Basilar tip fenestration giving rise to Percheron's and mesencephalic arteries.

The basilar bifurcation region is a common site for intracranial aneurysms, as well as it gives rise to a group of perforating arteries that supply the mesencephalon and the thalamus. Complex vascular microanatomy poses a diagnostic and therapeutic challenge for neurosurgeons, neuroradiologists and neurologists. In this paper, we present a previously unreported case of basilar tip fenestration that gave rise to five perforating arteries: the artery of Percheron and four mesencephalic arteries. Due to invaluable clinical significance, the possibility of such a variant must be considered during performing various neurovascular procedures, since e.g., embolization of the fenestration misdiagnosed as an aneurysm would inevitably lead to severe neurological complications (consciousness disturbances, quadriplegia, and sensory loss). Comprehensive knowledge of the neuroanatomy and neuroembryology is crucial to safe execution of intracranial interventions.

Sonography for assessment of thoracic duct anatomy and physiology before and after meals.

The interest in clinical anatomy of the thoracic duct (TD) has recently grown, owing to discoveries linking its morphology to pathologies such as heart failure or liver cirrhosis. In the light of this knowledge, a cost-efficient and reliable in-vivo imaging method of TD should be devised. Ultrasonography satisfies these criteria and hence is a promising tool for assessment of TD's anatomy and function. Thirty-one healthy volunteers attended the examination after 6 h of fasting and 2 h without drink. Ultrasound of the left supraclavicular fossa was performed in search of TD's orifice into the venous angle. In each case, the largest diameter, number of orifices, presence of valves, tributaries, and motility of the TD were examined. We performed examinations in three sessions: after fasting, after standardized meal and 1 h after the meal. The statistical significance has varied among the three sessions. The strongest connection was shown in the third examination. The TD was visualized in 31 cases, 35 orifices were found, most of which drained into the venous angle. Multiple orifices were seen in four cases and valves in 15 cases. Tributaries were present in 17 cases. Mean widest and orifice diameter measured 3.23 and 2.0 mm, respectively. Spontaneous peristaltic-like movements of the TD were observed in 25 cases. We demonstrated that ultrasound is useful for assessment of TD's anatomy, allowing to visualize and quantify its key features. Moreover, our study is presumably the first to capture and describe TD's motility in vivo.

Mechanism of Spontaneous Intracerebral Hemorrhage Formation: An Anatomical Specimens-Based Study.

BACKGROUND: Despite advances in understanding various risk and prognostic factors, spontaneous intracerebral hemorrhage is connected to very high morbidity and mortality, while the therapy is mainly supportive. Understanding of the pathophysiology of initial hematoma expansion is limited due to insufficient clinical data and lack of a suitable animal model. METHODS: We injected 40 anatomic specimens of the basal ganglia with contrast medium, scanned them with a micro-computed tomography scanner and analyzed the results of radiological studies, direct and histological examinations. RESULTS: In 9 cases, micro-computed tomography and histological examinations revealed contrast medium extravasations mimicking intracerebral hematomas. The artificial hematomas spread both proximally and distally along the ruptured perforator and its branches in the perivascular spaces and detached the branches from the adjacent neural tissue leading to destruction of the tissue and secondary extravasations. Moreover, some contrast extravasations skipped to the perivascular spaces of unruptured perforators, created further extravasation sites and aggravated the expansion of the artificial hematoma. There was no subarachnoid extension of any artificial hematoma. CONCLUSIONS: We postulate that a forming basal ganglia intracerebral hematoma spreads initially in the perivascular space, detaches the branches from the neural tissue and causes secondary bleeding. It can also skip to the perivascular space of a nearby perforator. The proposed mechanism of hematoma initiation and formation explains extent of damage to the neural tissue, variability of growth in time and space, creation of secondary bleeding sites, and limited usefulness of surgical interventions. The model is reproducible, the extent of the artificial hematoma can be easily controlled, the rupture sites of the perforating arteries can be determined, and preparation of the model does not require specialized, expensive equipment apart from the micro-computed tomography scanner.

Method of creating 3D models of small caliber cerebral arteries basing on anatomical specimens.

The cerebral circulation is a common site of vascular lesions and concurrent hemodynamic accidents, which often lead to serious neurological disabilities. Recent advances in understanding pathogenesis, improving diagnostics and developing new treatment methods for these conditions result from an interdisciplinary approach to the problem - linking clinical sciences, basic medical sciences and hemodynamical analyses. Most common techniques used in such studies include computational fluid dynamics, which allows for development of 3D models of cerebral vasculature, basing on radiological studies. However, these methods remain flawed, mainly because of their spatial resolution, which is not high enough to visualize the smallest arterial branches (perforating branches) in the models. That leaves the perforators (<1.0 mm) out of most of the contemporary studies, whilst their clinical importance is widely recognized in clinical practice. Obstruction of these vessels by atherosclerotic plaques, thrombi or implantation of flow diverting stents may result in neurological complications such as paralysis or coma. Our research team has recently developed a new method of creating 3D models of the cerebral arterial system based on anatomical specimens and micro computed tomography (micro-CT). We have infused fresh brainstem vasculature specimens with contrast medium, subsequently scanned them using an industrial-grade micro-CT system and finally, created spatial models, which included branches of diameter less than 0.1 mm. None of the current methods have been able to produce models of detail as high as this, which allows us to presume, that our procedure may open up new opportunities for hemodynamical studies within cerebral circulation and beyond.

Acute platelet response to aneurysmal subarachnoid hemorrhage depends on severity and distribution of bleeding: an observational cohort study.

Microthrombosis after aneurysmal subarachnoid hemorrhage (aSAH) is considered to initiate neuroinflammation, vessel remodeling, and blood-brain barrier leakage. We aimed to verify the hypothesis that the intensity of thrombogenicity immediately after aSAH depends on the amount and distribution of extravasated blood. This observational cohort study included 37 consecutive aSAH patients admitted no longer than 24 h after ictus. Volumes of subarachnoid and intraventricular hemorrhages as well as the Subarachnoid Hemorrhage Early Brain Edema Scale (SEBES) score were calculated in each case. Platelet system status was described by platelet count (PLT), mean platelet volume (MPV), MPV to PLT ratio, and platelet-large cell ratio (P-LCR). Median hemorrhage volume amounted to 11.4 ml (interquartile range 2.8-26.8 ml). Patients with more severe hemorrhage had lower PLT and higher MPV to PLT ratio (ρ = - 0.49, p < .002; ρ = 0.50, p < .002, respectively). PLT decreased by 2.80 G/l per 1 ml of hemorrhage volume (95% CL 1.30-4.30, p < .001). Further analysis revealed that intraventricular hemorrhage volume was associated with P-LCR and MPV (ρ = 0.34, p < .039; ρ = 0.33, p < .048, respectively), whereas SAH volume with PLT and MPV:PLT ratio (ρ = - 0.40, p < .013; ρ = 0.41, p < .013, respectively). The odds of unfavorable neurological outcome increased 3.95 times per 1 fl of MPV (95% CI 1.19-13.12, p < .025). MPV was independently correlated with SEBES (ρ = 0.44, p < .006). This study demonstrated that the extent and distribution of aneurysmal subarachnoid hemorrhage are related to different types of acute platelet response, which may be interpreted as local and systemic thrombogenicity. Increased mean platelet volume measured in the acute phase of aSAH may identify patients at risk for unfavorable neurological outcomes and may serve as a marker of early brain injury.

Transformation of a large multi-speciality hospital into a dedicated COVID-19 centre during the coronavirus pandemic.

INTRODUCTION: The article describes the process of converting a large multi-specialized hospital into one dedicated to COVID-19 patients, and present established standards of work organization in all the wards and training system of the medical and supporting staff. The several weeks pandemic of the COVID-19 disease has forced the healthcare systems of numerous countries to adjust their resources to the care of the growing number of COVID-19 patients. Managers were presented with the challenge of protecting the healthcare workers from transmission of the disease within medical institutions, and issues concerning the physical and psychological depletion of personnel. MATERIAL AND METHODS: Based on analyses of the structure and work processes in Central Clinical Hospital (CCH) reconstructive strategic plan was developed. It included: division of existing wards into observation and isolation wards; installing locks; weekly plan for supplying personal protection equipment (PPE); designating new access to the hospital and communication routes; training of medical and supporting staff. The plan was implemented from the first days of conversion of the hospital. RESULTS: The wards of the CCH were converted for observation and isolation, and each one was fitted with sanitary locks. There was a big improvement in the supply of PPE for the medical staff. Separation of the 'dirty' and 'clean' parts of the CCH were attained, and widespread intensive training not only protected personnel against infections, but also diminished unrest which was discernable at the beginning of conversion. CONCLUSIONS: The transformation efforts will ultimately be appraised at the end of the epidemic, but the data looks encouraging. Two weeks after conversion, the testing of hospital Staff was started and by the end of April, 459 tests were had been conducted, of which only 11 were positive.