Branches Of External Carotid Artery Research Articles

6645 Paraganglioma or Benign Ectopic Thyroid Tissue?

Abstract Disclosure: J.A. Dower: None. R. MacLeod: None. B. Cardoso: None. C. Matouk: None. S. Mehra: None. G. Riccio: None. L. Williams: None. S.K. Majumdar: None. Introduction: During gestation, cells destined to form the thyroid descend through the thyroglossal duct; ectopic thyroid tissue may deposit anywhere along this route from tongue base to mediastinum (1). Less commonly, thyroid tissue can be found lateral to the duct, either alone or in association with a lymph node (2). We present a case of lateral ectopic thyroid tissue mimicking paraganglioma. Clinical Case: A healthy 32-year-old woman presented to ENT with cervical adenopathy persisting for several months after a flulike illness. FNA showed no evidence of malignancy. A neck CT with contrast ordered for further evaluation revealed a 3.2 x 2.3 x 1.5 cm enhancing mass within the right carotid space, splaying the external and internal carotid artery branches, most concerning for paraganglioma. A second, smaller lesion was noted inferiorly. Neck MRI confirmed these findings and revealed a subcentimeter T2 lesion within the right thyroid lobe. The patient was referred to endocrine for further workup. She had no symptoms of sympathetic hyperactivity and no family history suggestive of pheochromocytoma or paraganglioma. Biochemical workup was largely within normal limits: plasma metanephrines 53 pg/mL (57), normetanephrines 94 pg/mL (148), calcitonin <2 pg/mL, TSH 1.210 uIU/mL (0.27-4.2), FT4 1.52 ng/dL (0.8-1.7). Follow-up 24-h urine studies were also unremarkable: metanephrines 166 mcg (36-190), normetanephrines 159 mcg (35-482). Brain MRI, chest CT, and abdomen/pelvis MRI were negative for additional masses. DOTATATE PET/CT was completed to determine if the thyroid lesion was another potential paraganglioma requiring resection versus a nodule amenable to biopsy; uptake was confined to the carotid space lesions, so FNA of the thyroid nodule was considered safe. Thyroid FNA revealed FLUS with genetic testing indicating low likelihood of malignancy. The patient underwent tumor embolization followed by neck dissection with successful removal of both the larger and smaller masses identified on imaging. Frozen and permanent tissue section revealed that both masses consisted of benign thyroid tissue without associated lymphoid tissue. The patient experienced jaw pain with eating after surgery and is under consideration for Botox injection. Conclusion: Benign thyroid tissue can deposit in unexpected places, mimicking malignancy and paraganglioma, alike. Even a very thorough workup can mistake the identity of a mysterious mass; only the tissue itself can make the diagnosis.

Vascular Blush Size Reduction, Technical Success and Safety of Intra-Arterial Embolization for Glomus Jugular Tumors: A Retrospective Cohort Study

Background: Glomus jugulare tumors are slow-growing neuroendocrine paragangliomas located in the temporal bone. Surgical excision, the standard treatment option, carries a high risk of intraoperative bleeding due to the vascular nature of these lesions. To mitigate this risk, current practice involves performing intra-arterial embolization prior to surgery. Objectives: The objectives of this study were to assess postintervention safety, technical success, and the rate of vascular blush size reduction in a group of patients with Glomus jugulare tumors who were planned for surgery and underwent pre-surgical intra-arterial embolization of the lesion. Patients and Methods: In this retrospective cohort study, all patients who underwent intravascular embolization for Glomus jugulare tumors from 2017 onwards were included. The study comprised 61 patients scheduled for surgery following embolization. All embolizations were completed in one session and were primarily performed via external carotid artery branches using polyvinyl alcohol (PVA). The size of the vascular blush was measured before and after embolization in coronal, supero-inferior sagittal, and antero-posterior sagittal planes, and the rate of blush size reduction was calculated. Procedure complications, including post-embolization pain, were recorded. In the statistical analysis, vascular blush size was compared between pre- and post-embolization times. Results: Pain after embolization was reported in 11 patients (18%). There were no other complications among the patients, indicating a high level of safety. All procedures were technically successful. The mean pre-embolization vascular blush diameter in the coronal plane was 29.1 ± 13.3 mm, which decreased to 16.8 ± 7.1 mm after embolization, representing an average diameter reduction of 38.5% (P < 0.001). Conclusions: The findings of this retrospective cohort study suggest that intra-arterial embolization for Glomus jugulare tumors is safe, technically successful, and effective in reducing vascular blush before surgery.

3-Fr steerable microcatheter system via the upper limb artery in RADPLAT for right maxillary cancer

Background To evaluate the efficacy of a catheter system using a 3-Fr sheath with a steerable microcatheter through right upper limb artery access for superselective intra-arterial cisplatin infusion and concomitant radiotherapy (RADPLAT) to treat right maxillary sinus squamous cell carcinoma (MS-SCC). Material and methods We retrospectively studied 46 sessions in eight patients treated between November 2020 and February 2023 using the catheter system briefly described below. A 3-Fr sheath was inserted into the distal radial, conventional radial, or brachial arteries. A coaxial catheter system with a 2.9-Fr steerable microcatheter and a 1.9-Fr microcatheter was advanced into the brachiocephalic artery. The right common carotid artery was selected by bending the tip of the steerable microcatheter. Coil embolization and intra-arterial cisplatin infusion after selecting each external carotid artery branch were achieved using this catheter system. Results Cisplatin infusion and coil embolization were successful in all sessions. Arterial occlusion at the sheath insertion sites was found in 29.4% (5/17) of the distal radial arteries and 33.3% (3/9) of the conventional radial arteries. No other major complications were observed during the procedure. Conclusion Using a 3-Fr catheter system with a steerable microcatheter through right upper limb artery access is a feasible method for RADPLAT in treating right MS-SCC.

The analysis of unconventional lymph node metastasis in tongue squamous cell carcinoma

Objective: To analyze the characteristics of cervical lymph node metastasis in tongue squamous cell carcinoma (TSCC). Methods: A retrospective study was conducted. A total of 329 patients with TSCC who underwent en bloc resection of primary tumor and neck dissection in the Second Xiangya Hospital of Central South University from June 2010 to March 2018 were included. There were 283 males and 46 females, aged from 26 to 80 years. All patients underwent the modified neck dissection. The main difference between the modified neck dissection and the traditional neck dissection lay in the managements of unconventional lymph nodes. The lymphatic adipose tissues adjacent to the superior thyroid artery, the base of facial artery and the branches of external carotid artery were thoroughly dissected. The primary tumor as well as lingual artery, tissues along the lingual artery and lymph nodes in the mouth floor were resected. χ2 test was used for comparison of count data, and linear regression model was used for multivariate analysis. Results: Cervical lymph node metastases were found in 136 patients (41.3%). Among 142 patients (T1-2cN0) with supraomohyoid neck dissection, 22 patients had pathologically occult lymph node metastases (15.5%), with a 5-year overall survival rate of 90.2%, which was similar to the 5-year overall survival rate of 92.1% in 120 patients without lymph node metastasis (χ2=0.156, P=0.693). Multivariate linear regression analysis showed that T stage, clinical stage and unconventional lymph node metastasis were important factors for cervical lymph node metastasis in tongue cancer patients (P<0.05). Unconventional lymph node metastases occurred in 30 patients (9.1%), including the metastases of lymph nodes in the floor of mouth (3.0%), the lingual artery (2.4%), the base of the external maxillary artery (2.1%), the superior thyroid artery (0.9%), and the external carotid artery (0.6%). There were significant differences in the unconventional lymph node metastasis rates between patients with negative and positive conventional lymph node metastases [4.9%(10/203) vs. 15.9%(20/126), χ2=11.242, P=0.001] and also between patients with depth of invasion ≤5 mm, 5 mm <depth of invasion ≤10 mm or depth of invasion >10 mm [3.1%(2/64) vs. 5.7%(6/106) vs. 13.8%(22/159), χ2=7.907, P=0.005]. Conclusion: Supraomohyoid neck dissection can achieve reliable control efficacy in patients with cN0 tongue cancer. All patients with lymph node dissection should undergo unconventional lymph node dissection. Unconventional lymph node dissection is strongly recommended for patients with conventional lymph node metastasis.

Upper respiratory tract and orofacial manifestations of new-onset giant cell arteritis: results from a large, prospective inception cohort study.

Giant cell arteritis (GCA) often features upper respiratory tract (URT) and orofacial manifestations, which signal the involvement of external carotid artery branches. In this study, we aimed to describe the frequency of various URT/orofacial symptoms at GCA onset, as well as the main characteristics of patients presenting these symptoms. We included all patients who were newly diagnosed with GCA between 1976 and April 2022 at the Internal Medicine Department of a tertiary-care hospital. Ten URT or orofacial symptoms were prospectively examined systematically in each patient. We used multivariate analyses to identify the GCA characteristics, including URT/orofacial symptoms, associated with temporal artery biopsy (TAB) positivity. At least 1 URT/orofacial symptom was present in 68.6% of the 599 patients (3 or more symptoms in 30% of cases). Jaw claudication, maxillary pain, and pain during mouth opening were the most prevalent symptoms. Dry cough was recorded in 17% of cases. GCA patients with URT/orofacial symptoms had more clinical abnormalities of the temporal artery bed and ischaemic ophthalmological complications, but less large-vessel vasculitis according to imaging. The likelihood of a positive TAB was increased in patients with an abnormal temporal artery upon clinical examination (OR 4.16; CI 2.75-6.37, p < 0.001) or jaw claudication (OR 2.18; CI 1.35-3.65, p = 0.002), and decreased in those with hoarseness (OR 0.47; CI 0.26-0.87, p = 0.02) or earache (OR 0.54; CI 0.31-0.95, p = 0.03). Isolated URT/orofacial presentation (i.e., without headache or visual signs) accounted for 5.2% of the entire cohort. Oral-facial symptoms were present in two-thirds of GCS cases. Thus, they could serve as leading clinical clues for a GCA diagnosis, and are a risk factor for permanent visual loss. Several URT/orofacial symptoms such as jaw claudication, hoarseness, and earache influenced the likelihood of a positive TAB. Isolated URT/orofacial presentation of GCA is a rare but potentially challenging occurrence.

The effect of arterial spin labeling MR angiography (ASL-MRA) in visualizing the branches of external carotid artery

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.

Variations in external carotid artery branches and common carotid bifurcation level: a computed tomography angiography study

BackgroundThe common carotid bifurcation level is an important surgical landmark during head and neck surgery, especially endarterectomy, that could be omitted in patients with high bifurcation levels to reduce damage to neighboring structures like the hypoglossal nerve. Additionally, having a thorough understanding of the variations in the external carotid artery branches is crucial for head and neck cancer surgeries and thyroidectomy. However, cadavers were employed in the majority of studies on these variations. In previous research, there were significant disparities in the incidence of these variations according to gender, laterality, and ethnicity. In order to identify these changes in Egyptian patients and to compare them in terms of gender and laterality, we used computed tomographic angiography.MethodsThe level of the common carotid bifurcation was assessed in a cross-sectional study utilizing computed tomographic angiography, which included 80 patients (160 carotid sides) for comparing the common carotid artery bifurcation level with the relevant vertebrae and anterior neck structures, and they were compared with regard to gender and laterality. Variations in the external carotid artery branches were also evaluated.ResultsThe most frequent location of the common carotid bifurcation level was between C3 and C4 (33.8%). It was 36.9% between the thyroid and the hyoid. 47.5% of patients had a high common carotid bifurcation (higher than the C3/4 level). The highest bifurcation was at C2, while the lowest was at D1. For external carotid artery branches variations, the superior thyroid artery emerged at and below the level of the common carotid bifurcation, respectively, at 19.4% and 23.7%. The facial artery had the largest diameter (2.38 ± 0.44 mm), while the ascending pharyngeal artery had the smallest (1.17 ± 0.11 mm). Seven types of trunks were found; the ascending pharyngeal artery-occipital artery trunk was the most common (25%) and was followed by the lingual artery-facial artery trunk (20%).ConclusionsMultiple anatomical variations in the external carotid artery branches and the common carotid bifurcation level were found by computed tomographic angiography. As a result, it can be utilized as a useful imaging technique to evaluate these variations before surgery.

Management of pseudoaneurysms of the internal maxillary artery derived from orthognathic surgery based on one case.

The purpose of this article is to highlight the risk of pseudoaneurysms formation after orthognathic surgery, their clinical features and management. A case report of a 24-year-old man who suffered a pseudoaneurysm of the internal maxillary artery after sagittal osteotomy during orthognathic is reported. After three bleeding episodes, a pseudoaneurysm was diagnosed with a computed tomography angiogram (CTA) and treated with an embolization of the internal maxillary artery with polyvinyl alcohol (PVA) successfully. Pseudoaneurysms derived from the external carotid artery are an uncommon complication of orthognathic surgery, especially related to sagittal osteotomy instead of LeFort I osteotomy. Pseudoaneurysms derived from external carotid artery branches must be suspected when patients show multiple episodes of bleeding (epistaxis or through the surgical approach) within the first two weeks after orthognathic surgery. If so, vascular CT or angiography should be performed to rule out the presence of vascular injuries. In case a pseudoaneurysm is identified, vascular embolization with N-butyl-cyanoacrylate seems to be the best treatment if available. If this treatment is not available or bleeding cannot be controlled, surgical ligature of the injured vessel is a valid treatment.

Abstract 018: External carotid artery Pseudo aneurysm induced Internal Carotid Artery compression causing acute ischemic stroke

Introduction Here, we describe a patient in whom ischemic stroke was caused by compression of the Internal Carotid Artery (ICA) by a Pseudoaneurysm (PSA) of the External Carotid Artery (ECA) after Gun Shot injury. Eventually, the PSA of the Internal maxillary artery (IMAX) was embolized, resulting in resolution of the patient's symptoms. Methods Case Report Results A 75‐year‐old male with a history of atrial fibrillation on Eliquis presented to the emergency department after sustaining a gunshot wound to the left face. He had extensive injuries through the left masticator and submandibular space with an inferior orbital wall fracture. A Computed Tomography Angiography (CTA) neck showed injuries to the left proximal IMAX with a small PSA. As the PSA was asymptomatic it was managed with observation. On HOD day 13, CTA was done for a brief period of unresponsiveness, which showed high‐grade narrowing of left cervical ICA due to extrinsic compression from PSA which was supplied by a branch of the left ECA with distal re‐constitution (image A). The next day, patient developed right sided plegia and aphasia with NIHSS of 17. A CT head showed no acute intracranial abnormality. The patient underwent emergent Digital Subtraction Angiography (DSA), which demonstrated occlusion of the left cervical ICA from compression from a left IMAX PSA which was treated with n‐butyl‐cyanoacrylate TRUFILL embolization with resolution of flow limitation in the left cervical ICA (Image B1,B2). After embolization, the patient was oriented and able to lift right arm and leg anti‐gravity. Magnetic Resonance Imaging (MRI) was contraindicated due to retained bullet fragments. Repeat CT head did not show stroke. Conclusion A Pseudo aneurysm is characterized by a rupture of the arterial wall and the formation of an aneurysmal sac by the adjacent structures while the sustaining artery remains intact. The most prevalent causes are penetrating or acute blunt neck trauma, hyperextension injury, and injury to the base of the skull (1). Predisposing factors for PSA include carotid endarterectomy or a late complication of carotid artery dissection, infection, radiotherapy, and malignancy (1‐2). Cox et al. reported 124 patients with significant neck and head penetrating injuries. Eleven patients were found to have thirteen head and neck PSA: two in the ICA, one in the vertebral artery, and ten involving branches of the ECA. Two of seven symptomatic PSAs manifested with episodes of massive hemorrhage (3). There have been case reports describing the consequences of an elongated styloid process causing an ischemic stroke due to subsequent dissection and PSA formation (4). According to our knowledge, this case report is one of the first to describe acute ischemic symptoms resulting from ECA PSA‐induced ICA compression, with resolution of symptoms following PSA embolization. The educational value of our case lies not only in the rarity of the condition but also in the uniqueness of its presentation. This case is a fundamental addition to the existing literature on rare neuro‐vascular anomalies leading to potential catastrophic outcomes.

Abstract 164: Chronic Total Occlusion of the Bilateral Internal Carotid Arteries, Vertebral Arteries and Basilar Artery

Introduction Bilateral internal carotid arteries (ICAs), vertebral arteries (VAs), and basilar artery chronic total occlusion is an exceedingly rare condition. Possible underlying etiologies include atherosclerosis, Moyamoya disease, dissection, among others. Methods Here we describe a 58‐year‐old man with chronic total occlusion of the bilateral ICAs, VAs and basilar artery of unknown etiology. Results A 58‐year‐old man who is independent for ADLs/iADLs with a history of prior ischemic strokes (first stroke at 40 years old) with residual left‐sided weakness and dysarthria, hypertension, hyperlipidemia, prior blood clots (previously on warfarin), post‐stroke epilepsy, and never smoker presented as a code stroke to the emergency department after waking that morning with worsening of his residual left‐sided weakness and dysarthria. On arrival, blood pressure was 165/94 mmHg and blood glucose was 108 mg/dL. His NIHSS was 6. His neurologic exam was grossly similar to that documented 19 months ago. In the CT scanner, he developed tonic‐clonic movements of the left arm and leg, confusion, and emesis. Later, he stated he had missed several doses of his prescribed levetiracetam. Head CT and brain MRI revealed encephalomalacia in the brainstem and bilateral cerebellar and cerebral hemispheres. Brain MRI did not demonstrate any diffusion restriction changes. CTA showed chronic occlusion of both ICAs (proximal, distal, and terminus), M1s, VAs (V4 segment), and basilar artery. CTA also revealed that the brain parenchyma was being perfused by collaterals between the external carotid artery (ECA) branches, superficial temporal artery, and M2 branches bilaterally and the bilateral posterior circulation arteries were small and reformed through collaterals. CTP showed a core and penumbra volumes of 0 mL. His presentation was consistent with a seizure. He was admitted to the stroke service for work‐up of his abnormal brain vasculature. Catheter angiography confirmed the CTA results demonstrating occluded bilateral cervical and intracranial segments of the ICAs, collaterals from bilateral ECA branches supplying the intracranial circulation, right VA occlusion distal to the right PICA, and left VA occlusion distal to the V3 segment. Remaining work‐up including A1c, LDL, urine drug screen, EKG, transthoracic echocardiogram, and telemetry was unrevealing other than for an LDL of 152. Routine EEG showed moderate generalized showing. During hospitalization, his home amlodipine and losartan medications were discontinued with the goal of maintaining a blood pressure target of 140‐160 systolic indefinitely, to minimize the risk of hypoperfusion cerebrally. Give his robust collaterals, surgical treatment with revascularization was not pursued. His home aspirin and rosuvastatin 40 mg daily were continued and ezetimibe 10 mg daily was added. His home levetiracetam was increased from 500 to 750 mg twice daily given recent unprovoked seizures at home. He was discharged to an inpatient rehabilitation facility. Conclusion To our knowledge, this is the first case report to show chronic total occlusion of the bilateral ICAs, VAs, and basilar artery. Diagnosis of Moyamoya disease stage VI ("disappearance of the Moyamoya") was entertained but felt to be less likely given involvement of the proximal ICAs and posterior circulation. Other diagnostic consideration included atherosclerosis. Overall, the underlying etiology of his condition remained elusive.

Abstract 110: Autoangiogenesis Secondary to Chronic Cocaine Use Mimicking Moya‐Moya

Introduction We present the case of a young male presenting with syncope who was found to have incidental hypodensities on computed tomography (CT) of his head, with magnetic resonance imaging (MRI) concerning for Moya‐Moya related occlusion of the right internal carotid artery, but with digital subtraction angiography (DSA) showing extensive autoangiogenesis and collateralization from all other intracranial vascular territories, without Moya‐Moya related changes. This presumably developed as reactive changes to severe chronic cocaine use. Methods We present a case from a tertiary care center in the borough of Manhattan, New York City, USA. All information is deidentified and exempt from IRB approval. Results A 36‐year‐old man with history significant for asthma, active smoker status, and active cocaine use, presented for loss of consciousness. The patient reported 3 days of upper respiratory symptoms and decreased oral intake with subsequent loss of consciousness immediately preceded by lightheadedness and nausea, and without any post‐event confusion, lacerations, or incontinence. Neurologic history is significant for right upper extremity weakness from 9/2022‐12/2022 that self‐resolved and was believed to be a peripheral nerve pathology. Admission exam without focal deficits. Admission CT of his head showed multifocal confluent hypodensities in the subcortical right frontal lobe. CT Angiogram of head and neck showed severe narrowing at right Internal Carotid Artery (ICA) terminus and right M1 segment with lenticulostriate arterial collateralization, severe bilateral A1 stenosis with distal Anterior Cerebral Artery (ACA) flow suggestive of chronic collateralization, and significant right Posterior Cerebral Artery (PCA) collateralization. Given concern for Moya‐Moya disease, MRI of the brain was obtained and despite no acute infarct, MRI was significant for multifocal white matter T2/FLAIR hyperintensities with the largest in the right frontal lobe. The patient subsequently underwent digital subtraction angiography (DSA) to assess collaterals and stratify for possible need for future encephaloduroarteriosynangiosis (EDAS). DSA showed significant auto‐angiogenesis between numerous vascular territories, including recruitment of right Posterior Cerebral Artery and External Carotid Artery branches to perfuse the territory of the severe right ICA terminus steno‐occlusive disease. With minimal anterograde flow into the right Anterior Choroidal Artery and none to the right Middle Cerebral Artery (MCA), the characteristic Moya‐Moya appearance was not appreciated on DSA given minimal anigogenesis around the right ICA occlusion site. Rather, distal perfusion of the R ICA territory was dependent on collaterals from the right PCA, right ACA via the Anterior Communicating Artery, angiogenesis between the right Anterior Falcine Artery and R ACA, and angiogenesis between the right MCA and ACA/MCA cortical branches. These proliferative changes involved all cranial vascular territories, including those without steno‐occlusive disease. Conclusion Acute cocaine use is associated with increased risk of acute ischemic stroke[1], due in part to its sympathomimetic effects causing vasospasm and to its arrhythmic properties[2]. Neuroadaptation after chronic cocaine use is less well understood though rat models suggest that as cerebral ischemia develops from chronic cocaine use, the HIF‐VEGF pathway is activated to promote angiogenesis to restore local blood flow[3]. We present this case as evidence of a similar angiogenic physiologic response in humans to minimize the microvascular ischemic injury from chronic cocaine use.

Endovascular Treatment of Vascular Injuries in the Craniocervical Region With a Graft Stent: A Single-Center Experience.

We aimed to evaluate the efficacy and safety of graft stent implantation in the endovascular treatment of vascular injuries in the craniocervical area. This study was carried out through the retrospective screening of eight (two females and six males) patients' records. Patients who used graft stents as an endovascular method were included in the study. The mean age of the patients was 43.6 years (with a range of 15-69 years). Due to different mechanisms, the patients had vascular injuries in the craniocervical region, and graft stent implantation was performed between 2010 and 2022. We evaluated patient demographics, admission symptoms, trauma mechanisms, angiographic findings, treatment modalities and materials, patient outcomes, and follow-up periods. Due to iatrogenesis for four patients, penetrating trauma for three patients, and blunt trauma for one patient, injuries were present in the right internal carotid artery {ICA} (n=1), left ICA (n=1), left common carotid artery {CCA} (n=3), right CCA (n=1), right vertebral artery (n=1), and left vertebral artery (n=1). Angiographically, pseudoaneurysm was detected in seven patients, and vascular rupture was detected in one patient using contrast agent extravasation. All patients who underwent the endovascular method had technical success. Since bleeding from the external carotid artery branches was seen in two patients, these branches were embolized with coils. No radiologically or neurologically pathological findings were recorded during the follow-up period (with a range of one week to 12 years). Graft stent use in the endovascular treatment of craniocervical vascular injuries is an operable, safe, and promising option, especially in patients with pseudoaneurysms and active bleeding.

Variability in the Arterial Supply of Intracranial Meningiomas: An Anatomic Study.

Intracranial meningiomas are a diverse group of tumors, which vary by grade, genetic composition, location, and vasculature. Expanding the understanding of the supply of skull base (SBMs) and non-skull base meningiomas (NSBMs) will serve to further inform resection strategies. We sought to delineate the vascular supply of a series of intracranial meningiomas by tumor location. A retrospective study of intracranial meningiomas that were studied using preoperative digital subtraction angiograms before surgical resection at a tertiary referral center was performed. Patient, tumor, radiologic, and treatment data were collected, and regression models were developed. One hundred sixty-five patients met inclusion criteria. The mean age was 57.1 years (SD: 12.6). The mean tumor diameter was 4.9 cm (SD: 1.5). One hundred twenty-six were World Health Organization Grade I, 37 Grade II, and 2 Grade III. Arterial feeders were tabulated by Al-Mefty's anatomic designations. SBMs were more likely to derive arterial supply from the anterior circulation, whereas NSBMs were supplied by external carotid branches. NSBMs were larger (5.61 cm vs 4.45 cm, P = <.001), were more often presented with seizure (20% vs 8%, P = .03), were higher grade ( P = <.001) had more frequent peritumoral brain edema (84.6% vs 66%, P = .04), and had more bilateral feeders (47.7% vs 28%, P = .01) compared with SBMs. More arterial feeders were significantly associated with lower tumor grade ( P = .023, OR = 0.59). Higher tumor grade (Grade II/III) was associated with fewer arterial feeders ( P = .017, RR = 0.74). Meningioma location is associated with specific vascular supply patterns, grade, and patient outcomes. This information suggests that grade I tumors, especially larger tumors, are more likely to have diverse vascular supply patterns, including internal carotid branches. This study may inform preoperative embolization and surgical considerations, particularly for large skull base tumors.

P.088 Computed tomography angiography for diagnosis of brain death; a technical review

Background: Brain death is defined as an irreversible cessation of all brain activity. Ancillary tests are an objective way to support an initial diagnosis of brain death. Computed tomography angiography (CTA) is an imaging modality utilized as an ancillary mean to assist clinicians with such diagnosis. Different criteria and scoring systems have been proposed, however clear criteria are yet to be recognized to demonstrate full brain circulatory arrest. We aim to discuss different scoring systems presented in the literature and make evidence-based recommendations. Methods: A literature search using titles and key terms was conducted for articles containing brain death ancillary testing diagnosis, and CTA as primary focus. Results: CTA has the benefits of being non-invasive, fast, readily and widely available and it is especially useful in unstable patients. It is essential, however, to confirm intravascular injection of contrast injection by checking opacification of External Carotid Artery branches on CTA to prevent false diagnoses. Conclusions: When faced with the challenging decision to declare brain death in a patient, radiologists often face great apprehension and concern for the large responsibility bestowed upon them. It is critical for radiologist to understand that the final diagnosis of brain death is based on clinical criteria.

Angiographic analysis of ophthalmic artery flow direction in children undergoing chemosurgery for retinoblastoma compared to age-matched controls.

Catheter-based intra-arterial chemotherapy (IAC) has revolutionized the treatment of retinoblastoma (RB). Variability in ophthalmic artery (OA) flow, either retrograde from external carotid artery branches, or anterograde from the internal carotid artery, necessitates multiple IAC techniques. We evaluated the direction of OA flow and identify OA flow reversal events over the course of IAC treatment as well in comparison to OA flow direction in non-RB children. We performed a retrospective analysis of OA flow direction in all RB patients treated with IAC, along with an age-matched control group who underwent cerebral angiography at our center from 2014 to 2020. IAC was administered to a total of 18 eyes (15 patients). Initial anterograde OA flow was demonstrated in 66% (n = 12) of eyes. Five OA reversal events were identified (3/5 anterograde-to-retrograde). All five events were in patients receiving multiagent chemotherapy. No correlation was found between OA flow reversal events and the initial IAC technique. A control group of 88 angiograms representing 82 eyes (41 patients) was utilized. The anterograde flow was observed in 76 eyes (86.4%). Our control group included 19 patients with sequential angiograms. One OA flow reversal event was identified. OA flow direction is dynamic in IAC patients. Anterograde and retrograde OA directional switches do occur and may necessitate delivery technique variation. In our analysis, all OA flow reversal events were associated with multiagent chemotherapy regimens. Both anterograde and retrograde OA flow patterns were observed in our control cohort, suggesting bidirectional flow can occur in non-RB children.

A Study of Morphological Variations of Carotid Bifurcation and Branching Pattern of External Carotid Artery in Adult Nigerian Cadavers

Background: Understanding the morphological differences in the branching pattern of carotid vessels has played a significant role in successful surgical operations around the neck region. This study aimed at evaluating the morphological variants of the external carotid artery (ECA) in relation to its carotid bifurcation (CB) and its branches. Methods: After obtaining twenty-five (25) hemi-necks and later dissected, 25 ECAs were examined (13 right and 12 left). The patterning of the superficial branches and CB from common carotid artery were photographed and later analyzed in terms of variations of origin. Results: CB appeared as V-shaped in 24 cases (96%). Superior thyroid artery (STA) originated majorly from both the ECA (40.91%) and from the CB (36.36%). The percentage distributions of occurrence of arterial branch origins from ECA in both hemi-neck sides are as follows; ascending pharyngeal (85.71%), lingual (84%), facial (88%) and occipital (95%). Conclusion: In adult Nigerian cadavers, the V-shaped carotid bifurcation pattern is more common and the CB was more prevalent at the level of the upper border of thyroid cartilage. Higher numbers of origins were observed more in STA compared to other superficial branches of ECA.

Post Traumatic Pseudo-Aneurysms From A Branch of Thyro-cervical Trunk and External Carotid Artery With Concomitant Arteriovenous Fistula-A Rare Entity and Diagnostic Challenge in Interventional Radiology

Post Traumatic Pseudo-Aneurysms From A Branch of Thyro-cervical Trunk and External Carotid Artery With Concomitant Arteriovenous Fistula-A Rare Entity and Diagnostic Challenge in Interventional Radiology

Configuration Origin Variants of Superior Thyroid, Lingual and Facial Arteries: A Proposal Updating of Current Classification

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.

Comparing internal versus external carotid artery branch delivery of intraarterial chemotherapy for the treatment of retinoblastoma.

The goal of this study was to compare the efficacy of intraarterial chemotherapy (IAC) for retinoblastoma delivered via the ophthalmic artery (OA) division of the internal carotid artery (ICA) versus alternative branches of the external carotid artery (ECA). We performed a retrospective chart review of patients receiving IAC for retinoblastoma at a single institution. Subjects were divided into three groups: those that received IAC solely through the OA branch of the ICA, those that initially received IAC through the OA branch of the ICA but were later switched to the ECA, and those that only received IAC through the ECA. The main outcomes compared included globe salvage rate and reduction in tumor thickness and size. A total of 30 eyes from 26 patients were included. A total of 91 (58%) sessions of IAC were performed through the OA division of the ICA and 65 (42%) were performed through branches of the ECA. Eleven eyes (37%) solely received IAC through the OA branch of the ICA, 16 eyes (53%) were converted to ECA treatment, and 3 eyes solely received IAC through branches of the ECA. Statistical analysis did not show any significant difference in globe salvage rate or reduction in tumor thickness and size. The use of alternative approaches for IAC when the OA branch of the ICA catheterization is not feasible allows for safe continued delivery of highly effective IAC, leading to similar outcomes in terms of globe salvage and reduction in tumor size.

A STUDY OF BRANCHING PATTERN OF EXTERNAL CAROTID ARTERY IN THE CAROTID TRIANGLE – A CADAVERIC STUDY

Background Carotid triangle is an important neurovascular area located in the anterior cervical region of the neck. Variations in the external carotid artery in carotid triangle may complicate surgeries like radical neck dissection, aneurysm repair in the carotid triangle To study the branching pattern and variations of external c Aim and Objective arotid artery in carotid triangle This study includes 30 formalin xed cadavers from the Department of Ana Method tomy, Sri lakshmi Narayana institute of medical sciences Puducherry . This study includes all the cadavers during routine anatomical dissection by the students. In this present study Results both sides of the neck regions , a total of 60 sides were dissected. External carotid artery branches in the carotid triangle were traced. In the study period we found 3% of superior thyroid artery arising from common carotid artery and common unilateral linguofacial trunk in 6% of cadavers. Other branches of external carotid artery in the carotid triangle were traced. Ca Discussion And Conclusion rotid triangle is a vascular area contains common carotid artery and its terminal branches, important area for auscultation and palpation of vessels. With in the carotid triangle common carotid artery divides into internal and external carotid arteries at the level of upper border of thyroid cartilage. External carotid artery gives eight branches with in this ve branches arises from carotid triangle. The study of branches of external carotid artery in the carotid triangle was paramount important to avoid iatrogenic injury during neck dissection.