Innervation of the heart: Anatomical study with application to better understanding pathologies of the cardiac autonomics.

Current advances in management of the cardiac neuroaxis in different cardiovascular diseases require a deeper knowledge of cardiac neuroanatomy. The aim of the study was to increase knowledge of the human fetal extrinsic cardiac nervous system. We achieved this by systematizing the origin and formation of the cardiac nerves, branches, and ganglia and their sympathetic/parasympathetic connections. Thirty human fetuses (60 sides) were subjected to detailed sub-macroscopic dissection of the cervical and thoracic regions. Cardiac accessory ganglia lying on a cardiac nerve or in conjunction with two or more (up to four) nerves before entering the mediastinal cardiac plexus were observed in 13 sides. Except for the superior cardiac nerve, the sympathetic cardiac nerves were individually variable and inconstant. In contrast, the cardiac branches of the vagus nerve appeared grossly more constant and invariable, although the individual cardiac branches varied in number and position of origin. Each cervical cardiac nerve or cardiac branch of the vagus nerve could be singular or multiple (up to six) and originated from the sympathetic trunk or the vagus nerve by one, two, or three roots. Sympathetic nerves arose from the cervical-thoracic ganglia or the interganglionic segment of the sympathetic trunk. Connections were found outside the cardiac plexus. Some cardiac nerves were connected to non-cardiac nerves, while others were connected to each other. Common sympathetic/parasympathetic cardiac nerve trunks were more frequent on right (70%) versus left sides (20%). The origin, frequency, and connections of the cardiac nerves and branches are highly variable in the fetus. Detailed knowledge of the normal neuroanatomy of the heart could be useful during cardiac neuromodulation procedures and in better understanding nervous pathologies of the heart.

Structural organization of the neuronal pathways of the superior ovarian nerve in the rat.

BACKGROUND: In the rat, studies have shown that ovary innervation arrives via the superior ovarian nerve (SON) and the ovarian plexus nerve, which originates from the celiac plexus (CP). In the present study, we performed a neuroanatomical technique to investigate the anatomy of the SON between the ovary and the CP. RESULTS: We found that the SON fibers were concentrated on the lateral border of the suprarenal ganglion and projected towards, then inserted into the suspensory ligament. Then, it ran parallel to the long axis of the ligament to reach and innervate the ovaries. At this level, the SON was composed of two coiled nerve fibers, each between 10 and 15 µm in diameter. The SON was linked to three different ganglia: the suprarenal ganglia, the celiac ganglia, and the superior mesenteric ganglion. CONCLUSIONS: The postganglionic fibers that project to the ovary via the SON emerge from the suprarenal ganglia. The trajectories on the right and left sides to each ovary are similar. The somas of ipsilateral and contralateral SON neurons are located in the prevertebral ganglia, mostly in the celiac ganglia.

Anatomical variation of the sympathetic trunk and aberrant rami communicantes and their clinical implications.

Surgical interventions involving the sympathetic trunk are increasingly performed to alleviate symptoms of several disorders such as hyperhidrosis. Anatomical variation has been highlighted as one of the main causes behind surgical failure and symptoms recurrence following surgeries conducted on the chain or its surroundings. This study therefore aimed to record anatomical variants within spinal segments C8-T10 of the sympathetic trunk. Thirty Thiel-embalmed cadavers were investigated bilaterally. The stellate ganglion was recorded on 29 sides. Its size was significantly greater in males and on the right side when the coalescence extended to the subsequent ganglion. The intrathoracic nerve of Kuntz was observed on 21 sides and was significantly more prevalent in males. There was a significant positive association between the presence of this nerve and the descending ramus in the first intercostal space. Aberrant rami found between spinal root C8 and the ventral ramus of the first intercostal nerve were introduced as rami communicantes superi. Aberrant rami communicantes were recorded 50 times in total, of which 70% were found in males. Descending rami showed the highest prevalence in upper intercostal levels, especially in males within the first intercostal space. Aberrant neuronal pathways in upper levels were significantly more prevalent when the stellate ganglion was present. The scientific literature has proven to be stochastic as results were significantly higher in past studies in regard to some sympathetic variants. Anatomical findings of the current study as well as the inconsistency of previous data should be acknowledged and considered for better surgical planning.

A comprehensive study of the abdominal ganglia part 3: An overview of the most commonly observed ganglion patterns.

Chronic pain from untreatable abdominal cancers or pancreatitis can severely decrease an individual's quality of life due to accompanying neuropathic pain, the most difficult pain mechanism to treat. Current treatment modalities focus on peripheral block or neurolysis procedures of the sympathetic ganglia in an attempt to curb the pain and improve quality of life. Reports indicated that these treatments are ineffective with patients either experiencing no relief or return the pain in a few weeks. The aim of this study was to investigate the location, macro- and microscopic morphology, and interconnections of the abdominal ganglia. The abdominal sympathetic ganglia of nine adult cadavers were investigated. The locations, morphology, interconnections, and microscopic structure were studied in 108 potential abdominal ganglia. Particular emphasis was placed on direct interconnectivity between the ganglia and histological morphology. A total of 100 ganglia were confirmed histologically to contain ganglion cells. The number and locations of most of the ganglia identified in our study does not correspond to that described by previous reports. Numerous interconnections between the different ganglia, as well as direct communications with the lumbar sympathetic chain ganglia were observed. The interconnections and presence of ganglion cells the nerves connecting the ganglia lead to the belief that the system should be considered as a unit and that pain fibers may be transmitted via alternative previously undiscovered pathways. If the pain treatments are to be reassessed with this information in mind, we believe that greater success could be achieved.

A comprehensive study of the abdominal ganglia part 2: Aorticorenal ganglia.

Investigation into reports of pain treatment for abdominal cancer and abdominal pain syndromes revealed the lack of human studies on some of the abdominal sympathetic ganglia. Recent studies on renal artery denervation therapy as treatment for resistant hypertension has made the aorticorenal ganglia of particular importance. The aim of this study was to investigate the location, morphology, interconnections, and histological nature of aorticorenal ganglia. We dissected nine abdominal cavities and harvested 37 aorticorenal ganglia. Hematoxylin and Eosin, and Masson's staining techniques were used to study the histological structure. Additionally, ganglia harvested from five individuals were stained with immunohistochemical techniques to test for tyrosine hydroxylase activity. All aorticorenal ganglia were located in proximity to the renal artery, and the majority were close to the vessel origin. Identification of multiple aorticorenal ganglia was the norm, and ranged from 2 to 4 on the left and 1 to 3 on the right. While the pattern of aorticorenal ganglia seemed to be unique in each individual case, the interconnections between these and other ganglia were vast. The aorticorenal ganglia shared direct connections with the celiac, gonadal, inferior mesenteric, and first lumbar sympathetic trunk ganglion. Contributions from the greater, lesser, and least thoracic splanchnic nerves were also observed. While the results of our study may not have direct clinical implications in isolation, the vast number of interconnections with the other abdominal ganglia may cause complications in procedures such as celiac ganglion block. In addition, aorticorenal innervation interruption may lead to hypotension.

A comprehensive study of the abdominal ganglia part 1: Celiac, phrenic and superior mesenteric ganglia.

INTRODUCTION: Patients with pancreatic cancer, chronic pancreatitis and other abdominal pain syndromes may develop debilitating pain throughout the course of their illness with little to no relief by most conventional methods. While some form of relief is experienced by patients, not all benefit from these procedures and side effects, while transitory in most cases are severe and often not expected. Our aim was therefore to investigate the anatomy surrounding the abdominal sympathetic ganglia, the target for the invasive procedures in an attempt to understand the variations in results. MATERIALS AND METHODS: The abdominal cavities of nine individuals were dissected and the ganglia investigated, harvested and histologically and immunochemical stained. RESULTS: The phrenic ganglion was found inconsistently and more often in the left than the right. If present it was located in association with the inferior phrenic artery and often connected to the celiac ganglion. The celiac ganglion was located anterior to the diaphragmatic crus on both sides and specifically posteromedial to the suprarenal gland and superior to the renal artery on the left. On the right it was located posterior to the suprarenal gland and inferior vena cava also superior to the renal vessels. The superior mesenteric ganglion was only positively identified in one individual and was located on the left lateral aspect of the superior mesenteric artery. CONCLUSION: The blockade procedures for treatment of pain are developed to target the area around the celiac artery where the ganglion is commonly described to be located. However, based on our results of its location and interconnections the ganglion is not located in the targeted area.

Morphotopographic characteristics of the extrinsic innervation of the heart in guinea pigs (Cavia porcellus).

BACKGROUND: No reports have been made on the entire extrinsic innervation of the heart in small laboratory animals. Therefore, this study examined the detailed morphotopographic features of the extrinsic cardiac autonomic nervous system (ECANS) with its adjacent structures (1) to record the general morpho-topography and variations of the ECANS in guinea pigs, (2) to compare it with previous reports on common laboratory rodents (rats, mice, and Syrian hamsters), rabbits, domesticated animals (cats, dogs, sheep, goats, oxen, pigs, and horses), primates, and humans, and (3) to infer the macroscopic evolutionary changes they presented. METHODS: The sympathetic ganglia, vagi, and emitting cardiac nerves/branches in the cervical and thoracic regions were dissected in 24 sides of 12 formalin-fixed, arterially injected adult male and female guinea pigs under a stereomicroscope. RESULTS: The ECANS in guinea pigs presented following general morphologic characteristics: (1) constant existence of the cranial cervical ganglion (CG) and placing caudal to the cranial base over the ventrolateral aspect of the longus capitis muscle, dorsomedial to the common carotid artery and communicating to the first two cervical spinal nerves, (2) the lack of the vago-sympathetic trunk, (3) the existence of the middle cervical ganglion (MG) and lying on the lateral aspect of the longus colli muscle (LC) at the level of the seventh cervical vertebra, (4) constant existence of the cervicothoracic ganglion (CT) composing generally from the caudal cervical ganglion and 1-3 thoracic ganglia and placing ventral to the first and second intercostal spaces over the lateral aspect of the LC and communicating to the eight cervical and first three thoracic spinal nerves in addition to the vertebral nerve, (5) constant existence of the limbs of the ansa subclavia (AS) joining the CT to MG, (6) the existence of individual thoracic ganglia from the 4th to the 12th and joining by single interganglionic branches (IGBs), and communicating to corresponding thoracic nerve, (7) the intimate relation between the caudal part of the thoracic sympathetic chain and the quadratus lumborum muscle, (8) the main cardiac nerves (CNs) emerging from the CT, (9) the lack of CNs springing generally from the CG, ST, AS, MG, or individual thoracic ganglia or their IGBs, and (10) the existence of the cardiac branches (CBs) emerging from the vagi and recurrent laryngeal nerves. The ECANS morphology in guinea pigs also shows sex and laterality differences. CONCLUSIONS: The general anatomical arrangement of the sympathetic components of the ECANS in guinea pigs extremely displaced features common to rats and Syrian hamsters regardless of the existence of MG and the close relation between the thoracic sympathetic chain and the quadratus lumborum muscle. However, the position and organization of the CT, along with its rami communicantes to spinal nerves in guinea pigs quite resembled those seen in rats. The general macroscopic arrangement of the sympathetic components of the ECANS in guinea pigs resembled that seen in rabbits regardless of the organization and location of the CT. The general morphology of the sympathetic components of the ECANS demonstrated markedly morphological variations and similarities among common laboratory rodents, rabbits, domesticated animals (DNs), primates, and humans. The main variations consisted of the position of the CG and its rami communicantes with the spinal nerves, the relation between the vagi and sympathetic trunks in the neck, the existence of the MG, the location and arrangement of the CT, the origins and incidences of the cardiac nerves, and the main sympathetic contributors. The general macroscopic architecture of the parasympathetic components of the ECANS in guinea pigs quite resembled that seen in domesticated animals, primates, and humans. Evolutionary comparative morphologic characteristics of the ECANS are discussed in detail and evolutionary differences and similarities of the ECANS have been found from common laboratory rodents, rabbits, domesticated animals, and primates to humans.

Cervicothoracic sympathetic system in the dog: new insights by the gross morphological description of each ganglion with its branches on each side.

BACKGROUND: Much published data exists on the position of cervicothoracic ganglion, but a little published research has been done on the cervicothoracic system of dog. Herein, we illustrated topographical position and shape of each ganglion of cervicothoracic system to determine the distribution of nerves dispersing from them on two sides, left and right. MATERIALS AND METHODS: Our work designed on the usage of 10 healthy adult dogs. Left cervicothoracic sympathetic system is represented by two ganglia: caudal and middle ganglion, while the right system is represented by three ganglia: caudal, middle cervical and small accessory ganglia. RESULTS: Left caudal cervical ganglion was elongated triangular, while the right one was elongated spindle in shape. Left caudal cervical ganglion was located on lateral surface of longus colli muscle, at the first intercostal space, while the right one was located at the level of the second rib. Left middle cervical ganglion was ovoid in shape and located at the first intercostal space, while the right one was located at the level of the second rib. There were two nerve trunks forming ansa subclavian trunk on both sides. There were three sympathetic-parasympathetic communicating branches on both sides. CONCLUSIONS: Our study recorded the first observation of left pericardial branch in dog, which originated from the caudal angle of middle cervical ganglion. There was a small ganglion located on the lateral surface of trachea at the level of the first rib.

Anatomical variations of the upper thoracic sympathetic chain: a review.

ABSTRACT OBJECTIVES: The objective of this study is to provide a thorough overview of the anatomical variations of the upper thoracic sympathetic trunk to improve clinical results of upper thoracic sympathectomy. In addition, this study strives for standardization of future studies regarding the anatomy of the upper thoracic sympathetic chain. METHODS: The Web of Science, PubMed and Google Scholar databases were searched using keywords, alone or combined, regarding the anatomy of the thoracic sympathetic chain. The search was limited to studies performed in humans. RESULTS: Fifteen studies were finally included. Cervicothoracic ganglion and nerve of Kuntz were present in 77% and 53%, respectively. The upper thoracic ganglia were predominantly located in their corresponding intercostal space with a relatively downwards shift at the lower thoracic levels. The right sympathetic trunk is prone to have more communicating rami then the left. The lower levels of ganglia tend to have more normal rami. No clear pattern was found concerning the presence of the ascending rami and there was a decrease in the number of descending rami as the chain runs caudally. The intercostal rami remain a rare anatomical variation. CONCLUSIONS: This study presents an overview of the anatomy of the upper thoracic sympathetic chain. Its results may guide upper thoracic sympathectomy to improve clinical results. This review also provides a baseline for future studies on anatomical variations of the thoracic sympathetic trunk. More uniform reporting is necessary to compare different anatomical studies.

The macro and micro-structure of the celiac and cranial mesenteric ganglia in a long-lived rodent - paca (Cuniculus paca, Linnaeus 1766) / La macro y micro estructura de los ganglios mesentéricos celíacos y craneales en un roedor longevo - paca (Cuniculus paca, Linnaeus 1766)

SUMMARY: The celiac, cranial mesenteric and celiacomesenteric ganglia of the paca (Cuniculus paca) were found between the celiac and cranial mesenteric arteries. Two predominant patterns were found: isolated celiac and cranial mesenteric ganglion and the celiacomesenteric ganglion. At the microscopic level, the ganglia are constituted by an agglomeration of neurons surrounded by capsule of connective tissue. Most of these neurons had a single eccentric nucleus. Satellite cells and mast cells were found around the soma. The mast cells were also found ar ound blood vessels and in the capsule of the ganglia.

RESUMEN: Los ganglios celíacos, mesentérico-craneales y celíaco mesentéricos de la paca (Cuniculus paca) se encontraron entre las arterias celíaca y mesentérica craneal. Se visalizaron dos patrones predominantes: celiaca aislada y ganglio mesentérico craneal y ganglio celiaco mesentérico. A nivel microscópico, los ganglios están constituidos por una aglomeración de neuronas rodeadas por una cápsula de tejido conectivo. La mayoría de estas neuronas tenían un solo núcleo excéntrico. Se encontraron células satélites y mastocitos alrededor del soma. Los mastocitos también se encontraron alrededor de los vasos sanguíneos y en la cápsula de los ganglios.

Radiological evaluation of the localization of sympathetic ganglia in the cervical region.

PURPOSE: To determine local variations of cervical sympathetic ganglia (CSG) according to vertebral levels on preoperative neck magnetic resonance imaging (MRI) by designating carotid artery (CA) as the standard landmark at the center, in attempts to prevent injury to CSG in the anterior-anterolateral approaches performed in the cervical spinal region. MATERIALS AND METHODS: The retrospective study reviewed neck MRI images of 281 patients, of which the images of 231 patients were excluded from the study based on the exclusion criteria. As a result, the MRI images of the remaining 50 patients were included in the study. The circumference of carotid artery (CA) was divided into eight equal zones with CA defined as the standard landmark at the center. High-risk zones were determined based on the anterior-anterolateral approaches. RESULTS: At C1 level, a superior ganglion was located on the right side in 32 (64%) and on the left side in 30 (60%) patients. At this level, it was most commonly located in Zone 6. Middle ganglion was observed most frequently at C3 level, which was detected on the right side in 17 (34%) and on the left side in 17 (34%) patients. At this level, it was most commonly located in Zone 2. CONCLUSION: Variations in the localizations of superior and middle cervical ganglia should be taken into consideration prior to surgical procedures planned for this region. This study sheds light on high-risk zones in the surgical site and could guide surgeons to better understand the location of cervical sympathetic ganglia before surgical planning.

The pharyngeal plexus: an anatomical review for better understanding postoperative dysphagia.

The pharyngeal plexus is an essential anatomical structure, but the contributions from the glossopharyngeal and vagus nerves and the superior cervical ganglion that give rise to the pharyngeal plexus are not fully understood. The pharyngeal plexus is likely to be encountered during various anterior cervical surgical procedures of the neck such as anterior cervical discectomy and fusion. Therefore, a detailed understanding of its anatomy is essential for the surgeon who operates in and around this region. Although the pharyngeal plexus is an anatomical structure that is widely mentioned in literature and anatomy books, detailed descriptions of its structural nuances are scarce; therefore, we provide a comprehensive review that encompasses all the available data from this critical structure. We conducted a narrative review of the current literature using databases like PubMed, Embase, Ovid, and Cochrane. Information was gathered regarding the pharyngeal plexus to improve our understanding of its anatomy to elucidate its involvement in postoperative spine surgery complications such as dysphagia. The neural contributions of the cranial nerves IX, X, and superior sympathetic ganglion intertwine to form the pharyngeal plexus that can be injured during ACDF procedures. Factors like surgical retraction time, postoperative hematoma, surgical hardware materials, and profiles and smoking are related to postoperative dysphagia onset. Thorough anatomical knowledge and lateral approaches to ACDF are the best preventing measures.

Anatomic variations of the intrathoracic nerves and the neural connections of the second and third thoracic sympathetic ganglia to the brachial plexus.

INTRODUCTION: This study investigated morphological variations of the intrathoracic nerves and the neural connections of the second and third thoracic sympathetic ganglia to the brachial plexus based on the existence of the intrathoracic nerves and the rami communicantes. MATERIALS AND METHODS: Fifty thoracic sympathetic trunks from 26 Korean adult cadavers were used. RESULTS: The first intrathoracic nerve connecting the first and second thoracic nerves was observed on 36 sides (72%), and the second intrathoracic nerve connecting the second and third thoracic nerves was found on three sides (6%). There were either one (62%) or two (10%) first intrathoracic nerves, and only one second intrathoracic nerve (6%). The neural connections of the second and third thoracic sympathetic ganglia to the first thoracic nerve were classified into three types based on the existence of the intrathoracic nerves: Type I (68%) had only the first intrathoracic nerve, Type II (26%) had no intrathoracic nerve, and Type III (6%) had both the first and second intrathoracic nerves. Types I, II, and III were further subdivided into 10, 6, and 3 types, respectively, according to the types of the rami communicantes arising from the second and third thoracic sympathetic ganglia. CONCLUSIONS: Improved knowledge of the variations in intrathoracic nerves and upper thoracic sympathetic ganglia will be helpful to thoracic surgeons when they are disrupting the sympathetic supply to the hand for treating palmar hyperhidrosis, and contribute to successful diagnoses and treatments.

Human adult cardiac autonomic innervation: Controversies in anatomical knowledge and relevance for cardiac neuromodulation.

BACKGROUND: Cardiac sympathetic blockade is a therapeutic approach for arrhythmias and heart failure and may be a beneficial effect of high thoracic epidural anesthesia. These treatments require detailed knowledge of the spatial location and distribution of cardiac autonomic nerves, however, there are controversies on this subject in humans. OBJECTIVE: To provide a systematic overview of current knowledge on human anatomy of the cardiac autonomic nervous system. RESULTS: In contrast to the often claimed assumption that human preganglionic sympathetic cardiac neurons originate mainly from thoracic spinal segments T1-T4 or T5, there is ample evidence indicating involvement of cervical spinal segment C8 and thoracic spinal segments below T5. Whether cervical ganglia besides the stellate ganglion play a role in transmission of cardiac sympathetic signals is unclear. Similarly, there is debate on the origin of cardiac nerves from different thoracic ganglia. Most human studies report thoracic cardiac nerves emerging from the first to fourth thoracic paravertebral ganglia; others report contributions from the fifth, sixth and even the seventh thoracic ganglia. There is no agreement on the precise composition of nerve plexuses at the cardiac level. After years of debate, it is generally accepted that the vagal nerve contributes to ventricular innervation. Vagal distribution appears higher in atria, whereas adrenergic fibers exceed the number of vagal fibers in the ventricles. CONCLUSION: Anatomy of the human cardiac autonomic nervous system is highly variable and likely extends beyond generally assumed boundaries. This information is relevant for thoracic epidural anesthesia and procedures targeting neuronal modulation of cardiac sympathetic innervation.

Anatomical and clinical implications of vagal modulation of the spleen.

The vagus nerve coordinates most physiologic functions including the cardiovascular and immune systems. This mechanism has significant clinical implications because electrical stimulation of the vagus nerve can control inflammation and organ injury in infectious and inflammatory disorders. The complex mechanisms that mediate vagal modulation of systemic inflammation are mainly regulated via the spleen. More specifically, vagal stimulation prevents organ injury and systemic inflammation by inhibiting the production of cytokines in the spleen. However, the neuronal regulation of the spleen is controversial suggesting that it can be mediated by either monosynaptic innervation of the splenic parenchyma or secondary neurons from the celiac ganglion depending on the experimental conditions. Recent physiologic and anatomic studies suggest that inflammation is regulated by neuro-immune multi-synaptic interactions between the vagus and the splanchnic nerves to modulate the spleen. Here, we review the current knowledge on these interactions, and discuss their experimental and clinical implications in infectious and inflammatory disorders.

Selective block of grey communicantes in upper thoracic sympathectomy. A feasibility study on human cadaveric specimens.

Background: Sympathetic chain interruption is the gold standard treatment for essential hyperhidrosis. Postoperative compensatory hyperhidrosis, the main reason for patients' dissatisfaction, is reduced by selectively lesioning white and grey rami communicantes (ramicotomy).Objective: To develop an endoscopic surgical technique that interrupts only T3 and T4 grey rami communicantes to minimize compensatory hyperhidrosis.Material and Methods: T3 and T4 grey rami communicantes ramicotomy in fifteen cold-preserved cadavers through a uniportal axillary endoscopic approach. The sympathetic chain, its ganglia, and white rami communicantes were left intact. On opening the chest, the sympathetic chain, rami communicantes and ganglia were dissected, photographed, measured and excised for histological examination.Results: Dissecting the grey rami communicantes is feasible as they consistently lie between the intercostal nerve and the homonymous sympathetic ganglion. At some levels, Kuntz nerves, as well as more than one grey ramus communicans, can be found. White rami communicantes are more medial, therefore damaging them can be avoided. Intercostal veins can be obstructive, but these can be controlled via coagulation or clipping if necessary.Conclusion: Uniportal endoscopic selective excision of the T3 and T4 grey rami communicantes is feasible without damaging the white rami communicantes, the sympathetic chain or its ganglia. Clipping the grey rami communicantes is technically possible but not reliable due to their thin diameter. This study confirms that T3 and T4 grey rami sympathetic block is technically feasible. Its application might reduce compensatory hyperhidrosis, but clinical studies are needed.

The "question-mark" MR anatomy of the cervico-thoracic ganglia complex: can it help to avoid mistaking it for a malignant lesion on 68Ga-PSMA-11 PET/MR?

Background Detectable uptake of 68Ga-PSMA-ligands in sympathetic ganglia may potentially lead to mistaking them for malignant lesions. Our aim was to investigate the anatomy of cervico-thoracic-ganglia-complex (CTG-C) in the MR part of multimodal 68Ga-PSMA-11 PET/MR imaging, in view of PET factors hindering its proper identification. Patients and methods In 106 patients, 212 sites of the CTG-C were retrospectively reviewed to assess the radiotracer uptake (SUVmax), size, shape, position, symmetry of location and visual uptake intensity. Asymmetry of PSMA-ligand uptake and increased uptake were regarded as risk factors of malignancy. Results In 66.0% left (L) and 53.8% right (R) CTG-C we noticed configurations, resembling the shape of an exclamation-mark, a question-mark, or its part (called "typical"). Tumor-like CTG-C shapes (oval, binodular or longitudinal) were detected in 28.3% L-CTG-C and in 40.6% R-CTG-C. When visual assessment of PET suggested malignancy, the recognition of "typical" shape of underlying CTG-C on MR generated a rise in the accuracy of their proper identification (from 34.4% to 75%, χ2(1) = 70.4; p < 0.001). Recognizing the shape of the CTG-C as "typical" in MR allowed us to classify as "not-suspicious" 61.9% of all CTG-C which were treated as "suspicious" after sole PET assessment. Conclusions The characteristic shape of cervico-thoracic-ganglia-complex (resembling a question-mark, or its part) helps in proper recognition of CTG-C on multimodal whole-body 68Ga-PSMA-ligand PET/MR imaging, when detectable uptake might lead to considering pathology.

The Embryonic Ascent of the Kidney Revisited.

Although the embryonic kidney's ascent is well established, the intermediate morphological changes that occur during the process are unclear. To evaluate the morphological events that accompany the kidney's ascent, we examined serial sagittal sections from 24 embryos at 5-7 weeks gestation. Six specimens had bilaterally ascending kidneys that were between the levels of the second to fifth lumbar vertebrae, and each kidney had a primitive renal cortex surrounding clusters of ampullae, which branched from the pelvis, and a dense tissue band that connected the renal cortex with the embryonic adrenal cortex or celiac ganglia, and there was no adipose capsule or renal artery. The tissue band contained abundant nerve twigs from the major splanchnic nerve; thus, it was conceivable that it was sufficiently rigid to support the length of the retroperitoneal tissue mass that included the embryonic adrenal cortex, celiac ganglia, and kidney. The lumbar vertebral body's height was much shorter than that of the ascending kidney. However, the lower vertebral column's curvature was often maintained, even when the kidneys had ascended. Therefore, vertebral column straightening was not the only factor required to drive the ascent. Together with the growth of the thorax and liver, the adrenal cortex, ganglia, and kidney appeared to change simultaneously at a position relative to the vertebrae. The renal artery established a connection to the renal cortex after the ascent. Evaluations of frontal sections from five additional specimens suggested that from its initial position, the kidney extended upwards between bilateral umbilical arteries. Anat Rec, 302:278-287, 2019. © 2018 The Authors. The Anatomical Record: Advances in Integrative Anatomy and Evolutionary Biology published by Wiley Periodicals, Inc. on behalf of Wiley-Liss, Inc.

Topographical study of the connections of the rami communicantes from the first to the fifth thoracic sympathetic ganglia.

This study investigated the morphological variations and histological patterns of the rami communicantes (RCs) arising from the first to the fifth thoracic sympathetic ganglia, and considered the clinical significance of these variations. Fifty upper thoracic portions from 26 adult Korean cadavers were used in this study. There were 731 RCs arising from the first to the fifth thoracic sympathetic ganglia. They were classified into three types depending on the connection between the sympathetic ganglion and the intercostal nerves: in type I, the RCs connected the ganglion to the corresponding intercostal nerve, and in types II and III, respectively, they connected it to the nerve one level above or below the corresponding intercostal nerve. Some RCs of types I and II could not be observed without additional preliminary surgical procedures. Diverse combinations of RC types arose from the first to the fifth thoracic sympathetic ganglia, combinations of types I and III being the most common (70%) in the first sympathetic ganglion and those comprising only type I being most frequent in the other ganglia. The RCs could not be identified by the naked eye in either fresh or fixed cadavers, so they were confirmed on the basis of their histological appearance. These results are expected to improve knowledge of morphological variations of the RCs in the upper five thoracic sympathetic ganglia, and to provide helpful information for clinical management in this region. Clin. Anat. 31:1151-1157, 2018. © 2018 Wiley Periodicals, Inc.

Characteristics of the Middle Cervical Sympathetic Ganglion: A Systematic Review and Meta-Analysis.

BACKGROUND: Understanding the characteristics of the middle cervical sympathetic ganglion (MCSG) may minimize procedure-related complications and maximize efficacy during surgery or ultrasound (US)-guided procedures. The location and detection rate of the MCSG were variable in small population studies. Therefore, a large population study or meta-analysis could give more information about the MCSG. OBJECTIVES: We aim to review the published literature and evaluate the anatomical features of the MCSG, including the detection rate, location, size, and a normal variation, and to review the clinical relevance of MCSG for procedures including, US-guided ganglion block, ethanol ablation (EA), or radiofrequency ablation (RFA). STUDY DESIGN: A systematic review and meta-analysis. The Ovid-MEDLINE and EMBASE databases were searched to find the detection rate, location, and other characteristics of the MCSG. SETTING: The pooled proportions for the detection rate of the MCSG were assessed using the DerSimonian-Laird random-effects model. METHODS: Heterogeneity among the studies was determined using a chi-square analysis for the pooled estimates and inconsistency index (I²). In order to reduce the heterogeneity, sensitivity analyses were performed. RESULTS: A review of 542 studies identified 8 eligible studies, with 273 MCSGs included in the meta-analysis. The pooled proportion for the detection rate of the MCSG was 50.4% (95% confidence interval [CI], 34.5 - 66.4%). Considerable heterogeneity among the studies was observed (I² = 94.9%). In the sensitivity analysis, when excluding one study, heterogeneity was reduced with a recalculated pooled proportion of 44.2% (95% CI, 32.1 - 56.2%; I² = 86.0%). The location of the MCSG is usually posterior to the carotid sheath and anterior to the longus colli muscle at the level of the C3 - C7 vertebrae. There was a variant where the cervical sympathetic trunk was located at the posterior wall of the carotid sheath and was adherent to the sheath. The size of the MCSG is as follows: the width, length, and height ranges were 3.8 - 6.3 mm, 6.3 - 10.5 mm, and 1.7 - 2.1 mm, respectively. A specific type of MCSG, referred to as the "double middle cervical ganglion", consisting of 2 ganglia, was demonstrated in 3 studies with a detection rate of 2.9 - 10%. LIMITATIONS: This meta-analysis included a relatively small number of studies. Significant heterogeneity was also present in the detection rate of MCSG in these studies. There was a lack of concentrated information about the MCSG, because the majority of the included studies focused on the entire cervical sympathetic chain, not only MCSG primarily. Improving complication rates might be limited due to the approximate 50% detection rate. CONCLUSION: Understanding the characteristics and variations of the MCSG could minimize complications and maximize efficacy during surgery and US-guided procedures. KEY WORDS: Middle cervical sympathetic ganglion, cervical sympathetic trunk, cervical sympathetic chain, ultrasound, nerve block, ethanol ablation, radiofrequency ablation, thyroid, Horner syndrome, meta-analysis.