Topohistology of sympathetic and parasympathetic nerve fibers in branches of the pelvic plexus: an immunohistochemical study using donated elderly cadavers / 대한해부학회지

Although the pelvic autonomic plexus may be considered a mixture of sympathetic and parasympathetic nerves, little information on its composite fibers is available. Using 10 donated elderly cadavers, we investigated in detail the topohistology of nerve fibers in the posterior part of the periprostatic region in males and the infero-anterior part of the paracolpium in females. Neuronal nitric oxide synthase (nNOS) and vasoactive intestinal polypeptide (VIP) were used as parasympathetic nerve markers, and tyrosine hydroxylase (TH) was used as a marker of sympathetic nerves. In the region examined, nNOS-positive nerves (containing nNOS-positive fibers) were consistently predominant numerically. All fibers positive for these markers appeared to be thin, unmyelinated fibers. Accordingly, the pelvic plexus branches were classified into 5 types: triple-positive mixed nerves (nNOS+, VIP+, TH+, thick myelinated fibers + or -); double-positive mixed nerves (nNOS+, VIP-, TH+, thick myelinated fibers + or -); nerves in arterial walls (nNOS-, VIP+, TH+, thick myelinated fibers-); non-parasympathetic nerves (nNOS-, VIP-, TH+, thick myelinated fibers + or -); (although rare) pure sensory nerve candidates (nNOS-, VIP-, TH-, thick myelinated fibers+). Triple-positive nerves were 5-6 times more numerous in the paracolpium than in the periprostatic region. Usually, the parasympathetic nerve fibers did not occupy a specific site in a nerve, and were intermingled with sympathetic fibers. This morphology might be the result of an "incidentally" adopted nerve fiber route, rather than a target-specific pathway.

Frey Syndrome after Retromandibular Approach for Condyle Fracture Reduction

Periosteal nociceptors induced hypotension and bradycardia under spinal anesthesia: A report of two cases / 대한마취과학회지

The sudden hemodynamic disturbance in the perioperative period can occur because of various surgical and anesthetic reasons but hemodynamic collapse due to noxious stimulus of periosteum stripping has not been described. We report two cases of severe hypotension and bradycardia during periosteum stripping in orthopedic surgery under subarachnoid block even though the block level was adequate. In our patients, hemodynamic collapse occurred specifically at a moment when surgeons manipulated periosteum and fall in blood pressure and heart rate was sudden in onset. The hemodynamic disturbance did not appear to be related to vagally mediated or due to blockade of sympathetic fibers but appeared to be related to periosteal nociceptors.

The mechanistic studies of acupuncture and moxibustion in Taiwan / 中国结合医学杂志

Traditional Chinese acupuncture has a history of over 2500 years. It is effective in the treatment of many conditions with few side effects. The best known mechanism is via endogenous opiates and their receptors. In addition to opioids, researchers have focused on the role of central monoamimergic systems. Acupuncture therapy is used not only to relieve pain but also to treat various medical conditions in traditional Chinese medicine (TCM). Some experiments have revealed a relationship between acupuncture and the autonomic nervous system (ANS). Besides, electroacupuncture (EA) can modulate the imbalance between innate and acquired immune systems. This review is focusing on the mechanistic studies of acupuncture that my colleagues and I have performed in Taiwan in recent years. We found that EA analgesia was closely related to not only the serotonergic neurons but also the adrenergic neurons in the central nervous system. The electrophysiological recordings suggested the involvement of the cerebral cortex in acupuncture. Local somatothermal stimulation inhibited the motility of sphincter of Oddi and internal anal sphincter through nitrergic neural release of nitric oxide. Mild local heat stress upregulated hepatic gene expression of heat shock protein 70 and protected the liver from subsequent ischemia-reperfusion injury. These studies supplement the knowledge of the mechanism of acupuncture.

Efeito do carvedilol a curto prazo na atividade simpática cardíaca pela cintilografia com 123I-MIBG / Effects of short-term carvedilol on the cardiac sympathetic activity assessed by 123I-MIBG scintigraphy

FUNDAMENTO: Alterações autonômicas na insuficiência cardíaca estão associadas a um aumento da morbimortalidade. Vários métodos não invasivos têm sido empregados para avaliar a função simpática, incluindo a imagem cardíaca com 123I-MIBG. OBJETIVO: Avaliar a atividade simpática cardíaca, por meio da cintilografia com 123I-MIBG, antes e após três meses de terapia com carvedilol em pacientes com insuficiência cardíaca com fração de ejeção do VE <45 por cento (FEVE). MÉTODOS: Foram recrutados para o estudo 16 pacientes, com idade média de 56,3 ± 12,6 anos (11 do sexo masculino), fração de ejeção média de 28 por cento ± 8 por cento e sem uso prévio de betabloqueadores. Realizaram-se imagens da inervação cardíaca com 123I-MIBG, determinando os níveis séricos de catecolaminas (epinefrina, dopamina e norepinefrina), e empreendeu-se a ventriculografia radionuclídica antes e após o uso de carvedilol por três meses. RESULTADOS: Houve melhora da classe funcional dos pacientes: antes do tratamento, metade se encontrava em CF II (50 por cento) e metade em CF III. Após 3 meses, 7 pacientes encontravam-se em CF I (43,8 por cento) e 9 em CF II (56,2 por cento), (p = 0,0001). A FEVE média avaliada pela ventriculografia radionuclídica aumentou de 29 por cento para 33 por cento (p = 0,017). Não houve variação significativa da atividade adrenérgica cardíaca avaliada pelo 123I-MIBG (imagem precoce, tardia e taxa de washout). Não foi observada variação significativa nas dosagens das catecolaminas. CONCLUSÃO: O tratamento em curto prazo com carvedilol promoveu a melhora clínica e da FEVE. Entretanto, não foi associado à melhora da atividade adrenérgica cardíaca pela cintilografia com 123I-MIBG, bem como da dosagem das catecolaminas circulantes.

BACKGROUND: Autonomic alterations in heart failure are associated with an increase in morbimortality. Several noninvasive methods have been employed to evaluate the sympathetic function, including the Meta-Iodobenzylguanidine (123I-MIBG) scintigraphy imaging of the heart. OBJECTIVE: to evaluate the cardiac sympathetic activity through 123I-MIBG scintigraphy, before and after three months of carvedilol therapy in patients with heart failure and left ventricular ejection fraction (LVEF) < 45 percent. PATIENTS AND METHODS: Sixteen patients, aged 56.3 ± 12.6 years (11 males), with a mean LVEF of 28 percent ± 8 percent and no previous use of beta-blockers were recruited for the study. Images of the heart innervation were acquired with 123I-MIBG, and the serum levels of catecholamines (epinephrine, dopamine and norepinephrine) were measured; the radioisotope ventriculography (RIV) was performed before and after a three-month therapy with carvedilol. RESULTS: Patients' functional class showed improvement: before the treatment, 50 percent of the patients were FC II and 50 percent were FC III. After 3 months, 7 patients were FC I (43.8 percent) and 9 were FC II (56.2 percent), (p = 0.0001). The mean LVEF assessed by RIV increased from 29 percent to 33 percent (p = 0.017). There was no significant variation in cardiac adrenergic activity assessed by 123I-MIBG (early and late resting images and washout rate). No significant variation was observed regarding the measurement of catecholamines. CONCLUSION: The short-term treatment with carvedilol promoted the clinical and LVEF improvement. However, this was not associated to an improvement in the cardiac adrenergic activity, assessed by 123I-MIBG scintigraphy, as well as the measurement of circulating catecholamines.

Influence of sympathetic activity on the progression of chronic kidney disease

There is clear evidence that chronic kidney disease [CKD] is often characterized by the presence of sympathetic hyperactivity. Data accumulating that this sympathetic hyperactivity is indeed important, because it may influence cardiovascular and renal prognosis. The aim of this study was to assess the relationship between glomerular filtration rate [GFR] and the levels of norepinephrine [NE] in serum and urine in the presence of variable degrees of renal functional impairment. A total of 75 CKD patients were divided into 5 groups according to GFR, group 1: 15 CKD patients with GFR>90ml/min/1.73m2 [stage 1CKD]. group 2: 15 CKD patients with GFR 60-89ml/min/1.73m2 [stage 2 CKD]. group 3: 15 CKD patients with GFR 30-59ml/min/1.73m2 [stage 3 CKD]. group 4: 15 CKD patients with GFR 15-29ml/min/1.73m2[stage 4 CKD]. group 5: 15 CKD patients with GFR<15ml/min/1.73m2 [stage 5, endstage renal failure], in addition to 15 healthy controls were studied. GFR was estimated by Cockroft-Gault formula. Norepinephrine was measured by an enzyme-linked immunosorbent assay. In addition, blood urea, serum creatinine, C-reactive protein [C-RP], fasting blood sugar [PBS], serum total cholesterol, triglycerides and 24-h urinary proteins were performed. Compared with controls, CKD patients had higher levels of serum norepinephrine, urinary norepinephrine was significantly lower among CKD patients. When GFR was reduced in CKD patients, serum norepinephrine was elevated and urinary norepinephrine was reduced suggesting greater renal impairment. In multivariate correlation, GFR were negatively correlated with serum norepinephrine and positively correlated with urinary norepinephrine. Serum norepinephrine levels were increased and urinary norepinephrine excretion were decreased in CKD patients, and may be one of the aggrevating factors for deterioration of renal function in those patients

Respiratory and non respiratory oscillations of the skin blood flow: a window to the function of the sympathetic fibers to the skin blood vessels

OBJECTIVE OF THE STUDY: The skin blood flow (SBF) has been known to oscillate in frequency and amplitude. The nature and type of these oscillations have remained obscure. We studied the oscillations of the SBF in frequency and amplitude with non invasive techniques during normal breathing at rest and compared it to the oscillations during rhythmic paced breathing at 6 cycles per minute. SUBJECTS AND METHODS: Thirty healthy subjects were studied under normothermic conditions. The following variables were recorded: 1) EKG signal; 2) SBF signal given by an infrared photoplethysmograph; 3) respiratory movements (RM). A correlation of the frequency of the respiration, the SBF and the EKG was made. The variability of the amplitudes of the SBF, RR intervals and pulse intervals was analyzed in the time domain and with spectral analysis using Fourier analysis. RESULTS: We found no clear respiratory modulation of the amplitude of the SBF during natural breathing at rest. With default breathing there was a low frequency oscillations (LF 0.04 to 0.15 Hz) modulation of the amplitude of the SBF that was non respiratory in nature. During rhythmic breathing at 0.1 Hz there was a strong modulation at LF of the SBF with a typical waxing and waning appearance, decreasing in amplitude during the tachycardia period and increasing in amplitude during the bradycardia period. CONCLUSIONS: Under normothermic conditions there is a consistent variability of the frequency and amplitude of the SBF with normal and rhythmic breathing. While breathing at rest the modulation of SBF amplitude was clearly seen at LF and non respiratory related. With rhythmic breathing there is a strong modulation of amplitude and frequency at the respiratory frequency.

Interpretación fisiopatológica de los diferentes estadios de una pulpitis / Physiopathological interpretation of the different pulpitis stages

La caries dental que vulnera los tejidos duros del diente y compromete a la pulpa provoca un proceso inflamatorio que progresa por varias fases o estadios: pulpitis reversible, pulpitis transicional, pulpitis irreversible y pulpa necrótica. El tejido pulpar agredido por microorganismos no experimenta una necrosis repentina, sino que va sucumbiendo progresivamente, y cada uno de los estadios pulpares por los que transita el proceso, se puede ir identificando mediante el dolor con sus características semiológicas propias de cada fase, lo que permite precisar con bastante certeza el estado pulpar por el que avanza el proceso inflamatorio en dicho tejido. La interpretación fisiopatológica de los diferentes estadios pulpares por los que transita una pulpitis y el seguimiento del dolor como síntoma cardinal del proceso inflamatorio, es una forma de diagnóstico que complementa el pensamiento interpretativo del clínico que atiende estas urgencias, y le permite una mejor comprensión de su evolución y establecer así el correcto tratamiento(AU)

The dental caries that harms the hard tissues of the tooth and compromises the pulp produces an inflammatory process that progresses through various phases or stages: reversible pulpitis, transitional pulpitis, irreversible pulpitis and necrotic pulp. The pulpar tissue attacked by microorganisms does not experiment a sudden necrosis, but it progressively succumbs and each of the pulpar stages the process goes through may be identified by the pain with its own semiological characteristics of every stage, which allows to determine with enough accuracy the pulpar stage through which the inflammatory process advances in this tissue. The physiopathological interpretation of the different pulpar stages of a pulpitis and the follow-up of pain as a cardinal symptom of the inflammatory process is a form of diagnosis complementing the interpretative thinking of the clinician that gives attention to these emergencies. It also contributes to a better understanding of its evolution and to apply an adequate treatment(AU)

Termometria cutânea: novos conceitos / Skin thermometry: new concepts

O artigo trata da utilização de um novo método diagnóstico na avaliação objetiva do grau de alterações funcionais dos pacientes com doenças vasculares. Conhecido como termometria cutânea infravermelha de alta sensibilidade, o exame não exige contato físico com o paciente, é não invasivo e não requer contraste. Os autores descrevem o método de exame, o aparato necessário e os parâmetros de avaliação qualitativa e quantitativa. Os resultados do exame possibilitam determinar o funcionamento do sistema vascular e, além disso, do sistema nevoso, do sistema músculo-esquelético, de processos inflamátórios e das condições dermatológicas, endócrinas e oncológicas. O exame permite avaliar o prognóstico clínico e, consequëntemente, resolver mais objetivamente as questões médicas...

Síndrome de Horner após cirurgia estereotaxica para doença de Parkinson / Horner syndrome after stereotactic Parkinson's surgery

Apresentamos estudo de dez pacientes com doença de Parkison, que foram submetidos a procedimentos ablativos estereotaxicos percutaneos e que desenvolveram síndrome de Horner ipsilateral imediatamente após a lesão. Sete pacientes foram submetidos a palidotomia, dois a subtalamotomia (campotomia de Forel) e talamotomia e um paciente a subtalamotomia. Sete desenvolveram miose e os dez desenvolveram semiptose ipsilateral a lesão. A ocorrência da síndrome de Horner resulta possivelmente de lesão de fibras simpaticas entre o hipotalamo, campo de Forel e tálamo

High concentrations of KCl release noradrenaline from noradrenergic neurons in the rat anococcygeus muscle

The aim of the present study was to investigate the effects of high concentrations of KCl in releasing noradrenaline from sympathetic nerves and its actions on postsynaptic alpha-adrenoceptors. We measured the isotonic contractions induced by KCl in the isolated rat anococcygeus muscle under different experimental conditions. The contractile responses induced by KCl were inhibited by alpha-adrenoceptor antagonists in 2.5 mM Ca2+ solution. Prazosin reduced the maximum effect from 100 to 53.9 ± 10.2 percent (P<0.05) while the pD2 values were not changed. The contractile responses induced by KCl were abolished by prazosin in Ca2+-free solution (P<0.05). Treatment of the rats with reserpine reduced the maximum effect induced by KCl as compared to the contractile responses induced by acetylcholine from 339.5 ± 157.8 to 167.3 ± 65.5 percent (P<0.05), and increased the pD2 from 1.57 ± 0.01 to 1.65 ± 0.006 (P<0.05), but abolished the inhibitory effect of prazosin (P<0.05). In contrast, L-NAME increased the contractile responses induced by 120 mM KCl by 6.2 ± 2.3 percent (P<0.05), indicating that KCl could stimulate the neurons that release nitric oxide, an inhibitory component of the contractile response induced by KCl. Our results indicate that high concentrations of KCl induce the release of noradrenaline from noradrenergic neurons, which interacts with alpha1-adrenoceptors in smooth muscle cells, producing a contractile response in 2.5 mM Ca2+ (100 percent) and in Ca2+-free solution, part of which is due to a direct effect of KCl on the rat anococcygeus muscle

Responses of isolated scale melanophores of a fresh water carp, Cirrhinus mrigala (Ham.) to zidovudine.

Zidovudine (AZT) induced concentration related aggregation in C. mrigala melanophores. Denervated melanophores failed to respond to AZT. Specific and nonspecific alpha adrenoceptor antagonists completely blocked the responses of fish melanophores to AZT. Histamine and prostaglandin antagonists also inhibited aggregation of the melanophores induced by AZT. The results suggest that AZT may release a mixture of neurotransmitter like substances, which cause the aggregation of this fish melanophores.

Hemodynamic Changes during a Thoracoscopic Thoracic Sympathicotomy in Primary Hyperhidrosis / 대한마취과학회지

BACKGROUND: A right thoracoscopic thoracic sympathicotomy involves the removal of T2 and T3 sympathetic chains. Since part of the sympathetic fibers to the heart traverse these two ganglia, we examined the hemodynamic changes during a thoracoscopic thoracic sympathicotomy in primary hyperhidrosis. METHODS: Noninvasive cardiac output monitoring was done on the both side of the neck and chest. A physiograph for measuring of continuous blood flow was taken from the right index finger and a thermometer was placed in the right palm. Following endotracheal intubation was done with double lumen endotracheal tube, anesthesia was maintained with isoflurane. Sympathicotomies were done for T2-3 during one lung ventilation. Heart rate (HR), mean arterial pressure (MAP), systemic vascular resistance index (SVRI), cardiac index (CI), accelerated contractility index (ACI), end-diastolic index (EDI), and temperature were recorded at arrival, before sympathicotomy, after sympathicotomy at 1, 2, 3, 4 and 5 minuets. The blood flow of the right index finger was recorded before and after the sympathicotomy. RESULTS: Concurrent with initiation of the sympathicotomy, MAP and SVRI were reduced, but the CI was elevated. It was accompanied with right palmar temperature elevation and an increase in the blood flow of the right index finger. CONCLUSIONS: A thoracoscopic thoracic sympathicotomy reduces MAP and SVRI and elevates CI, palmar temperature, and blood flow. We concluded that the hemodynamic changes during a thoracoscopic thoracic sympathicotomy seems to be the peripheral vasodilatation.

Botulinum A toxin for the treatment of focal hyperhidrosis: 5 cases / 대한흉부외과학회지

Thoracic sympathicotomy has been used safely and successfully to treat essential hyperhidrosis. However, it has been difficult to treat compansatory hyperhidrosis after thoracic sympathicotomy and focal hyperhidrosis. The sweat glands were innervated by post-ganglionic sympathetic fibers with acetylcholic serving as the transmitter. Botulinum A toxin has been reported to block neuro-transmission at the cholinergic autonomic nerve terminals. Prospecting its effect for the sweat gland, we treated 5 patients with focal hyperhidrosis with botulinum A toxin. Three patients received bilateral thoracic sympathectomy (1 case) and sympathicotomy(2 case) via VAT. The hyperhidrosis area was marked with betadine and was subdivided into squares of 2x2 cm(4cm(2)) each. Botulinum A toxin was injected intracutaneously in a dosage of 2.5U/0.1ml(100U/4ml) /4cm(2). A total dose of 100U of Botulinum A toxin was injected into the affected sites. Subjective assessment of sweat production by the patients using a visual analogue scale showed a 20~70% improvement. During the follow-up period, no toxic effects were observed.

Thoracoscopic surgery of palmar hyperhidrosis: sequelae and complications

Twenty patients with primary palmar hyperhidrosis were selected for bilateral thoracoscopic electrocautery of the sympathetic chain. Five out of time 20 patients had as well, axillary hyperhidrosis. The second and third thoracic ganglia were electrocoagulated and in patients associated with axillary hyperhidrosis, the fourth thoracic ganglion was also coagulated. Time procedure was successfully completed bilaterally in 17 patients [85%]. Unilateral failure to identify the sympathetic chain occurred in 3 patients [15%] which required conversion to open surgery on these limbs. Time mean operative time for each limb was 37 minutes. The mean postoperative hospital stay was 2.5 days and time patients resumed normal activity within 10 days postoperatively. Chest pain was the commonest postoperative complaint. It was usually relieved by a single dose of opiates given during hospital stay; however, 3 patients [15%] needed oral analgesics after hospital discharge for a mean period of 4 days. Complications in our study were few and mild: unilateral pneumothorax occurred in 2 patients [10%], unilateral hemothorax and transient Horner's syndrome occurred in 1 patient [5%]. Burst of palmar sweating for some hours, during the first postoperative week, occurred in 3 patients [15%]. Mild compensatory hyperhidrosis and gustatory sweating occurred in 6 patients [30%] and 2 patients [10%] respectively and they did not cause discomfort to our patients. Unilateral moderate recurrence of hyperhidrosis occurred in one patient [5%] after 4 months and he refused any more surgical interference. Some of our patients, who had plantar hyperhidrosis as well, noticed postoperative decrease of their feet sweating. Time thoracoscopic approach for palmar hyperhidrosis seems to offer the ideal surgical solution with excellent results, minimal complications, short hospital stay and early recovery

The Antivasospasmic Effect of Arterial Freezing on Acute Damaged Endothelium

During the microsurgery or during the postoperative period, the occurrence of the vascular spasm increases the failure rate of microvascular anastomosis,and in cases of trauma, the thrombogenic possibility is increased by the endothelial damage. The author thought that the vascular freezing of crushed vessels could improve the patency rate of microvascular anastomosis. Vascular freezing destroys most of the cells in the intima and media. There by causing degeneration of adrenergic fibers. Even though regeneration occurs after 2-3 weeks, regeneration in the smooth muscle layer is still incomplete. So vascular freezing has beneficial effects on relief of vasospasm. Fifteen Sprague-Dawley rats weighing approximately 300 g each were inflicted with crushing injury on the femoral arteries of the right side and the crushing injury with vascular freezing on the femoral arteries of the left side. The gross and histologic findings, as well as the patency rates, were observed at the postoperative 2nd, 10th, and 30th day,and the results were compared between the crushed and crush-freezing groups. The left side (crush-freezing group) showed less vasospasm and less thrombogenesis than the right side (crushed group). There were no significant differences in the patency rate between the crushed group and crush-freezing group. Vascular freezing is suggested to be effective on a potentially thrombogenic, endothelial damaged vessel as a prophylactic treatment method against vasospasm. Clinical application of vascular freezing awaits further experimentation.

Prueba de tabla basculante para desencadenamiento de síncopes cardíacos mediados por el Sistema Nervioso Neuro-Vegetativo / Half-full test of tilted table for outbreak of síncopes cardiac by the Neuro-vegetative nervous system

Analiza que la prueba de tabla basculante o Head Up Tilt Test (HUT) es un examen de realización simple que permite valorar síncopes cardíacos mediados por el sistema nervioso autónomo. (SNA). Hemos realizado entre jun. 1995 y ju. 1997 n=44 estudios, 18 hombres de edad promedio 35 años y 26 mujeres de edad promedio 32,3 años. El test se reveló positivo en n=25, (56xciento) pacientes. A partir de la clasificación de Tulesius hemos clasificado la respuestas en 16 vasovagales (36.4xciento) de N=44.9 (20.5xciento) hipoadrenérgicos de n=44. En 6 pacientes (13.6xciento) se obtuvo una reacción de tipo hipotensión ortostática y 13 pacientes (29.5xciento) fueron normales. Dentro de este grupo 3 pacientes (6.8xciento) presentaron una reacción hiperadrenérgica...

Intravenous Regional Block of Bretylium: Treatment of Reflex Sympathetic Dystrophy / 대한마취과학회지

BACKGROUND: Interruption of efferent sympathetic fibers is the mainstay of therapy in reflex sympathetic dystrophies(RSD) and be accomplished by temporary or permanent anesthetic blockade of sympathetic ganglia, surgical lesions of the sympathetic trunk, intravenous injecton of guanethidine or reserpine, or by systemic administration of adrenergic blocking drugs. In this study, the effects and the side effects of intravenous regional bretylium for the treatment of RSD were studied. METHODS: Seven patients have been administered with 2.0 mg/kg bretylium in 0.25% lidocaine with 100U of heparin three times weekly. A standard intravenous regional technique was used with 250~300 mmHg tourniquet pressure for 30 minutes. Blood pressure and pulse rate were monitored before injection, 1 minute and 5 minutes after injection, immediately before deflation of tourniquet, 1 minute, 5 minutes and 30 minutes after deflation of tourniquet. Pain and temperature evaluations were made before injection and at 1 week after every injection. RESULTS: The increase in skin temperature and decrease in pain score of the affected limb were noted after the use of bretylium in 5 patients out of 7 patients. These clinical effects probably resulted from bretylium,s ability to accumulate in adrenergic nerves and block norepinephrine release. One patient had hypotension immediately after tourniquet deflation. CONCLUSIONS: Intravenous regional bretylium provides significant pain relief for treatment of RSD.

Two Cases of Avellis Syndrome

Avellis syndrome is a clinical disorder characterized by ipsilateral paralysis of palate, larynx, and vocal cord paralysis and contralateral hemianesthesia. The syndrome is usually due to lesion of medulla oblongata. Involeved structures are nucleus ambiguus, lateral spinothalamic tract, and descending sympathetic fibers. We present 2 cases of Avellis syndrome with MRI findings, which showed infarction of right-sided upper medulla oblongata.