMI) do not provide insight into the timing of achieving reperfusion or whether coronary artery patency is sustained. We assessed the significance of ventricular arrhythmias in the non-invasive prediction of timely reperfusion and sustained restoration of coronary patency after thrombolysis in patients with AMI. METHODS: 24-hour Holter monitors were placed in 163 patients with an AMI before administration of thrombolytic therapy. Patients were classified into 3 groups of early (within 2 hours) or late reperfusion, or no-reperfusion, according with clinical and continuous ST-segment electrocardiographic criteria. Ventricular fibrillation, ventricular tachycardia (VT) and accelerated idioventricular rhythm (AIVR) were also categorized as having occurred early (within the first 2 hours) or late (after the first 2-hour period). Angiographic confirmation of coronary patency was determined 2 to 6 days after AMI. RESULTS: Early reperfusion was predicted by early sustained AIVR in 86% of patients and early non-sustained AIVR in 62.5% of patients, with sensitivity 38% and 77%, and specificity 96% and 69%, respectively; p<0.0001. Late non-sustained AIVR was commonly seen in early and late reperfused patients (92-97%) as well as in non-reperfused patients (74%). Sustained coronary patency was predicted by early sustained AIVR in 93% of patients, as well as by early non-sustained AIVR in 86% of patients and late non-sustained AIVR in 79% of patients, with sensitivity 22%, 55% and 94%, and specificity 95%, 71% and 18%, respectively; p<0.05. CONCLUSION: Only the occurrence of sustained AIVR, and probably early non-sustained AIVR convey useful information about both early reperfusion and sustained coronary artery patency. The absence of AIVR does not preclude successful thrombolysis.

Non-invasive estimation of pulmonary arterial hypertension in chronic obstructive pulmonary disease.

The feasibility and reliability of the combination of several noninvasive methods using a multivariate method of analysis to predict pulmonary artery hypertension (PAH) is evaluated in 20 patients with chronic obstructive pulmonary disease. These methods comprised arterial blood gases (Pao2, Paco2), pulmonary functional parameters (FEV1), echo-Doppler parameters (tricuspid regurgitation jets, acceleration time on pulmonary valve), computed tomography measurements (transhilar distance, hilar thoracic index, and measurement of the descending branch of the right pulmonary artery to the lower lobe). A multiple stepwise regression analysis (including one Doppler parameter, two parameters of arterial blood gases, and one functional parameter) revealed a coefficient of determination (R2) equal to 0.954 for mean pulmonary artery pressure (MPAP) with a standard error of estimate (S.E.E.) of 5.25 mmHg. A stepwise regression analysis including computed tomography and radiographic parameters revealed an R2 equal to 0.970 for PAP with a S.E.E. of 4.26 mmHg. Logistical regression analysis classified correctly 80% of patients with PAH using noninvasive methods such as the diameter of the main pulmonary artery and the diameter of the left pulmonary arterial branch calculated by computed tomography. Not only the presence of PAH but also the level of MPAP can be estimated by the combination of multiple stepwise and logistical regression analyses.