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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 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 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 Page 9 of 25 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 Page 14 of 25 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 Page 15 of 25 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 Page 20 of 25 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 Page 21 of 25 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 Page 22 of 25 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 Page 24 of 25 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 1. Suichi T, Hiro K, Hiromu M, et al. Maxillary Artery: Functional and Imaging Anatomy #for Safe and Effective Transcatheter Treatment. RadioGraphycs 2013 33:E209-E224. 2. Geibprasert S, Pongpech S, Armstrong D. Dangerous Extracranial-Intracranial 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 Española. OTORRI-259. 4. Choi J, Park HS. The clinical anatomy of the maxillary artery in the pterygopalatine fossa. J Oral Max- illofac Surg 2003;61(1):72-78. # Page 25 of 25