Retropharyngeal internal carotid artery: a review of three cases

Older age, carotid artery stenosis, and female sex as factors correlated with twisted carotid bifurcation based on 457 angiographic studies

BACKGROUND

Twisted carotid bifurcation (TCB) is a well-known anatomical variation of the carotid bifurcation in patients undergoing carotid endarterectomy. However, few investigations of TCB have focused on patients without internal carotid artery (ICA) stenosis. This study was performed to analyze the characteristics of TCB in patients with ICA stenosis and other diverse pathologies.

METHODS

All conventional cerebral angiographies performed in our institute for any reason from January 2012 to December 2018 were reviewed. The patients were divided into two groups, the TCB group and the anatomically normal non-TCB group, and the basic characteristics of the groups were analyzed.

RESULTS

Both sides of the carotid bifurcation were clearly visualized in 457 patients. TCB was found in 89 of 457 patients (19.5%); among these 89 patients, 74 (83.1%) had TCB only on the right side, 8 (9.0%) only on the left side, and 7 (7.9%) bilaterally. TCB was found more frequently on the right than left [81 (17.7%) and 15 (3.3%), respectively, on each of the 457 sides (p < 0.0001)]. TCB was significantly more frequent in older patients (p = 0.02), female patients (p < 0.001), and patients with ICA stenosis or occlusion at the bifurcation (p = 0.005). The prevalence of TCB was 19.5%, and 84.4% of cases were on the right side in patients with diverse pathologies.

CONCLUSIONS

Older patients, female patients, and patients with ICA stenosis or occlusion are more prone to have TCB.

Tortuous Carotid Arteries and Their Clinical Implications: A Report of Two Cases

The tortuous carotid artery is a rare anatomic abnormality defined as vascular elongation leading to an altered course. It can be discovered incidentally or have clinically significant manifestations. The most common location is the internal carotid artery or, less commonly, the common carotid artery. Bilateral tortuous carotid arteries can also occur, leading to "kissing carotids" where the carotid arteries are juxtaposed. We describe two cases of carotid artery tortuosity in patients with risk factors associated with its development. One case is of a 91-year-old female presenting with a cerebrovascular accident and an incidental finding of tortuosity of the right common carotid artery mimicking the appearance of "kissing carotids." The other case concerns a 66-year-old female with a symptomatic tortuous left internal carotid artery. This report aims to inform clinicians of the differences in the anatomical features, pathogenesis, and possible clinical implications of these variants.

[Aberrant internal carotid artery: a rare cause of cough: about a clinical case]

Aberrant course of the internal carotid artery is a rare congenital malformation. Aberrant course of cervical internal carotid artery accounts for 5% of cases. Several cases of fatal hemorrhage due to an injury to the aberrant internal carotid artery have been observed in patients undergoing pharyngeal surgery procedures. This was associated with a lack of detection during surgery. Ear nose and throat (ENT) practitioner need to know it. We here report a case of aberrant internal carotid manifesting as chronic cough due to the contact of the epiglottis with the pharyngeal mass caused by the aberrant artery. The patient was treated for chronic lung disease without success. This particular anatomical condition should be suspected in patients with pharyngeal mass before any invasive procedure.

Imaging of Aberrant Internal Carotid Arteries

OBJECTIVE

Aberrant internal carotid arteries (ICAs) may take abnormal courses in the cervical region. We present the ICA imaging features that suggest the presence of a submucosal mass in the posterior pharyngeal wall caused by such an aberration.

METHODS

Cervical computed tomography angiography images of 2400 patients obtained over 5 years were retrospectively reviewed. The ICA courses at the levels of the hypopharynx and oropharynx were evaluated. Aberrant ICAs running posterior to the pharynx were selected. Vessel location was classified into 3 types: lateral to the vertebral foramen (normal, type I); between the lateral foramen and the uncovertebral joint (type II); and medial to the uncovertebral joint (type III). Medical records were examined, and relationships between symptoms, the ICA variations, and imaging features evaluated.

RESULTS

Cervically aberrant ICAs of type II were detected in 45 patients and aberrations of type III in 18. In the latter group, the mean patient age was 66 years, 12 were men and 6 were women. Six (33%) patients (4 men) had clinical symptoms associated with their aberrant ICA courses. In 2 men (11%), both ICAs took aberrant courses. Otherwise, the right ICA was affected in 9 (50%) cases and the left ICA in 7 (39%).

DISCUSSION

Parapharyngeal ICA aberrations were both common and asymptomatic. Such ICAs may be damaged during pharyngeal surgery or intubation. The ICA location should be investigated before any interventional procedure.

Retropharyngeal internal carotid artery: a potential risk factor during nasotracheal intubation

PURPOSE

To investigate the potential risk of the retropharyngeal internal carotid artery (RICA) during nasotracheal intubation (NTI).

METHODS

We retrospectively surveyed 2028 patients and 90 healthy controls (HC) with neck computed tomography angiography (CTA). The incidence of RICA was analyzed, as well as the correlation between the average minimum carotid-pharyngeal distance (CPD) and the carotid-median plane distance (CMD). We also compared CPD between RICA and HC.

RESULTS

RICA was observed in 91 out of the 2028 patients, reaching an incidence of 4.5% (91/2028). RICA in female patients was 65.9% (60/91) compared to 34.1% (31/91) in male patients. The incidence of RICA at nasopharynx (NP), oropharynx (OP), and hypopharynx (HP) was 31.9% (29/91), 61.5% (56/91), and 6.6% (6/91), respectively. The incidence of the mucosal eminence of the posterior wall of the pharynx in RICA was 30.8% (28/91). In 15 cases, RICA caused the pharyngeal cavity to become narrow, with an incidence of 16.5% (15/91). Moreover, CPD and CMD was positively correlated (r = 0.56, p < 0.01). The average minimum CPD of RICA was only 2.25 ± 1.26 mm, which was much shorter than HC (17.62 ± 1.98 mm) (t = 62.46, p < 0.01). Some CPD of RICA was even less than 1 mm, with an incidence of 20.9% (19/91).

CONCLUSION

RICA is not uncommon in asymptomatic adults. It is very close to the midline and posterior wall of the pharynx and is more likely to occur in the nasopharynx (NP) and oropharynx (OP). RICA tear is likely to occur during NTI.

Aberrant internal carotid artery in the oropharynx space poses a life-threatening risk of surgery

BACKGROUND

Tortuosity of the internal carotid artery (ICA) is not a rare condition, but its clinical impact is underestimated. The differences in the course and shape of the ICA in the oropharynx just beneath the mucosa were investigated to determine the possible fatal bleeding for both major oropharyngeal tumor resection and less extensive procedures. We report two cases to reveal that the awareness of such an anatomical variation before performing oropharyngeal procedures.

METHODS AND RESULTS

We report two different pathologies of retropharyngeal ICAs, which presented with otolaryngological symptoms. Case 1 Retropharyngeal right ICA. The vessel's minimum distance to the pharyngeal wall was 1 mm (very high risk of vascular injury) with a tortuous pathway. Case 2 Retropharyngeal right ICA. A tortuous ICA was in contact with the posterior pharyngeal wall (very high risk of vascular injury).

CONCLUSION

The otolaryngologists surgeons must use caution in evaluating patients with masses in the pharynx and augment a careful and complete head and neck examination with appropriate imaging studies before operating.