Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Where is the external carotid artery located? Poster No.: C-2364 Congress: ECR 2014 Type: Educational Exhibit Authors: M. Carrillo García , S. Sánchez Jiménez , A. Andreo Sola , M. 1 2 2 2 2 2 Franulic Guggiana , M. Moreno Cascales , J. M. Garcia Santos ; 1 2 Cartagena/ES, Murcia/ES Keywords: Blood, Computer Applications-3D, CT-Angiography, Arteries / Aorta, Anatomy DOI: 10.1594/ecr2014/C-2364 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myESR.org Page 1 of 42 Learning objectives Fig. 1 References: Servicio de Radiología. HGU Morales Meseguer 1. To review the neck anatomy of external carotid artery (ECA) and its branches. 2. To identify their relationship with anatomic structures in cross-sectional imaging epecially in the usual axial images 3. To show how neck surgery affects these vessels in cross-sectional imaging. Images for this section: Page 2 of 42 Fig. 1 Page 3 of 42 Background These two following images help us to easily identify the external carotid branches. Fig. 2 References: Servicio de Radiología. HGU Morales Meseguer Page 4 of 42 Fig. 3: Digital Substraction Angiography. Selective injection of the external carotid angiography. Lateral view References: Servicio de Radiología. HGU Morales Meseguer 1. External Carotid Artery. It originates by the division of common carotid artery, in the upper edge of thyroid cartilage; at C4-level in the thyroidal space (carotid triangle) It first ascends in medial position, and then goes deep to posterior side of the digastrics muscle. Medially it describes a convex curve that approaches to the palatine tonsil through the diaphragm of styloid muscles and enters the parotid cell. Then it turns laterally, going deeper in the gland in an upright position from medial to lateral. The trunks of most of its branches are within the carotid triangle. It ends in the carotid region, behind and close to the neck of mandibular condyle, by bifurcation in: the maxillary artery and the superficial temporal artery. Page 5 of 42 Fig. 4 References: Servicio de Radiología. HGU Morales Meseguer 2. Branches of the External Carotid Artery a. Superior thyroid artery: It is the lowest of the three branches of the ECA. First is directed medially, below the greater horn of the hyoid bone. And then goes down towards the upper pole of the thyroid gland, where it ends. Medially contacting the thyrohyoid membrane. Page 6 of 42 Fig. 5 References: Servicio de Radiología. HGU Morales Meseguer b. Lingual Artery: It is a flexuous artery adapted to the mobility of the tongue. It originates at the level of greater horn of the hyoid bone. It's directed upwards and medially before leaning forward. Located on the deep surface of the hyoglossus muscle and it ends near the tip of the tongue, where it is called deep lingual artery. After a short segment in the carotid triangle, the artery is related to the submandibular, sublingual regions and then with his tongue. In the submandibular triangle is hidden laterally by the hyoglossus, medially supported on the middle constrictor muscle of the pharynx. Page 7 of 42 Fig. 6 References: Servicio de Radiología. HGU Morales Meseguer c. Facial Artery: It arises from the anterior aspect of the ECA from a common trunk which also emerges or lingual artery immediately above it. It lies deep to digastric and stylohyoid muscles, penetrates the submandibular region, where it goes up and sideways. Then crosses the lateral aspect of the body of the jaw and becomes shallow and sinuous. Browse the face back and forth, from the bottom up and from lateral to medial side anastomosing the dorsal nasal artery (branch of the ophthalmic artery) in the medial canthus. Relations: - In his short segment in the carotid triangle the artery is located medially and against the pharyngeal wall. Page 8 of 42 - it digs a canal in the posterior pole of the submandibular triangle and in the upper face of the submandibular gland, crosses under the deep surface of the medial pterygoid muscle and the inferior border of the mandible, in which marks a groove, after that is located superficially to masseter muscle. - In the posterior face is accompanied by facial vein. Take a path between the deep muscular plane (buccinator, elevators and the infraorbital nerve) and superficial muscular plane (platysma, giggly, and zygomatic branches of the facial nerve). Fig. 7 References: Servicio de Radiología. HGU Morales Meseguer d. Ascending pharyngeal artery It is a small artery that ascends vertically, generally medial to the internal carotid artery, lying against the lateral wall of the pharynx, which irrigates. e. Occipital artery Page 9 of 42 Originates at the rear face of the external carotid artery, at the height of the jaw angle and deep to it. It keeps the lower edge of the posterior belly of the digastric, up and back oblique muscle passes against the base of the skull, medial to the mastoid process, which prints its passage (groove of the occipital artery), lateral the lateral mass of the atlas. Get through the muscles of the neck to finish in the superficial layers of the region. Fig. 8 References: Servicio de Radiología. HGU Morales Meseguer f. Internal maxillary artery Bifurcation branch of external carotid artery originated near to parotid gland, it goes to the front side locating between mandibular condyle and sphenomandibular ligament and deep in the infratemporal fossa. Generally follows the lateral ptrigoideo muscle, in the depth or superficially. It ends in the bottom of pterygopalatine fossa, giving a branch (sphenopalatine artery). Page 10 of 42 Fig. 9 References: Servicio de Radiología. HGU Morales Meseguer g. Superficial temporal artery. It originates within parotid gland, behind the mandibular neck. Is directed obliquely up and laterally, situating between the temporal articular tubercle and de external auditive conduct. Cross the lateral side of articular tubercle, going under the skin of the temporal region and ends bifurcating in two branches: frontal and parietal arteries. Page 11 of 42 Fig. 10 References: Servicio de Radiología. HGU Morales Meseguer Images for this section: Page 12 of 42 Fig. 2 Page 13 of 42 Fig. 3: Digital Substraction Angiography. Selective injection of the external carotid angiography. Lateral view Page 14 of 42 Fig. 4 Page 15 of 42 Fig. 5 Page 16 of 42 Fig. 6 Page 17 of 42 Fig. 7 Page 18 of 42 Fig. 8 Page 19 of 42 Fig. 9 Page 20 of 42 Fig. 10 Page 21 of 42 Findings and procedure details 1. AXIAL ANATOMY a. Superior thyroid artery: Main references : membrane thyrohyoid and hyoid bone. Fig. 11: A)axial gross-section image B)axial contrast-enhanced CT image White arrow : Superior thyroid artery, 1:Common carotid artery, 2:Hyoid bone, 3:Thyrohyoid membrane References: Servicio de Radiología. HGU Morales Meseguer b. Lingual Artery: Page 22 of 42 Main references: greater horn of the hyoid bone and hyoglossus muscle. Fig. 12: A) Coronal gross-section image B) Axial contrast-enhanced CT image White arrow:Lingual artery, 1: Hyoid bone, 2: Hyoglossus muscle, 3:Mylohyoid muscle, 4:Tongue References: Servicio de Radiología. HGU Morales Meseguer c. Facial Artery: Main references: Submandibular gland and angle of the mandible. Page 23 of 42 Fig. 13: A)Coronal gross-section image B)Axial contrast-enhanced CT image. White arrow: Facial artery,1: Angle of the mandible, 2:Submandibular gland, 3:Mandible References: Servicio de Radiología. HGU Morales Meseguer d. Distal external carotid and occipital arteries Main references: - Distal external carotid artery: the styloid pyramid. - Occipital artery: the posterior belly of the digastric muscle and the base of the skull, medial to the mastoid process. Page 24 of 42 Fig. 14: A) Axial gross-section image B) Axial contrast-enhanced CT image White arrow: External carotid artery, 1: Stylopharyngeus muscle, 2:Styloglossus muscle, 3:Stylohioid muscle,4: Digastricus muscle , 5:Occipital artery,6: Parotid gland, 7: Mandible References: Servicio de Radiología. HGU Morales Meseguer e. Internal maxillary artery Main references: mandibular condyle and lateral ptrigoideo muscle. Page 25 of 42 Fig. 15: A) Axial gross-section image B) Axial contrast-enhanced CT image White arrow: Maxillary artery, 1: Temporal muscle, 2:Lateral pterygoid muscle, 3:Medial pterigoid muscle, 4:Masseter muscle, 5: Mandible. References: Servicio de Radiología. HGU Morales Meseguer f. Superficial temporal artery. Main references: mandibular neck . Page 26 of 42 Fig. 16: A) Axial gross-section image B) Axial contrast-enhanced CT image. White arrow: Superficial temporal artery, 1:Masseter muscle, 2: Mandibular condyle, 3:Lateral pterygoid muscle, 4:Medial pterygoid muscle. References: Servicio de Radiología. HGU Morales Meseguer 2. THE EXTERNAL CAROTID ARTERY AFTER LYMPH NODE DISSECTIONS Usually the main ECA branches are respected whatever the cervical lymphadenectomy technique was. However, in specific cases, in which the branches or even the main trunk of the external carotid artery are affected, resection could be mandatory. - Selective lymphadenectomy Page 27 of 42 Fig. 17: Before selective lymphadenectomy A) Coronal reformatted CT B) Axial contrast-enhanced CT image. White arrow: External carotid artery, 1: Tumor, 2: Necrotic lymphadenopathy, 3: Common carotid artery, 4: Internal carotid artery, 5: Internal yugular vein. References: Servicio de Radiología. HGU Morales Meseguer Page 28 of 42 Fig. 18: After Lymphadenectomy A) Coronal reformatted CT B) Axial contrastenhanced CT image. White arrow: External carotid artery,Triangle: Supposed location of internal yugular vein 3: Common carotid artery, 4:Internal carotid artery 5: Internal yugular vein References: Servicio de Radiología. HGU Morales Meseguer - Radical lymphadenectomy Page 29 of 42 Fig. 19: CT exam before surgery. A) Sagital reformatted CT B) Axial contrastenhanced CT image. White arrow: External carotid artery, 1: Common carotid artery, 2:Internal carotid artery, 3:Necrotic lymphadenopathy References: Servicio de Radiología. HGU Morales Meseguer Page 30 of 42 Fig. 20: CT exam after surgery A) Sagital reformatted CT B) Axial contrast-enhanced CT image. Black arrow: Supposed location of external carotid artery, 1: Common carotid artery 2:Internal carotid artery, 4:Right external carotid artery. References: Servicio de Radiología. HGU Morales Meseguer Images for this section: Page 31 of 42 Fig. 11: A)axial gross-section image B)axial contrast-enhanced CT image White arrow : Superior thyroid artery, 1:Common carotid artery, 2:Hyoid bone, 3:Thyrohyoid membrane Page 32 of 42 Fig. 12: A) Coronal gross-section image B) Axial contrast-enhanced CT image White arrow:Lingual artery, 1: Hyoid bone, 2: Hyoglossus muscle, 3:Mylohyoid muscle, 4:Tongue Page 33 of 42 Fig. 13: A)Coronal gross-section image B)Axial contrast-enhanced CT image. White arrow: Facial artery,1: Angle of the mandible, 2:Submandibular gland, 3:Mandible Page 34 of 42 Fig. 14: A) Axial gross-section image B) Axial contrast-enhanced CT image White arrow: External carotid artery, 1: Stylopharyngeus muscle, 2:Styloglossus muscle, 3:Stylohioid muscle,4: Digastricus muscle , 5:Occipital artery,6: Parotid gland, 7: Mandible Page 35 of 42 Fig. 15: A) Axial gross-section image B) Axial contrast-enhanced CT image White arrow: Maxillary artery, 1: Temporal muscle, 2:Lateral pterygoid muscle, 3:Medial pterigoid muscle, 4:Masseter muscle, 5: Mandible. Page 36 of 42 Fig. 16: A) Axial gross-section image B) Axial contrast-enhanced CT image. White arrow: Superficial temporal artery, 1:Masseter muscle, 2: Mandibular condyle, 3:Lateral pterygoid muscle, 4:Medial pterygoid muscle. Page 37 of 42 Fig. 17: Before selective lymphadenectomy A) Coronal reformatted CT B) Axial contrastenhanced CT image. White arrow: External carotid artery, 1: Tumor, 2: Necrotic lymphadenopathy, 3: Common carotid artery, 4: Internal carotid artery, 5: Internal yugular vein. Page 38 of 42 Fig. 18: After Lymphadenectomy A) Coronal reformatted CT B) Axial contrast-enhanced CT image. White arrow: External carotid artery,Triangle: Supposed location of internal yugular vein 3: Common carotid artery, 4:Internal carotid artery 5: Internal yugular vein Page 39 of 42 Fig. 19: CT exam before surgery. A) Sagital reformatted CT B) Axial contrast-enhanced CT image. White arrow: External carotid artery, 1: Common carotid artery, 2:Internal carotid artery, 3:Necrotic lymphadenopathy Page 40 of 42 Fig. 20: CT exam after surgery A) Sagital reformatted CT B) Axial contrast-enhanced CT image. Black arrow: Supposed location of external carotid artery, 1: Common carotid artery 2:Internal carotid artery, 4:Right external carotid artery. Page 41 of 42 Conclusion It is important that general radiologists know the anatomic landmarks of ECA branches in order to improve anatomical and pathological interpretation of neck CT exams. In this work we aimed to present those landmarks in anatomical and CT axial slices helping us to easily identify the main ECA branches in normal and abnormal crosssectional imaging. Personal information References SOBOTTA, J. A. Human Anatomy, Ed. Médica Panamericana, 21ª Edición, Buenos Aires. Argentina. 2000. LATARJET M, RUIZ LIARD, A. Human Anatomy. Volume II. Ed Medica Panamericana. 4ª Edition. Mexico, D F. 2004. MOORE, K. L. Anatomy. Guidance Clinic. Ed Medica Panamericana. Buenos Aires. Argentina. 2002. NETTER, F. H. A. Human Anatomy, 3ª Ed. Masson, Barcelona. Spain, 1996. Page 42 of 42