{"paper_id":"0aa92427-610e-4912-9bb1-70076d174f8a","body_text":"Postmortem discovery of a rare five-vessel aortic arch with aberrant right subclavian artery and bilateral anomalous vertebral artery origins: Embryological analysis and perioperative implications | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Postmortem discovery of a rare five-vessel aortic arch with aberrant right subclavian artery and bilateral anomalous vertebral artery origins: Embryological analysis and perioperative implications Pavel Alexandrovich Karavaikin, Mikhail Sergeevich Latyshev, Valery Sergeevich Arakelyan, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9124648/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Complex aortic arch branching variants with multiple direct branches and anomalous vertebral artery origins are rare and typically incidental. We report a postmortem-confirmed case of a rare five-vessel aortic arch configuration identified in a 65-year-old man who underwent elective mitral and tricuspid valve repair for severe mitral regurgitation. The postoperative course was complicated by delayed neurological deterioration and fatal tonsillar herniation. Examination of the thoracic aorta revealed a five-branch aortic arch consisting of the right common carotid artery, left common carotid artery, left vertebral artery arising directly from the arch, left subclavian artery, and an aberrant right subclavian artery with a retroesophageal course. The right vertebral artery originated anomalously from the proximal right common carotid artery. This rare vascular configuration highlights the embryological complexity of multi-branch aortic arch variants and suggests potential implications for vertebrobasilar perfusion during cardiothoracic procedures. Recognition of such variants through careful preoperative imaging of the supra-aortic vessels may help reduce unforeseen perioperative risks. Aortic arch branching Five-vessel aortic arch Aberrant right subclavian artery Arteria lusoria Anomalous vertebral artery origin Postmortem examination Figures Figure 1 Figure 2 Introduction Recent meta-analyses have demonstrated that the classic three-branch configuration of the aortic arch (brachiocephalic trunk, left common carotid artery (LCCA), and left subclavian artery (LSA)) is present in approximately 77–78% of individuals, as confirmed by both cadaveric dissections and radiological imaging studies [ 4 , 6 ]. In the absence of tracheoesophageal compression, anomalous branching patterns are generally asymptomatic and are typically identified incidentally. However, accurate recognition of aortic arch variants is crucial in cardiothoracic, esophageal, tracheal, or endovascular procedures, since unrecognized anomalies may influence cerebral perfusion or complicate surgical access. Herein, we describe a case of an aberrant right subclavian artery (ARSA) associated with anomalous origins of both vertebral arteries. Case Presentation A 65-year-old man was referred to the Bakulev National Medical Research Center for Cardiovascular Surgery with progressive exertional dyspnea (NYHA class III) secondary to severe mitral regurgitation caused by chordal rupture of the P2 scallop of the posterior mitral leaflet, as confirmed by transthoracic echocardiography. Routine preoperative laboratory tests and standard preoperative imaging (including transthoracic echocardiography) revealed no extracardiac abnormalities. No preoperative computed tomography angiography of the supra-aortic vessels was performed, as it was not indicated based on the initial clinical evaluation. The patient subsequently underwent mitral and tricuspid valve repair. Mitral valve reconstruction consisted of annuloplasty with a prosthetic ring and quadrangular resection of the prolapsing P2 scallop. Concomitant moderate tricuspid regurgitation was addressed with a De Vega annuloplasty. The procedure was performed via median sternotomy under standard cardiopulmonary bypass with aortic cannulation and bicaval venous drainage. Intraoperative findings and the postoperative course were uneventful with respect to the valvular repair. Postoperative transesophageal echocardiography demonstrated satisfactory hemodynamic results, showing only trivial residual regurgitation and preserved biventricular function. The patient was extubated 10 hours postoperatively without immediate neurological deficit. However, approximately seven hours later, he developed acute agitation and disorientation, rapidly progressing to hemodynamic instability, necessitating deep sedation and reintubation. Shortly thereafter, asystole ensued. Advanced cardiopulmonary resuscitation was initiated but ultimately proved unsuccessful. An autopsy was performed to elucidate the cause of the sudden postoperative deterioration and cardiac arrest. Postmortem examination revealed multiple focal intracerebral petechial hemorrhages, along with diffuse cerebral edema, asymmetrically more pronounced on the right side. The immediate cause of death was determined to be downward herniation of the cerebellar tonsils, secondary to acute intracranial hypertension. In addition to the intracranial findings, examination of the thoracic aorta revealed a rare five-vessel configuration of the aortic arch. The branching pattern, from proximal to distal, was as follows: right common carotid artery (RCCA), LCCA, left vertebral artery (LVA) arising directly from the arch, LSA, and, as the terminal branch, the ARSA following a retroesophageal course. The right vertebral artery (RVA) originated anomalously from the proximal RCCA (Fig. 1 ). Discussion We report a unique combination of rare aortic arch anomalies: a five-vessel arch with an ARSA following a retroesophageal course and anomalous origins of both vertebral arteries. This constellation was incidentally discovered at autopsy in a patient who had undergone cardiac valve surgery. To the best of our knowledge, only a limited number of comparable cases have been reported to date, all detected incidentally [ 2 , 5 , 9 ]. In contrast to the LVA, an anomalous origin of the RVA is considered relatively rare, with a reported prevalence ranging from 0.1% to 0.69% [ 3 , 7 ]. By comparison, an anomalous origin of the LVA has been observed in 4–6.5% of cases [ 3 , 7 ]. Bilateral aberrant vertebral artery origin is exceptional, with an estimated incidence of approximately 0.048% [ 3 ]. Specifically, the RVA originates from the RCCA in 0.13–0.36% of individuals overall [ 3 , 7 ]. Notably, the origin of the RVA from the RCCA appears to be almost invariably associated with the ARSA, as most reported cases describe their coexistence [ 5 , 8 ]. Only a limited number of reports have documented an isolated RVA originating from the RCCA without concomitant ARSA [ 1 , 8 ]. Anomalous aortic arch branching patterns result from alterations in normal embryological vascular development. In typical embryogenesis, the LSA develops from the seventh left cervical intersegmental artery (ISA), whereas the right subclavian artery (RSA) is formed by contributions from the right fourth aortic arch, a segment of the right dorsal aorta, and the right seventh ISA. The vertebral arteries arise from longitudinal anastomoses connecting the first through seventh cervical ISAs, followed by involution of the first to sixth ISAs [ 2 , 3 , 8 ]. Persistence of one or more of these proximal ISAs is the primary cause of anomalous vertebral artery origins. When a vertebral artery originates at a different segmental level than its ipsilateral subclavian artery, this reflects abnormal ISA persistence [ 2 , 7 , 9 , 10 ]. The ARSA develops when the right dorsal aorta persists distal to the origin of the seventh ISA, while the right fourth aortic arch regresses abnormally [ 8 , 9 ]. In the present case, we hypothesize that the observed five-vessel configuration resulted from concurrent persistence of both the right dorsal aorta (distal to the seventh ISA) and portions of the right fourth aortic arch and proximal dorsal aorta. Consequently, the ARSA likely derived from the persistent right dorsal aorta in continuity with the seventh (or possibly eighth [ 8 ]) ISA. The RVA, originating from the proximal RCCA, likely developed from an anomalous connection involving the right fourth aortic arch, a portion of the proximal right dorsal aorta, and a right ISA situated cranial to the one that gave rise to the RSA. On the left side, the LSA derived from the left seventh ISA, while the LVA arose directly from the aortic arch proximal to the LSA, reflecting persistence of a left ISA cranial to the seventh segment (Fig. 2 ). Yellow: Aortic sac derivatives (ascending aorta, proximal aortic arch, and pulmonary trunk). Purple: Aortic horn derivatives (proximal RCCA, middle segment of the aortic arch). Deep blue: Derivatives of the third aortic arches (distal RCCA, LCCA, proximal ICA). Cyan: Derivatives of the fourth aortic arches (middle segment of the aortic arch and proximal RVA). Grey: Derivatives of the sixth aortic arches (pulmonary arteries and ductus arteriosus). Red: Dorsal aorta derivatives (distal aortic arch, descending aorta, proximal ARSA, a segment of RVA). Orange: Angiogenic vessels – ISAs derivatives (LSA, LVA, and distal segments of ARSA and RVA) and ECA. RCCA right common carotid artery, RVA right vertebral artery, LCCA left common carotid artery, LVA left vertebral artery, LSA left subclavian artery, ARSA aberrant right subclavian artery, ICA internal carotid artery, ECA external carotid artery, ISA intersegmental artery Generally, anomalous aortic arch branching patterns remain asymptomatic in the absence of tracheoesophageal compression, and most individuals with such variants are identified incidentally during imaging or autopsy. Although several authors have suggested that aberrant origins of the vertebral arteries may influence cerebral hemodynamics, particularly within the vertebrobasilar territory, a direct causal relationship has not been definitively established [ 1 , 10 ]. In the present case, the fatal postoperative course raises the possibility that the undetected vascular configuration may have represented an additional risk factor for neurological deterioration. The anomalous origins of the vertebral arteries could have predisposed the patient to compromised vertebrobasilar perfusion during cardiopulmonary bypass or episodes of perioperative hypotension. Altered flow dynamics, relative hypoperfusion, or increased susceptibility to microembolic events in the posterior circulation may have contributed to the asymmetric cerebral edema and subsequent tonsillar herniation observed at autopsy. While this proposed mechanism remains speculative and warrants further investigation, the temporal association and postmortem findings justify consideration of such vascular variants as potential contributory factors in perioperative neurological decompensation. This case highlights the potential importance of thorough preoperative assessment of cerebral vascular anatomy, even in patients undergoing elective valvular surgery. Increased awareness of rare multi-branch aortic arch configurations, together with tailored perioperative neuromonitoring strategies (e.g., bilateral near-infrared spectroscopy), may help mitigate unrecognized risks in selected patients. Conclusion The present report describes a unique postmortem-confirmed five-vessel aortic arch configuration with aberrant right subclavian artery and bilateral anomalous vertebral artery origins in a patient who experienced fatal postoperative tonsillar herniation following mitral and tricuspid valve repair. Although most aortic arch variants are clinically silent, this case illustrates that incidental multi-branch anomalies can have unforeseen and devastating perioperative implications during cardiac surgery. Careful preoperative imaging review and tailored neuromonitoring may improve perioperative safety in similar scenarios. Declarations Competing Interests The authors declare that they have no competing interests. Patient Consent Written informed consent for publication of this case report and any accompanying images was obtained from the patient's next of kin. Author Contribution PA Karavaikin: Data analysis, Manuscript writing, Preparation of illustrations MS Latyshev: Data collection, Manuscript editing VS Arakelyan: Project development, Data analysis, Manuscript editing PV Kakhktsyan: Data analysis, Manuscript editing VG Papitashvili: Data analysis, Manuscript editing IN Shchanitsyn: Project development, Data analysis, Preparation of illustrations DR Tevosov: Data collection, Preparation of illustrations DY Khinchagov: Data collection Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. References Bernardi L, Dettori P (1975) Angiographic study of a rare anomalous origin of the vertebral artery. Neuroradiology 9:43–47. 10.1007/BF00330136 Brouwer PA, Souza MPS, Agid R, TerBrugge KG (2004) A five-vessel aortic arch with an anomalous origin of both vertebral arteries and an aberrant right subclavian artery. Interv Neuroradiol 10:309–314. 10.1177/159101990401000404 Lazaridis N, Piagkou M, Loukas M, Piperaki E-TT, Totlis T, Noussios G, Natsis K (2018) A systematic classification of the vertebral artery variable origin: Clinical and surgical implications. Surg Radiol Anat 40:779–797. 10.1007/s00276-018-1987-3 Natsis K, Piagkou M, Lazaridis N, Kalamatianos T, Chytas D, Manatakis D, Anastasopoulos N, Loukas M (2021) A systematic classification of the left-sided aortic arch variants based on cadaveric studies’ prevalence. Surg Radiol Anat 43:327–345. 10.1007/s00276-020-02625-1 Tsai I-C, Tzeng W-S, Lee T, Jan S-L, Fu Y-C, Chen M-C, Lin P-C, Liao W-C, Chen CC-C (2007) Vertebral and carotid artery anomalies in patients with aberrant right subclavian arteries. Pediatr Radiol 37:1007–1012. 10.1007/s00247-007-0574-2 Tsiouris C, Lazaridis N, Piagkou M, Duparc F, Antonopoulos I, Antonitsis P, Natsis K (2022) The left-sided aortic arch variants: prevalence meta-analysis of imaging studies. Surg Radiol Anat 44:673–688. 10.1007/s00276-022-02945-4 Tudose RC, Rusu MC, Hostiuc S (2023) The vertebral artery: A systematic review and a meta-analysis of the current literature. Diagnostics 13:2036. 10.3390/diagnostics13122036 Uchino A, Saito N, Takahashi M, Okada Y, Kozawa E, Nishi N, Mizukoshi W, Nakajima R, Watanabe Y (2013) Variations in the origin of the vertebral artery and its level of entry into the transverse foramen diagnosed by CT angiography. Neuroradiology 55:585–594. 10.1007/s00234-013-1142-0 Wu Y, Zhang H, Tang C (2021) Coexistence of an aberrant right subclavian artery and anomalous origins of bilateral vertebral arteries: A case report. Med (Baltim) 100:e25043. 10.1097/MD.0000000000025043 Yuan S-M (2015) Aberrant origin of vertebral artery and its clinical implications. Brazilian J Cardiovasc Surg 31:52–59. 10.5935/1678-9741.20150071 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 06 May, 2026 Reviewers agreed at journal 05 May, 2026 Reviewers invited by journal 27 Mar, 2026 Editor assigned by journal 19 Mar, 2026 Submission checks completed at journal 17 Mar, 2026 First submitted to journal 14 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-9124648\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":613957260,\"identity\":\"a0324ad5-86ce-4e0b-8215-d9c4e10c73e6\",\"order_by\":0,\"name\":\"Pavel Alexandrovich 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19:23:28\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-9124648/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-9124648/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":105844113,\"identity\":\"8c6cb32f-b63f-445f-b9e7-69fdbc947a94\",\"added_by\":\"auto\",\"created_at\":\"2026-03-31 17:30:50\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":1278985,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eMacroscopic postmortem specimen of the aortic arch from the present case. \\u003cstrong\\u003ea\\u003c/strong\\u003e Anterior view of the aortic arch preparation showing the branching pattern from proximal to distal: right common carotid artery (RCCA), left common carotid artery (LCCA), left vertebral artery (LVA) arising directly from the arch, left subclavian artery (LSA), and aberrant right subclavian artery (ARSA) as the terminal branch. The right vertebral artery (RVA) originates anomalously from the proximal RCCA. All major branches are labeled. \\u003cstrong\\u003eb\\u003c/strong\\u003e Posterior view of the same aortic arch preparation demonstrating the course of the ARSA and confirming the spatial relationships of the branches, including the anomalous origin of the RVA from the proximal RCCA. All major branches are labeled\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9124648/v1/4f94b2d7597b617b6b74c210.png\"},{\"id\":105844114,\"identity\":\"458cca85-6828-48ef-b885-fb5eaf97f301\",\"added_by\":\"auto\",\"created_at\":\"2026-03-31 17:30:50\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":42282,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eFig. 2\\u003c/strong\\u003e Schematic representation of the proposed embryological development of the five-vessel aortic arch configuration observed in the present case. \\u003cstrong\\u003ea\\u003c/strong\\u003e Embryonic arterial system showing the aortic sac, right and left aortic horns, aortic arches, ISAs, and other angiogenic vessels, color-coded to illustrate their contributions to the developing supra-aortic branches. Arabic numerals denote the first through ninth ISAs. \\u003cstrong\\u003eb\\u003c/strong\\u003eDefinitive (adult) configuration of the aortic arch corresponding to the observed five-branch pattern. Individual vascular segments are color-coded according to their embryological origins as depicted in panel (a). Rectangular color-coded labels on the right indicate the embryonic sources of each definitive vascular segment, matching the colors used in panels (a) and (b):\\u003c/p\\u003e\\n\\u003cp\\u003e· Yellow: Aortic sac derivatives (ascending aorta, proximal aortic arch, and pulmonary trunk).\\u003c/p\\u003e\\n\\u003cp\\u003e· Purple: Aortic horn derivatives (proximal RCCA, middle segment of the aortic arch).\\u003c/p\\u003e\\n\\u003cp\\u003e· Deep blue: Derivatives of the third aortic arches (distal RCCA, LCCA, proximal ICA).\\u003c/p\\u003e\\n\\u003cp\\u003e· Cyan: Derivatives of the fourth aortic arches (middle segment of the aortic arch and proximal RVA).\\u003c/p\\u003e\\n\\u003cp\\u003e· Grey: Derivatives of the sixth aortic arches (pulmonary arteries and ductus arteriosus).\\u003c/p\\u003e\\n\\u003cp\\u003e· Red: Dorsal aorta derivatives (distal aortic arch, descending aorta, proximal ARSA, a segment of RVA).\\u003c/p\\u003e\\n\\u003cp\\u003e· Orange: Angiogenic vessels – ISAs derivatives (LSA, LVA, and distal segments of ARSA and RVA) and ECA.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eRCCA\\u003c/em\\u003eright common carotid artery, \\u003cem\\u003eRVA\\u003c/em\\u003e right vertebral artery, \\u003cem\\u003eLCCA\\u003c/em\\u003eleft common carotid artery, \\u003cem\\u003eLVA\\u003c/em\\u003e left vertebral artery, \\u003cem\\u003eLSA\\u003c/em\\u003e left subclavian artery, \\u003cem\\u003eARSA\\u003c/em\\u003e aberrant right subclavian artery, \\u003cem\\u003eICA\\u003c/em\\u003einternal carotid artery, \\u003cem\\u003eECA\\u003c/em\\u003e external carotid artery, \\u003cem\\u003eISA\\u003c/em\\u003eintersegmental artery\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9124648/v1/e1568c7c13514421df0f50b6.png\"},{\"id\":105904958,\"identity\":\"a72828b0-df0c-48c8-8960-7b66d463f2ed\",\"added_by\":\"auto\",\"created_at\":\"2026-04-01 10:11:12\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1979650,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9124648/v1/2c70687e-7963-4d20-bea1-8345fa5d1da6.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Postmortem discovery of a rare five-vessel aortic arch with aberrant right subclavian artery and bilateral anomalous vertebral artery origins: Embryological analysis and perioperative implications\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eRecent meta-analyses have demonstrated that the classic three-branch configuration of the aortic arch (brachiocephalic trunk, left common carotid artery (LCCA), and left subclavian artery (LSA)) is present in approximately 77\\u0026ndash;78% of individuals, as confirmed by both cadaveric dissections and radiological imaging studies [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. In the absence of tracheoesophageal compression, anomalous branching patterns are generally asymptomatic and are typically identified incidentally. However, accurate recognition of aortic arch variants is crucial in cardiothoracic, esophageal, tracheal, or endovascular procedures, since unrecognized anomalies may influence cerebral perfusion or complicate surgical access. Herein, we describe a case of an aberrant right subclavian artery (ARSA) associated with anomalous origins of both vertebral arteries.\\u003c/p\\u003e\"},{\"header\":\"Case Presentation\",\"content\":\"\\u003cp\\u003eA 65-year-old man was referred to the Bakulev National Medical Research Center for Cardiovascular Surgery with progressive exertional dyspnea (NYHA class III) secondary to severe mitral regurgitation caused by chordal rupture of the P2 scallop of the posterior mitral leaflet, as confirmed by transthoracic echocardiography. Routine preoperative laboratory tests and standard preoperative imaging (including transthoracic echocardiography) revealed no extracardiac abnormalities. No preoperative computed tomography angiography of the supra-aortic vessels was performed, as it was not indicated based on the initial clinical evaluation.\\u003c/p\\u003e \\u003cp\\u003eThe patient subsequently underwent mitral and tricuspid valve repair. Mitral valve reconstruction consisted of annuloplasty with a prosthetic ring and quadrangular resection of the prolapsing P2 scallop. Concomitant moderate tricuspid regurgitation was addressed with a De Vega annuloplasty. The procedure was performed via median sternotomy under standard cardiopulmonary bypass with aortic cannulation and bicaval venous drainage. Intraoperative findings and the postoperative course were uneventful with respect to the valvular repair. Postoperative transesophageal echocardiography demonstrated satisfactory hemodynamic results, showing only trivial residual regurgitation and preserved biventricular function.\\u003c/p\\u003e \\u003cp\\u003eThe patient was extubated 10 hours postoperatively without immediate neurological deficit. However, approximately seven hours later, he developed acute agitation and disorientation, rapidly progressing to hemodynamic instability, necessitating deep sedation and reintubation. Shortly thereafter, asystole ensued. Advanced cardiopulmonary resuscitation was initiated but ultimately proved unsuccessful.\\u003c/p\\u003e \\u003cp\\u003eAn autopsy was performed to elucidate the cause of the sudden postoperative deterioration and cardiac arrest. Postmortem examination revealed multiple focal intracerebral petechial hemorrhages, along with diffuse cerebral edema, asymmetrically more pronounced on the right side. The immediate cause of death was determined to be downward herniation of the cerebellar tonsils, secondary to acute intracranial hypertension.\\u003c/p\\u003e \\u003cp\\u003eIn addition to the intracranial findings, examination of the thoracic aorta revealed a rare five-vessel configuration of the aortic arch. The branching pattern, from proximal to distal, was as follows: right common carotid artery (RCCA), LCCA, left vertebral artery (LVA) arising directly from the arch, LSA, and, as the terminal branch, the ARSA following a retroesophageal course. The right vertebral artery (RVA) originated anomalously from the proximal RCCA (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eWe report a unique combination of rare aortic arch anomalies: a five-vessel arch with an ARSA following a retroesophageal course and anomalous origins of both vertebral arteries. This constellation was incidentally discovered at autopsy in a patient who had undergone cardiac valve surgery. To the best of our knowledge, only a limited number of comparable cases have been reported to date, all detected incidentally [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIn contrast to the LVA, an anomalous origin of the RVA is considered relatively rare, with a reported prevalence ranging from 0.1% to 0.69% [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. By comparison, an anomalous origin of the LVA has been observed in 4\\u0026ndash;6.5% of cases [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. Bilateral aberrant vertebral artery origin is exceptional, with an estimated incidence of approximately 0.048% [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eSpecifically, the RVA originates from the RCCA in 0.13\\u0026ndash;0.36% of individuals overall [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. Notably, the origin of the RVA from the RCCA appears to be almost invariably associated with the ARSA, as most reported cases describe their coexistence [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. Only a limited number of reports have documented an isolated RVA originating from the RCCA without concomitant ARSA [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eAnomalous aortic arch branching patterns result from alterations in normal embryological vascular development. In typical embryogenesis, the LSA develops from the seventh left cervical intersegmental artery (ISA), whereas the right subclavian artery (RSA) is formed by contributions from the right fourth aortic arch, a segment of the right dorsal aorta, and the right seventh ISA. The vertebral arteries arise from longitudinal anastomoses connecting the first through seventh cervical ISAs, followed by involution of the first to sixth ISAs [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003ePersistence of one or more of these proximal ISAs is the primary cause of anomalous vertebral artery origins. When a vertebral artery originates at a different segmental level than its ipsilateral subclavian artery, this reflects abnormal ISA persistence [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]. The ARSA develops when the right dorsal aorta persists distal to the origin of the seventh ISA, while the right fourth aortic arch regresses abnormally [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIn the present case, we hypothesize that the observed five-vessel configuration resulted from concurrent persistence of both the right dorsal aorta (distal to the seventh ISA) and portions of the right fourth aortic arch and proximal dorsal aorta. Consequently, the ARSA likely derived from the persistent right dorsal aorta in continuity with the seventh (or possibly eighth [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]) ISA. The RVA, originating from the proximal RCCA, likely developed from an anomalous connection involving the right fourth aortic arch, a portion of the proximal right dorsal aorta, and a right ISA situated cranial to the one that gave rise to the RSA. On the left side, the LSA derived from the left seventh ISA, while the LVA arose directly from the aortic arch proximal to the LSA, reflecting persistence of a left ISA cranial to the seventh segment (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eYellow: Aortic sac derivatives (ascending aorta, proximal aortic arch, and pulmonary trunk).\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003ePurple: Aortic horn derivatives (proximal RCCA, middle segment of the aortic arch).\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eDeep blue: Derivatives of the third aortic arches (distal RCCA, LCCA, proximal ICA).\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eCyan: Derivatives of the fourth aortic arches (middle segment of the aortic arch and proximal RVA).\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eGrey: Derivatives of the sixth aortic arches (pulmonary arteries and ductus arteriosus).\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eRed: Dorsal aorta derivatives (distal aortic arch, descending aorta, proximal ARSA, a segment of RVA).\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eOrange: Angiogenic vessels \\u0026ndash; ISAs derivatives (LSA, LVA, and distal segments of ARSA and RVA) and ECA.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003eRCCA\\u003c/em\\u003e right common carotid artery, \\u003cem\\u003eRVA\\u003c/em\\u003e right vertebral artery, \\u003cem\\u003eLCCA\\u003c/em\\u003e left common carotid artery, \\u003cem\\u003eLVA\\u003c/em\\u003e left vertebral artery, \\u003cem\\u003eLSA\\u003c/em\\u003e left subclavian artery, \\u003cem\\u003eARSA\\u003c/em\\u003e aberrant right subclavian artery, \\u003cem\\u003eICA\\u003c/em\\u003e internal carotid artery, \\u003cem\\u003eECA\\u003c/em\\u003e external carotid artery, \\u003cem\\u003eISA\\u003c/em\\u003e intersegmental artery\\u003c/p\\u003e \\u003cp\\u003eGenerally, anomalous aortic arch branching patterns remain asymptomatic in the absence of tracheoesophageal compression, and most individuals with such variants are identified incidentally during imaging or autopsy. Although several authors have suggested that aberrant origins of the vertebral arteries may influence cerebral hemodynamics, particularly within the vertebrobasilar territory, a direct causal relationship has not been definitively established [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIn the present case, the fatal postoperative course raises the possibility that the undetected vascular configuration may have represented an additional risk factor for neurological deterioration. The anomalous origins of the vertebral arteries could have predisposed the patient to compromised vertebrobasilar perfusion during cardiopulmonary bypass or episodes of perioperative hypotension. Altered flow dynamics, relative hypoperfusion, or increased susceptibility to microembolic events in the posterior circulation may have contributed to the asymmetric cerebral edema and subsequent tonsillar herniation observed at autopsy. While this proposed mechanism remains speculative and warrants further investigation, the temporal association and postmortem findings justify consideration of such vascular variants as potential contributory factors in perioperative neurological decompensation.\\u003c/p\\u003e \\u003cp\\u003eThis case highlights the potential importance of thorough preoperative assessment of cerebral vascular anatomy, even in patients undergoing elective valvular surgery. Increased awareness of rare multi-branch aortic arch configurations, together with tailored perioperative neuromonitoring strategies (e.g., bilateral near-infrared spectroscopy), may help mitigate unrecognized risks in selected patients.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThe present report describes a unique postmortem-confirmed five-vessel aortic arch configuration with aberrant right subclavian artery and bilateral anomalous vertebral artery origins in a patient who experienced fatal postoperative tonsillar herniation following mitral and tricuspid valve repair. Although most aortic arch variants are clinically silent, this case illustrates that incidental multi-branch anomalies can have unforeseen and devastating perioperative implications during cardiac surgery. Careful preoperative imaging review and tailored neuromonitoring may improve perioperative safety in similar scenarios.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eCompeting Interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePatient Consent\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWritten informed consent for publication of this case report and any accompanying images was obtained from the patient\\u0026apos;s next of kin.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor Contribution\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003ePA Karavaikin: Data analysis, Manuscript writing, Preparation of illustrations\\u003c/p\\u003e\\n\\u003cp\\u003eMS Latyshev: Data collection, Manuscript editing\\u003c/p\\u003e\\n\\u003cp\\u003eVS Arakelyan: Project development, Data analysis, Manuscript editing\\u003c/p\\u003e\\n\\u003cp\\u003ePV Kakhktsyan: Data analysis, Manuscript editing\\u003c/p\\u003e\\n\\u003cp\\u003eVG Papitashvili: Data analysis, Manuscript editing\\u003c/p\\u003e\\n\\u003cp\\u003eIN Shchanitsyn: Project development, Data analysis, Preparation of illustrations\\u003c/p\\u003e\\n\\u003cp\\u003eDR Tevosov: Data collection, Preparation of illustrations\\u003c/p\\u003e\\n\\u003cp\\u003eDY Khinchagov: Data collection\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eBernardi L, Dettori P (1975) Angiographic study of a rare anomalous origin of the vertebral artery. Neuroradiology 9:43\\u0026ndash;47. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1007/BF00330136\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/BF00330136\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBrouwer PA, Souza MPS, Agid R, TerBrugge KG (2004) A five-vessel aortic arch with an anomalous origin of both vertebral arteries and an aberrant right subclavian artery. Interv Neuroradiol 10:309\\u0026ndash;314. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1177/159101990401000404\\u003c/span\\u003e\\u003cspan address=\\\"10.1177/159101990401000404\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLazaridis N, Piagkou M, Loukas M, Piperaki E-TT, Totlis T, Noussios G, Natsis K (2018) A systematic classification of the vertebral artery variable origin: Clinical and surgical implications. 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Neuroradiology 55:585\\u0026ndash;594. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1007/s00234-013-1142-0\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/s00234-013-1142-0\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWu Y, Zhang H, Tang C (2021) Coexistence of an aberrant right subclavian artery and anomalous origins of bilateral vertebral arteries: A case report. Med (Baltim) 100:e25043. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1097/MD.0000000000025043\\u003c/span\\u003e\\u003cspan address=\\\"10.1097/MD.0000000000025043\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eYuan S-M (2015) Aberrant origin of vertebral artery and its clinical implications. Brazilian J Cardiovasc Surg 31:52\\u0026ndash;59. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.5935/1678-9741.20150071\\u003c/span\\u003e\\u003cspan address=\\\"10.5935/1678-9741.20150071\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"surgical-and-radiologic-anatomy\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"sara\",\"sideBox\":\"Learn more about [Surgical and Radiologic Anatomy](http://link.springer.com/journal/276)\",\"snPcode\":\"276\",\"submissionUrl\":\"https://submission.nature.com/new-submission/276/3\",\"title\":\"Surgical and Radiologic Anatomy\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"Aortic arch branching, Five-vessel aortic arch, Aberrant right subclavian artery, Arteria lusoria, Anomalous vertebral artery origin, Postmortem examination\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-9124648/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-9124648/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eComplex aortic arch branching variants with multiple direct branches and anomalous vertebral artery origins are rare and typically incidental. We report a postmortem-confirmed case of a rare five-vessel aortic arch configuration identified in a 65-year-old man who underwent elective mitral and tricuspid valve repair for severe mitral regurgitation. The postoperative course was complicated by delayed neurological deterioration and fatal tonsillar herniation. Examination of the thoracic aorta revealed a five-branch aortic arch consisting of the right common carotid artery, left common carotid artery, left vertebral artery arising directly from the arch, left subclavian artery, and an aberrant right subclavian artery with a retroesophageal course. The right vertebral artery originated anomalously from the proximal right common carotid artery. This rare vascular configuration highlights the embryological complexity of multi-branch aortic arch variants and suggests potential implications for vertebrobasilar perfusion during cardiothoracic procedures. Recognition of such variants through careful preoperative imaging of the supra-aortic vessels may help reduce unforeseen perioperative risks.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Postmortem discovery of a rare five-vessel aortic arch with aberrant right subclavian artery and bilateral anomalous vertebral artery origins: Embryological analysis and perioperative implications\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-03-31 17:30:46\",\"doi\":\"10.21203/rs.3.rs-9124648/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"reviewerAgreed\",\"content\":\"173603197782056040249920318092741460985\",\"date\":\"2026-05-06T22:28:52+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"201644926162239582794331660727564924130\",\"date\":\"2026-05-05T13:01:18+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-03-27T07:14:00+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-03-19T13:05:16+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-03-17T09:16:28+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Surgical and Radiologic Anatomy\",\"date\":\"2026-03-14T19:17:05+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"surgical-and-radiologic-anatomy\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"sara\",\"sideBox\":\"Learn more about [Surgical and Radiologic Anatomy](http://link.springer.com/journal/276)\",\"snPcode\":\"276\",\"submissionUrl\":\"https://submission.nature.com/new-submission/276/3\",\"title\":\"Surgical and Radiologic Anatomy\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"c61e4d6c-0ddf-4c0a-bb29-ecdb5e39bd0b\",\"owner\":[],\"postedDate\":\"March 31st, 2026\",\"published\":true,\"recentEditorialEvents\":[{\"type\":\"reviewerAgreed\",\"content\":\"173603197782056040249920318092741460985\",\"date\":\"2026-05-06T22:28:52+00:00\",\"index\":23,\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"201644926162239582794331660727564924130\",\"date\":\"2026-05-05T13:01:18+00:00\",\"index\":22,\"fulltext\":\"\"}],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-03-31T17:30:46+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-03-31 17:30:46\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-9124648\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-9124648\",\"identity\":\"rs-9124648\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}