Anat Sci Int
DOI 10.1007/s12565-015-0301-2
ORIGINAL ARTICLE
A multitude of variations in the configuration of the circle
of Willis: an autopsy study
Wiesława Klimek-Piotrowska1 • Monika Rybicka1 • Aleksandra Wojnarska1
Agnieszka Wójtowicz1 • Mateusz Koziej1 • Mateusz K. Hołda1
Received: 14 March 2015 / Accepted: 15 September 2015
 Japanese Association of Anatomists 2015
Abstract The circle of Willis (CW) is an anastomotic
system of arteries located at the base of the brain. The aim
of the study was to evaluate the anatomic configuration of
the CW in the Polish population and to compare results
with previously conducted research. Brains were obtained
from 100 recently deceased human adults, and the diame-
ters of cerebral vessels were measured using a slide caliper.
Cerebral vessels were observed, paying attention to their
origin, diameter, typical configuration and variations.
Twenty-seven percent of cases presented the typical liter-
ature pattern. The remaining 73 % of all cases were atyp-
ical; in 16 % the CW was incomplete and in 57 %
complete. Atypical findings involved the posterior com-
municating artery (PcomA), 62 %; anterior communicating
artery (AcomA), 22 %; anterior cerebral artery (ACA),
14 %; posterior cerebral artery (PCA), 8 %. The most
common variations were bilateral hypoplastic PcomAs
(27 % of cases) and unilateral hypoplastic PcomAs (19 %
of cases). Only 9 of the 22 types of CW variations classi-
fied previously in the literature were observed, and 26
variations (36 cases) in our study were labeled as ‘other’
type. Mean diameter values for typical CW patterns were
internal carotid artery = 3.6 mm, ACA = 2.3 mm, Aco-
mA = 1.9 mm, PCA = 2.2 mm and PcomA = 1.4 mm.
Circle of Willis variations have a large impact on clinical
practice. This study shows many rare variations that should
be taken into consideration to avoid any unexpected com-
plications during surgical procedures involving cerebral
vessels.
& Wiesława Klimek-Piotrowska
wkpiotrowska@gmail.com
1
Department of Anatomy, Jagiellonian University Medical
College, Kopernika 12, 31-034 Krakow, Poland
•
Keywords Circle of Willis
Anterior communicating
artery
Anterior cerebral artery
Posterior communicating
artery
Posterior cerebral artery
Internal carotid artery
Abbreviations
CW Circle of Willis
AcomA Anterior communicating artery
ACA Anterior cerebral artery
ICA Internal carotid artery
PCA Posterior cerebral artery
PcomA Posterior communicating artery
CTA Computed tomography angiography
uSCP Unilateral selective cerebral perfusion
Introduction
The cerebral arterial circle, also called the circle of Willis
(CW), is a circulatory anastomosis system that supplies
blood to the the cerebrum and surrounding structures
(Willis 1971). The CW has been investigated by many
researchers using various methods. Sufficient knowledge of
the anatomical variations in the cerebrovascular system is
essential, as the presence of the typical appearance is found
in only 5–30 % of populations (Eftekhar et al. 2006;
Lazorthes et al. 1979; El Khamlichi et al. 1985; Riggs and
Rupp 1963; Fisher 1965; Siddiqi et al. 2013; Lasjaunias
et al. 2001).
The variations in the CW correlate significantly with
relative contributions by the flow rates of the bilateral
internal carotid arteries and basilar artery (Tanaka et al.
2006), and they have substantial clinical implications in
many pathologically serious conditions. Patients with
123

efficient collateral circulation have a lower risk of transient
ischemic attack and hemispheric stroke (Henderson et al.
2000; Hoksbergen et al. 2003). The lack of some CW
components may be dangerous for patients with internal
carotid artery stenosis (Zhang et al. 2014). Moreover, the
anatomical arrangement of the CW plays a major role in
the location of aneurysm development (Bor et al. 2008) and
its corrective surgery.
The purpose of this study was to investigate variations in
the configuration of the CW in Polish cadavers and com-
pare the obtained results with previous studies conducted
on corpses. The intention of this research was to continue
formerly adopted evaluation methods in order to compare
results.
Materials and methods
The study sample was obtained from 100 adult autopsy
subjects (77 males and 23 females) of varying ages
(18–93 years; mean age 47.3 ± 16.5 years) during routine
forensic medical autopsies performed at the Department of
Forensic Medicine, Jagiellonian University Medical Col-
lege, Krakow, Poland (Fig. 1). Observations were con-
ducted from October 2010 to May 2011. Brains of persons
with any known neuropathology, vascular disease or
obvious macroscopic pathology of the head found during
autopsy were not included. The causes of death of the
autopsy subjects were also noted.
In accordance with Polish Law [The Cell, Tissue And
Organ Recovery, Storage And Transplantation ACT of 1
July 2005 (the Official Journal of Acts Dziennik Ustaw
05.169.1411, as amended)], it is allowed to ‘‘recover cells,
tissues and organs from human cadavers for diagnostic,
therapeutic, research or didactic purposes’’ and to ‘‘recover
cells, tissues or organs also during postmortem examina-
tions that are being performed on the basis of separate
regulations’’ without obtaining written consent from the
donor or next of kin. In our study we personally studied
Fig. 1 Age distribution of the studied cases
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W. Klimek-Piotrowska et al.
brain vessels only from deceased persons who did not
express objections, when alive, and if the family did not
express objections.
Brains were removed from skulls in a routine manner
and examined. All the vessels were dissected using
microsurgical techniques, and photographs of the CW were
taken during forensic medical autopsy. Brains were not
collected and not preserved. Cerebral vessels were exam-
ined at the base of the brain and the origin, and variations
of all vessels forming the CW were stringently observed
and noted. The diameters of the vessels were measured
using a YATO (YT–7201) electronic slide caliper at the
thinner point. The vessels were closely examined with the
aid of magnification via a lens.
In our study the following vessels were particularly
analyzed: the anterior communicating artery (AcomA),
proximal fragments of the anterior cerebral artery (ACA)
up to their junctions with the AcomA, terminal segments of
both internal carotid arteries (ICA), both posterior com-
municating arteries (PcomA) and the proximal fragments
of the posterior cerebral arteries (PCA) from their origins
up to their junctions with the PcomA.
We defined the CW as a typical CW when all the above-
mentioned arteries were present with their normal origin,
course and diameter (Kapoor et al. 2008). Moreover, the
typical component vessels were not duplicated or tripli-
cated. Cases that did not satisfy these conditions were
considered atypical. Any vessel with a diameter \1 mm
was described as hypoplastic (Eftekhar et al. 2006; Kapoor
et al. 2008; Alpers and Berry 1963; Puchades-Orts et al.
1976). The circle was described as incomplete in case of
the absence of one or more of its component vessels as
observed by magnification. The circle was said to be
complete with the variation when all its vessels were pre-
sent but variations such as hypoplasticity, duplication, etc.,
were observed.
Statistical analysis was performed using StatSoft Sta-
tistica 10.0 for Windows. Data were presented in percent-
ages as the sample size was equal to 100. The Mann-
Whitney test was used to compare diameters between the
left and right side of the CW and within gender. In this
study the results were compared with other publications
using the previously described scheme of Riggs and Rupp
(1963) in which the CW variations are divided into 22
groups.
Results
In the data sample 27 of the 100 examined specimens
presented the typical pattern (23 males, 4 females). Mean
values of the diameter of the so-called literature type CW
are shown in Table 1. There were no significant differences
A multitude of variations in the configuration…

Table 1 Values of the diameters (mm) of typical circles of Willis Table 2 Variations in the circle of Willis in Polish cadavers
Mean SD Min Max Males Females Total
(%) (%) (%)
ICA R 3.6 0.8 2.1 5.6
ICA L 3.6 0.7 2.7 5.0 Total (n = 100) 77 23 100
ACA R 2.3 0.6 1.2 3.0 Typical pattern 29.9 17.4 27
ACA L 2.3 0.5 1.3 3.0 Circle with variations 70.1 82.6 73
AcomA 1.9 0.7 1.0 4.0 Incomplete circle (with absence of one 11.7 30.4 16
of its component vessels)
PCA R 2.2 0.7 1.1 3.5
Circle with variations without absence 58.4 52.2 57
PCA L 2.3 0.7 1.4 3.5
of any component vessels
PcomA R 1.4 0.4 0.8 2.6
Circle with one variation 23.4 39.1 27
PcomA L 1.4 0.4 1.0 2.5
Circle with two variations 37.7 21.7 34
SD standard deviation, AcomA anterior communicating artery, ACA Circle with three variations 6.5 17.4 9
anterior cerebral artery, ICA internal carotid artery, PCA posterior Circle with four variations 0 0 0
cerebral artery, PcomA posterior communicating artery, R right,
L left, AcomA anterior communicating artery, ACA anterior cerebral Circle with five variations 0 4.4 1
artery, A1 precommunicating part of the ACA, A2 postcommunicat- Anterior communicating artery 22.1 21.7 22
ing part of the ACA, ICA internal carotid artery, PCA posterior Absence 0 4.4 1
cerebral artery, P1 precommunicating part of the PCA, P2 post-
Hypolasticity 9.1 0 7
communicating part of the PCA, PcomA posterior communicating
artery Parallel duplication 9.1 13.0 10
Forked v-shape 1.3 4.4 2
Parallel duplication with 1.3 0 1
interconnecting stem
between the left and right portions of the typical CW and
Additional plexiform AcomA 1.3 0 1
between genders (p [ 0.05). The smallest average diameter
Anterior cerebral artery 11.7 21.8 14
was associated with the PcomA (1.4 mm) and the largest
Triplication 9.1 8.7 9
with the ICA (3.6 mm).
Left A1 hypolasia 1.3 0 1
Of 73 atypical circles, 16 were incomplete (9 males, 7
Right A1 hypoplasia 0 4.4 1
females) and 57 complete (45 males, 12 females). In the
Bifurcation of right ACA 1.3 0 1
analyzed data different numbers of variations in individual
Right ACA absence 0 4.4 1
CWs occurred. A single variation of the CW was observed
Loop formation on the A1 and A2 0 4.4 1
in 27 cases. Two variations in the component vessels of the
segment of ACA
circle were presented in 34 specimens. The combination of
Posterior communicating artery 57.1 78.3 62
three anomalies in the circle was revealed in 11 specimens.
Right PcomA hypoplasia 9.1 17.4 11
Circles with four anomalies were not found. A circle with
Left PcomA hypoplasia 15.6 17.4 16
five variations was observed in one female. All of the
Bilateral PcomA hypoplasia 20.8 13.0 19
variation frequencies of each CW portion are presented in
Right PcomA absence 6.5 21.7 10
Table 2.
Left PcomA absence 2.6 8.7 4
The vessel most frequently reported as the atypical was
Bilateral PcomA absence 2.6 0 2
PcomA (62 %), where unilateral and bilateral hypoplasia
Posterior cerebral artery 5.2 17.4 8
was found in 27 and 19 % of all cases, respectively.
Left P1 hypoplasia 1.3 0 1
Absence of the artery was noted bilaterally in 2 % of brains
Right P1 hypoplasia 1.3 8.7 3
and unilaterally in 14 % of brains, predominantly on the
right side. Left PCA absence 1.3 0 1
The second most common variability occurred in the Common trunk of the right PCA and 1.3 8.7 3
right superior cerebellar artery
AcomA (22 %) and mainly concerned duplication (10 %)
and hypoplasty (7 %). Other less common variations were All the listed data are percentages
a forked v-shape (2 %) and parallel duplication with an
interconnecting stem, additional plexiform AcomA and
absence, at 1 % each. variants were bifurcation of the right ACA (1 %), right
The third variable artery in our study was the ACA ACA absence (1 %), and loop formation on the A1 and A2
(14 %), where mainly triplication occurred (9 %). Unilat- segment of the ACA (1 %).
eral hypoplasia of the A1 ACA segment was found in 2 %. The last variable artery was the PCA (8 %). Hypoplasia
No bilateral hypoplasia was recorded. The remaining was noted only unilaterally in 4 % of all cases. The

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 W. Klimek-Piotrowska et al.

Table 3 Comparison of the variations of the circle of Willis with other studies performed on cadavers
Author Present Riggs and El Khamlichi Fisher Lazorthes et al. Eftekhar De Silva
study Rupp et al. (1965) (1979) et al. et al.
(1963) (1985) (2006) (2011)

Country Poland USA (1) Morocco USA (2) France Iran Sri Lanka
Total brains (n) 100 994 100 414 200 102 (92) 225
Configuration % % % % % % %

Typical 27 19 18 5 14.5 28 14
All segments 0 5 0 0 5 0 0
hypoplastic
Hypoplastic AComA 2 9 11 1 4.5 0 14
Unilateral hypoplastic PComA 11 9 14 6 14 20 11.5
Unilateral hypoplastic PComA and 3 4 6 3 5 4 7
AComA
Bilateral hypoplastic PComAs 16 13 24 32 22 27 23
Bilateral hypoplastic PComAs and 1 7 10 14 17 4 16
hypoplastic AComA
Hypoplastic A1 0 5 2 0 1.5 0 3
Unilateral hypoplastic P1 1 5 3 0.9 2.5 0.9 0.8
Bilateral hypoplastic P1 s 0 3 1 4 3 0 0.4
Hypoplastic P1 and contralateral A1 0 0.2 0 2 0 0 0
Hypoplastic P1 and ipsilateral A1 1 2 1 0.2 1.5 0.9 2
Bilateral hypoplastic P1 s and A1 0 0.5 0 0.7 0.5 0 0.4
Hypoplastic A1 and contralateral 0 0.7 0 0.2 0.5 0 0
PComA
Hypoplastic AcomA and P1 0 3.5 4 0 2 0.9 3
Hypoplastic PComA, ipsilateral A1 0 2 3 0.4 1 0 0
and AComA
Hypoplastic PComA and 2 3 0 11 1.5 2 0.4
contralateral P1
A1 and bilateral hypoplastic 0 6 0 5 3 0 2
PComAs
Hypoplastic PComA, AComA and 0 2 1 7 0.5 0.9 0
contralateral P1
Hypoplastic P1, contralateral 0 1 1 1 0 0 0
PComA and ipsilateral A1
Bilateral hypoplastic P1 s and 0 1 0 2 0.5 0 0.4
AComA
Hypoplastic PComA, ipsilateral A1 0 0.3 0 2 0 0 0
and contralateral P1
Others 36 0.5 1 2 0 0.9 2.2

All the listed data are percentages

AcomA anterior communicating artery, ACA anterior cerebral artery, A1 precommunicating part of the ACA, A2 postcommunicating part of the
ACA, ICA internal carotid artery, PCA posterior cerebral artery, P1 precommunicating part of the PCA, P2 postcommunicating part of the PCA,
PcomA posterior communicating artery

common trunk of the right PCA and right superior cere-
bellar artery was present in 3 % of cases. PCA absence was
noted only once.
In our sample, of the 22 types labeled in the literature,
we found only 9 types of CW variation (Table 3) (Riggs
and Rupp 1963). The most common was type 1, typical
CW (27 %), followed by type 6, bilateral hypoplastic
PcomA (16 %), and type 4, unilateral hypoplastic PcomA
(11 %). CW types that did not fit any of the criteria were
classified as ‘other type’ and were observed in 36 % of all
cases. These cases are listed and schematically presented
in Fig. 2. The most frequent in that group were unilateral

123
A multitude of variations in the configuration…

Fig. 2 Others: 26 schematic configurations of the circle of Willis in the present study

123

Fig. 3 Selected pictures of variations of the circle of Willis:
a Triplicated ACA and duplicated AcomA. b Hypoplastic PcomA
(left) and contralateral P1 (right). c Unilateral absence of the PcomA
(right), ipsilateral absence of the A1, absence of the AcomA,
ipsilateral common trunk of the PCA and SCA and contralateral
hypoplastic PcomA (left). d Unilateral hypoplasia of the PcomA
(right) and duplicated AcomA. e Unilateral absence of the PcomA
absence of the PcomA (6 cases) and triplicated ACA (3
cases).
Selected pictures of the CW are shown in Fig. 3. The
second connection of the duplicated AcomA occurred just
behind the first connection (Fig. 3g) or further (Fig. 3d).
Discussion
This research shows various configurations of the CW and
compares the findings with those of other authors in a previ-
ously described scheme of 22 variants (Riggs and Rupp 1963).
However, there are some limitations to the assessment between
samples. These include the selection of the study population,
sample size, gender ratio, age of specimens, and similar
methods and definitions. The latter was not precise in two of the
previously conducted studies (Lazorthes et al. 1979; Riggs and
Rupp 1963). Eftekhar et al. (2006) examined only male cases,
and, in other studies, the gender ratio was not noted (Lazorthes
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W. Klimek-Piotrowska et al.
(left). f Triplicated ACA. g Duplicated AcomA. h Bilateral hypoplas-
tic PcomAs and duplicated AcomA. AcomA Anterior communicating
artery; ACA anterior cerebral artery; A1 precommunicating part of the
ACA; PCA posterior cerebral artery; P1 precommunicating part of the
PCA; PcomA posterior communicating artery; SCA superior cerebel-
lar artery
et al. 1979; Riggs and Rupp 1963; Fisher 1965). Furthermore,
De Silva et al. (2011) used a global chi-square test and revealed
that there were significant variations in the CW among intra-
and inter-ethnic groups (Caucasian, African and Asian).
The most variable cerebral artery in our study was the
PcomA (62 % of the CW samples). The same trend
appeared in the other cited studies mentioned in Table 3
(Eftekhar et al. 2006; Lazorthes et al. 1979; El Khamlichi
et al. 1985; Riggs and Rupp 1963; Fisher 1965; De Silva
et al. 2011), where bilateral hypoplastic PcomAs were
reported as the most prevalent. In contrast, the number of
bilateral hypoplastic PcomA and hypoplastic AcomA cases
in the sample population was not as dominant. Performing
our study on cadavers, we could directly determine the
presence of small arteries under the dissecting lens.
According to Fig. 2, which presents variations listed as
‘other type,’ the PcomA was unilaterally absent in six
cases(Fig. 3e), and both PcomAs were absent int two cases.
Lavieille et al. (1966) collected data from 1570 brains and
A multitude of variations in the configuration…
Fig. 4 Schematic illustration
and pictures of the three most
frequent variations in the study,
with mean vessel diameters
(mm). a Typical complete
cerebral arterial circle, the so-
called textbook type. b Bilateral
hypoplastic posterior
communicating arteries
(PcomAs). c Unilateral
hypoplastic PcomA (presented
values refer to the right
hypoplastic posterior
communicating artery). R right,
L left
found the unilateral absence of the PcomA in 58 cases
(3.6 %) and the absence of both in 7 (0.4 %).
The variability of the PcomA can be explained by its
embryology (Puchades-Orts et al. 1976). In fetal develop-
ment, it forms in 5–6-mm embryos (±31 day) and achieves
the highest grade after the primitive trigeminal artery has
disappeared. Afterwards, it decreases when the vertebral
artery forms. When the trigeminal artery persists, the
PcomA can diminish even more, which results in hyplo-
plasia or even absence of the PcomA.
The AcomA was the second most variable portion of the
CW in the current study. It develops in 18-mm human
embryos as a reticulated anastomosis between the two
ACAs; then in 24-mm embryos a single trunk is formed
after fusion (Puchades-Orts et al. 1976). The anterior por-
tion of the circle is prone to being the most common
location of aneurysm formation (Beck et al. 2006). More-
over, aneurysm occurrence is accompanied by A1 ACA
hypoplasia in most cases (Stehbens 1963). In a standard
ACA-AcomA complex both A1s and AcomAs are of suf-
ficient size to allow circulation between the ICAs (Rhoton
2002). In 4 % of brains a third ACA arose from the AcomA
(Figs. 4a, 3f), which was described in 2–13 % of the cases
in the literature (Dimmick and Faulder 2009). However, it
could arise from the A1 segment (Fig. 4b). Parallel dupli-
cation of the AcomA was recorded in 10 % of cases, and
the additional artery was smaller than or equal to the first
AcomA that formed the circle. The duplicated artery was
just behind the first AcomA or even 3 cm further.
In our study we revealed a significant number of incom-
plete CWs. The entire closed circle was only observed in
84 % of all cases. In comparison to results based on
cadaveric studies, this number varied from 89 to 100 % (De
Silva et al. 2011; Kapoor et al. 2008; Eftekhar et al. 2006).
However, this amount is different in studies performed using
computed tomography angiography (CTA). Previously
reported results in the Polish population made using CTA
revealed the entire CW was closed in only 30.8 % (Klimek-
Piotrowska et al. 2013). Results obtained by CTA do not
correspond with those observed in specimens, so in this
article only cadaveric studies were taken into consideration.
The CTA sensitivity is limited in depicting hypoplastic
segments (Han et al. 2011). The available epidemiological
literature based on the Polish population is sparse.
Our study results present a large number of cases labeled as
the ‘other’ type. This group consisted of CWs with single or
more variations; even a case with five variations was noted.
According to the literature the occurrence in this group varied
from 0 to 2.2 % (Eftekhar et al. 2006; Lazorthes et al. 1979; El
Khamlichi et al. 1985; Riggs and Rupp 1963; Fisher 1965; De
Silva et al. 2011). This situation places doubt on the usage of
the ‘other’ classification, but so far a more applicable classi-
fication has not been presented. Moreover, it mostly has
anatomical significance and weak clinical correlation.
In some procedures, such as unilateral selective cerebral
perfusion (uSCP), examination of the CW with the baso-
vertebral artery system is essential (Papantchev et al.
2013). During this treatment, the brain receives blood only
via the right common carotid artery. Papantchev et al.
subdivided the circle variations into seven types according
to the number of major vessels at risk of hypoperfusion
during uSCP. Because of the lack of vertebral artery
examination, we are unable to compare the entire classifi-
cation regarding significance during uSCP; however, we
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 W. Klimek-Piotrowska et al.

Table 4 Comparison between our study and that of Papantchev et al.
investigating the circle of Willis in settings of the unilateral selective
cerebral perfusion (uSCP)
Type Papantchev et al. Present study
IA 35.6 % (178/500) 41 % (41/100)
IB 2 % (10/500) 8 % (8/100)
IIA 4.8 % (24/500) 9 % (9/100)
IIB 9.2 % (46/500) –
IIIA 6 % (30/500) 2 % (2/100)
IIIB 0.2 % (1/500) – E (2006) Are the distributions of variations of circle of Willis
IV 0.8 % (4/500) – different in different populations? Results of an anatomical study
Incompleteness of the table is due to the fact that only circles of
Willis without vertebral arteries were examined
did this partially (Papantchev et al. 2013): type IA (hy-
poplasia or absence of the left PcomA): 41 %; IB (hy-
poplasia or absence of AcomA): 8 %; IIA (hypoplasia or
absence of left PcomA and AcomA): 9 %; IIIA (hypoplasia
or absence of the right A1): 2 %. The zone at risk of
hypoperfusion if variation of the CW was present was,
respectively, type IA: left MCA; IB: left ACA; IIA: left
MCA and left ACA; IIIA: both ACA and left MCA
(Table 4). The frequency of type IA was 5.4 % higher in
our study, as well as the occurrence of type IB (6 %) and
type IIA (4.2 %). On the other hand, the frequency of type
IIIA was 4 % smaller in our study.
Conclusion
This article strengthens the previous confirmation that the
anatomic variability among different ethnicities may be
extreme and shows many rare variations that should be taken
into consideration to avoid any unexpected complications
during surgical procedures and angiographic evaluation of
the cerebral vessels. Performing research in diverse areas
using a similar method might reveal more about how eth-
nicity is correlated with the configuration of the CW and
about the origin of each change in the CW segments.
Compliance with ethical standards
Conflict of interest The authors have no conflicts of interest to
disclose.
Financial disclosure The authors have no financial relationships
relevant to this article to disclose.
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