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Objectives: This study explores how vascular stenosis and absence affect the regulation of cerebral blood flow in the Circle of Willis (CoW) and the hemodynamic changes downstream of the stenosis. Materials and Methods: Forty idealized CoW models were simulated to analyze the impact of vascular absence and internal carotid artery (ICA) stenosis on hemodynamics. Inlet conditions were set using a physiological pressure waveform, and outflow boundaries were modeled using three-element Windkessel models. Results: The absence of vessels such as RP1, LP1, RA1, or LA1 had a comparable effect on total blood flow to a 40% stenosis of the left internal carotid artery (LICA) across the entire CoW. Specifically, when LP1 and RA1 were absent with a 50% LICA stenosis, the total blood flow closely resembled that of a complete CoW with 75% LICA stenosis. In cases of proximal ICA stenosis, downstream regions showed elevated oscillatory shear index (OSI >0.2) and reduced time-averaged wall shear stress (TAWSS <1 Pa). With increasing stenosis severity, areas of high OSI shifted, and regions of low TAWSS expanded notably. At 75% stenosis, the area with TAWSS <1 Pa downstream significantly increased. Until complete occlusion, the area of low TAWSS and high OSI were maximized. Conclusion: This study underscores how anatomical variations in the CoW, combined with ICA stenosis, impact both total cerebral blood flow and its distribution among different outlets. Moreover, it highlights the potential for increased atherosclerosis development in affected areas. Particularly notable is the finding the absence of LP1 and RA1 vessels alongside 50% LICA stenosis results in blood flow patterns similar to those seen with 75% LICA stenosis in a complete CoW, emphasizing clinical implications for the patient. Hemodynamic changes, including TAWSS and OSI, are most pronounced downstream of the stenosis especially when the stenosis rate exceeds 75%.

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An 89-year-old Caucasian male cadaver with prostate cancer demonstrated bilateral persistence of the median artery and bifid median nerve (BMN) during upper limb dissection. The persistent median artery (PMA) originated from the common interosseous artery and coursed alongside the median nerve. Proximal to the carpal tunnel, the median nerve bifurcated into medial and lateral branches. To our knowledge, this is the first documented case of a bilateral PMA and BMN. While the majority of existing literature focuses on a unilateral PMA or unilateral BMN, bilateral occurrences of either variation are rare. This report presents a novel finding by documenting the simultaneous presence of a bilateral PMA and BMN.

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This study aimed to evaluate the pathological factors and anatomical variations in the maxillary sinus in patients undergoing dental implant treatment using cone beam computed tomography (CBCT). CBCT, as a key imaging technique in dentistry, offers high-resolution images to assess bone morphology and quality, crucial for preoperative dental implant planning. MATERIAL AND METHODS: The study included a cohort of 200 patients recommended for CBCT as part of their preoperative evaluation. The methodology involved detailed CBCT image analysis to identify and document various anatomical variations due to pneumatization, exostosis, hypoplasia, polyps, cysts, foreign bodies, and anthroliths within the maxillary sinus. RESULTS: Pneumatization was the most common variation, present in 77.5% of subjects. Polypoid lesions were found in 17.5% of patients, with a higher prevalence in younger age groups (57.1% in ages 20-35). Cysts and polyps affected 17.5% of subjects, predominantly males (65.7%). Anthroliths were observed in a minimal percentage (2%), and foreign bodies were found in 1.5% of the patients. Positive correlations were observed between the patient's age and both mucosal thickness and polypoid lesions and between the patient's gender and bone thickening (p-values < 0.05). CONCLUSIONS: The study concluded that CBCT is essential in the preoperative assessment of the maxillary sinus in dental implant candidates due to its superior imaging capabilities, allowing for the identification of critical anatomical variations and pathologies. This thorough evaluation is imperative to ensure the success of implant placement and to mitigate potential complications. However, further research with larger, more diverse populations is recommended to confirm these findings.

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BACKGROUND: The common femoral artery and radial artery constitute the most common access sites in contemporaneous endovascular neurosurgery. Oftentimes, it may be impossible to reach the vascular target safely due to different circumstances, necessitating alternative approaches. We aim to review these "last resource" access sites described in the literature, focusing on the technical aspects as a convenient reference. METHODS: We performed a comprehensive literature search of PubMed capturing articles from 1958 to 2022. RESULTS: We identified nine alternative approaches for endovascular access, after excluding direct carotid stick: superficial temporal artery access in 60 patients, calvarial foramina access in five patients, occipital artery access in seven patients, middle meningeal artery access in six patients, vertebral artery access in 23 patients and external carotid artery, internal maxillary artery, facial artery or lingual artery in 40 patients. Indications for the use of alternative access points included tortuous or occluded vessels, small vessel calibers, or anatomic variation. Pathologies treated included dural arteriovenous fistulas, arteriovenous malformations, intracranial aneurysms, acute stroke, and intracranial stenosis. Diagnostic brain angiograms were also performed. CONCLUSIONS: Alternative vascular access routes expand the proceduralists' toolkit, enhancing the capability to manage complex cerebrovascular interventions. This review advocates for a broader understanding and consideration of these techniques, given their potential to significantly increase treatment options in neuroendovascular surgery.

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BACKGROUND: Anatomical variations of origin of the internal carotid artery (ICA) are very uncommon and may pose a diagnostic and therapeutic challenge. OBJECTIVE: We report a case of direct origin of the right ICA from the innominate artery (aplasia of common carotid artery) and a case of duplication of right ICA in healthy patients who performed duplex ultrasound (DUS) for primary cardiovascular prevention screening. METHODS: In both cases, the ultrasound scan was performed both in a transverse plane and on the longitudinal axis, and in one of the two cases, a computed tomography angiography was performed to confirm the diagnosis. A review of the current literature about anatomical variations of origin of carotid arteries was also performed. RESULTS: The most frequent congenital anomaly is represented by the aplasia of the CCA, followed by the agenesis and by the duplication of the ICA. In most cases, the anomaly is discovered occasionally and symptoms are aspecific. Diagnosis is usually confirmed through a multimodality imaging approach, including DUS of extracranial carotid arteries, magnetic resonance imaging (MRI), and computed tomographic angiography. In most cases, treatment was conservative, with pharmacological therapy aimed at the symptoms. CONCLUSION: The recognition of such variations is mandatory, particularly when the patient needs a surgical treatment that may involve the vessel with the anatomical variations.

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Background: Several anatomical variations of the ilioinguinal nerve branches have been recorded in older studies. Knowledge of these variations is useful for the improvement of peripheral nerve blocks and avoidance of iatrogenic nerve injuries during abdominal surgeries. The purpose of this study is to perform a systematic review of the literature about the anatomical topography and variations of the ilioinguinal nerve. Methods: An extensive search in PubMed, Scopus, and Web of Science electronic databases was conducted by the first author in November 2021, with the use of the PRISMA guidelines. Anatomical or cadaveric studies about the origin, the course, and the distribution of the ilioinguinal nerve were included in this review. Thirty-one cadaveric studies were included for qualitative analysis. Results: Several anatomical variations of the ilioinguinal nerve were depicted including its general properties, its origin, its branching patterns, its course, its relation to anatomical landmarks, and its termination. Among them, the absence of ilioinguinal nerve ranged from 0% to 35%, its origin from L1 ranged from 65% to 100%, and its isolated emergence from psoas major ranged from 47% to 94.5%. Numerous anatomical variations of the ilioinguinal nerve exist, not commonly cited in classic anatomical textbooks. The branches of the ilioinguinal nerve may be damaged during spinal anesthesia and surgical procedures in the lower abdominal region. Conclusion: Therefore, a better understanding of the regional anatomy and its variations is of vital importance for the prevention of ilioinguinal nerve injuries.

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BACKGROUND: To conduct a morphological and morphometric analysis of the sacral hiatus (SH) using lumbosacral spine CT scans and to evaluate its clinical relevance in caudal epidural analgesia (CEA). MATERIALS AND METHODS: This retrospective study analyzed 77 lumbosacral spine CT scans from a diverse patient population. The shape of the SH was classified into common types: inverted U, inverted V, irregular, and bilobed. Morphometric measurements included the length, width, and depth at the apex of the SH. The apex level of the SH was also determined in relation to the sacral vertebrae, and statistical analysis was performed to identify any correlation between the apex level and the morphometric dimensions. RESULTS: The most frequent SH shape was inverted U (68.83%), followed by inverted V (20.77%), irregular (9%), and a single instance of a bilobed shape (1.29%). The apex of the SH was most commonly located at the level of the S4 vertebra (75.32%), followed by the S3 vertebra (20.77%), S5 in two (2.59) and S2 in one (1.29%). No significant correlation was found between the level of the apex and the length, width, or depth of the SH. These findings indicate a high degree of anatomical variability in the SH, independent of the apex level. CONCLUSIONS: The anatomical variability of the SH, as observed in this study, underscores the need for individualized assessment during CEA. The lack of correlation between the apex level and the morphometric dimensions of the SH highlights the importance of imaging modalities such as ultrasound or fluoroscopy to ensure precise localization and effective analgesia administration. These insights can improve clinical outcomes by enhancing the accuracy and safety of caudal epidural procedures.

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Rationale: Knowledge of the venous systems of the neck is important in microvascular anastomosis as well as to avoid unintended bleeding during neck dissection. Patient Concerns: We present three rare variations of the jugular system of the neck which could have complicated neck dissection. Diagnosis: The first case is of a posterior tributary from an internal jugular vein (IJV). The second case is an IJV with increased diameter of 3 cm and the third case is an aneurysm of the external jugular vein. Treatment: Careful dissection was carried out to avoid complications and to preserve the vessels for microvascular anastomosis. Outcome: No complications were encountered intraoperatively and post-operatively. Take-away Lessons: Variations from normal anatomy should be dealt with caution to avoid complications and to perform surgery precisely and efficiently.

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Purpose: Like other muscular compartments of the human body, the intrinsic muscles of the foot present considerable morphological variability. The aim of this review was to present variations that can potentially cause problems during surgery but might be detected during an ultrasound examination. Materials and methods: PubMed was searched for relevant articles. The identified papers were listed, and citation tracking was performed. Results: Even though lower limb structure is well studied, the variations associated with the intrinsic muscles of the foot and their related ultrasound examination are not. Conclusions: The muscles and tendons of the foot demonstrate similar degrees of variance as other regions of the human body; however, this subject is not as widely covered in the literature. Further ultrasound studies are needed to build awareness of morphological variability in this region, as the findings could prevent misdiagnosis.

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OBJECTIVE: TMD is a multifaceted condition with various contributing factors, but the actual impact of the lateral pterygoid plate on the development of TMD remains uncertain. This research aims to investigate the relationship between anatomical variations of the lateral pterygoid plate (LPP), including its angle and proximity to the condyle, and the prevalence of temporomandibular disorders (TMD), to improve diagnostic accuracy and therapeutic approaches for TMD. MATERIALS & METHODS: A retrospective analysis was conducted on 189 Cone Beam Computed Tomography (CBCT) images of individuals aged 18 to 45. Inclusion criteria were based on definitive diagnoses of degenerative joint disease, excluding individuals with orthodontic treatments, injuries, or craniofacial disorders.Participants were divided into TMD and control groups using standardized DC/TMD protocols for assessment. A radiologist, blinded to the patient's clinical status, then analyzed the CBCT images. LPP dimensions, angles, and condyle distances were measured using OnDemand 3D Imaging Software. RESULTS: The study found a statistically significant higher average LPP length in females compared to males (right LPP p < 0,001, left LPP p = 0,004), with no significant differences in LPP-condyle distances and angles between genders. Comparing the TMD and control groups revealed a positive correlation between lateral plate angles and TMJ disorders (p = 0,044), suggesting a potential biomechanical linkage. CONCLUSION: Conclusively, the study challenges the assumption that LPP anatomical variations significantly impact TMD while underscoring a potential link between LPP angle and TMD. The novel insight into the potential role of the LPP angle in TMD provides a new direction for research and clinical practice, emphasizing the importance of considering subtle anatomical differences in the management of TMD.

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Polydactyly is typically observed as isolated and sporadic occurrences, although familial cases do exist, albeit with lower frequency, manifesting in various inheritance patterns. In around 30% of polydactyly cases, there exists a familial history, suggesting the probable involvement of a single gene. Given its potential for hereditary transmission, thorough investigation of the patients' parents, first-degree relatives, grandparents, and even great-grandparents for similar disorders becomes imperative. In our clinic, we conducted an analysis focusing on patients presenting with foot polydactyly, along with occurrences of polydactyly among their first- and second-degree relatives spanning two to three generations of family history. The study encompassed three patients and their respective families, including a pair of siblings. We speculate that the inheritance type in our cases was autosomal dominant. Among our patients, one presented with central polydactyly, while the remaining patients and all familial cases displayed postaxial polydactyly. In terms of morphologic classification, one patient had a Y-shaped metatarsal, another had a T-shaped metatarsal, and the third patient exhibited a duplicated ray-shaped anomaly. In our review of the literature, we haven't come across a case spanning three generations like the ones we encountered. Additionally, the presence of a transverse accessory extensor tendon between both extensor tendons in cases with T- and Y-shaped metatarsals intrigued us from an anatomical perspective. Our goal is to present these rare cases of congenital familial polydactyly spanning three generations, highlighting the anatomical variations observed and aiming to contribute to the existing body of literature on the subject.

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PURPOSE: To assess the prevalence and configuration of bifid (BMC) and trifid (TMC) mandibular canals using computed tomography (CT), describing the anatomical characteristics of the accessory canals, especially of the retromolar type. MATERIALS AND METHODS: CT scans of 123 patients were analysed. BMCs were identified and the patterns of bifurcation were classified, including trifid canals. The width of accessory canals was measured. Retromolar canals were further classified according to their course and morphology, while their position and width were evaluated using linear measurements on CT images. RESULTS: The majority of patients (53.6%) presented at least one BMC or TMC. 36.2% of mandibular canals were bifid, while 4.5% were trifid. The forward canals (12.6%) and retromolar canals (10.2%) were the most common among BMCs. In relation to the retromolar canals, 60% were vertical and 40% curved, with a mean width of 1.03 ± 0.28mm. CONCLUSION: BMCs and TMCs are common 3D radiographic findings, so that they should be considered as anatomical variations, not anomalies. Preoperative CT or CBCT evaluation should aid in identifying these variations and analysing their position and course in surgical planning.

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An in-depth understanding of the anatomical variations of maxillary molars is essential for endodontic success. Unlike the maxillary second molars, the presence of a second palatal root is uncommon in the first maxillary molar. This case report describes two cases of non-surgical management of maxillary molars with extra palatal roots. Careful clinical examination, knowledge of the internal anatomy, and the use of advanced radiographic modalities like cone beam computed tomography (CBCT) can reveal the presence of variations in the internal and external anatomy of any tooth. Therefore, for nonsurgical as well as surgical management clinicians should always watch out for any deviations in a tooth and utilize all the available tools to diagnose and manage them successfully.

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BACKGROUND: Comprehension of the intrucate anatomy and variations in the termination of the popliteal artery (PA) is increasingly essential for endovascular interventionists, plastic surgeons, vascular surgeons, and orthopedic surgeons, due to the rise in procedures like embolectomy, vascular grafting, free fibular flap surgery, and high-tibial osteotomy. Few studies from India have reported on the variant anatomy of PA termination, and none have used 128-slice tomography. This study aimed to observe the terminal branching pattern of the PA and the morphology of its terminal branches using 128-slice computed tomography angiography (CTA) and to analyze its relation to gender and laterality. METHODOLOGY: A retrospective review of CTA images of 181 lower extremities from 100 patients (137 males and 44 females), aged five to 75 years, was conducted. RESULTS: The usual type I-A pattern was found in 75.69% of cases, while 24.31% exhibited variant patterns. Type III was the most common variation observed (19.34%), with type III-A being the most prevalent (11.05%). Types II-B and II-C were not observed. Among 84 bilaterally examined cases, 19.05% had unilateral variations and 15.48% had bilateral variations, with 8.33% showing bilaterally similar variations and 7.14% dissimilar variations. No significant difference in branching patterns was found between genders or sides. The mean length of the tibial-peroneal trunk (TPT) in the type I-A pattern was 3.00 ± 0.99 cm (right side: 3.21 ± 1.02 cm; left side: 2.82 ± 0.93 cm; males: 2.9 ± 1.00 cm; females: 3.37 ± 0.85 cm), with statistically significant differences between sides and genders. In the type II-A pattern, the mean TPT length was 7.16 ± 3.75 cm. An exceptionally long TPT (12.97 cm) was noted in one case of the III-B pattern. CONCLUSION: There is a high prevalence of variation in the termination pattern of the PA. Knowledge of these variations is crucial for any interventions in this region to avoid postoperative vascular complications and reduce patient suffering.

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INTRODUCTION: The purpose of this study was to characterize the morphological variations in the quadratus femoris muscle (QF) and to create an anatomical classification that could be used in the planning of surgical procedures in this area, radiological imaging, and rehabilitation. MATERIALS AND METHODS: Ninety-two lower limbs from 46 cadavers, fixed in 10 % formalin solution, were examined. RESULTS: The QF muscle was present in all specimens. According to morphology, the QF muscle was classified into three types. The most common type was Type I, characterized by one muscular belly (78.3 %), while the second most common type was Type II, characterized by two bellies, was observed in 17.4 % of cases. The rarest type was Type III. It was characterized by three bellies and was found in 4.3 % of the cases. CONCLUSIONS: The current classification system on quadratus femoris morphological variability is novel. Morphological variants may contribute to clinical issues, such as the ischiofemoral impingement syndrome, that could arise from type I quadratus femoris. Hence, the current study may be applicated to planning surgical procedures, imaging, and rehabilitation.

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BACKGROUND: Considering the tortuous course of the facial canal that houses the facial nerve, the stylomastoid artery and the homonymous vein, its morphological features are of great clinical significance in otologic, maxillofacial, oncologic, reconstructive and plastic surgery of the head and neck. The aim of this paper was to determine the individual specific features of the mastoid segment of facial canal and of the stylomastoid foramen. MATERIAL AND METHODS: The study was carried out on 82 temporal bones (41 right/41 left), at the Department of anatomy and clinical anatomy of Nicolae Testemitanu State University of Medicine and Pharmacy of the Republic of Moldova. The morphometry of the mastoid segment of the facial canal and of the stylomastoid foramen was performed. The morphometric parameters were statistically analyzed by descriptive and inferential statistics methods. RESULTS: The mastoid segment exited the facial canal by an obtuse, right and sharp angles, with a mean value of 113.1 ± 21.80° (right/left - 112.1 ± 23.85°/114.1 ± 19.76°), p = 0.701. The mean length of the mastoid segment was 15.1 ± 3.78 mm (right/left - 15.7 ± 3.66 mm/14.5 ± 3.84 mm), p = 0.153. The longitudinal diameter of the stylomastoid foramen had a mean of 3.0 ± 0.93 mm (right/left - 3.3 ± 0.96 mm/2.7 ± 0.81 mm), p = 0.007. The transverse diameter had a mean of 2.6 ± 0.74 mm (right/left - 2.9 ± 0.80 mm/2.4 ± 0.60 mm), p = 0.012. CONCLUSIONS: In otologic surgery and particularly in mastoidectomy, it should be taken into consideration that the mastoid segment of the facial canal could exit the temporal bone by a sharp, right and obtuse angles that along with high morphological variability of the stylomastoid foramen might be a predisposal factor for Bell's palsy.

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The lateral ankle joint is composed of three ligaments: the anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL) and calcaneofibular ligament (CFL). The ATFL and CFL demonstrate morphological variation, especially regarding their shape and number of bands. During standard anatomical dissection, an unusual type of triple CFL was observed: the CFL was composed of two bands originating on the lateral malleolus, and the presence of a lateral talocalcaneal ligament (LTC) originating on the talus bone. The insertion point of each band was located on the calcaneal bone. An understanding of these anatomical patterns provides a clearer view of ankle joint biomechanics, and improved the planning and performance of surgical treatment.

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PURPOSE: The gastrocnemius venous system presents different anatomical variants. There have been described four locations of myofascial trigger points (MTrPs) in this muscle. However, no studies have analyzed the coincidence between vessels and MTrPs present in the gastrocnemius. Therefore, the main objective was to study the anatomical variability of the venous system by ultrasound and its coincidence with the location of the MTrPs. METHODS: A total of 100 lower limbs were studied. The gastrocnemius vessels were analyzed one by one by sector (medial, central, and lateral), quantifying the number of vessels, their distribution, and the coincidence with MTrPs. RESULTS: All muscle heads showed at least one vessel per section. A large variability was observed, from one to eight vessels per muscle head, with the most frequent number being three in the gastrocnemius medialis and two in the gastrocnemius lateralis. In all cases, the location of the vessels coincided with the MTrPs. CONCLUSIONS: The proximal gastrocnemius venous pattern is very variable between subjects in number of vessels and distribution, which has made it impossible to define a "safe" approach window for invasive procedures without ultrasound guidance. The coincidence between the clinical location of MTrPs of the gastrocnemius and the presence of vessels is total.

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Knowledge of anatomical variability is extremely important in order to better understand the etiology of pain, if present, or to avoid iatrogenic consequences. Sometimes the anatomical "anomalies" have the same anamnesis but different causes. For example, sciatic neuralgia may be caused by a herniated disc or it may have a different origin. The sciatic nerve (SN), also known as the ischial nerve, is the widest in the human body. This huge peripheral nerve originates from the roots of the lumbosacral plexus (L4-S3) and passes through the great sciatic foramen, under the piriformis muscle (PM). However, there is much variability in the pattern of SNs about the muscle, which has been known since the first half of the 20th century. In the present study, we describe six different case reports of anatomical variations of the SN and its interplay with the PM. The observations were made during dissection classes at the ICLO Teaching and Research Centre (Verona, Italy), on both male and female cadavers aged between 58 and 84 years. The SN was reported as a single and divided nerve into the tibial nerve (TN) and the common peroneal nerve (CPN), passing alone above, below, or between the PM. However, the two parts of the SN may also interact with the PM in different ways, adding to the anatomical variability. A thorough knowledge of the anatomical variations in any part of the human body is extremely important. The various techniques used, from imaging to autopsy or surgery, are also useful in the SN pathway. Thus, the anatomical features and the understanding of each variation are useful for a correct approach that can lead to an effective and correct treatment with a favorable outcome.

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Background: Surgical procedures in the anterior mandibular region require a profound understanding of the complex anatomical structures to ensure patient safety. The lingual foramen (LF) and its intra-osseous canal are pivotal structures, supplying vascular and neural support to the mental region. The prevalence of LF is widely recognized, with variations among populations. Methods: The study involved 650 adult participants. Data were collected using high-resolution cone-beam computed tomography (CBCT), and statistical analysis was conducted, establishing inter-rater agreement. Results: The population had a varied age distribution, with males comprising 53.23% and females comprising 46.77%. The median lingual canal was found in the Supra and Infra spinosum (65.38%). Most participants had lateral lingual canals (60.92%). The most prevalent lingual foramina was 4 (30.62%). The study found no significant associations between gender and LF diameter, distribution in different travel directions, or LF locations. However, males had a slightly larger diameter. Conclusion: The findings provide valuable insights into LF variations based on anatomical locations, and there were no statistically significant differences in measurements across different age groups. This knowledge contributes to the evolving field of oral and maxillofacial surgery, ensuring better patient outcomes.