Anomalous coronary artery with tetralogy of Fallot and aortopulmonary window

Anomalous origin of the left main coronary artery from the pulmonary artery is rarely associated with other conditions. We report the case of an infant born with tetralogy of Fallot and aortopulmonary window who at the time of surgical repair was found to have an anomalous left main coronary artery originating from the right pulmonary artery.     

Intrahepatic cholestasis related to vanishing bile duct syndrome in Hodgkin''s disease

We report on a rare case of anomalous origin of left coronary artery from the noncoronary sinus of Valsalva. Intraaortic intravascular ultrasound study identified the origin of the left coronary artery and facilitated subsequent selective coronary angiography of the artery.     

Thallium-201 myocardial perfusion imaging in infants and children. Value in distinguishing anomalous left coronary artery from congestive cardiomyopathy

In infants and children, anomalous origin of the left coronary artery (ALCA) from the pulmonary artery may be difficult to distinguish from congestive cardiomyopathy (CCM) of other causes. We performed thallium-201 myocardial perfusion imaging in seven children with ALCA and in nine with CCM to study the usefulness of this technique in distinguishing between these lesions. Localized abnormalities of thallium uptake were present in each of the seven patients with ALCA, including two asymptomatic 4-year-old children. Thallium distribution was normal in five patients with CCM, diffusely irregular in three, and was absent in the lateral and posterobasal portions of the left ventricle in one patient. We conclude that thallium-201 imaging is a sensitive noninvasive method of detecting ALCA. However, perfusion abnormalities are not limited to patients with coronary artery abnormalities, and may be present in patients with myocardial ischemia or infarction of other causes.     

Acquired type 2a von Willebrand''s disease: response to immunoglobulin infusion

The faulty origin of the left coronary artery from the pulmonary artery is with an incidence of 1:300,000 newborns a very rare heart defect. We report a case of a pregnancy with two intrauterine blood transfusions in the 30th and 32nd week of gestation because of Rh-incompatibility and fetal anaemia. Dopplersonographic and echocardiographic parameters were normal. In the 32nd week of gestation delivery was induced (birth weight 2240 g, cord pH value 7.35, Apgar-score 8/9/9). Under a therapy with respiration, blood exchange transfusion and cardiotonic drugs the newborn died in the second week. The autopsy showed a general immaturity, a haemosiderosis of spleen, liver and lungs, a marked cellular jaundice and signs of a multi-organ-failure. The sinus of the pulmonary valve was the origin of the left coronary artery. In case of a seriously impaired pumping action and after exclusion of other heart defects the Bland-White-Garland-Syndrome (BWGS) has to be considered. Although a prenatal diagnosis of BWGS is with high resolution-ultrasound possible, the early postnatal diagnosis seems to be more relevant.     

Endocrine effects of IGF-I on normal and transformed breast epithelial cells: potential relevance to strategies for breast cancer treatment and prevention

We studied the origin, length, external diameter, disposition, branching patterns and the perforators of short central artery in the circle of Willis in eighty fresh, unfixed cerebral hemispheres (40 brains). We also examined the relationship of the short central artery, the recurrent artery of Heubner, and M1 perforators to the anterior perforated substance, caudate and putamen. The short central artery arises at 5.2 +/- 3.36 mm from the origin of the anterior cerebral artery, hidden and overlapped by the internal carotid artery bifurcation. The recurrent artery of Heubner arises distally to the origin of the short central artery. Four main anatomical variations were found: 1. Presence of short central artery and recurrent artery of Heubner (37.5%). 2. Isolated presence of the short central artery (27.5%). 3. Isolated presence of the recurrent artery of Heubner (21.25%). 4. Absence of short central artery and recurrent artery of Heubner (13.75%). Two different branching patterns were observed: 1. 2-4 straight perforators from the short central artery, perforators from the recurrent artery of Heubner and lenticulostriate from the most medial portion of the M1, in 42 of 80 hemispheres (52.5%). 2. 8-10 perforators from only short central artery in 10 of 80 hemispheres (12.5%) with absent or hypoplastic recurrent artery of Heubner and lenticulostriates from M1 and M2.     

The course of intracranial pressure during respirator weaning after severe craniocerebral trauma

An anomalous left coronary artery originating from the pulmonary artery is a rare, but frequently lethal congenital disorder. A wide range of symptoms due to heart failure and myocardial ischaemia may appear soon after birth. We describe a young woman who was admitted to the hospital after resuscitation for ventricular fibrillation. An anomalous origin of the left coronary artery from the pulmonary trunk was diagnosed. An echocardiographic evaluation in this adult patient illustrated the haemodynamic disturbances in the coronary circulation. The thallium scintigram showed reversible perfusion defects on exercise. Ischaemia may be implicated in the pathogenesis of the arrhythmia. Our patient was treated with an arterial graft and ligation of the left coronary artery at its origin.     

Duplication of the extracranial internal carotid artery

We describe a case of duplication of the left internal carotid artery from a point 1 cm distal to the origin to the proximal petrous segment where the vessel reunites. Duplication and fenestration of the internal carotid artery are discussed. A review of embryologic development is presented. Identification of these entities is important, especially in patients who require surgical intervention involving the internal carotid artery.     

Agenesis of the internal carotid artery associated with an aneurysm of the anterior communicating artery

We report a case of agenesis of the internal carotid artery which was revealed by a subarachnoid hemorrhage. Angiography showed a ruptured aneurysm of the anterior communicating artery and unilateral absence of the left internal carotid artery. Both the left anterior and middle cerebral arteries were perfused from the right carotid artery via the anterior communicating artery. Absence of the left carotid canal was proved on bone CT. Such an association is discussed. An hemodynamic stress on a congenital defect of the cerebral arterial wall could be the origin of the aneurysm development.     

More children are unable to get dental care than any other single health service

True congenital peripheral aneurysms of the cerebral arteries are rare and may constitute a special entity. We report a rare case of nonmycotic peripheral aneurysm of the posterior cerebral artery (PCA) found in association with aneurysms of distal middle cerebral artery (MCA), junction between basilar artery (BA) and superior cerebellar artery (SCA) and MCA trunk. Our present case was a 37-year-old man with a history of abrupt loss of consciousness. Cerebral angiography revealed a right PCA aneurysm originating at the junction between the trunk of the PCA and the posterior temporal branch, and also aneurysms of the right distal MCA, at the right BA-SCA junction and at the trunk of right MCA just distal to the anterior temporal artery. Distal PCA aneurysm causing subarachnoid hemorrhage was successfully clipped and all the other aneurysms were treated in a one-stage procedure. Pathological examination of the surgically excised distal PCA aneurysmal sac demonstrated no infectious etiology. There have not been any similar cases showing an association of vascular anomalies with distal PCA aneurysm. This is the only reported case with the association of nonmycotic peripheral aneurysms involving the MCA and PCA.     

Abnormal origin of the vertebral artery from the common carotid artery

An abnormal origin of the vertebral artery from the common carotid artery (VA-CC) may occur on the right or left side with different embryonic mechanisms. We describe a patient with a double developmental anomaly, a right VA-CC and a right aortic arch. The rotation of the aortic arch caused a "twist" of the embryonic mechanisms of VA-CC and misdirected the differential diagnosis of the embryonic mechanisms at first glance. We discuss the pivotal points in differentiating the embryonic mechanisms of VA-CC.     

A case of a ruptured lingual artery aneurysm treated with endovascular surgery

A rare case of a ruptured lingual artery aneurysm treated with endovascular procedure in presented. A 67-year-old woman undergoing treatment in our hospital for right thalamic hemorrhage complained of sudden swelling in the submandibular area and breathlessness. The swelling was so rapid and progressive that her breathing was disturbed. She was intubated as soon as possible. Computed tomography (CT) showed a massive subcutaneous hematoma, extending from the left submandibular area to the neck, which had compressed the trachea to the right. CT with contrast medium showed extravasation of the medium for this lesion. Angiography showed that the aneurysm was located on the periphery of the left ingual artery. Extravasation of contrast medium from the aneurysm was also observed. We considered that direct surgery was difficult to perform safely, so we chose an endovascular procedure to treat this lesion. The lingual artery was successfully embolized using four platinum coils. No rebleeding or other complication occurred after the coil embolization. Disturbance of breathing due to air way obstruction is an important symptom of a ruptured lingual artery aneurysm. Endovascular surgery may be the first choice for treatment of the bleeding origin.     

Iatrogenically induced cortical blindness associated with leptomeningeal enhancement

Leptomeningeal enhancement is usually infective or neoplastic in origin. We present a case in which a patient received total parenteral nutrition via a catheter unknowingly placed within the right vertebral artery. We postulate that the hyperosmolar nature of the infused solution induced temporary osmotic disruption of the blood-brain barrier, resulting in cortical blindness associated with localized leptomeningeal enhancement.     

Sudden death in cases with anomalous origin of the left coronary artery

Ectopic origin of the left coronary artery from the right sinus of valsalva with anterior and posterior courses are thought to be benign anomalies. Case reports: a 58-year-old woman died suddenly after a car accident without having sustained any injuries. The only abnormal finding was an ectopic origin of the left coronary artery from the right sinus with anterior free wall course. The anomaly was complicated by the absence of a left descending branch and a hypoplastic circumflex artery. A 38-year-old male died suddenly during work. Beside the ostium of the right coronary artery originated the normal calibered circumflex branch of the left coronary artery which passed behind the aorta. The left anterior descending branch had a normal origin. There was a 2 cm in diameter transmural infarct observed microscopically.     

Microanatomy of the perforators of the anterior communicating artery complex

We describe the microanatomy of the perforating arteries arising from the anterior communicating artery complex (5 mm distal of the anterior cerebral artery, the anterior communicating artery, and 5 mm proximal of the distal anterior cerebral artery). Thirteen unfixed human brains were used in this study. The origin and number of perforators are described, as is the site of brain penetration, and results are correlated with previous studies. The hemodynamics of blood flow in relation to the formation of an anterior communicating artery aneurysm and different surgical approaches are mentioned. The neuropsychological outcome after aneurysm clipping with regards to the pattern of blood supply from the anterior cerebral artery complex is also discussed.     

Anomalous origin of the left coronary artery from the pulmonary artery in adults. Long-term follow up

Anomalous origin of the left coronary artery from the pulmonary artery is a serious pathology, that untreated supposes a high mortality. Usually it becomes symptomatic in early infancy, but some cases reach adult life with no symptoms. We report four cases diagnosed in teenagers and adults, three of them with the oldest ages known in worldwide literature and one of them the oldest reported until now. We have completed a long follow-up in the various surgical techniques, where we did not observe any differences in their prognosis, and we recommend an anti-arrhythmia treatment joined with surgical treatment in adult patients with this pathology.     

Compression of anomalous circumflex coronary artery by a prosthetic valve ring

Anomalous origin of the circumflex coronary artery from the right aortic sinus, with a retroaortic course, is usually without consequence. We report a patient who underwent aortic valve replacement for bicuspid aortic valve. The prosthesis sewing ring distorted the circumflex, producing myocardial infarcts and sudden death during exercise.     

Ultrastructural changes in cerebral blood vessels following prolonged administration of L-dopa to laboratory animals

Patients with anomalous left coronary artery arising from the pulmonary artery rarely survive to adult life. Those who attain adulthood may present with angina indistinguishable from coronary artery disease and are liable to sudden death. Myocardial infarction, though rare in young adults, may occur and may be due to coronary artery steal. Accurate diagnosis requires coronary arteriography. Two further cases of coronary artery steal in adults with anomalous origin of the left coronary artery from the pulmonary artery are presented. In both patients aortocoronary bypass grafting using a reversed autogenous saphenous vein with closure of the origin of the anomalous left coronary artery was successfully performed. This operation provided complete symptomatic relief and may protect patients against the risk of sudden death.     

Dental health amongst 11-15-year-old children in Sevagram, Maharashtra

Although most subdural hematomas are considered to be venous in origin, they may also be of arterial origin. When subdural bleeding is due to the rupture of an intracranial aneurysm, most commonly at the middle cerebral or internal carotid arteries, the amount of subdural blood is usually small and of no clinical importance. We describe two patients with subdural hematomas secondary to rupture of an intracranial aneurysm, who needed prompt surgical treatment. The first patient had a left internal carotid artery aneurysm at the origin of the ophthalmic artery. In the second patient the aneurysm was at the anterior communicating artery and rebled into the subdural space directly through a right intraparenchymatous frontobasal hematoma. The most probable mechanism of subdural bleeding in our two patients was the existence of adhesions between the aneurysm and the arachnoid due to previous minor hemorrhages. The indication of cerebral angiography in a patient with subdural hematoma is based mainly upon the existence of meningeal signs, the presence of blood in more than one intracranial compartment or the rapid progression of bleeding.     

Spontaneous dissection of extra-intracranial intern carotid

Dissection of internal carotid artery is an unusual cause of stroke. It generally affects the extracranial portion of the vessel, rarely the intra-cranial portion and exceptionally both sections simultaneously. We present two cases of spontaneous dissection with extra and intra-cranial involvement. Two females, 46 and 36 years old, presented as stroke of the right internal carotid (ICA) associated with headaches and ipsilateral Horner's syndrome. An echo-Doppler was done on the first patient, which turned to be normal, and carotid angiography was done to both patients. The first patient showed a filiform stenosis of the right ICA that ran from the origin to the carotid siphon. The second patient showed a longitudinal stenosis of the right ICA 2 cm from the origin, which ended in an obstruction of the terminal branches. The control angiographs at five and six months respectively, showed partial re-channelling or complete re-channelling. The first case was treated with anti-aggregants and the second with anticoagulants. There were no new episodes in either cases. Dissection of the ICA usually only affects the extracranial portion of the artery, stopping in the petrous portion. We do not know why dissection also affected the intra-cranial section of the artery in these two cases.     

The role of transesophageal echocardiography in the detection of coronary anomalies and anatomical variations

OBJECTIVES: The aim of the study is to examine the role of transesophageal echocardiography (TEE) in the diagnosis of anomalies and anatomic variations of the coronary arteries. BACKGROUND: In the past, coronary angiography was the only method for diagnostic confirmation in all cases with coronary anomalies, but even during invasive procedures diagnostic difficulties could and can emerge. The different, varying origin of aberrant coronary arteries can prolong the diagnostic procedure, therefore can increase the irradiation time. So every method which seems to be suitable for diagnosis of suspected coronary anomalies can be helpful. METHODS: The origin and course of anomalous coronary arteries were studied by TEE and coronary angiography during a six-month period. RESULTS: We found 16 patients (2.8%) with coronary anomalies or variations by angiography, the diagnosis of which was technically difficult. Seven of these had TEE examination too. All seven anomalous origins proven angiographically and 2 of the 2 anomalous courses in the relation to the great vessels were diagnosed by TEE. (In two, the left circumflex originated from the right sinus of Valsalva, in two we found anomalous separate origin of left circumflex coronary artery from the left sinus, in another two a common ostium of the left anterior descending and circumflex artery from the left sinus and in one an accessory artery from the non-coronary sinus.) CONCLUSIONS: TEE in a useful test to diagnose the origin of anomalous coronary arteries and confirming their course in relation to the great arteries.