Raluca Arimie, MD

• Attending Cardiologist
• Ronald Reagan UCLA Medical CenterSanta
• Monica-UCLA Medical Center
• Los Angeles, California

The disorder evolves over several months fungus lens purchase cheap fluconazole online, with occasional complete or incomplete remissions marking its overall course fungus gnats nematodes cheap fluconazole 200 mg without a prescription. The lesion in the corpus callosum involves especially its anterior part antifungal cream yeast infection baby 400 mg fluconazole purchase overnight delivery, and frank cavitation can be seen fungal growth fluconazole 150 mg mastercard. The anterior commissure and occasionally other commissural bundles may be similarly involved nematodes for fungus gnats fluconazole 50 mg on-line, and lesions may spread from the corpus callosum into the centrum semiovale bilaterally. Despite the highly characteristic pathological changes, there is no typical clinical syndrome associated with the anatomical lesions. Myelin sheath stain demonstrating symmetric demyelination in the corpus callosum (solid arrow) and anterior commissure (dashed arrow). The sublenticular part of the internal capsule contains temporopontine and some parietopontine fibres, the acoustic (auditory) radiation from the medial geniculate body to the superior temporal and transverse temporal gyri (areas 41 and 42) and a few fibres that connect the thalamus with the temporal lobe and insula. Fibres of the acoustic radiation sweep anterolaterally below and behind the lentiform complex to reach the cortex. Cerebral Asymmetry the two human cerebral hemispheres are not simply mirror images of each other. The association of language 308 Extreme capsule Genu of corpus callosum Anterior horn of lateral ventricle Caudate nucleus (head) Septum pellucidum Anterior part of internal capsule Column of fornix Genu of internal capsule Putamen Globus pallidus Posterior part of internal capsule Thalamus Tail of caudate nucleus Hippocampus Optic radiation Inferior horn of lateral ventricle Striate area External capsule Claustrum Insula Posterior horn of lateral ventricle. Caudate nucleus (head) Anterior limb of internal capsule Putamen Insula Thalamus Genu of internal capsule Posterior limb of internal capsule. Descending motor fibres, yellow; corticofugal fibres to the thalamus and pons, red; ascending fibres, blue. For instance, a stimulus presented briefly to one visual field or placed in one hand is accessible only to the opposite hemisphere (because the projections are contralateral and all commissural connections have been severed). However, the object has undoubtedly been identified correctly, because the person can later pick it out from a selection of objects. These functional specializations are relative and apply to people with left hemisphere language representation. Neuropsychologia 17, 153­166, modified with permission from Elsevier; and Sperry, R. Much information on the lateralization of cerebral function has come from studying patients in whom the corpus callosum was divided (commissurotomy) to treat intractable epilepsy and rare subjects who lack part or all of the corpus callosum. The left hemisphere usually prevails for verbal and linguistic functions, mathematical skills and analytical thinking. The right hemisphere is mostly non-verbal; it is more involved in spatial and holistic or gestalt thinking, in many aspects of music appreciation and in some emotions. Memory also shows lateralization: verbal memory is primarily a left hemisphere function, and non-verbal memory is represented in the right hemisphere. These asymmetries are relative, not absolute, and they vary in degree according to the function and the individual. Those persons with a left-hand preference or mixed handedness make up a heterogeneous group that generally shows reduced or anomalous lateralization rather than a simple reversal of the situation in right-handers. Certain cerebral anatomical asymmetries are apparent at both the macroscopic and histological levels. One of the most notable is in the planum temporale, which is usually larger on the left side than the right. Probably as a result of this size difference, the lateral fissure is longer and more horizontal in the left hemisphere; this observation, together with the orientation of the overlying vasculature, provides a surface marker of temporal lobe asymmetry. There is evidence that planum temporale asymmetry originates almost entirely from right­left differences in the size of a cytoarchitectonic subfield called Tpt. Subtle asymmetries in the superior temporal lobe have been demonstrated in terms of overall size and shape, sulcal pattern and cytoarchitecture, as well as at the neuronal level. It seems reasonable to assume that these differences underlie some of the functional asymmetry for language representation. Asymmetries in areal size, cytoarchitecture or neurocytology occur elsewhere in the cerebral cortex as well as subcortically. For example, many brains have a wider right frontal pole and a wider left occipital pole. The cortical surface surrounding the central sulcus is larger in the left hemisphere, especially in the areas containing the primary somatosensory and motor maps of the arm, suggesting that one cerebral manifestation of hand preference is a larger amount of neural circuitry in the relevant parts of the cortex. Histological asymmetries are also found in areas that are not usually considered to be closely related to either language or handedness. The most interesting clinical implications of cerebral asymmetry occur when disturbed lateralization appears to be inherent in the nature or even the cause of a disorder. A number of studies suggest that the disease is associated with a failure to develop normal structural and functional cerebral asymmetry and that its pathology is characterized by a greater affliction of the left than the right hemisphere. Other putative neurodevelopmental disorders, including dyslexia and autism, may also be associated with asymmetric cerebral abnormalities. The brain shown here demonstrates marked asymmetry in size of the planum temporale, which is larger on the left in a majority of brains. The asymmetric length of the lateral border of the planum temporale underlies the asymmetries in the Sylvian fissure itself (see also B). Asymmetry of the planum temporale arises mostly from differences in the size of the cytoarchitectonic field Tpt (shaded in green). Tpt forms much of the posterior part of the planum temporale, although it also extends onto the lateral surface of the posterior superior temporal gyrus. B, Lateral views of the left and right hemispheres emphasizing differences between the two Sylvian fissures (red). Compared with the left hemisphere, the right Sylvian fissure is shorter and turns upward. This reflects planum temporale asymmetries (represented by adjacent red stippling). Presence of the 14-3-3 protein coupled with the clinical course strongly supports the diagnosis of Creutzfeldt-Jakob disease. A 65-year-old man first began to exhibit impaired judgment, anxiety and fatigue 18 months previously. His symptoms gradually worsened and became associated with severe recent and then remote memory problems. Abrupt myoclonic jerks of the upper extremities appeared several weeks before his neurological evaluation. Neurological examination now confirms dementia with evidence of marked memory loss, impairment of executive functions, dyscalculia, visuospatial disturbances and visual agnosia. Frequent myoclonic jerks of the upper extremities and left lower extremities are seen; his gait is unsteady, with impaired postural reflexes. Electroencephalogram shows a generalized periodic pattern of sharp waves at intervals of 0. Discussion: the combination of history, neurological examination and diagnostic test results points strongly to a diagnosis of Creutzfeldt-Jakob disease, a human prion disease and one of the so-called transmissible spongiform encephalopathies. Anatomically, the disorder involves grey matter diffusely throughout the neuraxis, with remarkable devastation. There is striking loss of neurones in the cerebral cortex, with a brisk astrocytic response and microcavitation (spongiform encephalopathy). New perspectives in basal forebrain organization of special relevance for neuropsychiatric disorders: the striatopallidal, amygdaloid and corticopetal components of the substantia innominata. Provides evidence that the region of the substantia innominata in the basal forebrain is composed of parts of three forebrain structures: the ventral striatopallidal system, the extended amygdala and the magnocellular corticopetal system. Pain processing during three levels of noxious stimulation produces differential patterns of central activity. Classic description of the organization of sensory and motor homunculi in the human cerebral cortex. It is situated in the neck opposite a line drawn down the side of the neck from the root of the auricle to the level of the upper border of the thyroid cartilage. It is deep to the internal jugular vein, the deep fascia and sternocleidomastoid, and anterior to scalenus medius and levator scapulae. Each ramus, except the first, divides into ascending and descending parts that unite in communicating loops. From the first loop (C2 and C3), superficial branches supply the head and neck; cutaneous nerves of the shoulder and chest arise from the second loop (C3 and C4). The superficial branches perforate the cervical fascia to supply the skin, whereas the deep branches generally supply the muscles. The superficial branches either ascend (lesser occipital, great auricular and transverse cutaneous nerves) or descend (supraclavicular nerves). Descending under platysma and the deep cervical fascia, the trunk divides into medial, intermediate and lateral (posterior) branches, which diverge to pierce the deep fascia a little above the clavicle. The medial supraclavicular nerves run inferomedially across the external jugular vein and the clavicular and sternal heads of the sternocleidomastoid to supply the skin as far as the midline and as low as the second rib. The intermediate supraclavicular nerves cross the clavicle to supply the skin over pectoralis major and deltoid down to the level of the second rib, next to the area of supply of the second thoracic nerve. The lateral supraclavicular nerves descend superficially across trapezius and the acromion, supplying the skin of the upper and posterior parts of the shoulder. It curves around the accessory nerve and ascends along the posterior margin of the sternocleidomastoid. Near the cranium it perforates the deep fascia and passes up onto the scalp behind the auricle. It supplies the skin and connects with the great auricular and greater occipital nerves and the auricular branch of the facial nerve. Its auricular branch supplies the skin on the upper third of the medial aspect of the auricle and connects with the posterior branch of the great auricular nerve. It has been suggested that compression or stretching of the lesser occipital nerve contributes to cervicogenic headache. It arises from the second and third cervical rami, encircles the posterior border of the sternocleidomastoid, perforates the deep fascia and ascends on the muscle beneath platysma with the external jugular vein. The anterior branch is distributed to the facial skin over the parotid gland, connecting in the gland with the facial nerve. The posterior branch supplies the skin over the mastoid process and on the back of the auricle (except its upper part); a filament pierces the auricle to reach the lateral surface, where it is distributed to the lobule and concha. The posterior branch communicates with the lesser occipital nerve, the auricular branch of the vagus nerve and the posterior auricular branch of the facial nerve. Communicating branches pass from the loop between the first and second cervical rami to the vagus and hypoglossal nerves and to the sympathetic trunk. The hypoglossal branch later leaves the hypoglossal nerve as a series of branches-namely, the meningeal, superior root of ansa cervicalis and nerves to thyrohyoid and geniohyoid. It perforates the deep cervical fascia and divides under platysma into ascending and descending branches that are distributed to the anterolateral areas of the neck. The ascending branches ascend to the submandibular region, forming a plexus with the cervical branch of the facial nerve beneath platysma. Some branches pierce platysma and are distributed to the skin of the upper anterior areas of the neck. The descending branches pierce platysma and are distributed anterolaterally to the skin of the neck, as low as the sternum. On the right the costal elements of the upper six cervical vertebrae have been removed to expose the cervical part of the vertebral artery. On the left most of the deep relations of the common carotid artery and the internal jugular vein are exposed. The first four cervical ventral rami each receive a grey ramus communicans from the superior cervical sympathetic ganglion. After giving a branch to the superior belly of omohyoid, it is joined by the inferior root of the ansa from the second and third cervical spinal nerves. The two roots form the ansa cervicalis (ansa hypoglossi), from which branches supply sternohyoid, sternothyroid and the inferior belly of omohyoid. Another branch descends anterior to the vessels into the thorax to join the cardiac and phrenic nerves. It descends on the lateral side of the internal jugular vein, crosses it a little below the middle of the neck and continues forward to join the superior root anterior to the common carotid artery, forming the ansa cervicalis (ansa hypoglossi), from which all infrahyoid muscles except the thyrohyoid are supplied. The inferior root comes from the second and third cervical ventral rami in approximately 75% cases, from the second to fourth in 15% and from the third alone in 5%. Occasionally, it may be derived either from the second alone or from the first to third. The phrenic nerve arises chiefly from the fourth cervical ventral ramus, but it also has contributions from the third and fifth. It is formed at the upper part of the lateral border of scalenus anterior and descends almost vertically across its anterior surface behind the prevertebral fascia. It descends posterior to the sternocleidomastoid, the inferior belly of omohyoid (near its intermediate tendon), the internal jugular vein, transverse cervical and suprascapular arteries and, on the left, the thoracic duct. At the root of the neck it runs anterior to the second part of the subclavian artery, from which it is separated by the scalenus anterior (according to some accounts, on the left side the nerve passes anterior to the first part of the subclavian artery), and posterior Phrenic Nerve Muscular Branches Muscular branches supply rectus capitis lateralis (C1), rectus capitis anterior (C1, C2), longus capitis (C1­3) and longus colli (C2­4). The inferior root of the ansa cervicalis and the phrenic nerve are additional muscular branches. The inferior root of the ansa cervicalis (nervus descendens cervicalis) is formed by the union of branches from the second and third cervical rami (see Inferior Root of Ansa Cervicalis 316 Chapter 17 / Cervical Plexus to the subclavian vein. The phrenic nerve enters the thorax by crossing medially in front of the internal thoracic artery. In the neck, each nerve receives variable filaments from the cervical sympathetic ganglia or their branches and may also connect with internal thoracic sympathetic plexuses. Lingual nerve Styloglossus Mandibular nerve Accessory nerve Sternocleidomastoid Accessory Phrenic Nerve Hyoglossus Stylohyoid Glossopharyngeal nerve Lingual artery Thyrohyoid Hypoglossal nerve Cricoid cartilage Inferior constrictor Ansa cervicalis Phrenic nerve Scalenus anterior Scalenus medius Omohyoid inferior belly Lesser occipital nerve Loop joining 1st and 2nd cervical ventral rami Splenius capitis Second cervical ventral ramus Third cervical ventral ramus Superior root of ansa cervicalis Fourth cervical ventral ramus Levator scapulae the accessory phrenic nerve is composed of fibres from the fifth cervical ventral ramus that run in a branch of the nerve to subclavius. This lies lateral to the phrenic nerve and descends posterior (occasionally anterior) to the subclavian vein.

The amygdala innervates most hypothalamic nuclei anterior to the mammillary bodies antifungal imidazole fluconazole 50 mg order online. Its corticomedial nucleus innervates preoptic and anterior hypothalamic areas and the ventromedial nucleus fungi journals 150 mg fluconazole order amex. The short ventral amygdalofugal path passes medially over the optic tract fungi fragmentation definition order discount fluconazole on line, beneath the lentiform complex kingdom fungi definition and examples fluconazole 100 mg order mastercard, to reach the hypothalamus brain fungus definition 100 mg fluconazole overnight delivery. The long, curved stria terminalis runs parallel to the fornix, separated from it by the lateral ventricle; it passes through the bed nucleus of the stria terminalis and is then distributed to the anterior hypothalamus via the medial forebrain bundle. Olfactory afferents reach the hypothalamus largely via the nucleus accumbens and septal nuclei, and most terminate in the lateral hypothalamus. Visual afferents leave the optic chiasma and pass dorsally into the suprachiasmatic nucleus. No auditory connections have been identified, although it is clear that such stimuli influence hypothalamic activity. However, many hypothalamic neurones respond best to complex sensory stimuli, suggesting that sensory information reaching the neocortex has converged and been processed by the amygdala, hippocampus and neocortex. Neocortical corticohypothalamic afferents to the hypothalamus are poorly defined but probably arise from frontal and insular cortices. Some may relay in the mediodorsal thalamic nucleus and project into the hypothalamus via the periventricular route. Other direct corticohypothalamic fibres may end in lateral, dorsomedial, mammillary and posterior hypothalamic nuclei, but all these connections are questionable. In addition, it receives a cholinergic input from the ventral tegmental ascending cholinergic pathway; a noradrenergic input to dorsomedial, periventricular, paraventricular, supraoptic and lateral hypothalamic nuclei from the ventral tegmental noradrenergic bundle; and dopamine fibres from the mesolimbic dopaminergic system. Group A11 innervates the medial hypothalamic nuclei, and groups A13 and A14 supply the dorsal and rostral hypothalamic nuclei. The medial forebrain bundle is a loose grouping of fibre pathways that mostly run longitudinally through the lateral hypothalamus. It connects forebrain autonomic and limbic structures with the hypothalamus and brain stem, receiving and giving small fascicles throughout its course. It contains descending hypothalamic afferents from the septal area and orbitofrontal cortex, ascending afferents from the brain stem and efferents from the hypothalamus. Connections of the Hypothalamus the hypothalamus has afferent and efferent connections with the rest of the body via two (possibly three) distinct routes: neural connections, the blood stream and (probably) the cerebrospinal fluid. Some hypothalamic neurones have specific receptors that sense the temperature, osmolarity, glucose, free fatty acid and hormone content of the blood. These control the anterior pituitary and act on organs such as the kidney, breast, uterus and blood vessels. Some of these neural connections, especially those to the mammillary bodies, form discrete myelinated fascicles; most, however, are diffuse and unmyelinated, and their origin and termination are uncertain. Most pathways are multisynaptic, which means that the majority of synapses on any hypothalamic neurone are derived from hypothalamic interneurones. Efferent neural projections are reciprocal to most of these sources; in particular, they impinge on and control the central origins of autonomic nerve fibres. The hypothalamus therefore exerts control via the autonomic and endocrine systems and through its connections to the telencephalon. The hypothalamus receives visceral, gustatory and somatic sensory information from the spinal cord and brain stem. It receives largely polysynaptic projections from the nucleus tractus solitarius, probably directly and indirectly via the parabrachial nucleus and medullary noradrenergic cell groups Efferent Connections Afferent Connections Hypothalamic efferents include reciprocal paths to the limbic system, descending polysynaptic paths to autonomic and somatic motor neurones and neural and neurovascular links with the pituitary. Septal areas and the amygdaloid complex have reciprocal hypothalamic connections along the paths described earlier. The medial preoptic and anterior hypothalamic areas give short projections to nearby hypothalamic groups. The ventromedial nucleus has more extensive projections that pass via the medial forebrain bundle to the bed nucleus of the stria terminalis, basal nucleus of Meynert, central nucleus of the amygdala and midbrain reticular formation. Some tuberal and posterior lateral hypothalamic neurones project directly to the entire neocortex and appear to be essential for maintaining cortical arousal, but the topography of these projections is unclear. She also reports difficulties with memory, concentration and attention and diffuse headaches in association with sleepiness. In addition, she reports automatisms, wherein she types illegibly on the computer as she falls asleep. Upon questioning, she reports vivid dreams during sleep, usually with a threatening content and associated with an inability to move to extricate herself from the imagined danger. She also recalls rare episodes of cataplexy-the sudden onset of weakness in her facial muscles after laughter or anger. On one occasion, she collapsed in a store when she lost all motor ability in both legs for a few minutes; she was rushed to the emergency room and released within a few hours, with no positive findings. She naps for 2 hours a day on weekends, finding naps to be refreshing; naps are associated with dreams. Past medical and psychiatric histories are negative, and she takes no medications. She consumes two caffeinated beverages in the morning, which allows her to function at a nominal cognitive level in the morning. Multiple sleep latency testing performed during the day following the nocturnal polysomnogram reveals a mean sleep latency of 2. Although the cause of human narcolepsy is unknown, recent studies have demonstrated an enhanced pattern of gliosis, as visualized through glial fibrillary acidic protein­labelled astrocytes in the hypothalamus and, to a lesser extent, the thalamus of narcoleptic brains compared with those of controls. Gliosis is thought to be the basis of the destruction of hypocretin or orexin neurones in the perifornical area of the posterior hypothalamus; under normal conditions, these neurones have widespread projections throughout the human central nervous system, with dense innervations of the hypothalamus, histaminergic tuberomammillary nucleus, noradrenergic locus coeruleus, serotoninergic raphe nuclei, dopaminergic ventral tegmental area, midline thalamus and nucleus of the diagonal band­nucleus basalis complex of the forebrain. This pattern of projections from the hypocretin neurones is thought to play an important role in arousal and maintenance of the awake state. Hypothalamic neurones projecting to autonomic neurones are found in the paraventricular nucleus (oxytocin and vasopressin neurones), perifornical and dorsomedial nuclei (atrial natriuretic peptide neurones), lateral hypothalamic area (-melanocyte-stimulating hormone neurones) and zona incerta (dopamine neurones). These fibres run through the medial forebrain bundle into the tegmentum, ventrolateral medulla and dorsal lateral funiculus of the spinal cord. In the brain stem, fibres innervate the parabrachial nucleus, nucleus ambiguus, nucleus of the solitary tract and dorsal motor nucleus of the vagus. In the spinal cord, they end on sympathetic and parasympathetic preganglionic neurones in the intermediolateral column. Both oxytocin- and vasopressin-containing fibres can be traced to the most caudal spinal autonomic neurones. The medial mammillary nucleus gives rise to a large ascending fibre bundle that diverges into mammillothalamic and mammillotegmental tracts. The mammillothalamic tract ascends through the lateral hypothalamus to reach the anterior thalamic nuclei, where massive projections radiate to the cingulate gyrus. The mammillotegmental tract curves inferiorly into the midbrain, ventral to the medial longitudinal fasciculus, and is distributed to the tegmental reticular nuclei. The pituitary gland, or hypophysis cerebri, is a reddish grey ovoid body approximately 12 mm in transverse diameter and 8 mm in anteroposterior diameter, weighing approximately 500 mg. It is continuous with the infundibulum, a hollow, conical inferior process from the tuber cinereum of the hypothalamus. It lies within the pituitary fossa of the Pituitary Gland sphenoid bone, where it is covered superiorly by a circular diaphragma sellae of dura mater. The latter is pierced centrally by an aperture for the infundibulum and separates the anterior superior aspect of the pituitary from the optic chiasma. Inferiorly, it is separated from the floor of the pituitary fossa by a venous sinus that communicates with the circular sinus. The pituitary has two major parts-neurohypophysis and adenohypophysis- which differ in their origin, structure and function. The infundibulum has a central infundibular stem that contains neural hypophysial connections and is continuous with the median eminence of the tuber cinereum. Thus, the neurohypophysis includes the median eminence, infundibular stem and neural lobe or pars posterior. Surrounding the infundibular stem is the pars tuberalis, a component of the adenohypophysis. Although usually obliterated in childhood, remnants may persist in the form of cystic cavities near the adenoneurohypophysial frontier, sometimes invading the neural lobe. It may be partially displaced into the neural lobe, so it has been included in the anterior and posterior parts by different observers. Apart from this equivocation, which is of little significance in view of the exiguous status of 272 Chapter 15 / Diencephalon Anterior commissure Anterior cerebral artery Tuber cinereum Posterior cerebral artery Oculomotor nerve Trochlear nerve Superior cerebellar artery Lamina terminalis Optic recess Optic chiasma Optic nerve Infundibular recess Arachnoid Posterior communicating artery Posterior lobe of hypophysis cerebri Basilar artery Sphenoidal sinus Anterior lobe of hypophysis cerebri. When the associated infundibular parts continuous with these lobes are included, the names adenohypophysis and neurohypophysis become appropriate and are used here as follows: neurohypophysis includes the pars posterior (pars nervosa, posterior or neural lobe), infundibular stem and median eminence; adenohypophysis includes the pars anterior (pars distalis or glandularis), pars intermedia and pars tuberalis. Neurohypophysis In early fetal life, the neurohypophysis contains a cavity continuous with the third ventricle. They form the neurosecretory hypothalamohypophysial tract and terminate near the sinusoids of the posterior lobe. Some smaller parvocellular neurones in the periventricular zone have shorter axons and end in the median eminence and infundibular stem among the superior capillary beds of the venous portal circulation. These small neurones produce releasing and inhibitory hormones, which control the secretory activities of the adenohypophysis via its portal blood supply. The neurohormones stored in the main part of the neurohypophysis are vasopressin (antidiuretic hormone), which controls reabsorption of water by renal tubules, and oxytocin, which promotes the contraction of uterine smooth muscle in childbirth and the ejection of milk from the breast during lactation. Storage granules containing active hormone polypeptides bound to a transport glycoprotein, neurophysin, pass down axons from their site of synthesis in the neuronal somata. The granules are seen as swellings along the axons and at their terminals, which can reach the size of erythrocytes. Near the posterior lobe, astrocytes are replaced by pituicytes, which constitute most of the nonexcitable tissue in the neurohypophysis. Pituicytes are dendritic neuroglial cells of variable appearance, often with long processes running parallel to adjacent axons. Typically, their cytoplasmic processes end on the walls of capillaries and sinusoids between nerve terminals. Although they are close to the walls of sinusoids, they remain separated from them by two basal laminae-one around the nerve endings, and the other underlying the fenestrated endothelial cells. The epithelial endocrine cells, which secrete the different adenohypophysial hormones, are distinguished in part by their differing affinities for acidic and basic dyes. Cells staining strongly are described as chromophils, and those with low affinity for dyes are chromophobes. Chromophils that stain strongly with acidic dyes are classed as acidophils, whereas basophils stain strongly with basic dyes; the latter are more prevalent in the central part of the gland. Chromophobes are thought to be quiescent or degranulated chromophils or immature precursor cells; they constitute up to one half the cells of the adenohypophysis. Neurones that secrete the peptides and amines that control the anterior lobe are widely distributed within the hypothalamus. They are situated mainly in the medial zone, arcuate nucleus, medial parvocellular part of the paraventricular nucleus and periventricular nucleus. The pars intermedia contains follicles of chromophobe cells that surround cyst-like structures lined by epithelium and filled, to varying degrees, with glycosylated colloidal material. Secretory products of this region may include cleavage products of pro-opiomelanocortin, but their functional significance is uncertain. The pars tuberalis contains a large number of blood vessels, between which are cords or clusters of gonadotrophs and undifferentiated cells. A small collection of adenohypophysial tissue lies in the mucoperiosteum of the human nasopharyngeal roof. By 28 weeks in utero, it is well vascularized and capable of secretion, receiving blood from the systemic vessels of the nasopharyngeal roof. This is replaced in the second half of fetal life by venous sinuses, and a transsphenoidal portal venous system develops, bringing the nasopharyngeal tissue under the same hypothalamic control as the cranial adenohypophysial tissue. The peripheral vascularity of the pharyngeal hypophysis persists until about the fifth year. The organ is then reinvested by fibrous tissue and is presumed to be controlled again by factors present in systemic blood. Although it does not change in size after birth in males, in females it becomes smaller, returning to natal volume during the fifth decade, when it may once again be controlled 273 Chapter 15 Section V / the Cerebrum Hypothalamic nuclei respond to emotional and exteroceptive stimuli Paraventricular nucleus Supraoptic nucleus Mammillary body Optic chiasma Superior hypophysial artery the trabecular artery connects the superior and inferior hypophysial arteries Primary capillary plexus in the upper infundibulum receives releasing and inhibitory neuroendocrine factors from hypothalamic nuclei axon terminals Portal veins carry neuroendocrine factors to the adenohypophysis Secondary capillary plexus Acidophil Basophil Chromophobe Hypophysial vein (to dural sinuses) Anterior lobe Hypothalamohypophysial portal system Inferior hypophysial artery Axon terminal Capillary plexus of the posterior lobe Hypophysial vein (to dural sinuses) Posterior or neural lobe. The human pharyngeal hypophysis may be a reserve of potential adenohypophysial tissue, which may be stimulated, particularly in females, to synthesize and secrete adenohypophysial hormones in middle age, when intracranial adenohypophysial tissue begins to fail. Vessels of the Pituitary the arteries of the pituitary arise from the internal carotid arteries via a single inferior and several superior hypophysial arteries on each side. The former comes from the cavernous part of the internal carotid artery, and the latter come from its supraclinoid part and from the anterior and posterior cerebral arteries. The inferior hypophysial artery divides into medial and lateral branches, which anastomose across the midline and form an arterial ring around the infundibulum. Fine branches from this circular anastomosis enter the neurohypophysis to supply its capillary bed. The superior hypophysial arteries supply the median eminence, upper infundibulum and, via arteries of the trabeculae, lower infundibulum. A confluent capillary net, extending through the neurohypophysis, is supplied by both sets of hypophysial vessels. Reversal of flow can occur in cerebral capillary beds lying between the two supplies. The arteries of the median eminence and infundibulum end in characteristic sprays of capillaries, which are most complex in the upper infundibulum. The external plexus, fed by the superior hypophysial arteries, is continuous with the infundibular plexus and is drained by long portal vessels that descend to the pars anterior.

It was elected to further debulk the distal area of residual stenosis with additional atherectomy antifungal soap for ringworm purchase fluconazole cheap online. However fungus jublia order fluconazole australia, new linear contrast collections parallel the arterial lumen at the distal treatment zone definition of mold fungus buy fluconazole 400 mg amex. Complication of Atherectomy (Arterial Perforation antifungal cream yeast infection baby buy fluconazole 100 mg otc, Delayed Image) Complication of Atherectomy (Covered Stent Deployment) (Left) Delayed image shows contrast extravasation arising from the distal treatment zone fungus unity generic fluconazole 50 mg without a prescription, indicating a breach to the arterial integrity at this level. Arterial perforations or arteriovenous fistulas can occur with overly aggressive plaque removal, which violates the media. Covered stent placement eliminated the extravasation & restored vascular integrity. Any underlying abnormality such as this should be corrected to prevent recurrent thrombosis. Additional subsequent therapies (in this case surgical release, then angioplasty) are often necessary following thrombolysis. Venous Thrombosis (Postthrombolysis) 40 Thrombolysis General Principles · Portal venous thrombosis Primary form: Idiopathic Secondary: Known etiologic factor ­. Manninen H et al: Catheter-directed thrombolysis of proximal lower extremity deep vein thrombosis: a prospective trial with venographic and clinical follow-up. Karnabatidis D et al: Quality improvement guidelines for percutaneous catheter-directed intra-arterial thrombolysis and mechanical thrombectomy for acute lower-limb ischemia. Small transpelvic and right internal iliac artery collaterals reconstitute diminutive runoff vessels in the right lower extremity. Bypass Graft Thrombolysis (Initial Traversal of Thrombosis) Bypass Graft Thrombolysis (Thrombolysis Catheter Placement) (Left) Antegrade guidewire passage through the occlusion, using a reverse-curve catheter at the graft bifurcation, was unsuccessful. The distal anastomosis of the thrombosed right limb was accessed, and a guidewire and catheter were passed retrograde through the occlusion. After traversing the left iliac occlusion, an EkoSonic catheter was placed from the left into the right iliac vein. An internal occlusion wire blocks the end of the catheter, forcing thrombolytics to flow out through the side-holes. However, partially occlusive thrombus remains, and many distal branches are truncated. A hematoma in the right hemipelvis, adjacent to the graft and internal thrombolysis catheter, halted further thrombolysis. The right graft hood is also seen, but the graft is not identified below this level. The previously identified right bypass proximal anastomotic graft hood terminates blindly. Plug Occluding Device (Amplatzer) Gelfoam Slurry (Left) A Gelfoam slurry can be made relatively quickly and deployed intraarterially to gain control of in cases of massive bleed. When the exact focus of bleed cannot be found or accessed, a Gelfoam slurry can rapidly halt blood flow to an entire tissue bed. The beads shown are tinted blue for easy visualization and are used as a delivery agent for chemotherapeutics delivered to hepatic tumors. Particles (Oncologic Beads) 50 Embolization General Principles ­ Retrieval not always possible if coil fully deployed or too much time elapsed ­ Multiple detachment designs exist. The strips may be rolled tightly into "torpedoes", which can be injected via syringes, sheaths, or guide catheters. Temporary Embolic, Step-By-Step Preparation (Cut Into Strips) Temporary Embolic, Step-By-Step Preparation (Gelfoam Torpedo) (Left) the rolled torpedo can be inserted into the hub of a small-volume (1-3 cc) syringe, which has been filled with saline or contrast, and then injected into the desired location. To make the slurry, cut the Gelfoam strips into smaller pieces and placed them into a 10-cc syringe. Temporary Embolic, Step-By-Step Preparation (Gelfoam Slurry) Temporary Embolic, Step-By-Step Preparation (Gelfoam Slurry) (Left) the Gelfoam-filled syringe is attached to a 3-way stopcock and a contrast-filled syringe. As the solution is agitated and passed through the smaller lumen, Gelfoam particles are reduced in size, resulting in greater penetration of the slurry and reduced risk of catheter clogging during deployment. While Gelfoam embolization initially controlled the hemorrhage, resultant vasodilatation allowed reperfusion and rebleeding. Findings include abrupt cutoff of the superior splenic branch artery, intraparenchymal defects, and separation of the spleen from the diaphragm consistent with subcapsular hematoma. Detachable coils are ideal in this situation because they can be positioned prior to release, limiting the risk that the coil will shunt through the nidus to systemic arteries. The low risk of nontarget embolization favored use of inexpensive nondetachable coils over detachable coils. When embolizing, it is important to achieve distal control to prevent retrograde perfusion of an injury. Particle embolization is an ideal embolic to occlude the innumerable end-arterial branches supplying the fibroid tissue. Particle embolization attains distal arteriolar occlusion, while leaving the proximal artery patent for repeat embolization in the future (proximal coils would inhibit subsequent treatment). Oncologic beads (chemotherapeutic-loaded drug-eluting beads or yttriumloaded radioembolic beads) may offer treatment options. Preoperatively before nephrectomy, inexpensive Gelfoam and coils may be appropriate. In a nonoperative situation, particles and liquids will have the best outcome, but be cautious of shunting suspected on preembolization image. Together, these embolic agents should reduce the risk of further gastric variceal hemorrhage. Glue and Onyx Embolization of Extrasegmental Bile Duct Leak (Diagnostic Sinogram) Glue and Onyx Embolization of Extrasegmental Bile Duct Leak (During Embolization) (Left) Embolics have nonvascular utility [e. Contrast injected through a surgical drain tracks into a biliary duct, inadvertently surgically excluded from the biliary system. Slow Onyx injection, followed by rapid "glue" injection and access removal, successfully halted the leak. Covered Stents (Stent-Grafts) Stent Deployment (Photographic Appearance) (Left) Photograph of a selfexpanding stent shows the tapered catheter tip, the partially expanded stent, and the retractable sheath, which constrains the stent until it is unsheathed within the target vessel. Stent Deployment (Fluoroscopic Appearance) 62 Stents: Vascular General Principles Self-expanding: Sheathed in retractable delivery system; spontaneously expands after retraction ­ Most frequently constructed from nitinol Alloy regains original shape when no longer compressed/constrained ­ Requires appropriate oversizing to achieve secure intravascular fixation ­ Typically more flexible ­ Conforms to changing vessel diameters Drug-eluting: Stent coated with medication. Basavarajaiah S et al: Treatment of drug-eluting stent restenosis: comparison between drug-eluting balloon versus second-generation drug-eluting stents from a retrospective observational study. Expected Outcomes · High initial technical success rate Initial technical success depends on ­ Anatomic location of lesion. Subclavian Steal (Left Subclavian Arteriogram) Subclavian Steal (Post Stent Deployment) (Left) Selective arteriogram of the left subclavian artery reveals a partially obstructive linear defect near the subclavian artery origin. Hepatic Artery Aneurysm (Aortogram) Hepatic Artery Aneurysm (Stent Deployment) (Left) After surgery failed to treat, it was decided that the aneurysm would be excluded with a covered stent (off-label usage). Contrast injected through the guide sheath outlined the aneurysm during stent deployment. Healthy vascular tissue adjacent to the diseased segment is critical to covered stent exclusion of an aneurysm. The stentgraft excludes the aneurysm from circulation, eliminating the potential for aneurysm thrombosis or distal embolization. There are proximal and distal radiopaque markers that denote the stent margins for precise deployment. Note that the balloon expands first at the proximal and distal end of the stent, preventing the stent from migrating as it is deployed. Once dilated, the high intrinsic radial force of the stent maintains patency of the vessel. Renal Artery Balloon-Mounted Stent Deployment (Diagnostic Arteriogram) Renal Artery Balloon-Mounted Stent Deployment (Diagnostic Arteriogram) (Left) A diagnostic right renal arteriogram was obtained via a reverse curve catheter selectively engaged at the arterial takeoff. Emergent celiac arteriography revealed a bleeding proper hepatic artery pseudoaneurysm. Arteriobiliary Fistula (Placement of Balloon-Mounted Covered Stent) (Left) Due to the close proximity of the bleed to the adjacent takeoff arteries and the short available landing zone, we opted to maximize stent position by placing a balloon-mounted stent. The bare metal portion of the stent is placed within the portal vein, allowing antegrade flow to continue unobstructed through the portal vein. Central Venous Occlusion (Prestent) Central Venous Occlusion (Poststent) (Left) A patient who had been receiving hemodialysis via a left arm graft complained of recently increased left arm swelling. Venous In-Stent Restenosis (Fractured Stent, Subclavian Vein) Venous In-Stent Restenosis (Hemodialysis Fistula Outflow) (Left) Stenting of the subclavian vein often leads to stent fracture and resultant instent stenosis. In this case, stenosis was associated with a high-flow hemodialysis fistula and rapidly reoccurred despite repeated angioplasty. Splenic artery aneurysms are 4x more common in women than men, particularly if there is a history of multiple pregnancies. Treatment options that were considered included placing a covered stent across the aneurysm neck to exclude the aneurysm vs. Contrast has been injected via the microcatheter, opacifying the aneurysm and confirming the catheter tip position. The stent prevents the coils from prolapsing into, and occluding, the splenic artery. Stent-Assisted Coil Embolization (Coil Deployment into Aneurysm) 72 Stents: Vascular General Principles In-Stent Intimal Hyperplasia (Diagnostic Aortogram) In-Stent Intimal Hyperplasia (Post Deployment of Balloon-Mounted Stent) (Left) High-grade proximal right renal artery stenosis is seen in a patient with poorly controlled hypertension and mild renal insufficiency. In-Stent Intimal Hyperplasia (10-Month Follow-Up) In-Stent Intimal Hyperplasia (Restent) (Left) Hypertension was initially well controlled after stent placement, but the patient presented 10 months later with recurrent hypertension. Repeat angiography revealed a narrowed lumen within the stent with a normal-caliber renal artery distally, findings consistent with instent intimal hyperplasia. Angiography is often necessary to diagnose intimal hyperplasia when there is clinical concern. It has many applications, including treatment of colonic, biliary, and vascular obstructions. Additional important but offlabel uses exist, including emergent treatment of arterial bleeding when exact stent location is necessary. The stent contains covered (above) and fenestrated (below) segments separated by a radiopaque band. Ureteral Stent Colorectal Stent (Left) A double J ureteral stent has been deployed in a patient with ureteral obstruction from peritoneal carcinomatosis. The proximal pigtail is in the renal pelvis, and the distal pigtail in the bladder. Subsequently, this cholangiogram revealed an obstructing stone in the left main biliary duct. This particular stent may be manipulated after deployment by grasping and pulling on the blue radiopaque band. A stent can be introduced over the guidewire and any debris aspirated via the sheath. Contrast injection via the sheath is used to confirm an appropriate stent position prior to deployment. A guidewire placed via the sheath is advanced across the stenosis while the sheath is aspirated. Contrast injection shows the guidewire crossing the stenosis and a large calcified plaque at the proximal end of the stenosis. A 2nd filling defect, more cephalad in the popliteal artery, has not yet been captured in the device. These were isolated varices that were located mainly in the gastric fundus with no obvious esophageal varices seen. A balloon occlusion catheter was advanced through the left renal vein, and the tip was placed in the gastrorenal shunt. Various sclerosing agents can be used, including ethanolamine oleate iopamidol, sodium tetradecyl sulfate, and polidocanol, in either liquid or foam consistency. N-butylcyanoacrylate (glue) and absolute ethanol have also been used as liquid sclerosants. The access needle is inserted perpendicular to the vessel and parallel to the plane of scan. An access needle is inserted from the side of the vessel and seen in entire length. An access needle is inserted parallel to the vessel and perpendicular to the plane of scan. An access needle is inserted parallel to the vessel and parallel to the plane of scan. The access needle is inserted parallel to the plane of scan over the vessel and seen in entire length. Continued pressure while advancing the needle allows puncture of the tented wall and lumen entry. Intraluminal position of the needle tip is confirmed with blood return at the needle hub. The inner dilator of the microaccess sheath and the microwire are removed, and an 0. Optimal location of the femoral venous access is inferior to the inguinal ligament. The common femoral vein lies medially and slightly posterior to the common femoral artery. Femoral Vein Access (Venography) Central Venogram (Left) Venogram shows the femoral vein in the thigh (also called the superficial femoral vein), joined by the greater saphenous and profunda femoral veins to form the common femoral vein. This is optimal position for the subclavian vein access as underlying 1st rib reduces chances of pneumothorax. If the vein is punctured at this point, the underlying rib will prevent the needle from entering the lung and causing a pneumothorax. Right side of the image shows that the vein is compressible while the artery is not.

A hepatic venogram shows the "spider web" pattern of collaterals that form around the occluded hepatic veins of patients with Budd-Chiari syndrome antifungal for tinea versicolor fluconazole 100 mg buy low price. Residual thrombus in the left portal vein was treated with systemic anticoagulation fungus like ringworm 150 mg fluconazole order free shipping. Injected contrast provided a target for the transjugular catheter antifungal roof treatment cheap fluconazole 200 mg otc, allowing transhepatic access into a right portal vein candlesnuff fungus xylaria hypoxylon 150 mg fluconazole buy amex. These are typical vascular imaging findings that are seen in congestive hepatopathy fungus control for lawns discount fluconazole 150 mg otc. Lymphangiogram: Abdominal Lymphangiogram: Thoracic (Left) the thoracic duct is seen in the left hemithorax, turning laterally to join with the left brachiocephalic vein. The lymphatic fluid will then enter the venous system at the junction of the thoracic duct and left brachiocephalic vein. A microcatheter has been advanced into the thoracic duct to the level of the mid chest. Sheybani A et al: Cerebral embolization of ethiodized oil following intranodal lymphangiography. The dye accumulates in the lymphatics just deep to the skin, which are then accessed with a 30-g needle. Step-by-Step: Lymphography (Intranodal Access Setup) Step-by-Step: Lymphography (Fluoroscopic Monitoring at Pelvis) (Left) Rather than pedal access, nodal access can be achieved. The needle is then attached to an insufflator filled with Ethiodol, which is injected at 2 mm Hg. Here, contrast fills the right external iliac and common iliac lymphatic channels, plus inguinal and external iliac lymph nodes. Step-by-Step: Lymphography (Fluoroscopic Monitoring at Abdomen) Step-by-Step: Lymphography (Identification of Cisterna Chyli) (Left) Ethiodol contrast opacifies the right paracaval lymphatics including paracaval lymph nodes. This sac-like dilatation is formed by the confluence of the paralumbar (paraaortic/paracaval) lymphatics, which are joined by lymphatics that drain the intestinal tract. The thoracic duct continues from the cephalad end of the cisterna chyli and initially courses to the right of midline before ascending in the posterior mediastinum. The thoracic duct arises from the cisterna chyli and ascends to the base of the neck. Bilateral Groin Lymphangiogram Lymphangiogram in Upper Chest (Left) Postlymphography (A) frontal and (B) lateral images show that, within the chest, the thoracic duct courses posteriorly on the left. Its terminal end drains into the left subclavian vein at the internal jugular vein confluence. Contrast from the thoracic duct opacifies the venous system but also leaks into the pleural space. Thoracic Duct Embolization: Embolization With Coils and Glue Thoracic Duct Embolization: Needle Maceration of Cisterna Chyli (Left) Multiple embolization coils were placed along the duct; the leak is no longer present. The lower duct and needle entry into the cisterna chyli were sealed with Trufill (n-butyl cyanoacrylate). This diverts chyle flow into retroperitoneum, as shown by the extravasation, thereby allowing healing of the leak in the thorax. Inadvertent arterial access superior to the inguinal ligament can lead to intraabdominal bleeding. Access is inferior to the inferior epigastric artery, marking the inguinal ligament bordering common femoral & external iliac arteries. In addition to the superficial & deep femoral arteries, the deep circumflex iliac artery is seen. The 45-70° angle of the percutaneous needle will result in arterial access slightly superior to the hemostat. Step-by-Step: Femoral Artery Access (Superficial Anesthesia) Step-by-Step: Femoral Artery Access (Superficial Nick) (Left) Subcutaneous tissues are anesthetized with lidocaine. A small (1-2 cm) subcutaneous wheal is first delivered, helping guide the location of the future skin nick. After waiting 5-10 seconds for the lidocaine to work, deep lidocaine (5-8 cc) is delivered medial & lateral to the planned access route. Step-by-Step: Femoral Artery Access (Blunt Dissection) Step-by-Step: Femoral Artery Access (Palpating Pulse) (Left) the shallow skin nick prevents inadvertent cutting of the common femoral artery. The small incision can now be enlarged & deepened with blunt dissection of the soft tissues, performed with a hemostat. Instead, the femoral pulse was palpated above & below the skin nick prior to attempting access. If no blood is returned, continue advancing the until contacting the femoral head (lidocaine can be delivered via the needle). As the needle enters the arterial lumen, a loss of resistance may be felt & pulsatile bright red blood seen. Step-by-Step: Femoral Artery Access (Accessing Artery) Step-by-Step: Femoral Artery Access (Advancing 0. Fluoroscopy can be used to visualize the guidewire path & confirm arterial placement. After the needle is removed over the guidewire, manual compression on the artery should be maintained to prevent hematoma. Slight traction on the guidewire will straighten the wire & assist sheath advancement. Step-by-Step: Femoral Artery Access (Advancing Transitional Sheath) Step-by-Step: Femoral Artery Access (Advancing 0. The hemostatic valve minimizes blood loss, & the 3way stopcock allows for both contrast injection through the sheath & connection to a pressure bag for continuous flushing of the sheath. Variants can be inadvertently punctured during attempted access of the femoral artery or vein. Spectral waveform suggests the proximal subclavian & axillary arteries are free of stenosis. More centrally (B), a catheter has been advanced over a J-tip guidewire into the subclavian artery. Type D waveform suggests an occluded ulnopalmar arch & is a contraindication to radial artery access. Once the radial pulse is palpated, an Angiocath & needle are advanced completely through the artery. The wire is ready to be threaded through the access catheter as soon as pulsatile blood is encountered upon catheter withdrawal. Step-by-Step: Radial Artery Access (Angiocath Withdrawal) Step-by-Step: Radial Artery Access (Percutaneous Wire Advancement) (Left) Pulsatile blood confirms intraluminal arterial access. A cocktail of nitroglycerin, heparin, & verapamil is then injected through the sheath. This 5-Fr radial sheath is bored out to facilitate a larger 6-Fr inner diameter; however, this makes the sheath less rigid & not suitable for femoral access. Step-by-Step: Radial Artery Access (Percutaneous Sheath Placement) 312 Arterial Access Arterial Procedures Hemostasis: Postradial Artery Access Complication: Postradial Artery Access (Left) Following the procedure, the sheath is removed & a nonocclusive wrist band applied for up to 2 hours. At times, the patient is asked to hold on object (syringe), occupying hand & minimizing movement during recovery period. Access-related radial artery injury can occur but is usually self-limiting & almost always asymptomatic due to the intact ulnopalmar arch. Translumbar access is typically performed via a left-sided paraspinal point of access so as to avoid the right-sided inferior vena cava. Extravascular polyethylene glycol sealant is then deposited, and the balloon is deflated and withdrawn. Mechanical Seal Closure Device Obtain Angiogram Prior to Closure (Left) A sheath enters a disease-free femoral artery above the femoral bifurcation and below the inferior epigastric and deep circumflex iliac arteries at an ideal location for using a closure device. Whether or not a closure device is utilized (operator preference), the patient must be closely observed to ensure intraabdominal hemorrhage and groin hematoma do not occur. Things to Avoid · Repeat arterial access (same site) in short time frame May be problematic with mechanical seal devices ­ Plug deposited outside vessel ­ Inflammatory reaction at closure site Typically is not issue with suture/clip device 4. Each closure device has multiple deployment steps that are unique to that closure device and must be closely replicated. Suture-Mediated Closure Device Suture-Mediated Closure Device (Left) During deployment of a PerClose closure device, sutures are deployed via a stepwise process and then trimmed below the skin. Some devices use absorbable sutures or compressive devices; others employ permanent metal. Topical hemostasis pads are composed of elements that are designed to promote clot formation and are activated upon contact with blood. Topical Hemostasis Pad Assisted Compression Device (Left) A Safeguard compression device with an inflatable "bladder" and adhesive backing has been placed over the femoral artery. As the sheath is removed, the pad is positioned directly over the skin entry point. Topical Hemostasis Pad 318 Closure Devices Arterial Procedures Contraindication to Closure Device High Arterial Puncture (Left) Two focal areas of eccentric atherosclerotic plaque result in a stenosis just above the arterial access sheath. Closure device use is contraindicated in severely diseased or very small arteries. It is difficult to achieve hemostasis with either manual compression or a closure device, as the artery is mobile in the pelvis. A vascular sheath & guidewire enter the superficial femoral artery in antegrade fashion for a planned infrainguinal intervention. Coils were subsequently placed proximal to the site of injury to prevent antegrade perfusion of the artery and rebleeding. Gabrielli R et al: Thrombin injection and compression with removable guidewire in the treatment of postcatheterization femoral pseudoaneurysm. Variant Anatomy: Aberrant Right Subclavian & Diverticulum of Kommerell Variant Anatomy: Right Aortic Arch With Aberrant Left Subclavian Artery (Left) the most common type of right aortic arch has an associated aberrant left subclavian artery. This form of right aortic arch has a low incidence of associated congenital heart disease. Variant Anatomy: Right Aortic Arch With Aberrant Left Subclavian Artery 326 Thoracic Aorta and Great Vessels Arterial Procedures ­ Pseudoaneurysm: Disruption of 1 or more arterial wall layers; forms contained rupture May be due to aortic injury following penetrating or blunt trauma. Aiello F et al: Open and endovascular management of subclavian and innominate arterial pathology. Radiology 224: 536-41, 2002 Alternative Procedures/Therapies · Surgical Surgical repair/revascularization. Small amount of hemorrhage in the anterior mediastinum is partially visualized, consistent with rupture. Intramural Hematoma With Rupture Intramural Hematoma With Periaortic Hematoma (Left) A spontaneous intramural hematoma of the aortic arch with associated ulcer-like projection increases risk of aortic rupture. A small amount of periaortic hematoma is partially visualized in the anterior mediastinum. The aberrant artery usually courses posterior to the trachea & esophagus & may compress these structures. When identified, these aneurysms should be either surgically resected or repaired with a stent-graft, as in this case. In adults with untreated coarctation, the lower body is perfused via extensive collaterals, such as the intercostal arteries. This may resemble true coarctation on imaging & is differentiated by absence of a hemodynamically significant gradient & a lack of collaterals. The left subclavian arterial segment distal to the occlusion is thus dependent upon the left vertebral artery for perfusion. The left vertebral & distal left subclavian arteries are patent & opacify in a delayed but antegrade fashion. In-Stent Stenosis & Antegrade Vertebral Flow (Recanalization of Stent) In-Stent Stenosis & Antegrade Vertebral Flow (Angioplasty + Embolic Protection) (Left) Because of the antegrade flow in the left vertebral artery, an embolic protection device was placed in the vessel from a retrograde brachial artery approach. A guidewire was then advanced antegrade through the in-stent stenosis via a transfemoral arterial approach. Although there was marked improvement in the luminal caliber after angioplasty, there was residual narrowing seen proximally in the stent. This new stent was extended more proximally to correct the residual stenosis that had been seen. This demonstrates a satisfactory result with a widely patent left subclavian stent & native artery. An arteriogram via an axillary catheter revealed an 11-cm-long proximal brachial artery occlusion. Thromboembolism of Proximal Brachial Artery (Surgical Embolectomy Required) Thromboembolism of Forearm and Hand (Endovascular Thrombolysis) (Left) A patent foramen ovale led to thromboemboli of the distal brachial artery, interosseous artery, distal radial artery, and superficial palmar arch. Treatment of distal forearm arteries is challenging due to their propensity to spasm. Parethesia and weakness resolved completely following intraoperative aneurysm resection. Ulnar Aneurysms (Surgical Resection Required) 336 Upper Extremity Arteries: Revascularization Arterial Procedures 1° Raynaud phenomenon (Raynaud disease): Exaggerated smooth muscle cell vasoconstriction in otherwise normal digital artery; usually cold induced ­ No identifiable underlying arterial abnormality ­ Environmental trigger causes primary vasospasm 2° Raynaud phenomenon (Raynaud syndrome): Vasospastic digital ischemia associated with underlying arterial pathology ­ Most commonly associated with cutaneous & connective tissue disorders ­ Triggered by cold, nicotine, caffeine, & stress · Thoracic outlet syndrome: Clinical disorder caused by extrinsic compression of neurovascular structures exiting or entering thorax May be predominantly neurogenic, venous, or arterial ­ Symptoms from arterial compression in < 5% Pain, coolness, pallor, diminished pulses Distal thromboembolic symptoms. Arterial thoracic syndrome was suspected as the possible etiology, but the examination did not suggest a focal process. The location is typical of hypothenar hammer syndrome in which the segment of the ulnar artery coursing adjacent to the hook of the hamate sustains repetitive trauma. The superficial palmar arch and common digital arteries are discontinuous, multiple proper digital arteries are occluded, and the digital tufts are absent. Because the disease involves small-caliber arteries, endovascular or surgical revascularizations are rarely treatment options. Photograph after several weeks of hyperbaric oxygen treatment shows near-total ulcer healing.

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