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The carotid artery: Embryology, normal anatomy, and physiology

Article  in  Neuroimaging Clinics of North America · December 1996

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IMAGING OF CAROTID ARTERY DISEASE
THE CAROTID ARTERY
Embryology,Normal Anatomf , andPhysiology
David H. Dungan, MD, and ]oseph E. Heiserman, MD, PhD
The word carotid is derived from the Greek
KotpaLv, to stupefy. The vessel has also been
termed the apoplectic or sopornl artery in recog-
nition of the'common effect of compression of
both carotids. Aristotle is credited as the earli-
est source of this observation.26 The Greek phy-
sician Galen (129-799) laid early groundwork
for the understanding of blood flow by estab-
lishing that arteries contain blood and not air;
however, he considered the liver to be the pri-
mary organ of the vascular system and_ be-
lieved thit blood was delivered to the end or-
gans through both arteries and veins.E The
circulation of the blood was established by the
physician William Harvey (1,578-1.657), who
published his revolutionary findings in 1628
lnExercitotio Aruttomic de Motu C{udis et Sangui-
nis in Animalibus (Analomical Essay on the Mo-
tion of the Heart and Blood in Animals).31
Early attempts to delineate the structural el-
ements of the human vascular system date to
the artist and scientist Leonardo da Vinci
(1.452-1519). His understanding was based on
a modification of Galenic theory, and his obser-
vations were based on dissections of animals
and a detailed study of a 100-year-o1d human
circa 1504-1506. Although his depiction of the
neck arteries in his famous notebooks does
include the carotid arteries, the details are
flawed. A notation on his anatomic drawing
of the neck (in his distinctive mirror script)
indicates his understanding of the importance
of the carotids26:
From the Divisions of Neuroradiology (lEH) and Neurosurgery (DHD); Barrow Neurological Institute, St. Joseph's
Hospital and Medical Center, Phoenix, Arizona
NEUROIMAGING CLINICS OF NORTH AMERICA
VOLUME 6. NUMBER 4. NOVEMBER 1996
1052-51.49/96 $0.00 + .20
"If you compress the 4 vessels [carotids and
jugulars] of either side where they are in the
thioat, he who has been compressed will sud-
denly fall to the ground asleep as though dead
and will never wake himself; and if he is left
in this condition for the hundredth part of an
hour, he will never wake, neither of himself
nor with the aid of others."
It was the anatomist Andreas Vesalius
(151,4-1,564) who first observed in systematic
detail the human vascular system. His master-
work, De Humani Corporis Fabrica (1543), is
considered by some to be the greatest contribu-
tion to the medical sciences. This work is based
on both animal and human dissections, and
his drawings of the vascular system in book
III reflect this experience and his Galenic un-
derstanding of blood flow (Fig. 1).34
With the acceptance of Harvey's concept of
the circulation, understanding of the vascular
anatomy improved.3l Details regarding the
outflow of the carotids was provided by the
work of the London physician Thomas Willis
(7627-7675) published in Cerebri anatome
nervorumque (166$. The physician and anato-
mist Antonio Scarpa (7752-1832) was the first
to depict the carotid sinus in Tabulae neurologi-
cae adillustrondum historiam anotomicom cardiac-
orum neralrum (1794). The role of variation in
the vascular tree was explored by the surgeon
and anatomist Richard Quain (1800-1887),
who published the results of dissections of
nearly a thousand subjects in The nnatomy of
789
790 DUNCAN & HEISERMAN

Figure 1. Early depiction of the vascular system by Vesalius from

De Humani Corporis Fabrica, 1543. The carotid arteries are shown
primarily supplying the choroid plexus, with branches anastomosing
to the transverse sinuses. (Adapted from Saunders, O'Malley: The
lllustrations from the Works of Andreas Vasalius of Brussels. New
York, Dover, 1973, p. 136; with permission.)

the arteries of the human body with its applications
to pathology and operntiae surgery in lithographic
drawings with practical commentaries (7844).
These investigators and others set the stage
for the radiographic evaluation of the carotid
arteries in the living patient, which was made
possible by the techniques of angiography dis-
cussed by Egas Moniz in his classic workL'An-
giogr nphie Cerebr nle (1934).'?1
EMBRYOLOGY
The embryologic vascular system develops
immediately before the appearance of so-
mites, at approximately 19 days. Primitive
spongy mesoderm, mesenchyme, forms vas-
cular channels within the embryonic disc that
coalesce into blood vessels. A pair of longitu-
dinally directed channels arise in a paramed-
ian location to ultimately become the dor-
sal aortae.3
From 21 to 25 days, the heart tubes fuse into
a primitive heart, and the ventral aortic sac
becomes connected to the dorsal aortae by the
paired first aortic arches. By 32 days, six pairs
of aortic arches have formed, coursing around
the five branchial arches. The first three arches
are present by 28 days, but the first two arches
involute before formation of the fifth and sixth,
so that the arches are not all present at any
one time.28 The pattern of persistence or regres-
sion of these arches is reflected in the normal
anatomy and anatomic variations of the
great vessels.
The first two paired aortic arches involute
without a significant remnant in the adult vas-
culature. The third arches are precursors to the
carotid system, and the fourth arches develop
asymmetrically. The left fourth aortic arch re-
mains in continuity with the aortic sac and
left dorsal aorta, forming the normal adult left
aortic arch. The right fourth arch, together with
part of the right dorsal aorta, forms the proxi-
mal right subclavian artery. The fifth aortic
arches, similar to the corresponding fifth
branchial arches, are rudimentary or nonexis-
tent in humans. The sixth aortic arches contrib-
ute to the pulmonary arteries and truncus arte-
riosus.l
The carotid system develops as a result of
regression of three separate arterial segments.
Before involution of the first two aortic arches,
blood flows to the cranial region from the ven-
tral aortic sac to the dorsal aorta through the
first arches. However, by 29 days the first and

second arches have significantly involuted,
and by 6 weeks there is also regression of the
dorsal aortae between the third and fourth
arches (the ducttts carotidus). Regression of
these vascular segments leaves one predomi-
nant connection to the cranial region, from the
ventral aortic sac through the third aortic arch
to the cranial extension of the dorsal aorta.13 It
is this combination of ventral aortic sac, third
aortic arch, and dorsal aorta rostral to the third
arch that form the common and internal ca-
rotid arteries (Fig. 2).
The external carotid artery forms from a di-
rect branch of the aortic sac, the ventral pha-
ryngeal artery, which supplies the first and
second pharyngeal arches. At approximately
40 days, rapid descent of the heart causes the
origin of the external carotid to migrate from
the aortic sac for a variable distance along the
third arch. This migration of the external ca-
rotid origin determines the site of the carotid
bifurcation, and accounts for the third arch
becoming a precursor to both the common and
internal carotid arteries (Fig. 3).1
DA----..>
DC *--**--">
lnterseg
Vert **+
.rDA*_
Figure 2. Embryologic origin of the carotid system. From
21 to 32 days, six paired aorlic arches (l-Vl) develop to
connect the aortic sac (AO) to the dorsal aortae (DA). The
first two arches and part of the dorsal aoda, the ductus
carotidus (DC), regress. This leaves a single conduit (gray)
from the aortic sac to the cranial region. Asymmetric growth
of the fourth arches leads to asymmetry of the carotid
origins. The sixth arches contribute to the pulmonary arter-
'es (MPA). Anastomoses between the first seven interseg-
mental arteries (lnterseg) form the vefiebral arteries (Vert).
THE CAROTID ARTERY 791
Figure 3. Normal adult aortic arch. Persistence of the left
fourth aortic arch leads to left-sided arch anatomy. The
right fourlh arch contributes to the subclavian artery. The
right carotid arises from the innominate artery, which is a
remnant of the ventral aortic sac. The left carotid arises
directly from the (fourth) arch. The carotid bifurcations re-
flect migration of the origin of the ventral pharyngeal artery
for a variable distance along the third arch. Compare with
Figure 2.
The distal internal carotid divides into cra-
nial and caudal branches by 29 days. The cra-
nialbranch is the olfactory artery, which subse-
quently supplies multiple branches to the
rapidly growing forebrain, including the ante-
rior choroidal, anterior, and middle cerebral,
and anterior communicating arteries. The cau-
dal branch becomes the posterior communicat-
ing and posterior cerebral arteries.2s
Anomalous connections between the carotid
and vertebrobasilar systems derive from early
embryologic anastomoses. On the 3-mm em-
bryo (24 days), a plexus of vessels forms along
the ventral surface of the rhombencephalon to
become bilateral longitudinal neural arteries,
the precursors of the basilar. At the same time,
a branch of the dorsal aorta forms at the first
aortic arch and travels dorsally to the region
of the trigeminal (gasserian) ganglion. This
vessel, the trigeminal artery, forms an anas-
tomosis with the longitudinal neural artery
and becomes the main blood supply to the
rhombencephalon. Because the cranial end of
the dorsal aorta becomes the distal internal
carotid artery, the trigeminal artery becomes
an internal carotid branch. Smaller connections
792 DUNGAN & HEISERMAN
between the internal carotid and primitive
neural arteries include the first cervical inter-
segmental, hypoglossal, and otic arteries.
These arteries supplement the trigeminal and
are transiently present be tw een 24 and 29 day s.
At29 days, the caudal branch of the internal
carotid forms the posterior communicating ar-
tery. The posterior communicating artery
quickly becomes the main blood supply of the
rhombencephalon, and the trigeminal artery
recedes between 29 and 32 days. Between 32
and 35 days, the vertebral arteries form from
the anastomoses between cervical interseg-
mental arteries and join with the proximal end
of the basiIar.28,a1
NORMAL ANATOMY
The asymmetric fate of the embryologic
fourth arches leads to asymmetry of the defin-
itive carotid origins. The right common carotid
is one of the terminal branches the brachio-
cephalic (innominate) artery, arising at the
base of the neck posterior to the right sternocla-
vicular joint. The left common carotid is the
second branch of the aortic arch, arising at the
highest part of the aortic arch, posterolateral
to the brachiocephalic trunk. From its origin
in the superior mediastinum, the left common
carotid ascends anterior then anterolateral to
the trachea to enter the neck behind the left
sternoclavicular joint.
Variations in position of the carotid origins
are usually related to variations of aortic arch
anatomy. The most common variant is a com-
mon origin of the brachiocephalic and left com-
mon carotid arteries. This variant, the so-called
bovine arch, occurs in 7"/" to 27'/" of patients.2r
In 2.5"/" of patients, the right common carotid
arises directly from the arch. This is usually
associated with an aberrant right subclavian
artery arising distally from the arch, with the
right carotid as the first branch off the arch. In
7.2o/,, of patients, there is a common origin of
the left common carotid and subclavian arter-
ies, leading to bilaterally symmetric brachio-
cephalic trunks.2a
The common carotid arteries take similar
courses through the neck. The right common
carotid averages 9.4 cm in length, and the left
is 13.4 to 74.4 cm.12 There are no significant
side branches, and thus the caliber of the vessel
remains constant, averaging 8 mm as deter-
mined by angiography.e Ultrasound measure-
ments give similar results, and demonstrate a
gradual increase in size with age.a2
At the base of the neck, the common carotid
is deep to the sternomastoid, sternohyoid, and
sternothyroid muscles and anterior to the
fourth through sixth cervical transverse pro-
cesses. The artery becomes more superficial at
the level of the cricoid cartilage, where it
crosses posterolateral to the intermediate ten-
don of the omohyoid muscle to enter the ca-
rotid triangle (Fig. a).
The carotid triangle is in the infrahyoid por-
tion of the anterior triangle of the neck and is
bounded anteroinferiorly by the superior belly
of the omohyoid, posteriorly by the sternoclei-
domastoid, and superiorly by posterior belly
of the digastric muscle. The carotid sheath lies
in the posterolateral aspect of the carotid trian-
gle. Within the carotid sheath the common ca-
rotid artery is medial to the internal jugular
vein and anteromedial to the vagus nerve. The
cervical sympathetic chain is embedded on the
'
,i '1,, r,,
, /,,t,E \\ \\
|I
)1
7l,r n1,
Figure 4. The carotid triangle is part of the anterior triangle
of the neck. The borders of the carotid triangle are the
omohyoid muscle (Om) anteriorly, the sternocleidomastoid
muscle (SCM) posteriorly, and the posterior belly of the
digastric muscle (DG) superiorly. The carotid artery
crosses posterior and deep to the omohyoid muscle to
enter the carotid triangle. The carotid bifurcation lies within
the triangle, and the internal carotid exits the carotid triangle
deep to the posterior belly of the digastric muscle. Trape-
zius (Trap) muscle is the posterior border of the poste
rior triangle.

posteromedial wall of the sheath.36 Above the
bifurcation, the internal carotid remains in the
carotid sheath and retains the same relation-
ship to the internal jugular vein and vagus
nerve.
At approximately the superior border of the
thyroid cartilage, each common carotid bifur-
cates into internal and external branches. The
carotid bulb, or sinus, represents the fusiform
dilatation at the carotid bifurcation encom-
passing the proximal internal carotid and dis-
tal common carotid and is present in 40"/" of
cases.2r From the bifurcation, the internal ca-
rotid usually projects posterolateral to the ex-
ternal carotid. The artery then ascends medial
to the posterior belly of the digastric muscle
and leaves the carotid triangle. Above the pos-
terior belly of the digastric, the artery lies deep
in the suprahyoid carotid space, immediately
posterior and lateral to the parapharyngeal
space.ro
Near the skull base, the internal carotid is
anterior and medial to the internal jugular
vein. The ninth, tenth, and eleventh cranial
nerves and the superior cervical ganglion of
the sympathetic trunk are posterior to the ar-
tery. The twelfth nerve lies posterior and me-
dial, then crosses the artery in the carotid trian-
gle. The carotid enters the petrous carotid
canal and ascends for 1 cm before turning ante-
rior and medial within the petrous bone. Proxi-
mally, the horizontal segment is anterior and
medial to the middle ear cavity. At the foramen
lacerum the vessel turns superiorly to emerge
from the carotid canal. The artery then runs
anteriorly and medially, lateral to the sella tur-
cica, into the cavernous sinus. It then turns
upward and medial to the anterior clinoid pro-
cess and pierces the dura to enter the subarach-
noid space.
Within the cavernous sinus, the abducens
nerve lies on the inferolateral aspect of the
internal carotid. The oculomotor and trochlear
nerves and the ophthalmic and maxillary divi-
sions of the trigeminal nerve lie along the lat-
eral wall of the sinus.
There is considerable variation in the course
and position of the common carotids and ca-
rotid bifurcations. Elongation of the common
and internal carotid arteries leads to tortuosity
and kinking. Angiographic studies have re-
vealed tortuosity in 10% to 43"/" and a kink
rn 4"/o to 16%. Ischemic symptoms caused by
kinking of the carotid have been reported but
are uncommon.s Although often believed to
THE CAROTID ARTERY 793
be part of the aging process, evaluation of pa-
tients fewer than 50 years of age reveals tortu-
osity or coiling in up to 27"k of patients, and
kinking in 3.57n.5'18
The position of the carotid bifurcation re-
flects the degree of embryologic migration of
the external carotid artery and is, therefore,
variable. Angiographic studies report the level
of the bifurcation with respect to the cervical
vertebrae. Huber reports the bifurcation at C4
to C5 in 48"/" of 658 bifurcations, and at C3
to C4 in 34"/".12 There are reported cases of
bifurcation of the carotid in the thorax down
to the T3 level,ao and the bifurcation can occur
as high as C2.In children the bifurcation is
slightly higher, seen at C2 to C3 in 40% and
at C3 to C4 in 40%.18 The level of the bifurcation
is symmetric in28"/" and is within one vertebral
segment from side to side in 65"h of patients.35
Other variations in the cervical carotids in-
clude external carotid branches off the com-
mon or internal carotid, aplasia of the internal
carotid, and separate origins of the internal
and external carotids.lE
At the authors' institution, an increasing
number of patients are undergoing carotid
endarterectomy without prior conventional
angiography. To assist preoperative localiza-
tion of the carotid bifurcation, the authors have
begun filming cervical magnetic resonance
(MR) angiography studies with annotation ref-
erencing the slice level to the cervical spine
scout localizer. Using this MR angiography
technique, the authors reviewed the level of
bifurcation in 237 carotid arteries. The mean
overall cervical level was C4-f 1.5 vertebral
bodies (95% confidence)with a range from C2
to C3 to C6 to C7. Patients fewer than 30 years
of age had slightly higher bifurcations (C3-4
level), which was not statistically significant.
Variations in the orientation of the carotid
bifurcation also have been described. In about
80% of patients, the internal carotid arises pos-
terior or posterolateral to the external carotid.
In an evaluation of 587 angiograms, Tea137
found that in 4"/" the internal carotid is medial,
and in 8% the internal carotid is posteromedial.
Smith and Larsen reported that in 100 angio-
grams, the internal carotid artery arises pos-
terolateral to the extension of the common ca-
rotid artery axis in 38%, posterior in 507,, and
posteromedial in 87o.3s Trigaux and cowork-
ers38 evaluated 200 arteries at angiography and
found that the internal carotid lies posterolat-
eral to the external carotid in 48"/", posterior
794 DUNGAN & HEISERMAN

in 3 4o/o, and posteromedial in 73"/,. Knowled ge
of these variations is not only important for
angiographers but necessary for appropriate
interpretation of carotid ultrasonography.
The size and appearance of the carotid sinus
is highly variable. The maximal diameter of
the sinus averages 9.3 mm with a standard
deviation of 1.6 mm.e The caliber of the cervical
internal carotid arteries is usually symmetric,
and averages approximately 6.3 mm at the
midcervical level.e The size of the distal cervi-
cal segment of the vessel is constant or de-
creases slightly near the skull base.q'11 In a
study using carotid ultrasonography in 32nor-
mal volunteers aged 13 months to 79 years, no
significant difference in the internal diameter
of the common carotid arteries was found.22
Individual patients, however, may display
asymmetry in carotid caliber. Angiographic
evaluation of 142 patients demonstrated
greater than 5% difference in caliber of the
cervical internal carotid arteries in 25'/r. The
difference could be explained by hypoplasia
of the anterior cerebral ipsilateral to the
smaller carotid.lT
The wall thickness of the normal carotid ar-
tery has been evaluated using Doppler tech-
niques and is interesting in evaluating athero-
sclerotic plaque morphology. The wall of the
common carotid artery measures approxi-
mately 0.7 rnrn, about 10% of the vessel lumen
diameter.2s The geometry of the carotid bifur-
cation has been studied to evaluate normal
ranges for flow models. In a series of 35 angio-
grams of essentially normal carotid bifurca-
tions, the bifurcation angle between the inter-
nal and external carotid artery was 53o with a
standard deviation of 20o.e Because of the many
sources of variation in the morphology of the
carotid bifurcation, this segment of the vessel
has a highly variable appearance on carotid
angiograms (Fig. 5).

t
ts

$
STF

Figure 5. Lateral angiograms of eight carotid bifurcations. Variability in the appearance of the bifurcation
and carotid sinus is caused by both variations in the angle and sizes of the vascular lumens as well
as projection effects associated with the variable orientation of the bifurcation in the neck.

The most common persistent carotid to ver-
tebrobasilar anastomosis is the normal poste-
rior communicating artery. Other anastomotic
channels are unusual, with an incidence be-
tween 0.1% and 1.2%. Persistent trigeminal ar-
tery is the most common, (85%) followgd bI
the hypoglossal artery; the otic and proatlantal
interiegmental (persistent first cervical inter-
segmental) arteries are rare.rl
A persistent trigeminal artery is readily
identified on both angiography and MR angi-
ography as a prominent branch of the proximal
cavernous carotid. The artery courses posteri-
orly within the cavernous sinus medial to the
ophthalmic division of the trigeminal nerve.
The vessel then follows the course of the fifth
cranial nerve or passes through the dorsum
sella to join the midbasilar artery. There is usu-
ally a hypoplastic vertebral and posterior com-
municating artery ipsilateral to the trigemi-
nal artery.27
The hypoglossal artery is a branch of the
distal cervical internal carotid artery, arising
between the C1 and C3 levels (Fig. 5). The
artery courses posteriorly and superiorly to
entei the skull base through the hypoglossal
canal to join the proximal basilar artery. The
otic artery is a rare vessel extending medially
from the petrous carotid through the internal
auditory canal to the proximalbasilar. The pro-
atlantal-intersegmantal artery connects the
distal cervical internal carotid or external ca-
rotid to the vertebral artery, and courses be-
tween the occiput and the arch of C1.
Figure 6. Lateral angiogram of a persistent hypoglossal artery, an
unusual branch of the cervical internal carotid artery. (Courtesy of
Anton Hasso, MD, lrvine, CA.)
THE CAROTID ARTERY 795
PHYSIOLOGY
Blood flow in the carotid artery is more com-
plex than the commonly discussed steady flow
of a simple fluid in a rigid, straight tube. Blood
is a non-Newtonian fluid, which means that
the viscosity of blood can vary with shear rate.
This may be an important effect in areas of
slow flow, such as the carotid sinus and in
pathologically narrowed arteries. The carotid
lrtery ii a bifurcated conduit with complex
curves. The vessel walls are significantly dis-
tensible, and this elasticity changes with age
and in the presence of disease. The flow within
the artery varies with time in response to the
pulsatile driving pressure. Although this com-
plexity limits our current understanding of ca-
rotid flow dynamics, innovative expcriments
have revealed a great deal of detail.1s' 16
Our understanding of carotid flow rests pri-
marily on experiments in cadaver and model
arteries, Doppler ultrasound velocity, MR
angiography and ultrasound volume flow
studies, and numerical simulations. Doppler
ultrasound techniques provide a rnethod for
quantification of peak systolic and diastolic ve-
locities in the common and internal carotid
arteries. In young individuals, resting peak
systolic velocities average 100 cm/s in the
common carotid artery and 90 cm/s in the
internal carotid.a'a2 The internal carotid and
common carotid arteries peak systolic ratio lies
in the range 0.3 to 1.0 in normal individuals.
These velocities decrease with age. The mea-
796 DUNCAN & HEISERMAN

sured velocities in the internal carotid increase
in the presence of stenosis, and this forms the
basis of noninvasive e\.aluation of carotid ste-
nosis by Doppler ultrasonography.
Volume flow information can be obtained
from Doppler and B-mode ultrasound mea,
surements2s; however, the approach requires
detailed knowledge of the velocity profile
within the vessel and this limits the accuracy of
the method. Cine-phase contrast MR scanning
provides a direct measurement of volume flow
throughout the cardiac cycle (Fig. 7), and can
thus evaluate per cycle or per minute flow
rates in the carotid artery, which are approxi-
mately 300 mllmin at rest.7
Flow within the carotid artery is driven by
the blood pressure. The putse'pressure, th"e
difference between the systolic and diastolic
pressures/ averages 50+9 mm Hg in young
populations and increases slightly in older
populations. Because of blood vessel elasticity,
there is a slight increase in the diameter of
the carotid artery in systole compared with
diastole, measurable by ultrasound. In young
populations, the increase at the level of the
common carotid artery is about 10%, with a
steady decrease to about 6% in older poputa-
tions.3o Similar values are observed af thb ca-
rotid bulb.2e This variation could lead to vari-
ability in measurements of percent carotid
stenosis using angiography or MR angiogra-
phy. Cross-sectional area measurements
throughout the cardiac cycle should also be
possible using gradient echo recalled MR im-
aging, which could demonstrate nonconcen-
tric size changes, as seen in the aorta.6
Flow in the region of the carotid artery bifur-
cation reflects the complex vessel anatomy in
this segment. The carina of the bifurcation acts
as a flow divider, with approximately two
thirds of the flow entering the internal carotid
artery. Fluid velocities in the proximal internal
carotid artery tend to be greatest along the
wall adjacent to the bifurcation. Flow adjacent
to the opposite wall of the carotid sinus is
characterized by recirculation in young indi-
viduals, documented by carotid ultrasonogra-
phy. Flow reversal occupies about one third
of the carotid sinus, beginning at early or peak
systole and persisting for about 20"/" of the
cardiac cycle. Blood in this portion of the bulb
is stagnant in diastole.2e,20 Diastolic acquisition
of MR angiography data is a strategy that takes
advantage of this fact to minimize intravoxel
dephasing in the region of a stenosis.32 Similar
patterns of flow have also been documented
in fixed cadaver carotid bifurcations under
conditions of steady flow (Fig. B).23 This distri-
bution of velocities results in high shear
stresses along the wall adjacent to the bifurca-

400

300

.s
C
: 200
E

100

20 40 on 100
% Cardiac Cycle
Figure 7. Variation of flow within the internal carotid artery throughout the cardiac
cycle determined by phase contrast cine MR. Flow is antegrade throughout the
cardiac cycle in this low-resistance circuit. (Adapted from Enzmann DR, Ross MR,
Marks MP, et al: Blood flow in major cerebral arteries measured by phase contrast
cine MR. AJNR 15: 123-129, 1994 @ by American Society of Neuroradiology;
with permission.)
 THE CAROTID ARTERY 797

Figure 8. Patterns of flow in a fixed cadaver carotid bifurcation

under conditions of steady flow. A, Streamlines demonstrate
recirculation of flow in the posterior bulb region. Streamlines
near the axis of the common carotid are deflected posteriorly
by the llow divider and participate in this recirculation. fl Velocity
profiles demonstrate faster flow along the anterior wall of the
internal carotid, creating a region of relatively higher wall shear
stress. (Adapted from Molomiya M, Karino T: Flow patterns in
the human carotid artery bifurcation. Stroke 15:50-56, 1984;
with permission.)

tion and lower shear stresses along the oppo-

site wall, where atheromatous plaques typi-
cally occur.
Recent work in elastic models of cadaver
bifurcations using physiologic pulsatile flow
and a Newtonian fluid sheds light on the three-
dimensional paitern of flow.la The stagnant re-
gion in the posterior bulb seems to act as a
buffer in systole, deflecting streamlines anteri-
orly into a high flow, high shear region (Fig.
9A, see Color Plate).14 In diastole, there is re-
duction of flow and some associated stagna-
tion can occur. However, antegrade flow is
maintained in the internal carotid artery be-
tw
cause of the low peripheral vascular resistance.
Because of higher peripheral resistance in the -Vte,
external carotid outflow, some reflux can occur
in diastole from the external to the internal )'iilul il
carotid (Fig. 98, see Color Plate).i6 The flow
patterns observed at the carotid bifurcation in fl [\
systole and diastole are summarized in Fig-
ure 10.
Departures from ideal geometry can affect
t rfl
the patterns of flow within a vessel. In a curved il tfl
segment of vessel, because of the inertia of
A B 1I i] fll
the fluid, a secondary, helical flow pattern is
established that distributes the fastest moving Figure 10. Flow around the carotid bifurcation in systole
portions of the fluid to the outer margin of the (4) and diastole (B). Compare with models of Figure 9.
bend.16, 1e Subtle asymmetries of the common (Courtesy of Charles Kerber, MD, San Diego, CA.)
798 DUNGAN & HEISERMAN
Tab|e 1. PROPERTIES OF THE ADULT CAROTID ARTERY
Lumen diameter (mm)
Wall thickness (mm)
Length (cm)
Right
Left
Bifurcation
Angle
Level
Ad/d-
Peak systolic velocity (cm/sec)
Mean flow (mUmin)
- ld/d : (systolic lumen diameter-diastolic diameter)/diastolic diameter. This relative diameter change rs an index of vessel compliance.
Values are mean/standard deviation.
carotid artery can result in a superimposed
helical flow pattern in the internal carotid ar-
tery.r6 Secondary flow in a curved vessel can
be a source of signal loss in magnetic resonance
angiography.33 These conditions apply to the
carotid artery at the skull base, where multiple
bends result in helical flow patterns, as has
been demonstrated in models and simula-
tions.la
Focal areas of vascular narrowing have little
effect on total flow in a vessel until a critical
stenosis is reached. Beyond this value, gener-
ally about a 70/" reduction in area or a 50'/"
reduction in diameter, flow rapidly decreases
as the pressure drop across the stenosis in-
creases.'
CONCLUSION
Advances in the imaging evaluation of the
carotid artery have contributed to a more com-
plete understanding of the normal anatomy
and physiology of this important vessel. This
improved understanding has pointed the way
to a more accurate and less invasive evaluation
of carotid artery disease (Table 1).
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