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Rare anatomical variant of the cervical internal carotid artery
ARTICLE IN PRESS
YBJOM-5107; No. of Pages 3
Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
Short communication
Rare anatomical variant of the cervical internal carotid artery G. Agrawal a,∗,1 , A. Gupta a,2 , V. Chaudhary a,3 , H. Mazhar b,4 , S. Tiwari a,5 a b
Regional Cancer Center, PTJNM Medical College, Raipur, Chhattisgarh 492001, India Resident Maxillofacial Surgery, Rungata Dental College, Bhilai, Chhattisgarh
Accepted 21 January 2017
Abstract Neck dissection is routine for the management of cancers of the head and neck. Knowledge of anatomical variants in the carotid artery system at various levels of dissection should prevent inadvertent injury to major blood vessels, which can cause massive bleeding. We report a rare 180◦ sharp bend in the cervical course of the internal carotid artery at level II, which we found during a modified neck dissection. © 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Neck dissection; Internal carotid artery; Kinking; Tortuosity; Coiling
Introduction Despite the surgeon having detailed knowledge of the anatomy of the head and neck, either a major or minor variant may be encountered in the course of the carotid arterial system during operation.1,2 According to most of the anatomical references, the major abnormalities lie in the cervical part of the system near its origin, or in the distal segment at the level of the atlas or axis.3 Different anatomical variants in the cervical course of the internal carotid artery have been reported and they are classified as tortuosity, kinking, and coiling.4 The term “dolichoarteriopathies” has been used for such anomalies.5,10
∗
Corresponding author. E-mail addresses: [email protected] (G. Agrawal), Ashutosh [email protected] (A. Gupta). 1 Tel.: 09827479600. 2 Tel.: 07489179721. 3 Tel.: 9826064727. 4 Tel.: 09522600821. 5 Tel.: 09713505050.
Coiling and kinking comprise 6% and 5% of anatomical variants respectively,6,7 and may be at risk of massive bleeding during operation.8,9 Case report A 50-year-old man came to our department with a welldifferentiated squamous cell carcinoma of the left side of the tongue, for which he was treated by a modified radical neck dissection and hemiglossectomy under general anaesthesia. During dissection (at level II A), we noted a sharp 180◦ bend in the cervical course of the right internal carotid artery with a posteromedial folding, just behind the internal jugular vein and spinal accessory nerve, which crossed over the middle scalene muscle (Fig. 1). We confirmed this by computed tomographic (CT) angiography, (Fig. 2) because of its rarity.
Discussion According to Gray’s anatomy, the carotid arteries run straight in the neck, and rarely coil.3,9 The internal carotid artery
http://dx.doi.org/10.1016/j.bjoms.2017.01.011 0266-4356/© 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Agrawal G, et al. Rare anatomical variant of the cervical internal carotid artery. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.01.011
YBJOM-5107; No. of Pages 3
2
ARTICLE IN PRESS G. Agrawal et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
Fig. 2. Computed tomographic angiogram showing the variant.
Fig. 1. Photograph showing the abnormal variant of the internal carotid artery.
has more such anomalies than the external carotid.6 Intracranial portions are highly tortuous, while its cervical course is almost straight. There are two points of fixation in the cervical portion: at the bifurcation of the common carotid artery, and where it enters into the temporal bone. If the vessel is longer than the distance between these two points, curves and loops can develop. Weibel et al defined “tortuosity” as any ripple or elongation of the internal carotid artery in an “S” or “C” shape, while “coiling” is the elongation or redundancy of the configuration of the internal carotid artery with an exaggerated “S”, or a circular configuration. “Kinking” is the angulation of one or more segments associated with stenosis of the segment of the vessel.4 Paulsen et al6 further classified the course of the internal carotid artery into four types. If the deviation from the vertical axis is less than 15◦ it is straight; if it is greater than 15◦ and less than 70◦ it is curved; and if the deviation is between 90◦ and 145◦ it is coiled or kinked. If the deviation is 360◦ , it is looped. To avoid complications such as heavy bleeding during operation, most centres examine all patients with CT or mag-
netic resonance imaging to assess the course of major blood vessels. During clearance at level II, surgeons should palpate the area behind the internal jugular vein and feel for pulsations and, if there are any, there will be a variant in the course of the internal carotid artery. In our search of publications, we have found no other description of a variant such as this.
Conflict of interest We have no conflicts of interest.
Ethics statement/confirmation of patient’s permission This is accidental finding as no prospective study was carried out and the identity of the patient has not been disclosed.
References 1. Akpek S, Arat A, Morsi H, et al. Self-expandable stent-assisted coiling of wide-necked intracranial aneurysms: a single-center experience. AJNR Am J Neuroradiol 2005;26:1223–31. 2. Bates MC, Kyer PD, Kavasmaneck C, et al. Stent-supported angioplasty correction of symptomatic critical carotid angulation. W V Med J 2003;99:22–4. 3. Gray’s anatomy: the anatomical basis of clinical practice.Standring S, editor. 39th ed. Philadelphia: Elsevier; 2005.
Please cite this article in press as: Agrawal G, et al. Rare anatomical variant of the cervical internal carotid artery. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.01.011
YBJOM-5107; No. of Pages 3
ARTICLE IN PRESS G. Agrawal et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
4. Weibel J, Fields WS. Tortuosity, coiling, and kinking of the internal carotid artery: II. Relationship of morphological variation to cerebrovascular insufficiency. Neurology 1965;15:462–8. 5. Pellegrino L, Prencipe G, Vairo F. Dolicho-arteriopathies (kinking, coiling, tortuosity) of the carotid arteries: study by color Doppler ultrasonography. Minerva Cardioangiol 1998;46:69–76. Paper in Italian. 6. Paulsen F, Tillmann B, Christofides C, et al. Curving and looping of the internal carotid artery in relation to the pharynx: frequency, embryology and clinical implications. J Anat 2000;197:373–81. 7. Ozgur Z, Celik S, Govsa F, et al. A study of the course of the internal carotid artery in the parapharyngeal space and its clinical importance. Eur Arch Otorhinolaryngol 2007;264:1483–9.
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8. Genee P, Klausberger EM. Angiocinematographic evaluation of tortuosity, coiling and kinking of the cervical portion of the internal carotid artery. Fortschr Geb Rontgenstr Nuklearmed 1974;120:724–32. 9. Pellegrino L, Prencipe G. Dolichoarteriopathies (kinking, coiling, tortuosity) of carotid arteries and atherosclerotic disease: an ultrasonographic study. Cardiologia 1998;43:959–66. Paper in Italian. 10. Del Corso L, Moruzzo D, Conte B, et al. Tortuosity, kinking, and coiling of the carotid artery: expression of atherosclerosis or aging? Angiology 1998;49:361–71.
Please cite this article in press as: Agrawal G, et al. Rare anatomical variant of the cervical internal carotid artery. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.01.011
YBJOM-5107; No. of Pages 3
Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
Short communication
Rare anatomical variant of the cervical internal carotid artery G. Agrawal a,∗,1 , A. Gupta a,2 , V. Chaudhary a,3 , H. Mazhar b,4 , S. Tiwari a,5 a b
Regional Cancer Center, PTJNM Medical College, Raipur, Chhattisgarh 492001, India Resident Maxillofacial Surgery, Rungata Dental College, Bhilai, Chhattisgarh
Accepted 21 January 2017
Abstract Neck dissection is routine for the management of cancers of the head and neck. Knowledge of anatomical variants in the carotid artery system at various levels of dissection should prevent inadvertent injury to major blood vessels, which can cause massive bleeding. We report a rare 180◦ sharp bend in the cervical course of the internal carotid artery at level II, which we found during a modified neck dissection. © 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Neck dissection; Internal carotid artery; Kinking; Tortuosity; Coiling
Introduction Despite the surgeon having detailed knowledge of the anatomy of the head and neck, either a major or minor variant may be encountered in the course of the carotid arterial system during operation.1,2 According to most of the anatomical references, the major abnormalities lie in the cervical part of the system near its origin, or in the distal segment at the level of the atlas or axis.3 Different anatomical variants in the cervical course of the internal carotid artery have been reported and they are classified as tortuosity, kinking, and coiling.4 The term “dolichoarteriopathies” has been used for such anomalies.5,10
∗
Corresponding author. E-mail addresses: [email protected] (G. Agrawal), Ashutosh [email protected] (A. Gupta). 1 Tel.: 09827479600. 2 Tel.: 07489179721. 3 Tel.: 9826064727. 4 Tel.: 09522600821. 5 Tel.: 09713505050.
Coiling and kinking comprise 6% and 5% of anatomical variants respectively,6,7 and may be at risk of massive bleeding during operation.8,9 Case report A 50-year-old man came to our department with a welldifferentiated squamous cell carcinoma of the left side of the tongue, for which he was treated by a modified radical neck dissection and hemiglossectomy under general anaesthesia. During dissection (at level II A), we noted a sharp 180◦ bend in the cervical course of the right internal carotid artery with a posteromedial folding, just behind the internal jugular vein and spinal accessory nerve, which crossed over the middle scalene muscle (Fig. 1). We confirmed this by computed tomographic (CT) angiography, (Fig. 2) because of its rarity.
Discussion According to Gray’s anatomy, the carotid arteries run straight in the neck, and rarely coil.3,9 The internal carotid artery
http://dx.doi.org/10.1016/j.bjoms.2017.01.011 0266-4356/© 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Agrawal G, et al. Rare anatomical variant of the cervical internal carotid artery. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.01.011
YBJOM-5107; No. of Pages 3
2
ARTICLE IN PRESS G. Agrawal et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
Fig. 2. Computed tomographic angiogram showing the variant.
Fig. 1. Photograph showing the abnormal variant of the internal carotid artery.
has more such anomalies than the external carotid.6 Intracranial portions are highly tortuous, while its cervical course is almost straight. There are two points of fixation in the cervical portion: at the bifurcation of the common carotid artery, and where it enters into the temporal bone. If the vessel is longer than the distance between these two points, curves and loops can develop. Weibel et al defined “tortuosity” as any ripple or elongation of the internal carotid artery in an “S” or “C” shape, while “coiling” is the elongation or redundancy of the configuration of the internal carotid artery with an exaggerated “S”, or a circular configuration. “Kinking” is the angulation of one or more segments associated with stenosis of the segment of the vessel.4 Paulsen et al6 further classified the course of the internal carotid artery into four types. If the deviation from the vertical axis is less than 15◦ it is straight; if it is greater than 15◦ and less than 70◦ it is curved; and if the deviation is between 90◦ and 145◦ it is coiled or kinked. If the deviation is 360◦ , it is looped. To avoid complications such as heavy bleeding during operation, most centres examine all patients with CT or mag-
netic resonance imaging to assess the course of major blood vessels. During clearance at level II, surgeons should palpate the area behind the internal jugular vein and feel for pulsations and, if there are any, there will be a variant in the course of the internal carotid artery. In our search of publications, we have found no other description of a variant such as this.
Conflict of interest We have no conflicts of interest.
Ethics statement/confirmation of patient’s permission This is accidental finding as no prospective study was carried out and the identity of the patient has not been disclosed.
References 1. Akpek S, Arat A, Morsi H, et al. Self-expandable stent-assisted coiling of wide-necked intracranial aneurysms: a single-center experience. AJNR Am J Neuroradiol 2005;26:1223–31. 2. Bates MC, Kyer PD, Kavasmaneck C, et al. Stent-supported angioplasty correction of symptomatic critical carotid angulation. W V Med J 2003;99:22–4. 3. Gray’s anatomy: the anatomical basis of clinical practice.Standring S, editor. 39th ed. Philadelphia: Elsevier; 2005.
Please cite this article in press as: Agrawal G, et al. Rare anatomical variant of the cervical internal carotid artery. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.01.011
YBJOM-5107; No. of Pages 3
ARTICLE IN PRESS G. Agrawal et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
4. Weibel J, Fields WS. Tortuosity, coiling, and kinking of the internal carotid artery: II. Relationship of morphological variation to cerebrovascular insufficiency. Neurology 1965;15:462–8. 5. Pellegrino L, Prencipe G, Vairo F. Dolicho-arteriopathies (kinking, coiling, tortuosity) of the carotid arteries: study by color Doppler ultrasonography. Minerva Cardioangiol 1998;46:69–76. Paper in Italian. 6. Paulsen F, Tillmann B, Christofides C, et al. Curving and looping of the internal carotid artery in relation to the pharynx: frequency, embryology and clinical implications. J Anat 2000;197:373–81. 7. Ozgur Z, Celik S, Govsa F, et al. A study of the course of the internal carotid artery in the parapharyngeal space and its clinical importance. Eur Arch Otorhinolaryngol 2007;264:1483–9.
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8. Genee P, Klausberger EM. Angiocinematographic evaluation of tortuosity, coiling and kinking of the cervical portion of the internal carotid artery. Fortschr Geb Rontgenstr Nuklearmed 1974;120:724–32. 9. Pellegrino L, Prencipe G. Dolichoarteriopathies (kinking, coiling, tortuosity) of carotid arteries and atherosclerotic disease: an ultrasonographic study. Cardiologia 1998;43:959–66. Paper in Italian. 10. Del Corso L, Moruzzo D, Conte B, et al. Tortuosity, kinking, and coiling of the carotid artery: expression of atherosclerosis or aging? Angiology 1998;49:361–71.
Please cite this article in press as: Agrawal G, et al. Rare anatomical variant of the cervical internal carotid artery. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.01.011