External Cartoid Artery: Imaging Anatomy Atlas for Endovascular Treatment 9789811547850, 9789811547867

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External Cartoid Artery: Imaging Anatomy Atlas for Endovascular Treatment
 9789811547850, 9789811547867

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Hiro Kiyosue Editor

External Carotid Artery Imaging Anatomy Atlas for Endovascular Treatment

123

External Carotid Artery

Hiro Kiyosue Editor

External Carotid Artery Imaging Anatomy Atlas for Endovascular Treatment

Editor Hiro Kiyosue Department of Radiology Oita University Hospital Yufu, Oita, Japan

ISBN 978-981-15-4785-0    ISBN 978-981-15-4786-7 (eBook) https://doi.org/10.1007/978-981-15-4786-7 © Springer Nature Singapore Pte Ltd. 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Contents

1 External Carotid Artery�����������������������������������������������������������������������������������������������   1 Hiro Kiyosue 2 Anterior (Visceral) Branches from the Proximal ECA (Superior Thyroidal, Lingual, and Facial Arterial System) �������������������������������������   7 Hiro Kiyosue 3 Posterior (Neural) Branches from the Proximal ECA�����������������������������������������������  37 Hiro Kiyosue and Yuji Matsumaru 4 Superficial Arteries from the Distal ECA�������������������������������������������������������������������  75 Hiro Kiyosue 5 Maxillary Artery����������������������������������������������������������������������������������������������������������� 109 Hiro Kiyosue and Shuichi Tanoue

v

1

External Carotid Artery Hiro Kiyosue

The external carotid artery (ECA) gives off various branches supplying musclocutaneous organs, visceral organs (pharynx, oral cavity, larynx, and thyroid), cranial nerves, facial and skull bones, and dura matter. It communicates to the cerebral arteries and ophthalmic artery via various potential anastomoses. It is essential for successful and safe endovascular treatment to know imaging anatomy of the ECA and its branches particularly these potential anastomoses and cranial nerve supply. The external carotid artery (ECA) generally originates anteromedially from the common carotid artery at the level of C4. The ECA gives off the superior thyroid artery inferiorly at its origin, and runs superiorly toward the parotid gland with giving off the lingual artery and the facial artery anteriorly, the occipital artery, the ascending pharyngeal artery, and the posterior auricular artery posterosuperiorly. After it penetrates the parotid gland, it bifurcates into two terminal branches of the superficial temporal artery and the maxillary artery at the level of mandibular neck (Figs.  1.1 and 1.2). Branches of the ECA are delivered from the remnants of the embryological arteries including the 1st and the 2nd aortic arch (communicating between the ventral and dorsal aorta) and carotid-vertebrobasilar anastomoses (communicating between the dorsal aorta and the vertebral/basilar artery) [1– 3]. Therefore, various potential anastomoses exist between the ECA and the internal carotid artery or vertebrobasilar artery. Six paired aortic arches are formed between the ventral aorta and dorsal aorta in the six pharyngeal arches at early embryo. These aortic arches are formed in order from cranial to caudal, and the 1st and 2nd aortic arch becomes arterial plexus and then regressed. The dorsal aorta cranial to the third aortic arch becomes the internal carotid artery. The remnants

of ventral parts of arterial plexus from the 1st and the 2nd aortic arch form some of the branches of the ECA (Fig. 1.3). The proximal portion of the second arch forms the ventral pharyngeal artery further becoming the trunk of the facial and lingual artery. Carotid-vertebrobasilar anastomoses is another important communication in embryo, which exist between the dorsal aorta and the vertebra-basilar artery. Carotidvertebrobasilar anastomoses include primitive trigeminal artery, primitive otic artery, primitive hypoglossal artery, and the 1st and 2nd proatlantal arteries. The carotid-vertebrobasilar anastomoses regress and disappear according to the development of vertebrobasilar arterial system except for case of rare anatomical variant. The ascending pharyngeal artery and the occipital artery are partially formed from the primitive hypoglossal artery and the proatlantal artery, respectively. The middle meningeal artery and the maxillary artery are formed from ventral part of the remnant arterial plexus of the 1st and 2nd aortic arch which connect with the hyoid artery (dorsal stem of the remnant second aortic arch) via a transient embryologic artery called the stapedial artery. The stapedial artery runs through the stapes in the tympanic cavity and is divided into two terminal branches of supraorbital division and maxillomandibular division. The former becomes the middle meningeal artery and the later becomes the maxillary artery. The stapedial artery regresses and disappears according to the development of the stem of the ECA, and the residual parts of the stapedial artery becomes small branches the ECA distribute the tympanic cavity. As described above, the ECA is formed by various process of the regression of the 1st and 2nd aortic arch and the arterial plexus, embryological anastomoses, and formation of newly developed arterial routes, and therefore, various potential anastomoses and several anatomical variations can exist.

H. Kiyosue (*) Department of Radiology, Oita University Hospital, Oita, Japan e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 H. Kiyosue (ed.), External Carotid Artery, https://doi.org/10.1007/978-981-15-4786-7_1

1

2 Fig. 1.1  Schematic drawing of the external carotid artery and its major branches. SThA, superior thyroid artery; ICA, internal carotid artery; ECA, external carotid artery; LA, lingual artery; Facial A, facial artery; APA, ascending pharyngeal artery; APalA, ascending palatine artery; OA, occipital artery; PAA, posterior auricular artery; STA, superficial temporal artery; TFA, transverse facial artery; MMA, middle meningeal artery; AMA, accessory meningeal artery; IDA, inferior dental artery; MDTA, middle deep temporal artery; Max, maxillary artery; ADTA, anterior deep temporal artery; DPA, deep palatine artery; PSDA, posterior superior dental artery; IOA, inferior orbital artery; SPA, sphenopalatine artery; 1, artery of superior orbital fissure; 2, artery of foramen rotundum; 3, artery of pterygoid canal (vidian artery); 4, pharyngeal artery (pterygovaginal artery)

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1  External Carotid Artery

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Fig. 1.2  Angiographic images of the right external carotid artery in a case of occlusion of the right internal carotid artery. Right lateral view (a) and left lateral view (b) of the 3D VR images and, and right anterior oblique view (c) of the common carotid angiography. SThA, superior thyroid artery; ICA, internal carotid artery; ECA, external carotid artery; LA, lingual artery; Facial A, facial artery; APA, ascending pharyngeal artery; APalA, ascending palatine artery; OA, occipital artery; PAA, posterior auricular artery; STA, superficial temporal artery; TFA,

transverse facial artery; MMA, middle meningeal artery; AMA, accessory meningeal artery; IDA, inferior dental artery; MDTA, middle deep temporal artery; Max, maxillary artery; ADTA, anterior deep temporal artery; DPA, deep palatine artery; LPA, lesser palatine artery; GPA, greater palatine artery; PSDA, posterior superior dental artery; IOA, inferior orbital artery; SPA, sphenopalatine artery; MMA-OA, anastomosis between the anterior branch of the middle meningeal artery and the ophthalmic artery

4

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Fig. 1.3  Embryonic development of external carotid artery. Schematic drawing of (a) CRL 4 mm, (b) CRL 9 mm, and (c) CRL 18 mm embryo (d) after birth. (a) DorA, dorsal aorta; 1st, first aortic arch; 2nd, second aortic arch; 3rd, third aortic arch; 4th, forth aortic arch; 6th, 6th aortic arch; C1, 1st cervical spinal nerve; VentA ventral aorta; PMaxA, primitive maxillary artery; POlfA, primitive olfactory artery; OpV, optic vesicle; Cranial div, cranial division; Caudal div, caudal division; V-XII,5th–12th cranial nerves; OtV, otic vesicle; PTA, primitive trigeminal artery; POA, primitive otic artery; PHA, primitive hypoglossal artery; PPA. Primitive proatlantal artery. (b) DA, dorsal aorta; 1st, first aortic arch; 2nd, second aortic arch; 3rd, third aortic arch; 4th, forth aortic arch; C1, 1st cervical spinal nerve; PMaxA, primitive maxillary artery; POlfA, primitive olfactory artery; OpV, optic vesicle; Cranial div, cranial division; Caudal div, caudal division; V,XI, XII,5th, 11th, 12th cranial nerves; OtV, otic vesicle; PTA, primitive trigeminal artery; PHA, primitive hypoglossal artery; PPA.  Primitive proatlantal artery; VPA, ventral pharyngeal artery; PManA, primitive mandibular artery; BA, basilar artery; hyoid a, hyoid artery; VA, vertebral artery; SCA, subclavian artery. (c) MHT, meningohypophyseal trunk; V, 5th cranial

ICA

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nerve; PPA, primitive proatlantal artery; ASA, anterior spinal artery; VPA, ventral pharyngeal artery; PManA, primitive mandibular artery; BA, basilar artery; hypod a, hypoid artery; VA, vertebral artery; CCA, common carotid artery; ECA, external carotid artery; ICA, internal carotid artery; OA, occipital artery; APA, ascending pharyngeal artery; hyoid a, hyoid artery; staped a, stapedial artery; Mand. Div, mandibular division; SupOrbit div, supraorbital division; DOPA, dorsal ophthalmic artery; VOPA, ventral ophthalmic artery; PcomA, posterior communicating artery; SCA, subclavian artery. (d) MHT, meningohypophyseal trunk; V, 5th cranial nerve; C1, 1st cervical spinal nerve; VidA, vidian artery; APC; artery of pterygoid canal; BA, basilar artery; SCA, subclavian artery; VA, vertebral artery; CCA, common carotid artery; ECA, external carotid artery; ICA, internal carotid artery; OA, occipital artery; APA, ascending pharyngeal artery; CTA (hyoid a), caroticotympanic artery (hyoid artery); SthA, superior thyroid artery; LA, lingual artery; Facial A, facial artery; APA, ascending pharyngeal artery; OA, occipital artery; STA, superficial temporal artery; Max, maxillary artery; IDA, inferior dental artery; MMA, middle meningeal artery; PB, petrosal branch of middle meningeal artery; SCA, subclavian artery

1  External Carotid Artery

References 1. Paget DH.  The development of the cranial arteries in the human embryo. Contrib Embryol. 1948;32:205–61.

5 2. Lasjaunias P, Berenstein A, Ter Brugge KG. Surgical neuroangiography. In: Clinical vascular anatomy and variations, vol. 1. 2nd ed. Berlin: Springer; 2001. p. 15–87. 3. Hiruma T, Nakajima Y, Nakamura H. Development of pharyngeal arch arteries in early mouse embryo. J Anat. 2002;201:15–29.

2

Anterior (Visceral) Branches from the Proximal ECA (Superior Thyroidal, Lingual, and Facial Arterial System) Hiro Kiyosue

The superior thyroidal artery, lingual artery, and the facial artery supply the musculocutaneous tissue, visceral organs including buccal mucosa, oral cavity, oropharynx, hypopharynx and larynx, salivary glands, and thyroid glands at the upper cervical and facial level. These arteries anastomose each other via their branches, and often originate from the common trunk.

2.1  Superior Thyroidal Artery The superior thyroidal artery is the first branch of the ECA (Figs. 2.1 and 2.2). It originates anteriorly at the origin of the ECA, and then turn downward with acute curvature. It occasionally originates from the common carotid artery (approximately 20%), and rarely originates from common trunk with the lingual artery (approximately 3%) (Fig. 2.3) [1–2]. The superior thyroidal artery descends along the lateral wall of the larynx to the thyroid gland, and it bifurcates into the anterior and posterior branches supplying the thyroid glands.

2.1.1 Branches of the Superior Thyroidal Artery (Figs. 2.1, 2.2, 2.4, 2.5, and 2.6) 2.1.1.1 Infrahyoid Branch The infrahyoid branch originates at the level below the hyoid bone, and runs along the inferior surface of the hyoid bone. It supplies the hyoid bone and adjacent muscles, and has anastomoses with contralateral counterpart. 2.1.1.2 Sternocleidomastoid Branch The sternocleidomastoid artery runs inferolaterally along the sternocleidomastoid muscle, and it supplies the inferior half

of the muscle and adjacent musculocutaneous tissue. It rarely originates independently from the ECA.

2.1.1.3 Superior Laryngeal Artery The superior laryngeal artery originates anteromedially from the superior thyroidal artery. It penetrates the thyrohyoid ligament to the larynx, and then it bifurcates into ascending and descending branches. The ascending branch distributes to the epiglottis and anastomoses with lingual artery. The descending branch further divides into anterior and posterior branches after giving off a branch to the vestibular fold. The anterior branch supplies vocal cord and laryngeal mucosa, and anastomoses with the anterior branch or cricothyroid branch of the superior thyroidal artery. The posterior branch distributes to the thyroepiglottic, thyroarytenoid, and lateral cricoarytenoid muscles and adjacent mucosa [3]. The superior laryngeal artery may originate from the ECA, the ascending pharyngeal artery, or the lingual artery (Fig. 2.3). 2.1.1.4 Cricothyroid Branch The cricothyroid branch runs medially under the sternothyroid muscle, and supplies the cricothyroid muscle and larynx. It has anastomosis with the contralateral counterpart (Fig. 2.4). 2.1.1.5 Anterior and Posterior Branch (Figs. 2.4 and 2.5) The anterior and the posterior branches are the terminal branches, which originates above the thyroid gland and supplies the superior portion of the gland. The anterior branch anastomoses with the contralateral anterior branch (Fig. 2.6a), and posterior branch anastomoses with the inferior thyroidal artery (Fig. 2.6b).

H. Kiyosue (*) Department of Radiology, Oita University Hospital, Oita, Japan e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 H. Kiyosue (ed.), External Carotid Artery, https://doi.org/10.1007/978-981-15-4786-7_2

7

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Fig. 2.1  Angiographical anatomy of the proximal branches of the external carotid artery in a case of severe stenosis of the internal carotid artery at the proximal portion (∗) frontal (a) and lateral (b) images of 2DDSA, lateral view of 3DVR image (c), and Sagittal (d) and axial (e) images of MPR images. SPA, sphenopalatine artery; DPA, descending palatine artery; MMA, middle meningeal artery; IOA inferior orbital artery; STA, superficial temporal artery; APA, ascending pharyngeal artery; Max, maxillary artery, TFA, transverse facial artery; DMBs,

d1 descending muscular branches; ApalA, ascending palatine artery; Facial A, facial artery; OA, occipital artery; DLA, deep lingual artery; LA, lingual artery; SubMA, submental artery; GB, granular branch; SLA superior laryngeal artery; SthA, superior thyroidal artery; IHB infrahyoid branch; Ascend B, ascending branch; Descend B, descending branch; SCMB, sternocleidomastoid branch; CTB, cricothyroidal branch; Ant B, anterior branch; Post B, posterior branch; ∗, stenosis of the internal carotid artery

2  Anterior (Visceral) Branches from the Proximal ECA (Superior Thyroidal, Lingual, and Facial Arterial System)

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2  Anterior (Visceral) Branches from the Proximal ECA (Superior Thyroidal, Lingual, and Facial Arterial System)

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2  Anterior (Visceral) Branches from the Proximal ECA (Superior Thyroidal, Lingual, and Facial Arterial System)

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2  Anterior (Visceral) Branches from the Proximal ECA (Superior Thyroidal, Lingual, and Facial Arterial System)

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2  Anterior (Visceral) Branches from the Proximal ECA (Superior Thyroidal, Lingual, and Facial Arterial System)

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2  Anterior (Visceral) Branches from the Proximal ECA (Superior Thyroidal, Lingual, and Facial Arterial System)

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bone, passing deeply to the hyoglossus muscle, and then it becomes the deep lingual artery after giving off the sublingual artery.

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e33 Fig. 2.1 (continued)

2.1.1.6 Prevertebral Branch Although there is no description in literatures, a small branch often originates from proximal portion of the superior thyroid artery to be distributed prevertebral space. It runs ­transversely across the prevertebral space and anastomoses with the contralateral branch of the superior thyroid artery.

2.2  Lingual Artery (Figs. 2.1, 2.2, 2.7, and 2.8) The lingual artery is the second branch of the ECA, which originates anteromedially from the ECA just below the origin of the facial artery. It supplies the ipsilateral side of the tongue, buccal and oral mucosa. The lingual artery and facial artery are derived together from the ventral pharyngeal artery which is a remnant of the ventral part of the second aortic arch, and therefore, it often originates from a common trunk with the facial artery (Fig.  2.2). It rarely originates from a common trunk of lingual–superior thyroidal artery or lingual–facial–superior thyroidal artery (Fig. 2.3). The lingual artery runs anterosuperiorly to the greater horn of the hyoid bone. It turns inferiorly, and then anteriorly, forming a loop crossed by the hypoglossal nerve. It runs horizontally forward along the greater horn of the hyoid

2.2.1.1 Pharyngeal Branch The lingual artery gives off pharyngeal branch at the proximal portion. The pharyngeal branch supplies the middle constrictor muscles and tonsil, which has potential anastomosis with the ascending palatine artery and ascending pharyngeal artery. 2.2.1.2 Superior Hyoidal Branch The superior hyoidal branch arises at the descending portion of the lingual artery, and it runs anteroinferiorly along the hyoid bone to supply the adjacent muscles. It has anastomoses with the contralateral counterpart and the superior thyroidal artery. 2.2.1.3 Dorsal Lingual Branch A few dorsal lingual branches originate at the horizontal portion of the lingual artery, which ascends to supply the base of tong, tonsil, and epiglottis. The dorsal lingual branches often originate from common trunk. 2.2.1.4 Sublingual Artery The sublingual artery arises at the anterior border of the hyoglossus muscle, and it runs anterolaterally between the genioglossus muscle and mylohyoid muscle in the sublingual region. It arises from the facial artery in 25% of cases. It gives off branches supplying sublingual glands, mucosa, and muscles of the floor of the mouth, submandibular gland, and mandible, and then it divides into two terminal branches of mandibular branch and submental branch. The mandibular branch runs anteromedially to supply medial part of mandible, mucosa of floor of mouth, and gingiva. It anastomoses with the deep lingual artery and the inferior dental artery. The submental branch runs anteroinferiorly to supply suprahyoid muscles, and anastomoses with the submental artery arising from the facial artery. 2.2.1.5 Deep Lingual Artery The deep lingual artery is the terminal branch of the lingual artery, which gives off numerous small branches supplying the tongue. Majority of these branches originate upward from the deep lingual artery and anastomose each other to form arterial network in the submucosal space of the tongue.

2  Anterior (Visceral) Branches from the Proximal ECA (Superior Thyroidal, Lingual, and Facial Arterial System)

DLA

APalA Facial A

APA

GB

APA

SubLA

Facial A

SLA

Ascend B Descend B

*SCMB

SThA

Ascend B Descend B

SLA SThA

Lingual A

IHB

LA Ant B

ICA

IHB

SubMA

ICA

Lingual A

FLT DLBs

OA

21

SCMB

* Post B

CTB

CTB

Post B Post B And B

And B

a

APalA

b

APalA ECA

ICA

ICA

Facial A GB

Facial A GB

SCMB

SCMB

c1 Fig. 2.2  Angiographic anatomy of the superior thyroid artery and facial lingual artery in a case of left internal carotid artery stenosis. Frontal (a), lateral (b) views and sagittal MPR images (c) of the left common carotid angiography. Note the facial and lingual arteries originate by a common trunk (facial–lingual trunk: FLT). APA, ascending pharyngeal artery; Facial A, facial artery; OA, occipital artery; ICA,

c2 internal carotid artery; Lingial A, lingual artery; SthA, superior thyroidal artery; IHB, infrahyoid branch; SLA, superior laryngeal artery; SCMB, sternocleidomastoid muscle, Ascend B, ascending branch; Descend B. descending branch; CTB, cricothyroid branch; Ant B, anterior branch; Post B, posterior branch; ∗, stenosis of the internal carotid artery

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H. Kiyosue

APal A

APal A Facial A

Facial A APA

APA ECA

Lingual A

ICA

IHB SLA

Lingual A

SThA

ECA FLT

FLT

GB

SCMB

SThA

SCMB

CTB

Post B

Ant B

Post B

c3

c4

APalA Facial A

DLBs Lingual A

APA Lingual A

ECA FLT

FLT

IHB

Hyoid bone

Hyoid bone

SLA

SLA

SThA Post B

CTB

CTB

Ant B

Ant B

c5 Fig. 2.2 (continued)

c6

2  Anterior (Visceral) Branches from the Proximal ECA (Superior Thyroidal, Lingual, and Facial Arterial System)

23

DLA

DLA

DLBs

DLBs Lingual A SubLA

SubLA

Ascend B

Ascend B Post B

Hyoid bone

Post B

Hyoid bone ANt B

ANt B

CTB

CTB Ant B

c8

c7 Fig. 2.2 (continued)

2.3  Facial Artery (Figs. 2.1, 2.8, 2.9, and 2.10)

APalA Facial A

CT

LA

SLA

SThA

The facial artery originates at the anterior aspect of ECA slightly above the origin of the lingual artery, and it supplies musculocutaneous tissue of the face and mandible, and submandibular gland. It often forms common trunk with the lingual artery. It runs anterosuperiorly, and turns inferiorly with forming concavity and descends in the parapharyngeal space to reach submandibular gland. Then, it runs anterolaterally with crossing the deep surface of the submandibular gland. After giving off the submental artery, it runs anterosuperiorly by crossing the mandible just in front of masseter muscle, and gives of branches to the muscle, chin, lips, and face. In the half of cases, the facial artery terminates at the level of ala of the nose with giving of superior labial artery and/or ala artery. In the remaining half, it becomes the angular artery, which runs upward in the naso-labial fold to reach the angle of eye.

2.3.1 Branches of the Facial Artery Fig. 2.3  Variation of the origin of the superior thyroidal artery and the superior laryngeal artery in a case of cervical lymph node metastasis. Lateral view of the left common carotid angiography shows the superior thyroidal artery (SThA) originates by a common trunk (CT) with the lingual artery (LA). The superior laryngeal artery (SLA) originates from the lingual artery. Facial A: facial artery, APalA: ascending palatine artery

2.3.1.1 Ascending Palatine Artery The ascending palatine artery arises superiorly on the uppermost portion of the convex part of the facial artery. It may arise independently from the ECA, the ascending pharyngeal artery, or the lingual artery (Figs. 2.8 and 4.1). It runs upward between the styloglossus and stylopharyngeus muscles with

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PVB SLA Ascend B

PVB

Ascend B

SLA

Descend B SCMB

Descend B CTB

SCMB CTB

Ant B

Post B

Ant B

a

Post B

b

Fig. 2.4  Branches of the superior thyroidal artery. Frontal view (a) and lateral view (b) of selective angiography of the left superior thyroidal artery Note the cricothyroid branch anastomoses with the contralateral counterpart across the midline. PVB, prevertebral branch; SLA, supe-

rior laryngeal artery; SCMB, sternocleidomastoid branch, Ascend B, ascending branch; Descend B. descending branch; CTB, cricothyroid branch; Ant B, anterior branch; Post B, posterior branch

giving off branches to tonsil (Fig. 2.9). It reaches soft palate, and then runs anteriorly to supply soft palate or superiorly to supply the auditory tube [4–5]. It anastomoses with pharyngeal or palatine branch of the ascending pharyngeal artery, the descending palatine artery, the accessory meningeal artery, and its contralateral counterpart (Fig. 2.11). Injury of the ascending palatine artery during tonsillectomy can cause massive bleeding.

2.3.1.4 Submental Artery The submental artery is the third major branch which originates at the submandibular portion of the facial artery. It runs anteriorly upon the mylohyoid muscle and give off branches to the neighboring musculocutaneous tissue, submandibular gland, and mandible (Fig. 2.10). It anastomoses with the submental branches of the lingual artery, and the inferior dental artery at the mental foramen.

2.3.1.2 Tonsillar Branch The tonsillar branch originates at the proximal descending portion of the facial artery, and it ascends between the internal pterygoid muscle and styloglossus muscle. It runs anteromedially to supply the palatine tonsil and root of tongue. It can be a source of bleeding after tonsillectomy when it is injured.

2.3.1.5 Masseter Branches and Buccal Branches A few masseter branches and buccal branches originate superiorly from the facial artery after giving off the glandular branch. Masseter branches run along the anterior surface of the masseter muscle and supply it and neighboring skin. It anastomoses with the transverse facial artery. Buccal branches supplies mucosa of the cheek and it anastomoses with the buccal artery originating from the maxillary artery.

2.3.1.3 Glandular Branches A large glandular branch originates inferiorly at the submandibular portion of the facial artery, and small glandular branches originate posteroinferiorly from submental portion of the facial artery or submental artery. These branches ­supply the submandibular gland and adjacent lymph nodes and neighboring muscles.

2.3.1.6 Inferior and Superior Labial Arteries The facial portion of the facial artery gives off the inferior labial artery and then the superior labial artery to lips. The inferior labial artery originates anterosuperiorly from the facial artery below the angle of the mouth, and it runs along

2  Anterior (Visceral) Branches from the Proximal ECA (Superior Thyroidal, Lingual, and Facial Arterial System)

25

CTB CTB

a

b

Superior laryngeal a Infrahyoid a

c1

c2

Thyrohyoid membrane

Inferior laryngeal a

c3 Fig. 2.5  Imaging anatomy of superior thyroidal artery in case with laryngeal cancer. (a, b) Frontal (a) and lateral (b) views of selective left lingual arteriogram show branches of the superior thyroidal artery. Superior laryngeal artery (arrows) originates from proximal segment of superior thyroidal artery to reach laryngeal wall. Anterior (black arrowheads) and posterior (white arrowheads) branches are terminal branches to supply thyroid gland. In this case, a well-developed superior laryn-

c4

Glandular branch (anterior/posterior)

d

geal artery gives off cricothyroid branch (CTB). (c) Axial MPR images of superior thyroidal arteriogram show superior laryngeal artery (white arrowheads) originating from superior thyroidal artery to reach larynx with penetrating thyrohyoid membrane. Right glottic cancer (black arrowheads) is supplied by superior laryngeal artery. (d) Origins and course of superior thyroidal artery branches are demonstrated on schematic drawing

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H. Kiyosue

Ascend B SLA

Descend B CTB SCMB

Ant B

Post B

a

b

Fig. 2.6  Contralateral (a) and caudocranial (b) anastomoses of the superior thyroidal artery in a case of occlusion of the right superior thyroidal artery due to radiation injury. (a) Thyroidal branches of the right superior thyroidal artery are opacified via an anastomosis between the anterior branches (Ant B). Right superior laryngeal artery is also

supplied via an anastomosis (white arrows) between the ascending branches (Ascend B) of the superior laryngeal arteries (SLA). Descending B, descending branch; CTB, cricothyroid branch; Post B, posterior branch; SCMB, sternocleidomastoid branch

the edge of the lower lip. The superior labial artery runs along the edge of the upper lip. Both arteries supply the labial glands, the mucous membrane, and the neighboring muscles, and anastomoses with their contralateral counter parts at midline. The inferior labial artery has potential anastomosis with the inferior dental artery. The superior labial gives off small branches to the nasal septum and the ala of the nose. The inferior and superior labial artery occasionally originate from a common trunk.

There are some variations in branching pattern of the facial artery in this area. The facial artery occasionally terminates as the lateral nasal artery (approximately 12%). The facial artery terminates as the angular artery and the lateral nasal artery originates from the superior labial artery in 25% of case [6]. The lateral nasal artery gives off branches to the ala and dorsum of the nose, and anastomoses with the dorsal nasal branches of the ophthalmic artery, contralateral counterpart across the midline.

2.3.1.7 Lateral Nasal Artery After giving off the superior labial artery, the facial artery becomes the lateral nasal artery which runs superiorly along the side of nose and terminates as the angular artery.

2.3.1.8 Angular Artery (Fig. 2.10) The angular artery is the terminal branch of the facial artery, which runs along the nasojugal fold and it gives off the medial palpebral artery supplying eye lids and forming pal-

2  Anterior (Visceral) Branches from the Proximal ECA (Superior Thyroidal, Lingual, and Facial Arterial System)

a

27

b

c Fig. 2.7  Imaging anatomy of lingual artery in case with maxillary cancer. (a, b) Selective left lingual arteriogram (a, frontal view; b, left lateral view) shows course of lingual artery. This artery originates from distal segment of origin of superior thyroid artery and runs anteromedially. Descending suprahyoid branch (white arrowheads) and sublingual artery (black arrowheads) were given off from lingual artery. Deep lin-

gual artery (arrows) is a terminal branch of lingual artery having numerous small branches supplying tongue. (c) Sagittal section of partial MIP from fusion images of selective lingual arteriogram and cone beam CT.  This image clearly shows lingual artery giving off descending suprahyoid artery (white arrowheads), sublingual artery (black arrowheads), and deep lingual artery (arrow)

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H. Kiyosue

APalA DLA APalA

PhBs DorsLB

DLA SubLA

MandB

MandB SubMB SubMB

SHB

SubLA

a

SHB

b

LNA

LNA SLabA

MBs

SLabA

TB

BB BB

ILabA

ILabA SubMA

c

Fig. 2.8  Angiographic anatomy of the lingual artery and the facial artery in a case of maxillary cancer. Frontal (a) and lateral (b) views of selective lingual angiography. Frontal (c) and lateral (d) views of selective facial angiography. Axial (e) and Sagittal (f) MPR images of selective 3D angiography of facial artery. Note the uncommon origin of the

SubMA

d

ascending palatine artery (APalA) originating from the proximal portion of the lingual artery. APalA, ascending palatine artery; PhBs, pharyngeal branches; DorsLA, dorsal lingual artery; SHB, suprahyoidal branch; SubLA, sublingual artery; MandB, mandibular branch; SubMB, submandibular branch; DLA, dorsal lingual artery

2  Anterior (Visceral) Branches from the Proximal ECA (Superior Thyroidal, Lingual, and Facial Arterial System)

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GB

GB SubMA

GB

SubMA

GB

e1

e2

ILabA

BB

BB MB

MB

e3 Fig. 2.8 (continued)

e4

30

H. Kiyosue SLabAB

SLabAB LNA

LNA

BB

BB

MB

e5

e6

ILabA

BB BB

MB

MB

e7 Fig. 2.8 (continued)

e8

2  Anterior (Visceral) Branches from the Proximal ECA (Superior Thyroidal, Lingual, and Facial Arterial System)

31

LNA

BBs

BB

SLabA MB

ILabA SubMA

e9

LNA

f1

LNA BBs

BBs

MB

ILabA

ILabA SubMA

Fig. 2.8 (continued)

f2

SubMA

f3

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H. Kiyosue

BB

BBs

MB

MB

MB SubMA

SubMA ILabA

f4

ILabA

f5

GB

BB

BB MB MB

MB BB

ILabA

Fig. 2.8 (continued)

GB

f6

GB

f7

2  Anterior (Visceral) Branches from the Proximal ECA (Superior Thyroidal, Lingual, and Facial Arterial System)

33

pebral arcade with lateral palpebral artery from the lachrymal artery. It also gives off several small branches to upper third of nose and neighboring skin. It often originates from the ophthalmic artery (more than 50%), and it may originate from the infraorbital artery [7]. The angular artery has anastomoses with the ophthalmic artery, contralateral counterparts, lateral nasal artery medially, and infraorbital artery laterally. The facial artery gives off small branches to the mental region, cheek, and face during its course, and anastomoses with other branches of the ECA supplying these areas via these branches.

BB MB

BB

f8 Fig. 2.8 (continued)

c

a Fig. 2.9  Imaging anatomy of facial artery in case with maxillary cancer. (a, b) Selective left facial arteriogram (a, frontal view; b, left lateral view) shows course of facial artery. This artery originates from the external carotid artery above the origin of lingual artery. It runs anteroinferiorly with giving off submandibular branch (white arrowheads). Note the ascending palatine artery (black arrowheads) and submental

b branch (arrows) arising from proximal segment of facial artery. After turning anterosuperiorly, it runs with feeding cheek and lip to reach canthus. (c) Coronal section of partial MIP from fusion images of selective facial arteriogram and cone beam CT. This section shows ascending palatine artery arising from proximal segment of facial artery and supplying lateral wall of oral cavity and soft palate (arrowheads)

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c Fig. 2.9 (continued)

STA-FA STA-FA

PB OPA

AA

FB OPA

FB

PB

ASOF AA ADTA

ASOF STA

IOA

ADTA

STA

LNA LNA

a

Fig. 2.10  Anastomosis of the periorbital arteries in a case of the left internal carotid artery occlusion. Frontal (a) and lateral (b) views and coronal MPR images (c) of left common carotid angiography Facial artery ascends to become the lateral nasal artery (LNA) and then the angular artery which runs medially to the eyelid and anastomoses with the terminal branch (dorsal nasal artery) of the ophthalmic artery (OPA). The ophthalmic artery anastomoses with the frontal branch (FB) of the superficial temporal artery (STA) via the other terminal branch

b (frontal artery: FA). The anterior deep temporal artery anastomoses with the lacrimal artery (Lac) via the lateral orbital wall. The infraorbital artery anastomoses with the medial muscular branches (MM) of the ophthalmic artery in orbit and with the superficial temporal artery at periorbita. The artery of superior orbital fissure (ASOF) also anastomose with the ophthalmic artery inferiorly. PB, parietal branch of the superficial temporal artery

2  Anterior (Visceral) Branches from the Proximal ECA (Superior Thyroidal, Lingual, and Facial Arterial System)

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STA

STA-FA

AA MM

IOA

IOA

STA LacA

MMA

ADTA

ASOF

c Fig. 2.10 (continued)

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References PA DPA

GPA

LPA

APalA

Fig. 2.11  Selective angiography of the ascending palatine artery. The ascending palatine artery anastomoses with the greater palatine artery (GPA) (arrowheads) and the pharyngeal artery (PA) (white arrowheads). LPA, lesser palatine artery (LPA); DPA, descending palatine artery (DPA)

1. Sanjeev IK, Anita H, Ashiwini M, Mahesh U, Rairam GB. Branching pattern of external carotid artery in human cadaver. J Clin Diagn Res. 2010;4:3128–33. 2. Shintani S, Terakado N, Alcalde RE, et al. An anatomical study of the arteries for intraarterial chemotherapy of head and neck cancer. Int J Clin Oncol. 1999;4:327–30. 3. Imanishi N, Kondo T, Kishi K, Aiso S. Angiographic study of the superior laryngeal artery. Okajimas Folia Anat Jpn. 2009;86:61–5. 4. Cho JH, Kim JW, Park HW, Suh JD, Kim JK, Yoon JH. Arterial supply of the human soft palate. Surg Radiol Anat. 2017;39(7):731–4. 5. Kashiwagi N, Nakanishi K, Kozuka T, et al. Vascular supply with angio-CT for superselective intra-arterial chemotherapy in advanced maxillary sinus cancer. Br J Radiol. 2010;83(986):171–8. 6. Lombardo G, Tamburino S, Tracia L, Tarico MS, Perrotta RE. Lateral nasal artery perforator flaps: anatomic study and clinical applications. Arch Plast Surg. 2016;43:77–83. 7. Hou D, Fang L, Zhao Z, Zhou C, Yang M. Angular vessels as a new vascular pedicle of an island nasal chondromucosal flap: anatomical study and clinical application. Exp Ther Med. 2013;5:751–6.

3

Posterior (Neural) Branches from the Proximal ECA Hiro Kiyosue and Yuji Matsumaru

3.1

 ccipital and Ascending Pharyngeal O Arterial System

Cerebral arteries are developed from the primitive carotid artery derived from brachial arch and longitudinal neural artery (future vertebrobasilar artery) derived from segmental arteries. In embryonic periods, the longitudinal neural artery is supplied by the carotid-vertebrobasilar anastomoses (homologue of the segmental arteries in spinal arterial system). The ascending pharyngeal artery and the occipital artery are derived from remnant of the carotid-­vertebrobasilar anastomoses of the primitive hypoglossal artery and the pro-­ atlantal artery [1–2]. Therefore, the both arteries give off branches supply cranial nerves, and they have potential anastomoses with the vertebral arterial system (Fig.  3.1). The longitudinally adjacent segmental arteries in the spinal level have anastomoses via paravertebral, epidural, and dural branches. Similarly, the ascending pharyngeal artery has anastomoses with anterior meningeal artery from the vertebral artery, meningohypophyseal trunk (derived from the remnant of primitive trigeminal artery, a carotid-basilar anastomosis) of the internal carotid artery via the clival branches and the carotid branch. Because embolization from the ascending pharyngeal artery and the occipital artery has a potential risk of cranial nerve injury or cerebral infarction, knowledge of imaging anatomy of the two arteries is essential for safe procedure.

H. Kiyosue (*) Department of Radiology, Oita University Hospital, Oita, Japan e-mail: [email protected] Y. Matsumaru Department of Neurosurgery, Faculty of Medicine, Tsukuba University, Tsukuba, Japan e-mail: [email protected]

3.2

Occipital Artery

The occipital artery originates posterosuperiorly from the proximal portion of the ECA just below or above the origin of the ascending pharyngeal artery (Fig. 3.2a–c). It occasionally originates from a common trunk with the ascending pharyngeal artery (Fig. 3.2d), and more rarely from the vertebral artery, the deep cervical artery, or the posterior auricular artery. It runs posterosuperiorly to reach the occipital glove of the temporal bone (first segment), and then runs horizontally to the superior nuchal line (second segment), and then ascend at the distal occipital region (third segment) (Figs. 3.3 and 3.4) [3]. It mainly supplies the musculocutaneous tissue and bone.

3.2.1 Branches of the Occipital Artery 3.2.1.1 Sternocleidomastoid Branches (Figs. 2.1, 3.3, and 3.4) The upper and lower sternocleidomastoid branches originate from proximal portion of the occipital artery, and they supply upper third of sternocleidomastoid muscle and neighboring skin. The lower branch runs anteroinferiorly to enter the sternocleidomastoid muscle, and the upper sternocleidomastoid branch runs in company with the accessory nerve to enter the deep surface of the sternocleidomastoid muscle. 3.2.1.2 Stylomastoid Artery The stylomastoid artery arises from the first segment of the occipital artery, and it runs vertically upward to enter the stylomastoid foramen together with the facial nerve (Fig. 3.5). It enters the tympanic cavity and anastomoses with the superior tympanic artery (a petrosal branch of the middle meningeal artery) to form the facial nerve arterial arch (Fig. 3.6). It also has potential anastomoses with the inferior tympanic artery (a branch of the ascending pharyngeal artery), caroticotympanic artery (a branch of the internal carotid artery), and arcuate artery (a branch of the anterior inferior cerebellar

© Springer Nature Singapore Pte Ltd. 2020 H. Kiyosue (ed.), External Carotid Artery, https://doi.org/10.1007/978-981-15-4786-7_3

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H. Kiyosue and Y. Matsumaru MHT

SPS DCA MCB LCB JF

MMA

SS MB

VidA

APC

TS

CB

AccMA DPA

SPB MPB IPB

JB

SSB

JB

PMA

HC HB MuB

APalA

DMB IJV AMA

APA

FA

VA

OA Lingual A

ECA

ICA

SThA

Fig. 3.1  Schematic drawing of the major branches of the occipital artery and the ascending pharyngeal artery and their potential anastomoses. APA, ascending pharyngeal artery; MuB, muscular branch; IPB, inferior pharyngeal branch; MPB, middle pharyngeal branch; SPB, superior pharyngeal branch; CB, carotid branch; HB, hypoglossal branch; HC, hypoglossal canal; JF, jugular foramen; JB, jugular branch; MCB, medial clival branch; LCB, lateral clival branch; DCA, dorsal clival artery; MHT meningohypophyseal trunk; SSB, sigmoid sinus branch; PMA, posterior meningeal artery; OA, occipital artery; DMB, descending muscular branch; MB, mastoid branch; ECA, external carotid artery; ICA, internal carotid artery; FA, facial artery; APalA, ascending palatine artery; DPA, descending palatine artery; APC, artery of pterygoid canal; VidA, vidian artery; AccMA, accessory meningeal artery; MMA, middle meningeal artery; Lingual A, lingual artery; SthA, superior thyroidal artery; IJV internal jugular vein; SS, sigmoid sinus; SPS, superior petrosal sinus; TS, transverse sinus

artery). It supplies tympanic antrum, mastoid cells, the semicircular canal, and facial nerve [4]. It often arises from the posterior auricular artery (Fig. 2.1).

3.2.1.3 Jugular Branch (Meningeal Branch) The jugular branch originates at the first segment of the occipital artery, and it runs superomedially along the internal jugular vein to jugular foramen and into the posterior condylar canal (Figs. 3.4 and 3.7). It supplies the dura mater of the posterior cranial fossa, and may supply the vasa nervorum of cranial nerves IX, X, and XI. 3.2.1.4 Descending Muscular Branch Superficial and deep descending branches arises from the second segment, and it runs inferiorly to supply the splenius muscle, and dura matter and cranial nerve at the suboccipital cavernous sinus (Figs. 3.3 and 3.4). The descending muscular branch anastomoses with the muscular branch of the vertebral artery at C1–C2 level (Fig. 3.8).

3.2.1.5 Mastoid Branches Several mastoid branches arise from the second segment of the occipital artery, and they ascend to supply mastoid bone and skin. The largest one runs superiorly, and then it turns anteriorly to enter the cranial cavity through the mastoid foramen to supply the dulla matter of the posterior fossa (Figs. 2.10 and 3.1). It divides into three branches of descending, ascending, and posteromedial branches. The descending branches runs along the sigmoid sinus toward the jugular foramen and anastomoses with the meningeal branch (sigmoid sinus branch) of the jugular branch of the ascending pharyngeal artery. The ascending branches posterosuperiorly along the sigmoid sinus, and it anastomoses with the petrosquamosal branch and/or the posterior convexity branch of the middle meningeal artery. It also has potential anastomosis with the subarcuate branch of the anterior inferior cerebellar artery. The posteromedial branch runs inferomedially and anastomose with meningeal artery of the hypoglossal and jugular branches of the ascending pharyngeal or the jugular branch or the posterior meningeal artery of the vertebral artery. 3.2.1.6 Small Muscular Branches and Transosseous Branch The occipital artery gives off muscular branches supplying posterior cervical and occipital muscles including the digastric, stylohyoid, splenius, and longus capitis muscles, neighboring skin and bones. These branches have anastomoses with the muscular branches of the posterior auricular artery, superficial temporal artery, deep and ascending cervical arteries, and contralateral counterpart. Small osseous branches originate from distal portion of the occipital artery and supply temporooccipital bones. Some of them penetrate skull to enter cranial cavity and anastomose with meningeal branches. Those transosseous branches often supply dural arteriovenous fistulas and meningiomas (Figs. 3.3 and 3.7).

3.3

Ascending Pharyngeal Artery

The ascending pharyngeal artery is derived from the remnant of the primitive hypoglossal artery (segmental artery origin) and the remnant of the second aortic arch (brachial arch origin) as described before. It usually originates from posteromedial aspect of the proximal portion of the ECA just above or below the origin of the occipital artery. However, the origin of the ascending pharyngeal artery is variable. It can originate from carotid bifurcation, the internal carotid artery, or by the common trunk with the occipital artery or ascending palatine artery (Figs. 3.2 and 3.9). It ascends in parallel and medial to the internal carotid artery, and it gives off small muscular branches. And then, it divides into two major

3  Posterior (Neural) Branches from the Proximal ECA

39

PB NMT PB NMT APA OA OA

a

PB

NMT

APA

b

O OA APA A

OA APA A

c Fig. 3.2  Various origin of the occipital artery and the ascending pharyngeal artery. (a, b) The occipital artery (OA) originating just below the ascending pharyngeal artery (APA) in a case of dural arteriovenous fistulas of the transverse sigmoid sinus. (c) The occipital artery (OA)

d

originating above the origin of the ascending pharyngeal artery (APA) in a case of occlusion of the internal carotid artery. (d) The occipital artery originating by a common trunk with the ascending pharyngeal artery

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H. Kiyosue and Y. Matsumaru

TOB

PCB SAAA

3rd segment

Anast SAAA & PAA

MB 3rd segment

STA MB

nd

2 segment

STA

PAA

MMA

2nd segment DMBs

1st segment OA

PAA

1st segment

Max

a

OA

SCMB

b

Max

Max

MMA ECA

ECA

PAA OA 1st seg STA

PAA OA 1st seg STA

SCMB

SCMB

PB

DMB

DMB

c1 Fig. 3.3  Angiographic anatomy of the occipital artery and neighboring arteries. Frontal (a) and lateral (b) views of right external carotid angiography, and axial images of 3DDSA of the right external carotid artery in a case of transverse sinus dural arteriovenous fistulas. Max, maxillary artery; ECA, external carotid artery; PAA, posterior auricular artery; OA, occipital artery; STA, superficial temporal artery; SCMB, sternocleidomastoid muscle from the occipital artery; DMB, descending muscular branch from the occipital artery; PB, parotid branch; TFA, transverse facial artery; MMA, middle meningeal artery; AMA, acces-

c2 sory meningeal artery; ATA, anterior tympanic artery; SMA, stylomastoid artery from the posterior auricular artery; Pinna B, branch of posterior auricular artery to the pinna; PCB, posterior convexity branch; SAAA, superior anterior auricular artery; MB, mastoid branch; Anast PAA and SAAA, anastomosis between the posterior auricular and the superior anterior auricular artery; SSB, sigmoid sinus branch contiguous with the mastoid branch of the occipital artery; TOB, transosseous branch

3  Posterior (Neural) Branches from the Proximal ECA

Max MMA

41

AMA

MMA

STA ATA

PAA

TFA

PB

PAA

OA 1st seg

STA

OA 1st seg PAA

PB

DMB

DMB

c3

c4

MMA

MMA STA ATA PAA

PAA

SMA PAA

SMA

OA 2nd seg

OA 2nd seg

Pinna B DMB

c5 Fig. 3.3 (continued)

c6

42

H. Kiyosue and Y. Matsumaru

MMA PCB

PCB

SAAA PAA

PAA

Pinna B

OA 2nd seg

OA 2nd seg MB

c8

c7

SAAA

PCB SAAA

PCB

Anast PAA & SAAA PAA

MB

Pinna B

OA 2nd seg

MB

OA 3rd seg

c9 Fig. 3.3 (continued)

c10

3  Posterior (Neural) Branches from the Proximal ECA

43

PCB

PCB

SSB

SSB

OA 3rd seg

OA 3rd seg

c12

c11

PCB PCB

SSB TSB dAVF

TOB OA 3rd seg

OA 3rd seg

c13 Fig. 3.3 (continued)

TOB

c14

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H. Kiyosue and Y. Matsumaru

LTA from Post B(AMA)

PCB

PSB PostB PB PSB PCB

OA 3rd seg

MMA

LTA from Post B(AMA)

JB (APA)

JB (APA) PB LatB(SSB) MedB (PMA) MB

AMA

PostB

JB (OA)

MMA

OA 3rd seg

AMA

OA 2nd seg

Max

PAA

PAA

APA

SCMB

APalA

OA 1st seg

OA 1st seg

a

SCMB

TFA

OA 2nd seg DMB

MDTA Max

MDTA PhB

MMA

PAA

b

Max PhB

STA MMA NMT

NMT IJV

JB (OA)

JB (OA) PAA JB Lat B Med B (PMA)

OA 2nd seg

OA 2nd seg

c1 Fig. 3.4  Angiographic anatomy of the occipital artery and the ascending pharyngeal artery in a case of transverse sigmoid sinus dural arteriovenous fistulas. (a–e) Right external carotid angiography: Frontal (a) and lateral (b) views, and axial (c), coronal (d), and sagittal (e) MPR images. (f, g) Selective angiography of the occipital artery: Frontal (F) and lateral (G) views. (h, i) Selective angiography of the ascending pharyngeal artery: Frontal (H) and lateral (I) views. The jugular branch (JB) of the occipital artery (OA) and the ascending pharyngeal artery (APA) are clearly demonstrated. Note additional anatomical variations of deep course of the second segment of the maxillary artery (Max). The accessory meningeal artery (AMA) originates independently from

c2 the maxillary artery, and lateral tentorial artery (LTA) (superior branch of the inferolateral trunk) originates from the posterior branch of the accessory meningeal artery. OA, occipital artery; APA, ascending pharyngeal artery; SCMB, sternocleidomastoid muscle branch; Max, maxillary artery; PAA, posterior auricular artery; AMA, accessory meningeal artery; MMA, middle meningeal artery; JB (APA), jugular branch of the ascending pharyngeal artery; PostB, posterior branch of the accessory meningeal artery; PSB, petrosquamosal branch of the middle meningeal artery; PB, petrosal branch of the middle meningeal artery; PCB, posterior convexity branch of the middle meningeal artery; LTA, lateral tentorial artery

3  Posterior (Neural) Branches from the Proximal ECA

MDTA

45 MDTA

Max

Max AMA

AMA MMA

STA

PhB

MMA

STA

JB

(APA)

PAA

JB

(APA)

HGB

JF IJV

JF

PAA

JB (OA)

PhB

HGC

B JB (OA)

SS

Lat B (SSB)

HGB

HGC

Lat B (SSB) Med B

Med (PMA)B

OA 3rd seg

OA 3rd seg

c3 MDTA

c4

Max

Max

MDTA

AMA

AMA MMA

STA

MMA

STA

JB

JB

(APA)

(APA)

JF B

PAA

SS

JB (OA)

SS

JB (OA)

Lat B (SSB)

Lat B (SSB)

MB

Med B (PMA)

OA 3rd seg

Med B (PMA)

OA 3rd seg

c5 Fig. 3.4 (continued)

JF B

PAA

c6

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H. Kiyosue and Y. Matsumaru

PSB

PB

LTA from PostB (AMA)

LTA from PostB (AMA)

PCB

PSB

PB

PostB (AMA)

PhB

PhB

JB (OA)

JB (OA) IJV

IJV

APA

APA

PAA

PAA

d1

OA 1st seg

d2

OA 1st seg

LTA from PostB (AMA)

LTA from PostB (AMA)

PB

PSB

PSB

JF

JF SS

HGB

JB (APA) HGB

(APA)

SCMB

d3 Fig. 3.4 (continued)

HGC B JB (OA)

JB (OA) JB

OA 1st seg

PB

OA 2nd seg

d4

3  Posterior (Neural) Branches from the Proximal ECA

47

LTA from PostB (AMA)

PSB PB

PSB

PB

SS HGC

SS

MB

MB

B JB

(APA)

LatB (SSB)

HGB

Med B

OA 2nd seg OA 2nd seg

LatB (SSB)

(PMA)

d6

d5

LTA from Post B (AMA)

LTA from Post B (AMA)

PostB

PostB

(AMA)

(AMA)

JB

JB

(APA)

(APA)

Med B

Med B

(PMA)

PhB

(PMA)

HGB

PhB NMT

APalA APalA MB (APA)

MB (APA)

APA

APA

e1 Fig. 3.4 (continued)

e2

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H. Kiyosue and Y. Matsumaru

LTA from Post B (AMA)

LTA from Post B (AMA)

PB JB

JB

MMA

(APA)

Med B

AMA

(APA)

B

AMA

(PMA)

IJV

PhB Max

Max

APalA APalA

DMB

e3

e4

LTA from Post B (AMA)

LTA from Post B (AMA)

PB

PB

MMA

B MMA

SS Max

IJV

Max

JB

(OA)

SS

IJV JB

(OA)

OA 2nd seg

APalA OA 1st seg

DMB

e5 Fig. 3.4 (continued)

OA 2nd seg IDA

OA 1st seg

DMB

e6

3  Posterior (Neural) Branches from the Proximal ECA

JB (OA)

49

MB

OA 3nd seg JB (OA)

OA 3rd seg

MB OA 2nd seg

OA 2nd seg

SCMB

DMB OA 1st seg

DMB SCMB OA 1st seg

f

JB (APA)

g

MedB (PMA)

JB (APA) LatB (SSB)

PhB

HGB

LatB(SSB)

NMT

PhB

MedB (PMA)

MB(APA)

MB(APA)

h Fig. 3.4 (continued)

HGB NMT

i

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H. Kiyosue and Y. Matsumaru

SMA

SMA

OA

DMB SCMB SCMB

a

b

SMA SMA

Styloid process

c Fig. 3.5  Stylomastoid artery originating from the occipital artery (case of meningioma at the foramen magnum). (a) Lateral view of the right occipital angiography. (b) Sagittal MIR image of 3D angiography of the right external carotid artery. (c, d) Axial (C) and sagittal (D) images of

d the cone beam CT.  Stylomastoid artery originates from the proximal portion of the occipital artery, and it runs upward to enter into the facial nerve canal through the stylomastoid foramen

3  Posterior (Neural) Branches from the Proximal ECA

51

PB PB

SMA

SMA

a

b

Fig. 3.6  Facial nerve arcade. Lateral view (a) and sagittal MPR image (b) of the right external carotid angiography in a case of transverse sigmoid sinus dural arteriovenous fistulas. The stylomastoid artery

(SMA) runs upward along with the facial nerve to enter facial nerve canal and anastomoses with petrosal branch (PB) of the middle meningeal artery to form facial nerve arcade

branches of the neuromeningeal trunk and the pharyngeal trunk. The neuromeningeal trunk runs posterosuperiorly, and it gives off branches supplying the IX–XII cranial nerves, and dura matter [5]. The pharyngeal trunk runs anterosuperiorly, and it gives off branches to nasopharynx, eustachian tube, oropharynx, and soft palate. Imaging anatomy of these branches of the ascending pharyngeal artery is very important for endovascular embolization because they have ­important anastomoses with various extracranial and intracranial arteries and their blood supply to the cranial nerves (Fig. 3.10).

from the third segment of the maxillary artery and the vidian artery originating from the internal carotid artery. The Eustachian tube branch and carotid branch originate from the superior pharyngeal artery or the pharyngeal trunk. The Eustachian tube branch supply the Eustachian tube and the submucosal space of the Rosenmüller fossa. The carotid branch enters the cranial cavity through the foramen lacerum, and runs along the internal carotid artery. It anastomoses with the recurrent artery of the foramen lacerum which originates from the internal carotid artery at cavernous segment. It also has potential anastomosis with the inferolateral trunk of the internal carotid artery [6]. Knowledge of these anastomoses between the pharyngeal branches and the internal carotid artery is important.

3.3.1 B  ranches of the Ascending Pharyngeal Artery 3.3.1.1 Pharyngeal Branches (Figs. 3.11, 3.12, and 3.13) Three pharyngeal branches of superior, middle, and inferior pharyngeal branches arise from the pharyngeal trunk or the main trunk of the ascending pharyngeal artery. The inferior pharyngeal branch runs anteroinferiorly, and it supplies oropharynx and may anastomose with the ascending palatine artery. The middle pharyngeal branch runs anteromedially to supply the nasopharynx and soft palate. It has potential anastomoses with the pterygovaginal artery (pharyngeal artery), the accessory meningeal artery, and the descending palatine artery of the branches of the maxillary artery. The superior pharyngeal branch runs superiorly to supply the nasopharynx and soft plate. The superior pharyngeal branch has anastomoses with the artery of the pterygoid canal originating

3.3.1.2 Inferior Tympanic Artery (Fig. 3.14) The inferior tympanic artery originates from either the pharyngeal trunk, neuromeningeal trunk or bifurcation of the pharyngeal and neuromeningeal trunk, and it runs superiorly through the canal of Jacobson and enter into the tympanic cavity. It supplies the accessory nerve and the facial nerve, and it anastomoses with the anterior tympanic artery (a branch of the maxillary artery), petrosal branch of the middle meningeal artery, the stylomastoid artery, and caroticotympanic artery. The caroticotympanic artery is a small branch from the petrous portion of the internal carotid artery, which is the dorsal portion of the second aortic arch. Although the caroticotympanic artery is usually invisible on angiography, the well-developed anastomosis between the inferior tympanic and caroticotympanic arteries can form a rare anatomical variant of the aberrant internal carotid artery (Fig. 3.15) [7].

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H. Kiyosue and Y. Matsumaru

JB JB

b1

a

JB JB

b2

c

Fig. 3.7  Lateral view of the left occipital angiography (a), and sagittal (b, c) and axial (d) MPR images of the 3D angiography of the left external carotid angiography in a case of transverse sinus dural arteriovenous fistulas). A hypertrophied jugular branch (JB) originating superiorly from the proximal portion of the occipital artery enters the jugular fora-

men. It turns posteriorly to enter the posterior fossa, and runs posteriorly on the surface of the posterior fossa to feed the dural arteriovenous fistulas. Mastoid branch (arrow) and transosseous branches (arrowheads) from distal portion of the occipital artery anastomose with the jugular branch to feed the AVF

3.3.1.3 Neuromeningeal Branches (Figs. 3.4, 3.11, 3.12, 3.13, and 3.16) Neuromeningeal trunk divides into two major branches of the hypoglossal branch and the jugular branch (Figs. 3.4 and 3.16). The hypoglossal branch runs superomedially, and it turns posteriorly at a right angle at the level of the hypoglossal canal (anterior condylar canal) to enter the cranial cavity

through the canal. It supplies the hypoglossal nerve, and divides into several meningeal (epidural) branches. Medial branch ascends along the medial portion of the clivus and anastomoses with the medial clival artery from the meningohypophyseal trunk of the internal carotid artery (Figs. 3.11, 3.12, 3.13, and 3.16). Descending branch runs inferiorly and anastomoses with the odontoid arch formed by bilateral

3  Posterior (Neural) Branches from the Proximal ECA

53

DMB DMB OA

C2 OA

APA

APA ECA

C3

ECA

a Fig. 3.8  Anastomoses between the vertebral artery and the occipital artery via muscular branches. Frontal (a) and lateral (b) views of left vertebral angiography under balloon occlusion of the left common carotid artery in a case of stenosis of the left internal carotid artery. The descending muscular branch (DMB) of the occipital artery (OA) anas-

a

b tomoses with the muscular branches of c2 and c3 segmental arteries (c2) and (c3) of the vertebral artery (VA). An anastomosis between the vertebral artery and the left ascending pharyngeal artery (APA) via the periodontoid anastomoses (anterior meningeal artery—the descending branch of the hypoglossal branch: arrows) is also demonstrated

b

Fig. 3.9  The ascending pharyngeal artery (arrows) arising from the internal carotid artery in a case of transverse sigmoid sinus dural arteriovenous fistulas. Frontal (a) and Lateral (b) views of right internal carotid angiography

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H. Kiyosue and Y. Matsumaru

MHT MCA

(medB)

7

LCA AICA

6 2

CB ITA

AMA

5

JB

SPB

DPA

LB MB

(medAB)

VidA

APC

PICA

PMA

HGB

MPB

Odontoid arch 4

1 IPB

NMT

LPA

AntMA APalA

MB 3

Fig. 3.10  Schematic drawing of the ascending pharyngeal artery and various anastomoses. (1.) Middle pharyngeal anastomosis: the middle pharyngeal branch (MPB) and/or the inferior pharyngeal artery (IPA) with the ascending palatine artery (APalA) and lesser palatine artery (LPA). (2.) Superior pharyngeal anastomosis: the superior pharyngeal branch (SPB) or carotid branch (CB) with vidian artery (VidA) from the internal carotid, artery of pterygoid canal (APC), and accessory meningeal artery (AMA). (3.) Muscular anastomoses: the muscular branch (MB) with the muscular branch of the vertebral artery. (4.) Periodontoid anastomosis: the descending branch of the hypoglossal branch (odontoid arch) with anterior meningeal branch (AntMA) of vertebral artery. (5.) Posterior meningeal anastomoses: the medial branch of the jugular branch (JB) or posterior branch of the hypoglossal branch (HB) with the posterior meningeal artery (PMA) of the vertebral artery and/or the posterior inferior cerebellar artery (PICA). (6.) Posterior Petrous anastomosis: the jugular branch with the dural branch of the anterior inferior cerebellar artery (AICA). (7.) Clival anastomosis: the ascending medial branch artery of the jugular branch and the medial branch of the hypoglossal branch with medal/lateral clival artery (MCA, LCA) of meningohypophyseal trunk (MHT). DPA, descending palatine artery; ITA, inferior tympanic artery; MB, medial branch of the jugular branch; LB, lateral branch of the jugular branch

anterior meningeal arteries from the vertebral arteries [5, 8] (Figs. 3.11 and 3.12). Posterior branches runs inferomedially on the floor of the posterior fossa (Figs. 3.12 and 3.16). The

posterior branch running close to the falx cerebelli is the falx cerebelli artery, and that running more laterally is the posterior meningeal artery. Both can originate from the vertebral artery or the posterior inferior cerebellar artery, and therefore, the hypoglossal branch has potential anastomoses with vertebral artery and the posterior inferior cerebellar artery. Furthermore, the hypoglossal branch is the remnant of primitive hypoglossal artery, and therefore, the posterior inferior cerebellar artery may originate directly from the hypoglossal branch. The jugular branch runs superiorly and posteriorly to enter the cranial cavity through the jugular foramen. The jugular foramen is in vertical direction, and the hypoglossal canal is located more medially and in horizontal direction. Therefore, angiography shows the hypoglossal branch runs more medially on frontal view and more horizontally in the canal on lateral view than the jugular branch. The jugular branch supplies the glossopharyngeal, vagus, and accessory nerves, and gives off meningeal branches. Ascending medial branch runs along the inferior petrosal sinus and anastomoses with the lateral clival artery from the meningohypophyseal trunk (Figs.  3.4, 3.11, and 3.12). Sigmoid branch runs posteriorly along the sigmoid sinus and the transverse sinus and anastomose with meningeal branches from the middle meningeal artery (petrosal branch, petrosquamosal branch, and posterior convexity branch) and the occipital artery (mastoid branch). The posterior meningeal artery can arise from the jugular branch (Figs.  3.4 and 3.16). A small ascending branch supplies dura matter around the internal auditory canal, and it may have a potential anastomosis with the anterior inferior cerebellar artery (Fig. 3.16).

3.3.1.4 Muscular Branches Small muscular braches originates from the main trunk, the pharyngeal and neuromeningeal branches, and they supply prevertebral and paravertebral muscles and adjacent bone. As described above, the ascending pharyngeal artery supplies lower cranial nerves, and has multiple anastomoses with the vertebrobasilar artery and the internal carotid artery (Figs. 3.17 and 3.18), and therefore, endovascular embolization should be done with special attention.

3  Posterior (Neural) Branches from the Proximal ECA

55

JB (medial ascend B) - MCA

HGB (medial B) - MCA

JB (medial ascend B) - MCA

HGB

APC

APC

HGB (medial B) - MCA

JB (OA) JB (APA)

SPB

T JB (APA)

HGB

MPB JB (OA)

a

HGB (medial B) - MCA

b

JB (APA) (medial ascend B) -LCA JB (APA)

HGB (medial B) - MCA

JB (OA)

JB (APA)

Odontoid arch

Odontoid arch JB (OA)

HGB

HGB

c1 Fig. 3.11  Selective ascending pharyngeal angiography in a case of meningioma at jugular tuberculum (T). Frontal (a) and lateral (b) views, and coronal (c), sagittal (d) and axial (e) images of selective angiography of the left ascending pharyngeal artery. Clival anastomoses including medial branch of the hypoglossal branch (HGB) with medial clival artery (MCA) and medial ascending branch with lateral clival artery. Jugular branch of the occipital artery (JB OA) is retro-

c2 gradely opacified via potential anastomosis with the jugular branch of the ascending pharyngeal artery (JB APA). Pharyngeal branches supply the posterior part of the pharynx, Eustachian tube, prevertebral muscle and anterior part of the vertebral body and clivus. Note superior pharyngeal anastomosis between the superior pharyngeal branch and artery (SPB) of the pterygoid canal (APC)

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H. Kiyosue and Y. Matsumaru

HGB (medial B) - MCA

JB (APA) (medial ascend B) -LCA

HGB (medial B) - MCA

JB (APA)

JB (OA)

HGB

HGB

c3

HGB (medial B) - MCA

JB (APA) (medial ascend B) -LCA

JB (APA) (medial ascend B) -LCA

JB

c4

HGB (medial B) - MCA

JB (APA) (medial ascend B) -LCA

APA

c5 Fig. 3.11 (continued)

c6

3  Posterior (Neural) Branches from the Proximal ECA

57

JB (APA) (medial ascend B) -LCA HGB (medial B) - MCA JB (OA)

d1

c7

JB (APA)

JF

JF JB (OA)

JB (OA) PB NMT

APA Fig. 3.11 (continued)

d2

d3

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H. Kiyosue and Y. Matsumaru

JB (APA)

JB (APA)

JB (OA)

HGC HGB)

HGB

d4

d5

JB (APA) (medial ascend B) -LCA T

JB (APA)

HGB

d6 Fig. 3.11 (continued)

d7

3  Posterior (Neural) Branches from the Proximal ECA

59

HGB (medial B) -MCA

MPB

T

SPB NMT

JB (OA)

Odontoid arch

e1

d8

SPB

SPB JB (APA) JB (OA)

JB (APA) JB (OA) HGB

HGB

HGC

e2 Fig. 3.11 (continued)

e3

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H. Kiyosue and Y. Matsumaru

APC

JB (APA)

JB (APA)

JB (OA)

JB (OA)

HGB (medial B)

HGB (medial B)

HGB

T

e4

JB (APA) (medial ascend B) -LCA HGB (medial B) - MCA

HGB (medial B) - MCA T

T

e6 Fig. 3.11 (continued)

e5

JB (APA) (medial ascend B) -LCA

e7

3  Posterior (Neural) Branches from the Proximal ECA

61

APC HGB

HGB H

PA DB MB

SPB

DB

postB

VA

AMA AMA

MB

a Fig. 3.12  Pharyngeal branches and hypoglossal branch of the ascending pharyngeal artery. Frontal (a) and lateral (b) views of selective angiography of the left ascending pharyngeal artery immediately after transvenous embolization of dural arteriovenous fistula at the right anterior condylar confluence. Numerous pharyngeal branches run medially to anastomose with contralateral counterparts. Distal portion (third segment) of the maxillary artery is visualized via anastomoses of the superior pharyngeal branch (SPB) with the pharyngeal artery (PA)

b and artery of pterygoid canal (APC) on lateral view. Odontoid arch (arrows) from the descending branch (DB) of the hypoglossal branch (HGB) is clearly demonstrated on frontal view. The vertebral artery is also demonstrated via the anterior meningeal artery (AMA) from odontoid arch and via the anastomoses of muscular branches (MB). The medial branch ascends to anastomose with medial clival artery (arrowheads) from the internal carotid artery. The posterior branch (postB) runs posteriorly on the floor of the posterior fossa

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H. Kiyosue and Y. Matsumaru

SP

CS

CS

MAB OsB CB

JB

MB HGB

SP

APC CB

SPB

PA

JB

SPB

HGB

PA PB

NMT

a

b

PA

PA

OsB

SPB

SPB CB

CB

MB

OsB

HGB

JB

c1 Fig. 3.13  Pharyngeal branches of the ascending pharyngeal artery in a case of right cavernous sinus dural arteriovenous fistulas. Frontal (a) and lateral (b) views, and axial MPR images (c) of selective angiography of the left ascending pharyngeal artery. Multiple feeding arteries from pharyngeal and neuromeningeal branches of the ascending pharyngeal artery converge on a shunted pouch (SP) medial to the right cavernous sinus (CS). The main feeding arteries includes medial clival

MB-MCA

JB

c2 artery (MCA)—medial branch (MB) of the hypoglossal branch (HGB), lateral clival artery (LCA)-medial ascending branch (MAB) of the small jugular branch (JB), and carotid branch (CB) and osseous (OsB) branch from the superior pharyngeal branch (SPB). Numerous additional transosseous feeders penetrating sphenoid bone from pharyngeal branches are also noted

3  Posterior (Neural) Branches from the Proximal ECA

63

APC

OsB

OsB

CB CB

MedB-MCA MB-MCA

MAB (JB) - LCA

MAB (JB)

c3

OsB

c4

CB CS

SP

MB-MCA

MAB (JB) - LCA

c5 Fig. 3.13 (continued)

c6

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H. Kiyosue and Y. Matsumaru

T

T

ITA ITA

APA

APA

OA

OA

b

a

APC

T

T

SSB ITA

SSB ITA

HGB HGB

PB

NMT

APA

PB MB

MB APA

c Fig. 3.14  Inferior tympanic artery in a case of glomus tympanic tumor. Frontal (a) and lateral (b) views of right external carotid angiography, and frontal (c) and lateral (d) views and axial (e), coronal (f) and sagittal (g) MPR images of selective angiography of the right ascending pharyngeal artery. The inferior tympanic artery (ITA) originates upward from the neuromeningeal trunk, and it between the carotid canal and jugular foramen (canal of Jacobson) to enter tympanic cavity and sup-

d plies the glomus tumor (T). The ascending pharyngeal artery (APA) originates from the external carotid artery just above the origin of the occipital artery (OA). PB, pharyngeal branch; MB, muscular branch; HGB, hypoglossal branch; ITA, inferior tympanic artery; SSB, sigmoid sinus branch; T tumor; APC, artery of pterygoid canal; IPB, inferior pharyngeal branch; MPB, middle pharyngeal branch; SPB, superior pharyngeal branch; JF, jugular foramen; CC, carotid canal

3  Posterior (Neural) Branches from the Proximal ECA

65

IPB

IPB

APA

PB

NMT

MB

MB

e1

e2

MPB PB

PB NMT

NMT

e3 Fig. 3.14 (continued)

e4

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H. Kiyosue and Y. Matsumaru

APC

SPB

SPB

ITA

ITA

HGB

HGB

e6

e5

APC

CC

CC

T ITA JF

ITA

SSB

SSB

e7 Fig. 3.14 (continued)

JF

e8

3  Posterior (Neural) Branches from the Proximal ECA

67

T

CC T

ITA NMT

SSB

APA

e9

T HGB ITA NMT PB

MB

APA

g Fig. 3.14 (continued)

HGB

f

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H. Kiyosue and Y. Matsumaru

APA

a

b

c Fig. 3.15  Aberrant course of internal carotid artery (intratympanic internal carotid artery) in a case of carotid artery stenosis. Frontal (a) and lateral (b) views of left common carotid angiography, and axial CT images (c). The left internal carotid artery shows an unusual lateral bending (arrows) at the proximal petrous portion. CT shows lack of lateral wall of the carotid canal and protrusion of the internal carotid

artery to the tympanic cavity. Note the ascending pharyngeal artery (APA) originate from unusually upper portion of the internal carotid artery. Atherosclerotic stenosis is seen at the proximal portion of the internal carotid artery. This variant is thought to be a well-developed collateral pathway via inferior tympanic artery and carotid tympanic artery

3  Posterior (Neural) Branches from the Proximal ECA

69

V BA AICA

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c1 Fig. 3.16  Neuromeningeal branches and potential anastomoses in a case of tentorial arteriovenous fistulas. Frontal (a) and lateral (b) views, and axial (c) and sagittal (d) MPR images of selective angiography of the left ascending pharyngeal artery. The ascending pharyngeal artery divides into pharyngeal and neuromeningeal trunk (NMT), and the NMT further divides into the hypoglossal branch (HGB) and the jugular branch (JB). The HGB runs posteriorly through the hypoglossal canal to enter the posterior fossa and divides into medial and posterior branches. The posterior branch (postB) runs posteriorly on the floor of the posterior fossa to be the posterior meningeal artery. The medial branch (MedB) runs medially and gives off descending branch contiguous with the odontoid arch (od arch), and then runs anteriorly and superiorly to anastomose with the medial clival artery (MCA) from the

c2 internal carotid artery (ICA) at cavernous portion. The JB enter the posterior fossa through the jugular foramen and divides into the posterior branch (postB) and lateral branch (sigmoid sinus branch: SSB). The SSB runs along the sigmoid sinus and the transverse sinus and feeds the tentorial AVF (AVF) at the lateral tentorial sinus. The posterior branch runs on the floor of the posterior fossa laterally to the posterior branch of the HGB. The JB anastomoses with the anterior inferior cerebellar artery (AICA) via small dural branches. A pharyngeal anastomosis between the pharyngeal branch and artery of pterygoid canal (APC) is demonstrated on lateral view. Opacification of the stylomastoid artery (SMAvia anastomosis between the muscular branch (MB) is also demonstrated on sagittal MPR image

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Odnarch

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c5 Fig. 3.16 (continued)

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3  Posterior (Neural) Branches from the Proximal ECA

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d4 Fig. 3.16 (continued)

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DB

RAPA VA VA

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a Fig. 3.17  Anastomoses between the ascending pharyngeal artery and vertebral artery. Frontal (a) and lateral (b) views of selective angiography of the left ascending pharyngeal artery. The ascending pharyngeal artery anastomoses with the vertebral artery (VA) via two different pathways of periodontoid anastomosis (the hypoglossal branch-­ odontoid arch-anterior meningeal artery: arrowheads) and muscular branch (MB) anastomosis. The hypoglossal branch gives off the medial

Fig. 3.18  Anastomoses between the ascending pharyngeal artery and the vertebral artery in a case of cavernous sinus dural arteriovenous fistula. Lateral view of the left vertebral angiography. The ascending pharyngeal artery (APA) was opacified via anastomosis between muscular branches (MB). Blood supply to the hypoglossal branch (HGB) via epidural branch (arrowheads) of the C2 segmental artery (c2) and descending branch (DB) is also seen. Cavernous sinus dural AVFs (CS) is fed by carotid branch (CB) from the pharyngeal branch (PB) and medial clival artery (MCA) from the hypoglossal branch. The occipital artery (OA) is slightly visualized via the anastomosis between muscular branch of C2 segmental artery (c2) and descending muscular branch (DMB) of the occipital artery

b branch anastomosing with the right medial clival artery (MCA) to the meningohypophyseal trunk (MHT). The pharyngeal branch (PB) anastomose with the artery of pterygoid canal (APC) to third segment of the maxillary artery and vidian artery (VidA) to the internal carotid artery (ICA). The pharyngeal artery also has anastomosis with contralateral counterpart. RAPA, right ascending pharyngeal artery; DB, descending branch

CS MCA

CB DB HGB PB APA C2 MB

DMB

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3  Posterior (Neural) Branches from the Proximal ECA

References 1. Lasjaunias P, Théron J, Moret J.  The occipital artery. Anatomy— normal arteriographic aspects—embryological significance. Neuroradiology. 1978;15(1):31–7. 2. Lasjaunias P, Moret J. The ascending pharyngeal artery: normal and pathological radioanatomy. Neuroradiology. 1976;11(2):77–82. 3. Alvernia JE, Fraser K, Lanzino G. The occipital artery: a microanatomical study. Neurosurgery. 2006;58:114–22. 4. Geibprasert S, Pongpech S, Armstrong D, Krings T.  Dangerous extracranial-intracranial anastomoses and supply to the cranial nerves: vessels the neurointerventionalist needs to know. AJNR Am J Neuroradiol. 2009;30(8):1459–68.

73 5. Hacein-Bey L, Daniels DL, Ulmer JL, et al. The ascending pharyngeal artery: branches, anastomoses, and clinical significance. AJNR Am J Neuroradiol. 2002;23(7):1246–56. 6. Quisling RG, Seeger JF.  Ascending pharyngeal artery collateral circulation simulating internal carotid artery hypoplasia. Neuroradiology. 1979;18:277–80. 7. Nicolay S, De Foer B, BernaertsA,Van Dinther J, Parizel PM. Aberrant internal carotid artery presenting as a retrotympanic vascular mass. Acta Radiol Short Rep. 2014;3(10):2047981614553695. https://doi.org/10.1177/2047981614553695. 8. Shimizu S, Garcia AS, Tanriover N, Fujii K. The so-called anterior meningeal artery: an anatomic study for treatment modalities. Interv Neuroradiol. 2004;10:293–9.

4

Superficial Arteries from the Distal ECA Hiro Kiyosue

4.1

 osterior Auricular Artery P and the Superficial Temporal Artery

Both of the posterior auricular artery and the superficial temporal artery supply the musculocutaneous tissue of the superficial layer including face, scalp, and pinna, and the parotid gland. Both arteries often give a branch to the tympanic cavity: stylomastoid artery from the posterior auricular artery and anterior tympanic artery from the superficial temporal artery.

4.2

 osterior Auricular Artery P (Figs. 1.1, 2.1, 4.1, and 4.2)

The posterior auricular artery originates from the posterior aspect of the distal portion of the ECA at the tail of the parotid gland. It runs posterosuperiorly beneath the parotid gland along superior surface of the posterior belly of the digastric muscle to reach the level of mastoid process [1]. It then turns superficially and runs posterosuperiorly in the posterior auricular sulcus between the mastoid process and the pinna. It divides into the auricular and occipital branches [2]. The auricular branch runs anteriorly to supply medial surface of pinna, and it anastomoses with the anterior auricular artery from the superficial temporal artery. The occipital branch runs posterosuperiorly to supply the retroauricular skin and muscles, and bone. Arterial territory of the occipital branch is variable depend upon the degree of development of the occipital artery.

4.2.1 B  ranches of the Posterior Auricular Artery 4.2.1.1 Parotid Branches The parotid branches are small branches arising from proximal portion of the posterior auricular artery. They supply inferior portion of the parotid gland, and anastomose with parotid gland branches from the ECA and the superficial temporal artery (Fig. 4.1). 4.2.1.2 Muscular Branches The posterior auricular artery gives off several muscular branches to the digastric muscle, stylohyoid muscle, and the sternocleidomastoid muscle. 4.2.1.3 Stylomastoid Artery It is an important artery entering the tympanic cavity through the stylomastoid foramen. It originates from the posterior auricular artery in 40% or the occipital artery in 60% of cases. Referring to “Occipital artery” (Figs. 3.5, 3.6, 4.1, and 4.2).

4.3

Superficial Temporal Artery (Figs. 1.1, 1.2, 2.1, and 4.3)

The ECA terminates by dividing into two major branches of the superficial temporal artery and the maxillary artery behind the neck of the mandible in the parotid gland. The superficial temporal artery ascends laterally along the posterior margin of the condylar process of mandible, and crosses the posterior root of the zygomatic process of the temporal bone. It divides into two terminal branches of the frontal branch and the parietal branch. It supplies lateral aspect of the scalp and face.

H. Kiyosue (*) Department of Radiology, Oita University Hospital, Oita, Japan e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 H. Kiyosue (ed.), External Carotid Artery, https://doi.org/10.1007/978-981-15-4786-7_4

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STA Pinna B from IAAA

IAAA Pinna B from PAA

Pinna B from PAA

c1 Fig. 4.1  Anatomy of the posterior auricular artery in a case of dural arteriovenous fistulas at the transverse sigmoid sinus. Frontal (a) and lateral (b) views, and sagittal (c) and axial (d) MPR images of selective angiography of the left ascending pharyngeal artery. ECA, external carotid artery; PAA, posterior auricular artery; SMA, stylomastoid artery; MB, muscular branch; PB, parotid branch; AuB, auricular branch; OB, occipital branch; TOB, transosseous branch; Pinna B, auricular branches to pinna; SAAA, superior anterior auricular artery; MMA, middle meningeal artery; PSqB, petrosquamosal branch; PCB,

c2 posterior convexity branch; STA, superficial temporal artery; Max, maxillary artery; APalA, ascending palatine artery; MDTA, middle deep temporal artery; ∗ and ∗∗, superficial preauricular anastomoses between anterior and posterior auricular arteries; TFA, transverse facial artery; Pinna B from PAA, branches of the auricular arteries to pinna; IAAA, inferior anterior auricular artery; ATA, anterior tympanic artery; AVFs, arteriovenous fistulas; IDA inferior dental arteries; JV, jugular vein; SS, Sigmoid sinus; TS, transverse sinus; TSJ, transverse sigmoid junction; SPS, superior petrosal sinus

4  Superficial Arteries from the Distal ECA

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Pinna B from PAA TFA

c5 Fig. 4.1 (continued)

c6

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Max

ATA MB Max

ECA

Fig. 4.1 (continued)

PAA MB

MB

c9

IDA

PAA ECA

c10

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PAA

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c12

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MMA

MMA

Max PAA

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Fig. 4.1 (continued)

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c14

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FO

AMA

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c17 Fig. 4.1 (continued)

c18

4  Superficial Arteries from the Distal ECA

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d3 Fig. 4.1 (continued)

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d7 Fig. 4.1 (continued)

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Pinna B

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d11 Fig. 4.1 (continued)

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d14 Fig. 4.1 (continued)

MAAA

d15

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d18 Fig. 4.1 (continued)

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TOB Pinna B TS AVF TOB

OB

d20 Fig. 4.1 (continued)

4.3.1 Branches of the Superficial Temporal Artery 4.3.1.1 Transverse Facial Artery (Fig. 4.4) The transverse facial artery originates at the origin of the superficial temporal artery in parotid region. It often ­originates independently from the terminal portion of the ECA. It divides into superior and inferior trunks at the anterior portion of the parotid gland, and both pass through the parotid gland with giving off branches to the parotid gland [3]. The superior trunk runs anteriorly between the inferior border of the zygomatic arch and the parotid duct, and it supplies face, parotid duct, muscles, and the facial nerve. It anastomoses with the neighboring arteries including the infraorbital artery, zygomatico-malar artery, inferior palpebral artery, buccal artery and the facial artery. The inferior trunk descends superficial to the masseter fascia, and distributes the masseter muscle and neighboring skin. It anastomoses with the masseteric branches of the maxillary artery. 4.3.1.2 Anterior Tympanic Artery (Figs. 4.2 and 4.3) The anterior tympanic artery is a small branch distributing to the mandibular joint and tympanic cavity. It can arise from the proximal portion of the superficial temporal artery, but more frequently from the maxillary artery. Details of this artery is described in Chapter “Maxillary artery.”

4.3.1.3 Anterior Auricular Branches (Figs. 4.2, 4.3, and 4.4) The superficial temporal artery gives of three branches to the auricle, the superior anterior auricular artery, the middle anterior auricular artery, and the inferior anterior auricular artery [4–5]. Two or all three those branches can originate from a common trunk. The superior anterior auricular artery arises near the spine of helix, and it runs posterosuperiorly toward the helical rim and contributes the helical rim arterial arcade. It gives off branches supplying the anterosuperior part of the auricle and proximal skin. The middle anterior auricular artery is a small branch which runs posteriorly to supply the tragus, the helical root, and the anterior-superior wall of the external auditory meatus. The inferior anterior auricular artery runs posteroinferiorly toward the earlobe and form capillary network of the ear lobe. The network continues to the helical arcade. The peripheral branches of those auricular arteries anastomose with each other and with the perforating and circumferential branches of the posterior auricular artery. 4.3.1.4 Zygomatico-Orbital Artery (Figs. 2.1, 4.3, and 4.4) The zygomatico-orbital artery originates just below the bifurcation of the superficial temporal artery into the frontal and parietal branches. It runs anteriorly along the upper border of the zygomatic arch to the lateral angle of the orbit. It supplies anterior temporal and malar region, and orbicularis oculi muscle. It anastomoses with the palpebral artery, lachrymal artery, and the anterior deep temporal artery. 4.3.1.5 Posterior Deep Temporal Artery The posterior deep temporal artery originates at the level of zygoma, and it runs posteroinferiorly to supply the posterior part of temporal muscle. It anastomoses with the middle and anterior temporal arteries. It may arise from the maxillary artery or a common trunk with the zygomatico-orbital artery. 4.3.1.6 Frontal Branch and Parietal Branch (Terminal Branches) (Figs. 2.1, 3.10, and 4.3) The superficial temporal artery bifurcates into two terminal branches of the frontal and parietal branches at approximately 2 cm above the superior margin of the zygomatic arch [6]. Both branches supply the skin, muscle, and the skull. The frontal branch runs anterosuperiorly toward the eyebrow with forming a convex curve. It anastomoses with supraorbital artery and the frontal artery from the ophthalmic artery (Fig. 2.1). The parietal branch runs superiorly and slightly backward toward midline. It has multiple anastomosis with the frontal branches anteriorly, the occipital artery, deep middle temporal artery, and the posterior auricular artery inferiorly (Fig. 4.5). It also anastomoses with the middle meningeal artery via transosseous branches (Fig. 4.6).

4  Superficial Arteries from the Distal ECA

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c1 Fig. 4.2  Posterior auricular artery in a case of transverse sigmoid sinus dural arteriovenous fistulas. Frontal (a) and lateral (b) views, and axial (c) and sagittal (d) MPR images of selective angiography of the left

c2 posterior auricular artery. SMA, stylomastoid artery; MB, muscular branch; AB, auricular branch; OB, occipital branch; TOB, transosseous branch; Pinna B, auricular branches to pinna

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v

c5 Fig. 4.2 (continued)

c6

4  Superficial Arteries from the Distal ECA

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c9 Fig. 4.2 (continued)

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c13 Fig. 4.2 (continued)

ECA

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4  Superficial Arteries from the Distal ECA

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d3

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d4 Fig. 4.2 (continued)

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Pinna B Pinna B

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d10 Fig. 4.2 (continued)

d9

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c1 Fig. 4.3  Anatomy of the superficial temporal artery and middle meningeal artery in a case of left convexity meningioma. Frontal (a) and lateral (b) views, and axial (c) and sagittal (d) MPR images of left external carotid angiography. STA, superficial temporal artery; TFA, transverse facial artery; IAAA; inferior anterior auricular artery; MAAA, middle anterior auricular artery; ZOA, zygomatico-orbital artery; SAAA, superior anterior auricular artery; FB, frontal branch; PB, parietal branch; M, meningioma; Max, maxillary artery; MMA, middle meningeal artery; PCB, posterior convexity branch; AB, anterior branch; AMA, accessory meningeal artery; Pinna B, auricular branches to pinna; ECA,

IAAA

c2 external carotid artery; IDA, inferior dental artery; DPA, descending palatine artery; IOA, inferior orbital artery; GPA, greater palatine artery; LPA, lesser palatine artery; DPA, descending palatine artery; PSDA, posterior superior dental artery; FA, facial artery; SPA, sphenopalatine artery; IB, inferior branch of the posterior septal artery (PSA); ITB, inferior turbinate branch of the posterior lateral nasal artery (PLNA); MTB, middle turbinate branch of the PLNA; ATA, anterior tympanic artery; MDTA, middle deep temporal artery; ADTA, anterior deep temporal artery; BA, buccal artery

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MMA extracranial seg ATA STA MAAA

c5 Fig. 4.3 (continued)

ITB

MMA extracranial seg

ATA STA MAAA

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c9 Fig. 4.3 (continued)

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c13 Fig. 4.3 (continued)

pterional seg PCB

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c17 Fig. 4.3 (continued)

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PB

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c21 Fig. 4.3 (continued)

c22

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PB

M

M

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c24

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PB

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SAAA STA MAAA

MAAA ZOA IAAA

Fig. 4.3 (continued)

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M

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PCB

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FB STA

STA ATA

IAAA TFA

Fig. 4.3 (continued)

d5

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4  Superficial Arteries from the Distal ECA

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Fig. 4.3 (continued)

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FS MMA

IOA ADTA PSDA

FA

Fig. 4.3 (continued)

extracranial seg

Max

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d13

FA

Max

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ITB

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Fig. 4.3 (continued)

MMA

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PLNA

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a Fig. 4.4  Anatomy and arterial territory of the transverse facial artery in a case of maxillary cancer (M). Lateral view of superficial temporal angiography (a). TFA, transverse facial artery; SAAA, superior anterior auricular artery; ZOA, zygomatico-orbital artery; FB, frontal branch; PB, parietal branch. CT during selective angiography of the transverse

b1 facial artery (TFA) (b) showing TFA supplies anterior part of the parotid gland, the masseter muscle, subcutaneous soft tissue of the cheek, lateral wall of the maxillary sinus and maxillary cancer (M). MC indicates a tip of the microcatheter at the proximal portion of the TFA

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a Fig. 4.5  Superficial anastomoses of the superficial temporal artery with neighboring arteries. Frontal (a) and lateral (b) views of selective superficial temporal angiography showing superficial anastomoses including frontal branch anteriorly with the supraorbital artery of the

ophthalmic artery (SOA), frontal branch and zygomatico-orbital artery inferolaterally with the middle deep temporal artery (MDTA), and parietal branch posteriorly with the occipital artery (OA)

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a Fig. 4.6  Transosseous branch of the superficial temporal artery in a case of the superior sagittal sinus dural arteriovenous fistulas. Frontal (a) and lateral (b) views, and sagittal (c) MPR images of left external carotid angiography showing the dural arteriovenous fistulas (S) fed by

b the paramedian arteries (arrows) of the middle meningeal artery (MMA). Transosseous branch (TOB) of the parietal branch (PB) of the superficial temporal artery penetrates the parietal bone to anastomose with the paramedian artery to feed the AVFs

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References 1. Kolhe PS, Leonard AG.  The posterior auricular flap: anatomical studies. Br J Plast Surg. 1987;40:562–5690. 2. McKinnon BJ, Wall MP, Karakla DW.  The vascular anatomy and angiosome of the posterior auricular artery. Arch Facial Plast Surg. 1999;1:101–4. 3. Yang HJ, Gil YC, Lee HY. Topographical anatomy of the transverse facial artery. Clin Anat. 2010;23(2):168–78. 4. Imanishi N, Nakajima H, Aiso S.  Arterial anatomy of the ear. Okajimas Folia Anat Jpn. 73(6):313–24. 5. Zilinsky I, Erdmann D, Weissman O, et al. Reevaluation of the arterial blood supply of the auricle. J Anat. 2017;230(2):315–24. 6. Kim BS, Jung YJ, Chang CH, Choi BY. The anatomy of the superficial temporal artery in adult Koreans using 3-dimensional computed tomographic angiogram: clinical research. Cerebrovasc Endovasc Neurosurg. 2013;15(3):145–51.

TOB

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c Fig. 4.6 (continued)

5

Maxillary Artery Hiro Kiyosue and Shuichi Tanoue

The maxillary artery is the larger one of the two terminal branches of the ECA, which runs a long distance from the mandibular neck to the apex of the pterygopalatine fossa and gives off multiple branches distributing blood to various organs including temporal and mandibular bones, adjacent musculocutaneous tissue, the parotid gland, nasopharynx, paranasal sinuses, orbita, cranial nerves, and dura matter. It is involved by various diseases of those organs, and therefore it can be a target artery frequently for endovascular treatment of the head and neck lesions as well as intracranial lesions. The maxillary artery originates behind the neck of mandible in the parotid gland, and it runs anterosuperiorly and then anteriorly between the ramus of the mandible and the sphenomandibular ligament. It runs toward the pterygopalatine fossa, and then it turns medially and runs in the pterygopalatine fossa deeply to the sphenopalatine foramen. It is divided into three segments [1] (Figs. 5.1 and 5.2). The first (mandibular) segment from its origin to the lateral pterygoid muscle, lies medially to the mandibular neck. The first segment of the maxillary artery gives off five branches including the deep auricular artery, the anterior tympanic artery, the middle meningeal artery, the accessory meningeal artery, and the inferior alveolar (dental) artery (Fig. 5.3a). The second segment runs forward on superficial or deep surface of the lateral pterygoid muscle to reach the pterygopalatine fossa (Figs. 2.1 and 4.3). The second segment gives off the middle deep temporal artery, pterygoid branches, anterior deep temporal artery, the masseteric artery, and the buccal artery (Fig. 5.3b). When the second segment runs on the deep surface of the lateral pterygoid muscle, the middle meningeal artery arises at the proximal portion of the second segment, and the accessory meningeal artery independently

originates from the second segment of the maxillary artery (Fig. 5.4). The middle deep temporal artery can arise from the first segment by a common trunk with the inferior dental artery (Figs. 2.1 and 5.4). The third segment runs medially in the pterygopalatine fossa with giving off seven branches, including, posterior superior dental artery, infraorbital artery, descending palatine artery, pharyngeal artery, artery of the foramen rotundum, artery of pterygoid canal (Vidian artery), and artery of the superior orbital fissure. Then, it becomes the terminal branch of the sphenopalatine artery at the medial end of the fossa (Figs. 5.3c and 5.5). Djindjian classified the branches of the maxillary artery into six groups. The six groups and their individual branches are described below [2]. (a) Ascending cranial and intracranial branches Anterior tympanic artery, middle meningeal artery, accessory meningeal artery (b) Ascending extracranial muscular branches Anterior deep temporal artery, middle deep temporal artery, (c) Descending branches Inferior dental artery, pterygoid branches, masseteric artery, buccal artery (d) Anterior branches Posterior superior dental artery, infraorbital artery, descending palatine artery (e) Recurrent branches Pharyngeal artery, artery of the foramen rotundum, artery of the pterygoid canal (Vidian artery) (f) Terminal branches Sphenopalatine artery

H. Kiyosue (*) Department of Radiology, Oita University Hospital, Oita, Japan e-mail: [email protected] S. Tanoue Faculty of Medicine, Department of Radiology, Kurume University, Kurume, Japan e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 H. Kiyosue (ed.), External Carotid Artery, https://doi.org/10.1007/978-981-15-4786-7_5

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a2

a1 Fig. 5.1  Schematic drawing demonstrating anatomy of maxillary artery with segments. (a-1), left lateral view; (a-2), cranial view. Maxillary artery can be divided into three segments, including the first segment (blue square, originating upward from main trunk of external

carotid artery and turning anteriorly), the second segment (pink square, running across external pterygoid muscle), and the third segment (yellow square, entering into pterygopalatine fossa and traveling anteromedially)

3rd

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a Fig. 5.2  Angiographic anatomy of the maxillary artery and its branches on biplane DSA images of external carotid arteriogram (a, frontal view; b, lateral view). The first and second segments are easily identified on the lateral view of the external carotid arteriogram, in contrast, the third segment is clearly identified on the frontal view. MMA, middle menin-

IDA

b geal artery; IDA, inferior dental artery; MDTA, middle deep temporal artery; BA, buccal artery; PSDA, posterior superior dental artery; IOA, infraorbital artery; DPA, descending palatine artery; SPA, sphenopalatine artery

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Fig. 5.3  Schematic drawing of branches given off from the maxillary artery. (a, b), left lateral view; (c), cranial view. First segment gives off anterior tympanic artery (ATA), middle meningeal artery (MMA), accessory meningeal artery (AMA), and inferior dental artery (IDA). The second segment gives off the middle deep temporal artery (MDTA), pterygoid branches (PA), anterior deep temporal artery (ADTA), and

the posterior deep temporal artery, the masseteric artery (MA), and the buccal artery (BA). The third segment gives off the infraorbital artery (IOA), posterior superior dental artery (PSDA), artery of foramen rotundum (AFR), artery of pterygoid canal (APC), pharyngeal artery (PhA), artery of superior orbital fissure (ASOF), and sphenopalatine artery

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c1 Fig. 5.4  Deep course of the second segment of the left maxillary artery in a case of convexity meningioma. Frontal (a) and lateral (b) views, and axial MPR images (c) of left external carotid angiography showing the second segment of maxillary artery (yellow arrows) runs on the deep surface of the lateral pterygoid muscle. The middle meningeal artery (MMA) originates at the second segment of the maxillary artery, and the accessory meningeal artery (AMA) originates independently from the maxillary artery. The middle deep temporal artery (MDTA) originates by a common trunk with the inferior dental artery (IDA). The inferior orbital artery (IOA) originates by a common trunk with the

ECA

c2 posterior superior dental artery (PSDA) from the third segment of the maxillary artery. Enlarged posterior convexity branches of the MMA give off numerous feeders to the meningioma (M). The petrosal branch (PB) and the petrosquamosal branch (PSqB) also supply the tumor, the two branches originate at the proximal portion and distal portion of the horizontal segment of MMA, respectively. Transosseous branches of MDTA also supply the meningioma. STA, superficial temporal artery; IOA, infraorbital artery; DPA, descending palatine artery; ECA, external carotid artery; PSDA, posterior superior dental artery; SPA, sphenopalatine artery; PSA, posterior septal artery

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c5 Fig. 5.4 (continued)

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5.1

Branches of the First Segment

5.1.1 The Anterior Tympanic Artery (Fig. 5.6) ADTA MDTA MMA

As described before, the maxillary artery derived from the mandibulo-maxillary division of the stapedial artery (Fig. 1.3), and the anterior tympanic artery develops from the remnant of the stapedial artery at the side of the maxilla-­ mandibular division (Fig. 5.7) [3].

Development of Arterial Branches of Tympanic Cavity (Fig. 5.7)

PB PSqB STA

c19 Fig. 5.4 (continued)

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Fig. 5.5  Schematic drawing of maxillary artery traveling in the pterygopalatine fossa (superolateral view). The third segment of the maxillary artery runs in pterygopalatine fossa with a close relationship to pterygopalatine ganglion. Pterygopalatine fossa is a perpendicularly directed slit-shape space, from where maxillary artery gives off branches supplying orbit, nasal cavity, paranasal sinuses, cavernous sinus, palate, and oral cavity though the relevant foramina, canals, and fissures. AFR, artery of foramen rotundum; VA, Vidian artery; ASOF, artery of superior orbital fissure; SPA, sphenopalatine artery; DPA, descending palatine artery; PSDA, posterior superior dental artery; IOA, infraorbital artery

The anterior tympanic artery is derived from the remnant of the maxilla-mandibular division of the stapedial artery that is a transit embryonic artery supplying the orbital and maxilla-mandibular areas. In early embryo, the perioptic and maxilla-mandibular are supplied by the primitive maxillary artery and the first aortic arch. Otic and pharyngeal-facial regions are mainly supplied by the second aortic arch. All of these embryonic arteries regresses and their ventral portion becomes arterial plexus. The dorsal portions of the primitive maxillary artery, the first aortic arch, and the second aortic arch become the inferior hypophyseal artery (and inferolateral trunk), primitive mandibular artery (future Vidian artery), and hyoid artery (future caroticotympanic artery). The stapedial artery originates from the hyoid artery and runs superiorly in the tympanic cavity and divides into the two major divisions of the supraorbital division and the maxilla-­mandibular division. According to the development of the stem of ECA from the remnants of the arterial plexus of the second aortic arch and the ventral pharyngeal artery, those two divisions connects to the ECA. Then, the stapedial artery regresses and disappears in humans. Distal portion of the maxilla-­ mandibular division beyond the connection becomes the maxillary artery, and the remnant of the proximal portion becomes the anterior tympanic artery. Similarly, the distal portion of the supraorbital division further becomes the intracranial part of the middle meningeal artery, and the remnant of the proximal portion becomes the superior tympanic artery and/or the superficial petrosal artery both of which distribute in the tympanic cavity. The hyoid artery becomes caroticotympanic artery, a small branch of the internal carotid artery to the tympanic cavity. Small remnants of the proximal arterial plexus from the second arch distribute to the tympanic cavity become the inferior tympanic artery and the stylomastoid artery. Those five small arteries and the subarcuate artery from the anterior inferior cerebellar artery distribute tympanic cavity and have anastomoses.

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a

c Fig. 5.6  Imaging anatomy of anterior tympanic artery in a case with glomus tympanic tumor. (a) Postcontrast T1-weighted image shows hypervascular mass in tympanic cavity (arrow). Reactive mucoid fluid collection is also seen in mastoid air cells (arrowhead). (b) Lateral view of left external carotid arteriogram demonstrates a contrast blush at left middle ear fed by petrosal branch of middle meningeal artery (arrow) and anterior tympanic artery arising from the first segment of maxillary

b

d

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artery (arrowheads). (c) Sagittal reconstruction of color fusion image shows anterior tympanic artery passing upward behind ramus mandibulae (arrowheads). (d–g) Axial reconstructions of color fusion image showing course of anterior tympanic artery (arrowheads). Anterior tympanic artery originates from the first segment of the maxillary artery, travels upward behind ramus mandible, enters into tympanic cavity through petrotympanic fissure, and supply middle ear

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segmental arteries

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Fig. 5.7  Schematic drawing showing the developmental process of external carotid artery and maxillary artery. (a) The first and second primitive aortic arch dwindle by the embryonal period of CRL 4–5 mm. (b) Primitive mandibular artery develops from the dorsal remnant of the first aortic arch and the hyoid artery develops from the dorsal remnant of the second aortic arch. (c) The stapedial artery develops from the hyoid artery. The dwindling of the proximal segment of the stapedial artery is led by and the anastomosis between its supraorbital division, maxillo-mandibular division, and the ventral pharyngeal artery con-

maxillary artery

facial artery lingual artery

d

duces the dwindling of the proximal segment of the stapedial artery. The supraorbital division gives of ventral branch and dorsal branch, which are developing to orbital branch and middle meningeal artery, respectively. The maxillo-mandibular division develops to main trunk of maxillary artery. The adult type of the external carotid artery is formed by the remodeling. (d) The superior tympanic artery is formed by the remnant of the stapedial artery at the supraorbital division. (e) The anterior tympanic artery is formed by the remnant of the stapedial artery at the side of the maxilla-mandibular division

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eg ls na ro co

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e

FS extracranial segment

Fig. 5.7 (continued)

The anterior tympanic artery arises from the proximal portion of either the maxillary artery or the superficial temporal artery in the infratemporal fossa [4]. It ascends behind the temporomandibular joint and divides into the anterior and posterior branches. The anterior branch distributes the dorsal portion of the temporomandibular joint, and the posterior branch enters via the petrotympanic fissure into the tympanic cavity to supply the mucosa of the tympanic cavity and the tympanic membrane. Although it most frequently originates from the maxillary artery (45–78%) or the superficial temporal artery (20–46%), it may arise from the terminal portion of the ECA (4%) or the proximal portion of the other branches including the inferior dental artery, accessory meningeal artery, and middle meningeal artery. The anterior tympanic artery is very thin and difficult to identify on conventional angiography in normal subjects.

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5.1.2 M  iddle Meningeal Artery (Figs. 2.1, 4.3, 5.8, and 5.9) The middle meningeal artery is the most common feeder for various types of diseases including arteriovenous shunts and tumors, and therefore transarterial embolization for such lesions underwent most frequently via the middle meningeal artery, Anatomical knowledge of the middle meningeal artery is very important. The middle meningeal artery ­usually originates superiorly from the first segment of the maxillary artery via a common trunk with the accessory meningeal artery. When the second segment of the maxillary artery runs on the deep surface of the lateral pterygoid muscle, each of the middle meningeal artery and accessory meningeal artery arises from the maxillary artery independently. The middle meningeal artery runs superior and

Fig. 5.8  Segments of the middle meningeal artery in the case of parasagittal meningioma. Frontal (a) and lateral (b) views of the middle meningeal artery. PCB, posterior convexity branch; AB, anterior branch; PMA, paramedian artery; M, meningioma

medially to the spinous foramen (extracranial segment), and pass the spinous foramen into the middle cranial fossa. Then, it turns just after giving off small petrosal and cavernous sinus branches and runs laterally on the great wing of sphenoid bone to reach petrosquamous suture (horizontal segment). The middle meningeal artery gives off a petrosquamosal branch running posteriorly on the petrosquamosal suture, and it runs anteriorly along the middle meningeal sulcus on the great wing of the sphenoid bone to reach pterion (temporal segment). It forms small bends around the

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c1 Fig. 5.9  Angiographic anatomy of the middle meningeal artery and other maxillary arterial branches relevant to the cavernous sinus in a case of cavernous sinus dural arteriovenous fistulas. Frontal (a) and lateral (b) views, and axial (c) and sagittal (d) MPR images of left external carotid angiography. STA, superficial temporal artery; TFA, transverse facial artery; IAAA; inferior anterior auricular artery; MAAA, middle anterior auricular artery; ZOA, zygomatico-orbital artery; SAAA, superior anterior auricular artery; FB, frontal branch; PB, parietal branch; M, meningioma; Max, maxillary artery; MMA, middle meningeal

c2 artery; PCB, posterior convexity branch; AB, anterior branch; AMA, accessory meningeal artery; Pinna B, auricular branches to pinna; ECA, external carotid artery; IDA, inferior dental artery; DPA, descending palatine artery; IOA, inferior orbital artery; GPA, greater palatine artery; LPA, lesser palatine artery; DPA, descending palatine artery; PSDA, posterior superior dental artery; IB, inferior branch of the posterior septal artery; ITB, inferior turbinate branch; ATA, anterior tympanic artery; MDTA, middle deep temporal artery

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c5 Fig. 5.9 (continued)

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c9 Fig. 5.9 (continued)

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c13 Fig. 5.9 (continued)

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d3 Fig. 5.9 (continued)

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d7 Fig. 5.9 (continued)

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d11

Fig. 5.9 (continued)

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Fig. 5.10  Branches of the middle meningeal artery to the cavernous sinus in a case of left cavernous sinus dural arteriovenous fistulas. Axial MPR images of the left external carotid artery. antCSB, anterior cavernous sinus banch; MMA, middle meningeal artery; AMA, accessory

meningeal artery; PB, petrosal branch; postCSB, posterior cavernous sinus branch; AFR, artery of foramen rotundum; AB, anterior branch; RMA, recurrent ophthalmic artery

pterion (pterional segment), and then it runs upward along the coronal suture at the convexity (coronal segment) toward the midline. It becomes terminal branches of paramedian artery distributing along the superior sagittal sinus [1, 2]. There are some variations in origin of the middle meningeal artery based upon regression and persistence of embryologic vessels during development of the middle meningeal artery from the supraorbital division of the stapedial artery. The variations include the ophthalmic origin of the middle meningeal artery, the middle meningeal artery from persis-

tent stapedial artery, and the middle meningeal artery from the Vidian artery [3, 5–7] (Figs. 1.3 and 5.7).

5.1.2.1 Branches of the Middle Meningeal Artery Horizontal Segment 1. Anterior cavernous sinus branch (Fig. 5.10) Anterior cavernous sinus branch originates at the proximal portion of the horizontal segment of the middle meningeal artery, and it runs anteromedially to the anterolateral part of

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the cavernous sinus. It anastomoses with the artery of foramen rotundum and anterior branch of the meningeal artery.

petrous bone to the posterior part of the cavernous sinus. It anastomoses with the medial clival artery and carotid branch of the ascending pharyngeal artery.

2. Posterior cavernous sinus branch (Figs. 5.9 and 5.10) 3. Petrosal branch (Figs. 3.6, 5.4, 5.9, 5.10, and 5.11) Posterior cavernous sinus branch originates from posterior aspect of the horizontal segment of the middle meningeal artery, and it runs medially on the superior surface of the

Petrosal branch originates posteriorly from the proximal portion of the horizontal segment of the middle meningeal

PCB

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c Fig. 5.11  Angiographic anatomy of the petrosal and petrosquamosal branches of the middle meningeal artery in a case of tentorial (superior petrosal) dural arteriovenous fistulas. Frontal (a) and lateral (b) views and axial (c) and sagittal (d) MPR images of right middle meningeal angiography show the dural arteriovenous fistulas (AVF) fed by the petrosal

d1 branch (PB) and the petrosquamosal branch (PSqB). The AVF drains via the petrosal vein (PV) and the superior petrosal sinus (SPS). The petrosal branch and the petrosquamosal branch usually overlap on the lateral view of angiography. The two branches can be easily distinguished on the frontal view. PCB, posterior convexity branch; AB, anterior branch

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PV

PSqB

AVF

SPS

AVF PB

PB

AMA

d2

AMA

d3

Fig. 5.11 (continued)

artery. It supplies dura matter covering the petrous bone, tentorium and transverse-sigmoid sinus, and it has potential anastomoses with the accessory meningeal artery, tentorial arteries from the inferolateral trunk or meningohypophyseal trunk of the internal carotid artery, and dural branches from the anterior inferior cerebellar artery (Figs. 5.12 and 5.13). Among the petrosal branch, superficial petrosal artery runs through the facial nerve canal and supplies the facial nerve. It anastomoses with the stylomastoid artery that runs through the stylomastoid canal into the tympanic cavity to form the facial arcade. The superficial petrosal artery also has potential anastomoses with the superior tympanic artery (a petrosal branch distributing to the tympanic cavity), caroticitympanic artery, inferior tympanic artery, tubal branch of the accessory meningeal artery, subarcuate artery (a branch of anterior inferior cerebellar artery) at the tympanic cavity. These potential anastomoses are important for risk of cranial nerve injury or unintended penetration of embolic materials into the anterior inferior cerebellar artery or the basilar artery. 4. Petrosquamosal branch (Figs. 4.1, 5.4, 5.9, 5.10, and 5.11)

view of the angiography, but they can be easily separated on the frontal view. It sometimes originates via a common trunk with the posterior convexity branch. Temporal Segment 1. Posterior convexity branches The middle meningeal artery gives off some posterior convexity branches widely distributing convexity dura matter of temporal, parietal and occipital regions and superior sagittal sinus, and transverse sinus (Figs. 4.3, 5.8, and 5.9). They originate from temporal segment and coronal segment, and from horizontal segment via a common trunk with petrosquamosal branch. The posterior convexity branch is often used as a target artery for transarterial embolization because it runs relatively straight course and does not supply cranial nerve (Fig. 5.14.). However, it has potential anastomosis with small dural branches arising from the peripheral portion of the cerebral cortical arteries in case of dural AVFs and hypervascular tumor with pial arterial supply (Fig. 5.15). 2. Anterior branches

Petrosquamosal branch originates posteriorly from the distal end of the horizontal segment of the middle meningeal artery. It runs posteriorly along the petrosquamous suture to distribute lateral part of the tentorium, temporal dura matter, and transverse-sigmoid sinuses. It is difficult to separate the petrosal branches from the petrosquamosal branch on lateral

Anterior branches originate from temporal segment, and they run medially along the lesser wing of the sphenoid bone to the anterior part of the cavernous sinus (Figs.  5.9 and 5.10). They anastomose with the ophthalmic artery via the meningolacrymal artery through the cranio-orbital foramen (canal of

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LTA ILT S

LTA ILT PB MMA S

PostB

PostB AMA

AMA

& PB MMA

b

a

PB

S

S

PB AntB

PostB

PostB MMA

MMA

AntB

AMA AMA

c Fig. 5.12  Arterial anastomoses between the dural branches from the internal carotid and external carotid arteries on the petrous bone in a case of tentorial (petrosal) dural arteriovenous fistulas. Frontal (a) and lateral (b) views of the right common carotid artery show dural arteriovenous fistulas at the petrous apex. The lateral tentorial artery (LTA) of the inferolateral trunk (ILT) from the internal carotid artery, posterior branch (PostB) of the accessory meningeal artery (AMA), and petrosal branch (PB) of the middle meningeal artery (MMA) converge on the shunt point (S). Frontal (c) and lateral (d) views and sagittal (e) and axial (f) MPR images of the middle meningeal angiography show the posterior branch (PostB) of the accessory meningeal artery (AMA) running upward into the middle cranial fossa through the foramen ovale (FO) and then posteriorly on the surface of the petrous bone to feed the

d dural AVF (S). The petrosal branch (PB) of the middle meningeal artery (MMA) originates posteriorly from the middle meningeal artery just after entering middle cranial fossa through the foramen spinosum. It runs posteriorly and anastomoses with the posterior branch. The dural arteriovenous fistula drains into the petrosal vein and transverse pontine vein. Fusion MPR image of the middle meningeal angiography and internal carotid angiography (g) and selective angiography of the posterior branch of the accessory meningeal artery (h) show the posterior branch (PostB) anastomoses with the lateral tentorial artery (LTA) and it shunts to the petrosal vein (PB). CT MIP image after injection of NBCA–lipiodol mixture (i) clearly demonstrates the distribution and anastomosis between the AMA and the lateral tentorial artery. S, dural arteriovenous fistula; PV, petrosal vein

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PostB PB PostB

MMA

AntB

AntB

APA

e1

e2

MMA

PB AMA

MMA

AMA

e3 Fig. 5.12 (continued)

f1

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MMA

MMA

AntB

AMA

PostB

AMA

f3

f2

MMA FO PostB

PB

PostB

PB

f4 Fig. 5.12 (continued)

f5

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PostB PB

PostB

LTA

PB

PV S

S

PV

g

f6

LTA

S PV

PoBAMA

PostB

ILT TB PB MMA PV

h Fig. 5.12 (continued)

i

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S

S

PostB

PB

PB

MMA

AMA

MMA AMA

b

a

MMA

PB

MMA

Max

Max

c1 Fig. 5.13  Dural branches of the anterior inferior cerebellar artery supplying the dural arteriovenous fistulas involving the superior petrosal sinus (SPS). Frontal (a) and lateral (b) views, and sagittal MPR images (c) of the left external carotid artery show dural arteriovenous fistulas (S) fed by the posterior branch (PB) of the accessory meningeal artery (AMA) and petrosal branch (PB) of the middle meningeal artery (MMA) on the surface of the petrous bone. Frontal (d) and lateral (e)

c2 views and sagittal MPR images (f) of the left vertebral angiography show the multiple dural branches from the anterior inferior cerebellar artery (AICA) also feed the dural arteriovenous fistulas that drains into the superior petrosal sinus (SPS). Therefore, there are potential anastomoses between the dural branches of AICA and MMA or AMA. Max, maxillary artery; AntB, anterior branch; Post B, posterior branch; PICA, posterior inferior cerebellar artery; CT, common trunk

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PB PB

PostB

MMA

MMA

AMA

AMA

c3

c4

S

PB

PostB

PostB AMA

AMA

c5 Fig. 5.13 (continued)

c6

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S

S

DB from AICA

PostB

CT AICA-PICA

c7

d

S DB from AICA

AICA DB from AICA

S

PICA

CT AICA-PICA

e Fig. 5.13 (continued)

f1

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S

SPS

SPS AICA

CS

DB from AICA

DB from AICA

AICA

PICA

f2

CS

AICA

PICA CT AICA-PICA

f4 Fig. 5.13 (continued)

f3

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b

a

c Fig. 5.14  Catheterization and embolization via the posterior convexity branch for the tentorial dural arteriovenous fistulas at the lateral tentorial sinus (The same case as Fig. 5.30). Frontal (a) and lateral (b) views of the left external carotid angiography show tentorial dural arteriovenous fistulas fed by an enlarged posterior convexity branch (arrows) of the left middle meningeal artery. A large varix is also noted. Selective angiography via a 1.6F microcatheter (c) shows the microcatheter was

d navigated into the venous side through the posterior convexity branch. The dural arteriovenous fistulas were embolized with coils and NBCA. Sagittal MPR image of CT (d) shows NBCA–lipiodol mixture in the varix, fistulas, and feeders. Lateral view of the left common carotid artery after embolization (e) shows disappearance of dural arteriovenous fistulas

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Hyrtl) and meningo-ophthalmic artery and/or recurrent meningeal artery through the superior orbital fi ­ ssure (Figs. 5.16, 5.17, 5.18, and 5.19). These m ­ eningo-­ophthalmic anastomoses play an important role of collateral circulation to the eyes. They also have potential ­anastomoses with dural branches distributing the lateral wall of the cavernous sinus such as cavernous sinus branch of the middle meningeal artery, artery of foramen rotundum, and the inferolateral trunk of the internal carotid artery. Careful attention should be paid for these anastomoses during embolization of anterior branches because of risk of migration of embolic materials via those anastomoses. Pterional Segment–Coronal Segment 1. Posterior convexity branches have already described before. 2. Anterior branches Several anterior branches arise from the coronal segment, and they distribute dura matter covering the anterior convexity and anterior cranial fossa (Figs. 5.20 and 5.21). Anterior branch to the anterior cranial fossa has anastomosis with the anterior ethmoidal artery from the ophthalmic artery.

e Fig. 5.14 (continued)

*

*

a Fig. 5.15  Anastomosis between the cerebral cortical artery and dural artery in a case of transverse sinus dural arteriovenous fistulas. Lateral views of 2D (a) and 3D (b) angiography of the right internal carotid artery shows dural arteriovenous fistula (asterisk) at the transverse

b sinus. The dural arteriovenous fistulas are fed by the lateral tentorial artery. The posterior parietal artery, a branch of the middle cerebral artery, anastomoses with the posterior convexity branch of the middle meningeal artery (arrows) and supplies the dural arteriovenous fistulas

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MOA OPA MOA OPA CRA AntB

LA AntB

MMA

MMA AMA AMA

a

b

MOA

TFA

MMA

MaxA

AntB

AMA

AMA

MMA

c

Fig. 5.16  Angiographic anatomy of the meningo-ophthalmic artery. Frontal (a) and lateral (b) and (c) views of the right external carotid angiography and axial (d) and sagittal (e) MPR images of right common carotid angiography. Late arterial phase of the lateral view of the right external carotid angiography (c) clearly shows retinal blush (arrowheads). MMA, middle meningeal artery; AMA, accessory men-

d1 ingeal artery; AntB, anterior branch; LA, lacrimal artery; MOA, meningo-ophthalmic artery; OPA, ophthalmic artery; CRA, central retinal artery; TFA, transverse facial artery; MaxA, maxillary artery; SPA, sphenopalatine artery; LPCA, lateral posterior ciliary artery; MLA, meningolacrimal artery; LMB, lateral muscular branch; MMB, medial muscular branch; IOA, infraorbital artery

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MaxA

MaxA

AMA

AMA

MMA MMA

d3

d2

MaxA

MMA

SPA

SPA

MMA

AMA

d4 Fig. 5.16 (continued)

d5

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LA

OPA CRA

OPA

AntB LPCA

AntB LPCA

MMA

MMA

d6

d7

OPA LA MLA

OPA AntB MOA

MMA

d8 Fig. 5.16 (continued)

e1

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MLA

OPA CRA

MOA LA

LPCA&LMB MMB

MMB

IOA Max

e2

e3

MLA

AntB LA

AntB

MMA IOA Max

AMA

e4 Fig. 5.16 (continued)

e5

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pAN

MOA

pAN

LA MMA

OPA

ASOF

MOA AntB

OPA

ASOF

STA

LA

Max

MMA

PSA

STA

b

a

Max

MDTA

MDTA

MMA

PSA

ASOF

MMA PCB

STA

c1 Fig. 5.17  Ophthalmic collateral pathway via meningo-ophthalmic artery and artery of superior orbital fissure in a case of iatrogenic pseudoaneurysm of the middle meningeal artery after STA-MCA bypass surgery. Frontal (a) and lateral (b) views and axial (c), coronal (d) and sagittal (e) MPR images of the left external carotid angiography, and frontal (f) and lateral (g) views of selective middle meningeal angiography after embolization clearly show collateral pathways via the anterior branch (AntB) of the middle meningeal artery (MMA) and the meningo-­

PCB

STA

c2 ophthalmic artery (MOA) to the lacrimal artery (LA). Another collateral of artery of superior orbital fissure (ASOF) from the third segment of the maxillary artery (Max) continues to the first portion of the ophthalmic artery (OPA). pAN, pseudoaneurysm of the middle meningeal artery; STA, superficial middle temporal artery; PCB, posterior convexity branch; PSA, posterior septal artery; MDTA, middle deep temporal artery; SOV, superior ophthalmic vein; MM, medial muscular branch

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MDTA

MDTA

MMA

ASOF OPA

ASOF

MMA

STA

STA

PCB

PCB

c3

c4

SOV

SOV

LA

LA

OPA MDTA MOA

MDTA AntB MMA MOA

MMA

STA

STA PCB

PCB

c5 Fig. 5.17 (continued)

c6

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MDTA

MDTA MOA

AntB MMA

AntB

STA

STA

PCB

PCB

c8

c7

MDTA AntB MMA

STA

SOV

LA

PCB OPA

c9 Fig. 5.17 (continued)

CRA

d1

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SOV

SOV

MOA

LA

OPA

LA

LPCA CRA

LPCA OPA

MPCA

CRA MPCA

d2

d3

pAN

SOV

MOA

SOV

AntB

MOA

AntB MDTA

OPA

MMA

LPCA CRA

OPA

d4 Fig. 5.17 (continued)

d5

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149

pAN

MMA

MOA

OPA

OPA

MMA

MDTA MDTA

ASOF

d7

d6

pAN

MMA

MMA MDTA

PCB

MDTA PCB

e1 Fig. 5.17 (continued)

e2

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AntB

MMA

MMA PCB

e3

MDTA

LA

MOA

AntB

LA

MMA

MMA

e5 Fig. 5.17 (continued)

e4

e6

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151

MOA

SOV

MOA

LPCA

e7

e8

LPCA

OPA

CRA Fig. 5.17 (continued)

OPA

e9

ASOF

MPCA MM

e10

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MOA

MMA

OPA

OPA

AntB

LA ASOF

ASOF

e11

LA

MOA

OPA

Fig. 5.17 (continued)

MMA AntB

ASOF

g

PSA

f

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153

a

b1

b2 Fig. 5.18  Recurrent meningeal artery in a case of cavernous sinus dural arteriovenous fistulas. Lateral view (a) and axial MPR images (b) of the left internal carotid angiography shows the recurrent meningeal

artery (arrows) from the ophthalmic artery runs posteriorly through the superior orbital fissure to feed the dural arteriovenous fistulas

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OPA AntB

MMA

OPA AntB

MMA

MMA

a

b

OPA RMA

MMA

MMA PEA

c1 Fig. 5.19  Recurrent meningeal artery and meningolacrimal artery. Frontal (a) and lateral view (b) and axial MPR images (c) of left internal carotid angiography show the recurrent meningeal artery (white arrows and RMA in c) from the ophthalmic artery runs through the superior orbital fissure and continues to the anterior branch (AndB) of

AntB

c2 the middle meningeal artery (MMA). MPR images show other anastomoses of meningolacrimal artery (MLA) from the lacrimal artery (LA) to the AntB. Note a variation of posterior ethmoidal artery originating from the recurrent meningeal artery

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LA MLA

MLA MMA

MMA RMA

c3

c4

Fig. 5.19 (continued)

3. Paramedian artery Anterior and posterior paramedian arteries are the terminal branches of the middle meningeal artery. They run forward or backward along the superior sagittal sinus, and anastomoses with the anterior or posterior falcine artery (Figs. 5.8, 5.21, and 5.22). They also give off small branches to the wall of the superior sagittal sinus and falx cerebri. The falcine branches have potential anastomoses with dural branch from the posterior cerebral artery (artery of Davidoff and Schechter) and the superior cerebellar artery (medial dural-tentorial branch) at the falcotentorial junction (Fig. 5.22). All of the peripheral branches of the middle meningeal artery distributing the convexity and superior sagittal sinus, transverse sinus have anastomoses with the superficial arteries such as superficial temporal artery and the occipital artery via transosseous branches, and furthermore, they have potential anastomoses with cortical arteries via small dural/leptomeningeal branches [8] (Fig. 5.20).

5.1.3 Accessory Meningeal Artery The accessory meningeal artery usually originates anterosuperiorly from extracranial portion of the middle meningeal artery (Figs. 2.1, 4.1, 5.9, 5.12, 5.13, and 5.16). As a note before, it can originate independently from the maxillary artery when the second segment of the maxillary artery runs

deep course (Fig. 3.4). It divides into anterior and posterior branches. The anterior branch runs anterosuperiorly along the auditory tube to reach the torus tubarius and supplies adjacent pharyngeal mucosa, bone, and tensor veli palatini muscle. It anastomoses with the Vidian artery from the internal carotid artery, the artery of pterygoid canal, the pharyngeal artery, and the pharyngeal branch of the ascending pharyngeal artery at the infratemporal fossa [9] (Figs. 5.23 and 5.24). The posterior branch runs superiorly and enters middle cranial fossa through the foramen ovale or the foramen Vesalius. It supplies the trigeminal ganglion, adjacent dura matter, and superior part of the petrous bone. The posterior branch anastomoses with the inferolateral trunk of the internal carotid artery, and recurrent meningeal artery from the ophthalmic artery, cavernous branches of the middle meningeal artery, and artery of foramen rotundum laterally to the cavernous sinus (Figs. 5.23, 5.25, and 5.26). It potentially anastomoses with the meningohypophyseal trunk and subarcuate artery of the anterior inferior cerebellar artery at the petrous bone [10]. The posterior branch often becomes a feeding artery for some pathologic conditions including dural arteriovenous fistulas of cavernous sinus or tentorium on the petrous bone. The accessory meningeal artery ­occasionally gives off the superior branch of inferolateral trunk. The superior branch supplies the superior wall of the cavernous sinus, tentorium, and IIIrd-IVth cranial nerve (Figs.  5.23 and 5.27). Careful attention should be paid for those anastomoses and blood supply to the cranial nerves during embolization of the accessory meningeal artery.

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PCB

PCB AntB

AVF

PCB AntB

AVF

AntB

AntB

a

b

FPA AVF

AntB AVF AFA

AEA

c Fig. 5.20  Anterior branches in a case of frontal dAVFs. Frontal (a) and lateral (b) views of the left middle meningeal angiography shows a dAVF (AVF) fed by anterior branches (AntB) originating from the coronal segment of the middle meningeal artery. The dAVF drains via the olfactory vein, anterior cerebral vein, and uncal vein into the cavernous sinus. Another anterior branch from the temporal segment supplies orbita. PCB, posterior convexity branch. Lateral view of the right internal carotid angiography (c) shows the dAVF (AVF) fed by pial feeders

d from the frontopolar artery (FPA) and anterior falcine artery (AFA) from the anterior ethmoidal artery (AEA). Frontal (d) and lateral (e) views of selective angiography of the anterior branches (AntB) of the middle meningeal artery clearly demonstrate the dAVF (AVF). 20% glue was injected via the anterior branch to occlude the dAVFs. Frontal view of the left external carotid artery after embolization (f) shows disappearance of the dAVFs

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AntB

AVF

f

e Fig. 5.20 (continued)

5.1.4 I nferior Dental Artery (Inferior Alveolar Artery) The inferior dental artery originates from the first segment of the maxillary artery, and it runs inferiorly along the inferior alveolar nerve and the inferior alveolar vein (Figs. 2.1, 4.3, and 5.28). It often originates from a common trunk with the middle deep temporal artery as described before (Figs. 1.2 and 5.4). It enters the mandibular canal through mandibular canal located medial surface of the mandibular ramus, and then it runs anteroinferiorly and medially toward the mental foramen within the mandibular canal, accompanied by the inferior alveolar nerve and vein. It divides into two terminal branches of incisor branch and mental branch. The incisor branch runs medially to the midline and anastomoses with the contralateral counterpart. The mental branch runs anteriorly to exit the mandibular bone through the mental foramen, and it distributes the chin. The mental branch anastomoses with the submental branch and inferior labial branch of the facial artery. The inferior dental artery divides into two segments. The first segment is the extramandibular portion from its origin to the mandibular canal. The first segment is mobile according to the mobility of the mandibular bone, and it gives off branches to the pterygoid muscle, mylohyoid muscle, and the lingual nerve. The second segment running through the mandibular canal gives off multiple branches to the teeth and mandibular bone (Fig. 5.29). The inferior dental artery can be injured during extraction of molar teeth when the root deeply involves the mandibular

canal. Therefore, the inferior dental artery can be a source of massive bleeding during or after extraction of molar teeth, and selective transarterial embolization requires for hemostasis in some cases [11] (Fig. 5.30).

5.2

Branches of the Second Segment

5.2.1 Middle Deep Temporal Artery The middle deep temporal artery originates from proximal portion of the second segment (Figs. 1.2, 2.1, 4.3, 5.3, and 5.9). It often originates from a common trunk with the inferior dental artery when the maxillary artery runs deep surface of the lateral pterygoid muscle (deep course) [1, 2] (Fig. 5.4). It runs superiorly along the outer surface of the temporal bone with giving off small branches to the temporal bone and temporal muscle (Fig. 5.31). It anastomoses with the anterior deep temporal artery and superficial temporal artery (Fig. 4.5) and it also has transosseous anastomoses with the middle meningeal artery (Fig. 5.32).

5.2.2 Anterior Deep Temporal Artery The anterior deep temporal artery originates superiorly from distal portion of the second segment of the maxillary artery near the lateral pterygoid plate (Figs. 1.2, 5.3, and 5.9). It may originate from a common trunk with the buccal artery

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(Figs. 4.3 and 5.33). It runs anterosuperiorly along the anterior border of the temporal muscle and supplies the muscle (Figs. 5.31 and 5.33). It anastomoses with the middle deep

temporal artery and the superficial temporal artery. It also anastomoses with branches of the ophthalmic artery [12] (Fig. 2.10).

PMA

PMA

PCB

AFA AFA

AntB

AntB AVF

AVF PCB

AntB

AntB

PSqB

a

PSqB

b

PMA PMA AntB

AFA AFA

AVF AVF

c Fig. 5.21  Paramedian artery and the anterior branch of the middle meningeal artery. Frontal (a) and lateral (b) views of the right middle meningeal angiography and frontal (c) and lateral (d) views of the selective angiography of the paramedian artery (PMA) show the dural arteriovenous fistulas (AVF) at the anterior cranial fossa. The dAVFs

d are fed by the anterior falcine artery (AFA) via the paramedian artery (PMA) and the anterior branch (AntB) from the coronal segment of the middle meningeal artery. Another AntB from the temporal segment runs toward the orbita

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PMA

PMA

FB

FB

T T

b

a

TOB FB

TOB

FB

T

T

OA OA

c Fig. 5.22  Falcine branch from the paramedian artery and falcine branch anastomoses between the external carotid artery and the vertebral artery in a case of falcine meningioma. Frontal (a) and lateral (b) views of the left middle meningeal angiography show a falcine branch (FB) originating from the paramedian artery (PMA) of the middle meningeal artery supply the anterior part of the tumor (T). Arrowhead in b indicates the falcine branch which is the same as the falcine branch from the medial dural-tentorial branch (MDTB) from the right superior cerebellar artery (arrowhead in f). Frontal (c) and lateral (d) views of left occipital angiography show a falcine branch (FB) from the transosseous branch (TOB) of the occipital artery (OA) supplies the posterior part of the tumor. Sagittal MPR image of rotational angiography of the left external carotid artery (e) clearly shows anteroinferior part is fed by the middle meningeal artery (MMA) and the occipital artery (OA) supply the posterior part of the tumor (T). Lateral view of the left vertebral angiography (f) the tumor fed by the two dural branches. The posterior

d falcine artery (PFA), contiguous with the posterior meningeal artery (PMA), supply the posterior part of tumor (T). A falcine branch of the medial dural-tentorial branch (MDTB) supply the anteroinferior part of the tumor. Embolization with diluted glue was performed via the two falcine branches from the middle meningeal artery and the occipital artery. Sagittal MPR CT image after embolization (g) shows glue cast in the falcine branches and tumor vessels in the tumor. Fusion image of the glue cast (color image) and the preembolization vertebral angiography (white color) (h) shows the falcine branch from the middle meningeal artery anastomoses with the medial dural-tentorial branch from the superior cerebellar artery, The falcine branch from the occipital artery also anastomoses with the posterior falcine artery from the posterior meningeal artery. Left vertebral angiography shows disappearance of tumor staining even though the feeders from the vertebral artery has not been embolized

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PMA

FB(MMA)

TOB

PFA

T

FB(OA)

FB (MDTB)

T

PMA

f

e

FB (MMA)

FB (OA)

FB (MDTB)

PFA

PMA

g Fig. 5.22 (continued)

h

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161

i Fig. 5.22 (continued)

III IV

SB (TA)

ILT

LTA

ILT

ASOF

V PetB

AFR

AICA

PB APC

FO

VidA

PhA

CB AB Max

MMA

AMA SPB PB (APA)

Fig. 5.23  Schematic drawing of the intracranial and extracranial anastomoses of accessory meningeal artery. Anterior branches (AB) of the accessory meningeal artery (AMA) supply pharynx and anastomose with pharyngeal artery (PhA), artery of pterygoid canal (APC) from the third segment of the maxillary artery (Max) and Vidian artery (VidA) from the internal carotid artery. Carotid branch (CB) of the ascending pharyngeal artery (APA). Posterior branch (PB) enters the middle fossa through the foramen ovale (FO) and it supply the dura matter and tri-

geminal nerve (V). The posterior branch anastomoses with the posteromedial branch of the inferolateral trunk (ILT) and artery of foramen rotundum (AFR) at the cavernous sinus. It also anastomoses with the petrosal branch (PetB) of the middle meningeal artery (MMA), lateral tentorial artery (LTA) of the ILT, and the subarcuate artery of the anterior inferior cerebellar artery (AICA) on the petrous bone. The AMA occasionally gives off the superior branch (SB) of the ILT

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OPA OPA MMB

MMB

ILT AFR

IOA

ILT IOA AFR

VidA VidA

AB

ICA

ICA SPB

PA

Max

AMA

AMA

APA SPB

APalA

APalA

a

b1

OPA

OPA MMB IOA PA

VidA

PA

ICA

ICA

AB

AB Max

SPB Max

VidA

AMA

SPB APalA

APA

APA

APalA

b2 Fig. 5.24  Pharyngeal arterial anastomoses in a case of left internal carotid artery occlusion. Lateral view (a) and sagittal (b) and coronal (c) MPR images of the left common carotid angiography shows collateral pathway from multiple pharyngeal branches from the external carotid artery to the internal carotid artery (ICA) via the Vidian artery (VidA). Pnaryngeal arterial network consisting of the pharyngeal artery (PA) from the third segment of the maxillary artery (Max), anterior

b3 branch (AB) of the accessory meningeal artery (AMA), the superior pharyngeal branch (SPB) of the ascending pharyngeal artery (APA), the ascending palatine artery (APalA), and the Vidian artery (Vid), forms collateral pathway to the internal carotid artery. Note other collateral pathways from the infraorbital artery (IOA) to the ophthalmic artery (OPA) via the medial muscular branch (MMB) and from the artery of foramen rotundum (AFR) to the inferolateral trunk (ILT)

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OPA

OPA

VidA

VidA

Max

Max AMA

AMA APalA

APalA

c2

c1

ICA

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c Fig. 5.25  Anastomoses of the accessory meningeal artery with the artery of foramen rotundum in a case of parasellar meningioma. Frontal (a) and lateral (b) views of the left external carotid angiography and frontal (a) and lateral (b) views of the selective accessory meningeal angiography shows markedly dilated accessory meningeal artery (arrowheads) and artery of foramen rotundum (AFR) feeds the menin-

d gioma (T). The posterior branch (PB) of the accessory meningeal artery ascends through the foramen ovale and anastomoses with the artery of foramen rotundum and the anterior cavernous sinus branch (ACSB) of the middle meningeal artery (MMA). APC, artery of pterygoid canal; AB, anterior branch

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Fig. 5.26  Intracranial anastomoses from the accessory meningeal artery to the internal carotid artery and the ophthalmic artery in a case of severe stenosis of the right internal carotid artery. Frontal (a) and lateral (b) views of the right common carotid angiography show a large collateral (arrowheads) from the posterior branch of accessory

meningeal artery (AMA) to the internal carotid artery (ICA) via the inferolateral trunk. An another collateral from the accessory meningeal artery and the artery of foramen rotundum (AFR) to the ophthalmic artery (OPA) via anterior branch of the ILT is also noted (white arrowhead in b)

5.2.3 Pterygoid Branches

the ascending branch of the facial artery and the superior masseteric branch of the transverse facial artery (Fig. 5.34).

Pterygoid branches are small branches originating inferiorly from the second segment of the maxillary artery, and they supply the medial and lateral pterygoid muscles.

5.2.4 Masseteric Artery The masseteric artery originates from the proximal portion of the second segment of the maxillary artery, and it runs laterally through the mandibular notch between the coronoid process and the condyloid process to the deep surface of the masseter muscle (Fig. 2.1). It supplies medial part of the masseter muscle and has anastomoses with the deep masseteric branches of the facial artery and transverse facial artery.

5.2.5 Buccal Artery The buccal artery originates from the distal portion of the second segment of the maxillary artery. It descends obliquely to supply the buccal mucosa, buccinator muscle, Stenon’s duct, and overlying skin (Fig. 2.1). It has anastomoses with

5.3

Branches from the Third Segment

5.3.1 Posterior Superior Dental Artery The posterior superior dental artery arises from the most proximal portion of the third (pterygopalatine) segment of the maxillary artery. It often originates by a common trunk with the infraorbital artery [1, 2]. It runs anteroinferiorly on the lateral surface of the maxillary bone (Fig. 5.35). It gives off antral branches supplying maxillary bone and mucosal membrane of the maxillary sinus, and small lateral descending branches supplying the buccal mucosa, buccinators ­muscle, and then it enters in the maxillary bone, and it runs in the superior alveolar canal in the maxillary bone toward the incisor foramen [13]. It has anastomoses with the infraorbital artery around the maxillary sinus, and transverse facial or facial artery at cheek, and the descending palatine artery around the incisor foramen. Similar to the inferior dental artery, the posterior superior dental artery can be injured during molar teeth exaction and be a potential source of massive bleeding (Fig. 5.36).

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c Fig. 5.27  Anatomical variation of the superior branch of inferolateral trunk originating from the accessory meningeal artery in a case of transverse-­sigmoid sinus dural arteriovenous fistulas. Frontal (a) and lateral (b) views of the left external carotid angiography shows dural arteriovenous fistulas (dAVF) at the transverse-sigmoid junction. The dAVFs are fed by the superior branch (arrowheads) originating from the posterior branch of the accessory meningeal artery (AMA) and petro-

d squamosal branch (PSqB) of the middle meningeal artery (MMA). Lateral view of the selective angiography of the superior branch shows the dAVFs. Embolization with glue (20% NBCA) was performed. Lateral view of the external carotid angiography after embolization shows disappearance of the dAVFs. However, trochlear palsy developed after embolization which continued for a few months

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Fig. 5.28  Imaging anatomy of inferior alveolar artery. (a) inferior dental artery arises from the first segment of maxillary artery and runs antero-inferiorly. (b) Axial reconstructed images of 3D-rotational external carotid arteriography demonstrating the course of inferior dental artery (arranged in order from rostral to caudal side). After originat-

ing from the first segment of maxillary artery, it runs downward medial to ramus mandibulae (First segment of inferior alveolar artery), enters the mandibular canal through the mandibular foramen, and travels within the mandibular canal (second segment) toward the mental foramen

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c Fig. 5.29  Mandibular neck tumor supplied by the inferior dental artery. Frontal (a) and lateral (b) views of the left external carotid angiography shows marked contrast blush supplied by multiple feeders from the inferior dental artery (IDA) and the ascending palatine artery (APalA). The first segment of the maxillary artery (Max) is slightly displaced upward, and the first segment (extramandibular portion) of the inferior dental artery is medially displaced by the tumor. Frontal (c)

d and lateral (d) views of fluoroscopic image after introduction of a microcatheter (arrow) show the microcatheter passes through the mandibular foramen (arrowhead) and is placed in the second segment of the inferior dental artery in the mandibular canal. Frontal (c) and lateral (d) views of selective angiography of the inferior dental artery shows multiple osseous branches supply the tumor at the mandibular neck

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e

f

Fig. 5.29 (continued)

5.3.2 Infraorbital Artery

5.3.3 Artery of the Foramen Rotundum

The infraorbital artery originates anterosuperiorly from proximal portion of the third segment of the maxillary artery (Figs.  5.2 and 5.3). It often originates by a common trunk with the posterior superior dental artery (Fig. 5.4). It ascends in a short distance on the dorsal surface of the posterior wall of the maxillary sinus, and then it turns anteriorly to enter the orbit through the inferior orbital fissure (Fig. 5.37). It gives off small branches to the posterior part of the maxilla and maxillary sinus before entering the orbit [13]. It runs forward on the orbital floor and in the infraorbital groove with giving off small orbital branches that supplies orbital floor, and adjacent muscle and anastomoses with inferior muscular branches of the ophthalmic artery (Figs.  5.38 and 5.39). It runs anteroinferiorly and exits orbit through the infraorbital canal below the lower lid, and then it divided into several terminal branches including ascending palpebral branches, descending muscular branches, and superficial branches. Ascending palpebral branches anastomose with superficial temporal artery and ophthalmic artery (Fig. 5.39). The other terminal branches anastomoses with the facial artery, and/or the transverse facial artery (Figs. 2.10, 5.38, 5.39, and 5.40).

Three branches of the maxillary artery including the artery of foramen rotundum, artery of pterygoid canal, and pharyngeal artery are called as “recurrent arteries” because these three branches run posteriorly from the terminational portion of the maxillary artery [2] (Figs.  5.23 and 5.41). The artery of foramen rotundum arises posterosuperiorly from deep portion of the third segment of the maxillary artery (Figs.  5.3, 5.23, and 5.24). It runs along with the maxillary nerve and enters the cranial cavity through the foramen rotundum (Figs. 5.41, 5.42, and 5.43). It supplies the maxillary nerve and adjacent dura matter. It has an anastomosis with the internal carotid artery via the anterolateral branch of the inferolateral trunk [14, 15] (Figs. 5.23, 5.24, 5.38, 5.44, 5.45, and 5.46). This anastomosis is an important collateral pathway between the external and the internal carotid artery. A great attention should be paid for this anastomosis and cranial nerve supply during embolization of the maxillary artery system with particles or liquid embolic material.

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c Fig. 5.30  A case of arterial bleeding after molar tooth extraction. (a, b) Lateral view of left external carotid arteriogram (a) and selective inferior dental arteriogram (b) demonstrates a pseudoaneurysm (arrowhead) located at the main trunk of inferior dental artery (c) A microcatheter was navigated to the proximal portion to the pseudoaneu-

b

d rysm, and embolization was performed with glue (a mixture of 25% n-butyl cyanoacrylate and Lipiodol) (arrowheads). Arrow indicates the tip of microcatheter. (d) Lateral view of external carotid arteriogram after embolization demonstrates disappearance of the pseudoaneurysm

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Fig. 5.31  Imaging anatomy of deep temporal arteries in a case of right internal carotid artery occlusion. (a, b) Frontal (a) and lateral (b) views of right common carotid arteriogram show anterior and middle deep temporal arteries arising from the second segment of maxillary artery. Middle deep temporal artery is given off from the proximal part of second segment and runs anterosuperiorly (white arrowheads), whereas anterior deep temporal artery is given off from the distal part of second segment (black arrowheads). Note the retrograde filling of the ophthalmic artery (arrows) via anterior deep temporal artery and superficial temporal artery. (c) Axial MPR images of right common carotid arteri-

ography demonstrating the course of anterior/deep temporal artery (arranged in order from caudal to rostral side). Middle deep temporal artery originates from proximal second segment and runs anterosuperiorly on the external surface of temporal bone with giving off muscular branches for temporal muscle (white arrowheads). It has potential anastomosis with anterior deep temporal artery. Anterior deep temporal artery originates from distal second segment and runs upward along with anterior aspect of temporal muscle (black arrowheads). Note the anastomosis with lacrimal artery through the zygomaticotemporal foramen (white arrows)

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c1 Fig. 5.32  Transosseous branches of the deep middle temporal artery in a case of meningioma at the middle cranial fossa. Frontal (a) and lateral (b) views, axial (c) and coroal (d) MPR images of right external carotid angiography, and frontal (e) and lateral (f) views of selective angiography of middle deep temporal artery show a marked tumor staining (T) supplied by numerous feeders from meningeal branches of the middle

c2 meningeal artery (MMA), accessory meningeal artery (AMA), and artery of foramen rotundum (AFR). The middle deep temporal artery (MDTA) gives off multiple transosseous branches (white arrowheads) which anastomose with the middle meningeal and accessory meningeal arteries and supply the tumor

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c5 Fig. 5.32 (continued)

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Fig. 5.32 (continued)

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f Fig. 5.32 (continued)

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a Fig. 5.33  Arteriovenous fistula of the anterior deep temporal artery. Frontal (a) and lateral (b) views and coronal MPR images (c) of the left external carotid angiography show left infratemporal arteriovenous fistula (AVF) fed by the anterior deep temporal artery (ADTA). The anterior deep temporal artery originates from the distal portion of the second

b segment of the maxillary artery (Max) by a common trunk with the buccal artery (BA), it runs anterosuperiorly along the posterolateral wall of the maxillary sinus and lateral wall of the orbita, and it directly connects to a large varix (V). The ADTA gives off several muscle branches (MB) and an osseous branch (OB)

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c3 Fig. 5.33 (continued)

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c7 Fig. 5.33 (continued)

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b Fig. 5.34  Imaging anatomy of buccal artery in a case with gingival cancer. (a) Lateral view of right external carotid arteriogram shows descending branches of maxillary artery. Buccal artery (arrowheads) originates from the second segment adjacent to the lateral pterygoid plate, descends behind the maxillary tuberosity, and supply the buccal

c mucosa, buccinator muscle, and Stensen duct. (b, c) Frontal (b) and lateral (c) views of selective maxillary arteriogram clearly show the course of the buccal artery and fine contrast blush representing the tumor (arrowhead). Note the anastomosis with ascending branch of the facial artery (arrow)

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Fig. 5.35  Imaging anatomy of posterior superior dental artery in case with facial hemangioma. (a) Lateral view of left external carotid arteriogram shows contrast blush of gingival hemangioma (arrows) mainly fed by posterior superior dental artery. This artery is given off from the most proximal part of the third segment. The posterior superior dental artery can be identified by its characteristic downward course to run around the zygoma and tortuous course of the distal side. (b) Lateral view of 3D volume rendering image of external carotid arteriogram

clearly demonstrates the configuration and course of the posterior superior dental artery (arrowheads). (c) Axial MPR images of maxillary arteriogram demonstrate relationships the course of posterior superior dental artery and maxillary bone. This artery originates from proximal part of third segment and descends along with lateral wall of maxillary sinus with showing tortuous course and supplying gingiva (arrowheads). Finally, it enters maxillary bone through alveolar canal and supplies each alveolar sockets and maxillary sinus

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c Fig. 5.36  Arterial bleeding after extraction of impacted molar tooth of maxilla. (a) Postcontrast CT shows pseudoaneurysm adjacent to lateral wall of maxillary sinus (arrowhead). (b) Lateral view of left maxillary arteriogram demonstrates the pseudoaneurysm of the posterior superior dental artery (arrowhead). (c) Lateral view during selective embolization of posterior superior dental artery. A microcatheter was navigated

d

into the posterior superior dental artery close to the pseudoaneurysm. The artery including the pseudoaneurysm was embolized with liquid embolic agent (33% mixture of n-butyl cyanoacrylate and lipiodol). (d) Lateral view of external carotid arteriogram immediately after the embolization shows disappearance of the pseudoaneurysm

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a

c Fig. 5.37  Imaging anatomy of infraorbital artery in case with facial arteriovenous malformation (AVM). (a, b) Right external carotid arteriogram (a, lateral view of DSA; b, volume rendering of 3D rotational angiography, right lateral view) shows dilated infraorbital artery feeding facial AVM.  Infraorbital artery originates from the third segment and runs along with the inferior orbital wall (arrowheads). (c, d) Partial MIP images (c, oblique sagittal reconstruction; d, axial reconstruction)

b

d1

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d4

demonstrates the course of infraorbital artery. It originates from the third segment of maxillary, runs upward, and enters the orbit through the inferior orbital fissure (arrow). Within the orbital space, infraorbital artery runs along with the infraorbital groove (arrowheads) and exit the orbit via infraorbital foramen (double arrow) to reach the facial subcutaneous tissue

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c1 Fig. 5.38  Orbital and periorbital external–internal carotid arterial collateral pathways in a case of right internal carotid artery occlusion. Frontal (a) and lateral (b) views, and sagittal (c) and coronal (d) MPR images of right common carotid angiography show multiple collateral pathways from external carotid arterial branches to the internal carotid artery (ICA) via the ophthalmic artery (OPA) and inferolateral trunk (ILT). Orbital collateral pathways include anastomoses between orbital branches of the infraorbital artery (IOA) and medial muscular branch (MMB) of the ophthalmic artery, between the artery of superior orbital fissure and ophthalmic artery, and between the anterior branch (AntB) of the middle meningeal artery (MMA) and lacrimal artery (LacA) of the ophthalmic artery via the meningoorbital artery (MOA), and between the zygomaticoorbital artery and the lacrimal artery. Periorbital

c2 collateral pathways include a medial anastomosis between the infraorbital artery (IOA) and dorsal nasal artery (DNA) of the ophthalmic artery via the angular artery (AA) and superior anastomosis between the frontal branch (FB) of the superficial temporal artery (STA) and frontal artery (FA) of the ophthalmic artery (OPA). Another collateral pathways from the artery of foramen rotundum (AFR) and the accessory meningeal artery (AMA) to the inferolateral trunk (ILT) are also noted. DPA, descending palatine artery; SPA, sphenopalatine artery; PSA, posterior septal artery; PLNA, posterior lateral nasal artery; ADTA, anterior deep temporal artery; SOF; superior orbital fissure, IOF, inferior orbital fissure; IOG, infraorbital groove, IOC, infraorbital canal; FR foramen rotundum; OC, optic canal

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c5 Fig. 5.38 (continued)

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d2 Fig. 5.38 (continued)

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d10 Fig. 5.38 (continued)

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c Fig. 5.39  Potential anastomoses between ophthalmic artery and external carotid arterial branches in a case with proximal internal carotid artery occlusion. (a, b) Lateral view of left common carotid arteriograms at early arterial phase (A) and late arterial phase (b) shows retrograde filling of the ophthalmic artery (arrowheads) and the internal carotid artery from external carotid artery branches. (c) Left anterior oblique view of left common carotid arteriogram demonstrates peri pal-

pebral arterial anastomoses among supraorbital artery (black arrowheads), infraorbital artery (white arrowheads), frontal branch of superficial temporal artery (black arrows), and facial artery (white arrows). The superficial temporal artery and facial artery are contiguous with angular artery (double arrows). The infraorbital artery has intraorbital anastomoses with ophthalmic artery via medial or lateral muscular branches (asterisks)

190 Fig. 5.40  Schematic drawing of peri-palpebral subcutaneous and orbital arterial anastomosis between ophthalmic and maxillary arterial branches from the anterolateral view of orbit. Supraorbital artery from ophthalmic artery and infraorbital artery from maxillary artery communicate with superficial temporal artery, facial artery, and/or transverse facial artery

H. Kiyosue and S. Tanoue posterior septal artery of sphenopalatine artery

ophthalmic artery

posterior ethmoidal artery anterior ethmoidal artery supraorbital artery

lateral posterior ciliary artery central retinal artery and medial posterior ciliary artery

anastomoses to superficial temporal artery and facial artery

lacrimal artery

anterior deep temporal artery

5.3.4 Artery of Superior Orbital Fissure The artery of superior orbital fissure originates superior medially from the deep portion of the maxillary artery after giving off the artery of foramen rotundum (Figs. 2.10, 5.3, and 5.5, 5.23). It may arise by a common trunk with the artery of foramen rotundum. It runs upward through the most medial portion of the sphenopalatine fossa to the superior orbital fissure (Fig. 5.17). It anastomoses with the anteromedial branch of the inferolateral trunk of the internal carotid artery and/or the first portion of the ophthalmic artery via the superior orbital fissure [16] (Figs. 5.17, 5.23, and 5.42). As described before, the inferolateral trunk has anastomoses with the artery of foramen rotundum via anteriorlateral branch, artery of foramen rotundum via anteromedial branch, accessory meningeal artery via the posterolateral branch and the middle meningeal artery via the posterior branch (Figs. 5.23 and 5.46).

5.3.5 A  rtery of the Pterygoid Canal (Vidian Artery) The artery of pterygoid canal develops from a remnant of the first aortic arch. During the early embryonic period, the first

Infraorbital artery

anastomoses to facial artery and transverse facial artery

aortic arch regresses to arterial plexus, and proximal portion from the dorsal aorta becomes a primitive mandibular artery supplying the pharynx. The second aortic arch also regresses, and its ventral portion becomes ventral pharyngeal artery (precursor of the stem of the external carotid artery). The dorsal portion becomes the hyoid artery that gives off a stapedial artery dividing into two terminal branches of supraorbital division and maxillomandibular division. The primitive mandibular artery regresses, and the proximal part becomes small branch from the internal carotid artery (the artery of pterygoid canal or Vidian artery from the internal carotid artery). Ventral part of primitive mandibular artery connects with the maxillomandibular division of the stapedial artery at 20–24  mm stage of embryo (Fig. 1.3). ECA develops and replaces the stapedial artery to form adult type of the maxillary artery, and it forms the artery of pterygoid canal from the maxillary artery. Therefore, there are two types of artery of pterygoid canal, one from the internal carotid artery and the other from the third segment of the maxillary artery, and these two arteries can anastomoses each other (Fig. 1.3). Dominancy of either of the two arteries of pterygoid canal from the maxillary artery or the internal carotid artery depends on the degree of regression of the primitive mandibular artery during embryonic periods. The artery of pterygoid canal originates posterosuperiorly from the third portion of the maxillary artery, near the spheno-

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c Fig. 5.41  Recurrent arteries in a case of anterior condylar dural arteriovenous fistulas. Frontal (a) and lateral (b) views of the right maxillary angiography, and lateral 3DVR (c), axial (d), and sagittal (e) MPR images of the right external carotid angiography. The common trunk of the artery of pterygoid canal (APC) and pharyngeal artery (PA) originates posteromedially from the third segment of the maxillary artery, and then it divides into APC and PA at the pterygoid canal. The APC runs posteriorly through the pterygoid canal and the PA runs inferomedially to the pharynx. The artery of foramen rotundum (AFR) originates

d1 superior-medially from maxillary artery at just distal portion to the origin of the common trunk of APC and PA. It turns posteriorly and enters the cranial cavity through the foramen rotundum (FR). It anastomoses with the accessory meningeal artery (AMA), which enters the middle cranial fossa through the foramen Vesalius (FV). Note two branching variations of common trunk of the anterior deep temporal artery (ADTA) and buccal artery (BA), and common trunk of infraorbital artery (IOA) and the posterior superior dental artery (PSDA). MMA, middle meningeal artery; FS, foramen spinosus; FO, foramen ovale

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d4 Fig. 5.41 (continued)

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e2 Fig. 5.41 (continued)

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e8 Fig. 5.41 (continued)

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b2 Fig. 5.42  Artery of SOF and recurrent arteries in a case of cavernous sinus dural arteriovenous fistulas. Lateral view (a), and sagittal (b) and axial (c) MPR images of the left external carotid angiography show dural arteriovenous fistulas (dAVFs) involving the cavernous sinus. The artery of foramen rotundum (AFR), artery of pterygoid canal (APC), and pharyngeal artery (PA) originate posteriorly from the third segment of the maxillary artery, and the artery of superior orbital fissure (ASOF) originates superiorly and turn posteriorly at the superior orbital fissure to enter the cranial cavity to supply the dAVFs. The AFR runs posterosuperiorly to feed the dAVFs. The APC runs posteriorly through the

b3 pterygoid canal and the PA runs inferomedially. The superior branch of the accessory meningeal artery (AMA) also supply the dAVF. All feeders converge to the shunted pouch (SP) at the posterior portion of the cavernous sinus. Note the facial nerve arcade (white arrows in a) consists of petrosal branch (PB) of the middle meningeal artery (MMA) and stylomastoid branch (SMB) is clearly depicted on axial MPR images (c). IOA, infraorbital artery; PLNA, posterior lateral nasal artery; PSA, posterior septal artery; JB jugular branch; Max, maxillary artery

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c1 Fig. 5.42 (continued)

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c5 Fig. 5.42 (continued)

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c7 Fig. 5.42 (continued)

a Fig. 5.43  Potential anastomoses between recurrent branches and other surrounding arteries in a case of facial AVM. Maxillary artery was surgically ligated at second segment. (a, b) Frontal (a) and lateral (b) views of left external carotid angiography shows AVM fed by facial artery (black arrow), transverse facial artery (dotted black arrow), and infraorbital artery (white arrow). The infraorbital artery is depicted by anastomoses via artery of pterygoid canal (Vidian artery, white arrowhead) and artery of foramen rotundum (black arrowhead). The artery of pterygoid canal is filled through the superior pharyngeal branch of ascending pharyngeal artery (double white arrowhead), whereas artery of foramen rotundum is filled through accessory meningeal artery (double black arrowhead). (c) 3D volume rendering image of external

b carotid angiography demonstrates anastomotic channels between infraorbital artery, artery of pterygoid canal (white arrowhead), and artery of foramen rotundum (black arrowhead) via superior pharyngeal branch of ascending pharyngeal artery (double white arrowhead) and the accessory meningeal artery (double black arrowhead). (d) Axial MPR images external carotid artery demonstrate the course of recurrent branches. Artery of foramen rotundum passes though foramen rotundum (black arrowhead), in contrast artery of pterygoid canal artery passes through pterygoid canal (white arrowhead). Note the artery of pterygoid canal (pterygoid canal) is located inferomedially to the artery of foramen rotundum

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palatine foramen (Figs. 5.3, 5.23, and 5.41). It may originate by a common trunk with the artery of foramen rotundum or the pharyngeal artery (Fig. 5.41). It runs posterolaterally through the pterygoid canal, along with the corresponding nerve, to the foramen lacerum (Figs. 5.23, 5.41, 5.43, and 5.44). It gives off branches to the nasal and oropharyngeal mucosa, and those branches form rich anastomoses with the ascending pharyngeal, accessory meningeal, and ascending palatine arteries (Fig. 5.23). It also gives off osseous branches in the pterygoid canal, and Eustachian tube. The osseous branches can penetrate sphenoid bone, and they often supply the dural or epidural arteriovenous shunts (Fig.  5.41). It ­terminates at the foramen lacerum where it often anastomoses with another Vidian artery arising from the horizontal segment of the petrous portion of the internal carotid artery (Fig. 5.23 and 5.44).

5.3.6 P  haryngeal Artery (Pterygovaginal Artery) The pharyngeal artery originates deeply from the third segment of the maxillary artery just before entering the sphenopalatine foramen (Figs. 5.3, 5.23, and 5.41). It may originate by a common trunk with the artery of pterygoid canal or the sphenopalatine artery. It runs posteromedially and inferiorly through the pterygovaginal canal (pharyngeal canal) along with the pharyngeal nerve to give off branches to the roof of pharynx and pharyngeal end of the Eustachian tube. It may anastomose with the pharyngeal branches and Eustachian branches of the ascending pharyngeal artery, Vidian artery, and accessory meningeal artery (Figs. 5.42 and 5.45).

5.3.7 Descending Palatine Artery The descending palatine artery originates inferiorly from deep portion of the third segment of the maxillary artery (Figs. 1.1, 1.2, 2.1, 4.3, 5.4, 5.5, and 5.47). It occasionally originates by a common trunk with the posterior lateral nasal artery (Fig. 5.48) It runs inferiorly along with the great palatine nerve through the greater palatine canal (pterygopalatine canal) with giving off lesser palatine arteries which exit the canal via lesser palatine canals and foramens to supply the soft palate. Then, it turns anteriorly and runs through the greater palatine foramen where it becomes the greater palatine artery (Figs. 2.1 and 5.48). It runs anteriorly under the hard palate and divides into terminal branches to supply the

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hard plate, gingiva and nasal septum. It has potential anastomoses anteroinferiorly with the posterior septal artery (medial sphenopalatine artery) via the incisive foramen, and posteriorly with the ascending palatine artery (Fig. 2.9). The descending palatine artery can be injured with maxillary fracture, and cause massive bleeding (Fig. 5.49).

5.3.8 Sphenopalatine Artery The sphenopalatine artery is the terminal branch of the maxillary artery, which runs medially through the sphenopalatine foramen to enter the nasal cavity to supply nasal cavity and paranasal sinuses (Figs. 2.1, 5.3, 5.4, 5.5, 5.47, 5.48, and 5.50). It divides into two terminal branches of posterior lateral nasal artery (lateral sphenopalatine artery) and posterior septal artery (medial sphenopalatine artery) in the most medial portion of the pterygopalatine fossa or in the nasal cavity. The posterior lateral nasal artery runs inferomedially within the lateral wall of the nasal cavity. It occasionally originates by a common trunk with the descending palatine artery. The posterior lateral nasal artery gives off one or two branches anteriorly to supply the middle turbinate and meatus, and then it becomes the inferior turbinate branch running anteroinferiorly to supply the inferior turbinate (Figs.  5.48 and 5.50) [17]. The inferior turbinate branch often anastomoses with a branch from the descending palatine artery. At the anterior ends of these turbinate branches, they anastomose with nasal branches of the facial artery or other superficial nasal arterial branches. The posterior lateral nasal artery gives off branches to the medial and posterior wall of the maxillary sinus. The middle turbinate branch also gives off small branches superiorly to the ethmoid sinus and potentially anastomoses with the anterior and posterior ethmoid arteries from the ophthalmic artery. The posterior septal artery runs medially toward the superior turbinate with giving off a branch to the sphenoid ostium, and it divides into superior and inferior branches (Figs. 5.48 and 5.50) [18]. A small branch of superior turbinate arises from the superior branch or the stem of the posterior septal artery. The superior branch runs medially to reach the nasal septum, then anteriorly on the septum. It divides further into septal branches some of which anastomose with branches of the anterior ethmoidal artery superiorly with joining Kiesselbach’s plexus (Fig.  5.50) [19]. The inferior branch follows the posterior edge of the septum, then it turns anteriorly on the septum. It anastomoses with a branch of the descending palatine artery via the incisive foramen.

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c Fig. 5.44  Recurrent artery playing a role of collateral flow for internal carotid artery (ICA) in a case with proximal ICA occlusion. (a, b) Lateral view of right common carotid arteriogram (a, early arterial phase; b, late arterial phase) shows collateral flow from external carotid artery via Vidian artery (black arrowheads) and artery of foramen rotundum (white arrowhead). Note another anastomotic channel between

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d frontal branch of superficial temporal artery and supraorbital artery of ophthalmic artery is also seen (arrows) (c, d). Partial MIP reconstructions (c, axial reconstruction; d, sagittal reconstruction) show the course of Vidian artery (arrowheads). Vidian artery communicates the third segment of maxillary artery with the internal carotid artery at the level of foramen lacerum via pterygoid canal

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c Fig. 5.45 Angiographic anatomy of collateral pathways from the artery of foramen rotundum and the pharyngeal artery to the internal carotid artery in a case of occlusion of the internal carotid artery. Lateral view (a) and sagittal (b) and axial (c) MPR images of the left common carotid angiography show two collateral pathways from the third portion of the maxillary artery (Max) to the internal carotid artery (ICA).

The artery of foramen rotundum runs posterosuperiorly connects to the anterolateral branch of the inferolateral trunk (white arrowheads). The pharyngeal artery runs posteroinferiorly and medially and anastomoses with the Vidian artery (arrowheads). It also anastomoses with the superior branch of the ascending pharyngeal artery (SPB of APA) and ascending palatine artery (APalA). APC, artery of pterygoid canal

5  Maxillary Artery Fig. 5.46  Schematic drawing of potential communications between recurrent arteries, meningeal arteries, and branches of internal carotid arteries observed from laterosuperior view of middle cranial base. Anteromedial branch of the inferolateral trunk (ILT) anastomoses with the artery of superior orbital fissure (ASOF) through the superior orbital fissure. Anterolateral branch of inferolateral trunk (ILT) anastomoses with artery of foramen rotundum from third segment of maxillary artery through foramen rotundum (white arrowheads), and posteromedial branch of ILT anastomoses with accessory meningeal artery via foramen ovale. These channels have also potential communication with transosseous branches from the artery of pterygoid canal and ascending pharyngeal artery, and dural branches of the middle meningeal artery

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Fig. 5.47  Anatomy of descending palatine artery and sphenopalatine artery in a case with nasopharyngeal tumor (myoepithelioma). (a, b) Frontal (a) and lateral (b) views of 3D volume rendering images of right external carotid angiography. The descending palatine artery originates medially from third segment of maxillary artery, and descends. After reaching the palate, it turns anteriorly and supplies the soft and hard palate (white arrowheads). It gives off greater palatine artery (white arrow) and lesser palatine artery (white double arrow). The sphenopalatine artery is an end artery of the maxillary artery. After ascending in pterygopalatine fossa, it turns medially and supplies nasal wall and mucosa (yellow arrowheads). Sphenopalatine artery gives off posterior lateral nasal artery supplying lateral nasal wall (yellow arrow) and posterior septal artery supplying nasal septum (yellow double

arrow). The origins of these branches are easily identifiable on the frontal view. (c) Axial MPR images of right external carotid angiography demonstrate course of the descending palatine and the sphenopalatine artery. Sphenopalatine artery enters into nasal cavity through sphenopalatine foramen (yellow arrowheads) and supplies lateral nasal wall and nasal septum with branching posterior lateral nasal artery (yellow arrows) and posterior septal artery (yellow double arrows). Descending palatine artery runs inferiorly in pterygopalatine canal and branches greater and lesser palatine arteries (white arrowheads). (d, e) Frontal (a) and lateral (b) views of 3D fusion volume rendering images of right external carotid angiography demonstrating 3D relationships among nasal wall, palate, descending palatine artery, and sphenopalatine artery

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c1 Fig. 5.48  Angiographic anatomy of the sphenopalatine artery and the descending palatine artery. Frontal (a) and lateral (b) views of selective angiography of the left maxillary artery, and axial (c) and sagittal (d) MPR images of left external carotid angiography show a variation of branching pattern of the terminal portion of the maxillary artery. The posterior lateral nasal artery (PLNA) originates inferomedially by a common trunk with the descending palatine artery (DPA) at the deep in the pterygopalatine fossa. The PLNA runs medially and divides into medial turbinate branches and inferior turbinate branch. The inferior turbinate branch runs anteroinferiorly at the lateral wall of the nasal cavity and supplies the inferior turbinate, and the middle turbinate branches run anteromedially to supply the middle turbinate. The descending palatine artery (DPA) runs inferiorly through the pterygo-

c2 palatine canal with giving off lesser palatine arteries (LPA), and then, it turns anteriorly and runs through the greater palatine foramen to become the greater palatine artery (GPA). GPA runs anteriorly under the hard palate to supply the hard palate, gingiva, and nasal septum. The posterior septal artery (PSA) runs medially to the nasal septum. It gives off a small branch to the sphenoid bone (SphB) and divides into the superior and inferior branches. The superior branch supplies the superior turbinate and runs anteriorly to supply the nasal septum. It gives off small branches to the ethmoid sinus, and they potentially anastomose with the anterior or posterior ethmoidal artery of the ophthalmic artery. The inferior branch follows the posterior edge of the septum, then it turns anteriorly on the septum

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Fig. 5.49  A pseudoaneurysm of the descending palatine artery in a case of traumatic facial injury. (a) Contrast-enhanced CT at arterial phase shows maxillary bone fractures with diffuse subcutaneous and nasopharyngeal hematoma. A pseudoaneurysm is depicted on the left lateral nasal wall adjacent to the pterygopalatine canal (arrowheads). (b) Lateral view of left common carotid arteriogram shows a pseudoaneurysm at the distal segment of maxillary artery (arrowhead). (c, d) Frontal (c) and lateral (d) views of selective maxillary arteriogram dem-

onstrate the pseudoaneurysm located at greater palatine artery (arrowheads). (e) Lateral view of selective angiography during injection of glue (33% NBCA–lipiodol mixture) from greater palatine artery at just proximal portion of the pseudoaneurysm. The glue fills in the pseudoaneurysm and the short segment of the great palatine artery distal and proximal to the pseudoaneurysm. (f) Left common carotid arteriogram immediately after embolization shows disappearance of the pseudoaneurysm

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c Fig. 5.50  Angiographic anatomy of the sphenopalatine artery in a case of dural arteriovenous fistulas at anterior cranial fossa. (a, b) Lateral (a) and frontal (b) views of the left internal carotid angiography show the dural arteriovenous fistulas (AVFs) fed by the anterior ethmoidal artery (AEA) and the posterior ethmoidal artery (PEA). The AVFs drain into the ascending frontal vein and the olfactory vein. An anastomosis between the PEA and the posterior septal artery (PSA) via a sphenoid branch (arrowheads) is noted. (c, d) Lateral (c) and frontal (d) views of the left external carotid angiography show the dural arteriovenous fistulas (AVFs) fed by multiple small feeders from the sphenopalatine artery and a frontal branch of the superficial temporal artery. The ophthalmic artery (OPA) is retrogradely opacified via the anastomosis between the PEA and the posterior septal artery (PSA) (arrowheads). Note another anastomosis (white arrowheads) from the anterior deep temporal artery (ADTA) and lachrymal artery (LacA) (e, f) Lateral (e) and frontal (f) views of the left maxillary angiography at the third portion clearly show anatomy of the sphenopalatine artery.

d The dural arteriovenous fistulas (AVFs) fed by multiple tiny feeders from the posterior septal artery (PSA) and middle turbinate branches (MTB) of the posterior lateral nasal artery (PLNA). PSA runs medially and divides into superior and inferior branches, and PLNA divides into MTBs and inferior turbinate branch (ITB). MTB runs anteromedially and ITB runs anteroinferiorly. The anastomosis between the PEA and the posterior septal artery (PSA) is also seen (arrowheads). (g, h) Lateral (g) and frontal (h) views of selective angiography of the posterior septal artery show the superior branch gives off multiple tiny feeders (asterisks) running upward through the ethmoid sinus to feed the dural AVFs (AVF). Note normal nasal staining of the nasal septa and superior turbinate. (i, j) Lateral (i) and frontal (j) views of selective angiography of the posterior lateral nasal artery (PLNA) show the dural arteriovenous fistulas (AVFs) fed by multiple tiny feeders (asterisks) originate upward from the middle turbinate branches (MTBs). The middle turbinate is supplied by MTBs, and the inferior turbinate is supplied by the inferior turbinate branch (ITB)

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References 1. Tanoue S, Kiyosue H, Mori H, Hori Y, Okahara M, Sagara Y. Maxillary artery: functional and imaging anatomy for safe and effective transcatheter treatment. Radiographics. 2013;33:209–24. 2. Djindjian D, Merland JJ. Super-selective arteriography of the external carotid artery. Berlin: Springer; 1978. p. 22–36. 3. Paget DH.  The development of the cranial arteries in the human embryo. Contrib Embryol. 1948;32:205–61. 4. Wasicky R, Pretterklieber ML. The human anterior tympanic artery. A nutrient artery of the middle ear with highly variable origin. Cells Tissues Organs. 2000;166(4):388–94. 5. Hiruma T, Nakajima Y, Nakamura H. Development of pharyngeal arch arteries in early mouse embryo. J Anat. 2002;201:15–29. 6. Silbergleit R, Quint DJ, Metha BA, et al. The persistent stapedial artery. AJNR. 2000;21:572–7. 7. Kawai K, Yoshinaga K, Koizumi M, et  al. A middle meningeal artery which arises from the internal carotid artery in which the first branchial artery participates. Ann Anat. 2006;188:33–8. 8. Waga S, Morikawa A, Kojima T.  Dural-cortical anastomosis in pial arteriovenous malformation. Case report. J Neurosurg. 1979;50:522–4. 9. Lasjaunias P, Théron J.  Radiographic anatomy of the accessory meningeal artery. Radiology. 1976;121:99–104. 10. Komiyama M, Kitano S, Sakamoto H, Shiomi M.  An additional variant of the persistent primitive trigeminal artery: accessory meningeal artery—antero-superior cerebellar artery anastomosis associated with moyamoya disease. Acta Neurochir. 1998;140: 1037–42.

11. Sagara Y, Kiyosue H, Tanoue S, et  al. Selective transarterial embolization with n-butyl-2-cyanoacrylate for the treatment of arterial hemorrhage after third molar extraction. Neuroradiology. 2013;55(6):725–31. 12. Quisling RG, Seeger JF. Orbital anastomosis of the anterior deep temporal artery. Neuroradiology. 1975;8:259–62. 13. Flanagan D.  Arterial supply of maxillary sinus and potential for bleeding complication during lateral approach sinus elevation. Implant Dent. 2005;14:1–4. 14. Lasjaunias P, Moret J, Mink J.  The anatomy of the inferolat eral trunk (ILT) of the internal carotid artery. Neuroradiology. 1977;27(13):215–20. 15. Salaud C, Decante C, Ploteau S, Hamel A. Implication of the inferolateral trunk of the cavernous internal CAROTID artery in cranial nerve blood supply: anatomical study and review of the literature. Ann Anat. 2019;226:23–8. 16. Kiyosue H, Tanoue S, Hongo N, Sagara Y, Mori H. Artery of the superior orbital fissure: an undescribed branch from the pterygopalatine segment of the maxillary artery to the orbital apex connecting with the anteromedial branch of the inferolateral trunk. AJNR Am J Neuroradiol. 2015;36(9):1741–7. 17. Orhan M, Midilli R, Gode S, Asylam CY, Karci B. Blood supply of the inferior turbinate and its clinical applications. Clin Anat. 2010;23:770–6. 18. Zhang X, Wang EW, Wei H, et al. Anatomy of the posterior septal artery with surgical implications on the vascularized pedicled nasoseptal flap. Head Neck. 201(37):1470–6. 19. MacArthur FJ, McGarry GW. The arterial supply of the nasal cavity. Eur Arch Otorhinolaryngol. 2017;274:809–15.