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Cerebral veins and dural sinus thrombosis (CVT) represents a rare cause of stroke. In adults, CVT has a higher frequency among cases with inherited thrombophilia, mostly women, patients with malignancy, or infections. Two pathophysiological mechanisms contribute to their clinical presentation: diminution of cerebrospinal fluid absorption and increase of venular and capillary pressure. Four major syndromes have been described as isolated or in combination: intracranial hypertension, focal neurological deficits, seizures, and encephalopathy. Non-enhanced CT (NECT) of the head is the most frequently performed imaging study in the emergency department. Features of CVT on NECT can be divided into direct signs (detection of venous clot within a venous channel) and, more frequently, indirect signs (such as cerebral edema or cerebral venous infarct). CVT diagnosis is confirmed with CT venography, which can be performed immediately after NECT, and detects the venous clot as a filling defect, or magnetic resonance imaging (MRI)/MR venography. Different imaging techniques may need to be combined to avoid pitfalls. Conclusions: CVT is a relatively rare disorder in the general population and due to its wide clinical spectrum is frequently misdiagnosed upon initial examination. The knowledge of variable clinical aspects and imaging signs will be essential in providing a timely diagnosis.

The authors report a case of a 74-year-old woman found to have an extremely rare case highlighted by multidetector computed tomography (MDCT) angiography, with the presence of a replaced right hepatic artery (RRHA) arising from the splenic artery (SA). In this case, the SA arose from a gastrosplenic trunk (GST). The GST had an endoluminal diameter of 9.2 mm at its origin and a length of 9.3 mm. It arose directly from the anterior abdominal aortic wall, at the level of the T12–L1 intervertebral disc. The SA branched off from the GST and travelled in front of the abdominal aorta (AA) for 18.2 mm up to the level of the L1–L2 intervertebral disc. The SA then continued along an upward and tortuous path towards the splenic hilum. The inflection point of the SA trunk was located above the origin of superior mesenteric artery (SMA). The RRHA arose from the right of this inflection point. The RRHA had an endoluminal diameter of 3.0 mm at its origin and a length of 96.0 mm; it had a downward trajectory towards the hepatic hilum. The common hepatic artery (CHA) had an endoluminal diameter of 6.2 mm at origin and arose directly from the anterior wall immediately to the right of the mediosagittal plane of the AA. Knowledge of this rare anatomical variation is important for interventional radiologists, oncologists, hepatic and abdominal surgeons.

Cavernous sinus thrombosis (CST) usually produces a characteristic clinical syndrome. Septic CST represents a sporadic, but severe complication of infection of the cavernous sinuses, which can bring high mortality and morbidity rates if not treated right away. Case presentation: The current research is a case report of a 64-year-old woman with inherited thrombophilia who developed an acute mastoid infection that resulted in septic right CST. The clinical diagnosis was verified by laboratory studies and evidence from high-resolution computed tomography (HRCT), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA). Clinical medical care resulted in the patient being successfully treated with low-molecular-weight heparin and broad-spectrum intravenous antibiotics, which avoided severe complications.

Aim : Contrast-enhanced ultrasound (CEUS) has become a relevant imaging method for the evaluation of focal liver le- sions (FLL). The aim of this study was to evaluate the performance of CEUS for the assessment of focal nodular hyperplasia (FNH) in a large study group. Material and methods : We performed a multicentre prospective observational study, which included successive CEUS examinations from fourteen Romanian centres. CEUS examinations were performed in de novo FLL, using low mechanical index ultrasound, following an intravenous bolus of 2.4 ml SonoVue. CEUS was considered conclusive for FNH if a typical pattern was present following contrast (rapid “spoke-wheel” enhancement during the arterial phase, hyperenhanced lesion during venous phase, hyper- or isoenhanced in the late phase). In all cases a reference method was available (contrast enhanced CT or MRI or biopsy). The trial was registered in clinicaltrials.gov (Identifier NCT01329458). Results : During the 6 years study, 2062 “de novo” FLL were evaluated by CEUS. From this cohort, 94/2062 (4.5%) had a typical enhancing pattern for FNH as described in the EFSUMB guidelines. Contrast enhanced CT/MRI and biopsy diagnosed additional 15 FNH. From the 94 cases diagnosed as FNH by CEUS, in nine the final diagnosis was different (five of them adenomas). CEUS had 85% sensitivity, 99.5% specificity, 90.4% positive predictive value, 99.2% negative predictive value and 98.8% diagnostic accuracy for the diagnosis of FNH. Conclusions : CEUS is a sensitive and very specific method for the diagnosis of FNH.

Primary biliary tract neuroendocrine tumors (NETs) are extremely rare tumors that account for 0.2-2% of all gastrointestinal neuroendocrine tumors. The typical presentation is with jaundice and other symptoms related to biliary obstruction.We present a case of right hepatic duct NET in a 27-year-old female patient, asymptomatic, presented for a routine ultrasound examination that revealed moderate dilatation of the intrahepatic biliary ducts and a 20 mm hyperechoic lesion in the right hepatic biliary duct. Additional imaging was performed with the presumptive diagnosis of cholangiocarcinoma. After surgery, the histopathological and immunohistochemical report was conclusive for the diagnosis of G2 well-differentiated NET

The authors report the case of a 53-year-old male found to have an extremely rare case of a triple anatomical variation highlighted by multidetector computed tomography (MDCT) angiography, with the presence of a hepato-spleno-mesenteric trunk (HSMT) in association with an accessory left hepatic artery (ALHA) and a common trunk origin of right (RIPA) and left (LIPA) inferior phrenic arteries from left gastric artery (LGA) arising independently from the abdominal part of aorta (AA). The HSMT with an endoluminal diameter of 10.9 mm at its origin, and a length of 4 mm arose from the anterior wall of the AA at the level of 1∕2 upper part of the L1 vertebral body. From the distal portion of HSMT, give birth to the hepato-splenic trunk (HST) and to the superior mesenteric artery (SMA). HST, with a diameter at origin of 9.2 mm and 22.3 mm long, has an upward trajectory and done with the anterior face of AA an open angle to the top of 69°. From the distal part of the HST, arise common hepatic artery (CHA) and splenic artery (SA). The LGA, with an endoluminal diameter of 4.2 mm at origin, arose directly from the anterior wall of the AA at the level of the lower 1∕3 of T12 vertebral body, 8.2 mm above the origin of the HSMT. It ran upwards in front of the AA and after 59.5 mm gave rise to an ALHA. At 18.6 mm from its aortic origin, LGA gives birth to an inferior phrenic artery trunk (IPAT), which has at origin an endoluminal diameter of 2.6 mm and a length of 2.4 mm. The RIPA and LIPA have to origin a diameter of 2.3 mm and 1.7 mm, respectively. Knowledge of this anatomical variation is important for anatomists, interventional radiologists, vascular medicine experts, oncologists, vascular, and hepatic surgeons.

We report a very rare case of a 67-year-old male with the presence of a common hepatic artery (CHA) arising from the left gastric artery (LGA) in association with a presence of a gastro-splenic trunk (GST), found incidentally on multidetector computed tomography (MDCT) angiography, used to investigate peripheral vascular disease. The GST arises from the anterior aspect of the abdominal aorta (AA), at the level of lower 1∕3 of L1 vertebral body. The GST has a slightly concave trajectory to the right, and ends dividing into splenic artery (SA) and LGA. In the initial part of its trajectory, the SA it is wedged at 180°, pointing to the left, to the splenic hilum. The LGA has two different portions: the first dilated, initially oriented towards the higher, and then aligns to the infero-lateral left and gives birth to the second portion; the narrow portion, oriented initially horizontally, and then lower to the right. Dilated portion of LGA is continued with CHA. The CHA trunk is cuddling in a horizontal plane, at 180°, and is then oriented towards the fissure of the ligamentum venosum for entering in the liver parenchyma. At 51.7 mm from the origin, the CHA gives rise to the left hepatic artery (LHA), and after another 58 mm to the right hepatic artery (RHA), and finally continues with the gastroduodenal artery (GDA). Knowledge of this anatomical variation should be considered in planning and performing vascular surgery in the supramesocolic floor of the abdominal cavity.

Gaucher Disease (GD) is a rare inherited lysosomal storage disease caused by biallelic mutations in the gene encoding the lysosomal enzyme acid β-glucocerebrosidase, with progressive accumulation of the sphingolipid glucosylceramide in the lysosomes of macrophages, mainly in the liver, spleen, bone, and bone marrow. It is characterized by anemia, thrombocytopenia, hepatosplenomegaly, sometimes severe bone involvement and, in certain forms, neurological involvement. We present the case of a 77-year-old male, diagnosed in 2006, at 63, with GD type1. At the onset, the patient presented fatigue, asthenia, upper abdominal discomfort, skin pallor and minor bone pain. During follow-up, CT was performed and displayed an enlarged spleen (25 cm) and a well-defined mass in the kidney cortex, but it could not establish whether it was malignant or not. Considering the patient refused surgery at that moment, a new CT exam was performed six months later, and the kidney tumor significantly increased in size. Nephrectomy and necessity splenectomy were performed, and recovery was uneventful. The histopathological examination revealed clear cell renal cell carcinoma, grade 2 Fuhrman. Enzyme substitution therapy with Imiglucerasum was initiated in 2012 with favorable evolution. Seven years later, during a routine ultrasound follow-up, a 4/3.8 cm hyperechoic mass was found in the eighth liver segment. The biological tests revealed a high value of alpha-fetoprotein (AFP-185.2 ng/mL). Considering the patient’s history, possible diagnoses of the newly found focal liver lesion were: gaucheroma, metastasis secondary to kidney cancer, or a primitive liver tumor. Core biopsy was performed, and it was suggestive of a poorly differentiated hepatocellular carcinoma G3. A non-anatomical resection of liver segments VII and VIII with partial resection of inferior vena cava was performed, followed by full post-operative recovery. A histopathological examination confirmed the initial diagnosis. Currently, one month postoperatively, the patient in good clinical condition, continues the enzyme replacement treatment and is undergoing oncological follow-up. We presented a complex case of GD, diagnosed at an advanced age, who responded well to substitution therapy in regard to hematologic and bone symptoms, but who unfortunately developed two types of cancer managed aggressively despite the advanced age.

The authors illustrate a case of a 61-year-old male who presented an extremely rare association of anatomical variations highlighted by multi-detector computed tomography (MDCT) angiography, with a replaced right hepatic artery (RRHA) arising from inferior pancreaticoduodenal artery (IPDA), in association with left multiple renal arteries (RAs). The celiac trunk (CT) arises from the abdominal aorta (AA), at the level of middle 1∕3 of L1 vertebral body. The superior mesenteric artery (SMA) origin was located at the anterior aspect of AA, at 2.5 mm below the origin of CT, at the level of L1∕L2 intervertebral discs. The SMA has at origin an endoluminal diameter of 11.3 mm. At 22.7 mm from its aortic origin, from the right aspect of the SMA trunk, arises IPDA. At 10.4 mm from its origin in IPDA, arises RRHA with a 78.5 mm artery length and the endoluminal diameter at origin of 2.9 mm. From the arising point, the RRHA is oriented ascending to the right, passing initially posterior to the hepatic portal vein and the head of the pancreas, then lateral to the head of the pancreas and posterior to the hepatic portal vein, after entering the hepatic parenchyma to bifurcate into the anterior and posterior branches. From left aspect of AA arise three RAs: one main, one additional (from AA), and an accessory renal (from left common iliac artery). Knowledge of this hepatic and renal anatomical variation is important for interventional radiologists, vascular experts, oncologists, vascular, hepatic and urologic surgeons.

The authors describe a case of a 61-year-old female patient, which presented on multidetector computed tomographic (MDCT) angiography a gastrosplenic trunk (GST) and common hepatic artery (CHA) arose independently from abdominal aorta (AA). The GST arose from the anterior wall of the AA, at the level of upper edge of the L1 vertebral body. The left gastric artery (LGA) arose from the superior wall of the GST. The splenic artery (SA) continuous the path of GST. The CHA arose from the anterior wall of the AA, at the level of upper one third of the L1 vertebral body, at 15.3 mm above the origin of superior mesenteric artery (SMA). The incidence and developmental and clinical significance of this vascular variation is discussed with a detailed review of the literature.

Network security must be a permanent concern for every company, given the fact that threats are evolving today more rapidly than in the past. This paper contains a general classification of cryptographic algorithms used in today networks and presents an implementation of virtual private networks using one of the most secure methods - digital certificates authentication.

We present a case of a 73-year-old male with peripheral vascular disease of the lower limbs, who on shown MDCT angiography, to have a hepatomesenteric trunk (HMT), and left gastric artery (LGA) and splenic artery (SpA) arising independently from the abdominal aorta (AA), and with additional right renal arteries. The HMT with a length of 5 mm (with an aspect of a common stem origin of common hepatic artery (CHA) and superior mesenteric artery (SMA) arose from the anterior wall of the AA at the level of upper one-third of the L2 vertebral body. The CHA originating from the superior part of the right edge of the HMT, have an ascendent path in front of AA, and finally fork in gastroduodenal artery and hepatic artery proper. With a descending path the SMA across the left renal vein, uncinate process, and inferior part of the duodenum (D3) made an aortomesenteric angle of 61°. The aortomesenteric distance at the level of the L3 vertebral body was 51 mm. The present case is only the 13th reported HMT in association with an independently arising LGA and SpA from the AA, the first case report with this condition using MDCT angiography. Knowledge of the variations in origin and distribution of the HMT is important for planning and performing procedures such as duodenopancreatectomy, liver transplantation, and chemoembolization of the pancreas and hepatic tumors.

The authors report a case of a 44-year-old male found to have unusual origins of the celiac trunk (CT) and superior mesernteric artrery (SMA) as revealed by routine multidetector computed tomograph (MDCT) angiography. The CT and SMA originate from the thoracic aorta (TA) 21 mm and 9 mm above the aortic hiatus, respectively. The median arcuate ligament (MAL) is located at the level of the L1–L2 intervertebral disc. The course of the CT descends in the thoracic cavity making a 14° acute downward angle in front of the TA; below the level of the MAL, the CT descends, making an angle of 47°. The course of the SMA descends at both the thoracic and abdominal level making an angle of 17°, and having an aortomesenteric distance of 9 mm at the level of the third part of the duodenum. In the present case, the supradiaphragmatic origin of the CT and the SMA was determined by their incomplete caudal descent, associated with a pronounced apparent descent of the diaphragm. A thoracic origin of the CT and SMA and the acute downward aortomesenteric angle (17°) associated with a reduced aortomesenteric distance at the level of the third part of the duodenum (9 mm), although no clinical signs are present, may predispose the patient to develop simultaneously a triple syndrome: the compression of CT by MAL (celiac axis compression syndrome), the compression of SMA by MAL (superior mesenteric artery compression syndrome), and the compression of the duodenum by the SMA (superior mesenteric artery syndrome). Clin. Anat. 26:975–979, 2013. © 2013 Wiley Periodicals, Inc.

We describe in this paper a rare case of a 45-year-old male with a common stem origin of the left gastric artery (LGA), right inferior phrenic artery (RIPA), and left inferior phrenic artery (LIPA), in association with the presence of a hepatosplenomesenteric trunk (HSMT) arising from the abdominal aorta (AA), as revealed by routine multidetector computed tomography (MDCT) angiography. The common stem origin of the LGA, RIPA, and LIPA had an endoluminal diameter of 3.3 mm, the LGA of 2.8 mm. The endoluminal diameter of the RIPA and LIPA was at the origin of approximately 1 mm, complicating selective chemoembolization of the liver parenchyma. Clin. Anat. 26:980–983, 2013. © 2012 Wiley Periodicals, Inc.

The authors report the case of a 51-year-old male that shown to have, independently of the vascular lesions of the lower limbs, the presence of a gastrosplenic trunk (GST) in association with a replaced common hepatic artery (CHA), arising from the superior mesenteric artery by multidetector computed tomography angiography. The GST with an endoluminal diameter of 5.6 mm at its origin and a length of 18.8 mm arose from the anterior wall of the AA at the level of middle 1/3rd of the L1 vertebral body. The replaced CHA with an endoluminal diameter at the origin of 4.8 mm has a lateral right ascendent path, initial in front of the superior mesenteric vein, in the middle portion penetrating the pancreatic parenchyma, in the terminal portion crossing the anterior aspect of hepatic portal vein, and finally fork in the gastroduodenal artery and hepatic artery proper. The knowledge of the variations of the GST and the replaced CHA is important for planning and performing procedures such as duodenopancreatectomy and liver transplantation.

There are four embryonic anastomoses that exist between the internal carotid artery (ICA) and the vertebrobasilar (VB) system, which may fail to regress postfetal life; one of which is the trigeminal artery. Other persistent anastomoses include those formed by the hypoglossal, otic and proatlantic intersegmental arteries. In addition, other cerebrovascular variations may accompany a persistent primitive trigeminal artery (PPTA); such as arteriovenous malformations, aneurysms, carotid-cavernous fistulas and stenotic cerebral vessels. We present two very rare cases of a left PPTA. In the first case, there was a past medical history significant for cervico-thoraco-lumbar spondylitis and in the second case of an operated occipital astrocytoma. In both cases, the PPTA was associated with a fusiform aneurysm located in the carotidian (lateral) aspect of the PPTA as well as other cerebrovascular anatomic variations. In the first case, the length of the PPTA was 26.0 mm and its endoluminal diameter, at its origin at the ICA, was 1.8 mm; the aneurysm has a length of 8.4 mm. In the second case, the length of the PPTA was 31.0 mm and its endoluminal diameter at its origin at the ICA was 3.0 mm; the aneurysm have a length of 7.6 mm. Identification of these variant vessels should not be ignored before planning and execution of neurosurgeries to prevent possible perioperative risks.

Cerebral artery fenestrations are usually detected incidentally during angiography, have a reported incidence ranging from of 0.03% to 1%, and rarely cause neurological symptoms. They can, however, be associated with aneurysmal dilatation at the proximal or distal end of the fenestration, cerebral arteriovenous malformations, or (rarely) ischemic symptoms. We present a case of a 54-year-old obese woman who presented with a large convex-lens-like fenestration of the right middle cerebral artery (MCA) at the M1 segment (distal to the origin of the temporopolar artery) associated with a transient ischemic attack. The MCA fenestration caused a local change in hemodynamic blood flow, which leads to cerebral ischemia. Magnetic resonance angiography (MRA) also revealed an associated small slit-like fenestration of the basilar artery (BA), hypoplasia of the A1 segment of the right anterior cerebral artery, bilateral fetal posterior cerebral arteries, and bilateral absence of the posterior communicating arteries. To our knowledge, this is the sixth reported case of MCA fenestration with an associated ischemic attack. In our case, fenestrations of the MCA, the BA, and hypoplasia of the A1 segment of ACA were not associated with any aneurysms.

The vertebrobasilar system (VBS) consists in the intracranial parts of the vertebral arteries (VAs), the basilar artery (BA) and its branches. The presence of a duplication at the level of the intracranial segment of VA (V4) is generally an incidental finding, but may be associated with aneurysms or arteriovenous malformations. We present an extremely rare case of duplication of the distal end of the left vertebral artery, associated with fenestration of the right posterior cerebral artery. The distal end of the left VA was duplicated into two arms (the right with a length of 5.5 mm and a diameter of 2.3 mm that connected with the contralateral VA; and the left with a length of 11.0 mm and a diameter of 1.6 mm, which connected more distally with the BA). The right posterior cerebral artery (PCA) had a fenestration in the posterior segment of the posterior communicating part (P2), with a length of 6.8 mm.

The celiac trunk is the first unpaired midline branch of the abdominal aorta that usually gives rise to the left gastric artery (LGA), the common hepatic artery (CHA) and the splenic artery (SpA). Despite this classic arrangement, many variations exist. We describe an atypical case of an absent CT and anomalous origin of the LGA, CHA and the SpA from the abdominal aorta using multidetector computed tomography angiography (MDCTA) in a 72-year-old male patient. The LGA arose from the anterior wall of the AA at the level of the T12-L1 intervertebral disk [33.8 mm above the origin of the superior mesenteric artery (SMA)]. The SpA originated directly from the anterolateral wall of the AA at the junction of the upper-third and middle-third of the L1 vertebral body (24.8 mm above the origin of the SMA). The CHA branched directly from the anterior wall of the AA at the level of the middle-third of the L1 vertebral body (17 mm above the origin of the SMA). The 64-slice MDCTA system has become the primary tool for evaluation of abdominal blood vessels. It is important to be aware of such a variation as it can have a significant impact on surgical and clinical practice.

Crossed fused renal ectopia (CFRE) is the second most common fusion anomalies (FAs) of the kidneys after horseshoe kidney. Crossed fused renal ectopia (CFRE) results from one kidney crossing over to the opposite side and subsequent fusion of the parenchyma of the two kidneys. We report, by multidetector-row computed tomography (MDCT) angiography, an extremely rare case of a left CFRE (L-shaped kidney type), consisting of multiple renal arteries (one main renal artery for the upper renal parenchyma, and three renal arteries (one main and two additional) for the lower renal parenchyma) and two left renal veins, which produced a double nutcracker syndrome (both anterior and posterior). The L-shaped left kidney has a maximum length of 18.5 cm, a maximum width of 10.2 cm, and a maximum thickness of 5.3 cm. The upper pole of the kidney is located at the level of the lower third of T12 vertebral body (4.6 cm left to the mediosagittal plan); the lower pole is located along the lower half of the L5 vertebral body (1.5 cm left to the mediosagittal plan). The following case will focus on the relevant anatomy, embryology, and the clinical significance of this entity.

Aim: Contrast enhanced ultrasound (CEUS) improved the characterization of focal liver lesions (FLLs), but is an operatordependent method. The goal of this paper was to test a computer assisted diagnosis (CAD) prototype and to see its benefit in assisting a beginner in the evaluation of FLLs.Material and method: Our cohort included 97 good quality CEUS videos[34% hepatocellular carcinomas (HCC), 12.3% hypervascular metastases (HiperM), 11.3% hypovascular metastases (HipoM), 24.7% hemangiomas (HMG), 17.5% focal nodular hyperplasia (FNH)] that were used to develop a CAD prototype based on an algorithm that tested a binary decision based classifier. Two young medical doctors (1 year CEUS experience), two experts and the CAD prototype, reevaluated 50 FLLs CEUS videos (diagnosis of benign vs. malignant) first blinded to clinical data, in order to evaluate the diagnostic gap beginner vs. expert. Results: The CAD classifier managed a 75.2% overall (benign vs. malignant) correct classification rate. The overall classification rates for the evaluators, before and after clinical data were: first beginner-78%; 94%; second beginner-82%; 96%; first expert-94%; 100%; second expert-96%; 98%. For both beginners, the malignant vs. benign diagnosis significantly improved after knowing the clinical data (p=0.005; p=0,008). The expert was better than the beginner (p=0.04) and better than the CAD (p=0.001). CAD in addition to the beginner can reach the expert diagnosis. Conclusions: The most frequent lesions misdiagnosed at CEUS were FNH and HCC. The CAD prototype is a good comparing tool for a beginner operator that can be developed to assist the diagnosis. In order to increase the classification rate, the CAD system for FLL in CEUS must integrate the clinical data.

We describe in this paper a rare case of a 45-year-old male with a common stem origin of the left gastric artery (LGA), right inferior phrenic artery (RIPA), and left inferior phrenic artery (LIPA), in association with the presence of a hepatosplenomesenteric trunk (HSMT) arising from the abdominal aorta (AA), as revealed by routine multidetector computed tomography (MDCT) angiography. The common stem origin of the LGA, RIPA, and LIPA had an endoluminal diameter of 3.3 mm, the LGA of 2.8 mm. The endoluminal diameter of the RIPA and LIPA was at the origin of approximately 1 mm, complicating selective chemoembolization of the liver parenchyma.

The authors report a case of a 44-year-old male found to have unusual origins of the celiac trunk (CT) and superior mesernteric artrery (SMA) as revealed by routine multidetector computed tomograph (MDCT) angiography. The CT and SMA originate from the thoracic aorta (TA) 21 mm and 9 mm above the aortic hiatus, respectively. The median arcuate ligament (MAL) is located at the level of the L1-L2 intervertebral disc. The course of the CT descends in the thoracic cavity making a 14° acute downward angle in front of the TA; below the level of the MAL, the CT descends, making an angle of 47°. The course of the SMA descends at both the thoracic and abdominal level making an angle of 17°, and having an aortomesenteric distance of 9 mm at the level of the third part of the duodenum. In the present case, the supradiaphragmatic origin of the CT and the SMA was determined by their incomplete caudal descent, associated with a pronounced apparent descent of the diaphragm. A thoracic origin of the CT and SMA and the acute downward aortomesenteric angle (17°) associated with a reduced aortomesenteric distance at the level of the third part of the duodenum (9 mm), although no clinical signs are present, may predispose the patient to develop simultaneously a triple syndrome: the compression of CT by MAL (celiac axis compression syndrome), the compression of SMA by MAL (superior mesenteric artery compression syndrome), and the compression of the duodenum by the SMA (superior mesenteric artery syndrome).