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NEUROIMAGE
Year : 2021  |  Volume : 69  |  Issue : 5  |  Page : 1271-1272

Scour the Unthinkable – Intrathoracic Bifurcation of the Common Carotid Artery With Hypoplastic Internal Carotid Artery


Department of Radiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Date of Submission19-Jan-2021
Date of Decision25-Jan-2021
Date of Acceptance05-May-2021
Date of Web Publication30-Oct-2021

Correspondence Address:
Gokulraja Srinivasaraja
Department of Radiology, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai - 600 116, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.329594

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How to cite this article:
Srinivasaraja G, Rangasami R. Scour the Unthinkable – Intrathoracic Bifurcation of the Common Carotid Artery With Hypoplastic Internal Carotid Artery. Neurol India 2021;69:1271-2

How to cite this URL:
Srinivasaraja G, Rangasami R. Scour the Unthinkable – Intrathoracic Bifurcation of the Common Carotid Artery With Hypoplastic Internal Carotid Artery. Neurol India [serial online] 2021 [cited 2021 Dec 3];69:1271-2. Available from: https://www.neurologyindia.com/text.asp?2021/69/5/1271/329594




A 33-year-old male patient presented to the neurology department with complaints of headache and neck pain. His past medical history was unremarkable. The results of physical and neurological examinations were normal. He underwent magnetic resonance imaging (MRI) brain with intracranial and cervical magnetic resonance (MR) angiography, using a 1.5 T MR scanner (GE Signa HDxt). Imaging of the brain revealed no abnormality. The angiography revealed a short right common carotid artery (CCA) measuring ~ 4 mm, and it was seen to bifurcate subsequently at the level of the T1 vertebra. The right internal carotid artery (ICA) appeared hypoplastic measuring ~3 mm throughout its course. A correlative ultrasound examination of the carotid vessels was performed. The ultrasound scan demonstrated an extremely short CCA on the right, with apparently normal flows and normal spectral wave patterns/velocities in the external and internal carotid arteries (ECA and ICA) [Figure 1].
Figure 1: (a) Oblique coronal maximum-intensity projection-reformatted image and (b) volume-rendered image of time-of-flight MR angiography showing a short right common carotid artery (CCA) with a subsequent intrathoracic bifurcation (Arrow) and right hypoplastic internal carotid artery (HICA). Note the normal cervical level of bifurcation of left CCA (*). (c) Ultrasound gray scale image and (d) color Doppler image showing the short bifurcation of the right CCA with HICA (Arrowhead). (e and f) Pulsed wave Doppler images showing normal spectral wave patterns of right external and internal carotid arteries, respectively

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To the best of our knowledge, there have been only two previously reported cases of intrathoracic bifurcation of CCA along with hypoplastic internal carotid artery (HICA) in the literature.[1],[2] The prevalence of HICA is estimated to be about 0.01%.[3] Intrathoracic carotid bifurcation may present a diagnostic challenge because they can be inaccessible to sonographic evaluation or lying outside the region of interest during MR cervical angiography. They carry a high risk of inadvertent catheterization above the carotid bifurcation during conventional cerebral angiography if they are associated with a short CCA and hypoplastic ICA, as in the reported case. Patients with HICA may remain completely asymptomatic due to collateral blood supply or they may present with symptoms due to cerebrovascular insufficiency that might ultimately lead to cerebral ischemia. Thus, it warrants the diagnostic need for the early recognition of HICA in the clinical workup of such patients. Last, in the case of atheromatous disease of the carotid vessels, the intrathoracic location of the bifurcation would make carotid endarterectomy very arduous, requiring an alternative therapeutic strategy, such as angioplasty and stenting. Hence, one must not forget to anticipate such anatomical variants during the reporting of MR cervical angiographic studies and must utilize a multidisciplinary approach with careful follow-up to identify early and optimal management.

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  References Top

1.
Dawson AG, Wilson A, Maskova J, Murray AD, Reid JM, Kuhan G. Hypoplastic internal carotid artery stenosis with a low-lying carotid bifurcation causing cerebral ischemia. J Vasc Surg 2012;56:1416-8.  Back to cited text no. 1
    
2.
Gomez CK, Arnuk OJ. Intrathoracic bifurcation of the right common carotid artery. BMJ Case Rep 2013;2013:bcr2012007554.  Back to cited text no. 2
    
3.
Nicoletti G, Sanguigni S, Bruno F, Tardi S, Malferrari G. Hypoplasia of the internal carotid artery: Collateral circulation and ultrasonographic findings. A case report. J Ultrasound 2009;12:41-4.  Back to cited text no. 3
    


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