Imaging and Clinical Findings in Patients with Aberrant Course of the Cervical Internal Carotid Arteries

Abstract

Background and Purpose:Aberrrant course of the cervical internal carotid arteries (ICAs) may result in submucosal masses in the posterior pharyngeal wall, may cause confusion at physical examination, may be symptomatic, and can be at risk of surgical injury. The aim of this report is to present the clinical and imaging characteristics associated with aberrant course of the cervical portion of the ICAs.Methods:Imaging studies of 5.500 patients were prospectively selected from CT studies of the head and neck performed in a five years period, in which the course of the one or both ICAs at the level of the hypopharynx and oropharynx was assessed as aberrant by means of a proposed classification. We then reviewed the medical records to establish which symptoms were present and if these symptoms could be caused by these variations in the course of the ICAs. In selected cases, further studies including magnetic resonance (MR) imaging, MR angiography (MRA), or selective catheter angiography were obtained. Results:In our restricted classification, we found 14 (0.2%) patients who met the cervical ICA aberrancy criteria. In all patients contrast enhanced CT or CT angiography was performed, 4 also have had MRI and MRA, and in two additional catheter angiograms were performed. Mean age was 62 years. Eight patients were male and seven were female. Four patients (28%) were considered to have clinical symptoms related to aberrant course of the ICAs. In most of the symptomatic patients both ICAs had aberrant courses. Overall, the course of the right ICA was aberrant in 43%, the left ICA in 14%, and both in 43%. In 50% of the cases the aberrancy of the artery was focal (localized to the oropharynx or laryngopharynx) and in the other 50% it involved the entire cervical course of the ICA.Conclusions:In most of our patients variations in the course of the cervical portion of the ICA involved the right side and were asymptomatic, except with regard to potential surgical risks. However, in about 25% of our patients these variations were thought to be the culprit of patient complaints, particularly oropharyngeal pulsatile sensation. Furthermore, extreme degrees of medialization of the ICAs resulted in progressive symptoms including hoarseness and upper respiratory distress.

BILATERAL TORTUOUS INTERNAL CAROTID ARTERIES – a case report, otorhinolaryngologic and general clinical implications

“…Although the unilateral tortuosity of the right ICA has been more often described, an abnormal course of the left ICA and bilateral changes are not much rarer. Taking into account the anatomy, the right carotid artery seems to be more prone to deviation, because of its origin and shorter length [8,21,22]. However, there are a lot of discrepancies which arise from differences in the methods, analysed population, terminology, etc.…”

“…However, there are a lot of discrepancies which arise from differences in the methods, analysed population, terminology, etc. [2, 3,7,8,9,15,17,23].…”

“…Some authors have separated the terms "tortuosity/coiling", described as any alteration in the shape and route of the artery, from "kinking", and considered to be associated with stenosis and atherosclerotic changes within the vessel [8,15]. Paulsen (2000) in his studies on cadavers differentiates between straight course, curved course (forming C-or S-shape), kinking (acute angulation of the vessel) and coiling (creating a loop or double loop).…”

“…This classification relies on assessment of the artery's shape and can be useful for clinicians, but subsequent divisions proposed by other authors that include the severity of arterial angulation and presence of atherosclerosis, seem to be more valuable regarding the clinical implications [9]. The classification which assumes evaluating the degree of kinked segments' angle primary proposed by Metz (1961) and modified later by many of researchers may be helpful in assessing the risk of cerebrovascular insufficiency and the occurrence of symptoms [2, 3,8,9,15,16,17]. According to that, the hemodynamically significant kinking occurs when an angle is lower than 60° [17].…”

“…dysphagia, dysphonia, snoring, foreign body sensation in the throat, difficulties in breathing. The term "dangerous loop" is used when this anomaly poses a risk for the surgical procedures performed within the area of the neck [6,7,8,9]. It is compelling for otolaryngologists, radiologists, surgeons, anaesthesiologists and other specialists to keep in mind that this kind of distinctness can be encountered, to distinguish it from other pathologies like aneurysms, neoplasms or abscesses.…”