Download Maxillary artery: functional and imaging anatomy and correlation

Maxillary artery: functional and imaging anatomy and
correlation with perfused cadaver heads
Poster No.:
C-0837
Congress:
ECR 2016
Type:
Educational Exhibit
Authors:
D. CAÑÓN MURILLO , E. Garcia Garrigos , J. R. GRAS
1
2
1
1
1
CABRERIZO , J. J. ARENAS , A. J. Mantilla Pinilla , R. E. Correa
3
1 1
2
Soto , B. ROMERA BARROSO ; ALICANTE/ES, BARCELONA/
3
ES, SALAMANCA/ES
Keywords:
Education and training, Education, CT-Angiography, Head and
neck, Arteries / Aorta, Anatomy
DOI:
10.1594/ecr2016/C-0837
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Page 1 of 25
Learning objectives
1. To describe the functional and imaging anatomy of the maxillary artery (MA) and its
branches, using computed tomography and angiographic images.
2. To illustrate their anatomic correlation with cadaver heads dissections perfused with
a radiopaque material.
Background
The maxillary artery (MA) is the larger of the two terminal branches of the external carotid
artery (ECA). It originates in the parotid gland, behind the neck of the mandible and ends
in the pterygopalatine fossa (PPF) (Fig. 1), where it divides into many branches irrigating
the deepest part of the face and nose, being in hemodynamic balance with the facial
artery.
Its major practical role is to serve as the most important source of collateral flow from
the outer to the inner system and can supply the vascularization of the eye and brain
by anastomosing with the main trunk of the cavernous internal carotid artery (ICA)
and ophthalmic artery, being likewise, a potential source of eye, brain and cranial
complications after endovascular interventional or surgical procedures.
In this poster we will review the normal functional anatomy of the MA and its branches.
Computed tomography (CT) and three-dimensional angiographic images obtained from
patients and from cadaver heads perfused with a solution consisting of latex, dextrin and
lead tetroxide will be used to show these vessels.
Images for this section:
Page 2 of 25
Fig. 1: Sagittal reconstructed image from rotational angiographic data from right external
carotid artery, shows the first, second, and third segments of the maxillary artery
(separated by dotted lines).
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
Page 3 of 25
Findings and procedure details
The MA can be divided into three segments, regarding the craniofacial bones: the
mandibular segment, the zygomatic or pterygoid segment, and the pterygopalatine
segment (Fig. 2). The first two segments, located in the pterygomaxillary or zygomatic
fossa, are better assessed in the lateral projection and the third, located in the PPF, is
in the anteroposterior projection.
1. First (Mandibular) Segment: (Fig. 3) It starts vertically, then turns horizontally and is
accompanied by the internal maxillary vein.
Branches:
- Anterior tympanic artery (ATA)
- Middle meningeal artery (MMA)
- Accessory meningeal artery (AMA)
- Inferior dental artery (IDA)
2. Second (Zygomatic Or Pterygoid) Segment: (Fig. 4) It can run superficial or deep
to the lateral pterygoid muscle and makes an anteromedial turn to enter into the PPF.
The MMA and AMA have a common origin if it runs superficial to the pterygoid muscle
and a different origin when runs deep to it (Fig. 5).
Branches:
- Anterior deep temporal artery (ADTA)
- Middle deep temporal artery (MDTA)
- Pterygoid artery (PtA)
- Masseteric artery (MA)
- Buccal artery (BA)
3. Third (Pterygopalatine) Segment: (Fig. 6) It is the most tortuous segment, to suit
the chewing movements. It turns transversely at the entrance to the pterygopalatine
fossa and runs upward #to the superior fossal region, below the maxillary nerve and
accompanying the maxillary vein.
Page 4 of 25
Branches:
- Posterior superior dental artery (PSDA)
- Infraorbital artery (IOA)
- Descending palatine artery (DPA)
- Sphenopalatine artery (SPA)
- Pharyngeal artery (PhA)
- Artery of the foramen rotundum (AFR)
- Vidian artery (VA)
ANATOMICAL RELATIONSHIPS OF THE PTERYGOPALATINE FOSSA
The pterygopalatine fossa contains the maxillary and petrosal nerves, as well as the third
segment of the maxillary artery and the maxillary vein, and it functions as an intersecting
channel that communicates with the intracranial cavity, nasal cavity, nasopharynx, orbit,
and infratemporal fossa (Fig. 7).
NORMAL ANATOMY #AND IMAGING APPEARANCES #OF THE MAXILLARY
ARTERY BRANCHES
#
The maxillary artery branches (Fig. 8) can be classified into six groups on the basis of
their course and distribution: the ascending cranial and intracranial branches, ascending
extracranial muscular branches, descending branches, anterior branches, recurrent
branches, and terminal branch (1). We will show highlighted in blue, in the text, the
possible anastomosis with the internal carotid system.
The origin, course, and distribution of these branches can be well depicted on
reconstructed images from rotational angiographic data.
1. Ascending Cranial And Intracranial Branches
- ANTERIOR TYMPANIC ARTERY: Originates from the first MA segment and supplies
the external auditory canal (Fig. 9).
Page 5 of 25
- MIDDLE MENINGEAL ARTERY: Originates from the first MA segment (Fig. 10). It
passes through the foramen spinosum and is divided into anterior and posterior convexity
branches (Fig. 11), the anterior one supplies the orbital region and the dura mater in
the anterior cranial fossa and may anastomose with the ophthalmic artery through the
recurrent meningeal artery (RMA), proximal lacrimal artery, and anterior or posterior
ethmoidal arteries, (2) (Fig. 12) or the meningo-pituitary axis of the ICA, through the
petrosal branch that supplies the facial nerve. The posterior branch supplies the dura at
the temporo-parietal region.
- ACCESSORY MENINGEAL ARTERY: Originates from the first MA segment (Fig.
10), supplies the pharynx, eustachian tube, and meninges. It can anastomose to the
cavernous or petrosal portions of the ICA, and the anterior inferior cerebellar artery in
the middle ear.
2. Ascending Extracranial Muscular Branches
- ANTERIOR DEEP TEMPORAL ARTERY (Fig. 13): Originates from the second MA
segment and supplies the temporal muscle. It may anastomose with ophthalmic artery
through distal lacrimal artery (2).
- MIDDLE DEEP TEMPORAL ARTERY (Fig. 13): Originates from the second MA
segment, it is the main artery supplying the temporal muscle.
3. Descending Branches
- INFERIOR DENTAL ARTERY: Originates from the first maxillary artery segment, runs
along the mandibular canal (Fig. 14) and supplies the nerve, teeth, gingiva, and bone. It
anastomoses to its contralateral counterpart (1).
- PTERYGOID ARTERY: Originates from the second MA segment, supplies pterygoid
muscle.
- MASSETERIC ARTERY: Originates from the second MA segment, supplies the
masseter muscle and anastomoses to the facial artery.
- BUCCAL ARTERY: Originates from the second MA segment, supplies the skin and
mucosa surrounding the buccinator muscle and can also anastomose to the facial artery.
4. Anterior Branches
Page 6 of 25
- POSTERIOR SUPERIOR DENTAL ARTERY (Fig. 15): originates from the third MA
segment, inside the pterygopalatine fossa. This has many branches that supply the
buccal and gingival mucosae, the buccinator muscle, the maxillary sinus and molarpremolar teeth.
- DESCENDING PALATINE ARTERY: Originates in the third MA segment and enters in
the posterior palatine canal (Fig. 16). It supplies the mucosae of the gingiva, soft palate,
and tonsils.
- INFRAORBITAL ARTERY (Fig. 17): Originates from the third MA segment. It supplies
the inferior rectus muscle, inferior oblique muscle, and lachrymal sac. It can anastomose
to the ophthalmic artery by the angular artery, branch of the ophthalmic artery.
5. Recurrent Branches
- VIDIAN ARTERY (Fig. 19): Originates from the third MA segment and enters in to the
vidian canal. It supplies the mucosa of the pterygopalatine fossa and nasopharyngeal
cavity, and can anastomose to the homonymous artery arising from the ICA. It is an
important landmark in transpterygoid approach because it is a direct way to reach the
lacerum foramen (Fig. 18).
- PHARYNGEAL ARTERY (Fig. 19): Originates from the third MA segment, and can form
a common trunk with the vidian artery. It supplies the mucosa of the pharyngeal roof,
the choanae, and the pharyngeal eustachian tube. It is also an important landmark in
transpterygoid approach allowing localization of the vidian nerve and artery that runs
lateral to it in the sphenoid bone.
- ARTERY OF THE FORAMEN ROTUNDUM: Originates in the third MA segment. It can
anastomose to the cavernous portion of the ICA by the inferolateral trunk.
6. Terminal Branch
- SPHENOPALATINE ARTERY (Fig. 20): This artery is particularly important because it
is used for obtaining flaps to cover defects in the skull base. It originates in the third MA
segment in the pterygopalatine fossa, enters the nasal cavity through the sphenopalatine
foramen, specifically in the back of the upper turbinate, and immediately divides into two
branches: the posterior lateral branch and the septal branch, supplying most parts of the
nasal mucosa. It can anastomose to the ophthalmic artery by the posterior ethmoidal
artery.
Page 7 of 25
Images for this section:
Fig. 1: Sagittal reconstructed image from rotational angiographic data from right external
carotid artery, shows the first, second, and third segments of the maxillary artery
(separated by dotted lines).
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
Page 8 of 25
Fig. 2: Scheme of the pathway of the maxillary artery and its three different segments.
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
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Fig. 3: Scheme of the branches of the first (maxillary) segment: ATA (anterior tympanic
artery), MMA (middle meningeal artery), AMA (accessory meningeal artery) and IDA
(inferior dental artery).
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
Page 10 of 25
Fig. 4: Scheme of the second segment of the maxillary artery with its five branches: ADTA
(anterior deep temporal artery), MDTA (middle deep temporal artery), PtA (pterygoid
artery), MA (masseteric artery), BA (buccal artery).
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
Fig. 5: Maximum-intensity projection CT images (MPR) showing the two possible
locations of the second portion of the maxillary artery related to the lateral pterygoid
muscle (asterisk).
Page 11 of 25
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
Fig. 6: Scheme of the third segment of the maxillary artery with its seven branches: PSDA
(posterior superior dental artery), DPA (descending palatine artery), PhA (pharyngeal
artery), VA (vidian artery), AFR (artery of the foramen rotundum), SPA (sphenopalatine
artery) and IOA (infraorbital artery).
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
Page 12 of 25
Fig. 7: Axial CT images demonstrate the pathways passing through the pterygopalatine
fossa (see text for color description).
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
Page 13 of 25
Fig. 8: Maxillary artery branches. Sagittal reconstructed image from rotational
angiographic data.
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
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Fig. 9: Sagittal CT MIP reconstructed image showing the ATA origin (yellow arrow) from
the first MA segment.
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
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Fig. 10: Proximal segments of MMA (yellow arrow) and AMA (red arrow). Sagittal
reconstructed images from rotational angiographic data (a) and external carotid
arteriogram (left lateral projection) (b).
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
Page 16 of 25
Fig. 13: Origin of ADTA (red arrow) and MDTA (yellow arrow) from the second
MA segment. Sagittal (a) and right oblique (b) reconstructed images from rotational
angiographic data.
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
Fig. 11: Axial (a) and coronal (b) reconstructed images from CT angiographic data
demonstrate the course of the MMA (yellow arrows) from the foramen spinosum (blue
arrows), and the anterior and posterior convexity branches (red arrows).
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
Page 17 of 25
Fig. 14: Origin of IDA (yellow arrow) from the first MA segment. Sagittal MIP
reconstructed image from CT angiographic data.
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
Page 18 of 25
Fig. 15: Origin of PSDA (yellow arrows) from the third MA segment. Coronal oblique (a),
axial (c) reconstructed images from rotational angiographic data. Dissection specimen
(b).
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
Fig. 16: Pathway of the PSDA (yellow arrows) from the pterygopalatine canal to the
inferior palatine foramen. Axial (a, c) and sagittal (b, c) reconstructed images from
rotational angiographic data.
Page 19 of 25
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
Fig. 17: The pathway of the IOA (yellow arrows) along the infraorbital groove (b) in the
roof of the maxillary sinus, entering trough the infraorbital canal (blue arrow in c). Sagittal
(a) axial (b) and coronal (c) reconstructed images from rotational angiographic data.
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
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Fig. 18: Relationship between the Vidian canal/artery (yellow arrow) and lacerum carotid
segment (red circle). Axial reconstructed images from rotational angiographic data.
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
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Fig. 19: Coronal CT MIP reconstructed image from rotational angiographic data showing
the close relationship between right vidian artery (yellow arrow) and bilateral pharyngeal
arteries (red arrows) in the sphenoid bone.
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
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Fig. 20: Bifurcation of the sphenopalatine artery (SPA) into posterior lateral branch (blue
arrows) and the posterior septal branch (yellow arrow) after passing the sphenopalatine
foramen. Dissection specimen (a) and coronal reconstructed image from rotational
angiographic data (b).
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
Page 23 of 25
Fig. 12: Communication of the middle meningeal artery (MMA) with the ophthalmic
artery (OA), through the recurrent meningeal artery (RMA) in a patient with juvenile
nasopharyngeal angiofibroma (asterisk). Lateral angiography projection obtained from
external carotid artery (ECA).
© Servicio de Radiología. Hospital General Universitario de Alicante/Alicante-ES
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Conclusion
Knowledge of the functional and imaging anatomy of the maxillary artery and the potential
anastomotic routes to intracranial arteries are crucial to help the interventional radiologist,
neurosurgeon and otolaryngologists to avoid complications to the brain and cranial
nerves during procedures.
Reconstructed images from CT and rotational angiographic data can demonstrate the
basic maxillary artery anatomy and variations of its branches in the intra and extracranial
areas, providing useful information for diagnosing and treating maxillary artery lesions (1).
Personal information
This poster comes from the Radiology Department of: Hospital General Universitario de
Alicante. Alicante - Spain.
e-mail adress of the first author: [email protected]
References
REFERENCES
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Safe and Effective Transcatheter Treatment. RadioGraphycs 2013 33:E209-E224.
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Anastomoses and Supply to the Cranial Nerves: Vessels the Neurointerventionalist
Needs to Know. Am J Neuroradiol 2009 30:1459-68.
3. Gras Cabrerizo JR, Gras Albert JR, Monjas Canovas I, et al. Pedicle flaps based
on the sphenopalatine artery: Anatomical and surgical study. Acta otorrinolaringológica
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