Neurology Commons^™

Editorial Perspective., Jens R Chapman

Articles, Abstracts, and Reports

No abstract provided.

Widespread Theta Synchrony And High-Frequency Desynchronization Underlies Enhanced Cognition., E. A. Solomon, J. E. Kragel, Michael R. Sperling, Ashwini Sharan, G. Worrell, M. Kucewicz, C. S. Inman, B. Lega, K. A. Davis, J. M. Stein, B. C. Jobst, K. A. Zaghloul, S. A. Sheth, D. S. Rizzuto, M. J. Kahana

Department of Neurology Faculty Papers

The idea that synchronous neural activity underlies cognition has driven an extensive body of research in human and animal neuroscience. Yet, insufficient data on intracranial electrical connectivity has precluded a direct test of this hypothesis in a whole-brain setting. Through the lens of memory encoding and retrieval processes, we construct whole-brain connectivity maps of fast gamma (30-100 Hz) and slow theta (3-8 Hz) spectral neural activity, based on data from 294 neurosurgical patients fitted with indwelling electrodes. Here we report that gamma networks desynchronize and theta networks synchronize during encoding and retrieval. Furthermore, for nearly all brain regions we studied, …

The Technique Of S2-Alar-Iliac Screw Fixation: A Literature Review, Ai-Min Wu, Dong Chen, Chun-Hui Chen, Yu-Zhe Li, Li Tan Li Tang, Kevin Phan, Kern Singh, Brittany E. Haws, Daniele Vanni, Yusef I. Mosley, Srinivas K. Prasad, James Harrop, Zhong-Ke Lin, Yan Lin, Wen-Fei Ni, Xiang-Yang Wang

Department of Neurosurgery Faculty Papers

The distal fixation in thoracolumbar deformity surgery can be challenging for spine surgeons. When isolated S1-pedicle screws are utilized as the sole distal fixation in long thoracolumbar posterior constructs, there is a high rate of failure, due to loosening, breakage, and pseudarthrosis. Unfortunately, with iliac screw fixation the entry point at the posterior superior iliac spine requires considerable soft tissue dissection and may potentially increase the likelihood of wound complications. S2-alar-iliac (S2AI) screw fixation technique was developed recently to provide increased fixation with a lower profile screw and rod construct. These screws can be inserted with percutaneous or free hand …

Anaesthetic Management Of Supratentorial Tumor Craniotomy Using Awake-Throughout Approach, Faraz Shafiq, Fahad Salim, Ather Enam, Jai Parkash, Mohammad Faheem

Department of Anaesthesia

The authors are reporting an anaesthetic management of patient presenting with left parietal lobe space occupying lesion and scheduled for Awake-craniotomy. Awake-throughout approach using scalp block was planned. Among techniques reported for keeping patient awake during the surgery, this one is really underutilized. The successful conduct requires thorough preoperative assessment and psychological preparation. We used powerpoint presentation as a preoperative teaching tool. The anatomical landmark technique was used to institute scalp block, where individual nerves were targeted bilaterally. Patient remained stable throughout and participated actively in intraoperative neurological monitoring. Postoperative period showed remarkable recovery, better pain control, and shorter length …

Silent Sentence Completion Shows Superiority Localizing Wernicke's Area And Activation Patterns Of Distinct Language Paradigms Correlate With Genomics: Prospective Study., Kamel El Salek, Islam S. Hassan, Aikaterini Kotrotsou, Srishti Abrol, Scott H. Faro, Feroze B. Mohamed, Pascal O. Zinn, Wei Wei, Nan Li, Ashok J. Kumar, Jeffrey S. Weinberg, Jeffrey S. Wefel, Shelli R. Kesler, Ho-Ling Anthony Liu, Ping Hou, R. Jason Stafford, Sujit Prabhu, Raymond Sawaya, Rivka R. Colen

Department of Radiology Faculty Papers

Preoperative mapping of language areas using fMRI greatly depends on the paradigms used, as different tasks harness distinct capabilities to activate speech processing areas. In this study, we compared the ability of 3 covert speech paradigms: Silent Sentence Completion (SSC), category naming (CAT) and verbal fluency (FAS), in localizing the Wernicke's area and studied the association between genomic markers and functional activation. Fifteen right-handed healthy volunteers and 35 mixed-handed patients were included. We focused on the anatomical areas of posterosuperior, middle temporal and angular gyri corresponding to Wernicke's area. Activity was deemed significant in a region of interest if P < 0.05. Association between fMRI activation and genomic mutation status was obtained. Results demonstrated SSC's superiority at localizing Wernicke's area. SSC demonstrated functional activity in 100% of cancer patients and healthy volunteers; which was significantly higher than those for FAS and CAT. Patients with 1p/19q non-co-deleted had higher extent of activation on SSC (P < 0.02). Those with IDH-1 wild-type were more likely to show no activity on CAT (P < 0.05). SSC is a robust paradigm for localizing Wernicke's area, making it an important clinical tool for function-preserving surgeries. We also found a correlation between tumor genomics and functional activation, which deserves more comprehensive study.

Piercing Of The Lumbocostal Ligament By The Subcostal Nerve: A Previously Unreported Case., Marc Vetter, Joe Iwanaga, Rod J Oskouian, R Shane Tubbs

Articles, Abstracts, and Reports

As lateral approaches gain popularity in lumbar spine surgery, detailed discussions regarding anatomical variations in the innervation of the thoracolumbar region are of increasing importance. Damage to intercostal or subcostal nerves can lead to post-operative complications including regional loss of sensitivity, motor function, or abdominal wall hernias. More specifically, the subcostal nerve has been identified in the literature as one of the more vulnerable structures during such procedures. A clear understanding of the position of the subcostal nerve relative to nearby anatomical structures is therefore important for medical professionals. We herein report a rare anatomical variation in which the subcostal …

Reading Between The Joints-Using Spinal Magnetic Resonance Imaging For Evaluation Of Instability, Komal Naeem, S. Ather Enam

Section of Neurosurgery

No abstract provided.

Comparison Between Endoscopic And Microscopic Approaches For Surgery Of Pituitary Tumours, Inamullah Khan, Muhammad Shahzad Shamim

Section of Neurosurgery

Surgical techniques for resection of pituitary tumours have come a long way since it was first introduced in late 18th century. Nowadays, most pituitary surgeries are performed through trans-nasal trans-sphenoidal approach either using a microscope, or an endoscope. Herein the authors review the literature and compare these two instruments with regards to their outcomes when used for resection of pituitary tumours. .

Hidden Blood Loss Between Pccp And Pfna In Elderly Femoral Intertrochanteric Fracture, Tao Ding, Huilin Yang, James Harrop, Xiaofeng Gu, Dehong Feng, Yafeng Zhang, Fan Zhan Zhang, Yuntao Xue

Department of Neurosurgery Faculty Papers

To compare perioperative hidden blood loss in the treatment of femoral intertrochanteric fractures with percutaneous compression plate (PCCP) and proximal femoral nail anti-rotation (PFNA) in elderly patients, and analyse its influencing factors in order to provide the necessary data support for clinical perioperative treatment, and choice of appropriate internal fixation method. Retrospective analyses was carried out on data obtained from 158 patients with intertrochanteric fracture treated with PCCP or PFNA from January 2010 to May 2017. Data were obtained from variables such as age, gender, height, weight, operative bleeding and postoperative drainage, operation time, etc. Upon blood routine examination before …

Absence Of The Lumbosacral Trunk., Cameron K Schmidt, Joe Iwanaga, Emre Yilmaz, Charlotte Wilson, Rod J Oskouian, R Shane Tubbs

Articles, Abstracts, and Reports

The lumbosacral trunk, typically comprised of part of the fourth lumbar ventral rami and the entirety of the fifth lumbar ventral rami, serves as a connection between the lumbar and sacral plexuses. Developmental differences underlie the variable relative contributions of L4 and L5 to the lumbosacral trunk. Herein, we report a rare case in which dissection of an adult male cadaver revealed no L4 contribution to the lumbosacral plexus. We discuss the surgical and clinical implications of such an anatomic variation.

Sex Differential In 15-Hydroxyprostaglandin Dehydrogenase Levels In The Lumen Of Human Intracranial Aneurysms., Nohra Chalouhi, Pascal Jabbour, Mario Zanaty, Robert M. Starke, James Torner, Daichi Nakagawa, David M. Hasan

Department of Neurosurgery Faculty Papers

BACKGROUND: Aspirin is a promising medical therapy for the prevention of intracranial aneurysm (IA) rupture. Recently, we found that men have a better response to aspirin than women. The purpose of this study was to determine whether a sex differential exists in the level of 15-hydroxyprostaglandin dehydrogenase (15-PGDH) in the lumen of human IAs.

METHODS AND RESULTS: Consecutive patients undergoing coiling or stent-assisted coiling for a saccular IA at our institution were enrolled. Two samples (A and B) were collected from IA lumens, and the plasma level of 15-PGDH was measured using an ELISA-based method. The study included 38 patients, …

Hematoma In The Bucco-Mandibular Space: First Case Report., Joe Iwanaga, Charlotte Wilson, Emre Yilmaz, Cameron K Schmidt, Rod J Oskouian, R Shane Tubbs

Articles, Abstracts, and Reports

Our previous studies based on intraoral dissection of fresh cadavers revealed that the fissure and loose connective tissues deep to the mucosa between the incisivus labii inferioris muscle and buccinator muscle form the entrance of the newly discovered bucco-mandibular space. To support the clinical significance of this space, we report the finding of a hematoma within this space in an adult fresh cadaver. Such a finding lends credence to studying the bucco-mandibular space and might help better understand the spread of some infections in the oral region.

Efficiency Of Spinal Anesthesia Versus General Anesthesia For Lumbar Spinal Surgery: A Retrospective Analysis Of 544 Patients., John T. Pierce, Guy Kositratna, Mark A. Attiah, Michael J. Kallan, Rebecca Koenigsberg, Peter Syre, David Wyler, Md, Paul J. Marcotte, W. Andrew Kofke, William C. Welch

Department of Anesthesiology Faculty Papers

BACKGROUND: Previous studies have shown varying results in selected outcomes when directly comparing spinal anesthesia to general in lumbar surgery. Some studies have shown reduced surgical time, postoperative pain, time in the postanesthesia care unit (PACU), incidence of urinary retention, postoperative nausea, and more favorable cost-effectiveness with spinal anesthesia. Despite these results, the current literature has also shown contradictory results in between-group comparisons.

MATERIALS AND METHODS: A retrospective analysis was performed by querying the electronic medical record database for surgeries performed by a single surgeon between 2007 and 2011 using procedural codes 63030 for diskectomy and 63047 for laminectomy: 544 …

Delayed Spinal Cord Infarction Following Anterior Cervical Surgical Decompression, Muhammad Faheem Khan, Rashid Jooma, Fauzan Alam Hashmi, Muhammad Faraz Raghib

Section of Neurosurgery

Anterior cervical discectomy and fusion (ACDF) for cord compression is a safe and effective procedure with good outcomes. However, worsening of myelopathy is the most feared adverse event of the surgery. We report the case of a 36-year-old male patient who presented with an acute non-traumatic C5-6 cervical disc herniation causing incomplete quadriparesis. He underwent an uncomplicated ACDF at C5-6, and after an initial period of improvement, he developed a delayed onset of an anterior cord syndrome on day 3, without any discerning cause. We have reviewed similar cases reported in the literature and believe that our patient's postsurgical course …

Cadaveric Study For Intraoral Needle Access To The Infratemporal Fossa: Application To Posterior Superior Alveolar Nerve Block Technique., Joe Iwanaga, Emily Simonds, Rod J Oskouian, R Shane Tubbs

Articles, Abstracts, and Reports

The posterior superior alveolar (PSA) nerve block is, from an anatomical perspective, challenging because the mandibular ramus and the zygomatic process of the maxilla can interfere with the course of the needle. Dentists empirically know that shifting the patient's mandible to the ipsilateral side can improve visibility and accessibility for such blocks. This cadaveric study aimed to establish anatomical evidence for the ipsilateral mandible shifting used in the PSA. The distance between the lateral most bulging point of the alveolar part of the maxilla and ipsilateral anterior border of the ramus of the mandible ranged from 1.4 to 6.9 mm …

Direct Insertion Of The Papillary Muscle Into The Anterior Mitral Leaflet: Cadaveric Findings., Sarvenaz Sheikh, Joe Iwanaga, Jocelyn R Gonzales, Tsuyoshi Saga, Marios Loukas, Rod J Oskouian, R Shane Tubbs

Articles, Abstracts, and Reports

Direct insertion of the anterior papillary muscle (DPM) into the mitral valve is uncommon. During the routine dissection of an adult female, a DPM into the mitral valve with abnormal chordae tendinae was observed. This abnormal papillary muscle was measured as 28.0 mm in length from myocardial to insertion, 14.8 mm in width, and 7.0 mm in depth. The embryology, symptoms, associated cardiac diseases, and surgical precautions of this congenital malformation in the heart are reviewed.

Role Of 5-Ala In Improving Extent Of Tumour Resection In Patients With Glioblastoma Multiforme, Muhammad Waqas, Inamullah Khan, Muhammad Shahzad Shamim

Section of Neurosurgery

Goal of surgery for patients with Glioblastoma Multiforme (GBM) is gross total resection with no new neurological deficits. Surgical resection is often restricted due the difficulty in differentiating the tumour from surrounding normal brain using either naked eye, or standard intra-operative white light microscopy. GBM uptakes orally administered 5-ALA becomes fluorescent when viewed by a special light, and this property has been used to improve intra-operative tumour identification. This technique should therefore allow better extent of tumour resection. The hypothesis has been tested through several studies and even though most studies are of low quality, they strongly favour the use …

Video Microscope Robotic Arm-Assisted, Neuronavigation-Guided Glioma Resection And Regional Sampling, Muhammad Waqas, Ather Enam, Fauzan A Hashmi, Fatima Mubarak, Fazal Arain

Section of Neurosurgery

High-grade gliomas possess internal pathological heterogeneity. Selective sampling of different tumor regions can help in the study of this heterogeneity. In this report, we have described the use of a novel navigation and optical system for the selective regional sampling of a high-grade glioma lesion. A 45-year-old gentleman presented to us with complaints of intermittent frontal headaches for past eight months. On examination, he had subtle pyramidal weakness in left upper and lower extremities. Magnetic resonance imaging (MRI) showed a large contrast-enhancing, space-occupying lesion in the right frontal lobe causing perilesional edema and midline shift. We marked four different regions …

Mini-Craniotomy Under Local Anesthesia For Chronic Subdural Hematoma: An Effective Choice For Elderly Patients And For Patients In A Resource-Strained Environment, Shaikh Danish Mahmood, Muhammad Waqas, Mirza Zain Baig, Aneela Darbar

Medical College Documents

Background: Mini-craniotomy for chronic subdural hematoma (CSDH) is associated with lower rates of recurrence. However, the procedure is performed mostly with the patient under general anesthesia (GA) and therefore frequently requires an intensive care unit (ICU) facility, especially in the elderly population. Because of the unavailability of ICU beds, and to avoid GA, we started to perform this procedure with the patient under local anesthesia (LA).
Materials and methods: This was a retrospective medical chart review conducted in the section of Neurosurgery at the Aga Khan Hospital in Karachi, Pakistan. The study duration was 1 year. We included patients aged …

Diffusion Tensor Imaging For Ruptured Cerebral Arteriovenous Malformation, Muhammad Waqas, Ayesha Siddiqui, Fatima Mubarak, Ather Enam

Section of Neurosurgery

Non-ruptured arteriovenous malformations (AVMs) rarely cause tract disruption. Few studies have described how ruptured AVMs influence white matter (WM) tract morphology. We reviewed consecutive AVM cases treated at a tertiary care hospital where diffusion tensor imaging (DTI) tractography was obtained preoperatively. DTI was performed using the Synaptive Plan (Synaptive Medical Inc., Toronto, Canada). Quality control was performed by clinical application specialist. Perinidal fractional anisotropy (FA) value of corticospinal tracts (CST) was obtained. A reference FA value was obtained from the corresponding area on the contralateral side. Images were evaluated by a consultant neuroradiologist. Radiological findings were correlated with clinical findings. …

Self‑Resolving Prepontine Cyst, Muhammad Waqas, Inamullah Khan, Reehana Khawaja, Ayesha Quddusi, Ather Enam

Section of Neurosurgery

Background: Intracranial prepontine cysts are rare and include epidermoid cysts, arachnoid cysts, and neurenteric cysts. Symptomatic prepontine cysts may require surgical intervention. Reports of spontaneous resolution of cysts are rare.
Case description: We describe the case of a young gentleman who presented with headache and fever. Magnetic resonance imaging of the brain identified a prepontine lesion with features consistent with epidermoid cyst. During admission, the patient received symptomatic management in addition to empirical antibiotic therapy and dexamethasone. The patient improved symptomatically in the next 48 hours and was discharged. Follow-up imaging at 6 months and 1 year showed significant reduction …

A Clinical Practice Guideline For The Management Of Patients With Acute Spinal Cord Injury And Central Cord Syndrome: Recommendations On The Timing (≤24 Hours Versus >24 Hours) Of Decompressive Surgery, Michael G. Fehlings, Lindsay A. Tetreault, Jefferson R. Wilson, Bizhan Aarabi, Paul Anderson, Paul M. Arnold, Darrel S. Brodke, Anthony S. Burns, Kazuhiro Chiba, Joseph R. Dettori, Julio C. Furlan, Gregory Hawryluk, Langston T. Holly, Susan Howley, Tara Jeji, Sukhvinder Kalsi-Ryan, Mark Kotter, Shekar Kurpad, Ralph J. Marino, Allan R. Martin, Eric Massicotte, Geno J. Merli, James W. Middleton, Hiroaki Nakashima, Narihito Nagoshi, Katherine Palmieri, Anoushka Singh, Andrea C. Skelly, Eve C. Tsai, Alexander R. Vaccaro, Albert Yee, James S. Harrop

Department of Rehabilitation Medicine Faculty Papers

Objective: To develop recommendations on the timing of surgical decompression in patients with traumatic spinal cord injury (SCI) and central cord syndrome. Methods: A systematic review of the literature was conducted to address key relevant questions. A multidisciplinary guideline development group used this information, along with their clinical expertise, to develop recommendations for the timing of surgical decompression in patients with SCI and central cord syndrome. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weak recommendation is presented as “we suggest.” Results: Conclusions from the systematic review included (1) isolated studies reported statistically significant and …

A Clinical Practice Guideline For The Management Of Patients With Degenerative Cervical Myelopathy: Recommendations For Patients With Mild, Moderate, And Severe Disease And Nonmyelopathic Patients With Evidence Of Cord Compression, Michael G. Fehlings, Lindsay A. Tetreault, K. Daniel Riew, James W. Middleton, Bizhan Aarabi, Paul M. Arnold, Darrel S. Brodke, Anthony S. Burns, Simon Carette, Robert Chen, Kazuhiro Chiba, Joseph R. Dettori, Julio C. Ferlan, James S. Harrop, Langston T. Holly, Sukhvinder Kalsi-Ryan, Mark Kotter, Brian K. Kwon, Allan R. Martin, James Milligan, Hiroaki Nakashima, Narihito Nagoshi, John Rhee, Anoushka Singh, Andrea C. Skelly, Sumeet Sodhi, Jefferson R. Wilson, Albert Yee, Jeffrey C. Wang

Department of Neurosurgery Faculty Papers

Study Design: Guideline development. Objectives: The objective of this study is to develop guidelines that outline how to best manage (1) patients with mild, moderate, and severe myelopathy and (2) nonmyelopathic patients with evidence of cord compression with or without clinical symptoms of radiculopathy. Methods: Five systematic reviews of the literature were conducted to synthesize evidence on disease natural history; risk factors of disease progression; the efficacy, effectiveness, and safety of nonoperative and surgical management; the impact of preoperative duration of symptoms and myelopathy severity on treatment outcomes; and the frequency, timing, and predictors of symptom development. A multidisciplinary guideline …

Intracranial Eeg Fluctuates Over Months After Implanting Electrodes In Human Brain., Hoameng Ung, Steven N. Baldassano, Hank Bink, Abba M. Krieger, Shawniqua Williams, Flavia Vitale, Chengyuan Wu, Dean Freestone, Ewan Nurse, Kent Leyde, Kathryn A. Davis, Mark Cook, Brian Litt

Department of Neurosurgery Faculty Papers

OBJECTIVE: Implanting subdural and penetrating electrodes in the brain causes acute trauma and inflammation that affect intracranial electroencephalographic (iEEG) recordings. This behavior and its potential impact on clinical decision-making and algorithms for implanted devices have not been assessed in detail. In this study we aim to characterize the temporal and spatial variability of continuous, prolonged human iEEG recordings.

APPROACH: Intracranial electroencephalography from 15 patients with drug-refractory epilepsy, each implanted with 16 subdural electrodes and continuously monitored for an average of 18 months, was included in this study. Time and spectral domain features were computed each day for each channel for …

Timing Of Decompression In Patients With Acute Spinal Cord Injury: A Systematic Review, Jefferson R. Wilson, Lindsay A. Tetreault, Brian Kwon, Paul M. Arnold, Thomas E. Mroz, Christopher I. Shaffrey, James S. Harrop, Jens R. Chapman, Steven Casha, Andrea C. Skelly, Haley K. Holmer, Erika D. Brodt, Michael G. Fehlings

Department of Neurosurgery Faculty Papers

Study Design: Systematic review. Objective: To conduct a systematic review and synthesis of the literature to assess the comparative effectiveness, safety, and cost-effectiveness of early (≤24 hours) versus late decompression (>24 hours) in adults with acute spinal cord injury (SCI). Methods: A systematic search was conducted of Medline, EMBASE, the Cochrane Collaboration Library, and Google Scholar to identify studies published through November 6, 2014. Studies published in any language, in humans, and with an abstract were considered for inclusion. Included studies were critically appraised and the overall strength of evidence was determined using methods proposed by the Grading of …

Efficacy And Safety Of Methylprednisolone Sodium Succinate In Acute Spinal Cord Injury: A Systematic Review, Michael G. Fehlings, Jefferson R. Wilson, James S. Harrop, Brian Kwon, Lindsay A. Tetreault, Paul M. Arnold, Jeffrey M. Singh, Gregory W.J. Hawryluk, Joseph R. Dettori

Department of Neurosurgery Faculty Papers

Study Design: Systematic review and meta-analysis. Objective: The objective of this study was to conduct a systematic review to assess the comparative effectiveness and safety of high-dose methylprednisolone sodium succinate (MPSS) versus no pharmacological treatment in patients with traumatic spinal cord injury (SCI). Methods: A systematic search was performed in PubMed and the Cochrane Collaboration Library for literature published between January 1956 and June 17, 2015. Included studies were critically appraised, and Grades of Recommendation Assessment, Development and Evaluation methods were used to determine the overall quality of evidence for primary outcomes. Previous systematic reviews on this topic were collated …

Chiari I Malformation And Spinal Cord Ischemia In A Cadaver., Faizullah Mashriqi, Marios Loukas, Rod J Oskouian, Anthony V D'Antoni, R Shane Tubbs

Articles, Abstracts, and Reports

With advanced imaging, the Chiari I malformation (CIM) is more frequently diagnosed than in the past when this entity was identified most commonly at autopsy. Herein, we report the rare case of an adult cadaver found not only to have CIM but also adjacent spinal cord ischemia. This case is discussed in the context of chronic compression of the spinal cord by a CIM and the need for close monitoring of these patients.

Role Of Surgery In Brain Metastases, Altaf Ali Laghari, Syed Ijlal Ahmed, Muhammad Shahzad Shamim

Department of Surgery Docs

Abstract Brain metastases remain the commonest type of brain tumour, being four times more common than primary brain tumours. Although surgical intervention may be recommended for one of various reasons in the management of these tumours, including but not limited to conformation of diagnosis, relief of mass effect, improvement of neurological status and prolongation of survival, the guidelines for management of brain metastases remain largely subjective and therefore controversial. Herein the authors have attempted to review some of the existing evidence on role of surgery in the management of brain metastases and have presented their selected guidelines for the readers.

Quantitative Anterior And Posterior Clinoidectomy Analysis And Mobilization Of The Oculomotor Nerve During Surgical Exposure Of The Basilar Apex Using Frameless Stereotaxis., Aclan Dogan, Justin S Cetas, Gregory J Anderson, Andy Rekito, Johnny B Delashaw

Articles, Abstracts, and Reports

No abstract provided.

Variant Prevertebral Muscle: Unique Cadaveric Findings., Jocelyn R Gonzales, Joe Iwanaga, Rod J Oskouian, R Shane Tubbs

Articles, Abstracts, and Reports

The levator scapulae muscle typically runs from the transverse process of the atlas to the superior angle of the scapula. In this paper, we describe a rare finding identified during a dissection of a male cadaver, wherein a continuation of the right levator scapulae ran past its normal attachment to the C1 transverse process, fusing with the inferior attachment of the rectus capitis lateralis muscle. No variants were found on the opposite side, and the innervation of the levator scapulae muscle variant was typical of that of a normal levator scapulae. We also describe other related variants of the cranial …