Aberrant Anatomy Research Articles

Anomalous venous collaterals in Apert and Crouzon syndromes and their relationship to ventricle size and increased intracranial pressure.

The exact association between the frequently present anomalous intracranial venous vasculature, emissary collaterals, ventriculomegaly, and increased intracranial pressure (ICP) in children with Apert and Crouzon syndromes remains an enigma. This study aimed to evaluate the association between the aberrant venous system and ventricle size and increased ICP, and to assess the development of the venous structures over time. This retrospective cohort study included all patients with Apert or Crouzon syndrome with available CT venography (CTV) scans of the brain. Anomalous venous vasculature was assessed by the total collateral score (TCS), which scored 9 intra- and extracranial venous structures (TCS range 0-16). Ventricle size (fronto-occipital horn ratio [FOHR]) was measured on the same scan. The presence of increased ICP, a shunt, tonsillar herniation, and head circumference were extracted from electronic patient records and were used as secondary covariates. Subsequent CTV scans were scored when available. Ninety patients were included in this study. The mean TCS was 7.5 ± 2.5, and was comparable for patients with Apert and Crouzon syndromes (mean 8.0 and 7.3, respectively). The presence of an extra abnormal venous structure was associated with an increase of the FOHR of 3.2% (p < 0.01). After dividing the venous structures into intra- and extracranial, a similar association between both and the FOHR was found (4.1% and 2.3%, respectively; p < 0.01). The TCS was similar for patients with normal and increased ICP at the time of the scan. Sixteen patients had dual CTV scans. The median time between both scans was 3.2 years. The presence of collaterals remained stable over time (median ΔTCS = 0.3). Seven patients with functioning shunts also maintained high TCSs (median TCS = 9). In patients with Apert and Crouzon syndromes, a close relationship between venous collaterals and ventricle size was observed, in which a more extensive aberrant venous drainage pattern, both intra- and extracranial, was associated with larger ventricles. Preliminary longitudinal data suggested that the presence of venous collaterals remained constant over time despite effective treatment of increased ICP, indicating reliance on these collaterals even in cases of normal ICP. The authors hypothesize that this dependence on collateral drainage is the result of their aberrant internal venous anatomy and predisposes individuals to increased ICP.

Microvascular Decompression for Trigeminal Neuralgia Secondary to Vertebrobasilar Dolichoectasia: Review of the Literature and Illustrative Case

Classical trigeminal neuralgia (TN) is a chronic pain disorder characterized by severe, unilateral facial pain, often resulting from vasculonervous conflict. A less common cause of TN is vertebrobasilar dolichoectasia (VBD). Microvascular decompression (MVD) is the preferred surgical intervention for TN, but in case of VBD, the surgical procedure is more complex due to the aberrant vascular anatomy. This study aims to review the evidence on MVD for VBD-induced TN, and analyze operative challenges, efficacy, and postoperative outcomes. An illustrative case is also presented. We report on the case of a 62-year-old male with a 7-year history of right-sided TN affecting the maxillary (V2) and mandibular (V3) territories. The patient underwent MVD using the interposition technique, where Teflon sponges were placed between the basilar artery and the nerve. Postoperatively, the patient experienced complete pain relief without neurological deficits. At 12 months follow-up, the patient remained pain-free and off medications. We performed an extensive literature review using PubMed, Scopus, and Web of Sciences, highlighting the most relevant studies and findings on the topic. The literature review showed that, while MVD is effective in providing long-term pain relief in VBD-induced TN, the choice between interposition and transposition techniques remains debated. Interposition is easier to perform but may inadvertently increase nerve compression in some cases, whereas transposition offers more definitive decompression but carries higher technical risks. Our case and the available literature highlight the importance of individualized treatment planning in achieving optimal outcomes for patients with VBD-induced TN. Further research is needed to refine surgical techniques and minimize complications in this subset of TN patients.

Aberrant right subclavian artery intervention can provide relief of dysphagia.

An aberrant right subclavian artery represents the most common aortic arch vascular anomaly. Conventional wisdom states that these anomalies do not result in dysphagia, but rather serve as "red herrings". Clearly, in the vast majority of cases, this holds true. Nonetheless, one should never say never. Herein, we present a cohort of four children with debilitating dysphagia resulting from an aberrant right subclavian artery. Subclavian reimplantation via a right posterolateral thoracotomy was performed successfully in all cases. Dysphagia resolved postoperatively, and all patients were able to advance to a normal diet. They were able to gain appropriate weight postoperatively and continue to do well at most recent clinical follow-up. This case series suggests that aberrant right subclavian artery anatomy should be considered a potential aetiology of dysphagia, albeit rarely. Surgical intervention for select patients can provide dramatic resolution of symptoms.

Non-Surgical Endodontic Management of Teeth with Aberrant Anatomy: A Case Series

The root canal therapy aims to remove the necrotic and vital pulp tissue remnants from the root canal to treat the periradicular inflammation. The knowledge of the tooth anatomy is essential to ensure a successful treatment. However, the deviation of the tooth anatomy complicates the diagnostic and treatment processes. Effective management of such complexities requires a tailored approach, utilizing detailed imaging and precise endodontic techniques to achieve successful outcomes and restore patient function and comfort. This case series presents the endodontic management of three different anatomic variations of permanent teeth that include taurodontism in the mandibular molar, two rooted mandibular canine and dilacerated maxillary central incisor and underscores the importance of personalized treatment planning and advanced diagnostic tools in managing complex dental anomalies.

Clinical implications of aberrant anatomy of the common hepatic duct in liver surgery: a systematic review and meta-analysis.

Knowledge of anatomical variants that affect the hepatic duct (HD) are of particular clinical relevance during hepatobiliary surgical procedures. More specifically, the aberrant anatomy of the common HD is the most common anatomical variation affecting the biliary tree. Below, we describe different classifications of anatomical variants that affect this canal. According to Huang's classification, variations are determined depending on the insertion of the right posterior hepatic duct (RPHD). Medline, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS databases were investigated until January 2024. The methodological quality was assessed with an anatomical studies assurance tool (AQUA). Pooled prevalence was estimated using a random effects model. For the subgroup analysis, Student's T-test was used. The prevalence rate of aberrant hepatic duct (AHD) was 15% (confidence interval [CI] of 7-22%). The first subgroup had cadavers and images. For the cadavers, the prevalence was 15.83% (CI: 11.22-18.3%), while the images had a prevalence of 22.06% (CI: 18.12-25.33%). This subgroup analysis showed no statistically significant difference between these groups (p = 0.127). The second subgroup comprised the continents where the included studies were from. In this subgroup, no statistically significant differences were found (p = 0.613). Finally, regarding the right or left laterality of the HD variant, there were no statistically significant differences (p = 0.089). A AHD corresponds to a finding that can occur in a significant percentage of our society, which could be an accidental discovery during surgeries or present asymptomatically throughout life and be a cadaveric discovery later. We believe it is important for surgeons to have prior knowledge of the possible variants of HD to prevent possible complications during and after surgery.

The Middle Mesial Canal: Combined Endodontic and Restorative Treatment Approach - A Case Report

The management of the middle mesial canal (MMC) in mandibular first molars presents considerable challenges during endodontic treatment due to its complex anatomy. Challenges may arise throughout various stages of treatment, including canal location, instrumentation, and obturation. The inability to identify and shape this canal can lead to endodontic failure and post-treatment apical periodontitis. Therefore, understanding this aberrant root canal anatomy and its clinical implications during the various stages of endodontic treatment is essential for successful management, including the selection of the optimal coronal restoration to enhance the efficacy of the obturation’s coronal seal and to ensure the restoration’s maximal longevity. This case report describes the diagnosis and successful endodontic and restorative management of an MMC in a mandibular first molar.

Pharyngeal Arches, Chapter 2: Ear and Neck Abnormalities.

The pharyngeal arches are the foundation of face and neck development. Impaired development of these embryologic structures can result in craniofacial abnormalities. Surgeons who manage head and neck pathology will invariably encounter conditions associated with aberrant pharyngeal arch anatomy, and a thorough understanding of the normal development of these structures is paramount to accurate diagnosis and treatment. This manuscript is the second of a four-part series written for plastic surgeons, focusing on the abnormal development of pharyngeal arches leading to pathologic ear and neck anomalies seen in clinical practice.

Endodontic management of an aberrant root canal anatomy: a case report and literature review

Endodontic management of an aberrant root canal anatomy: a case report and literature review

Cardiopulmonary crisis caused by bronchial blocker malposition in a patient with aberrant tracheal anatomy: a case report

BackgroundDouble-lumen tubes (DLTs) and bronchial blockers (BBs) can be used to establish one-lung ventilation (OLV) for thoracic surgery. BBs are a good alternative when DLTs are not suitable or patients have difficult airways. However, BBs are more prone to malposition, leading to adverse events.Case presentationWe present a 68-year-old male patient who was scheduled for thoracoscopic left lower lobectomy. The patient was not expected to have airway malformation preoperatively. When the DLT could not be inserted into the bronchus after general anesthesia induction, we used a BB to perform OLV. During surgery, malposition of the BB resulted in the development of an “incomplete balloon valve”, leading to a cardiopulmonary crisis.ConclusionsPreviewing chest computed tomography scans to assess the airway anatomy before thoracic surgery is essential. Three-dimensional reconstruction of the airway can provide a more intuitive assessment of airway anatomy. During OLV with BBs, we should pay attention to balloon malposition to prevent cardiopulmonary crises.

Outcomes of robot-assisted laparoscopic pyeloplasty among pediatric patients with complex renal anatomy: A retrospective comparative study

Robot-assisted laparoscopic pyeloplasty (RALP) has been increasingly utilized in the treatment of pediatric ureteropelvic junction obstruction (UPJO) with reported success rates of >95%. Complex renal anatomy can make some cases challenging to reconstruct. To evaluate outcomes of children undergoing RALP with aberrant renal anatomy and compare it to those with simple renal anatomy. An IRB approved prospective registry was queried to retrospectively identify all patients who underwent robotic pyeloplasty at our institution from 2012 to 2022. Patients undergoing re-do pyeloplasty were excluded. Complex anatomy was defined as horseshoe kidney, ectopic/pelvic kidney, duplex collecting system, fully bifid renal pelvis and severe malrotation (≥180°). A comparative analysis of baseline demographics, pre-operative clinical/radiological characteristics, intra and post-operative details, and long-term success was performed between those patients with complex anatomy and those without. Of 405 total robotic pyeloplasty's, 375 patients (378 total pyeloplasty; 353 simple, 22 complex) met inclusion criteria. 27 re-do were excluded from analysis. The complex pyeloplasty cohort included 9 horseshoe kidneys, 8 duplex collecting systems, 3 ectopic/pelvic kidneys and 2 kidneys with severe malrotation. There was no difference in age (58 vs 31 months; p=0.38), procedure time (203 vs 207min; p=0.06), length of stay (1.4 vs 1.3 days; p=0.99), or success (91.6% vs 100%; p=0.24) between the simple and complex groups. Etiology of obstruction differed significantly between groups - high insertion was more common (3.9% vs 18.2%, p=0.02) and intrinsic narrowing was less common (60.1% vs 36.4%, p=0.04) in patients with complex anatomy. A multivariate logistic regression was adjusted for age, gender, etiology of obstruction, preoperative differential renal function and post-operative complications and found no difference in success between complex and simple RALP. The findings showed no significant differences in age, procedure time, length of hospital stay, or success rates between the two groups. Specifically, the success rates were 91.6% for the complex group and 100% for the simple group (p=0.24), indicating comparable efficacy. However, the etiology of obstruction varied significantly, with high ureteral insertion more common in the complex anatomy group (18.2% vs. 3.9%, p=0.02) and intrinsic narrowing less common (36.4% vs. 60.1%, p=0.04). Despite these differences, multivariate logistic regression, adjusted for confounders, confirmed no difference in success rates between the groups. RALP is a safe and efficacious approach in patients with complex anatomy with success rates comparable to index patients. High ureteral insertion does appear to be more common in patients with complex anatomy undergoing pyeloplasty.

Case report: Conservative management of a blunt trauma to a horseshoe kidney

With trauma representing the leading cause of death in children, and renal injuries representing a large proportion of that trauma, understanding the appropriate management of renal injuries is vital to preventing pediatric morbidity and mortality. Cases involving aberrant anatomy are even more crucial to understand as there is less data on appropriate management. Here, a case is presented of a 7-year-old male presenting after a horse kick to the abdomen resulting in traumatic disruption of a previously unknown horseshoe kidney and the subsequent conservative management. The patient presented with abdominal pain, leukocytosis, and elevated liver function enzymes. An abdominal and pelvic Computed Tomography (CT) demonstrated a horseshoe kidney with a grade IV laceration to the isthmus and left lower pole of the kidney resulting in fracture/disruption of previously fused horseshoe kidneys. Additionally, there was a large retroperitoneal hematoma and hemoperitoneum. The patient was successfully managed with observation, and hemodynamic monitoring and has had resolution of hematoma and preserved kidney function through 8 months of follow-up. In conclusion, this is an example of how a patient with complicated renal anatomy can be managed conservatively to model for potential future cases.

Comparative study of left vertebral artery revascularization in patients with and without aberrant left vertebral anatomy: Presented at the Thirty-eighth Annual Meeting of the Western Vascular Society, Kauai, Hawaii, September 9-12, 2023.

Comparative study of left vertebral artery revascularization in patients with and without aberrant left vertebral anatomy: Presented at the Thirty-eighth Annual Meeting of the Western Vascular Society, Kauai, Hawaii, September 9-12, 2023.

Aortic Arch:Embryology and Remodeling

A right aortic arch and aberrant subclavian artery result from an interruption in the remodeling of the pharyngeal arch arteries. We occasionally encounter this anatomical variation during angiography. Patients with disorders such as Down syndrome and congenital heart disease show a high incidence of an aberrant right subclavian artery, and this anomaly can cause symptomatic esophageal or tracheal compression. The root of the aberrant artery may show dilatation(referred to as a Kommerell diverticulum), dissection, intramural hematoma, or rupture necessitating cardiac intervention using a surgical or endovascular approach. Neurointerventionalists should have working knowledge of the anatomy to rapidly understand the anatomy and ensure a safe procedure. A left transradial approach should be considered if prior knowledge of the aberrant subclavian anatomy is available.

3D printed temporal bones for preoperative simulation and planning

ObjectiveDemonstrate the utility of 3D printed temporal bone models in individual patient preoperative planning and simulation. Methods3D models of the temporal bone were made from 5 pediatric and adult patients at a tertiary academic hospital with challenging surgical anatomy planned for cochlear implantation or exteriorization of cholesteatoma with complex labyrinthine fistula. The 3D models were created from CT scan used for preoperative planning, simulation and intraoperative reference. The utility of models was assessed for ease of segmentation and production and impact on surgery in regard to reducing intraoperative time and costs, improving safety and efficacy. ResultsThree patients received cochlear implants, two exteriorization of advanced cholesteatoma with fistulas (1 internal auditory canal/cochlea, 1 all three semicircular canals). Surgical planning and intraoperative referencing to the simulations by the attending surgeon and trainees significantly altered original surgical plans. In a case of X-linked hereditary deafness, optimal angles and rotation maneuvers for cochlear implant insertion reduced operating time by 93 min compared to the previous contralateral side surgery. Two cochlear implant cases planned for subtotal petrosectomy approach due to aberrant anatomy were successfully approached through routine mastoidectomy. The cholesteatoma cases were successfully exteriorized without necessitating partial labyrinthectomy or labyrinthine injury. There were no complications. Conclusion3D printed models for simulation training, surgical planning and use intraoperatively in temporal bone surgery demonstrated significant benefits in designing approaches, development of patient-specific techniques, avoidance of potential or actual complications encountered in previous or current surgery, and reduced surgical time and costs.

Successful coil embolization of a ruptured pseudoaneurysm of the superior gluteal artery after a percutaneous awake robot-assisted sacroiliac joint fusion: illustrative case.

Robot-assisted sacroiliac joint (SIJ) fusion has gained popularity, but it carries the risk of complications such as injury to the superior gluteal artery (SGA). The authors present the case of an awake percutaneous robot-assisted SIJ fusion leading to an SGA pseudoaneurysm. An 80-year-old male, who had undergone an awake percutaneous robot-assisted SIJ fusion, experienced postoperative left hip pain and bruising. Subsequent arteriography demonstrated an SGA branch pseudoaneurysm requiring coil embolization. An SGA injury, although uncommon (1.2% incidence), can arise from percutaneous screw placement, aberrant anatomy, or hardware contact. Thorough preoperative imaging, precise robot-assisted screw insertion, and soft tissue protection are crucial to mitigate risks. Immediate angiography aids in prompt diagnosis and effective intervention. Comprehensive knowledge of anatomical variants is essential for managing complications and optimizing preventative measures in robot-assisted SIJ fusion.

Left Vertebral Artery Revascularization in Distal Aortic Arch Surgery: Comparative Study of Patients With and Without Aberrant Left Vertebral Anatomy

Left Vertebral Artery Revascularization in Distal Aortic Arch Surgery: Comparative Study of Patients With and Without Aberrant Left Vertebral Anatomy

Defining the Shape of the Mylohyoid Muscle: A Morphometric Imaging Study.

Implantable hypoglossal nerve stimulation (HNS) therapy is an evolving therapeutic alternative for patients with refractory obstructive sleep apnea (OSA). The muscular anatomy of this region has implications for surgical access through this zone as well as positioning and anchoring of hardware in this area. The purpose of this study was to radiologically describe the topography of the mylohyoid muscle and adjacent structures across a wide age spectrum. We retrospectively evaluated computed tomography scans of the neck in 102 patients who were imaged for reasons unrelated to the floor of mouth or submental space. Patients with prior surgery or pathology in the area of interest were excluded. Fourteen relevant muscle measurements were made on a midline sagittal image and a coronal image positioned at the midpoint between the hyoid bone and the mandible. We included 49 men and 53 women with an average age of 44 years (range 19-70). The average mylohyoid length was 42 mm; the average distance between the anterior digastric bellies was 17 mm. The average angle of the central mylohyoid was 174° in the sagittal plane and 164° in the coronal plane. Several measurements were significantly correlated with patient age, including the angle measurements and the distance between the digastric muscles. Aberrant digastric anatomy was common. The mylohyoid muscle has multiple radiologically distinct segments with predictable curvatures. An understanding of submental muscular anatomy, along with its variability between patients, may be beneficial to the development of bilateral implantable neurostimulation technology for the treatment of refractory OSA. N/A Laryngoscope, 134:2970-2975, 2024.

Defective pollen tube tip growth induces neo-polyploid infertility.

Genome duplication (generating polyploids) is an engine of novelty in eukaryotic evolution and a promising crop improvement tool. Yet newly formed polyploids often have low fertility. Here we report that a severe fertility-compromising defect in pollen tube tip growth arises in new polyploids of Arabidopsis arenosa. Pollen tubes of newly polyploid A. arenosa grow slowly, have aberrant anatomy and disrupted physiology, often burst prematurely, and have altered gene expression. These phenotypes recover in evolved polyploids. We also show that gametophytic (pollen tube) genotypes of two tip-growth genes under selection in natural tetraploid A. arenosa are strongly associated with pollen tube performance in the tetraploid. Our work establishes pollen tube tip growth as an important fertility challenge for neo-polyploid plants and provides insights into a naturally evolved multigenic solution.

Retrograde Epidural Spinal Cord Stimulation for the Treatment of Intractable Neuropathic Pain Following Spinal Cord and Cauda Equina Injuries: A Case Report and Literature Review

AbstRactSpinal cord stimulation (SCS) offers an alternative treatment for refractory pain resulting from various etiologies. Generally, SCS electrodes are inserted in an anterograde fashion, moving from caudal to rostral direction. However, there are instances where anterograde placement is unfeasible due to technical limitations. We present the use of retrograde surgical electrode placement in SCS for a patient with extensive epidural fibrosis at the site intended for electrode insertion. A 48-year-old female suffering from refractory neuropathic pain caused from injuries to the conus medullaris and cauda equina opted for SCS. During the SCS trial procedure, challenges emerged when attempting percutaneous electrode insertion at the site of a prior T12 laminectomy. However, the trial stimulation resulted in significant pain relief. For the permanent placement of the stimulator, utilizing a surgical electrode centered at T11 vertebral level, a considerable amount of epidural fibrosis was encountered at the entry of the spine, particularly at the T12 vertebral level. To avoid dural injury and ensure accurate electrode positioning, a retrograde technique for surgical electrode was employed via partial laminectomies at the T9-T10 level. The final electrode positioning was in accordance with the preoperative plan, well-centered at the T11 vertebral level. The patient experienced sustained relief from neuropathic pain over the long term. Retrograde epidural SCS is a suitable option for cases characterized by extensive epidural fibrosis resulting from a previous spinal surgery or when the anterograde placement of the electrode is unattainable due to aberrant vertebral anatomy.

End-to-end revascularization between the occipital Artery(OA) and the p1 segment of posterior inferior cerebellar Artery(PICA) for a patient with posterior circulation ischemia via a far-lateral approach:2-Dimensional Operative video

Vertebral artery （VA）Aneurysms involving the origin of the posterior inferior cerebellar artery (PICA) ,occasionally, induce cerebellum and brainstem infarction due to intraluminal thrombus and calcific VA stenosis. At times, vessel occlusion and revascularization is necessary for successful obliteration of these aneurysms.2 The occipital artery (OA) is often the preferred donor graft for lesions of the posterior fossa. Although most OA-PICA bypasses can be performed using the p3 segment as the recipient site for an end-to-side anastomosis, a more feasible alternative to conventional OA-p3 PICA bypass in cases of high-riding caudal loops , aberrant anatomy or p3 multiple perforators is to free the p1 PICA, transpose it away from the lower cranial nerves, and perform an end-to-end OA-p1 PICA bypass instead. This video captures the dissection of the OA using an orientational anterograde harvesting technique and the end-to-end anastomosis of the OA to the PICA at the p1 segment. This was performed in a 56-year-old man who presented with posterior circulation ischemia from a fusiform aneurysm with calcific vertebral artery stenosis located at the origin of the right PICA. The patient tolerated the procedure well and suffered no major complications related to the operation. He did experience some mild, posterior neck rigidity at the time of his 6-month follow-up, likely due to nerve injury that occurred while harvesting the OA. Overall, the patient remains in good neurologic status 1 year after the operation. The operation proved the feasibility of end-to-end bypass in OA-p1 PICA.