The Basal or Sphenopetrosal Superficial Middle Cerebral Vein Type.

Background and Objectives: The adult superficial middle cerebral vein (SMCV) commonly drains into the middle cranial fossa. However, different embryonic types persist, in which the SMCV drains into the lateral sinus. The basal type of SMCV coursing on the middle fossa floor is a scarce variant. Materials and Methods: During a retrospective study of archived computed tomography angiography (CTA) and magnetic resonance angiography (MRA) files, three rare adult cases of the basal or sphenopetrosal type of SMCV were found and further documented. Results: In the first case, which was evaluated via CTA, the basal type of SMCV formed a sagittal loop. It continued on the middle fossa floor, over a dehiscent tegmen tympani, to drain into the lateral sinus. In the second case, documented via MRA, the basal type of SMCV's anterior loop was in the coronal plane and closely related to the internal carotid artery and the cavernous sinus. It continued with the basal segment over a dehiscent glenoid fossa of the temporomandibular joint (TMJ). In the third case, documented via CTA, the initial cerebral part of the SMCV had a large fenestration. The middle fossa floor coursed within a well-configured sulcus of the SMCV and received a tributary through the tympanic roof. Its terminal had a tentorial course. Conclusions: Beyond the fact that such rare variants of the SMCV can unexpectedly interfere with specific approaches via the middle fossa, dehiscences of the middle fossa floor beneath such variants can determine otic or TMJ symptoms. Possible loops and fenestrations of the SMCV should be considered and documented preoperatively.

The Diversity of the Linguofacial Trunk.

Background and Objectives: Typically, the external carotid artery (ECA) sends off separate anterior branches: the superior thyroid, lingual, and facial arteries. These could, however, form common trunks: thyrolinguofacial, linguofacial (LFT), or thyrolingual. Although known, the LFT variant was poorly detailed previously, and most authors just counted the variant. We aimed to demonstrate the individual anatomical possibilities of the LFT on a case-by-case basis. Materials and Methods: 150 archived angioCT files were used. After applying inclusion and exclusion criteria, 147 files of 86 males and 61 females were kept for this study. Results: In 34/147 cases, LFTs were found (23.12%). Bilateral LFTs were found in 13/34 cases (38.24%) and unilateral LFTs in 21/34 (61.76%) cases. Forty-seven LFTs were thus identified and further studied for different variables. Regarding the vertical topography of LFT origin, type 1a (suprahyoid and infragonial) was found in 28 LFTs (59.57%), type 1b (suprahyoid and gonial) was found in eight LFTs (17.02%), type 3 (suprahyoid and supragonial) was found in two LFTs (4.25%), type 2 (hyoid level of origin) in eight LFTs (17.02%), and type 3 (infrahyoid origin) in just one LFT (2.12%). Types of the initial course of the LFT were determined: type I, ascending, was found in 22/47 LFTs; type II, descending, in 12/47 LFTs; and type III, transverse, in 13/47 LFTs. Regarding the orientation of the first loop of the LFT, 23/47 LFTs had no loop, 4/47 had anterior loops, 1/47 had a posterior loop, 5/47 had superior loops, 5/47 had inferior loops, and 9/47 had medial loops. The position of the LFT relative to the ECA was classified as medial, anterior, or antero-medial. An amount of 12/47 LFTs were anterior to the ECA, 22/47 were antero-medial, 10/47 were medial, 2/47 were inferior, and 1/47 was lateral. Regarding their general morphology, 23/47 LFTs had a rectilinear course, 22/47 had loops, and 2/47 were coiled. A case-by-case presentation of results further demonstrated the diversity of the LFT. Conclusions: In conclusion, the morphology and topography of the LFT are individually specific and unpredictable. It can be anticipated case-by-case by surgeons on CT or MR angiograms.

Superior laryngeal artery originating from the lingual artery.

In most cases, the superior laryngeal artery (SLA) branches from the superior thyroid artery, which, in turn, leaves the external carotid artery. Few dissection studies found previously that the SLA could originate from the lingual artery. We report here probably the first evidence of such a rare anatomical variation found unilaterally in a retrospectively evaluated by computed tomography angiography adult male case. The left SLA left a suprahyoid coil of the lingual artery and continued over the greater hyoid horn to enter the larynx through the thyrohyoid membrane. On both sides, thyroid foramina were found, but only the right one used for the entry of the right SLA. Therefore, the rare SLA origin from the lingual artery can be documented on computed tomography angiograms, which could help during preoperative evaluations and prevent unwanted surgical complications.

Lowered hyoid bone overlapping the thyroid cartilage in CT angiograms.

BACKGROUND: The ventral enclosure of the thyroid cartilage by a collapsed hyoid bone (CHB) is poorly encountered in previous research. It was aimed to observe whether or not these malformations could be found and detailed anatomically in a consistent lot of computed tomography (CT) files. METHODS: Two hundred archived CT angiograms were explicitly observed for the CHB anatomical variant. RESULTS: Different possibilities of CHB were found in 6/200 cases, five males and one female. The symmetrical overlap of the thyroid cartilage by the hyoid body was found in one male case. In three cases, two males and one female, there was asymmetrical overlapping due to tilted hyoid bones. In one male case with such asymmetrical CHD, an ossified anterior longitudinal ligament was noted: the tips of the superior horns of the thyroid cartilage reached lateral to it, thus being retropharyngeal. A different male case had a lowered hyoid with a greater horn fused to the superior horn of the thyroid cartilage, with an interposed ossified triticeal cartilage. In the last male case, the right greater horn collapsed laterally to an ossified triticeal cartilage fused with the thyroid cartilage's superior horn. CONCLUSIONS: The CHB is an undeniable anatomical possibility of an atavism that alters conventional anatomical and surgical landmarks. Different anatomical components of the hyoid bone can descend uni- or bilaterally.

The retromandibular loop of the external carotid artery.

BACKGROUND: The external carotid artery (ECA) is a major artery of the head and neck. Although numerous studies describe the variability of ECA branches, the course variation of the ECA was seemingly overlooked. It was aimed to study the morphological possibilities of the retromandibular segment of the ECA. METHOD: A retrospective study was performed on 60 computed tomography angiograms of 26 male and 31 female adult patients. Three types of retromandibular ECA were defined: type 1 - the ECA has a straight course deep to the anatomical plane of the ramus of the mandible; type 2 - the ECA makes a retromandibular loop directed laterally, extending externally to the anatomical plane of the ramus of the mandible; and type 3 - the retromandibular loop directed laterally reaches just behind the posterior margin of the ramus of the mandible. RESULTS: Type 1 was found in just 43.33%, type 2 in 18.33%, and type 3 in 38.33% of 120 sides cases. On the right, type 1 was significantly associated with the male gender, and type 3 with the female gender (Pearson Chi2=10.9, p=0.004). On the left, there were no statistically significant associations (Pearson Chi2=3.5, p=0.153). In 20 cases, the retromandibular course of the ECA was asymmetrical; in 21 cases, type 1 was recorded bilaterally; in 5 cases, type 2 was bilaterally symmetrical; and in 14 cases, type 3 was found bilaterally. CONCLUSION: These previously undocumented types of ECA are relevant during parotid surgery and should be investigated preoperatively on a case-by-case basis.

Persisting carotid duct and proximal external carotid artery agenesis in an adult.

The carotid duct (CD) is a transient embryological structure connecting the 3rd and 4th aortic arches. We found a persisting CD in an adult female case, by studying the computed tomography angiogram. On the left side, the proximal external carotid artery (ECA) agenesis was noted. The CD was inserted into the left subclavian artery and continued upwards to reach the level of the atlas, and then it descended to connect to a normally configured segment of that ECA. It could be speculated that the CD-to-ECA connection was possible via unregressed 1st and/or 2nd aortic arches. The segmental ECA agenesis is extremely rare, while its supply via a persisting patent CD was not reported previously to the authors' knowledge. The variants are extremely important during neck surgery because damaging the CD could determine hemorrhage, as well as ischemia in the ECA territory.

The Maxillary Artery Loops Dangerously Approaching the Mandible's Lingula and Inferior Orbital Fissure.

The maxillary artery (MA) leaves from the external carotid artery and further courses through the infratemporal fossa to reach the pterygopalatine fossa. It typically has an ascending course either on the lateral or on the medial side of the inferior bundle of the lateral pterygoid muscle. While studying retrospectively, the computed tomography angiogram of an adult male case with peculiar tortuosities of the MA was documented. The left MA described a large inferior sagittal loop applied on the mandible's ramus's inner cortical in the pterygomandibular space's upper part. That loop reached 1.66 cm inferior to the mandible's notch and 0.5 cm superior to the mandibular foramen and was applied on the mandible's lingula (spine of Spix). That MA continued to the pterygomaxillary suture, and a second superior coronal loop was found applied on the posterior wall of the maxillary sinus, reaching the inferior orbital fissure. It is therefore mandatory to take good care in the decortication of the mandibular ramus or during osteotomies of the ramus. When an inferior loop of the MA approaches the spine of Spix, bleeding when an inferior alveolar nerve block is performed seems hardly avoidable.

An Update on the Superior Cerebellar Artery Origin Type.

Background and Objectives: The microanatomy of the superior cerebellar artery (SCA) is clinically significant. We, thus, aimed at patterning unilateral and bilateral possibilities of SCA origin. Materials and Methods: In total, 205 archived records of computed tomography and magnetic resonance angiograms were used. There were defined types of SCA origin from the basilar artery (BA): "0"-absent SCA, "1"-preterminal, "2"-collateral SCA, with SCA appearing as a terminal branch of BA, and "3"-SCA from the posterior cerebral artery (PCA) of the cerebral type. Fenestrations and duplications of SCA were recorded. Bilateral combinations of types were recorded as follows: A (1 + 0), B (1 + 1), C (1 + 2), D (1 + 3), E (1 + duplicated SCA), F (2 + 2), G (2 + 3), H (3 + 3), I (3 + duplicated SCA), J (1 + fenestrated SCA). Results: Type 0 SCAs were found in 0.25%, type 1 in 71.29%, type 2 in 19.06%, and type 3 in 9.41%. Absent and fenestrated SCAs were each found in a single case. The most frequent combinations were B (58.05%), C (13.17%) and F (13.17%). Bilateral symmetrical types occurred in 70.7% of cases. Fetal types of PCA and the artery of Percheron modified the BA ends. Combinations of C, F, and G changed the BA ends or tips; thus, different subtypes resulted in five BA bifurcation patterns, including five BA trifurcations and one BA quadrifurcation. BA trifurcation was also found in cases with duplicated SCAs. Conclusions: The SCA has various anatomical possibilities of origin and bilateral combinations that are not presented in anatomical lectures. Details on the specific end of the BA should be gathered on a case-by-case basis.

Astrocytes - friends or foes in neurodegenerative disorders.

Astrocytes (AS) are the most abundant glial cells in the central nervous system (CNS). They have various morphologies and numerous (50-60) branching prolongations, with roles in the maintenance of the CNS function and homeostasis. AS in the optic nerve head (ONH) have specific distribution and function and are involved in the pathogenesis of glaucoma and other neural diseases, modify their morphologies, location, immune phenotype, and ultrastructure, thus being the key players in the active remodeling processes of the ONH.

The Axial Spin of the Carotid Bifurcation.

(1) Background: Twisted carotid bifurcations (CBs) lead to lateralized external carotid arteries (ECAs). Such variants are usually reported on a case-by-case basis. We aimed to study the anatomical possibilities of the axial spin of CB. (2) Methods: Determinations were made bilaterally on a retrospectively assessed sample of 150 cases, 88 males and 62 females. The following types of the axial spin of the CB were determined: type CK1-CB in the coronal plane, with ICA lateral of ECA; type CK3-CB in the coronal plane, with ECA lateral of ICA; the oblique type OK1, with the ECA antero-medial of ICA; the oblique type OK3a, with the ICA antero-medially; the oblique type OK3b, with the ICA postero-laterally; the sagittal type SK2a, with ECA anterior of ICA. (3) Results: In the overall group of 300 CBs, type OK1 was found in 40%, type OK3a in 1%, type OK3b in 2%, type CK1 in 9%, type CK3 in 5.67%, and type SK2a in 42.33% of the bilateral BC group. The types SK2a (46.67%) and OK1 (33.33%) prevailed on the right side. The types OK1 (46.67%) and SK2a (38%) prevailed on the left side. There was no statistically significant association between gender and left or right subtypes. A very strong symmetry existed between the left and right sides (Pearson Chi2 = 53.93 p < 0.001) for types OK1 and SK2a. Asymmetrical types were found in different bilateral combinations. (4) Conclusions: The spin of the CB is relatively symmetrical bilaterally, especially for the variants with the ECA antero-medial or anterior to ICA.

Ring-shaped Dandy's superior petrosal vein.

BACKGROUND: Dandy's superior petrosal vein (SPV) anatomy is highly relevant for neurosurgeons. The SPV drains into the superior petrosal sinus (SPS), closely related to the trigeminal and internal auditory pores. METHOD: The archived enhanced MRI files of a male patient were studied. RESULTS: An infratentorial ring-shaped (RS) SPV was found on the petrosal surface of the right cerebellar hemisphere. It was inserted in the SPS above the internal auditory pore, postero-lateral to the trigeminal pore. The anterior arm of that venous ring received a delicate supratrigeminal plexus of veins from the pontine surface and continued as a single venous trunk on the cerebellar surface. CONCLUSION: Such previously unreported RS-SPV is of utmost importance to be identified before subtemporal transtentorial and retrosigmoid approaches for different neurosurgical reasons.

The Carotid-Hyoid Topography Is Variable.

Background and Objectives: The carotid bifurcation (CB) is presented in most anatomy textbooks as having a unique location at the upper margin of the thyroid cartilage. Although a number of case reports have provided evidence of the possibility of carotid artery location either lateral or medial to the greater hyoid horn, these reports have not established specific anatomic possibilities and prevalences. Materials and Methods: We retrospectively analysed a batch of 147 CT angiograms for 12 types of carotid-hyoid relationships and classified the bilateral combination possibilities of these types. Results: In 168/294 sides there were no carotid-hyoid relationships. Type I, external carotid artery (ECA) medial to the greater horn of the hyoid bone (GHHB), was observed in 0.34%; type II, internal carotid artery (ICA) medial to GHHB, in 0.34%; type III, ICA and ECA medial to GHHB, in 1.02%; type IV, common carotid artery (CCA) medial to GHHB, in 1.02%; type V, CB medial to GHHB, in 0.34%; type VI, ECA lateral to GHHB, in 20.41%; type VII, ICA lateral to GHHB, was not recorded; type VIII, ECA and ICA lateral to GHHB, in 3.74%; type IX, CCA lateral to GHHB, in 8.5%; type X, CB lateral to GHHB, in 6.46%; type XI, ECA lateral and ICA medial to GHHB, in 0.34%; and type XII, ICA lateral and ECA medial to GHHB, in 0.34%. Bilateral symmetry was found in 70.74% of cases, including the null types without carotid-hyoid relationships as well as types IV, VI, VIII, IX, and X. There was a highly significant association between the left and right variants of the carotid-hyoid relationship. Conclusions: Mechanical compression of the hyoid bone on the carotid arteries has various undesirable effects on the ICA and cerebral circulation. Underlying these are several variational anatomical patterns of carotid-hyoid relationships, which can be accurately documented on CT angiograms. A case-by-case anatomical study is better than assuming the carotid anatomy learned from textbooks.

Bihemispheric Right Anterior Cerebral Artery, Fenestrated Origin of the Left Pericallosal Artery, Fenestrated Basilar Artery, Double Right Posterior Cerebral Artery.

Anatomical variations of the cerebral vasculature are frequently encountered. The archived magnetic resonance angiogram of a 62-year-old male patient was studied anatomically on planar slices and 3-dimensional volume renderings. Numerous anatomical variants were found in that single case. In the vertebrobasilar system were found: the proximal basilar artery fenestration, with a unilateral origin from that fenestration of an anterior inferior cerebellar artery, and the unilateral origin of the superior cerebellar artery from the P1 segment of the main posterior cerebral artery (PCA). There were also unilateral variants of the right internal carotid artery (ICA): a subvariant of an accessory PCA leaving the ICA as a hyperplastic anterior choroidal artery and united to the main PCA by a short communicating branch, distinctive of the posterior communicating artery in that side (unilateral double PCA); a right bihemispheric anterior cerebral artery (ACA) but with complete agenesis of the contralateral A1 ACA segment; from the right ACA continued an anatomically normal ipsilateral A2 segment and a short transverse contralateral A2 that, in turn, sent off long pericallosal and callosomarginal arteries; and fenestrated origin of the left pericallosal artery. Therefore, an arterial variant in one of the main cerebral circulations could not exclude anatomical variants in the other cerebral circulatory beds.

Anatomical Variations of the External Jugular Vein: A Pictorial and Critical Review.

(1) Background: The external jugular vein (EJV) descends on the sternocleidomastoid muscle to drain deep into the subclavian vein. Anatomical variations of the EJV are relevant for identification of the greater auricular nerve, flap design and preparation, or EJV cannulation. (2) Methods: Different publications were comprehensively reviewed. Dissections and three-dimensional volume renderings of peculiar cases were used to sample the review. (3) Results: Different anatomical possibilities of the EJV were critically reviewed and documented: fenestrations and double fenestrations, true or false duplications, triplication, absence, aberrant origin or course, or bifurcation. Tributaries of the EJV, such as the facial and posterior external jugular veins, are discussed. The internal jugular vein termination of the EJV is also presented. (4) Conclusions: Care should be taken when different morphological features of the EJV are encountered or reported.

A rare variant of accessory posterior cerebral artery.

BACKGROUND: The posterior cerebral artery (PCA) leaves from the distal end of the basilar artery (BA) and is joined to the internal carotid artery (ICA) by the posterior communicating artery (PComA). METHOD: The archived computed tomography angiogram of a 67 y.o. male patient was studied anatomically. RESULTS: Anatomically normal PCAs left the BA. Both anterior choroidal arteries were found but the right one was hyperplastic. As the latter distributed parieto-occipital and calcarine branches, it was regarded as an accessory PCA. It was laterally to the normal one, inferior to the vein of Rosenthal. CONCLUSION: The terms "accessory PCA" and "hyperplastic anterior choroidal artery" describe the same morphology. Rare anatomical variants could benefit from a homogenous terminology.

Vertical Levels of the Occipital Artery Origin.

Background and Objectives. The occipital artery (OA) is a posterior branch of the external carotid artery (ECA). The origin of the OA is commonly referred to a single landmark. We hypothesized that the origin of the OA could be variable as referred to the hyoid bone and the gonial angle. We thus aimed at patterning the vertical topographic possibilities of the OA origin. Materials and Methods. One hundred archived computed tomography angiograms were randomly selected, inclusion and exclusion criteria were applied, and 90 files were kept (53 males, 37 females). The cases were documented bilaterally for different levels of origin of the OA origin: type 1-infrahyoid; type 2-hyoid; 3-infragonial; 4-gonial; 5-supragonial; 6-origin from the internal carotid artery (ICA). Results. The incidence of unilateral types in the 180 OAs was: type 1-1.11%, type 2-5.56%, type 3-40.56%, type 4-28.33%, type 5-23.33% and type 6, ICA origin of the OA-1.11%. There was found a significant association between the location of the left and right origins of the OAs (Pearson Chi2 = 59.18, p < 0.001), which suggests the presence of a strong symmetry of the origins. Bilateral symmetry of the vertical types of the OA origin was observed in 56.67% of cases; in 43.33% there was bilateral asymmetry. Conclusions. The ICA origin of the OA is an extremely rare variant. For surgical planning or prior to endovascular approaches the topography of the OA origin should be carefully documented, as it may be located from an infrahyoid to a supragonial level.

The Infraoptic or Infrachiasmatic Course of the Anterior Cerebral Artery Emerging an Elongated Internal Carotid Artery.

(1) Background: The normal A1 segment of the anterior cerebral artery (ACA) has a supraoptic course. The proximal infraoptic course of an A1 segment leaving the internal carotid artery (ICA) near the origin of the ophthalmic artery is a rare possibility. This study aimed to determine the prevalence and detailed anatomy of infraoptic A1 segments. (2) Methods: We retrospectively studied 145 computed tomography angiograms from 92 male and 53 female cases, with ages varying from 61 to 78 y.o. (3) Results: In 21/145 cases, infraoptic or infrachiasmatic horizontal-medial courses of A1 segments that emerged distally from the ICA were found. Distal infraoptic A1 segments were bilateral in 16/145 cases and unilateral in 3/145 cases. Infrachiasmatic A1 segments were found bilaterally in 2/145 male cases. All the infraoptic/infrachiasmatic A1 segments left long ICAs with low bifurcations. In 7/34 sides with distal infraoptic or infrachiasmatic A1 segments, supracarotid courses were present. In one female, the right A1 segment had an anterior supraclinoid, supracarotid and infraoptic course. In two female cases with a bilateral distal infraoptic A1, the segment was almost contacting the respective posterior cerebral artery. (4) Conclusions: In cases with dolicho(ectatic) ICAs, the A1 segments could have infraoptic and supracarotid courses the neurosurgeons should be aware of.

High bilateral fenestration of the internal jugular vein.

Duplications and fenestrations of the internal jugular vein (IJV) are rare anatomic variations. There were previously found mostly unilateral fenestrated internal jugular veins, either empty, or traversed by the spinal accessory nerves. It was documented the computed tomography angiogram of a 65 year-old female patient and bilateral high fenestrations of the IJVs were found. On both sides, the superior ends of the fenestrations were in the jugular foramina. On the right side the fenestration had 3.8 cm length and was located in front of the transverse processes of the first two cervical vertebrae. On the opposite side the fenestration had 1.5 cm length and was antero-lateral to the transverse process of the atlas vertebra. On both sides the antero-medial arms of the fenestrations received the inferior petrosal sinuses and anterior condylar veins. Such highly placed fenestrations of the IJVs should be carefully documented either preoperatively, or prior to central venous access.

Extruded Nucleoli of Human Dental Pulp Cells.

Background and Objectives: The dental pulp stem cells are highly proliferative and can differentiate into various cell types, including endothelial cells. We aimed to evaluate the ultrastructural characteristics of the human dental pulp cells of the permanent frontal teeth. Materials and Methods: Human adult bioptic dental pulp was collected from n = 10 healthy frontal teeth of five adult patients, prior to prosthetic treatments for aesthetic purposes. Tissues were examined under transmission electron microscopy. Results: We identified cells with a peculiar trait: giant nucleoli resembling intranuclear endoplasmic reticulum, which mimicked extrusion towards the cytoplasm. These were either partly embedded within the nuclei, the case in which their adnuclear side was coated by marginal heterochromatin and the abnuclear side was coated by a thin rim of ribosomes, or were apparently isolated from the nuclei, while still being covered by ribosomes. Conclusions: Similar electron microscopy features were previously reported in the human endometrium, as nucleolar channel system; or R-Rings induced by Nopp140. To our knowledge, this is the first report of extruded nucleolar structure in the dental pulp. Moreover, the aspect of giant extruded nucleoli was not previously reported in any human cell type, although similar evidence was gathered in other species as well as in plants.

Adding myofibroblasts to the lacrimal pump.

The lacrimal sac (LS) empties in the nasolacrimal duct to drain the tears in the inferior nasal meatus. Different studies indicated the role of the lacrimal pump in the lacrimal drainage. Although controversial, the lacrimal pump mechanism is an extrinsic one, either active, or passive. An intrinsic contractile potential of the LS was not documented previously. We thus aimed a retrospective immunohistochemical study to test the alpha-smooth muscle actin (α-SMA) and h-caldesmon expression in the LS wall. We used archived paraffin-embedded samples of LS from ten adult patients. The α-SMA + phenotype was detected in basal epithelial cells, in subepithelial ribbons of stromal cells, in vascular smooth muscle cells, as well as in pericytes. H-caldesmon was exclusively expressed in pericytes, vascular smooth muscle cells and myoepithelial cells of the subepithelial glands. The most striking feature we found in all samples was a consistent stromal network of α-SMA+/h-caldesmon- myofibroblasts. This finding supports an intrinsic scaffold useful for the lacrimal pump.