Multiple Anatomical Variations Research Articles

A three-headed psoas major muscle: a case report.

Multiple anatomical variations, from anomalous courses to additional structures, have been reported in muscles from different compartments of the human body. We report an extremely rare case of a psoas major muscle presenting as a three-headed structure with variable morphology. During a routine dissection of the posterior abdominal wall of a 82-year-old male cadaver, an anomalous PM muscle with supernumerary head was identified, photographed and subjected to further measurement. Although the anatomy of the dissected posterior abdominal wall structures was typical, a three-headed psoas major muscle composed of superficial, intermediate and deep heads was identified. It is important to be aware of morphological variability of muscles, especially those considered to be constant, since an anomalous structure might interfere not only with their functions, but also lead to further clinical consequences.

Possible vascular complications due to anatomical variations in dental surgical treatments

The facial artery undergoes multiple anatomic variations that condition the territory that vascularizes to the facial level. During the dissection of several pieces, we find a curious anatomic alteration in which the transverse facial artery is the one that replaces the facial artery because it disappears at the level of the submandibular gland. This anatomic variance can help to improve the knowledge of the vascularization of this area and be helpful in the different surgical or aesthetic processes in the facial region, and doing so minimizes the damages that can be caused in the anatomical surfaces treated. This is why in the planning of the treatment it would be always useful to know the path of the main vessels and nerves to avoid their possible injury and, in this case, we recommend the use of means such as ultrasound.

Anatomical variations in the first dorsal compartment of the wrist: meta-analysis.

The first dorsal compartment of the wrist includes tendons of abductor pollicis longus (APL) and extensor pollicis brevis (EPB). However, many studies have showed multiple anatomical variations including anomalies in the number of both APL and EPB tendons and presence of intercompartmental fibro-osseous septum. Unfortunately, studies describing those variations are not consistent, hence, the aim of this study was to provide most accurate data about these anatomical variations in the population, using systematic review and meta-analysis. For this purpose, PubMed, Scopus, Web of Science, Embase and a number of minor online libraries were searched. Articles which included exact data about the number of APL or EPB tendons or a presence of intercompartmental septum were qualified for a more precise evaluation. Therefore, out of 1629 studies initially evaluated, 68 were finally included in this meta-analysis. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 5229 studied wrists have been included in this study. Double APL and single EPB are the most common variations of tendons in the first dorsal compartment, both in cadavers and patients with de Quervain's disease, with no statistically significant differences between those two groups. Presence of intercompartmental fibro-osseus septum is much more common in patients with de Quervain's disease than in cadavers. Our results should improve the awareness of anatomical variations in the first dorsal compartment, which in turn should have impact on treatment of de Quervain's disease in clinical practice.

The complete anatomy of the lingual nerve: A meta-analysis with implications for oral and maxillofacial surgery.

Lingual nerve (LN) injury during surgical procedures in the third molar region warrants a detailed study of its common pathway and important variations. Therefore, the objective of this study was to analyze and compile the multiple anatomical variations of the LN for use in oral and maxillofacial surgery. It is anticipated that the results of the present meta-analysis may help to minimize the possible complications when performing procedures associated with this anatomical entity. Major online databases such as PubMed, Web of Science, Scopus, Embase were used to gather all relevant studies regarding the LN anatomy. The results were established based on a total of 1665 LNs. The pooled prevalence of the LN being located below the lingual/ alveolar crest was found to be 77.87% (95% CI: 0.00%-100.00%). The LN was located above the lingual/ alveolar crest in 8.21% (95% CI: 4.63%-12.89%) of examined nerves. The most common shape of the LN was established to be round with a prevalence of 40.96% (95% CI: 23.96%-59.06%), followed by oval at 37.98% (95% CI: 23.98%-53.02%) and flat at 25.16% (95% CI: 12.85%-39.77%). In conclusion, we believe that this is the most accurate and up-to-date study regarding the anatomy of the LN. The LN was found to be located below the lingual/alveolar crest in 77.87% of the cases. Furthermore, the LN was found to enter the tongue under the submandibular duct in 68.39% of the cases. Knowledge about the anatomy of the LN is crucial for numerous oral and maxillofacial procedures such as during the extraction of the third molar.

Ascending palatine branch from the lingual artery with multiple other variations of the external carotid artery.

The external carotid artery (ECA) is the major blood supply for structures in the head and neck. Typically, it has 8 separate branches; but there are many anatomical variations, making it difficult to predict surgical outcomes and complications without 3-dimensional imaging. This case study focuses on a cadaver with multiple anatomical variations in the ECA, i.e., lingual, facial, occipital, ascending pharyngeal, and posterior auricular arteries, found during routine dissection of the right cadaveric neck. We also discuss the incidences of several other anatomical variations of the ECA branches and their surgical implications and potential complications.

Variations in renal arteries and pelvicalyceal system: A case report

To describe a complex case of anomalous kidneys involving right early division of renal artery, left accessory renal artery, bilateral upper polar arteries and bilateral extrarenal calyces. This is a very rare case documented having these four anomalies together. The variations were observed during routine anatomical dissection in a male cadaver at department of anatomy, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry, IndiaDuring dissection, multiple anatomical variations involving the structures at the hilum of right kidney were found. Right kidney showed early division of renal artery (RRA) 1.4 cm close to aorta. Left kidney showed accessory renal artery (LARA) 5 mm above origin of main renal artery (LRA), running obliquely entering the hilum. Two polar arteries were seen entering upper pole on right kidney as well as left kidney (RUPA1, RUPA2, LUPA1, LUPA2). Extrarenal calyces were observed to be present in both the kidneys, two on the right and three on the left. The variations observed are of importance as multiple anomalies are present in a single cadaver. They are of significance during surgical procedures like renal transplantation, aortic surgeries and in radiological interpretation.

Two unusual variants of pulmonary intra-lobar sequestration.

A pulmonary sequestration is a congenital malformation characterized by non-functional lung tissue with abnormal arterial systemic supply and abnormal connection to the bronchial tree. This may lead to recurrent infections rendering a surgical intervention more demanding. Because of multiple anatomic variations, it is important to obtain high-quality preoperative radiological clarification to determine the most suitable surgical approach. Although a non-surgical technique, consisting of embolization of the aberrant artery has been described, a surgical technique remains the treatment of choice in operable patients. Preoperative embolization of the aberrant artery may reduce the risk of haemorrhage but could cause technical challenges in a hybrid approach and therefore unforeseen peroperative stress to the surgical team. We report 2 adult patients with unusual intra-lobar sequestration with aberrant vascular rare anatomy. Both were treated by surgery. In the latter patient, we performed a hybrid approach. This was complicated by peroperative coils exposure making it a technical challenge to proceed.

Anomalous Obturator Arteries with Multiple Pelvic Branches: A Urogynecological Approach

The obturator artery (OA) is known to often present multiple anatomical variations. These can be due to atypical origin, variable anastomosis, or abnormal course within the pelvis. We report a rare arterial variation in a Puerto Rican female cadaver that showed two abnormal obturator arteries with multiple pelvic branches. The OA emerged from the anterior branch of the internal iliac artery, which normally runs anteroinferior along the lateral wall of the pelvis to the upper part of the obturator foramen where it exits the pelvis. Within the pelvis, the atypical obturator artery provided two anatomically variant branches: abnormal obturator artery I (AOAI) gave rise to three branches, while abnormal obturator artery II (AOAII) gave rise to two branches. Identification of these accessory arteries and anastomoses is important for surgical interventions. Therefore, knowledge of the anatomical variations in this region must be taken in multiple pelvic, gynecological, and urological procedures to avoid iatrogenic injury.

Biliary balloon dilator impaction in a non-dilated bile duct with anatomical variations: a case report

BackgroundWhile techniques for extracting large stones from dilated bile ducts are increasing, options for small stones impacted in non-dilated bile ducts are limited.Case presentationWe report the case of an impacted biliary balloon dilator in a choledocholithiasis patient with a non-dilated bile duct and multiple anatomical variations, including low insertion of the cystic duct. After unsuccessful attempts with a stone extraction basket and balloon, a biliary balloon dilator with a sharp catheter tip was advanced into the bile duct. The balloon could not be removed from the bile duct even when deflated. The duodenoscope fell back into the stomach, causing the shaft of the dilator to break near the ampulla. We then removed the broken tip with a snare, which caused the balloon sheath to separate from the shaft and remain in the bile duct. Finally, we removed the sheath with rat-tooth forceps, leading to successful extraction of the stone-and-balloon complex.ConclusionsThe exceedingly rare possibility of balloon impaction should be kept in mind when using biliary balloon dilators in non-dilated bile ducts.

Factors affecting dimensions of the ethmoid infundibulum and maxillary sinus natural ostium in a normal population.

Objectives:To investigate the ethmoid infundibulum (EI) and maxillary sinus natural ostium (MSNO) dimensions in normal sinuses of the Asian population; identified variation between sides, gender, and age groups; and to assess the effects of such variation on the measurements.Methods:We assessed EI dimension and MSNO diameter in computed tomography (CT) scans of the normal paranasal sinus of 100 patients who underwent trans-sphenoid endoscopic surgery. We compared demographic data and multiple anatomical variations.Results:The gap difference in EI length between the right and left sides significantly differed from 0 (0.47±1.38 mm). We found wider EI in people aged ≥60 years (2.44±0.59 mm), compared to people aged <60 years (2.25±0.31 mm). Ethmoid infundibulum length was greater among individuals with Haller cells (8.84±1.56 mm) than in individuals without them (7.92±1.47 mm). Furthermore, MSNO diameter was greater with accessory ostium (3.48±0.77 mm versus 3.02±0.72 mm, presence versus accessory ostium absence).Conclusion:Multiple factors may affect EI and MSNO dimensions. Ethmoid infundibulum length differed between both sides. Ethmoid infundibulum width differed between individuals aged ≥60 years and individuals aged <60 years. Haller cells and accessory ostium presence were associated with significant differences in those measurements.

Early Internal Branch of Superior Laryngeal Nerve Bifurcation Passes Through Double Thyroid Foramen.

Internal branch of superior laryngeal nerve (ibSLN) provides sensory innervation mostly to the supraglottic part of the larynx and thus prevents aspiration during ingestion. Normally, it is distributed to the larynx after piercing the thyrohyoid membrane above the superior laryngeal artery. Multiple anatomical variations in the course of ibSLN have been reported. An early ibSLN bifurcation and course through double thyroid foramen constitutes an interesting anatomical variation that may easily lead to an injury during procedures in the thyroid gland and the larynx. Knowledge of the anatomical variability is essential in order to prevent surgical complications that could potentially impact the patient's quality of life.

Hand-assisted laparoscopic donor nephrectomy in kidneys with multiple renal arteries versus a single renal artery: An analysis of vascular complications from 1,350 cases.

Laparoscopic donor nephrectomy (LDN) has been shown to be a safe approach with better morbidity results. Impact of multiple renal arteries (MRAs) and anatomical variations has been reviewed by many authors. In our study, the relationship between the donors with MRAs and risk of perioperative vascular complications related to donor nephrectomy was investigated. Patients who underwent hand-assisted LDNs between January 2007 and February 2018 were reviewed retrospectively. Patient age, sex, body mass index (BMI), waist circumference, side of donor nephrectomies, donors with MRAs, intraoperative vascular complications, conversion rates, hospitalization durations, and operative times were extracted. Risk factors for perioperative vascular complications were defined. There were MRAs in 288 kidney donors (21.3%). The number of patients who underwent a right donor nephrectomy was 113 (8.4%). BMI, waist circumference, and postoperative hospital stay were not significantly different between donors with one artery and those with MRAs (p>0.05). The renovascular complication rate and overall conversion rate to open surgery were significantly higher in donors with MRAs (p<0.05). Perioperative safety of the kidney donors is of crucial importance. Surgeons performing LDNs must be aware of the potential risks. Our analysis suggests that procurement of kidneys from donors with MRAs is a risk factor for renovascular complications.

Tomographic description of the root canal system of mandibular first premolars in Colombian population

AbstractIntroductionThe success of endodontic treatment depends on a good knowledge of the root canal system. Aim: The purpose of this study was to describe the anatomical configuration of mandibular first premolars using cone‐beam computed tomography (CBCT) in a group of Colombian population according to Vertucci's classification, as well as the frequency of the presence of anatomical variations.Materials and MethodsA descriptive study was carried out using 100 mandibular first premolars to obtain CBCT images. The root length, root curvature, configuration of the root canals, number and location of the apical foramen, and shape of the entrance orifice to the root canal were analyzed.ResultsThe average length of the mandibular first premolars was 21.16 mm, and 33% showed different grades of the curvature. The most frequent configuration was type I (53%), and the least common were types VII and VIII (1%). Eighty‐three teeth had some anatomical variations, and the apical foramen was located laterally in 38%. There was a high incidence of oval canals 1C1 (67%), followed by 1A1 (27%).ConclusionA mixture of phenotypes leads to multiple anatomical variations in mandibular first premolars between individuals within a population. Herein, CBCT provided useful information about root canal anatomical variations of mandibular first premolars in Colombian population. Type I was the most frequently found configuration, and anatomical variations occurred more frequently in the middle third.

Usual and Unexpected Variations in the Veins of the Posterior Abdomen: A Case Study

Two venous system components comprise the drainage of the posterior abdominal cavity. One component drains blood from the visceral derivatives of the urogenital ridge (e.g., kidneys, gonads) directly to the inferior vena cava (IVC). The other venous system collects blood from the body wall and drains into the azygos system through the subcostal vein, ascending lumbar vein, and lower posterior intercostal veins. Veins, and especially the azygos system, are notoriously variable. Much of this variability arises from the complex embryological development of the caval venous system in the thoracic and abdominopelvic cavities; but the formation of venous anastomoses representing multiple routes of drainage from a single region also contribute to the variability of veins.During routine dissection of the abdomen of a male cadaver (Caucasian, 67 years), the right testicular vein demonstrated multiple anatomical variations. An anomalous vein arising from several small tributaries at the lateral end of the 11th and 12th ribs was discovered during the dissection. This vein crossed the posterior abdominal wall inferomedially to drain into the right testicular vein. Further exploratory dissection revealed direct communication between the anomalous vein and the right 11th posterior intercostal vein, which could be traced from the origination of the anomalous vein to the connection with the azygos vein at the appropriate vertebral level. The anomalous vein represents an unusual route for collateral venous circulation between the azygos system and the caval system in the abdomen via the right 11th posterior intercostal vein. Additionally, the right testicular vein drained into the right renal vein instead of directly draining into the IVC. No other notable variations were observed in the abdominal vasculature. The left testicular vein, left renal vein, left posterior intercostal veins, and left subcostal vein all demonstrated typical merging patterns. Accompanying renal, testicular, and posterior intercostal arteries on the right side also appeared to have normal branching patterns.

Predictors of No-Reflow Phenomenon in ST-Elevation Myocardial Infarction in Patients undergoing Primary Percutaneous Coronary Intervention

Abstract Background Functional single ventricle (FSV) is a spectrum of severe congenital heart disease, with multiple anatomic variations but similar surgical treatment strategies. FSV patients are living longer into adulthood compared to two or three decades ago, and they are more frequently undergoing imaging to assist in clinical and surgical management. Objective To assess the relation between admission eGFR, HDL, Monocytes, CRP &amp; albumin levels in patients presenting with acute STEMI and angiographic no-reflow after primary PCI. Material and Methods From October 2018 to February 2019, 60 patients with STEMI who underwent primary PCI in Ain-Shams University hospitals. All patients subjected to history, clinical examination, ECG pre and post pPCI, pre-pPCI eGFR, monocytes, HDL, CRP and albumin, echocardiography. Patients were divided into two groups based on post-pPCI Thrombolysis in Myocardial Infarction (TIMI) flow grade. No reflow was defined as TIMI flow grades ≤ 2, and normal reflow was defined as TIMI 3 flow grade. All the laboratory parameters were measured on admission before pPCI. Results The study population was divided into 2 groups: reflow (n = 31) and no-reflow (NR) (n = 29) groups. CRP over albumin ration “CAR” (7.9 [4.41-16.18] vs 1.74 [1.54-2.35] (P &amp;lt;.001) were significantly higher in the NR group than in the reflow group, and these factors were found to be independent predictors of NR development. However, eGFR and Monocytes over HDL ratio “MHR” didn’t show any statistical differences between the two groups. Conclusion No-reflow can be predicted by systemic inflammation markers including monocytes, CRP, albumin and HDL. CAR has the highest positive predictive value for no-reflow.

Impact of ventricular morphology on myocardial deformation in patients with single ventricle

Abstract Background Functional single ventricle (FSV) is a spectrum of severe congenital heart disease, with multiple anatomic variations but similar surgical treatment strategies. FSV patients are living longer into adulthood compared to two or three decades ago, and they are more frequently undergoing imaging to assist in clinical and surgical management. Objective To determine impact of ventricular morphology on myocardial deformation in patients with single ventricle. Material and Methods From November 2017 to July 2018, 41 patients with single ventricle morphology or Physiology who were referred to Ain-Shams University hospitals for follow up Echocardiography or diagnostic cardiac catheterization were enrolled in the study.All patients subjected to history, clinical examination Echocardiography (conventional 2D and speckle tracking “global longitudinal strain and strain rate”.Dominant ventricular strain was analyzed using conventional two-dimensional echocardiographic. The region of interest was obtained by tracing the dominant ventricle endocardial borders at end-systole. An automated software program was used to calculate the frame-to-frame displacements of speckle pattern within the region of interest throughout the cardiac cycle. Results There is statiscially significance between the basic anatomy of the single ventricle and the ejection fraction (p value 0.001) and global longitudinal strain pattern by speckle tracking echocardiography with (p value 0.031) with no statistically effect of the side of dominance. Conclusion: Regarding the side of dominant ventricle there is no significant relation between the side of dominant ventricle on myocardial deformation (by ejection fraction, global strain and strain rate by speckle tracking echocardiography) but there is significant relation between the ventricular morphology and the myocardial deformation that was assessed by by the ejection fraction and global longitudinal strain (by speckle tracking echocardiography) but with no significant effect on the strain rate (by speckle tracking echocardiography)

Could there be an association between ethmoid anatomical variations and chronic rhinosinusitis? A clinicoradiological study

Background The complicated anatomy of the ethmoid bone is associated with multiple anatomical variations. These anatomical variations may have clinical significance in pathogenesis of rhinosinusitis, which is still unclear, and in the surgical workup to avoid the risk of potential complications. Aim The aim of this study was to evaluate the rate of the different ethmoid anatomical variants in the patients with chronic rhinosinusitis (CRS) and to assess if there is any correlation between these variants and CRS. Patients and methods This case–control study included 40 patients with CRS (study group) and 20 healthy individuals with no criteria of CRS (control group). Anatomical variations of ethmoid complex were evaluated as either being present or absent in each side in both groups. In the study group, Lund-Mackay scores of the different sinuses were evaluated and compared in relation to the detected ethmoid variants. Results No statistically significant difference was found between the rate of different ethmoidal anatomical variations in the study and control groups. There was also no significant difference in the Lund-Mackay scores of the different sinuses in relation to the presence of anatomic variations. The most common ethmoidal anatomical variation in both groups was agger nasi cell. Conclusion This study showed that there is no significant association between ethmoidal anatomical variations and CRS, and so, these anatomical variations are not a potential risk factor for chronicity of sinusitis.

Nonaneurysmal cerebrovascular conditions associated with intracranial arterial fenestrations

Background: Cerebral arteries have been identified with multiple anatomical variations, including a concomitant fenestration with aneurysms, but no association is proven. Aim: to investigate non aneurysmal disorders associated with intracranial arterial fenestration. Methods: A thorough and detailed analysis of the available literature from 1970 to 2020 in PubMed were contemplated to identify and address all the disorders associated with arterial fenestration with exclusion of intracranial aneurysms. Results: While segmental vulnerability may induce invisible anatomical histological and hemodynamic changes, cadaveric studies showed that the frequency of fenestration is up to 40% higher than the clinical reports, and the cadaveric reports also showed a higher occurrence of such fenestrations as compared to radiological studies. The vertebrobasilar system, the most common site of fenestration. Fused vertebrae and other vascular defects of up to 7% are previously associated with the vertebral artery fenestration. Conclusion: intracranial fenestration is a critical anatomical variant. Thus, A comprehensive angiographical examination can enhance overall prognosis in presurgical planning in association with other vascular abnormalities.

Technical Considerations in Liver Transplantation for Biliary Atresia With Situs Inversus.

In liver transplantation (LT) for biliary atresia (BA) with situs inversus (SI), the surgical procedure is technically challenging due to multiple anatomical variations. We evaluated the surgical procedures and the outcomes in our patients and in the previously reported patients undergoing LT for BA with SI. Between November 2005 and October 2018, 235 children underwent LT with an overall 10-year graft survival of 94.7%. Of these, 6 (2.6%) patients received LT for BA with SI. Living donor liver transplantation (LDLT) was applied in all patients. Vascular anomalies at our center included the absence of the inferior vena cava (IVC; n=5), a preduodenal portal vein (PV; n=4), and an aberrant hepatic artery (HA; n=1). Hepatic vein (HV) outflow obstruction occurred in 1 patient with an absent IVC and necessitated repositioning of the graft immediately after LDLT. PV stenosis occurred in 1 patient with a preduodenal PV at 5months after LDLT. The overall survival of our patients was 80.0% at 3years. In the literature, 49 patients with LT for BA with SI were reviewed. The survival rate was 91.8%, and the vascular complications included HV outflow obstruction (2.0%), PV complications (10.2%), and HA thrombosis (4.1%). All PV complications occurred in LDLT patients with a preduodenal PV (5/23; 21.7%). In conclusion, the detailed assessment of the surgical procedures and the systematic literature review demonstrated excellent outcomes after LT for BA with SI. Liver recipients with a preduodenal PV are exposed to a higher risk for vascular complications after a very challenging LT procedure with overall good outcomes.

Significance of leaf morphoanatomical markers for the authentication of adultered drugs sold in herbal markets of district Lahore, Pakistan.

A number of herbal plants sold in herbal markets of Lahore are under adulteration threat which can pose harmful health effects to end-user. This adulteration problem of medicinal plants can be resolved by the implication of some valuable taxonomic parameter such as leaf epidermal anatomical characteristics. Hence, this research was aimed to provide viable anatomical markers in order to resolve this adulteration issue persisted in some common marketed medicinal plants of district Lahore, that is, Cinnamomum verum Presl., Cinnamomum tamala (Buuch.-Ham.) T.Nees&Eberm., Gymnema sylvestre (Retz.) R.Br.ex Sm., Sphaeranthus indicus Linn., Artemisia maritima Linn., Achillea millifolim L., Adhatoda vasica Nees, Butea monosperma (Lam.) Taub, and Morus nigra L. Overall multiple anatomical variations (epidermal cell shape, their length and width, type of stomata, length and width of guard cells along with presence or absence of trichomes) had been reported in the study that could be worthwhile for the correct identification of medicinal plants. Irregular shapes of epidermal cells were observed in Cinnamomum verum and Achillea millifolium while pentagonal and polygonal cells were found in their adultaerants, that is, Canella winterana and Adhatoda vasica, respectively. Types of stomata were also strikingly varied among genuine plant and its adulterant, for example, anisocytic stomata were observed in Artemisia maritima while in its adulterant (Artemisia absinthium) anomocytic stomata were found. Similarly, paracytic stomata were observed in Butea monosperma, whereas its adulterant plant (Averrhoa carambola) characteristically possessed anisocytic stomata. Hence, anatomical characteristics were proved to be a valuable taxonomic tool in resolving the adulteration issue of medicinal plants.