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A New Classification of Cavernous Segment of the Internal Carotid Artery

Article  in  The Journal of craniofacial surgery · July 2013

DOI: 10.1097/SCS.0b013e318292c970 · Source: PubMed

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 ANATOMICAL STUDY

A New Classification of Cavernous Segment of the

Internal Carotid Artery
Chenyu Wang, MD,*Þ Jianan Xie, MD,* Dong Cui, MD,* Ye Cheng, MD,*Þ and Siwen Zhang, MD*

Introduction: The shape of the cavernous segment of the internal

carotid artery (CSICA) is various in different people, which makes
it difficult to be located and causes a higher possibility of injury in
the transsphenoidal approach. Hence, a comprehensive study of the
CSICA and a meaningful classification of it are rather helpful to the
approach and other operations related to the CSICA.
Purpose: Our study aimed to make a comprehensive measurement
and classify the CSICA into different types so as to better describe its
shape and position.
Materials and Methods: Computed tomographic angiography
images of 146 internal carotid arteries in individuals (76 males and
70 females) ranging in age from 17 to 78 years (mean, 49.49 y) were
reviewed. We measured the distances between the bilateral CSICA
at 5 positions in the coronal plane and the angle of the posterior
curve segment in the sagittal plane. According to these statistics, we
divided the CSICA into different types.
Results: The distance between the medial walls of the bilateral
internal carotid artery is similar to the previous relevant study. We
classified the horizontal segment of the CSICA into 5 types: types 1,
2, 3, 4, and 5. Among the individuals we measured, the proportion
of each type is 8.2%, 25.3%, 39.7%, 19.9%, and 6.9%. In addition,
the posterior curve segment of the CSICA can be classified into
4 types: types Z, A, S, and O. Among the 292 sides we measured,
the proportion of each type is 22.6%, 17.8%, 21.9%, and 37.7%.
Furthermore, 80.8% of the people with bilateral sides of type O
belonged to type 3 and 72.7% of the people with bilateral sides of
type Z belonged to type 2.
Conclusions: The detailed classification of the CSICA is helpful
to understand its complexity. The classification of the CSICA can
guide the surgeons in the transsphenoidal approach to avoid in-
juring and to simplify the location of the whole CSICA.
Key Words: CSICA, classification, transsphenoidal surgery
(J Craniofac Surg 2013;24: 1418Y1422)
I nternal carotid artery (ICA) is one of the important arteries of blood
supply to the brain tissue, which commits more than half of the
blood supply of the bilateral cerebral hemispheres. Bouthillier et al1
has split ICA into 7 segments: C1, cervical; C2, petrous; C3,
lacerum; C4, cavernous; C5, clinoid; C6, ophthalmic; and C7,
communicating. The C4 segment is also called the cavernous seg-
ment of the internal carotid artery (CSICA), which is located in the
cavernous sinus and around the sphenoid sinus, so it is easy to be
injured in transsphenoidal surgery. Located near the anterior clinoid
process, the anterior part of CSICA is also easy to be injured in the
anterior clinoid processYrelated surgeries such as the anterior
clinoidectomy.2 Hence, it is the important anatomic structure in
the process of surgery to sellar region lesions.3,4 The CSICA is a
complex-shaped segment of the ICA and can be split into 5 parts
including the anterior straight segment, the anterior curve (AC)
segment, the horizontal segment, the posterior curve (PC) segment,
and the posterior straight segment.5 Computed tomographic angi-
ography (CTA) images showed a great variation of the shape of the
CSICA in different people. Some data in the former study about the
CSICA do not seem to be suitable to everybody, so a new classi-
fication of it is rather helpful to describe the variation as well as the
anatomy importance and the guidance of expand transsphenoidal
surgery and other surgeries related to the CSICA such as arterial
catheter insertion.
MATERIALS AND METHODS
The CTA images of 146 ICAs in individuals (76 males and
70 females) ranging in age from 17 to 78 years (mean, 49.49 y) were
reviewed. All the CTA images are obtained by the Toshiba 320-row
volume computed tomographic system (0.5 mm between 2 pictures)
in the Third Hospital of Jilin University. The images displaying ICA
stenosis, ICA distensibility, and other ICA diseases were excluded
from our study. The measurement was performed on the coronal,
sagittal, and axis planes after multiplanar reformation (MPR).

From the *Department of Human Anatomy, Norman Bethune Medical

School of Jilin University; and †China-Japan Union Hospital of Jilin
University, Changchun, China.
Received February 19, 2013.
Accepted for publication March 10, 2013.
Address correspondence and reprint requests to Ye Cheng, MD, No. 71 Xinmin St,
Chaoyang District, Changchun, China; E-mail: yeivy0815@gmail.com;
Siwen Zhang, MD, No. 71 Xinmin St, Chaoyang District, Changchun,
China; E-mail: Zhangsiwen_1991@163.com
Chenyu Wang and Jianan Xie contributed equally to this work.
The authors report no conflicts of interest.
Copyright * 2013 by Mutaz B. Habal, MD
ISSN: 1049-2275 FIGURE 1. The 5 positions in which the measurement of distance between the
DOI: 10.1097/SCS.0b013e318292c970 bilateral CSICA was done.

1418 The Journal of Craniofacial Surgery & Volume 24, Number 4, July 2013

Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery & Volume 24, Number 4, July 2013
FIGURE 2. The distance between the bilateral CSICA. D indicates the distance
between the bilateral CSICA.
We did some measurements to understand the shape of the
CSICA. For example, the distances between the bilateral CSICA
were measured in 5 positions in the coronal plane (Figs. 1, 2). They
are the midpoint of the AC segment, the anterior quarter point be-
tween the AC and PC segments of the CSICA, the middle of the
horizontal segment, the posterior quarter point between the AC and
PC segments, and the midpoint of the PC segment. The 5 distances
are represented by the following parameters: the distance between
the medial walls of the bilateral ICA measured in the AC segment
(DA), the distance between the medial walls of the bilateral ICA
measured in the anterior quarter point between the AC and the PC
of ICA (DQA), the distance between the medial walls of the bilateral
ICA measured in the middle of the horizontal segment (DM), the
distance between the medial walls of the bilateral ICA measured in
the posterior quarter point between the AC and the PC of the ICA
(DQP), and the distance between the medial walls of the bilateral
ICA measured in the PC segment (DP). Their definitions are also
listed in Table 1. According to the value of DA, DQA, DM, DQP, and
DP, we classified the horizontal segment of the CSICA into 5 types
(Table 2).
The angle of the PC segment was measured in the sagittal
plane (Fig. 3). Considering the great variation of the angle, we
classified the PC segment of the CSICA into 4 types according to the
type of the angle (Table 3).
The Statistical Package for the Social Sciences 15.0 was used
in the study for the statistical analysis.
RESULTS
The Shape of the CSICA
The shape and position of the CSICA can be found and
identified easily on the CTA images. The distances between the
bilateral CSICA are listed in Table 4. The distance is relatively bigger
TABLE 1. Definitions of the Parameters in This Study
Parameter Definition
DA Distance between the medial walls of the bilateral ICA
measured in the AC segment
DQA Distance between the medial walls of the bilateral ICA measured
in the anterior quarter point between the AC and the PC of ICA
DM Distance between the medial walls of the bilateral ICA measured
in the middle of the horizontal segment
DQP Distance between the medial walls of the bilateral ICA measured
in the posterior quarter point between the AC and the PC of the ICA
DP Distance between the medial walls of the bilateral ICA measured
in the PC segment
* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
A New Classification of the CSICA
TABLE 2. Standard of Classification of the Horizontal Segment of the ICA
Definition
Type 1 ‘‘O’’ shape of the ICA in the axis plane; one of DQA, DM, DQP is
3 mm smaller than both DA and DP.
Type 2 ‘‘X’’ shape of the ICA in the axis plane, one of DQA, DM, DQP is
3 mm bigger than both DA and DP.
Type 3 Parallel shape of the CSICA in the axis plane; the range of the
5 parameters is smaller than 3 mm.
Type 4 ‘‘V’’ shape of the ICA in the axis plane; DA is more than 3 mm bigger
than DP. All of DM, DQA, and DQP cannot be 1 mm bigger than DA
and 1 mm smaller than DP.
Type 5 Anti ‘‘V’’ shape of the ICA in the axis plane; DP is more than 3 mm
bigger than DA. All of DM, DQA, and DQP cannot be 1 mm bigger
than DP and 1 mm smaller than DA.
Any shape of the ICA that is not classified as any of the 5 types previously mentioned
is regarded as irregular type (type VI), but none of this type was found in our study.
in the AC segment and relatively smaller in the PC segment. Our
results were similar to those of Wei et al5 and Xue and Jing,6 whose
results also indicated that the distance between the bilateral CSICA is
smaller in the PC segment and bigger in the AC segment. The dis-
tance in the middle position of the CSICA (DQP, DM, and DQA) is
relatively smaller than DA and bigger than DQ, which is also
identical to the results of Xue and Jing.6 However, the SD and the
range of DQA, DM, and DQP are much bigger compared with those
of DA and DP, which means great variations existed in the value of
DQA, DM, and DQP. Hence, it is not suitable to describe the distance
between the bilateral ICA just through the means of such values.
The Results of the Classification of the
Horizontal Segment of the CSICA
The 2 classifications of our study are mainly based on the
different shape of the horizontal segment and the PC segment of
the CSICA.
The results of the classification of the horizontal segment of
the CSICA are listed in Table 5. The shape of each type in the axis
plane is showed in Figures 4 to 7. In our study, there are 12 people
who belonged to type 1 (8.2%), 37 people who belonged to type 2
(25.3%), 58 people who belonged to type 3 (39.7%), 29 people
who belonged to type 4 (19.9%), and 10 people who belonged to
type 5 (6.9%), which indicated that most people belonged to type 3
(parallel shape of the CSICA) and that a small portion of people
belonged to types 1 and 5. After analyzing the results in Table 5, we
could find that there was indeed a great variance of the distance
between the bilateral ICA in different types especially in the middle
FIGURE 3. The CSICA of type 1.
1419
Wang et al The Journal of Craniofacial Surgery & Volume 24, Number 4, July 2013

TABLE 3. Standard of Classification of the Posterior Segment of the ICA TABLE 5. Types of the ICA in the Horizontal Segment

Classification Definition n (per Mean of Mean of Mean of Mean of Mean of

Type type) DA DQA DM DQP DP
Type Z The angle between the PC segment and the horizontal
segment is extremely small (0 to 45 degrees). 1 12 (8.2) 20.49 23.91 24.61 23.82 19.09
Type A The angle between the PC segment and the horizontal segment 2 37 (25.3) 21.15 15.72 13.83 14.43 18.56
is acute angle (45 to 75 degrees). 3 58 (39.7) 19.73 20.10 19.61 19.37 18.84
Type S The angle between the PC segment and the horizontal segment 4 29 (19.9) 21.87 19.37 17.45 16.70 14.67
is nearly straight (75 to 105 degrees).
5 10 (6.9) 16.35 19.44 20.40 20.92 21.49
Type O The angle between the PC segment and the horizontal
segment is obtuse angle.
in controlling the penetration width in the posterior of the SB to avoid
portion of the horizontal segment of the CSICA (a t test showed injury and serious complications of carotid artery injury.5
that the value of DQA, DM, and DQP are different in either 2 types; As the former study of the ICA showed that the symmetry of
PG 0.05). the bilateral ICA is well in all the portions,5 the distance between the
ICA and the coronal midline of SB is half of the distance between the
The Results of the Classification of the PC bilateral ICA, Therefore, another function of these data (Table 4) is
Segment of the CSICA that it can also be a guide to find the CSICA on the basis of the SB in
The type of the PC segment of the CSICA was not identical the transsphenoidal surgery.
in the bilateral CSICA. Hence, we analyzed 292 sides in 146
people. The shapes of each type in the sagittal plane are shown The Classification of the Horizontal Segment
in Figures 8 to 11. The results are listed in Table 6. A total of
66 sides (22.6%) belonged to type Z, 52 sides (17.8%) belonged to of the CSICA
type A, 64 sides (21.9%) belonged to type S, and 110 sides (37.7%) The shape of the CSICA is complex, and the distance between
belonged to type O. Most sides in our results belonged to type O, the bilateral CSICA is various, especially in the horizontal segment
and the other types were equally distributed. (Table 4). As the range of DM is 8.59 to 27.36 mm (SD, 4.35 mm),
in a transsphenoidal surgery, it is therefore not reliable to reckon
The Relationship Between the Type of the the distance between the bilateral ICA just on the basis of the means
Horizontal Segment and the PC Segment measured by scholars.
The relationship between the type of the horizontal segment A clear classification of the horizontal segment of the CSICA
and the PC segment was also analyzed. There are 26 people with in the axis plane is a kind of solution to the problem previously
bilateral O type of PC segment, and 21 (80.8%) of them belonged to mentioned and can provide useful information for transsphenoidal
type 3 of the horizontal segment. There were 11 people with bilateral surgery. As for the horizontal segment of type 1, the distance between
Z type of PC segment, and 8 (72.7%) of them belonged to type 2 of the bilateral CSICA is smaller in the position of the AC and PC seg-
the horizontal segment. ments and bigger in the middle of the horizontal segment, so the
penetration width should be strictly controlled in the position of the
AC and PC segments. As for type 2, the distance is smaller in the position
DISCUSSION of the middle of the horizontal segment and bigger in the position of
the AC and PC segments. People of this type have a higher risk for
Comparison With the Former Study injuring the CSICA in the removal surgery of the pituitary adenoma
A pretty exposure of the CSICA is the key to a successful because this surgery needs a penetration in the SB, which is near the
operation of transsphenoidal approach to deal with the sideways middle point of the horizontal segment of the CSICA. Most people
expansion of the sella region tumor without complications. Usually, belong to type 3; the bilateral horizontal segment of the CSICA is
after the penetration of the anterior wall of the sphenoid sinus, parallel to each other, and it can be located easily by the data mea-
protuberance of the ICA is the landmark to locate the ICA. When the sured in our study. Type 4 is of the shape narrow at the back and wide
protuberance of the ICA is invisible or not obvious, Xue and Jing’s6 in the front, and type 5 is of the shape narrow in the front and wide at
data of the distance between the bilateral CSICA and the sagittal the back. When transsphenoidal surgery is done in the 2 kinds of
midline of the sella bottom (SB) can be a reference to locate the ICA.
The additional point of measurement at DQP, DM, and DQA can be
more helpful to the location of CSICA. In our study, the distance
between the bilateral CSICA is relatively small in the PC segment
and the anterior portion of the horizontal segment (as the relatively
smaller value of DP and DQP), which remind surgeons to be careful

TABLE 4. Distance Between the Medial Walls of the Bilateral ICA

Mean SD Range 95% Confidence Interval

DA 20.38 2.73 13.86Y26.14 19.73Y21.02

DQA 18.98 3.63 9.62Y26.03 18.12Y19.83
DM 17.73 4.35 8.59Y27.36 16.71Y18.75
DQP 17.91 3.95 8.04Y26.99 16.98Y18.84
DP 17.72 2.74 11.07Y23.4 17.16Y18.28
Values are expressed in millimeters (mm).
FIGURE 4. The CSICA of type 2.

1420 * 2013 Mutaz B. Habal, MD

Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery & Volume 24, Number 4, July 2013 A New Classification of the CSICA

FIGURE 5. The CSICA of type 3. FIGURE 9. The CSICA of type A.

FIGURE 6. The CSICA of type 4. FIGURE 10. The CSICA of type S.

FIGURE 7. The CSICA of type 5.

FIGURE 11. The CSICA of type O.

people, the width of the penetration should be strictly controlled on 1

side of the horizontal segment of the CSICA.
There is no case of type 6 in our study, so a further research
about it is needed to be done in the future.

The Classification of the PC Segment

of the CSICA
The shape of the PC segment of the CSICA in the sagittal
plane also varies in different people. Xue and Jing7 have classified
the horizontal segment of the CSICA into 3 types according to the
degree of the distortion. Yang and Liu8 also divided the CSICA into
different classes according to the angle between the proximal seg-
ment and the distal segment. Although the method and the standard
FIGURE 8. The CSICA of type Z. are different between ours and theirs, the results are similar to each

* 2013 Mutaz B. Habal, MD 1421

Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Wang et al The Journal of Craniofacial Surgery
TABLE 6. Types of the ICA in the Posterior Segment
Sides Percentage
Type Z 66 22.6
Type A 52 17.8
Type S 64 21.9
Type O 110 37.7
other. The results of our study indicated that most of the people
belonged to type O (which is similar to the anti-L type of Xue and
Jing’s6 study). The proportion of the people of types Z, A, and S were
distributed evenly.
The CSICA of types Z and A has a feature of higher position
of the PC segment and the posterior portion of the horizontal seg-
ment (Fig. 8), which makes it far from the lateral wall of the
sphenoid sinus and easier to be deficient of ICA protuberance in
the position of the PC segment even if the sphenoid sinus are well
gasified as type 3 or 4 (according to Güldner9). When a surgeon
finds a discontinuous ICA protuberance in well-gasified sphe-
noid sinus, the CSICA can be ascertained to be type Z or type A.
Moreover, the whole position of the CSICA of type Z is hard to be
located visually, so the data measured in our study may be useful to
locate its position.
The results also indicated that most of the people who be-
long to type O or type S have characteristics of lower position of
the PC segment and post portion of the horizontal segment, which
makes it easy to form a protuberance and easy to locate in the sur-
gery. In addition, the CSICA of type O is convenient for a catheter
to reach, whereas there is a restriction of type Z because the research
of Mori et al10 showed that a stent cannot reach the vessel, which is
tortuous.
The Relationship Between the Type of the
Horizontal Segment and the PC Segment
Considering the close relationship between type O and type 3
and type Z and type 2, we can infer that the different types of the
CSICA are caused by their length and degree of bending. It is easy
to find visually that the CSICAs of type Z and type 2 have bigger
length and are more distorted compared with the CSICAs of type O
and type 3. Hence, the location of the PC segment can be crimped to
higher and outside as the shape of type Z and 2.
The view of the horizontal segment of the CSICA needs to be
seen in the axis plane, and the view of the PC segment needs to be
seen in the sagittal plane; hence, the whole description of the
1422
View publication stats Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
& Volume 24, Number 4, July 2013
CSICA needs an MPR. Considering the close relationship between
the shape of the horizontal portion and the PC segment, the shape of
the PC segment of the CSICA can be speculated after knowing the
type of the horizontal segment and the shape of the horizontal
segment of the CSICA can also be speculated after knowing the
type of the PC segment.
Hence, it is helpful to add the possibility to describe the whole
shape of the CSICA only visually when entering the sphenoid sinus
or in the condition of emergency or when MPR is not available.
CONCLUSIONS
The detailed classification of the CSICA is helpful to un-
derstand its complexity. The classification of the CSICA can guide
the surgeon in the transsphenoidal approach to avoid injuring and
simplify the location of the whole CSICA.
REFERENCES
1. Bouthillier A, van Loveren HR, Keller JT. Segments of the internal
carotid artery: a new classification. Neurosurgery 1996;38:425Y432
2. Abuzayed B, Tanriover N, Biceroglu H, et al. Pneumatization degree of
the anterior clinoid process: a new classification. Neurosurg Rev
2010;33:367Y374
3. Kitano M, Taneda M. Extended transsphenoidal approach with
submucosal posterior ethmoidectomy for parasellar tumor. Technical
note. J Neurosurg 2001;94:999Y1004
4. Dusick JR, Esposito F, Malkasian D, et al. Avoidance of carotid artery
injuries in transsphenoidal surgery with the Doppler probe and
micro-hook blades. Neurosurgery 2006;60(suppl 2):322Y329
5. Wei Y, Kang J, Wang R, et al. Microscopic and endoscopic anatomy of
the cavernous segment of the internal carotid artery. Chin J Minimally
Invasive Neurosurg 2008;13:64Y67
6. Xue L, Jing J-J. Microscopic anatomy of cavernous segment of internal
carotid artery via extended transnasal approach [J]. J Fourth Mil Med
Univ 2009;30:229Y231
7. Feng Y, Zhao JW, Liu M, et al. Internal carotid artery in the operative
plane of endoscopic endonasal transsphenoidal surgery. J Craniofac
Surg 2012;23:909Y212
8. Yang H, Liu J. Characteristics of internal carotid arteries and explore
their clinical significance in the endovascular treatment of cerebral
vascular diseases[C]. Guizhou: Guizhou Medical College, Department
of Neurosurgery, academic exchange press, 2006:26Y31
9. Güldner C, Pistorius SM, Diogo I, et al. Analysis of pneumatization and
neurovascular structures of the sphenoid sinus using cone-beam
tomography (CBT). Acta Radiol 2012;53:214Y219
10. Mori T, Mori K, Fukuoka M, et al. Percutaneous transluminnal cerebral
angioplasty for total occlusion of middle cerebral arteries.
Neuroradiology 1997;39:71Y74
* 2013 Mutaz B. Habal, MD