Acesso cirúrgico ao segmento cervical distal da artéria carótida interna e à bifurcação carotídea alta - revisão integrativa da literatura e proposta de protocolo / Surgical access to the distal cervical segment of the internal carotid artery and to a high carotid bifurcation - integrative literature review and protocol proposal

Resumo Diversas manobras já foram descritas para o acesso ao segmento distal cervical da artéria carótida interna ou à bifurcação carotídea alta; entretanto, há divergências na sistematização dessas técnicas. O objetivo deste estudo é revisar as técnicas descritas e propor um protocolo prático que auxilie na seleção da técnica mais adequada para cada caso. Para isso, foi realizada uma busca nas bases de dados PubMed Central, Biblioteca Virtual em Saúde e SciELO por artigos sobre o tema, em língua inglesa ou portuguesa, publicados entre os anos de 1980 e 2021. Entre as manobras descritas, parece razoável que as duas etapas iniciais sejam a abordagem ao músculo esternocleidomastóideo, seguida pela secção/retração do ventre posterior do músculo digástrico. Caso necessário, a subluxação mandibular temporária unilateral é um recurso adicional e preferível à divisão do aparato estiloide, devido ao menor potencial de morbidade. Exposições ainda mais amplas podem ser obtidas com as osteotomias mandibulares.

Abstract Several different maneuvers have been described for obtaining access to the distal cervical segment of the internal carotid artery or to a high carotid bifurcation. However there are different approaches to systematization of these techniques. The objective of this study is to review the techniques described and propose a practical protocol to support selection of the most appropriate technique for each case. The review is based on the results of database searches on PubMed Central, the Virtual Health Library (BVSalud), and SciELO for articles on the subject published in English or Portuguese from 1980 to 2021. Among the different maneuvers described, it appears reasonable that the first two steps should be to obtain access at the sternocleidomastoid muscle, followed by section or retraction of the digastric muscle posterior belly. If needed, temporary unilateral mandibular subluxation is an additional resource that is preferable to division of the styloid apparatus process, because of its lesser potential for morbidity. Even wider exposure can be obtained using mandibular osteotomies.

Effect of internal carotid artery aberrations on the distance between styloid process and carotid artery / Efecto de las variaciones de la arteria carótida interna en la distancia entre el proceso estiloides y la arteria carótida

SUMMARY: The objective of this study was to evaluate the role of the variations of carotid artery course on the relationship between styloid process (SP) and internal carotid artery (ICA). Carotid CT angiography scans of 170 patients were retrospectively evaluated. The variability of the course of ICA were classified. The length and medial angulation of the SP were measured on coronal 3D images. On axial images, the shortest distance between the bone edge of the SP and ICA were measured. The distance between SP and ICA among the course patterns of carotid artery were compared statistically. In the comparison of distances between SP and ICA with respect to the course of ICA, the difference between straight and curving (p <0.001) was statistically significant. Curving caused the separation of ICA and SP. The highest and the shortest distance was at the curving and coiling group, respectively. We found that SP-ICA distance has a positive and negative correlation with SP angle (p<0.001) and SP length (p<0.001), respectively. The course of ICA is one of the major determinants affecting the relationship of ICA and SP. The curving pattern of ICA has a tendency to increase the distance between SP and ICA.

RESUMEN: El objetivo de este estudio fue evaluar el rol de las variaciones que tiene el curso de la arteria carótida en la relación entre el proceso estiloides (PE) y la arteria carótida interna (ACI). Se evaluaron retrospectivamente angiografías por tomografía computarizada carotídea de 170 pacientes. Se clasificó la variabilidad del curso de ACI. Se midieron en imágenes coronales y en 3D la longitud y la angulación medial del PE. En las imágenes axiales, se midió la distancia más corta entre el margen del PE y la ACI. Se comparó estadísticamente la distancia entre PE y la ACI entre los patrones de trayecto de la arteria carótida. La comparación de las distancias entre PE y la ACI respecto al curso de ACI, fue estadísticamente significativa, siendo la diferencia entre arterias recta y curva (p <0,001). La arteria curva provocó la separación de la ACI y del PE. Las mayores y menores distancias estaban en el grupo de arterias curvas y enrolladas, respectivamente. La distancia PE-ACI tiene una correlación positiva y negativa con el ángulo PE (p <0,001) y la longitud del PE (p <0,001), respectivamente. El curso de la arteria carótida interna es uno de los principales determinantes que afectan la relación con el proceso estiloides. El patrón de curva de la ACI tiende a aumentar la distancia entre PE y la propia arteria arteria.

Traumatic Dissection of Arterial Cervical Vessels: Report of Two Cases and Literature Review

Even though traumatic dissection of cervical arterial vessels is themajor cause of stroke among adults, it is still an underdiagnosed disease in neurosurgical emergencies, since most patients do not have or present subtle clinical signs in the acute phase. The authors report two interesting cases of cervical artery dissection with different traumatic mechanisms and present a broad literature review about this subject.

Applied anatomy of round window and adjacent structures of tympanum related to cochlear implantation / Anatomia aplicada da janela redonda e estruturas adjacentes relacionadas ao implante coclear

Abstract Introduction: Various aspects of the round window anatomy and anatomy of posterior tympanum have relevant implications for designing cochlear implant electrodes and visualizing the round window through facial recess. Preoperative information about possible anatomical variations of the round window and its relationships to the adjacent neurovascular structures can help reduce complications in cochlear implant surgery. Objective: The present study was undertaken to assess the common variations in round window anatomy and the relationships to structures of the tympanum that may be relevant for cochlear implant surgery. Methods: Thirty-five normal wet human cadaveric temporal bones were studied by dissection for anatomy of round window and its relation to facial nerve, carotid canal, jugular fossa and other structures of posterior tympanum. The dissected bones were photographed by a digital camera of 18 megapixels, which were then imported to a computer to determine various parameters using ScopyDoc 8.0.0.22 version software, after proper calibration and at 1× magnification. Results: When the round window niche is placed posteriorly and inferiorly, the distance between round window and vertical facial nerve decreases, whereas that with horizontal facial nerve increases. In such cases, the distance between oval window and round window also increases. Maximum height of the round window in our study ranged from 0.51-1.27 mm (mean of 0.69 ± 0.25 mm). Maximum width of round window ranged from 0.51 to 2.04 mm (mean of 1.16 ± 0.47 mm). Average minimum distance between round window and carotid canal was 3.71 ± 0.88 mm (range of 2.79-5.34 mm) and that between round window and jugular fossa was 2.47 ± 0.9 mm (range of 1.24-4.3 mm). Conclusion: The distances from the round window to the oval window and facial nerve are important parameters in identifying a difficult round window niche. Modification of the electrode may be a better option than drilling off the round window margins for insertion of cochlear implant electrodes.

Resumo Introdução: Vários aspectos da anatomia da janela redonda e da anatomia da caixa timpânica posterior são relevantes, devido a suas implicações no desenho dos eletrodos para o implante coclear e na visibilidade da janela redonda através do recesso facial. Informações prévias sobre possíveis variações anatômicas da janela redonda e suas relações com as estruturas neurovasculares adjacentes podem ajudar a reduzir as complicações dessa cirurgia. Objetivo: O presente estudo foi realizado para avaliar as diversas variações da anatomia da janela redonda e sua relação com as estruturas adjacentes, o que pode ser relevante para a cirurgia de implante coclear. Método: Trinta e cinco ossos temporais normais de cadáveres humanos frescos foram dissecados para avaliação da anatomia da janela redonda e sua relação com o nervo facial, canal carotídeo, fossa jugular e outras estruturas da caixa timpânica posterior. Os ossos dissecados foram fotografados com uma câmera digital de 18 megapixels e as imagens importadas para um computador para determinar diversos parâmetros, utilizando-se o software ScopyDoc versão 8.0.0.22, após a calibração adequada e com ampliação de 1×. Resultados: Quando o nicho da janela redonda se encontra posicionado posteriormente e inferiormente, a distância entre a janela redonda e o nervo facial vertical diminui, enquanto aquela com o nervo facial horizontal aumenta. Em tais casos, a distância entre a janela oval e a janela redonda também aumenta. A altura máxima da janela redonda em nosso estudo variou de 0,51 a 1,27 mm (média de 0,69 ± 0,25 mm). A largura máxima da janela redonda variou de 0,51 a 2,04 mm (média de 1,16 a 0,47 mm). A distância mínima média entre a janela redonda e o canal carotídeo foi de 3,71 ± 0,88 mm (variação de 2,79 a 5,34 mm) e entre a janela redonda e a fossa jugular, em nosso estudo, foi de 2,47 ± 0,9 mm (variação de 1,24 ± 4,3 mm). Conclusão: A distância da janela redonda a partir da janela oval e do nervo facial são parâmetros importantes para a identificação do difícil nicho da janela redonda. A modificação do desenho do eletrodo pode ser uma opção melhor do que o broqueamento das margens da janela redonda para a inserção dos eletrodos no implante coclear.

Intrasphenoid septations inserted into the internal carotid arteries: a frequent and risky relationship in transsphenoidal surgeries / Septações intraesfenoidais inseridas nas artérias carotídeas internas: uma relação frequente e arriscada nas cirurgias transesfenoidais

Abstract Introduction: When an expanded endonasal transsphenoidal surgical approach is performed, intrasphenoid septations must be completely resected. If these structures are close to the internal carotid artery (ICA), then their manipulation might cause vascular injury. Objective: The objective of this study is to describe the frequency of intrasphenoid septations in the internal carotid artery protuberance (ICAp). Methods: Computed tomography (CT) scans of 421 patients were analysed. Intrasphenoid septations (classified as intersphenoid or accessory) and their relationship to the ICAp were described. Additionally, a sphenoid sinus classification was performed based on their degree of pneumatisation to determine whether a difference exists in the frequency of intrasphenoid septations inserted into ICAp with regard to sinus type. Results: The patient mean age was 39 ± 21.4 years. Overall, 219 patients (52%) had septations in the ICAp; 359 patients (85.3%) had intersphenoid septations; of the latter, 135 (37.6%) had septations in the ICAp. This frequency was higher among patients with sphenoid sinus type 4 or 5 (44.7% and 43.5%, respectively). Accessory septations were found in 255 patients (60.6%); 140 of these septations (54.9%) were in the ICAp. Among 351 patients with types 3, 4 or 5 sphenoid sinuses (i.e., only well-pneumatised sphenoid sinuses), 219 (62.4%) had septations in the ICAp. These frequencies are higher than those reported in most previous studies. Conclusion: The frequency of intrasphenoid septations in the ICAp found is considerable. It is higher among patients with more pneumatised sinuses. This finding justifies an appropriate pre-operative study, and careful attention must be paid during transsphenoidal surgery.

Resumo Introdução: Quando uma abordagem cirúrgica transesfenoidal endonasal ampliada é feita, septações intraesfenoidais devem ser completamente ressecadas. Se essas estruturas estiverem próximas à artéria carótida interna (ACI), a manipulação pode causar lesão vascular. Objetivo: O objetivo deste estudo foi descrever a frequência de septações intraesfenoidais na protuberância da artéria carótida interna (pACI). Método: Exames de tomografia computadorizada (TC) de 421 pacientes foram analisados. As septações intraesfenoidais (classificadas como interesfenoidais ou acessórias) e sua relação com a pACI foram descritas. Além disso, uma classificação do seio esfenoidal foi feita com base no seu grau de pneumatização para determinar se existe uma diferença na frequência de septações intraesfenoidais inseridas em pACI em relação ao tipo de seio. Resultados: Pacientes com idade média de 39 ± 21,4 anos foram incluídos. No geral, 219 pacientes (52%) apresentavam septações na pACI; 359 (85,3%) septações interesfenoidais; 135 (37,6%) septações na pACI. Essa frequência foi maior entre os pacientes com seio esfenoidal tipo 4 ou 5 (44,7 e 43,5%, respectivamente). As septações acessórias foram encontradas em 255 doentes (60,6%); 140 dessas septações (54,9%) estavam na pACI. Entre 351 pacientes com seios esfenoidais tipos 3, 4 ou 5 (isto é, apenas seios esfenoidais bem pneumatizados), 219 (62,4%) tinham septações na pACI. Essas frequências são superiores às relatadas na maioria dos estudos. Conclusão: A frequência de septações intraesfenoidais na pACI encontrada é considerável, é maior entre pacientes com seios mais pneumatizados. Esse achado justifica um estudo pré-operatório adequado e uma atenção especial deve ser dada durante a cirurgia transesfenoidal.

Bilateral internal carotid artery agenesis: a case report / Agenesia bilateral de artéria carótida interna: relato de caso

Agenesis of the internal carotid artery (ICA) is defined as a congenital absence of the carotid canal and occurs in less than 0.01% of the population. This anomaly is usually diagnosed as an incidental finding or after a cerebrovascular event. We present the case of a 36-year-old woman, with bilateral agenesis of the ICA who had suffered a subarachnoid hemorrhage due to ruptured aneurysm of the basilar artery. Therefore, agenesis of the ICA is a condition that, although rare, should be considered since there is a risk of coexistence with other life-threatening conditions such as aneurysms.

Agenesia da artéria carótida interna (ACI) é definida como uma ausência congênita do canal carotídeo e ocorre em menos de 0,01% da população. O diagnóstico dessa anomalia ocorre geralmente como um achado incidental ou depois de um evento cerebrovascular. Apresentamos o caso de uma mulher de 36 anos, hipertensa e tabagista, com agenesia bilateral de ACI, que abriu quadro com hemorragia subaracnoide decorrente de rotura de aneurisma de artéria de basilar. A agenesia da ACI é, portanto, uma condição que, embora rara, deve ser lembrada por estar associada a outras más formações potencialmente fatais, como os aneurismas cerebrais.

Severe autogenously fecal peritonitis in Wistar rats with permanent bilateral carotid occlusion. Response to intra peritoneal moxifloxacin combined with dexamethasone

To evaluate the treatment outcome of severe peritonitis in rats submitted to permanent bilateral carotid occlusion (PBCO). METHODS: Sixteen Wistar rats (mean age of 8.5 months) with PBCO underwent autogenously fecal peritonitis, and were treated with moxifloxacin combined with dexamethasone, and followed-up for 45 days. Ten rats (mean age five months) without PBCO were used as a control group. The variables were expressed by their mean and standard error of the mean (SEM). p<0.05 was used for rejecting the null hypothesis. The study was approved by the Ethics Committee. RESULTS: There was a significant increase (p=0.0002) in the mortality and morbidity in older rats that underwent PBCO (study group). However, even among the survival rats presenting with severe residual abscesses both in the abdomen and thorax cavities, they present an almost normal life. CONCLUSIONS: The treatment of severe autogenously fecal peritonitis with intraperitoneal moxifloxacin combined with dexamethasone was very effective in young rats without permanent bilateral carotid occlusion. The treatment reached reasonable results in older rats with PBCO, even considering residual abscesses on abdomen and thorax. Older age was the greater risk factor for the outcome of the treatment of severe peritonitis. Sepsis remains a challenging situation, especially in elderly.

Anatomical arrangement and distributionof the cerebral arterial circle in rats

The cerebral arterial circle is a polygonal shape-like arterial anastomosis placed in the brain base, whereit rounds the optic quiasm and the tuber cinereum, and also related to the interpeduncular fossa and theanterior perfurated substance. It is formed by the proximal parts of the anterior, middle and posterior cerebralarteries, and the right and left posterior communicating arteries. In order to describe the cerebral arterial circledisposition we investigated the brains of twenty rats. For each animal, the heart left ventricle was probed andacetone, distilled water at 37 °C and a solution of Neoprene Latex “450” stained with a specific red pigmentwere injected in sequence into it. To fix the brain in a better way, we isolated the head and made an apertureat the dorsal wall of the cranium and the whole specimen was fixed in a 15% formaldehyde solution. We tookoff the brain from the skull with the aid of a cold light source monocular magnifier. To take the photographicdata we used a semi-professional camera. The results showed that the cerebral arterial circle in rats is formedby branches of both internal carotid arteries and of the basilar artery, and is closed rostrally by the rostralcommunicating artery, and caudally by the right and left terminal branches of the basilar artery. We concludedfrom our data that the cerebral arterial circle in rats is compound by branches of both internal carotid arteriesand basilar artery, and that it is rostrally and caudally closed.

Características biométricas de la arteria coroidea anterior en su segmento cisternal / Biometrical characteristics of anterior choroidal artery in its cisternal segment

Las implicancias clínicas que tienen los procesos oclusivos de la Arteria Coroidea Anterior (AChA), son de considerable importancia y nos han motivado para efectuar su análisis biométrico incorporando algunos otros parámetros. Para su ejecución, se utilizaron cerebros inyectados con látex coloreado de rojo fijados en solución de formol, provenientes del Servicio Médico Legal, Santiago.Para su observación, se usó lupa luminiscente 4 X y las mediciones efectuadas con Caliper Mitutoyo Digital. Esta arteria se originó de la Carótida Interna (ACI) en un 83,3 por ciento y en un 16,7 por ciento de la Arteria Comunicante Posterior (ACoP ). El calibre medio observado en su origen fue de 0,68 +/- 0,31 mm; en el tercio medio de 0,60 +/- 0,21 mm; en el punto de entrada en el plexo coroideo de 0,48 +/- 0,23 mm. La longitud media desde el origen de la AChA al plexo coroideo fue de 28,67 +/-6,33 mm; la distancia media desde su origen al de la ACoP fue de 6,97 +/- 4,89 mm. El número promedio de ramas perforantes registradas fue de 6. Nuestros resultados pueden ser una contribución a considerar en la clínica...

The clinical implications of occlusive processes in the anterior choroidal artery (AChA) are of considerable importance and have motivated us to perform a biometrical analysis of the afore mentioned artery including new biometric parameters (measurements). This study was perfomed on vascularized brains that were both fixed with for formalin solution and injected whith red tinted latex and brains that were not fixed with formalin solution, which were obtained from the Medical Legal Service, Santiago. They were observed using a luminescent 4 X magnifying glass and the measurements perfomed using a Mitutoyo Digital Caliper. This artery originated from the internal carotid artery (ICA) in 83.3 percent of the cases observed, and in 16.7 percent it originated from the posterior communicating artery ( PCoA). The mean caliber (diameter) of the artery was 0.68 +/- 0.31 mm at the point of origin; the middle third was 0.60 mm +/- 0.21 mm; at the point of entry into the choroidal plexus it was 0.48 mm +/- 0.23 mm. The mean length from its origin at the AChA to the choroidal plexus was 28.67 mm +/- 6.33 mm; the mean distance from its origin at the PCoAwas 6.97mm+/- 4.89 mm. The number of perforating branches of the AChA was 6. Our results can be considered a clinical contribution...

Calcification of the left internal carotid artery and itsimplications: a case report in human

During routine activities in the laboratory, a calcified segment of the left internal carotid artery was observedin a caucasian cadaver skull. The calcification extends from the cerebral segment to the cavernous segmentof the internal carotid artery. Some important diseases seems to be related with calcification of the internalcarotid artery, thus, the present study shall be important for health sciences and those who keep some interestin pathologies associated with calcifications.

Grosor de íntima-media carotídea en niños sanos por técnica ecográfica computarizada / Arterial intima-media thickness in healthy Chilean children using an ultrasonographic computerized technique

Introduction: Vascular endothelium is a target organ in metabolic syndrome. Ultrasound measurement of intimae-media thickness (IMT) is used in adults to predict cardiovascular risk, but normal values in children are unknown. Objective: To describe arterial intima-media thickness in healthy children, by means of an ultrasonographic technique and a specific software. Subjects and Methods: Seventy-four healthy children, 39 males, ages 5-15 y.o., body mass index (BMI) 10-85 percentile were selected from an upper-middle socioeconomic background. Subjects were grouped by age. Three measurements were carried out to each subject at the middle third of the right common carotid for maximal intima-media thickness using a Phillips iU22 ultrasound system; a 12-5 MHz lineal transducer and QLAB advanced quantification software, which includes a specific program for automated IMT measurements, were used. Weight, stature, BMI, and abdominal circumference were registered. Results: No significant differences in the IMT values according to age or gender were found. Median IMT was 0.41 mm (0.40-0.56 mm); 5 children presented IMT 0.50-0.56 mm (> 75th percentile). The median IMT for those children with abdominal circumference < 50th percentile was the same for those over 50th percentile (0.41 mm). Conclusions: Measurements of carotid intima-media thickness for healthy Chilean children were found to be in the expected range, in relation with adult known values.

Introducción: Uno de los sitios de daño asociado a síndrome metabólico es el endotelio vascular; la medición ecográfica del grosor de intima-media carotídea (GIMC) es usado en adultos como un indicador de daño vascular, pero no se conocen valores de normalidad en niños. Objetivo: Estudiar el grosor de intima-media carotídea mediante programa computacional específico, en niños chilenos sanos. Pacientes y Método: Se seleccionaron 72 niños (percentiles 10-85 de IMC sin enfermedad conocida), 5 a 15 años de edad, de estratos socioeconómicos medio-altos, 33 niñas y 39 varones, agrupados por tramos de edad; se les efectuó y promedió 3 mediciones ecográficas en tercio medio de arteria carótida común derecha, mediante equipo Phillips modelo ÍU22; se usó un transductor lineal 12-5 MHz y un software de cuantificación avanzada QLAB, con programa específico de medición automática para grosor de GlMC Además se les midió: peso, talla, 1MC, perímetro abdominal (PA). Se solicitó previamente el consentimiento escrito a padres y niños. Resultados: No hubo diferencias en las mediciones de GlMC de acuerdo a edad o sexo, la mediana fue de 0,41 mm (0,40-0,56 mm); hubo 5 niños entre 0,50 y 0,56 mm (> percentil 75); no hubo correlación con PA o 1MC; los niños con PA < percentil 50 tuvieron una mediana de GlMC igual a aquellos con PA > percentil 50 (0,41 mm). Conclusiones: Las mediciones de grosor de intima-media carotídea de niños y adolescentes chilenos sanos mediante técnica ecográfica y programa computarizado, están dentro de valores esperados para la edad, comparados con valores conocidos de adultos.

Estudo da anatomia endoscópica do acesso transpterigóideo e da artéria carótida interna por via endonasal / Anatomical study of the endoscopic endonasal transpterygoid approach and the internal carotid artery

INTRODUÇÃO. Durante a última década, os avanços tecnológicos, o maior domínio da anatomia e das técnicas operatórias e de reconstrução da base do crânio por via endonasal propiciaram a expansão da cirurgia endoscópica para além dos limites da sela túrcica. O acesso transpterigóideo é uma etapa comum ao acesso as fossas cranianas média e posterior, e o conhecimento da anatomia endoscópica da artéria carótida interna (ACI) é um ponto fundamental e comum a estes acessos. OBJETIVO. Descrever a anatomia endoscópica relacionada ao acesso transpterigóideo e da ACI utilizando um modelo anatômico em cabeças cadavéricas frescas procurando definir os parâmetros seguintes: reparos anatômicos do acesso endoscópico a região supra e infrapetrosa, os limites para exposição endoscópica da ACI, os reparos anatômicos para localização dos seus segmentos lacerum, petroso e parafaríngeo. MÉTODOS. Foi realizado estudo anatômico em 20 espécimes (10 cabeças) de cadáveres frescos. As cabeças foram previamente preparadas com a injeção intravascular de silicone corado para enaltecer as estruturas vasculares (ACI, artéria maxilar e seus ramos e seio cavernoso). Em todos os casos foi realizado o acesso transpterigóideo às regiões supra e infrapetrosa, assim como a fossa infratemporal, e a dissecção endoscópica da ACI. RESULTADOS. A injeção de silicone corado no sistema arterial e venoso proporcionou modelo anatômico adequado para dissecção e documentação do acesso transpterigóideo assim como dos diferentes segmentos da ACI. A dissecção por etapas proporcionou exposição adequada da ACI do seu segmento cavernoso ao parafaríngeo distal. O acesso transpterigóideo forneceu exposição adequada do segmento lacerum da ACI e região suprapetrosa e seus principais reparos anatômicos foram o nervo vidiano, nervos maxilar e mandibular (V2, V3) e gânglio de Gasser. A exposição caudal da ACI (segmentos petroso e parafaríngeo) e região infrapetrosa requer maxilectomia medial para exposição...

INTRODUCTION. During the last decade, the technological advances, the mastery of the anatomy and operative techniques and skull base reconstruction using endonasal approaches have propelled endoscopic surgery for beyond the limits of sella turcica. The transpterygoid approach is a common step of the endoscopic approach to the middle and posterior cranial fossa and knowledge of the endoscopic anatomy of the internal carotid artery (ICA) is a common and paramount point to these approaches. OBJECTIVE. Describe the endoscopic anatomy related to the transpterygoid approach and ICA using an anatomical model with fresh human cadaveric heads to define: anatomical landmarks related to the endoscopic supra and infrapetrous areas approach, limits for endoscopic exposure of the ICA, anatomical endoscopic landmarks to lacerum, petrous and parapharyngeal ICA segments. METHODS. An anatomical study was performed using 20 specimens (10 heads) of fresh cadaveric heads. The heads were previously prepared with the injection of colored silicone to enhance the vascular structures (ICA, maxillary artery and its branches and cavernous sinus). In all cases we performed the transpterygoid approach to the supra and infrapetrous areas, as well as the infratemporal fossa, and the endoscopic dissection of the ICA. RESULTS. The injection of colored silicone in the arterial and venous system provided an adequate anatomical model for dissection and documentation of the transpterygoid approach as well as the different segments of the ICA. A stepwise dissection provided adequate exposure of the ICA from its cavernous to the distal parapharyngeal segment. The transpterygoid approach provided adequate exposure of the lacerum segment of the ICA and suprapetrous area and the landmarks were the vidian nerve, maxillary and mandibular nerves (V2, V3) and the Gasserian ganglion. Exposure of the caudal ICA (petrous and parapharyngeal) and the infrapetrous area required a medial maxillectomy for...

Utilização do anel metálico unitary anastomotic device (UAD) e da técnica convencional de sutura para anastomose da artéria carótida experimentalmente em cães / Utilization of the unitary anastomotic device metallic ring and the conventional technique of suture for experimental anastomosis of the carotid artery in dogs

O presente estudo teve como objetivo comparar a técnica de anastomose término-terminal convencional com a utilização do anel metálico Unitary Anastomotic Device (UAD). Seis cães machos, sem raça definida, adultos jovens foram submetidos à anastomose término-terminal experimental da artéria carótida, por meio das duas técnicas operatórias. Em um lado utilizou-se a técnica convencional com sutura contínua, com polipropileno 5-0 unindo três pontos equidistantes e, na artéria contralateral, empregou-se o anel metálico unindo as extremidades vasculares com o mesmo fio. Foram avaliados o tempo de execução das anastomoses a presença de hemorragia durante o procedimento cirúrgico, o diâmetro dos vasos e o pico de velocidade sistólica (PSV) após as anastomoses. Os dados foram submetidos a estudo estatístico (teste t de Student, com nível de significância igual a 0,05%), levando-se em consideração a natureza das variáveis estudadas. O tempo de execução foi estatisticamente menor no lado do anel metálico (P < 0,05), no qual não se observou episódio de hemorragia. A sutura convencional apresentou pequena hemorragia em dois animais, as quais foram contidas com pontos adicionais. Houve aumento estatístico do diâmetro do vaso observado no lado pósanastomose quando se utilizou a prótese (P < 0,05), o que contribuiu para um menor PVS no local quando comparado com o lado da sutura convencional, embora não tenham diferido estatisticamente (P > 0,05). Os resultados permitiram concluir que ambos os métodos são eficientes, porém o anel metálico propicia um tempo significativamente menor de execução, contribuindo principalmente para cirurgias laboriosas com múltiplas anastomoses, como os transplantes de órgãos, pois o tempo de isquemia do órgão pode ser determinante para a sobrevivência do paciente.

Unitary Anastomotic Device (UAD) metallic ring. The study was carried out with six mongrel dogs, young adult male dogs. The animals were submitted to experimental closing-terminal anastomosis of the carotid artery, by two surgical techniques. On one side, the conventional technique of continuous suture with polypropylene 5-0 was used with the union of three equally distant stitches and on the counter-lateral artery, the metallic ring was used bonding the vascular extremities with the same thread. The time of execution of the anastomosis, the presence of hemorrhage during the surgical procedure, the diameter of the vessels and the blood speed (PVS) through ultrasonography with a colored Doppler were all compared after the anastomosis. In the clinical evaluations, the methods used presented similar results. The time of execution was significantly shorter on the side of the metallic ring, in which no hemorrhage episode was observed. Vessel diameter on the side of metallic ring was statistical larger than the side of conventional suture which contributes for the lower PVS, although it does differ statistically (P > 0.05). In conclusion, both methods are efficient, however, the metallic ring provides a significantly shorter time of execution which contributes for laborious surgery with many anastomosis, like organs transplants, where the time of organ ischemy can be crucial for patient survival.

Estudo anatômico da cóclea para confecção de instrumental para a cirurgia de implante coclear com 2 feixes de eletrodos em cócleas ossificadas / Cochlear anatomy study used to design surgical instruments for cochlear implants with two bundles of electrodes in ossified cochleas

A ossificação da cóclea, decorrente principalmente de meningite, impede a inserção completa do implante coclear convencional. Os implantes com 2 feixes de eletrodos mais curtos do que o convencional foram desenvolvidos especialmente para cócleas ossificadas. Porém, durante essa cirurgia há um grande risco de lesão da artéria carótida interna (ACI). Portanto, a medida da profundidade das cocleostomias para inserir os dois feixes de eletrodos aumentaria a segurança desse procedimento. OBJETIVOS: 1) Obter as distâncias entre as cocleostomias e a ACI em ossos temporais de cadáver; 2) Confeccionar instrumento que possa ser usado na cirurgia de implante coclear com 2 feixes de eletrodos. FORMA DE ESTUDO: Experimental prospectivo. MATERIAL E MÉTODO: Em 21 ossos de cadáveres foi realizada: 1) mastoidectomia cavidade aberta; 2) cocleostomias nos giros basal e médio da cóclea; 3) identificação da ACI; 4) medida da distância entre as cocleostomias e a artéria. RESULTADOS: A medida média ± desvio padrão obtida para o túnel superior foi 8,2 ± 1,1mm e para o túnel inferior foi 8,1± 1,3mm. A menor distância encontrada foi 6,5mm para o túnel superior e 6,0mm para o túnel inferior. CONCLUSÃO: Apesar dos parâmetros calculados concluímos que a melhor medida para ser considerada na confecção do instrumento cirúrgico serão as mínimas medidas obtidas em cada um dos giros cocleares, pois é a maneira mais segura para evitar a lesão da ACI, que pode ser fatal.

Cochlear ossification, mainly secondary to meningitis, prevents the complete conventional cochlear implant insertion. Implants with two electrode bundles shorter than the conventional ones were specifically developed for ossified cochleas. However, during surgery there is a high risk of damaging the internal carotid artery (ICA). Therefore, measuring cochleostomy depth in order to insert the two electrode bundles would greatly increase the procedure's safety. AIMS: 1) Find the distances between cochleostomies and ICA in cadaver temporal bones. 2) Design an instrument that can be used in cochlear implant surgery to introduce an implant with two bundles of electrodes. STUDY DESIGN: Experimental prospective. MATERIALS AND METHODS: In 21 temporal bones from cadavers we performed: 1) canal wall down mastoidectomy; 2) cochleostomy in the cochlear basal and middle turns; 3) ICA identification; 4) Length determination between the cochleostomies and the artery. RESULTS: the average distance ± standard deviation obtained for the upper tunnel was of 8.2 ± 1.1 mm and for the lower tunnel it was of 8.1± 1.3 mm. The shortest distance found was of 6.5 mm for the upper tunnel and 6.0 mm for the lower tunnel. CONCLUSION: Despite the values calculated, we concluded that the best value to be considered in creating a surgical instrument are the minimum lengths obtained for each one of the cochlear turns, because this is the safest way to avoid damaging the ICA, that can be fatal.

Aspectos Biométricos de las Arterias Cerebral Anterior en el Segmento Proximal (Al) y Carótida Interna / Biometrical Aspects of the Anterior Cerebral Artery in its Proximal Segment (Al) and Internal Carotid Artery

La conformación del círculo arterial cerebral tiene relevancia en la clínica neuroquirúrgica por la relación compleja que presentan las arterias que lo originan y su gran variabilidad Debido a a esto, hemos decidido efectuar un análisis biométrico de las arterias cerebral anterior (Al) y de la arteria carótida interna (ACI) por posible asociación o correlación en estas estructuras. El trabajo se realizó en 36 cerebros disponibles en los laboratorios y cuyos datos bioantropológicos estaban registrados. El segmento Al de la arteria cerebral anterior derecha tuvo una longitud y calibre promedio de 12,86+1.58mm y 2,37±0,68mm, respectivamente. En el lado izquierdo la longitud y el calibre promedio de esta arteria fue 12,62+1.96mm y de 2,42±0,75mm, respectivamente. El calibre del lado derecho de la ACI fue 3,84±0,68mm y del lado izquierdo fue 3,96±0,87mm. Se observó variabilidad anatómica de los componentes que constituyen el círculo arterial cerebral cuando se considera lado, sexo e índice cefálico.

The conformation of the arterial circle of the base of the brain has relevancy in the neurochirurgical clinic as the complex relation that there present the arteries that originate it and its great variability. Due to the high frequency the aneurysms observed in the anterior communicating arteries, besides too, in the precommunicating segment (Al) of the anterior cerebral artery, we have decided to carry out a biometrical analysis of these arteries and the ICA for research possible association or correlation in these arteries.The work was realized in 36 available brains in the anatomical laboratories. These specimens had bioanthropological data. The segment Al of the anterior cerebral artery observed a length of 12,86 ± 1.58 mm and presents a diameter of 2.37 ± 0.68 mm in the right side. In the left side the length of this one segment is 12. 62 ± 1.96 mm and presents a diameter of 2.42 ± 0.75 mm. The external diameter of the ACI in the right side was 3.84±0.68 mm and in left side was 3.96 ± 0.87 mm. It is observed variability of the components that constitute the arterial cerebral circle when it is considered to be the side, the sex and cephalic index.

Microsurgical anatomy of the arterial compartment of the cavernous sinus: analysis of 24 cavernous sinus

O seio cavernoso é estrutura complexa localizada de cada lado da sela túrcica, sendo seu conhecimento microanatômico indispensável quando se considera abordar cirurgicamente esta região. Estudaramos em laboratório de microcirurgia a microanatomia dos componentes arteriais deste espaço em 24 seios cavernosos, sendo que em todos a artéria carótida interna estava preenchida com látex colorido. O tronco meningo-hipofisário esteve presente em 18 casos (75%). Quando ausente, as artérias constituintes deste tronco se originaram diretamente das artérias carótidas internas (ACIs) intracavernosas. Quando presente, em 14 casos (77,7%), estavam trifurcados e em 4 casos (23,3%) bifurcados. A artéria tentorial foi identificada em todos os casos, porém sua origem foi variada, ocorrendo no tronco meningo-hipofisário em 17 casos (70,8%) e na artéria carótida interna intracavernosa em 7 casos (29,1%). Em 1 caso verificou-se a presença de uma artéria tentorial acessória. A artéria meningéia dorsal estava presente em 22 casos (91,6%) e ausente em 2 casos (8,4%). Nos seios cavernosos onde a mesma foi identificada, a sua origem ocorreu no tronco meningo-hipofisário em 17 casos (77,2%), da ACI intracavernosa em 4 casos (18,1%) e da artéria hipofisária inferior em 1 caso (4,1%). A artéria hipofisária inferior foi identificada em todos os casos, tendo sua origem no tronco meningo-hipofisário em 16 (66,6%) e na ACI intracavernosa em 8 (33,3%) casos. A artéria inferior do seio cavernoso ou tronco ínfero-lateral foi isolada em 100% dos casos e em todos se originou da ACI intracavernosa. A artéria de McConnell não foi identificada em nenhum seio cavernoso.

Tortuosity of the internal carotid artery cervicalcourse: case reports and literature review

Variations in the course of the internal carotid arteries (ICA) are reported in the literature as coiling, looping,kinking or tortuosities of the vessels. Nevertheless, the definitions between these variants are confusing. Also, the clinical relevance of morphological anomalies of extracranial ICA is a matter of debate because of up to date the natural history of kinking, coiling and tortuosities of this artery is not well known. However, some authors consider that these conditions are burdened with disabling, even fatal neurological complications.Also, variations of the ICA cervical course may lead to direct contact of the artery with the pharyngeal wall, being of great clinical relevance due to the large number of routine procedures performed in this region. In the present study, we describe two cases of ICA tortuosities and review the current literature regarding the causes, symptoms and clinical significances of the variations of the cervical ICA course. Tortuosity of the cervical ICA is not a rare condition and they can easily be mistaken clinically for an aneurysm, a tumor or an abscess and subsequently injured during an attempted biopsy or excision. Thus, regardless the controversy of its causes (congenital or acquired) it should be included in the differential diagnosis of cervical soft tissue widening. Also, they should be taken into consideration on the diagnostic procedures for ischemic transitory attacks and/or stroke.

Tratamiento endovascular con sistema GDC de aneurismas del segmento carotideo de la arteria comunicante posterior: experiencia en 100 casos / Endovascular treatment with GDC system of posterior communicating internal carotid aneurysms: experience in 100 cases

Objetivo: en algunos casos de aneurismas que se originan del segmento comunicante posterior de la arteria carotida interna son dificil de tratar en forma microquirurgica, por lo que son remitidos para ser tratados por via endovascular. En una serie de estos casos evaluamos el resultado inmediato y tardia de la embolizacion, y resultados clinicos alejados. Metodos: en un periodo de diez años, 98 pacientes con 100 aneurismas fueron tratados con Guglielmi Detachable Coll system por el equipo medico del Centro Endovascular Neurologico Buenos Aires. Los resultados clinicos y angiograficos y seguimiento fueron evaluados retrospectivamente. Resultados: se logro una oclusion total o subtotal en 53 y 27 por ciento de los casos con 19 por ciento de oclusion subtotal y parcial. De los 98 pacientes unicamente 49 fueron evaluados en forma alejada desde el punto de vista clinico (87,8 por ciento mostraron una buena recuperacion, 5 pacientes tuvieron una moderada incapacidad y 1 paciente fallecio por causas no relacionadas) y 53 de los 100 aneurismas tuvieron seguimiento angiografico para evaluar la estabilidad de la oclusion, observando que 26,4 por ciento tuvieron compactacion de los coils. El grado de compactacion considerando el tamaño del cuello de aneurismas rotos reflejo un 7,1 por ciento de compactacion de los coils en aneurismas con cuello pequeño y un 50 por ciento en los de cuello grande. No observando resangrado aneurismatico en el seguimiento alejado. Conclusion: El resultado de este estudio indica que el tratamiento endovascular es una alternativa terapeutica segura y efectiva en los aneurismas del segmento carotideo de la arteria comunicante posterior, y ademas un cuarto de los aneurismas mostraron compactacion de los coils siendo a pesar de esto efectivo para la proteccion del sangrado y resangrado

Anatomia angiografica de los aneurismas carotidocomunicantes posteriores / Angiographic anatomy of the posterior communicating artery aneurysms

Objective: to study the anatomical features of posterior communicating artery aneurysms in relation to the anatomical variants of the paren vessels. Methods:Angiograms of 106 PCom aneurysms were reviewed. Results: Fetal Posterior Cerebral Artery was found in 19,8 por ciento of the cases; 57,5 por ciento of the aneurysms originated in the carotid artery; 78 por ciento of the aneurysms were smalls (less than 10mm). Conclusion: Pcom aneurysms most frecuently arise from the carotid artery itself. The presence of a fetal posterior cerebral artery is not related to the development of Pcom aneurysms

Anatomical study of the intrapetrous branches of the internal carotid artery

The description of the trajectory and ramifications of the petrous portion of the internal carotid artery (ICA) is not uniforme and knowledge of these variations is of great importance for image diagnosis profissionals and surgeons working in this area. In the present anatomical study, we injected a contrast mixture into the petrous portion of 30 ICA; we then observed 20 of then by microdissection, and obtained sections perpendicular to the horizontal portion of the carotid canal from the remeaning 10. Different results were obtained for the dissected and sectioned material. In 7 of the dissected specimens (35 per cent) the ICA are branched and in 6 of them ramification occurred in the horizontal segment. The branches were classified as periosteal in 7 cases and as arteries of the pterygoid canal in 5. In the 10 sectioned pieces, the ICA branched in only one case (10 per cent) and the branch was classified as an artery of the pterygoid canal. No branch that could be classified as a caroticotympanic of the ICA could be systematized in terms of the periosteal branches and pterygoid canal, but that more studies are needed for the caroticotympanic branch.