Variant origin of three main coronary ostia from the right sinus of Valsalva: report of a rare case

Observing anomalies in the origin of the coronary arteries is a rare but recognized scenario during coronarography. All the major coronary arteries originating from the right sinus of Valsalva is an extremely rare anomaly, its reported incidence being 0.008% in angiographic studies. Most coronary artery variations are benign and are therefore found accidentally or postmortem. However, some anomalies in the origin of the coronary arteries are associated with myocardial ischemia and a higher risk of sudden cardiac death. Herein, we report a sporadic case of anomalous origin of the coronary arteries, in which the right coronary artery, anterior interventricular artery and left circumflex artery arise separately from the right sinus of Valsalva, each originating from a separate ostium. Regardless of their low incidence rate, coronary artery anomalies can cause serious technical challenges during coronary angiography and percutaneous interventions because of the unusual location and course of the artery. Echocardiography, computed tomography, and magnetic resonance imaging can be useful in such cases

Radial artery variations in patients undergoing transradial heart catheterization

Nowadays, the transradial cardiac catheterization is performed regularly. This is a result of the lower incidence of complications in comparison to the femoral approach. The positive characteristics of the transradial approach are due to the fact that the radial artery is located just beneath the skin and is easy to access for hemostasis. This way, the common complications of hematoma, pseudoaneurysm and arteriovenous fistulas of the femoral ap­proach could be avoided. Moreover, if the above complications occur during the transradial approach, surgery is not needed and the treatment is usually non-operative. The other advantage of the transradial approach is dou­ble blood irrigation of the hand, which prevents hand ischemia after radial artery thrombosis or spasm. Although the transradial approach has the advantage of reduced local complications, it is associated with specific techni­cal challenges and has a relatively high incidence of catheterization failure. Commonly, the procedure challenges are due to a failure to puncture the artery, anatomic variations of the radial artery and radial artery spasm. The anatomical variations are the second most frequent factor impeding transradial catheterization. Therefore, the precise anatomical information about the variations of the radial artery should be kept in mind and the knowl­edge of interventional cardiologists will be helpful in performing the transradial coronary procedure during left heart catheterization

The extensor medii proprius muscle

The extensor indicis is a deep muscle of the posterior group of the forearm, which originates from the interosse­us membrane and the distal part of the body of the ulna. Its tendon passes under the fourth compartment of the extensor retinaculum and projects into the distal aponeurosis of the index finger. In the literature, many studies have discussed the clinical significance of the variations of this muscle in the region of plastic reconstruction of the hand and upper limb surgery.The present case report presents an additional muscle, which was observed in the posterior forearm region dur­ing a routine anatomical dissection of the left upper limb of a 69-year-old female cadaver. The muscle originated from the distal part of the extensor indicis muscle and its bundles ran parallel in distal direction. The final ten­don passed through the fourth extensor compartment along with the extensor indicis and the extensor digitorum and inserted into the dorsal aspect of the capsule of the metacarpophalangeal joint of the middle finger. The dis­section revealed that this muscle was innervated by the radial nerve.Numerous variations of the extensor indicis muscle have been described - absence, extremely distal origin, the presence of two heads or complete duplication of the muscle, the existence of extensor indicis brevis muscle, etc. The reported incidence of the extensor medii proprius muscle in cadaveric dissections ranges from 0% to 12%. Knowledge of the described muscle is clinically important, because it may be injured by inappropriate dissection or misdiagnosed as tumor-mimicking lesion. Furthermore, the tendon of this additional muscle may be used as a flap in reconstructive hand surgery

Age-related changes of nNOS immunoreactivity in renal corpuscles of spontaneously hypertensive rats

The immunohistochemical expression of neuronal nitric oxide synthase (nNOS) in the renal structure is predom­inantly described in macula densa - a structural component of the juxtaglomerular apparatus, represented by cells of the distal convoluted tubules. Under pathological conditions such as hypertension, the impaired nitric oxide (NO) bioactivity may be an important pathogenetic factor. In addition, the synthesized NO by nNOS is in­volved in the regulation of the afferent arteriole diameter, tubuloglomerular feedback mechanism, and the renin-angiotensin system. The aim of the present study was to make a detailed description of the nNOS expression in the renal corpuscles under hypertonic conditions in spontaneously hypertensive rats (SHRs). We used nine male SHRs and nine aged-matched male Wistar rats divided into the following groups: 4 months old, 6 months old and 12 months old, each group was represented by three SHRs and three Wistar rats. The immunohistochemical reac­tion was performed by specific monoclonal antibody for nNOS. In 4-month-old SHRs we observed heterogeneous expression of nNOS in the cells of parietal layer of Bowman`s capsule and glomerular capillary tuft (GCT), while the age-matched Wistar group was characterized by weak to missing immunoreactivity. During the period of tar­get organ damage (6- and 12-month-old rats) we found intensified immunoreactivity of nNOS in the cells of the parietal layer of Bowman`s capsule and GCT compared to the control groups and noted differences in the distribu­tion of the enzyme in the renal corpuscles of the cortical, midcortical and juxtamedullary nephrons.In conclusion, there are pronounced age-related differences of nNOS immunoreactivity in renal corpuscles of SHRs and Wistar rats. Most of the studies have discussed the role of macula densa nNOS-derived NO, but the in­formation about the function and significance of this enzyme in the other renal structures is still limited. Future studies may reveal in details the importance of nNOS-derived NO in renal pathology

Morphological characteristics of a synthetic bone graft in recurring giant cell tumor of bone

Giant cell tumour of bone (GCTB) is usually a benign bone tumour with a high rate of recurrence and possibility of `benign` pulmonary metastases or transformation in a malignant blastoma. The majority of patients with this tumour are effectively treated by intralesional curettage. After curettage, the bone defect is packed with bone grafts or polymethylmethacrylate bone cement. Bone grafts are divided into autografts, allografts, and synthetic bone substitutes. Synthetic bone grafts usually contain apatite-wollastonite-containing glass ceramic, hydroxyapatite, and tricalcium phosphate.The aim of this study was to analyse the morphological characteristics of β-tricalcium phosphate (TCP) synthetic bone graft (chronOS® - DePuy Synthes) from patients with recurring giant cell tumour of bone.Eight patients with giant cell tumour of bone were treated by curettage and grafting with TCP. One man and two women developed local recurrence. On second surgery, a new biopsy was taken to confirm the diagnosis. The tissue material showed a recurrence of the giant cell tumour, synthetic bone substitute and newly-formed bone.In our cases, we did not observe complications from the use of TCP. The graft was well incorporated into the surrounding host bone, but was not completely absorbed.The synthetic bone graft is a safe and useful method for grafting after curettage for GCTB

A variation of palmaris longus muscle: clinical significance for hand surgery

The palmaris longus muscle (PL) is one of the most variable muscles in the human body. The PL may be agenetic, double, split, tendinous, digastric and may have various insertions. It may be inserted on the flexor retinaculum, the fascia of the forearm, the fascia and the muscles of the hypothenar, the short abductor of the thumb, near the metacarpophalangeal joints, the tendon of the flexor carpi ulnaris muscle, the pisiform bone or the scaphoid bone.A digastric PL was observed in one left forearm from a 69-year-old formol-carbol fixed Caucasian male cadaver. It originated in a usual way through a short, flat tendon from the medial epicondyle of the humerus which then prolonged into a fusiform muscle belly. Approximately halfway through the forearm, this muscle belly sharply transformed into a wide tendon, situated superficially along the midline of the forearm. In the distal fourth of the forearm, this tendon gradually prolonged into a second muscle belly with a thinner proximal end and wider distal portion, which resembled a teardrop. This muscle belly arched over the flexor retinaculum and inserted into the palmar aponeurosis. The innervation of the two muscle bellies was provided by multiple branches extending from the median nerve.In conclusion, the possible presence of PL variations must be considered by clinicians during clinical examination of the forearm, during surgical interventions in that region, or while searching for an entrapment site of the median and/or ulnar nerve. Due to its limited action in carpal flexion and the fact that there is no functional loss in the forearm and hand after its removal, it is an ideal donor for plastic and reconstructive surgery. However, this muscle can also be responsible for median and/or ulnar nerve compression syndromes. It may also simulate a tumor in the region of the antebrachium

Anatomical variations of the abductor pollicis longus muscle tendon-relation to de Quervain`s disease

Anatomical variations of the abductor pollicis longus muscle tendons are essential for successful treatment of de Quervain`s disease. Surgery includes tenosynovectomy and decompression of the first extensor compartment of the hand. Many patients have additional tendons, usually the abductor pollicis longus.Materials and Methods: A total of 30 formol-carbol fixed human upper extremities from the autopsy material available at the Department of Anatomy, Histology and Embryology at the Medical University of Sofia were precisely examined for the presence of accessory tendons of the abductor pollicis longus muscle.Results: In all of the examined upper extremities, accessory tendons of the abductor pollicis longus muscle were detected. Accessory tendons of this muscle were established in 26 hands (86.7%), 18 of which had one accessory tendon (69.2%), 6 hands had two accessory tendons (23.1%), and 2 hands had three accessory tendons (7.7%). Mean length, width, and thickness of the accessory tendons were 63.2 mm, 4.9 mm, 1.9 mm respectively. The presence of accessory tendons showed no side-to side differences.Conclusion: Due to the high incidence of accessory tendons of the abductor pollicis longus muscle, we consider that such variation requires to pay close attention and could lead to misinterpretations during surgery of de Quervain disease

Rare cases of anatomical variations of the long head of the biceps brachii muscle and their significance for orthopaedic surgery

The biceps brachii muscle is one of the most variable muscles in the human body in terms of number and morphology of its heads. In contrast, the absence of the long or short head of the biceps brachii and variations in its insertions are quite rare. This could create difficulties in diagnosis in both magnetic resonance imaging and surgery.A total of 50 formol-carbol fixed human upper extremities from the autopsy material available at the Department of Anatomy, Histology and Embryology at the Medical University of Sofia were examined thoroughly for variations of the the long head of the biceps brachii. We observed six cases of variations of the long head of this muscle: five cases with hypoplasia and one case with three origins of the long head of biceps brachii.In conclusion, although rare, different variations of the long head of the biceps brachii muscle should always be borne in mind by clinicians. A hypoplastic long head could be present as swelling in the antero-lateral aspect in the distal part of the brachium during flexion of the forearm and in that way may simulate a rupture of the long head of the biceps brachii. Some of the variations could also increase the risk of acquiring shoulder instability and may create difficulty during shoulder arthroscopy

A unique variation of a four bellied digastric muscle named “real quadrigastric muscle”: a case report and literature review

From a topographical standpoint, the digastric muscle is key to the formation of several triangles of the neck, which are of the utmost clinical significance. Herein, we present a previously unrecognized variation of the digastric muscle: a quadrigastric muscle with two accessory bellies originating from the body and angle of the mandible and inserting to the intermediate tendon. Three new triangles are demarcated between the four bellies of the aberrant muscle. Detailed knowledge of variations of the digastric muscle, changing the borders and relationships of the topographic triangles, is paramount for radiologists and surgeons operating on the anterior region of the neck