Combined surgical treatment of arteriovenous malformation of the lower jaw

Background: External carotid artery is the main artery supplying the structures of neck and face. Variability in the branching pattern of external carotid artery is important surgically and radiologically from the point of view of procedures carried out in that region. Purpose of the present study was to study the branching pattern of external carotid artery.Methods: Carotid triangle of the neck and the infratemporal fossa was dissected for studying the external carotid artery.Results: Generally the common carotid artery bifurcates at the level of upper border of lamina of thyroid cartilage. Level of bifurcation of common carotid artery may vary; it may arise at a lower level or at a higher level than its normal level of origin, which was observed in this study. Amongst the branches of external carotid artery like the superior thyroid artery, the facial artery, the lingual artery usually shows variations in their origin. These include origin of superior thyroid artery from common carotid artery, common trunk for facial and lingual arteries and many other different types of variations were seen in this study.Conclusions: Variant origins of the branches of external carotid artery are of significance in surgeries of thyroid, parotid gland, tongue as well as important in diagnostic procedures of head, neck, face region.

To evaluate the sensitivity and specificity of computed tomographic angiography ( CTA) for dural arteriovenous fistulas ( DAVFs) in patients presenting with pulsatile tinnitus( PT). The clinical and imaging data were collected for all patients undergoing CTA for PT from 2008 to 2012. Nine PT patients with DAVFs confirmed by digital subtraction angiography ( DSA) and 9 age and gender-matched control PT patients without DAVFs were selected. The CTA images were blindly analyzed by two experienced neuroradiologists for the following signs: asymmetric venous collaterals in extracranial space , asymmetric attenuation of internal jugular vein ( IJV) , asymmetric external carotid artery( ECA) branches, "shaggy" appearance of dural venous sinus, multiple transcalvarial channels, enlarged foramen spinosum, asymmetric cavernous sinus and enlarged cortical veins. The sensitivities of the following DAVFs signs were quite different: asymmetric attenuation of IJV ( 89% ) , asymmetric venous collaterals ( 89%) , asymmetric ECA branches ( 78%) , shaggy dural venous sinus ( 67%) , multiple transcalvarial channels (67%), enlarged foramen spinosum (56%), stenosis of venous sinus (33%) and asymmetric cavernous sinus ( 2 2 % ) . The presence of asymmetric attenuation of IJV , asymmetric ECA branches, shaggy dural venous sinus, multiple transcalvarial channels and asymmetric cavernous sinus all demonstrated a highly specificity of 100% while the presence of asymmetric venous collaterals and enlarged foramen spinosum had a specificity of 89% . The presence of stenosis of venous sinus revealed a specificity of 78%. Enlarged cortical veins were all absent. CTA may be used as a screening examination for DA VFs in PT patients. The presence of asymmetric venous collaterals, asymmetric attenuation of UV,asymmetric ECA branches, shaggy dural venous sinus and multiple transcalvarial channels has a high sensitivity and specificity for diagnosis. Enlarged ECA branches usually serve as DA VFs feeders.Meanwhile, DA VF should be considered in PT patients when multiple transcalvarial channels and enlarged foramen spinosum are detected on high-resolution CT of temporal bone.

Introduction Intra-arterial chemotherapy (IAC) for children with retinoblastoma represents a new treatment strategy with increasing safety and effectiveness. However, proper technique is vital as complications can lead to stroke and blindness, and accurate drug delivery is critical to treatment success. As the arterial supply to the eye is often a hemodynamic balance between the ophthalmic artery (OA) and external carotid artery branches, it is often necessary to perform exploratory superselective angiography prior to initiating IAC (Klufas, Gobin, et al ., 2012). Additionally, some have described the use of an occlusion balloon distal to the OA to deliver IAC without the need to select the OA itself (Yamane, Kaneko, and Mohri, 2004). Materials and methods Our protocol for initiation of IAC for retinoblastoma begins with internal carotid artery angiography. If the OA is visualized, then an attempt is made to select it with a 1.3 or 1.5 French microcatheter. If no antegrade flow is seen in the OA (Figure 1A), then external carotid artery (ECA) branches are explored to identify supply to the eye. If no ECA supply is identified or if the OA could not be selected, then a HyperForm 4 mm × 7 mm balloon is advanced through a 4.3 French DAC, and inflated just distal to the OA. Angiography is then used to confirm antegrade flow in the OA before delivering IAC (Figure 1B). Results We have observed two cases that displayed no antegrade flow in the OA with carotid arteriography. In both cases, ECA branch exploration was undertaken. One patient exhibited robust ocular supply via the anterior deep temporal artery, which was used for IAC. However on subsequent angiography the anterior deep temporal supply was diminished and an alternative delivery route was needed. The other patient did not have significant ocular supply from ECA branches. Both patients were subsequently treated with the balloon technique and displayed antegrade OA opacification with a robust choroidal blush after balloon inflation (Figure 1). Treatments were successful and without complication. Conclusion IAC is a powerful new tool in the treatment of retinoblastoma, but relies on the technical ability to infuse chemotherapy into the OA. In cases when no antegrade OA flow is identified with carotid angiography, balloon occlusion distal to the OA may induce hemodynamic change allowing treatment via the carotid and OA. Disclosures M. Froehler: None.

Medical Thermography is a test that measures the temperature emitted by the human body capturing infrared waves (heat). Skin temperature is influenced by the blood supply and the autonomic nervous system. The vasculature of the face is performed by the branches of the internal and external carotid arteries, in a similar way between the right and left sides of the face. This study is a prospective, observational and transversal, which aims to study the temperature emitted face between the right and left sides in irrigated areas by branches of the external and internal carotid arteries. They were collected from June 2013 to May 2014 in the population of workers in both sexes (306), aged between 18-65 years at a medical clinic of occupational health. This study showed that thermography can reveal the irrigation perfusion conditions in the face in the areas irrigated by branches of the external and internal carotid arteries and thermal symmetry between the right and left sides. Thus the thermography is shown as a promising method in the evaluation of blood irrigation conditions of the face.

This study aimed to assess the performance of arterial-spin labeling MRA (ASL-MRA) for visualizing the external carotid artery (ECA) branches in comparison with time-of-flight MRA (TOF-MRA) and CT angiography (CTA). We retrospectively selected 31 consecutive patients, who underwent both MRAs and CTA, prior to the intra-arterial chemoradiotherapy (IACRT) for head and neck cancer. Four patients underwent IACRT bilaterally, so we analyzed 35 ECAs. Pseudo-continuous, three-dimensional ASL using a turbo field echo sequence was acquired. For the TOF-MRA and CTA, clinically used parameters were applied. Two observers evaluated each ECA branch with reference to the angiogram at the IACRT, using five-point scale, in consensus. Friedman test for multiple comparisons was applied. ASL-MRA and CTA better visualized the superior thyroid, lingual, facial, submental, transverse facial, and internal maxillary arteries (IMAs) better than TOF-MRA (p < 0.05). In addition, CTA was superior to ASL-MRA in visualizing only submental artery among these arteries (p = 0.0005). Alternatively, the ASL-MRA was superior for visualizing the middle meningeal artery (MMA) and IMA, compared to the CTA (p = 0.0001 and 0.0007, respectively). ASL-MRA was superior to the TOF-MRA and similar to the CTA in visualizing most of ECA branches. Furthermore, ASL-MRA can better visualize the periphery of MMA and IMA than CTA.

Owing to the lack of databases of blood flow distributions in the external carotid branches, surgeons currently rely on per-operative imaging and on their experience to choose the recipient vessels for microsurgical facial reconstructions. But, thanks to three-dimensional phase contrast angiography (PCA) and kinematic CINE phase contrast (PC) sequences, MRI technologies have the potential to provide quantitative anatomical and hemodynamic information without injection of contrast agent. Having developed and optimized PC-MRI sequences for the small facial vessels, our objective was to investigate the haemodynamic and blood flow distribution in the external carotid branches. We included 31 healthy volunteers in an MRI prospective study. Two-dimensional CINE PC-MRI sequences (average duration time of 2 min40 s ± 24 s) were performed in the external carotid collaterals (n = 290). A statistical analysis of the flow measurements showed that, despite large interpersonal variabilities, a general flow distribution pattern was obtained by dividing the vessel flow rates by the external carotid artery one (providing local percentages of the incoming flow). The vessels could then be classified in three haemodynamic groups (p < 0.05 Student's test): "low flow" group (lingual artery-12.5±5% of incoming flow), "intermediate flow" group (superior thyroid artery-16.5±10%, internal maxillary artery-20.5±11%, superficial temporal artery-18.4±6%), "high flow" group (facial artery -26.6±10%). Thanks to this general flow distribution mapping, it is now possible to estimate the flow rates in the distal branches of any individual from a single blood flow measurement in the external carotid artery.

Background: The aim of this study was to identify variations in the origins of the anterior branches of the external carotid artery (ECA) and to propose an update of the current classification. Methods: The study included 100 carotids arteries from fifty human donors. Classification of anterior branches of external carotid artery was performed according to Vaz’quez et al. (2009). Results: The configuration origins of anterior branches were found as follows: Type I, 82%; Type II, 1%; Type III, 16%. No Type IV was observed. The study identified seven subgroups of anterior branch variations in the external carotid artery. The most frequently observed variations were Subtype Ia in 40% (n = 20) of cases on the right side and Subtype Ib in 38% (n = 19) on the left side. In addition, a rare and previously unclassified configuration was observed in a 72-year-old male donor, where the carotid artery was pentafurcated on the left side. Conclusions: In conclusion, the presence of anatomical variants not previously included in the anterior external carotid artery branching classifications supports the consideration of a revision to the present classification system.

Multidetector computed tomography (MDCT) angiography in the evaluation of external carotid artery

Knowledge of branching patterns of external carotid artery (ECA) is essential for planning and execution of head and neck surgeries. Digital subtraction angiography (DSA) images of 532 ECAs from 302 consecutive patients were retrospectively evaluated. We classify the branch variants of ECA into three types, simply based on the number of branches arising close together. Type A, Type B, and Type C variants are defined as two, three, and four or more branches of ECAs arising at a common point from the proximal ECA, respectively. In this classification, the distal ECA was counted as one branch. Of 532 ECAs, Type A was found in 344 ECAs (64.6%) of 237 patients (78.5%), Type B in 134 ECAs (25.2%) of 110 patients (36.4%), and Type C in 54 ECAs (10.2%) of 49 patients (16.2%). The distance from the common carotid artery (CCA) bifurcation to the first branch of ECA with Type C was 14.7 ± 6.6 mm; its distance is shorter compared with Type A (21.8 ± 15.6 mm) and Type B (20.6 ± 8.9 mm) (P < 0.05). The position of CCA bifurcation with Type C was detected at the third-fourth junction cervical vertebral level or higher in 52 of 54 ECAs (96.3%), significantly higher than those of the other types (P < 0.05). In conclusion, Type C ECA has aggregated vessels with short distance from CCA and high position of CCA bifurcation. Type C ECA is not uncommon; thus, special consideration should be paid to avoid complications during surgeries.

INTRODUCTION: There are several studies on the microstructure of main arteries of the body but limited have been dealt with the neck arteries. It has been mentioned that the vascular pathologies like the thrombo-embolism, atherosclerosis and infarction are common in the branches of vertebral and internal carotid artery as compared to the branches of external carotid artery. OBJECTIVE: To study the histological structure of the 3 medium sized arteries of neck namely external carotid, internal carotid and vertebral artery, calculation of their mean pulse pressure and pulsatory power and to find any association between them if present. METHOD: Fresh samples of external carotid, internal carotid and vertebral artery each measuring 10mm in length were taken from five cadavers and prepared for histological examination under microscope using orcein and H&E stain. The mean pressure and pulsatory power of these arteries were calculated by taking the measurements such as wall thickness, lumen circumference, arterial wall area, and smooth muscle fibre density in tunica media in that arterial segment. RESULT: The pulsatory power of external carotid artery, internal carotid artery and vertebral artery is found to be 120, 273.3, 400 Joules /heart beat and the mean pressure is 17.1 mm Hg, 27.3 mm Hg and 33.3 mm Hg respectively. CONCLUSION: The thickness of tunica media of an artery is directly proportional to its pulsatory power. The mean pulse pressure, pulsatory power as well the number of smooth muscles fibres in tunica media are more in internal carotid artery and vertebral artery in comparison to external carotid artery. It may be a very important reason why vascular pathologies are less common in branches of external carotid as compare to internal carotid and vertebral artery.

The so called “spontaneous” carotid-cavernous fistulae are mostly dural shunts between the meningeal branches of internal or external carotid arteries and dural veins in the vicinity of cavernous sinus. The spontaneous external carotid-cavernous fistula could be treated by ligation or embolization of branches of external carotid artery. On the other hand, the direct closure of internal carotid-cavernous fistula is quite a challenge to neurosurgeons. Here is a report of a technique for direct closing of a spontaneous internal carotid-cavernous fistula which does not impair internal carotid blood flow. Exposure of cavernous sinus wall is achieved by means of a frontotemporal craniotomy. Operative angiography is performed in order to establish the topographical relationship of internal carotid artery, Parkinson's triangle of the cavernous sinus and fistula. Fine copper on copper compound wire is threaded transdurally into the lumen of the sinus. A direct current (0.2 mA to 2 mA) is applied to the copper wire for 1 to 2 minutes. The closure of fistula is verified by operative angiograms. Our experiences of the three cases suggest that electrothrombosis is an ideal treatment of spontaneous internal carotid-cavernous fistula.

Objective To investigate the feasibility, complications and efficacy of main blood-supply cavernous sinus dural arteriovenous fistulas (CSDAVFs) for the embolization treatment of the branches of external carotid artery with Onyx via artery approach. Methods The clinical data and follow-up results of 15 patients (13 patients from the Neurointerventional Department of Beijing Tiantan Hospital and 2 patients from the Department of Neurosurgery, the Second Hospital of Yulin) treated with the main blood-supply CSDAVFs for the embolization treatment of the branches of external carotid artery with Onyx from August 2005 to October 2014 were analyzed retrospectively. Results Immediately after procedure, angiography revealed that 12 patients were embolized completely, 3 had partially residual fistula. The postoperative ocular symptoms of 14 patients were relieved, 3 complicated with ipsilateral facial numbness, one had facial paralysis, and one had diplopia. They were followed up for 3 to 24 months, angiographic findings revealed that 13 patients were cured completely, one had recurrence and received the second embolization, and the residue did not have any change in one case. The clinical follow-up showed that their ocular symptoms were all relieved, no hemorrhage was observed, and all the complications were relieved. Conclusions Microcatheter can reach CSDAVFs of fistula via the branches of external carotid artery approach. Onyx embolization of CSDAVFs is feasible. It is an alternative scheme which the microcatheter can not be in place via venous approach or after treatment failure. Key words: Meninges; Arteriovenous fistula; Cavernous sinus; Embolization, therapeutic

The arterial pattern of the human body is one of the systems that show a large number of variations. Many reports are available regarding variations of common carotid, external and internal carotid arteries and branches of external carotid artery. We describe a very rare case of lateral position of external carotid artery. The external carotid artery was lateral to the internal carotid artery at the bifurcation of the common carotid artery. The clinical importance of this variation is discussed.

The arterial pattern of the human body is one of the systems that show a large number of variations. Many reports are available regarding variations of common carotid, external and internal carotid arteries and branches of external carotid artery. We describe a very rare case of lateral position of external carotid artery. The external carotid artery was lateral to the internal carotid artery at the bifurcation of the common carotid artery. The clinical importance of this variation is discussed.

PurposeThe eight typical External Carotid Artery (ECA) branches are the superior thyroid artery, ascending pharyngeal artery, lingual artery, facial artery, occipital artery, posterior auricular artery, maxillary artery, and superficial temporal artery. The Internal Carotid Artery (ICA) has no branches in the cervical region before entering the carotid canal. We identified a variant of the Occipital Artery (OA) and Ascending Pharyngeal Artery (APA) originating in the cervical portion of the ICA and wish to explore the clinical implications this variation may have.MethodsBetween August and December 2023, 28 formaldehyde donors were dissected in the anatomy course for first-year medical and physician assistant students at the Creighton University School of Medicine, Phoenix campus.ResultsIn one donor, dissection of the right common carotid artery (CCA) revealed a variation of the ECA branches. Two branches were found on the proximal portion of the ICA. After tracing the branches cranially, we identified these as the OA and APA. These two arteries typically originate from the ECA. The bifurcation angle was observed to be nearly 180 degrees. This variation was only observed on the right side.ConclusionAs the prevalence of this variation has only been described in one study, reporting at 0.14%, documentation and education of this anatomy aids surgeons and interventional radiologists in head and neck procedures. Exploring the paths of these ectopic arteries promotes informed decision making and risk stratification for carotid endarterectomy, arterial embolization, bypass procedures, and arterial harvesting. Furthermore, performing thorough imaging such as CT angiograms on patients preoperatively provides better foresight to minimize complications.