Anatomical, histological and radiological study of the rotator cuff interval of the shoulder

The Rotator cuff interval [RCI] is the triangular capsular space between the insertion of tendons of supraspinatus and subscapularis muscles. This RCI is supposed to be reinforced superficially by the coracohumeral ligament and deeply by the superior glenohumeral ligament SGHL. In addition to the ligamentous structures, the participation of the supraspinatus and subscapularis muscles tendons in the composition of the RCI has been pointed out. The aim of the present work was to study RCI, its boundaries and components, macroscopically and microscopically in correlation to MRI. Fourteen adult human cadaveric shoulder regions [5 right and 9 left] obtained from the Anatomy Department, Faculty of Medicine, Ain Shams University, were used in the present study. Specimens with gross pathology, trauma or previous surgery were excluded. Retrospectively the normal MRI findings were examined in 19 volunteers [10 right and 9 left shoulders, after obtaining consents] to demonstrate the boundaries and contents of the RCI using 1.5 tesla [General Electric Medical System [Milwaukee]. Results gross dissection at the apex of RCI revealed extension of fibers from subscapularis and supraspinatus tendons across the location of the RCI. They merge together in this region forming a confluence of fibers amalgamating with the capsule from outside. The long bicipital tendon was supported anteriorly by the suspension sling formed by the SGHL which seems to stabilize the long head of biceps in the RCI. The subscapularis tendon and the middle glenohumeral [GH] ligament, supported the antero-medial wall of the RCI. Sections taken from the lateral part of the roof, near the apex of the RCI and the superomedial part showed three distinct layers of connective tissue bundles. In sections taken in close proximity to the tendinous insertions into the tuberosities showed a zone of fibrocartilage. Sections from antero-medial part of the roof of RCI showed a meshwork of loose connective tissue. The RCI is best demonstrated in sagittal cuts. However, coronal and axial cuts can be helpful in identification of the relationship and contents. The coracohumeral [CHL] is always well identified in the mid portion of the RCI and is visualized in all planes, but sagittal images are the most useful for analysis of this structure. In conclusion studying the anatomy of RCI and determining [RCI] at MR imaging is important as it will provide a scientific background to the surgeon to repair any interval tear to stabilize the shoulder and may explain to some extent the superior instability observed in shoulders with rotator cuff tears

Early and mid term results of endovascular therapy of TASC type B and C femoropopliteal disease; the role for hemodynamic surveillance

Endovascular therapy of moderate femoropopliteal arterial occlusive disease remains controversial. This study reviewed our experience with endovascular therapy for TransAtlantic InterSociety Consensus [TASC] type B and C disease. Stenosis free patency was used as an objective end point to evaluate the hemodynamic success. Since January 2001 through January 2004, all patients who had endovascular therapy for their intractable lower limb ischemia due to TASC type B and C femoropopliteal occlusive disease presenting to Dr Erfan and Bagedo Hospitals, Jeddah; KSA, were examined. All had either MRA or CT angiography as a method of pretreatment evaluation. Balloon angioplasty was used initially in all patients and stenting was used selectively as an adjunct to suboptimal angioplasty. The treated segments were examined with duplex ultrasound scanning at 1, 6, 12, and 18 months intervals. Stenosis free patency was defined as the absence of stenosis greater than 50% diameter in the treated segment with standard Duplex criteria. Forty one limbs in 38 patients were studied. The indications for treatment were claudication in 19 limbs [46.3%], minor tissue loss in 13 limbs [31.7%] while rest pain and major tissue loss in 22%. Single lesions were present in 22 limbs and multiple lesions in the rest. Selective stenting were used in 33 limbs where in 9 of them more than one stent were used. Balloon angioplasty alone was performed in 8 limbs. Endovascular therapy was technically successful in all but one patient [97.4%], and there were no perioperative mortality. During follow up recurrent stenosis was detected in 9 limbs [21.9%]. Two patients [4.8%] underwent surgical bypass due to endovascular failure while others had repeat endovascular therapy. Stenosis free patency was 100%, 92.3%, 87.5% and 78.5% by 1, 6, 12, and 18 months intervals. No statistical difference was recorded among either balloon angioplasty or those who required stenting. Regression analysis showed that Peak Systolic Velocity measurement is a good predictor for endovascular outcome. Endovascular therapy appears to be a reasonable treatment option for TASC type B and C femoropopliteal occlusive disease. In our series endovascular therapy proved a technically feasible and safe modality, and achieved clinical improvement in most patients. Recurrent stenosis not reocclusion was the most common study end point due to the virtue of the use of hemodynamic assessment of peak systolic velocity measure and most of them were redirected to repeat endovascular treatment thus fewer patients required surgical revascularization. Although treatment durability in this study was limited yet most patients has documented stenosis free patency at 18 months

Value of MRI findings in pituitary dwarfism

The purpose of this study is to demonstrate the value and spectrum of pituitary MRI findings in cases of pituitary dwarfism and to elicit the correlation between MRI findings and maximum growth hormone values. MR images of 56 patients with clinical and hormonal proven pituitary dwarfism were reviewed retrospectively. All cases were performed on a 1- Tesla MR unit using sagittal and coronal T1 SE of pituitary gland pre and post contrast administration and coronal T2 FSE, Detailed review of all patients' records regarding patient's chronological age, height and height SDS, body mass index, bone age, expected adult height, growth hormone levels and other pituitary hormones were performed. According to clinical and hormonal findings, the patient populations were classified into two groups: Group 1: 30 patients [53.6%] had isolated growth hormone deficiency [IGHD]. The mean chronological age was 10.4 +/- 2.71 years [range 3.6-14.9]. The MRI findings were as follows: 20 cases [66.7%] were normal, 4 cases [13.33%] of pituitary hypoplasia with or without neurohypophyseal ectopia, 3 cases [10%] of pituitary micro adenoma, and one case [3.33%] of each of craniopharyngioma, Rathke's cleft cyst and Langerhans histocytosis. Group II: 26 patients [46.4%] had combined pituitary hormones deficiency [CPHD]. The mean chronological age was 12.21 +/- 3.63 years [range 3.6-17]. The MRI findings were as follows: 14 cases [53.8%] of pituitary hypoplasia with or without neurohypophyseal ectopia, 4 cases of craniopharyngioma [15.4%], 4 cases [15.4%] of pituitary microadenoma, 3 cases of normal MRI [11.6%] and one case of medulloblastoma [3.8%] secondary to radiation exposure. In both groups, the MRI findings correlated with maximum growth hormone values

Conclusion: pituitary gland abnormalities of different causes are present in 58.9% of patients with pituitary dwarfism and MRI findings correlate with growth hormone levels. So MR imaging is strongly recommended for patients with complete growth hormone deficiency and combined pituitary hormone deficiency

Value of percutaneous antegrade ureteric stenting in management of ureteric obstruction

Double-J stints were placed between the renal pelvis and the urinary bladder in ureters in 18 patients with impaired renal function. In those cases, retrograde cystocpy deployment was impossible. The mean age of patients was 55 years. The ureteric obstruction was malignant in 10 cases, benign condition in 5 cases and immediate post-operative complications in 5 cases. primary antegrade placement of internal ureteric patients was tried in all patients but 3 [3 ureters] in malignant obstruction group as the ureteric lumen was significantly compromised by the malignant process. In those patients, two was successfully stented after primary percutaneous nephrostomy, one was failed even after nephrostomy. In conclusion, Precutaneous antegrade ureteric stinting, whether primary or secondary to nephrostomy is a significantly valuable technique in managing ureteric obstruction not amenable to retrograde cystoscopic deployment

Prognostic value of MRI in nasopharyngeal carcinoma

The nasopharyngeal carcinoma [NPC] therapeutic outcome depends on the initial tumor staging. We aim to evaluate the role of v1RI in prediction of the tumor response to radiotherapy. Fifty-two NPC patients underwent MRI before and after radiotherapy to the local disease and the nodal involvement. MRI assessment included twenty-five anatomical sites. The MRI assessed the size, site, signal intensity, enhancement pattern and extension of the regional disease. Radiotherapy was carried out using the X-rays of 4-6 MV Linac. Complete remission [CR] rates in the lateral, anterior, inferior, intracranial, orbital, skull base and paranasal sinuses extensions were 77%, 89%, 68%, 15%, 0%, 16% and 31% respectively. The CR rate of the lateral, anterior, inferior extensions collectively [almost TI-2 lesions] was 77% compared with 17.6% for intracranial, orbital, skull base and paranasal sinuses extensions collectively [T3-4 lesions] [p<0.00001]. Among T2 lesions the CR rate was 89% for nasal versus 68% for oropharyngeal extension p=0.04]. In cases with parapharyngeal involvement, the CR rate was 90% in the MRI bulging extensions compared with 62% for the MRT infiltrative extensions [p=0,047]. The partial remission [PR] rate among the lateral, anterior, inferior, intracranial, orbital, skull base and paranasal sinuses extensions were 22%, 11%, 32%, 75%, 100%, 59% and 66% respectively. The intracranial, orbital, skull base and paranasal sinuses extensions of NPC were associated with a significantly lower rate of CR. Nasal extension responded more favorably to radiotherapy than oropharyngeal extension and bulging parapharyngeal extension responded better than infiltrative parapharyngeal extension