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Hepatic and splenic lacerations are managed conservatively but might require laparotomy or intervention erectile dysfunction treatment cincinnati silagra 50 mg discount on line. This reveals quick filling of the splenic vein erectile dysfunction treatment exercises cheap 100 mg silagra overnight delivery, indicating a traumatic arteriovenous fistula. There is diffuse arterial vasoconstriction because of the hypotension from lively bleeding. It is important throughout embolization that the coils are placed each proximal and distal to the lesion, as this prevents reperfusion in either an antegrade or retrograde trend. In an actively bleeding hypotensive affected person, coil embolization of the injured artery can rapidly enhance hemodynamics. Atherosclerotic renal artery stenoses sometimes have an result on the proximal 1/3 of the renal artery, as in this instance. Stents are reserved for issues of balloon angioplasty, corresponding to move limiting dissection or vessel rupture. Both stents project into aortic lumen by 1-2 mm, which is considered to be perfect positioning. Treatment of bilateral stenoses in a single setting may be performed if contrast quantity is stored low. Renal Artery Stenosis (Post Treatment Angiogram) Ostial Atherosclerotic Stenosis (Treatment With Angioplasty) (Left) Graphic exhibits that balloon angioplasty of an ostial atherosclerotic stenosis is usually ineffective, as the plaques will recoil upon deflation and removal of the angioplasty balloon. This graphic exhibits a balloonmounted stent correctly positioned at the website of the stenosis, projecting 1-2 mm into the aortic lumen. This place prevents the aortic plaque from covering the proximal portion of the stent and prevents plaque recoil. The stenosis and irregularity is healthier outlined by the selective renal arteriogram. An angled sheath, such as an Ansel sheath, is then superior over the wire an into the renal ostium. Repeat angiogram via the sheath may be performed to confirm desired location of the stent. Mild residual irregularity of the artery is anticipated after angioplasty: Avoid the urge to over dilate or stent. Fibromuscular Dysplasia (Balloon Dilation) Fibromuscular Dysplasia (Postprocedure Angiogram) (Left) Because of her severe hypertension, regardless of the gentle angiographic appearance, it was determined to proceed with balloon angioplasty. After a wire was used to traverse the lesion, a 6-Fr Ansel sheath was superior into the renal artery ostium. The guidewire was saved in place till confirmation of procedural success and exclusion of great problems. This can lead to arterial thrombosis and irreversible renal ischemia if not handled promptly. Treatment options for an in-stent stenosis include restenting with a lined stent or balloon angioplasty. A guidewire has been handed via the stenotic lesion, and the tip has been positioned distally. The balloon used was inappropriately sized, chosen to match the scale of the adjacent aneurysm. A selective right renal angiogram through this sheath showed severe ostial stenosis. Pressures have been measured across the stenosis with an preliminary gradient of fifty two mm Hg Renal Artery Stent Fracture (Selective Renal Angiogram Through Sheath) 426 Renal Arteries: Revascularization Arterial Procedures Renal Artery Stent Fracture (Post 1st Stent Placement Angiogram) Renal Artery Stent Fracture (Final Angiogram) (Left) A 6x15-mm PalMaz Blue balloon expandable stent was chosen. Spot radiography at the time of her repeat angiogram showed an unexpected discovering, a fracture of the superior portion of the stent. A 7-mm balloon was advanced and, through repeated gentle forwards and backwards actions, the fracture was deliberately completed. Renal Artery Stent Fracture (Treatment of Fracture Stent) Renal Artery Fracture (Final Renal Angiogram) (Left) (A) the fractured portion of the stent was then deployed within the left iliac artery, utilizing an 8-mm balloon. Markedly elevated peak systolic velocity (240 cm/second) and aliasing on the origin of the transplanted renal artery are according to stenosis at the external iliac to transplanted renal artery anastomosis. Transplant Renal Artery Stenosis Transplant Renal Artery Stenosis (Left) Given the worsening renal function, the decision was made to proceed with angiogram and potential intervention. Angiography confirmed extreme stenosis at the origin of the transplanted renal artery. This malpositioning precludes subsequent renal artery intervention and places the iliac artery at risk for subsequent stenosis. When contemplating revascularization of an acutely ischemic kidney, the previously thought 1- to 3hour window for revascularization is just too brief, as constructive outcomes have been reported with initiation of the procedure up to 19 hours after the ischemic event. Angiogram showed occlusion of the mid proper renal artery with a meniscus of distinction at the proximal portion of the clot and focal growth of the occluded portion of the renal artery. The aim is to devascularize the tumor whereas preserving adjacent normal renal parenchyma. Hellmund A et al: Rupture of renal artery aneurysm throughout late pregnancy: clinical options and diagnosis. Penetrating Renal Trauma (1st Embolization) (Left) the distal branch artery answerable for the lateral contrast extravasation was chosen and embolized. Penetrating Renal Trauma (2nd Embolization) Penetrating Renal Trauma (Selective Upper Pole Angiogram) (Left) the Simmons-1 catheter was positioned into the upper pole renal artery department, and repeat distinction injection was performed exhibiting extravasation at the site of laceration. Blunt Renal Trauma (Coil Deployment) Blunt Renal Trauma (Angiogram After Embolization) (Left) Spot radiograph reveals that a microcatheter has been coaxially introduced by way of the Cobra catheter. Pseudoaneurysm After Endopyelotomy (Renal Arteriogram) Pseudoaneurysm After Endopyelotomy (Angiogram After Embolization) (Left) this patient developed gross hematuria following an endopyelotomy for ureteropelvic junction obstruction. A wedgeshaped defect within the renal parenchyma, distal to the embolized vessel, is in preserving with a small infarct. The diminutive caliber of the intrarenal arteries is from vasoconstriction in response to hypotension. Renal Arteriovenous Fistula (Aortogram) Renal Arteriovenous Fistula (Selective Angiogram) (Left) A 6-Fr sheath was superior to the site of fistulous connection between the right renal artery and proper renal vein. The vascularity is dependent upon the proportions of the varied elements of the hamartoma. Since some residual tumor stays, the patient was introduced back for extra embolization. No vascularity is demonstrated within the central or superior portion of the mass suggesting alternative feeding vessels. Angioplasty with a 5mm diameter balloon was carried out with marked enchancment in look. Coil embolization of this aneurysm (as properly as influx and outflow) would lead to an unacceptably large are of renal infarct. Moderatesized area of nonperfusion of the upper to mid pole of the kidney is seen, an anticipated consequence of department vessel occlusion by the stent graft.
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The drainage catheter is then superior off of the cannula alongside the guidewire using fluoroscopic monitoring erectile dysfunction support groups silagra 100 mg visa. The external hub of the catheter might be subsequently connected to a 3-way stopcock and drainage bag erectile dysfunction 20 discount silagra 100 mg overnight delivery. A radiopaque ring demarcates probably the most proximal sidehole, which is inside the duct. Percutaneous transhepatic biliary drainage was subsequently performed by way of a 2nd entry. Cholangiography via Cholecystostomy 748 Transhepatic Biliary Interventions Nonvascular Procedures Dilation of Biliary Stricture (Imaging Prior to Crossing Lesion) Dilation of Biliary Stricture (Catheter Crossing Lesion) (Left) Spot radiograph from a 62-year-old man with a historical past of a prior Whipple process for pancreatic acinar cell carcinoma and new onset of jaundice exhibits distinction injection of a 5-Fr Kumpe catheter that had been introduced via a transhepatic method. Dilation of Biliary Stricture (Angioplasty Balloon Placement) Dilation of Biliary Stricture (Angioplasty Balloon Inflation) (Left) Balloon angioplasty catheter was launched over an Amplatz guidewire through an access sheath & superior to the extent of the stricture. Radiopaque markers demarcating the proximal & distal extent of the deflated balloon are positioned to embody the stricture. Occasionally, the balloon might propel ahead into the bowel during inflation; countertraction on the catheter may be essential. Dilation of Biliary Stricture (Angioplasty Balloon Inflation) Dilation of Biliary Stricture (Appearance After Angioplasty) (Left) the balloon is inflated further and the "waist" is obliterated. The balloon is then deflated and the process is repeated for a total of 3 dilatations. Algorithms differ among interventionalists; in one regularly used algorithm, 3 remedy classes are employed, each 1-2 weeks aside. A 5-Fr Kumpe catheter has traversed a standard duct stricture, with the catheter tip in the bowel. The Wallstent is positioned to encompass the whole size of the stricture, with the ends of the stent extending at least 2-3 cm proximal and distal to the stricture margins. Percutaneous Biliary Stent Placement (Introduction of Self-Expanding Stent) Percutaneous Biliary Stent Placement (Self-Expanding Stent Deployment) (Left) Spot radiograph exhibits the Wallstent has been deployed. Note the distal tip is within the bowel and the proximal tip is inside intrahepatic ducts. It is essential the stent extends proximal and distal to the stricture, as the stent will shorten as it expands. This was confirmed on 4-hour delayed imaging and is consistent with acute cholecystitis. A rim of decreased activity within the hepatic parenchyma is suggestive of pericholecystic inflammation. Percutaneous Cholecystostomy Drain (Fluoroscopic Imaging) 752 Cholecystostomy Nonvascular Procedures � 18-g needle of acceptable length � 0. Contrast injected through the trocar could additionally be performed, and minimal quantity must be used. Malpositioned Cholecystostomy Tube (Wire Advancement Through Catheter) Malpositioned Cholecystostomy Tube (Advancement of New Drain) (Left) A new pigtail cholecystostomy drain (with plastic internal cannula) was superior over the Amplatz wire. The inside cannula and wire had been then removed, and positioning of recent pigtail drain was confirmed with distinction. Cholecystostomy Drain Rescue (Sinogram) Cholecystostomy Drain Rescue (Advancement into Gallbladder) (Left) the drain was removed over a guidewire. A hydrophilic Glidewire and a Kumpe catheter had been then advanced by way of the original cholecystostomy catheter tract. The findings are consistent with energetic bleeding, presumed secondary to drain placement. Contrast extravasation indicates lively bleeding, adjacent to the cholecystostomy catheter. An inside ureteral stent also has a proximal pigtail in the renal pelvis plus a distal pigtail within the bladder. Pressures are measured there and in the bladder through a Foley catheter, using transducers, to consider for ureteral stasis vs. Basiri A et al: Ultrasound-guided entry during percutaneous nephrolithotomy: getting into desired calyx with appropriate entry website and angle. This relatively avascular zone positioned between the anterior and posterior divisions of the renal artery lies 20-30� from the sagittal plane. The tip of the needle is well visualized throughout the dilated, echolucent accumulating system. Either a 1-stick method may be used, or, alternatively, a ring needle may be advanced into a different calyx underneath fluoroscopic steerage (2-stick technique). Percutaneous Nephrostomy: Antegrade Nephrostogram 764 Genitourinary Interventions Nonvascular Procedures Percutaneous Nephrostomy: 1-Stick Technique Percutaneous Nephrostomy: 1-Stick Technique (Left) Intraoperative photograph shows the 1-stick method by which a zero. If solely the floppy portion is inside the system, kinking of the wire throughout catheter exchanges could occur. The transition from the stiff to the floppy portion is readily identified fluoroscopically. During secondary access, repeated distinction filling and dilation of the renal amassing system is carried out by way of the initial entry as required. Percutaneous Nephrostomy: Coaxial Dilator-Sheath Percutaneous Nephrostomy: Guidewire Placement in Renal Pelvis (Left) the needle has been exchanged for a coaxial dilator-sheath, which was superior over the guidewire into the renal amassing system. The guidewire tip is in an higher pole calyx, though it could have been superior into the ureter as nicely. As the system enters the renal pelvis, the inside stiffener is unscrewed and held in place whereas the softer catheter tracks over the wire into the amassing system. Percutaneous Nephrostomy: Catheter Placement Percutaneous Nephrostomy: Catheter Placement (Left) After the nephrostomy catheter has been satisfactorily positioned within the collecting system, the guidewire is eliminated, and the string is pulled to form the distal pigtail of the catheter. Ensure that each the pigtail and the radiopaque marker lie throughout the renal pelvis. A hydrophilic wire and 4-Fr catheter traversed the obstruction, and distinction injected through the catheter confirmed intraluminal position inside the bladder. Percutaneous Nephroureteral Drain: Balloon Ureteroplasty Percutaneous Nephroureteral Drain: Antegrade Nephrostogram (Left) Ureteroplasty was carried out on the stenosis utilizing a 6-mm diameter balloon. Unfortunately, the ureteral stricture was due to extrinsic compression by metastatic cervical most cancers. Ideally, the proximal pigtail could possibly be withdrawn slightly within the renal pelvis. Ureteral Injury: Postoperative Ureteral Leak Ureteral Injury: Postoperative Ureteral Leak (Left) Suspected ureteral injury during hysterectomy was confirmed by antegrade ureterogram displaying both intra- and extracystic contrast. After 8 weeks, the ureter was healed, and the affected person was spared ureteral reimplantation surgery. Colorenal Fistula: Exchange for Percutaneous Nephrostomy Nephroureteral (Left) Follow-up imaging 1 month later shows resolution of the colorenal fistula. The proximal radiodense marker might be withdrawn barely because the pigtail is shaped. Contrast injected via a Foley catheter in the conduit through an ostomy reveals moderate to extreme anastomotic narrowing. Ileal Conduit: Normal Retrograde Ileal Conduit Anastomotic Stricture: Antegrade Pyelogram (Left) Contrast injected through a sheath accessing the superior renal calyx reveals severe hydronephrosis and slow passage of distinction into the ileal conduit.
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Imaging of gynecological disease (3): medical and ultrasound traits of granulosa cell tumors of the ovary erectile dysfunction statistics race silagra 100 mg effective. Enhancing vessels are seen bridging from the uterus to the mass (bridging vascular sign) erectile dysfunction 19 100 mg silagra generic mastercard, which assist set up the uterine origin of the mass. An eccentric low sign intensity blood clot is present within the high signal intensity part. An eccentric high signal intensity blood clot is current throughout the higher signal depth element. Most of the loculi demonstrate excessive signal depth; few show very low signal intensity. The enlarged ovary demonstrates elevated signal depth except for a segmental space of very low signal at the periphery. This case demonstrates the development of ovarian fibromatosis in large ovarian edema. Imaging in gynecological illness (5): clinical and ultrasound characteristics in fibroma and fibrothecoma of the ovary. Imaging of gynecological illness (4): clinical and ultrasound characteristics of struma ovarii. Chapter 5 the cardiovascular long case ic A rule of thumb within the matter of medical recommendation is to take every thing any physician says with a grain of aspirin. The whims of the long-case examiners might lead to concentrated questioning about the ischaemic coronary heart disease of a affected person in hospital for the administration of, say, renal transplant rejection. These sufferers usually have a tendency to present administration rather than diagnostic problems once they reach the status of long-case patients. The prognosis unstable angina is now not a half of this classification, however remains to be often used to describe patients with growing exertional angina. The presence of irregular cardiac markers signifies an antagonistic prognosis (increased threat of additional infarction or death) and these sufferers profit from early however not instant intervention (angioplasty or coronary surgery) and from immediate aggressive anti-platelet treatment and anticoagulation with fractionated or unfractionated heparin. The idea of risk stratification is predicated on these factors and determines the urgency and kind of therapy. Find out whether or not the patient has been or is in hospital due to a current myocardial infarction or an acute coronary syndrome, or for some other cardiac or non-cardiac cause. Clearly, these could characterize different pathophysiological states, various from occlusion of a coronary artery and inadequate collateral flow to rupture of a lipid-rich plaque with thrombus formation. Ask about obvious precipitating factors, corresponding to a gastrointestinal bleed or the onset of an arrhythmia. Also ask concerning the character of the chest pain and what precipitated the admission. You ought to be suspicious of the prognosis unless it has been confirmed by investigations. Acute coronary syndromes are managed with heparin and aspirin and clopidogrel, prasugrel or ticagrelor. Most patients have early angiography (within 48 hours) with the intention of angioplasty to the culprit lesion if this is sensible. Ask whether or not the patient knows details of what investigations or treatment have been carried out. If the patient has had an infarct during this or previous admissions find out in regards to the management, which may have included main angioplasty or thrombolysis, ht tp:// eb oo ks m ed ebooksmedicine. The threat is higher in every group for patients with previous ischaemic coronary heart illness or diabetes. In many hospitals a complete cardiac rehabilitation program will have been offered to the affected person. Remember that risk factors are of significant significance to long-term prognosis, but add little to the chance that undiagnosed chest pain is ischaemic. There is a few proof that statins have helpful results beyond their impact on levels of cholesterol (pleotrophic effects). Cardiac catheterisation is maybe essentially the most memorable of the investigations for ischaemic coronary heart illness. The patient might know what quantity of coronaries are abnormal and whether or not angioplasty was carried out. All issues are less widespread if early coronary patency and regular move have been achieved. Management It is finest to concentrate on discussing the management of the presenting drawback. If the patient has only recently been admitted with an infarct, this implies a discussion of thrombolysis and first angioplasty. Candidates should have some information of the most important thrombolysis and angioplasty trials. Alteplase is given as a bolus followed by an infusion, and reteplase is given as a double bolus injection with a 30-minute interval. Urgent coronary (primary) angioplasty, if available, is of proven benefit and has been proven to scale back mortality compared with remedy with thrombolytic medicine. The advantages, theoretical and actual, include particular re-opening of the infarctrelated artery in additional than 90% of sufferers (compared with < 60% of sufferers given thrombolytics), regular flow within the infarct-related artery generally, dilatation and stenting of the offending (culprit) lesion and often removing of clot, very low risk of stroke and shortening of hospital stay, typically to simply three days. Patients are treated with potent anti-platelet medication: aspirin, clopidogrel (or prasugrel or ticagrelor) and typically with one of the platelet aggregation inhibitors, abciximab or tirofiban. Prasugrel is more quickly efficient than clopidogrel and in plenty of protocols is now most popular for major angioplasty patients. There is now trial proof that transport of sufferers to a hospital the place this procedure may be carried out is preferable to remedy with thrombolytic medicine, if transport time is lower than 2�3 hours. There could also be spectacular bruises at venepuncture or femoral or radial puncture websites if the patient has had thrombolytic therapy. Abdominal wall bruising suggests subcutaneous low-molecular-weight heparin remedy, Occasionally the radial pulse may be absent after radial angioplasty. If the history has suggested issues resulting from the infarct, these should be discussed. Common problems embody: � ventricular arrhythmias � bradyarrhythmias (especially following an inferior infarct) � cardiac failure � further ischaemia or reinfarction. Control of cardiac risk factors is even more necessary as quickly as the presence of coronary artery illness has been established. Lipid-lowering drug therapy with a statin ought to be introduced for all sufferers who can tolerate it. Patients ought to be encouraged to take part in a cardiac rehabilitation program, if that is available, the place recommendation about secure exercise, weight reduction and adjustments to dietary and smoking habits can be inspired. What would you advise a surgeon or anaesthetist concerning the risks of surgery for this affected person How would you manage his or her anti-platelet remedy in the perioperative interval Patients with three-vessel illness and significant left ventricular harm or with left main coronary artery stenosis profit prognostically from coronary artery bypass surgery even when their signs have settled on medical treatment. Those with tight proximal (before the primary diagonal branch) left anterior descending lesions most likely also benefit from surgical procedure or angioplasty. Epleronone, an aldosterone antagonist, is indicated for sufferers with cardiac failure following an infarct. These procedures are so common that many patients with different presenting issues may have had them. Look at the sternal wound for indicators of an infection; osteomyelitis of the sternum is a uncommon but disastrous complication of surgery.
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She performs a monocular cowl check on herself and finds that her imaginative and prescient is regular in every eye when uncovered erectile dysfunction at age 20 generic 100 mg silagra overnight delivery. Her previous history is constructive for hypertension lipitor erectile dysfunction treatment silagra 50 mg purchase, coronary artery angioplasty and dyslipidemia. Examination reveals failure of adduction of the best eye on left gaze, with monocular nystagmus involving the left eye on left gaze. This is usually because of a number of sclerosis in the younger and to a vascular event within the aged. Pupillary Light Reflex the pupillary gentle reflex is a dynamic system for controlling the quantity of light reaching the retina. The direct component of the sunshine reflex mediates constriction of the pupil of the ipsilateral eye, and the consensual element elicits simultaneous constriction of the contralateral pupil. A gentle stimulus acting on the retinal photoreceptors provides rise to exercise in retinal ganglion cells, the axons of which kind the optic nerve. Activity is conducted via the optic chiasma and along the optic tract, and the vast majority of fibres end within the lateral geniculate nucleus of the thalamus. However, a small number of fibres depart the optic tract before it reaches the thalamus and synapse within the pretectal nucleus. The information is relayed from the pretectal nucleus by short neurones that synapse bilaterally with preganglionic parasympathetic neurones within the Edinger�Westphal nucleus of the oculomotor nerve complex within the rostral midbrain. Efferent impulses pass along parasympathetic fibres of the oculomotor nerve to the orbit, where they synapse in the ciliary ganglion. Postganglionic fibres (short ciliary nerves) cross to the eyeball to provide the sphincter pupillae, which reduce the dimensions of the pupil when it contracts. There can be a connection to the spinal sympathetic centre controlling the dilator pupillae. Postganglionic fibres arising from these neurones are distributed to the cavernous plexus; from there, they journey mainly via the lengthy ciliary nerves to the anterior part of the attention, the place they provide the dilator pupillae. Because pupillary measurement outcomes from the balanced motion of those two innervations, the pupil dilates when the parasympathetic stimulus ceases. The pupil also dilates in response to painful stimulation of virtually any a half of the physique. Presumably, fibres of sensory pathways join with the sympathetic preganglionic neurones described earlier. Accommodation Reflex When specializing in a close-by object, the eyes converge, the lens turns into more convex and the pupils constrict. Cortical efferent info passes to the pretectal space after which to the Edinger�Westphal nucleus, which accommodates preganglionic parasympathetic neurones whose axons journey in the oculomotor nerve. Efferent impulses pass in the oculomotor nerve to the orbit, the place they synapse within the ciliary ganglion. Postganglionic fibres (short ciliary nerves) pass to the eyeball and stimulate contraction of the ciliary muscle, which slackens the ligament of the lens and will increase the curvature of the lens for near vision. Contraction of the sphincter pupillae and relaxation of the dilator pupillae constrict the pupil. Simultaneously, contraction of the medial, superior and inferior recti (all innervated by the oculomotor nerve) converges the eyes on the close to target. The site of a lesion producing such an impact is unclear, however it might contain the periaqueductal grey matter. Afferent nerve fibres carrying style info are the peripheral processes of neuronal cell bodies within the geniculate ganglion of the facial nerve and within the inferior ganglia of the glossopharyngeal and vagus nerves. Taste from the anterior two-thirds of the tongue, excluding the vallate papillae, and from the inferior floor of the palate is carried in the sensory root of the facial nerve (nervus intermedius). Taste buds within the vallate papillae, posterior third of the tongue, palatoglossal arches, oropharynx and, to some extent, palate are innervated by the glossopharyngeal nerve. Those within the excessive pharyngeal a part of the tongue and the epiglottis are innervated by fibres of the vagus nerve. On coming into the brain stem, these afferent fibres constitute the tractus solitarius, and they terminate in the rostral third of the nucleus solitarius of the medulla. Second-order neurones arising from the nucleus solitarius cross the midline, and many ascend through the mind stem in the dorsomedial a half of the medial lemniscus. They terminate in the medial part of the ventral posteromedial nucleus of the thalamus. From the ventral posteromedial nucleus, third-order neurones project by way of the internal capsule to the anteroinferior part of the sensory cortex and to the limen insulae. Other ascending projections to the hypothalamus have been described that will characterize the pathway by which gustatory info reaches the limbic system. The axons represent the auditory part of the vestibulocochlear nerve, which enters the brain stem at the cerebellopontine angle. Afferent fibres bifurcate and terminate within the dorsal and ventral cochlear nuclei. The dorsal cochlear nucleus initiatives through the dorsal acoustic stria to the contralateral inferior colliculus. The ventral cochlear nucleus initiatives through the trapezoid body or the intermediate acoustic stria to relay centres within the superior olivary advanced, the nuclei of the lateral lemniscus or the inferior colliculus. The superior olivary advanced is dominated by the medial superior olivary nucleus, which receives direct input from the ventral cochlear nucleus on either side, and is concerned in localization of sound by measuring the time distinction between afferent impulses arriving from the two ears. The dorsal cortex lies dorsomedially, and the external cortex lies ventromedially. They converge in the central nucleus, which tasks to the ventral division of the medial geniculate physique of the thalamus. It projects to the medial division of the medial geniculate physique and, along with the central nucleus, additionally tasks to olivocochlear cells within the superior olivary complicated and to cells in the cochlear nuclei. The dorsal cortex receives an input from the auditory cortex and initiatives to the dorsal division of the medial geniculate body. Connections also run from the nucleus of the lateral lemniscus to the deep part of the superior colliculus, to coordinate auditory and visual responses. The ascending auditory pathway crosses the midline at several points each below and on the stage of the inferior colliculus. However, the enter to the central nucleus of the inferior colliculus and better centres has a transparent contralateral dominance. The medial geniculate body is connected reciprocally to the primary auditory cortex, which is located within the superior temporal gyrus, buried in the lateral fissure. They additionally set up essential connections for reflex movements governing the equilibrium of the body and the fixity of gaze. Functionally, the vestibular equipment is usually divided into two parts: the kinetic labyrinth, which provides details about acceleration and deceleration of the top, and the static labyrinth, which detects the orientation of the pinnacle in relation to the pull of gravity. In phrases of construction, the kinetic labyrinth consists of the semicircular canals and their ampullary cristae, and the static labyrinth consists of the maculae of the utricle and saccule. However, the saccular macula additionally responds to head movements, and each maculae may be stimulated by low-frequency sound and may due to this fact have minor auditory capabilities. Angular acceleration and deceleration of the pinnacle trigger a counterflow of endolymph within the semicircular canals, which deflects the cupula of each crista and bends the stereocilial and kinocilial bundles.
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The distance between the defect and the duodenum may be very brief and catheter stability is labile erectile dysfunction and smoking generic silagra 100 mg with visa. Arterioportal Fistula (Post Coil Embolization) Arterioportal Fistula (Post Stent Placement) (Left) A selective superior mesenteric angiogram after coil embolization of the defect reveals decreased but persistent distinction extravasation erectile dysfunction drugs forum cheap silagra 50 mg visa. Provocative Angiography (Coil Embolization) Provocative Angiography (Postembolic Arteriogram) (Left) A selective completion angiogram of the best colic artery by way of a microcatheter after coil embolization of three tiny facet branches exhibits no further hemorrhage and good antegrade flow. Ileocolic Hemorrhage (Nuclear Scintigraphy) 386 Lower Gastrointestinal Hemorrhage Arterial Procedures Ileocolic Hemorrhage (Superior Mesenteric Arteriogram) Ileocolic Hemorrhage (Superselective Arteriogram) (Left) A selective superior mesenteric arteriogram by way of a sheath reveals distinction extravasation from a branch of the ileocolic artery. Ileocolic Hemorrhage (Postembolic Arteriogram) Angiodysplasia of Cecum (Superior Mesenteric Arteriogram) (Left) Superior mesenteric arteriogram through a sheath shows resolution of the hemorrhage after microcoil embolization. Selective superior mesenteric angiography exhibits a sausagelike vessel off of the ileocolic artery, with hemorrhage within the cecum indicative of angiodysplasia. Angiodysplasia of Cecum (Colonoscopic Appearance) Angiodysplasia of Cecum (Histologic Injected Specimen) (Left) Angiodysplasia is far more regularly identified by colonoscopy than by angiography. The endoscopic appearance is one of a discrete, small space of vascular ectasia with scalloped or frond-like edges and a visual draining vein. A selective inferior mesenteric angiogram reveals focal extravasation in the mid descending colon. Diverticulitis (Superselective Arteriogram) Diverticulitis (Postembolization Arteriogram) (Left) A magnified view of angiogram was obtained publish microcoil embolization through a superselective microcatheter. Endovascular or surgical therapy could also be thought-about in acute hemorrhage/ischemia. Embolization of surgical anastomosis ought to be carried out with warning as the vascular changes related to the anastomosis could increase the risk of postembolization ischemia. Complication of Embolization (Segmental Jejunal Infarction) Complication of Embolization (Segmental Jejunal Infarction) (Left) An intraoperative photograph following Gelfoam embolization exhibits an infarcted section of the jejunum, with adjoining normal bowel. Although complications can happen following embolization for decrease gastrointestinal hemorrhage, the bulk are clinically insignificant. By report, ischemic problems from transcatheter embolization require remedy in only 0-6% of cases. Acute occlusive mesenteric ischemia from arterial embolus have to be handled instantly. Unfortunately, the patent luminal diameter of the celiac artery may not be a lot better. Emergency surgical revascularization, presumably together with bowel resection, have to be strongly considered in circumstances of impending (lactic acidosis or peritoneal signs) or precise bowel infarction. Diffuse, extreme vasoconstriction is present, with nearly no bowel parenchymal opacification and marked bowel dilatation. Repeat angiography 36 hours later shows important enchancment within the vasoconstriction and the bowel opacification. Conservative administration with hydration and anticoagulation is usually the preliminary therapy for this clinical entity. Residual intimal hyperplasia stays throughout the stent, which should be intently monitored. Although this was a persistent underlying situation, the massive territory concerned necessitated acute recanalization. The round density extrinsically narrowing the artery is the median arcuate ligament. The affected person was asymptomatic and was thus systemically heparinized with no opposed sequelae. Noncovered stents usually observe through tortuous vessels simpler than would coated stents. Stent-assisted coiling is beneficial for treating wide-necked aneurysms or pseudoaneurysms whereas preserving distal arterial perfusion. The celiac trunk is dilated and has a linear cleft suspicious for an arterial dissection. There is a subcapsular hematoma with central excessive attenuation, in preserving with bleeding. Stent-Assisted Coiling of Intrarenal Aneurysm (Diagnostic Renal Arteriogram) Stent-Assisted Coiling of Intrarenal Aneurysm (Coil Embolization) (Left) With intraparenchymal renal artery aneurysms, coil embolization may be extra acceptable than coated stent placement. Procedural Complication (Arterial Dissection) Procedural Complication (Arterial Dissection) (Left) Aortogram demonstrates a lobulated aneurysm located near the renal hilum and arising from the principle left renal artery. Hypertrophied arterial collaterals reconstitute the widespread femoral arteries bilaterally. There is a lumbar to iliolumbar connection, a superior rectal to internal iliac artery pathway, & an intercostal to deep circumflex iliac artery route. This affected person with right leg claudication had a constructive noninvasive arterial examine. Here, the patent left iliofemoral arteries (same patient) are a possible entry route for therapy. The anatomy of the proper chronic complete occlusion & of the reconstituted distal arterial phase is properly seen. A balloonmounted stent was deployed, spanning the lesion with a superb outcome. Extensive iliolumbar arterial collaterals present supplemental perfusion distal to the lesion. As before, access was maintained throughout therapy zones till affirmation of results. Five-year major patency rates of 7585% are reported after pelvic revascularization with assisted patency charges of up to 90%. Endovascular reconstruction of the aortic bifurcation was felt to be the most effective remedy option for this patient. It was gently distended with a compliant balloon in order that the stent configured to the aorta & tapered distally towards the bifurcation. They were positioned so that they prolonged into the lower portion of the coated aortic stent & then had been distended with angioplasty balloons. This now closely approximates the appearance of a normal native aortic bifurcation. The bleeding was managed with Gelfoam embolization of the superior gluteal artery. This aneurysm was initially treated by placing a lined stent across the origin of the internal iliac artery so as to remove inflow and induce thrombosis of the aneurysm. Common iliac artery aneurysms involving the iliac bifurcation could also be handled with flared limbs if an appropriately sized endograft is chosen. Internal Iliac Aneurysm Exclusion: Associated Common Iliac Aneurysm Internal Iliac Aneurysm Exclusion: Preservation of Internal Iliac Perfusion (Left) Via transbrachial access, a guidewire was placed distally within the left internal iliac artery. A coated stent was then positioned with the distal end terminating past the bottom extent of the internal iliac artery aneurysm, excluding the aneurysm while preserving perfusion. Embolization coils have occluded the right inner iliac artery aneurysm but have also eradicated arterial perfusion. Preserving left internal iliac perfusion reduces the potential of buttock claudication. The iliac limbs of the bifurcated endograft extend bilaterally into the exterior iliac arteries.
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In this case erectile dysfunction treatment operation 50 mg silagra discount with amex, the gastrostomy tube is held in place between an intraluminal balloon and external disc adjoining to the skin erectile dysfunction age 21 silagra 50 mg free shipping. Gastrostomy Tube Placement Gastrostomy Tube, Balloon Type (Left) this percutaneous gastrostomy (G) tube is held in place by the contrast-filled, intraluminal balloon. Yuruker S et al: Percutaneous endoscopic gastrostomy: technical problems, problems, and administration. Gastrostomy Tube Placement (Marking Liver Edge) Gastrostomy Tube Placement (Gastropexy Procedure) (Left) Intraprocedural photograph reveals that a Tfastener is being loaded onto the slot of an 18-gauge needle. Gastrostomy Tube Placement (Gastropexy Procedure) Gastrostomy Tube Placement (Gastropexy Procedure) (Left) the 2nd T-fastener is loaded onto a needle, which is superior into the stomach. Needle entry into the abdomen is confirmed when air is aspirated into the syringe. Gastrostomy Tube Placement (Gastropexy Procedure) 728 Gastrostomy/Gastrojejunostomy Nonvascular Procedures Gastrostomy Tube Placement (Gastropexy Procedure) Gastrostomy Tube Placement (Gastropexy Procedure) (Left) With needle tip place confirmed, the syringe is indifferent and a guidewire is superior by way of the needle to deploy the Tfastener into the stomach. A wire that bounces off of at least three walls of the stomach confirms an intraluminal, somewhat than an intraperitoneal, location. Gastrostomy Tube Placement (Needle Access Into Stomach) Gastrostomy Tube Placement (Needle Access Into Stomach) (Left) With 2-4 T-fasteners in place, a needle attached to a saline-filled syringe is inserted into the anesthetized insertion website central to the Tfasteners with a rightward trajectory towards the pylorus. Aspiration of air, or lateral imaging with distinction drip, confirms intraluminal location. Gastrostomy Tube Placement (Tract Dilatation) Gastrostomy Tube Placement (Tract Dilation) (Left) the needle has been removed and a dilator is being advanced over the guidewire. Sequentially bigger dilators will put together a sufficiently large gastrostomy tract to allow introduction of the G tube. Gastrostomy Tube Placement (Peel-Away Sheath) Gastrostomy Tube Placement (Pigtail-Type Tube Insertion) (Left) the G tube is superior over the indwelling guidewire through the peel-away sheath and into the abdomen. Placement of a balloon-retention G tube could require a peel-away 2-4 Fr sizes bigger than the G tube and will not track over a nonhydrophilic wire. Gastrostomy Tube Placement (Position Confirmation) Gastrostomy Tube Placement (Final Tube Position) (Left) In this pigtail-type G tube, the locking suture is pulled taut, forming the pigtail into a locked place, thereby securing the internal fixation mechanism of the G tube. Contrast injected via the tube outlines rugal folds in the decompressed abdomen. It is important to guarantee T-fasteners are deployed into the abdomen lumen; not positioned within the anterior abdominal wall. The tract is dilated with the dilator advanced over the guidewire by the measured distance. Subsequently, a peel-away sheath is launched, by way of which the G tube is advanced into the stomach. New gastric entry was obtained via the prevailing dermatotomy, toward the pylorus. Malpositioned Gastrojejunal Tube (New Access) Malpositioned Gastrojejunal Tube (Advancement to Jejunum) (Left) A hydrophilic wire and angled catheter were superior past the pylorus into jejunum. Gastrojejunal Tube (Normal Appearance) 732 Gastrostomy/Gastrojejunostomy Nonvascular Procedures Jejunostomy Tube (Over-The-Wire Exchange) Jejunostomy Tube (Retrograde Replacement) (Left) After exchanging a jejunostomy tube, inject distinction and observe the direction of peristalsis to insure that the jejunostomy tube is downstream of the balloon. This balloon could also be slightly overinflated in comparability with the diameter of the adjacent jejunum. Complication (Hemorrhage via Gastrostomy Tube) Complication (Hemorrhage through Gastrostomy Tube) (Left) the patient later presented with bleeding by way of the G tube. Of observe, the G tube has been eliminated over a guidewire so as to get rid of any possible tamponade effect by the tube. This analysis of achalasia is usually treated with surgical procedure or balloon dilatation, not stenting. Achalasia Stented Duodenal & Biliary Obstruction (Left) A patient with metastatic melanoma causing duodenal and biliary obstruction is proven after placement of duodenal and biliary stents. The mass was surgically resected and proved to be a large adenomatous polyp, precluding the need for either stent placement or balloon dilation. Review of the esophagram previous to stent placement is necessary, as this aids within the choice of the appropriate stent kind, diameter, and size. Esophageal Stricture Stenting (Initial Fluoroscopic Imaging) Esophageal Stricture Stenting (S/P Esophageal Stenting) (Left) Spot radiograph obtained during distinction esophagram exhibits that there has been placement of a covered Ultraflex esophageal stent. Covered stents placed for malignancy reduce the danger of tumor ingrowth when in comparability with noncovered stents. The stent is delivered via an over-thewire system, and the ends are flared to minimize migration threat. Stent placement can serve both as a palliative or a temporizing measure in malignant colonic obstruction. Biliary obstruction is a recognized complication of each noncovered and covered duodenal stents. Complication of Duodenal Stenting (Percutaneous Biliary Drainage) Complication of Duodenal Stenting (Percutaneous Biliary Stent Placement) (Left) Percutaneous biliary drainage was performed to decompress the obstruction. After gaining entry by way of a proper biliary radicle, a guidewire was superior through the interstices of the duodenal stent into the jejunum. Complication of Duodenal Stenting (Percutaneous Biliary Stent Placement) Complication of Duodenal Stenting (S/P Decompressive Biliary Stenting) (Left) After balloon dilatation, a noncovered Wallstent was deployed, extending from the intrahepatic biliary ductal bifurcation properly into the duodenal stent. In circumstances of simultaneous duodenal and biliary obstruction, biliary and duodenal stents may be deployed side by facet at the outset. Variant Biliary Anatomy Abnormal Biliary Dilatation (Left) Spot radiograph demonstrates an internal/external biliary drain with the pigtail loop within the bowel. There is biliary ductal dilatation as a result of a typical duct stricture, by way of which the drain has been passed. Choledocholithiasis � Biliary dilatation Diameter and size of balloon used Appearance pre/post dilatation � Biliary stent Type, size, and diameter of stent(s) deployed Indicate if security catheter left indwelling � Indicate if specimens sent for microbiology, cytology Alternative Procedures/Therapies � Radiologic Percutaneous cholecystostomy � May be used to present access to distal frequent bile duct abnormality � Surgical Open or laparoscopic surgical decompression �. An ultrasound probe with a sterile cowl can be used to identify and align the target intrahepatic duct into sonographic view. Efflux of bile could also be noticed upon removal of the internal stylet to confirm needle tip place. Site selection for the 2nd point of access is performed by inserting a hemostat over the potential web site and evaluating beneath fluoroscopy to decide if an appropriate intercostal trajectory is available. The dermatotomy ought to be giant sufficient to allow the position of an 8-Fr drainage catheter. The 1st needle remains in place in order that extra contrast could be injected if needed. If the stricture had not been initially crossed with the 3-J guidewire, a mixture of a hydrophilic guidewire and a Kumpe catheter could have been used to negotiate the stricture. Note that the primary entry has still been preserved, which is helpful if the secondary access is misplaced for any purpose. Also observe that there are embolization coils in the left lobe from therapy of prior hepatic harm.
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This is metastatic breast cancer (but is indistinguishable from major gastric most cancers by imaging) impotence with antihypertensives silagra 100 mg online. The surrounding mass is less evident erectile dysfunction doctor memphis silagra 50 mg buy online, though fluoroscopy showed a stiff, nonperistaltic distal physique and antrum that was discovered to be a large carcinoma at surgery. Recurrent ulcers have been a standard feature of Zollinger-Ellison syndrome previous to improved diagnosis & therapy. Esophagram exhibits a large epiphrenic diverticulum that simulated a hiatal hernia on different views in a 53-year-old man. An irregular collection of gas and particulate material is noted throughout the antral mass. The antrum is nondistensible and is infiltrated with a gentle tissue density mass because of metastasis, though the imaging findings are indistinguishable from major gastric carcinoma. There are indirect signs of extra fluid secretion with poor coating of the gastric mucosa by the barium. It is necessary to distinguish this tumor from the adjacent superior mesenteric vein. Similar findings were current within the esophagus, along with aspiration pneumonitis. Endoscopic biopsy and correlation with medical findings indicated that these were due to Crohn illness. The mixture of an ileus & the prevention of reflux of gas into the esophagus due to the fundoplication can lead to marked distention of the abdomen. The wall of the 2nd portion of duodenum is thickened, and the lumen is compressed, partly, by a pseudocyst. Note the mural thickening of the antrum and duodenum from acute exacerbation of pancreatitis. The antral wall is thickened and the lumen narrowed because of metastatic breast most cancers. It periodically herniated via the pylorus, causing partial gastric outlet obstruction. The 3rd portion of duodenum is markedly narrowed because it passes between the aorta and the superior mesenteric artery. Retained food particles and distention of the proximal stomach indicate gastric outlet obstruction. Just ventral to the duodenal bulb and antrum are small collections of extraluminal gas and oral distinction medium, confirming the source of perforation. Extraluminal distinction materials and gasoline are current near the anterior floor of the abdomen on the site of the perforated ulcer. An irregular assortment of gasoline & fluid is noted inside the antral mass, representing an ulcerated portion of the tumor. The appearance is indistinguishable from primary gastric carcinoma, but this obstruction was as a outcome of metastatic breast most cancers. The middle of the tumor is necrotic with an airfluid stage, indicating communication with the gastric lumen. There is a halo or capsule of edematous tissue across the pancreas, with comparatively little spread into adjoining tissues. The mass is nicely encapsulated and principally stable but has massive foci of central low density, doubtless representing necrosis. The mesenteric vessels are twisted and dilated with intensive infiltration of the mesentery and ascites, indicative of bowel ischemia. This affected person has continual Crohn disease with extensive mesenteric and bowel scarring. Any explanation for acute hepatic engorgement, including steatohepatitis, might cause ache and irregular liver perform. The abscess was caused by subacute diverticulitis with portal venous septic thrombophlebitis. High-attenuation fluid surrounding the mass and lengthening through the hepatic capsule represents spontaneous rupture with bleeding. The mesenteric vessels are crowded and distorted where they enter the inner hernia. A supine plain movie reveals the abdomen being compressed by an enlarged spleen and liver. The gastric origin is typically recommended by the presence of an airfluid level inside the necrotic middle of the mass, indicating communication with the gastric lumen. The individual cysts throughout the mass are few (~ 6), and relatively giant (~ 2 cm diameter). The splenic vein & pancreas have been displaced ventrally, serving to to distinguish this from a pancreatic mass. Near the pouch-enteric anastomosis is a large collection of gas, fluid, and enteric distinction medium that fills much of the left subphrenic house, together with that posterior to the spleen. The outstanding blood vessels and fats density foci establish them as angiomyolipomas. Endoscopy and biopsy revealed Brunner gland hyperplasia and hamartomatous change in a affected person with hyperacidity. The mass is comprised of small cysts separated by thin fibrous septa with a "scar" in the middle of the mass. Surgery confirmed groove pancreatitis, although pancreatic carcinoma might have an analogous look. Note the irregular gallbladder wall thickening and ascites, due to gangrenous, perforated cholecystitis. Percutaneous cholecystostomy yielded thick, contaminated bile, indicating empyema of the gallbladder. The 2nd portion of the duodenum was secondarily affected by the adjacent colonic inflammation. The look is similar to superior mesenteric artery syndrome, however the irregular, closely spaced fold sample of the small bowel helps to verify the prognosis of scleroderma. Note the pancreatic head calcification and gastric distention (chronic pancreatitis). These seem to be intraluminal, though they arise within the bowel wall, subsequently being drawn into the lumen by peristalsis. The jejunal anastomotic staple line was displaced, and mesenteric vessels have been distorted. The inferior mesenteric vein could probably be followed along the ventral surface of the hernia sac on sequential photographs. Mesenteric metastases are also hypervascular and lead to a desmoplastic response in the mesentery. Within the ileal mesentery there are engorged blood vessels and a proliferation of fibrofatty tissue. Associated findings include gastric varices, inflicting lively bleeding into the gastric lumen. This finding could be the most evident on imaging, resulting in the choice diagnosis of mesenteric adenitis/enteritis. The fold sample of the jejunum is abnormally effaced, resembling the expected pattern of the ileum.
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The most interesting medical implications of cerebral asymmetry happen when disturbed lateralization appears to be inherent within the nature and even the cause of a dysfunction erectile dysfunction pump how do they work silagra 100 mg purchase on-line. A number of research recommend that the illness is related to a failure to develop regular structural and useful cerebral asymmetry and that its pathology is characterized by a greater affliction of the left than the proper hemisphere erectile dysfunction statistics in canada discount 50 mg silagra visa. Other putative neurodevelopmental disorders, together with dyslexia and autism, can also be associated with uneven cerebral abnormalities. The mind shown right here demonstrates marked asymmetry in measurement of the planum temporale, which is larger on the left in a majority of brains. The uneven length of the lateral border of the planum temporale underlies the asymmetries within the Sylvian fissure itself (see also B). Asymmetry of the planum temporale arises principally from differences in the dimension of the cytoarchitectonic subject Tpt (shaded in green). Tpt types much of the posterior a 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 variations between the 2 Sylvian fissures (red). Compared with the left hemisphere, the right Sylvian fissure is shorter and turns upward. This displays planum temporale asymmetries (represented by adjacent purple stippling). Presence of the 14-3-3 protein coupled with the medical course strongly supports the diagnosis of Creutzfeldt-Jakob illness. A 65-year-old man first began to exhibit impaired judgment, anxiousness and fatigue 18 months beforehand. His signs progressively worsened and have become associated with extreme current and then distant reminiscence problems. Abrupt myoclonic jerks of the higher extremities appeared a number of weeks before his neurological evaluation. Neurological examination now confirms dementia with proof of marked memory loss, impairment of executive functions, dyscalculia, visuospatial disturbances and visual agnosia. Frequent myoclonic jerks of the upper extremities and left decrease extremities are seen; his gait is unsteady, with impaired postural reflexes. Electroencephalogram reveals a generalized periodic sample of sharp waves at intervals of 0. Discussion: the combination of history, neurological examination and diagnostic test outcomes points strongly to a diagnosis of Creutzfeldt-Jakob disease, a human prion disease and one of the so-called transmissible spongiform encephalopathies. Anatomically, the dysfunction entails gray matter diffusely all through the neuraxis, with outstanding devastation. There is putting loss of neurones within the cerebral cortex, with a brisk astrocytic response and microcavitation (spongiform encephalopathy). New perspectives in basal forebrain group of special relevance for neuropsychiatric problems: the striatopallidal, amygdaloid and corticopetal elements of the substantia innominata. Provides proof that the area of the substantia innominata within the basal forebrain is composed of components of three forebrain structures: the ventral striatopallidal system, the extended amygdala and the magnocellular corticopetal system. Pain processing during three ranges of noxious stimulation produces differential patterns of central activity. Classic description of the group of sensory and motor homunculi within the human cerebral cortex. It is located in the neck opposite a line drawn down the side of the neck from the foundation of the auricle to the extent of the upper border of the thyroid cartilage. It is deep to the inner jugular vein, the deep fascia and sternocleidomastoid, and anterior to scalenus medius and levator scapulae. Each ramus, besides the primary, divides into ascending and descending parts that unite in communicating loops. From the primary loop (C2 and C3), superficial branches supply the pinnacle and neck; cutaneous nerves of the shoulder and chest come up from the second loop (C3 and C4). The superficial branches perforate the cervical fascia to supply the pores and skin, whereas the deep branches usually provide the muscles. The superficial branches both ascend (lesser occipital, nice auricular and transverse cutaneous nerves) or descend (supraclavicular nerves). Descending beneath 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 provide the skin as far as the midline and as low as the second rib. The intermediate supraclavicular nerves cross the clavicle to provide the pores and skin over pectoralis major and deltoid all the way down to the extent of the second rib, subsequent to the realm of provide of the second thoracic nerve. The lateral supraclavicular nerves descend superficially across trapezius and the acromion, supplying the skin of the higher and posterior elements of the shoulder. It curves around the accent nerve and ascends along the posterior margin of the sternocleidomastoid. Near the skull it perforates the deep fascia and passes up onto the scalp behind the auricle. It supplies the pores and skin and connects with the good auricular and higher occipital nerves and the auricular department of the facial nerve. Its auricular department provides the skin on the higher third of the medial side of the auricle and connects with the posterior department of the good 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 exterior jugular vein. The anterior branch is distributed to the facial pores and skin over the parotid gland, connecting within the gland with the facial nerve. The posterior branch communicates with the lesser occipital nerve, the auricular department of the vagus nerve and the posterior auricular department of the facial nerve. Communicating branches cross 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 sequence of branches-namely, the meningeal, superior root of ansa cervicalis and nerves to thyrohyoid and geniohyoid. It perforates the deep cervical fascia and divides beneath platysma into ascending and descending branches which 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 higher anterior areas of the neck. The descending branches pierce platysma and are distributed anterolaterally to the skin of the neck, as little as the sternum.