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Intracranial Vascular Anomalies of the Internal Carotid System Are Well Studied in the Literature

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Intracranial Vascular Anomalies of the Internal Carotid System Are Well Studied in the Literature NEUROLOGIA medico-chirurgica Vol. 10, pp. 67-78, 1968 Intracranial Abnormalities of the External Carotid System Ahmed EL-BANHAWY and Fouad EL-NADI Intracranial vascular anomalies of the internal carotid system are well studied in the literature. Again, extracranial anomalies of the external carotid system- in the scalp and in the neck-have also been exhaustedly studied. On the other hand, intracranial anomalies of the external carotid artery and its branches received but meagre attention. Anatomical Considerations: The dissection room anatomy of the external carotid artery is fully dealt with in manuals of anatomy. As to the radiological anatomy, the following descriptive ;theme is probably most convenient for the purpose: Territorial Radiological Classification: For the purpose of clinical and radio- ogical studies it is found advisable to divide the area supplied by the external :arotid artery into four anatomicoradiological territories; cervical, pterygo-mandibu- ar, faciomaxillary and cranial (Fig. I): I. The Cervical Territory: The superior thyroid a., the ascending pharyn- ;eal a. as well as the main trunk of the external carotid and the proximal segments ofits remaining branches are represented in this area. In addition to the superior nd middle thyroid veins, the internal jugular vein, the external jugular v. and the ,osteriorfacial v. lie within this territory. II. The Pterygo-mandibular Territory: The maxillary and lingual aa. apply this region. The corresponding veins are often multiple and plexiform. III. The Facio-maxillary Territory: This territory could be subdivided into superficial or facial and a deep or maxillary zones. The former is supplied by ie facial artery and drained by the anterior facial vein. The latter is mainly sup- lied by the descending palatine branch of the maxillary a. and drains into the ilatine plexus of veins through the descending palatine vein. IV. The Cranial Territory: From before backwards, the following arteries ay be recognized, superimposed on the cranial part of the skull; supraorbital, iterior and posterior branches of the middle meningeal, anterior and posterior anches of the middle meningeal, anterior and posterior branches of the super- ial temporal, posterior auricular and lastly the occipital. Such a complete mial external carotid angiography was however only obtained in 30°70 of cases; supraorbital and posterior auricular often fail to be demonstrated. The Departmentof Neurosurgery,Maadi & Ain Shams University,Cairo, Egypt. -67- Fig. 1: The external carotid arterial system superimposed on the skull. veins draining the area correspond to the arteries but are less regularly demon- strated, the most constantly seen being the superficial temporal vein. Radiological Dynamics: Quoting from two previous communications (El-Banhawy & Walter, 1961- El-Banhawy, 1964), it was found out that the circulation time in the external carotid system is definitely slower than in the internal carotid one. Based on the study of a large number of 'normal' external carotid angiograms (El-Banhawy, 1964), it was found that arteries of the cervical, pterygomandibular and facio- maxillary territories fill almost simultaneously, while the cranial componentsusually lag 2 1 second behind. The order of venous filling usually follows the arterial one. The anterior facial vein is often the first to appear on facial area. Prominent lingual veins were in some cases the first veins to be demonstrated on the venogram. In common carotid (combined) angiograms, the internal jugular v. is an earlyand prominent feature of the venogram, being filled from the internal carotid a. via the venous sinuses. It is, however, less distinct in pure external carotid angiograms, being often preceded in the order of filling by the external jugular vein. Circulation Time: The whole arterial phase has an average durationof 5-6 seconds from the moment of the beginning of the injection. Then follows. a "blank" or a capillary phase that occupies the next ~-2 seconds. The firstvein is usually evident 6-8 seconds from the "shooting" moment. The internaljugular -68- vein is apparent one second later. All evidence of intravascular dye usually vanishes at the end of the 12th-14th second. INTRACRANIAL ABNOMALITIES OF THE EXTERNAL CAROTID ARTERY. The existence of intracranial branches of the external carotid artery-mainly the meningeal vessels, the peculiar character of the meningeal venous sinuses and the well known emissary veins; are all anatomical facts which favour the existence, development and symptomatisation of anomalies in these territories. Material Studies: Studying verified cases.of intracranial and extracranial angiomatous malforma- tions and aneurysms available at both Maadi Hospital Neurosurgical Centre and Ain Shams University Department of Neurosurgery it was possible to collect 62 cases with angiograms demonstrating adequately the external carotid circulation. Four cases were found to show 'Intracranial abnormalities of the external carotid circulation'. Reviewing the available literature on the subject; we were able to put each of the four cases into a different category, putting forward a tentative classification to this peculiar group of vascular anomalies. CLASSIFICATION Intracranial vascular abnormalities of the external carotid system are classi- fied into : 1. Aneurysms and Arterio-venous fistulae of the meningeal vessels. 2. Arteriovenous shunt between an external carotid extracranial branch and an intracranial dural sinus. 3. Intracranial angiomatous malformations supplied by extracranial external carotid branches. 4. Extracranial angiomatous malformations communicating with cerebral vessels. Aneurysms and Arterio-venous fistulae of the meningeal vessels Nakamura and his co-workers (1966) stressed the histo-anatomical fact, that the middle meningeal artery attains the characters of a cerebral artery as soon as it passes through the foramen spinosum. Two veins lie intradurally on both isides of the artery and its main branches; these veins-again-have the character of dural sinuses; being vascular channels between the two layers of the dura. In Isome cases, the meningeal artery lies within a single large meningeal dural sinus. Added to this are the findings of Hassler (1964) that medial defects are common in all meningeal arteries. The inference is thus obvious; aneurysms and arterio- -venous fistulae should be common sequelae of head injuries. This is not verified 0 -69- in the literature, since only eight cases of A.V. fistulae were described till the end of 1966 (Nakamura et al., 1966-Bemesconi and Canoschi, 1966) and fourteen false aneurysms till the beginning of 1968 (Bernesconi and Canoschi, 1966- El-Banhawy, 1968). Following is the case history of an interesting example of an aneurysm of the posterior branch of the middle meningeal artery. Case 1: A. K.S. is a 22 years old male, who was involved in a car accidenton September 8th, 1967 to lose consciousness immediately for a few minutes. lie was fairly well for one week. On the 8th day, he was transferred to hospital, being found in a state of semicoma with dysphasia. Clinical examination revealed, in addition, marked neck rigidity, bilateral papilledema, equal and reactive pupils and a right hemiparesis more marked in the right upper limb. Plan X-ray of the skull showed a fine fissure fracture in the parieto-occipital region. Left internal carotid angiography disclosed a shift of both anterior and middle cerebral arteries towards the right and-in the venous phase-an area of avascu- larity was delineated in the posterior parietal region. Unfortunately , the external carotid system was not visualised and the possibility of a subdural hematoma was the one put a first. Operation was carried out forthwith. Through a left parietal incision, a burr hole was made. An extensive extradural rematoma-2 to 3 cms thick-was en- countered extending in all directions. Its evacuation necessitated enlargementof the burr hole towards the temporal region, since a large part of the hematomawas seen to extend towards the base. The clot was completely evacuatd . No bleeding point was found. Immediately following the operation, the patient markedly improved, he was able to move his right side-though it remained weaker than the opposite side. Since both the dysphasia and right sided weakness did not clear out a further angiography was carried out one week after operation . A selective left external carotid angiogram was accomplished this time. This disclosed during all its phases -arterial , capillary and venous-an aneurysm about 5 mms in diameter attached or rather surrounding-as proved by oblique views-one of the branches of the posterior division of the middle meningeal artery (Fig. 2). A second operation was therefore decided upon . On September 28th, 1967, through a left temporoparietal osteoplastic flap, the posterior branch of the middle meningeal artery was exposed. An extradural clot was found and carefullyre- moved, to expose the 2 cm in diameter aneurysm surrounding the artery. This was removed into together with a clipped segment of the artery for pathological examination. Further exploration revealed neither a subdural nor an intracerebral hematoma. Serial longitudinal sections of the specimen re vealed absence of the arterial wall at one area with a communication of the intra -arterial lumen with a dilated space lined by an organized hematoma formed t o fibroblasts, collagen fib res, thin-walled capillaries and areas of interstitial hemorrha ges. The intimal -70-
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