Anatomical Variations Research Articles

The seasonal dynamics of cross-sectional tissue characteristics of Corylus mandshurica twig, petiole, and leaf vein are inconsistent

This study aims to explore how the environment affects the variation and trade-offs of anatomical traits in shrub plants, contributing to a deeper understanding of plant survival strategies and mechanisms of adaptation to the environment. The dominant shrub species Corylus mandshurica in the broad-leaved Korean pine (Pinus koraiensis) forest was selected as the research subject. Current-year twigs and leaves of C. mandshurica were collected in spring (May), summer (July), and autumn (September). Anatomical traits, including non-vascular column proportion (NVP), vascular column proportion (VP), phloem proportion (PP), and xylem proportion (XP), were measured for twigs, lower part of petioles, upper part of petioles, and leaf veins. We found that (1) Compared with seasons, organ type explained most of the variation in the four traits (NVP = 96%, VP = 87%, PP = 81%, XP = 76%). Lower part of petioles served as the turning point in the variation trend of tissue proportions in cross-sectional structure along the sequence of twigs, lower part of petioles, upper part of petioles, and leaf veins. (2) In spring, C. mandshurica exhibits higher NVP but lower VP and PP, while the results in summer and autumn are opposite to those in spring. Among different organs, twigs show lower NVP but higher VP and XP; whereas petioles and leaf veins show the opposite pattern. (3) Both hydrothermal conditions (monthly precipitation and mean monthly temperature) and light (canopy openness and total transmitted radiation) were the dominant environmental factors influencing anatomical trait variation. In different seasons, the response of NVP and VP in C. mandshurica twigs to dominant environmental factors was opposite to that of lower part of petioles, upper part of petioles, and leaf veins. The response of cross-sectional anatomical traits of current-year twigs, petioles, and leaf veins in C. mandshurica to seasonal changes exhibits distinct characteristics. Furthermore, twigs, petioles, and leaf veins demonstrate distinct survival strategies. Future research should focus on the variation of traits in different plant organs and their connecting parts.

Acroparesthesias: An Overview.

Acroparesthesia is a symptom characterized by a subjective sensation, such as numbness, tingling, prickling, and reduced sensation, affecting the extremities (fingers and toes). Despite its frequency, data regarding its diagnostic approach and management are scarce. The etiological diagnosis of acroparesthesia is sometimes challenging since it can be due to abnormality anywhere along the sensory pathway from the peripheral nervous system to the cerebral cortex. Acroparesthesia can reveal several diseases. It can be associated with rheumatic complaints such as arthritis or myalgia. Further cautions are required when paresthesia is acute (within days) in onset, rapidly progressive, severe, asymmetric, proximal, multifocal, or associated with predominant motor signs (limb weakness) or severe dysautonomia. Acroparesthesia may reveal Guillain-Barré syndrome or vasculitis, requiring rapid management. Acroparesthesia is a predominant symptom of polyneuropathy, typically distal and symmetric, often due to diabetes. However, it can occur in other diseases such as vitamin B12 deficiency, monoclonal gammopathy of undetermined significance, or Fabry's disease. Mononeuropathy, mainly carpal tunnel syndrome, remains the most common cause of acroparesthesia. Ultrasonography contributes to the diagnosis of nerve entrapment neuropathy by showing nerve enlargement, hypoechogenic nerve, and intraneural vascularity. Besides, it can reveal its cause, such as space-occupying lesions, anatomical nerve variations, or anomalous muscle. Ultrasonography is also helpful for entrapment neuropathy treatment, such as ultrasound-guided steroid injection or carpal tunnel release. The management of acroparesthesia depends on its causes. This article aimed to review and summarize current knowledge on acroparesthesia and its causes. We also propose an algorithm for the management of acroparesthesia.

Salvage Aneurysmorrhaphy as an Adaptable and Still Pertinent Technique in the Management of Challenging True Aneurysms of Arteriovenous Fistulas: A Case Series of Different Variations, With Illustrative Surgical Pictures

IntroductionAneurysmorrhaphy, described as reduction aneurysmoplasty, partial aneurysmectomy, or vessel wall recalibration, can be considered a suitable surgical plan for true aneurysms of arteriovenous fistulas (AVFs), allowing for a dynamic approach to reconstruction of aneurysmal AVFs of different severities, ensuring salvage of the native access. ReportSix challenging cases of AVF aneurysms are presented, some with extremely dilated and tortuous megafistulas, for which three surgical technique variations were performed. The patients had a mean age of 59.2 years, 50% were female, with brachiocephalic (n = 5, 83.3%) or brachiobasilic (n = 1, 16.7%) AVFs. The fistulas were created an average of 4.67 years previously, and the aneurysms had an average maximum diameter of 37.5 mm (range 25 – 60 mm). Surgical indications were rupture risk, thrombosis, or outflow stenosis compromising haemodialysis, infections, and concerns for quality of life (affected by post-puncture bleedings, disfiguring aesthetics, pain, and discomfort). The surgical techniques were simple aneurysmorrhaphy (n = 3, 50%), aneurysmorrhaphy with partial excision of aneurysmatic segment with end to end anastomosis of venous ends (n = 2, 33.3%), and aneurysmorrhaphy with establishment of new venous outflow (n = 1, 16.7%). All AVFs were patent post-operatively and at follow up (mean 5.6 months, median one month). Haemodialysis was resumed through the AVFs at a mean of 2.17 weeks post-operatively, with placement of an alternative route for haemodialysis in the meantime. No patients experienced post-operative complications. DiscussionExperience with the more challenging cases shows that aneurysmorrhaphy can still be considered an acceptable, flexible, and pertinent method for salvage of megafistulas, giving the surgeon the much needed versatility to adapt to anatomical and pathological variations, with high patency rates and minimum complications, especially when other treatment options are not possible in complicated cases. AVF salvage through aneurysmorrhaphy allows for a dynamic approach to the reconstruction of severely tortuous, dilated veins, ensuring patency of the native AVF.

Adrenal Vein Sampling: Tips and Tricks.

Adrenal vein sampling (AVS) is the standard method for distinguishing unilateral from bilateral sources of autonomous aldosterone production in patients with primary aldosteronism. This procedure has been performed at limited specialized centers due to its technical complexity. With recent advances in imaging technology and knowledge of adrenal vein anatomy in parallel with the development of adjunctive techniques, AVS has become easier to perform, even at nonspecialized centers. Although rare, anatomic variants of the adrenal veins can cause sampling failure or misinterpretation of the sampling results. The inferior accessory hepatic vein and the inferior emissary vein are useful anatomic landmarks for right adrenal vein cannulation, which is the most difficult and crucial step in AVS. Meticulous assessment of adrenal vein anatomy on multidetector CT images and the use of a catheter suitable for the anatomy are crucial for adrenal vein cannulation. Adjunctive techniques such as intraprocedural cortisol assay, cone-beam CT, and coaxial guidewire-catheter techniques are useful tools to confirm right adrenal vein cannulation or to troubleshoot difficult blood sampling. Interventional radiologists should be involved in interpreting the sampling results because technical factors may affect the results. In rare instances, bilateral adrenal suppression, in which aldosterone-to-cortisol ratios of both adrenal glands are lower than that of the inferior vena cava, can be encountered. Repeat sampling may be necessary in this situation. Collaboration with endocrinology and laboratory medicine services is of great importance to optimize the quality of the samples and for smooth and successful operation. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Liver ultrasound: Normal anatomy and pathologic findings

The goal of this article is to give an overview of intraoperative liver ultrasound, including the indications, different ultrasound techniques, and the ultrasound appearance of normal anatomy, more common anatomic variations, and common hepatic tumors.

The relationship of medial sigmoid depression and sigmoid notch morphology with vertical and sagittal growth patterns in Turkish population

Medial sigmoid depression (MSD) is an anatomical variation located just below the deepest point of the sigmoid notch (SN). The etiology of MSD is unknown. It has been reported that increased maximum bite force affects the occurrence of MSD, and vertical growth pattern affects SN morphology. The aim of this study was to investigate the effects of these malocclusions on the presence and morphology of MSD and SN, since bite force can change with vertical and sagittal growth patterns. This is the first study to investigate the effects of vertical growth pattern on the presence and morphology of MSD, and the effects of sagittal growth pattern on SN morphology. Panoramic and lateral cephalometric radiographs of a total of 634 (427 female, 207 male) patients aged from 18 to 35 years (mean 19.58) were included in this retrospective study. MSD and SN shapes, SN depth and width were evaluated on panoramic radiographs. Mann Whitney-U, Kruskal-Wallis and Chi-square tests were used for data analysis. Sagittal and vertical growth patterns were not significantly associated with the presence and shape of MSD (p>0.05). SN depth was greater in individuals with class III malocclusion, and both SN depth and width were lower in hyperdivergent individuals. There was no significant relationship between SN shapes and vertical and sagittal growth patterns (p>0.05). SN depth is affected by both vertical and sagittal growth pattern, and SN width is affected only by vertical growth pattern. The presence of MSD was not associated with growth pattern.

Co-occurrence of patent foramen ovale and Chiari network in a diabetic patient.

The coexistence of congenital cardiovascular anomalies provides valuable insights into the intricate nature of human cardiac anatomy and its potential interactions with underlying health conditions. This case report presents an autopsy analysis of a diabetic patient manifesting both a patent foramen ovale and a Chiari network. A 26-year-old male with a history of type 2 diabetes mellitus was admitted with post cardiac arrest. He died despite resuscitative efforts. Autopsy revealed notable findings including a patent foramen ovale and a Chiari network. Post-mortem biochemical markers indicated elevated HbA1c level and hyperglycaemia. The absence of cryptogenic strokes or paradoxical embolism prompted exploration into potential relationships between these anomalies and metabolic disturbances, and prompts a discussion about whether the observed anatomical variations could potentially serve as risk factors contributing to the patient's death due to complications of diabetes. The co-occurrence of a patent foramen ovale and a Chiari network within a diabetic patient, accompanied by elevated HbA1c level and hyperglycaemia, offers a unique perspective on the convergence of congenital cardiovascular variation and metabolic health. The juxtaposition of these anomalies with biochemical markers underscores the intricate interplay between cardiac morphology and metabolic conditions.

Morphometric analysis of the mastoid process using cone beam computed tomography

The sexual dimorphism of the mastoid process, as demonstrated by cone beam computed tomography (CBCT), is not well examined in forensic anthropology or clinical diagnostics. The mastoid region can be precisely imaged in three dimensions using CBCT, which reveals minute anatomical variations between males and females. These characteristics can help forensic professionals identify the sex of unidentified human remains, helping to solve crimes and aid in the search for missing persons. Moreover, recognising sexual dimorphism in the mastoid process in clinical settings can help with precise patient identification and individualised medical treatments, highlighting the important function of CBCT in both the forensic and medical areas.

A cone beam computed tomographic study on foramen transversarium

The foramen transversarium is a vital feature found in the cervical vertebrae of the spine. It serves as a protective passageway for the vertebral artery and vertebral vein, supplying blood to the brain and spinal cord. Any compromise to these structures within the foramen can lead to severe neurological complications, emphasizing its clinical significance. The study was carried out on 83 subjects of typical cervical vertebrae. Among them were 42 males and 41 females. All the foramen transversaria were observed for any anatomical variations. The anteroposterior, transverse diameters of all the foramen transversaria and the distance between the medial margin of uncinate process to the foramen transversarium were measured. The average transverse diameter of typical cervical vertebrae and seventh cervical vertebrae were ± 0.84mm and 5.13 ± 1.22 mm respectively. The average anteroposterior diameters of typical and seventh cervical vertebrae were 4.84 ± 0.69 mm and 3.91 ± 1.17 mm respectively. The distance from medial border of uncinate process to foramen transversaria was 4.28 ± 0.77 mm in typical and 5.44 ± 1.28 mm in seventh cervical vertebrae. The incidence of double bubble foramen in typical cervical vertebrae was reported to be17.5%. The incidence of double foramen transversaria was 12.5% in the seventh cervical vertebrae. Osteophytes were obstructing the foramen transversarium and narrowing it in 25% of vertebrae. In cone beam computed tomography (CBCT), the foramen transversarium plays a pivotal role in precise imaging of the cervical spine. Its significance lies in providing clear visualization of anatomical structures and potential abnormalities, aiding in the accurate diagnosis and treatment planning for various spinal conditions, thus enhancing patient care.

Safety and Tolerability of Online Adaptive High-Field Magnetic Resonance-Guided Radiotherapy.

In 2018, the first online adaptive magnetic resonance (MR)-guided radiotherapy (MRgRT) system using a 1.5-T MR-equipped linear accelerator (1.5-T MR-Linac) was clinically introduced. This system enables online adaptive radiotherapy, in which the radiation plan is adapted to size and shape changes of targets at each treatment session based on daily MR-visualized anatomy. To evaluate safety, tolerability, and technical feasibility of treatment with a 1.5-T MR-Linac, specifically focusing on the subset of patients treated with an online adaptive strategy (ie, the adapt-to-shape [ATS] approach). This cohort study included adults with solid tumors treated with a 1.5-T MR-Linac enrolled in Multi Outcome Evaluation for Radiation Therapy Using the MR-Linac (MOMENTUM), a large prospective international study of MRgRT between February 2019 and October 2021. Included were adults with solid tumors treated with a 1.5-T MR-Linac. Data were collected in Canada, Denmark, The Netherlands, United Kingdom, and the US. Data were analyzed in August 2023. All patients underwent MRgRT using a 1.5-T MR-Linac. Radiation prescriptions were consistent with institutional standards of care. Patterns of care, tolerability, and technical feasibility (ie, treatment completed as planned). Acute high-grade radiotherapy-related toxic effects (ie, grade 3 or higher toxic effects according to Common Terminology Criteria for Adverse Events version 5.0) occurring within the first 3 months after treatment delivery. In total, 1793 treatment courses (1772 patients) were included (median patient age, 69 years [range, 22-91 years]; 1384 male [77.2%]). Among 41 different treatment sites, common sites were prostate (745 [41.6%]), metastatic lymph nodes (233 [13.0%]), and brain (189 [10.5%]). ATS was used in 1050 courses (58.6%). MRgRT was completed as planned in 1720 treatment courses (95.9%). Patient withdrawal caused 5 patients (0.3%) to discontinue treatment. The incidence of radiotherapy-related grade 3 toxic effects was 1.4% (95% CI, 0.9%-2.0%) in the entire cohort and 0.4% (95% CI, 0.1%-1.0%) in the subset of patients treated with ATS. There were no radiotherapy-related grade 4 or 5 toxic effects. In this cohort study of patients treated on a 1.5-T MR-Linac, radiotherapy was safe and well tolerated. Online adaptation of the radiation plan at each treatment session to account for anatomic variations was associated with a low risk of acute grade 3 toxic effects.

Misdiagnosis or Missed Diagnosis - Hallux Sesamoid Fractures among Active-Duty Females in the United States Air Force: A Case Series

Background: Female service members tend to have a higher level of foot injuries than males. The United States Army spent $103 million in 2017 on fractures in toes and feet. Fractures of the tibial and fibular sesamoids are problem that often can be nonspecific, mainly related to pain at the plantar aspect of the first metatarsal head without an obvious traumatic event. Anatomic variation in these sesamoids exist after ossification which results in the possibility of multipartite sesamoids. Of the multipartite sesamoids, bipartite sesamoids are the relatively common and tripartite sesamoids are quite rare. The overall prevalence of bipartite sesamoids is presumed to be between 7 and 30%, with a majority occurring bilaterally. Methods: We completed a case series on three female active-duty Airmen. All three patients were active with their pain beginning following activity. All three were subsequently misdiagnosed, resulting in at least 6 months of pain prior to diagnosis and treatment. Results: Plain film radiography and subsequent imaging confirmed the diagnosis of a tibial or fibular sesamoid fracture. Following conservative treatment all three patients made a full recovery as confirmed by imaging and self-reported pain levels and they were able to return to full activity. Conclusion: Providers should keep a sesamoid fracture in the differential diagnosis when evaluating active female patients with pain in the area around the base of the great toe, especially in women in the military and others that may do higher levels of physical activity compared to the average patient. While the diagnosis of sesamoid fractures can be challenging, it is standard practice to obtain multiple views if using plain film radiography. Magnetic resonance imaging, weightbearing computed tomography and bone scans can be useful confirmatory studies.

Study of Anatomical Divergences in Facial Artery Endings

Facial artery supplies musculocutaneous tissue, visceral organs, and salivary glands at the upper cervical and facial level. This artery has wide range of anatomical variations in its course. Objective: To find the anatomical divergences in facial artery endings. Methods: It is a cross sectional study conducted at Jinnah international hospital, Abbottabad from January 2023 to July 2023 for duration of 6 months after taking approval from the ethical review committee. A group of 86 people were selected and anatomical course of facial artery was categorized in to four types. Angiographic images of each participant were evaluated by radiologist to categorize the course of facial artery. Results: The average Body Mass Index (BMI) of the participants was 28.3 ± 5.6. The study of angiographic images has concluded that 38.37% (n=33) has Type I course of facial artery, 47.67% (n=41) participants has Type II, 9.3% (n=8) participants has Type III and 4.65% (n=4) has Type IV category (p=0.01. Of the type I category of facial artery, 5 (15.2%) participants met the criteria of type IA, 7(21.2%) has Type IB and 21(63.6%) participants Type IC course of facial artery (p=0.01). Conclusions: This study has concluded that there exists vast variation in the anatomical course of facial artery in local population that streamlines with other studies conducted internationally. Facial artery with a nasal branch with or without alar endings is the most common anatomical variation.

Infraorbital canal variants and its clinical and surgical implications. A systematic review.

Recent literature highlights anomalous cranial nerves in the sinonasal region, notably in the sphenoid and maxillary sinuses, linked to anatomical factors. However, data on the suspended infraorbital canal (IOC) variant is scarce in cross-sectional imaging. Anatomical variations in the sphenoid sinuses, including optic, maxillary, and vidian nerves, raise interest among specialists involved in advanced sinonasal procedures. The infraorbital nerve's (ION) course along the orbital floor and its abnormal positioning within the orbital and maxillary sinus region pose risks of iatrogenic complications. A comprehensive radiological assessment is crucial before sinonasal surgeries. Cone-beam computed tomography (CBCT) is preferred for its spatial resolution and reduced radiation exposure. The aim of this study was to describe the prevalence of anatomical variants of the infraorbital canal (IOC) and report its association with clinical condition or surgical implication. We searched Medline, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS databases from their inception up to June 2023. Two authors independently performed the search, study selection, data extraction, and assessed the methodological quality with assurance tool for anatomical studies (AQUA). Finally, the pooled prevalence was estimated using a random effects model. Preliminary results show that three types are prevalent, type 1: the IOC does not bulge into the maxillary sinus (MS); therefore, the infraorbital foramen through the anterior wall of MS could be used for identification of the ION. Type 2: the IOC divided the orbital floor into medial and lateral aspects. Type 3: the IOC hangs in the MS and the entire orbital floor lying above the IOC. From which the clinical implications where mainly surgical, in type 1 the infraorbital foramen through the anterior wall of MS could be used for identification of the ION, while in type 2, since the lateral orbital floor could not be directly accessed an inferiorly transposition of ION is helpful to expose the lateral orbital wall directly with a 0 scope; or using angled endoscopes and instruments, however, the authors opinion is that direct exposure potentially facilitates the visualization and management in complex situations such as residual or recurrent mass, foreign body, and fracture located at the lateral aspect of the canal. Lastly, in type 3, the ION it's easily exposed with a 0° scope. This systematic review identified four IOC variants: Type 1, within or below the MS roof; Type 2, partially protruding into the sinus; Type 3, fully protruding into the sinus or suspended from the roof; and Type 4, in the orbital floor. Clinical recommendations aim to prevent nerve injuries and enhance preoperative assessments. However, the lack of consistent statistical methods limits robust associations between IOC variants and clinical outcomes. Data heterogeneity and the absence of standardized reporting impede meta-analysis. Future research should prioritize detailed reporting, objective measurements, and statistical approaches for a comprehensive understanding of IOC variants and their clinical implications. Open Science Framework (OSF): https://doi.org/10.17605/OSF.IO/UGYFZ .

Percutaneous Biliary Endoscopy: History, Indications, Techniques, and Outcomes

AbstractPercutaneous biliary endoscopy (PBE), also known as cholangioscopy, represents a significant advancement in the field of interventional radiology. This technique offers a minimally invasive alternative to traditional surgery or peroral approaches for a range of biliary diseases, including stone clearance, biliary stricture/mass evaluation, and biopsies, making it particularly valuable in the management of complex biliary pathologies. It is especially significant for patients with anatomical variations or high surgical risk, where traditional approaches like endoscopic retrograde cholangiopancreatography, or surgical options, are not feasible. This article delves into the evolution, indications, technical nuances, and clinical outcomes of PBE, integrating comprehensive data from extensive research.

Relationship to the superficial radial nerve and anatomic variations of the first extensor compartment in Thai population: a basis for successful de Quervain tenosynovitis treatment.

Knowledge of the superficial radial nerve (SRN) relationship and anatomic variations of the first extensor compartment (1st EC) will contribute to a better outcome of de Quervain tenosynovitis treatment. We dissected 87 embalmed cadaveric wrists to determine the relationship of the SRN, the 1st EC length, distance from the proximal and distal 1st EC borders to radial styloid process (RSP), abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendon slip numbers, and the presence of septum. Our results revealed SRN crossing over the 1st EC in 59.5%. The lateral branch of the superficial radial nerve to the 1st EC midline in most cases (61.9%) except for one specimen, where lateral antebrachial cutaneous nerve was the closest. Distances from proximal and distal 1st EC borders to the RSP were 19.7±4.1 mm and 7.6±1.8 mm, respectively. Extensor retinaculum (ER) width over 1st EC (1st EC length) was 14.8±3.2 mm. Complete and incomplete septa were found in 17.2%, and 42.5%, respectively. The most frequent APL tendon slip number in the compartment was two in overall 47 specimens (54.0%). Almost all compartments (85 specimens; 97.7%) contained one EPB tendon slip. We detected bilateral EPB absence in one cadaver. Moreover, we recorded a tendon slip from extensor pollicis longus traveling into 1st EC bilaterally in one cadaver and observed the EPB muscle belly extension into 1st EC in 9 wrists. Awareness of 1st EC anatomic variations would be essential for successful surgical and nonsurgical outcomes.

A new 3D-printed temporal bone: 'the SAPIENS'-specific anatomical printed-3D-model in education and new surgical simulations.

Otology and neuro-otology surgeries pose significant challenges due to the intricate and variable anatomy of the temporal bone (TB), requiring extensive training. In the last years 3D-printed temporal bone models for otological dissection are becoming increasingly popular. In this study, we presented a new 3D-printed temporal bone model named 'SAPIENS', tailored for educational and surgical simulation purposes. The 'SAPIENS' model was a collaborative effort involving a multidisciplinary team, including radiologists, software engineers, ENT specialists, and 3D-printing experts. The development process spanned from June 2022 to October 2023 at the Department of Sense Organs, Sapienza University of Rome. Acquisition of human temporal bone images; temporal bone rendering; 3D-printing; post-printing phase; 3D-printed temporal bone model dissection and validation. The 'SAPIENS' 3D-printed temporal bone model demonstrated a high level of anatomical accuracy, resembling the human temporal bone in both middle and inner ear anatomy. The questionnaire-based assessment by five experienced ENT surgeons yielded an average total score of 49.4 ± 1.8 out of 61, indicating a model highly similar to the human TB for both anatomy and dissection. Specific areas of excellence included external contour, sigmoid sinus contour, cortical mastoidectomy simulation, and its utility as a surgical practice simulator. We have designed and developed a 3D model of the temporal bone that closely resembles the human temporal bone. This model enables the surgical dissection of the middle ear and mastoid with an excellent degree of similarity to the dissection performed on cadaveric temporal bones.

Accessory Ostium of the Maxillary Sinus and Its Impact on Sinusitis

Background: One of the anatomical variations in the maxillary sinus is the accessory ostium (AO). In the nasal cavity, the lateral wall’s vertical plane is parallel to the form of the AO, which is round or oval in appearance. During a nasal endoscopic examination, AO may be seen in contrast to the normal ostium of the maxillary sinus, which is hidden behind the uncinate process. Methods: The search for recent research articles on AO of the maxillary sinus was done with databases Scopus, PubMed, Medline, and Google Scholar. This review article discusses the prevalence, development, endoscopic examination, clinical significance, surgical importance, relationship with chronic sinusitis, and its management. Results: AO may interfere with ventilation and drainage of the maxillary sinus. Hence, it is important to evaluate the anatomical features of the AO for its relationship with sinus pathology. The development of maxillary sinusitis may be significantly impacted by the anatomical variance known as AO of the maxillary sinus. The middle meatus’s posterior nasal fontanelle is where AO is most frequently observed. The possible mechanism for the formation of AO is obstruction of the natural ostium of the maxillary sinus by sinusitis or due to anatomical and pathological factors in the middle meatus leading to rupture of membranous regions such as fontanelle. Conclusion: Clinicians must have adequate knowledge regarding the anatomical variations of the AO. It frequently appears in the fontanelle, the membranous portion of the middle meatus’ lateral nasal wall that is between the uncinate process and inferior meatus.

Computer-assisted three-dimensional individualized extreme liver resection for hepatoblastoma in proximity to the major liver vasculature.

The management of hepatoblastoma (HB) becomes challenging when the tumor remains in close proximity to the major liver vasculature (PMV) even after a full course of neoadjuvant chemotherapy (NAC). In such cases, extreme liver resection can be considered a potential option. To explore whether computer-assisted three-dimensional individualized extreme liver resection is safe and feasible for children with HB who still have PMV after a full course of NAC. We retrospectively collected data from children with HB who underwent surgical resection at our center from June 2013 to June 2023. We then analyzed the detailed clinical and three-dimensional characteristics of children with HB who still had PMV after a full course of NAC. Sixty-seven children diagnosed with HB underwent surgical resection. The age at diagnosis was 21.4 ± 18.8 months, and 40 boys and 27 girls were included. Fifty-nine (88.1%) patients had a single tumor, 39 (58.2%) of which was located in the right lobe of the liver. A total of 47 patients (70.1%) had PRE-TEXT III or IV. Thirty-nine patients (58.2%) underwent delayed resection. After a full course of NAC, 16 patients still had close PMV (within 1 cm in two patients, touching in 11 patients, compressing in four patients, and showing tumor thrombus in three patients). There were 6 patients of tumors in the middle lobe of the liver, and four of those patients exhibited liver anatomy variations. These 16 children underwent extreme liver resection after comprehensive preoperative evaluation. Intraoperative procedures were performed according to the preoperative plan, and the operations were successfully performed. Currently, the 3-year event-free survival of 67 children with HB is 88%. Among the 16 children who underwent extreme liver resection, three experienced recurrence, and one died due to multiple metastases. Extreme liver resection for HB that is still in close PMV after a full course of NAC is both safe and feasible. This approach not only reduces the necessity for liver transplantation but also results in a favorable prognosis. Individualized three-dimensional surgical planning is beneficial for accurate and complete resection of HB, particularly for assessing vascular involvement, remnant liver volume and anatomical variations.

Psoriasiform Drug Eruption AsNeuro-Behçet’s Disease Presenting with Acute Psychosis: A Case Reportsociated with Carbamazepine

The fetal-type posterior cerebral artery (FTPCA) denotes an anomaly within the posterior cerebral circulation, characterized by the distal segment of the posterior cerebral artery (PCA) being supplied by a branch originating from the internal carotid artery (ICA) through the fetal posterior communicating artery (fetal PCOM). The presence of a fetal posterior communicating artery represents a recognized variation within the cerebral vascular anatomy, observed in 4-29% of individuals. This variant may pose distinct challenges in both the detection and management of cerebrovascular conditions or strokes. We report a 60-year-old man who presented with sudden onset left sided weakness and aphasia. A brain CT scan was performed, revealing a right posterior and middle cerebral arteries territories infarct with bilateral fetal-type posterior communicating arteries. CTA brain is commonly done in ischemic stroke cases to assess presence of large vessel occlusions and intracranial or extracranial atherosclerotic disease. However, this case depicts its additional role in detecting anatomical variants of cerebral circulation. In terms of clinical importance, presence of multiple territories infarction portends a poorer neurological outcome.

Unilateral cortical autoimmune encephalitis: A case series and comparison to late-onset Rasmussen's encephalitis

ObjectiveTo report a novel anatomical pattern of autoimmune encephalitis characterized by strictly unilateral cortical inflammation and a clinical picture overlapping with late-onset Rasmussen's encephalitis. MethodsWe retrospectively gathered data of patients identified at two tertiary referral academic centers who met inclusion criteria. ResultsWe identified twelve cases (average age 65, +/− 19.8 years, 58% female). All patients had unilateral cortical inflammation manifesting with focal seizures, cognitive decline, hemicortical deficits, and unilateral MRI and/or EEG changes. Six cases were idiopathic, two paraneoplastic, two iatrogenic (in the setting of immune checkpoint inhibitors), and two post-COVID-19. Serologically, ten patients were seronegative, one had high titer anti-GAD65, and one had anti-NMDAR. Five patients met Rasmussen's encephalitis criteria, and six did not fully meet the criteria but had symptoms significantly overlapping with the condition. Most patients had significant improvement with immunotherapy. DiscussionUnilateral cortical AE seems to be more prevalent in the elderly and more frequently idiopathic and seronegative. Patients with this anatomical variant of autoimmune encephalitis have overlapping features with late-onset Rasmussen's encephalitis but are more responsive to immunotherapy. In cases refractory to immunotherapy, interventions used in refractory Rasmussen's encephalitis may be considered, such as functional hemispherectomy.