Reviewer ’s report  
 
Title: Superior Mesenteric Artery Syndrome coexists with Nut cracker Syndrome in a female: a 
case report  
 
Version: 1 Date: 15 Oct 2018  
 
Reviewer: Silvío Mazziotti  
 
Reviewer's report:  
 
Although already des cribed in literature, SMA and Nutcracker phenomenon are rare pathological 
conditions that sometimes can coexist. Radiologists and clinicians should always be aware of 
these conditions in young patients with an history of weight loss and abdominal pain.  
 
 
The case is interesting and well written.  
 
 
However, some pints need to be clarified:  
 
- In literature the SMA syndrome is also known as "Wilkie's syndrome". I suggest to add this 
denomination too.  
 
- The authors refer to "Nutcracker phenomenon" and not to "Nut cracker syndrome". Indeed, it is 
true that the patients did not suffer from hematuria, but anyway a left flank pain was detected at 
the abdominal examination.  
 
 
Moreover, two different phenotypes of Nutcracker phenomenon/syndrome exist (anterior and 
posteri or). 
 
 
I would like that the authors could be clearer in the text about these two points.  
 
- The authors report that the upper gastrointestinal double -contrast radiograph was performed 
after the CT -scan. Considering the age and the gender of the patient, was  it really necessary to 
achieve a diagnosis? If yes, was that the right timing for its performance (after the CT -scan)?  
 
 
In this sense, I would like that the authors could briefly describe in discussion the different 
imaging modalities available (especiall y for the "radiation -free" alternatives), the indications and 
the principle findings for each one.  
 
Moreover, I would suggest  these articles:  
 
o Neri, S. , Signorelli, S. S., Mondati, E. , Pulvirenti, D. , Campanile, E. , Di Pino, L. , Scuderi, 
M. , Gius tolisi, N. , Di Prima, P. , Mauceri, B. , Abate, G. , Cilio, D. , Misseri, M. Scuderi, R. 
(2005), Ultrasound imaging in diagnosis of superior mesenteric artery syndrome. Journal of 
Internal Medicine, 257: 346 -351. doi:10.1111/j.1365 -2796.2005.01456.x  
 
o Cicero G, D'Angelo T, Bottari A, et al. Superior Mesenteric Artery Syndrome in Patients with 
Crohn's Disease: A Description of 2 Cases Studied with a Novel Magnetic Resonance 
Enterography (MRE) Procedure. The American Journal of Case Reports. 2018;19:431 -437. 
doi:10.12659/AJCR.908273.  
 
- In my opinion, the graphical overlay pointers of Fig. 1 c are a bit confusing. I think they should 
be put within the structure that they are labeling. Maybe a "zoomed" detail of the image could be 
easily understandable for th e reader.  
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comment s to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Unable to assess   
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional st atistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language  in the manuscript:  
 
Needs some language cor rections before being published  
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimburseme nts, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to al l of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my nam e will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website alon g with the authors' 
responses. I agree for my report to be made availabl e under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editors, which will no t be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title: Superior Mesenteric Artery Syndrome coexists with Nut cracker Syndrome in a female: a 
case report  
 
Version: 1 Date: 15 Oct 2018  
 
Reviewer: Silvío Mazziotti  
 
Reviewer's report:  
 
Although already des cribed in literature, SMA and Nutcracker phenomenon are rare pathological 
conditions that sometimes can coexist. Radiologists and clinicians should always be aware of 
these conditions in young patients with an history of weight loss and abdominal pain.  
 
 
The case is interesting and well written.  
 
 
However, some pints need to be clarified:  
 
- In literature the SMA syndrome is also known as "Wilkie's syndrome". I suggest to add this 
denomination too.  
 
- The authors refer to "Nutcracker phenomenon" and not to "Nut cracker syndrome". Indeed, it is 
true that the patients did not suffer from hematuria, but anyway a left flank pain was detected at 
the abdominal examination.  
 
 
Moreover, two different phenotypes of Nutcracker phenomenon/syndrome exist (anterior and 
posteri or). 
 
 
I would like that the authors could be clearer in the text about these two points.  
 
- The authors report that the upper gastrointestinal double -contrast radiograph was performed 
after the CT -scan. Considering the age and the gender of the patient, was  it really necessary to 
achieve a diagnosis? If yes, was that the right timing for its performance (after the CT -scan)?  
 
 
In this sense, I would like that the authors could briefly describe in discussion the different 
imaging modalities available (especiall y for the "radiation -free" alternatives), the indications and 
the principle findings for each one.  
 
Moreover, I would suggest  these articles:  
 
o Neri, S. , Signorelli, S. S., Mondati, E. , Pulvirenti, D. , Campanile, E. , Di Pino, L. , Scuderi, 
M. , Gius tolisi, N. , Di Prima, P. , Mauceri, B. , Abate, G. , Cilio, D. , Misseri, M. Scuderi, R. 
(2005), Ultrasound imaging in diagnosis of superior mesenteric artery syndrome. Journal of 
Internal Medicine, 257: 346 -351. doi:10.1111/j.1365 -2796.2005.01456.x  
 
o Cicero G, D'Angelo T, Bottari A, et al. Superior Mesenteric Artery Syndrome in Patients with 
Crohn's Disease: A Description of 2 Cases Studied with a Novel Magnetic Resonance 
Enterography (MRE) Procedure. The American Journal of Case Reports. 2018;19:431 -437. 
doi:10.12659/AJCR.908273.  
 
- In my opinion, the graphical overlay pointers of Fig. 1 c are a bit confusing. I think they should 
be put within the structure that they are labeling. Maybe a "zoomed" detail of the image could be 
easily understandable for th e reader.  
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comment s to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Unable to assess   
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional st atistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language  in the manuscript:  
 
Needs some language cor rections before being published  
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimburseme nts, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to al l of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my nam e will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website alon g with the authors' 
responses. I agree for my report to be made availabl e under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editors, which will no t be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title: Superior Mesenteric Artery Syndrome coexists with Nut cracker Syndrome in a female: a 
case report  
 
Version: 1 Date: 15 Oct 2018  
 
Reviewer: Silvío Mazziotti  
 
Reviewer's report:  
 
Although already des cribed in literature, SMA and Nutcracker phenomenon are rare pathological 
conditions that sometimes can coexist. Radiologists and clinicians should always be aware of 
these conditions in young patients with an history of weight loss and abdominal pain.  
 
 
The case is interesting and well written.  
 
 
However, some pints need to be clarified:  
 
- In literature the SMA syndrome is also known as "Wilkie's syndrome". I suggest to add this 
denomination too.  
 
- The authors refer to "Nutcracker phenomenon" and not to "Nut cracker syndrome". Indeed, it is 
true that the patients did not suffer from hematuria, but anyway a left flank pain was detected at 
the abdominal examination.  
 
 
Moreover, two different phenotypes of Nutcracker phenomenon/syndrome exist (anterior and 
posteri or). 
 
 
I would like that the authors could be clearer in the text about these two points.  
 
- The authors report that the upper gastrointestinal double -contrast radiograph was performed 
after the CT -scan. Considering the age and the gender of the patient, was  it really necessary to 
achieve a diagnosis? If yes, was that the right timing for its performance (after the CT -scan)?  
 
 
In this sense, I would like that the authors could briefly describe in discussion the different 
imaging modalities available (especiall y for the "radiation -free" alternatives), the indications and 
the principle findings for each one.  
 
Moreover, I would suggest  these articles:  
 
o Neri, S. , Signorelli, S. S., Mondati, E. , Pulvirenti, D. , Campanile, E. , Di Pino, L. , Scuderi, 
M. , Gius tolisi, N. , Di Prima, P. , Mauceri, B. , Abate, G. , Cilio, D. , Misseri, M. Scuderi, R. 
(2005), Ultrasound imaging in diagnosis of superior mesenteric artery syndrome. Journal of 
Internal Medicine, 257: 346 -351. doi:10.1111/j.1365 -2796.2005.01456.x  
 
o Cicero G, D'Angelo T, Bottari A, et al. Superior Mesenteric Artery Syndrome in Patients with 
Crohn's Disease: A Description of 2 Cases Studied with a Novel Magnetic Resonance 
Enterography (MRE) Procedure. The American Journal of Case Reports. 2018;19:431 -437. 
doi:10.12659/AJCR.908273.  
 
- In my opinion, the graphical overlay pointers of Fig. 1 c are a bit confusing. I think they should 
be put within the structure that they are labeling. Maybe a "zoomed" detail of the image could be 
easily understandable for th e reader.  
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comment s to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Unable to assess   
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional st atistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language  in the manuscript:  
 
Needs some language cor rections before being published  
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimburseme nts, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to al l of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my nam e will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website alon g with the authors' 
responses. I agree for my report to be made availabl e under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editors, which will no t be published.  
 
I agree to the open peer review policy of the journal  
assistant