Literature Review
Internal Carotid Artery Classification Systems: An Illustrative Review
Jhon E. Bocanegra-Becerra1, Gokhan Canaz2, Cvetina Vatcheva3, Jack Wellington4
Key words
- Classification systems
- ICA
- Internal carotid artery
- Neuroanatomy
- Nomenclature
Abbreviations and Acronyms
ACA: Anterior cerebral artery
CT: Computed tomography
ET: Eustachian tube
ICA: Internal carotid artery
ILT: Inferolateral trunk
MHT: Meningohypophyseal trunk
PCOM: Posterior communicating artery
PLL: Petrolingual ligament
From the 1School of Medicine, Universidad Peruana
Cayetano Heredia, Lima, Peru; 2Department of Neurosurgery,
Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey;
3
School of Medicine, Eberhard Karls University of Tübingen,
Germany; and 4School of Medicine, Cardiff University, United
Kingdom
To whom correspondence should be addressed:
Jhon E. Bocanegra-Becerra
[E-mail: jhon.bocanegra.b@upch.pe]
Citation: World Neurosurg. (2022) 163:41-49.
https://doi.org/10.1016/j.wneu.2022.03.116
Journal homepage: www.journals.elsevier.com/world-
neurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2022 Elsevier Inc. All
rights reserved.
INTRODUCTION
The internal carotid artery (ICA) course
has been the subject of different nomen-
clature systems; over time, the vessel tra-
jectory has been structured based on
distinct aims, materials, and methods.
Following the introduction of the first
classification by E. Fischer, authors have
dissected the ICA into a more precise
nomenclature for clinical, research, and
neuroanatomic purposes. Besides, with
the advent of neuroendoscopy techniques
to treat vascular and complex skull base
pathologies, special attention has been
focused on the systems’ capability to
improve operative performance, reduce
surgical complications, and facilitate
communication among disciplines.
We review the ICA course through an
illustrative and comparative description of
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The internal carotid artery (ICA) course has been discussed extensively. Several
classification systems have attempted to delineate an accurate and helpful
trajectory for microsurgical and endoscopic guidance, thus allowing a better
neurosurgical performance while avoiding intraoperative complications. Also,
the practicality of the classification systems has been emphasized for scholarly
communication among disciplines. Nevertheless, the nomenclature of the ICA
remains heterogeneous and confusing for health care professionals, trainees,
and students.
We present an illustrative review of 8 notable ICA classification systems using
lateral and anterior views as a rapid tool for neuroanatomic consultation. The
appraisal of the vessel anatomy from different perspectives while recognizing
their usefulness and limitations might provide a comprehensive understanding of
the ICA, optimize the intraoperative performance, and facilitate communication.
8 classification systems proposed by detailed ICA systems to guide the plan-
Fischer; Gibo, Lenkey, and Rhoton; Las- ning and execution of neurosurgical
jaunias et al.; Bouthillier et al.; Ziyal et al.; interventions.
Shapiro et al.; Labib et al.; and Abdulrauf
et al. (Table 1). In addition, illustrations of Gibo, Lenkey, and Rhoton Classification
the anterior and lateral views of the ICA In 1981, Gibo et al. used 50 formalin-fixed
are provided in Figures 1 and 2, adult cerebral hemispheres and a colored-
respectively. based dissection of arteries injected with
latex or acrylic to propose a new classifi-
INTERNAL CAROTID ARTERY cation focusing on the supraclinoid region
CLASSIFICATION SYSTEMS of the ICA. Notably, this region was 3 to 40
times magnified to analyze main arteries
The First Modern Nomenclature System along its course.2
In 1938, with the use of x-ray angiograms of Four ICA segments are described
displaced intracranial abnormalities and following the arterial blood flow and
cerebral arteries, Fischer published the first topographic correlation with the neck,
modern classification of the ICA.1 The goal skull base bones, and cavernous sinus.
was to help localize lesions of the base of These include the C1 or cervical portion,
the skull while considering how their form C2 or petrous portion, C3 or cavernous
and size affected the ICA segments. The portion, and C4 or supraclinoid portion
description included 5 intracranial (Figures 1B and 2B). The cervical portion
segments in numeric order and opposite (C1) starts in the common carotid artery
directions to the arterial blood flow. From bifurcation, following its course in the
C1 to C5: C1 or communicating segment, neck until it reaches the carotid canal.
C2 or ophthalmic segment, C3 or clinoidal The petrous portion (C2) follows its path
segment, C4 or cavernous segment, and embedded within the petrous part of the
C5 or petrous segment (Figures 1A and 2A). temporal bone until the cavernous sinus
The practicality of this classification was entry point. Next, the cavernous portion
limited by the retrograde fashion of the (C3) travels within the cavernous sinus.
description, the absent naming of the Then, the supraclinoid portion (C4), an
extracranial ICA portion, and the lack of intradural segment, emerges after
topographic correlation throughout the crossing the anterior clinoid process
vessel course. Nevertheless, these short- superiorly and terminates at the ICA
comings motivated the creation of more bifurcation into anterior and middle
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JHON E. BOCANEGRA-BECERRA ET AL.
cerebral arteries. Note that the C4 portion
divides into 3 parts: ophthalmic,
communicating, and choroidal segments.
The ophthalmic segment extends from
the origin of the ophthalmic artery to the
origin of the posterior communicating
artery (PCOM). Then, the communicating
segment follows until the origin of the
anterior choroidal artery. Lastly, the
choroidal segment continues until the
terminal ICA bifurcation.
The magnification of the C4 portion
allowed a millimetric description of its
trajectory. For example, the average di-
ameters at its origin and terminal bifur-
cation were 5.0 mm and 4.1 mm,
respectively. The total C4 portion length
ranged from 14 to 25 mm (average 19
mm), with the ophthalmic segment being
the longest and the communicating
segment the shortest. Although beyond
the scope of our review, the authors also
included technical notes in the treatment
of tumors and intracranial aneurysms of
the supraclinoid region based on perfo-
rating branches arising in the three seg-
ments of C4 (e.g., the superior
hypophyseal arteries).
An Embryologic Classification
In 1984, Lasjaunias et al. published an
embryologic methodology to identify
anatomic variants alongside segmental
agenesis of the ICA. This system focuses on
2 main aspects: (1) individual segments of
the ICA possess conspicuous embryologic
determinants, and (2) regression of subse-
quent segments of the ICA may be a
consequence of proximal agenesis to 1
segment. Such embryologic data may be
applied to understand and differentiate
congenital versus acquired modifications to
the ICA, with the clinician recognizing what
is considered a normal or aberrant ICA.3,10
The classification was designed with the
retrospective analysis of a single case study
reporting a 35-year-old woman with a 4-
month history of generalized epilepsy. Her
past medical history included a cutaneous
mandibular angioma treated with radio-
therapy at the age of 4 years and a thyroid-
ectomy at the age of 26 years. A meningioma
of the anterior clinoid process was diag-
nosed through histology and selective ca-
rotid angiography. However, such findings
from the ICA angiography revealed
segmental agenesis of the ICA alongside
intracavernous revascularization via a
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ICA CLASSIFICATION SYSTEMS: AN ILLUSTRATIVE REVIEW
trigeminal artery.3 From this, the authors
derived an embryologic classification
based on ICA development dependent on
the third aortic arch and dorsal aorta.
The ICA was divided into 7 segments,
demarcated by the origin of arterial
branches along its course and correlating
the embryologic origin with regional
anatomical entities (Figures 1C and 2C).
These consisted of the following
landmarks: the first segment of the ICA
analogous to the third aortic arch (the
cervical ICA in an adult) with proximal
and distal limits of the carotid bulb and
ICA cervical-petrous junction, respec-
tively. The second: dorsal aorta amid sec-
ond and third aortic arches (distal portion
corresponding to the hyoid and car-
oticotympanic arteries in an embryo and
adult, respectively), with proximal and
distal limits of the ICA cervical-petrous
junction and caroticotympanic artery,
respectively. The third: dorsal aorta amid
first and second aortic arches (segment
relates to between the hyoid and mandib-
ular, and caroticotympanic and vidian ar-
teries, in an embryo and adult,
respectively), with proximal and distal
limits of the caroticotympanic and vidian
arteries, respectively. The fourth: dorsal
aorta amid first aortic arch and trigeminal
artery origin (segment relates to between
vidian artery and meningohypophyseal
trunk [MHT] with respect to an adult), with
proximal and distal limits of the vidian
artery and MHT, respectively. The fifth:
dorsal aorta amid origins of trigeminal and
primitive dorsal ophthalmic arteries
(segment relates to horizontal cavernous
segment amid MHT and inferolateral trunk
[ILT] in respect to an adult), with proximal
and distal limits of the MHT and ILT,
respectively. The sixth: segment amid
origin and anastomosis of the primitive
dorsal and ventral ophthalmic arteries,
respectively (corresponds to the clinoid
segment amid origins of the ILT and
ophthalmic artery in an adult). Proximal
and distal limits involved the ILT and
ophthalmic artery, respectively. The sev-
enth: segment amid anastomosis of the
primitive ventral ophthalmic artery and
carotid bifurcation (relates to the supra-
clinoid portion of the ICA from origins of
ophthalmic and PCOM arteries in an adult,
the ophthalmic segment), proximal and
distal limits involve the ophthalmic and
PCOM arteries.3,10
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Although this classification was beauti-
fully engineered based on embryology and
anatomic correlation, it did not achieve
extensive use.
A Classification Suitable for Clinical Use
In 1996, Bouthillier et al. proposed a new
classification including contributions from
their predecessors but with a more accu-
rate delineation of the ICA. This, com-
bined with a more considerate approach to
looking at its course, namely, in the di-
rection of blood flow, created a more
practical system for clinical use than the
previous versions.4
The description was based on 20 speci-
mens from 10 cadaveric heads, 7 fixed with
formalin, and 3 fresh unembalmed. Colored
silicone rubber was injected into the inter-
nal jugular veins and ICA, which was
microscopically examined throughout its
course. Furthermore, additional observa-
tions were done during surgical procedures
that involved the skull base, the cavernous
sinus, and ophthalmic segment carotid an-
eurysms. The analysis of 20 dry human
skulls allowed a detailed description of bony
structures, including the foramen lacerum
and anterior clinoid process. In addition, 4
cadaveric pieces involving the skull base
portion of the ICA, from the entrance into
the carotid canal to its supraclinoid posi-
tion, were removed en bloc and underwent
histologic examination.
From C1 to C7, the ICA divides into 7
segments in ascending fashion, following
the direction of blood flow and consid-
ering neighboring anatomical structures
(Figures 1D and 2D). The cervical segment
or C1 starts from the common carotid
artery bifurcation, running within the
carotid sheath along the internal jugular
vein, the vagus nerve, a venous plexus,
and postganglionic sympathetic nerves
until it reaches the carotid canal. Then,
the petrous segment or C2 travels within
the periosteum of the carotid canal,
surrounded by a venous plexus and
postganglionic sympathetic nerve, and
ends at the posterior edge of the
foramen lacerum. Note that the ICA does
not pass through the foramen lacerum
but crosses over it. Also, C2 subdivides
into 3 smaller parts, which refer to the
planes on which it courses—a vertical
portion, a bend (ICA posterior loop), and
a horizontal portion that courses
anteromedially.
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JHON E. BOCANEGRA-BECERRA ET AL.

Table 1. Summary of Internal Carotid Artery Classification Systems
Study Fischer1 Gibo, Lenkey and Rhoton2 Lasjaunias et al.3 Bouthillier et al.4

Publication 1938 1981 1984 1996

year
Material and Based on x-ray angiograms of Based on 50 formalin-fixed brain hemispheres, and the Based on retrospective analysis of a single case study Based on the ICA microscopic description of 10
A

methods intracranial arterial injection of latex or acrylic into arteries. reporting a meningioma of the anterior clinoid process cadaveric heads, description of bony
3A 35 3A3 (
3

abnormalities. and segmental agenesis of the ICA alongside relationships from 20 dry human skulls, and
intracavernous revascularization via a trigeminal artery. histological examination of the ICA in the skull
D E3

base.
Number of 5 4 7 7
C /

segments
G D 2 A 3

Nomenclature C1 - Communicating C1 - cervical 1. Cervical C1 - Cervical

(segments) C2 - Ophthalmic C2 - petrous 2. Ascending intrapetrous C2 - Petrous
A C

C3 - Clinoidal C3 - cavernous 3. Horizontal intrapetrous C3 - Lacerum

C4 - Cavernous C4 - supraclinoid: 4. Ascending foramen lacerum C4 - Cavernous
C5 - Petrous Ophthalmic 5. Horizontal intracavernous C5 - Clinoid
CA D
2 E A CG ,D353 3 3A3 5 )

Communicating 6. Clinoid C6 - Ophthalmic

Choroidal 7. Terminal C7 - Communicating
Main features It was intended to help localize The C4 portion described several important perforating Segments are in between branches of the ICA. It merges previous classifications with accurate
3DC A 3 I ) GA

skull base lesions and correlate
their position with the ICA
segments.
The extracranial ICA description
was excluded.
branches (e.g., superior hypophyseal arteries) for
intraoperative consideration.
It included technical notes for treating intracranial
tumors and aneurysms of the supraclinoid region.
It is helpful for surgeries with a transcranial
microscopic approach
Provides embryological methodology identifying delineation of segments.
anatomical variants alongside segmental agenesis of the More practical for clinical use than their
ICA clinically. predecessors.
Focuses on individual segments of the ICA possessing It is helpful for surgeries with a transcranial
distinct embryological determinants and the regression microscopic approach.
of subsequent ICA segments as a consequence of

ICA CLASSIFICATION SYSTEMS: AN ILLUSTRATIVE REVIEW

C

proximal agenesis to one segment.

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3. G

Limitations The ICA portions are numbered Limited utility for endoscopic endonasal approach. It is unsuitable for most surgical interventions, as it does Limited utility for endoscopic endonasal
against the direction of blood It disregards the clinoid segment, which possibly not consider any topographical anatomical relationships approach, although DePowell et al.5 still found it
flow. creates a blind spot when differentiating between or any surgical or endoscopic experience. helpful.
A
E A

It does not consider any extradural and intradural abnormalities. The clinoid segment can only be localized
E A

anatomical relations to the The subdivision of the supraclinoid segment into microsurgically, as it does not appear on any
artery but rather its ophthalmic, communicating, and choroidal uses clinically available imaging modalities.
5

displacement due to intracranial specific branching points as a reference. Their high The lacerum segment could be misleading since
3A

abnormalities. variability makes them unreliable anatomical the ICA does not typically cross the lacerum
5 A

It disregards some key landmarks. foramen but passes above it.

anatomical landmarks, such as
the petrous and the cervical
A
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portions of the ICA.

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LITERATURE REVIEW
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JHON E. BOCANEGRA-BECERRA ET AL.

Study Ziyal et al.6 Shapiro et al.7 Labib et al.8 Abdulrauf et al.9

Publication 2005 2014 2014 2016

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year
Material and Based on 15 cadaveric head dissections using Based on cross-sectional studies and cerebral Based on bilateral endoscopic endonasal Based on cadaveric dissections of the ICA in 5
methods different surgical approaches, 5 dry skulls and 10 angiograms showing patterns of aneurysm formation dissections of 33 cadaveric specimens, along heads and CT angiography of 648 internal
bilateral angiograms from normal patients. and growth. with analysis of anatomic correlations. carotid arteries.
A

Number of 5 7 6 8
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3

segments
D E3

Nomenclature C1 - Cervical Cervical Parapharyngeal Cervical

(segments) C2 - Petrous Petrous Petrous Cochlear
C3 - Cavernous Cavernous Paraclival Petrous
C /
G D 2 A 3

C4 - Clinoidal Paraophthalmic Parasellar Gasserian-Clival

C5 - Cisternal Posterior communicating Paraclinoid Sellar
Anterior choroidal Intradural Sphenoid
A C

Terminus Ring
Cisternal
CA D

Main features Proposed as a classification suitable for clinical An endovascular and angiographic A description of the course of the ICA through a It may be applied uniformly to all skull base
2 E A CG ,D353 3 3A3 5 )

practice with minimal affection by anatomical description of the ICA. ventral perspective and with the help of key surgical approaches, including lateral
variations. anatomical landmarks as reference points. microsurgical and ventral endoscopic
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It is specifically designed to cater to the needs approaches.

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of endoscopic approaches. It highlights clinical information and surgical

risk to embedded structures in the
nomenclature.
Limitations Uses the PLL and distal dural ring as anatomical It uses branching points such as the PCOM and the Limited utility in transcranial microscopic It is the most numerous classification and
landmarks, which cannot be found in clinical ACA, making the classification susceptible to surgeries. introduces new terminology.
imaging. anatomical variations and unreliable for clinical use. It introduces new terminology for the

ICA CLASSIFICATION SYSTEMS: AN ILLUSTRATIVE REVIEW

C
3. G

It is based on cerebral angiograms, which lack the description of the ICA, making it potentially
microsurgical precision needed to define each confusing.
segment’s boundaries properly.
A
E A

ACA, anterior cerebral artery; ICA, internal carotid artery; CT, computed tomography; PLL, petrolingual ligament; PCOM, posterior communicating artery.
E A
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JHON E. BOCANEGRA-BECERRA ET AL.
The lacerum segment or C3 extends
from the end of the carotid canal, where it
further goes above the exocranial foramen
lacerum, creating the lateral loop of the
ICA and running upwards towards the
posterior cavernous sinus. C3 ends at the
superior margin of the petrolingual liga-
ment (PLL), a continuation of the perios-
teum of the carotid canal.
The cavernous segment or C4 begins
from the superior margin of the PLL,
accompanied by a venous plexus and
postganglionic sympathetic nerves. It is
subdivided into 4 smaller portions: a ver-
tical portion, a posterior bend (medial
loop of the ICA), a horizontal portion, and
an anterior bend. The cavernous segment
terminates at the proximal dural ring.
From this point, the clinoid segment or C5
forms the anterior loop of the ICA and
ends at the distal dural ring (intradural
segment of the ICA). Then, the
ophthalmic segment or C6 follows, from
which 2 major arterial branches arise: the
ophthalmic and superior hypophyseal ar-
teries. C6 terminates at the origin of the
PCOM artery, which marks the beginning
of the communicating segment or C7—the
anterior choroidal artery arises from this
portion. Lastly, C7 ends at the terminal
bifurcation of the ICA.
An Anatomic Study With Angiographic
Interpretation
In 2005, Ziyal et al. noticed that systems
relying on the arterial blood flow without
considering anatomical variations could
mislead the ICA nomenclature. For
example, the ophthalmic artery had been
reported to be originated in the clinoidal
segment, the cavernous segment, and,
rarely, in the middle meningeal ar-
tery.2,11-13 Therefore, they aimed to
establish a nomenclature with clinical
utility and minimal affection by
anatomical variations, based on constant
anatomical structures such as bone,
dura, and dural/periosteal folds.6
Ziyal et al. dissected the ICA course in 15
cadaveric heads with microfilm examina-
tion under the pterional, orbitozygomatic,
subtemporal, subtemporal-infratemporal,
petrosal, transsphenoidal, transbasal, and
transfacial approaches. Also, 5 dry skulls
allowed the bilateral study of bone land-
marks, including the foramen lacerum,
sphenoid, petrous, and occipital bones.
Moreover, the ICA trajectory was revised in
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carotid angiograms from 10 normal patients
and 1 where the ophthalmic artery arose
from the cavernous segment.
This classification includes 5 ICA seg-
ments, from C1 to C5, delimited by the ca-
rotid foramen, carotid canal, the PLL, and
the proximal and distal dural rings
(Figures 1F and 2F). First, the cervical
segment (C1) extends from the carotid
common bifurcation to the carotid
foramen. Then, it continues in an
intraosseous horizontal course as the
petrous segment (C2) until it reaches the
superior border of the PLL. Importantly,
the authors reported that none of the
analyzed ICA specimens passed through
the foramen lacerum, alluding to the name
attributed by Bouthillier et al.,4 which they
considered a misleading term. The
superior margin of the PLL marks the
entry point of the ICA into the cavernous
sinus as it moves towards the proximal
dural ring, thus constituting the cavernous
segment (C3). The clinoidal segment (C4),
a wedge-shaped portion, follows in be-
tween the proximal and distal dural rings
and is surrounded by the carotid collar.
Finally, the cisternal segment (C5) con-
tinues inside the subarachnoid space and
terminates at the ICA bifurcation into the
anterior and middle cerebral branches. The
main branches of the C5 segment include
the superior hypophyseal, ophthalmic,
PCOM, and anterior choroidal arteries.
An Endovascular Classification System
The need for an optimized endovascular
perspective of the ICA drove Shapiro et al.
to publish a new nomenclature in 2014.
The authors proposed a system based on
cerebral angiograms (depicting the aneu-
rysm formation and growth patterns in the
ICA) and cross-sectional studies from the
New York University Langone Medical
Center and associated hospitals.7
The system divides the ICA into 7 seg-
ments without an alphanumeric order
following the arterial blood flow: cervical,
petrous, cavernous, paraophthalmic, pos-
terior communicating, anterior choroidal,
and terminus segments (Figures 1G and
2G). Due to angiography limitations to
visualize the PLL and dural ring, some of
the hallmark points for segmentation
had to be estimated based on previous
microsurgical classifications.
First, the “cervical segment” extends
from the common carotid bifurcation to
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the carotid foramen. Then, the “petrous
segment” follows within the temporal
bone and partially above the foramen lac-
erum, containing the caroticotympanic
and vidian branches. Notably, Shapiro
et al. disregarded the lacerum segment of
the Bouthillier et al.4 classification after
obtaining data from the pattern
formation and extension of nontraumatic
temporal bone aneurysms in such area
(those lesions either extended into the
petrous or cavernous segments but were
not focal to the lacerum segment). The
“cavernous segment” starts after crossing
the estimated margin of PLL and
following its course until the
approximated location of the proximal
dural ring. The cavernous segment is
further divided into a proximal ascending
segment, proximal genu, horizontal
segment, distal genu, and distal
ascending segment—the MHT originates
mainly from the posterior genu;
meanwhile, the ILT arises from the
horizontal segment.
The “paraophthalmic segment” extends
from the estimated distal border of the
cavernous segment to the ostium of the
PCOM artery, which in turn demarcates
the beginning of the “posterior commu-
nicating segment.” The latter extends to-
wards the anterior choroidal artery. The
“anterior choroidal segment” is delimited
around the choroidal ostium, and ulti-
mately, the “terminus segment” surges
beyond the choroidal ostium and finishes
in the terminal ICA bifurcation.
An Endoscopic Perspective of the ICA
The emerging use of the endoscopic
endonasal approach to treat lesions in the
median sagittal and paramedian plane
inspired authors to contemplate a more
comprehensive ICA nomenclature from
this standpoint. On the other hand, the
limited attributions of the endoscope op-
tics, namely, bidimensional view and
barrel-type spatial distortion, made it
challenging to extrapolate microsurgical
anatomy into the ventral view of the ICA
under the endoscope.
Labib et al. conceived a reliable system
attending the endoscopic issues regarding
the distortion of distance and perspective
concerning the vessel course.8 Although
not a pioneered system from the
endonasal endoscopic approach, the
previous efforts had lacked accuracy and
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JHON E. BOCANEGRA-BECERRA ET AL. ICA CLASSIFICATION SYSTEMS: AN ILLUSTRATIVE REVIEW

Figure 1. Lateral view of the internal carotid artery (ICA)
classification systems. Basal illustration showing anatomical
landmarks and branches of the ICA (E). ICA classification
systems: Fischer1 (A); Gibo, Lenkey and Rhoton2 (B); Lasjaunias
et al.3 (C); Bouthillier et al.4 (D); Ziyal et al.6 (F); Shapiro et al.7 (G);
Labib et al.8 (H); Abdulrauf et al.9 (I). ACA, anterior cerebral
artery; ILT, inferolateral trunk; MHT, meningohypophyseal trunk;
Oph, ophthalmic artery; PCOM, posterior communicating artery;
PLL, petrolingual ligament.

46 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2022.03.116

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JHON E. BOCANEGRA-BECERRA ET AL. ICA CLASSIFICATION SYSTEMS: AN ILLUSTRATIVE REVIEW

Figure 2. Anterior view of the internal carotid artery (ICA)
classification systems. Basal illustration showing anatomical
landmarks and branches of the ICA (E). ICA classification
systems: Fischer1 (A); Gibo, Lenkey and Rhoton2 (B); Lasjaunias
et al.3 (C); Bouthillier et al.4 (D); Ziyal et al.6 (F); Shapiro et al.7 (G);
Labib et al.8 (H); Abdulrauf et al.9 (I). ACA, anterior cerebral
artery; ILT, inferolateral trunk; MHT, meningohypophyseal trunk;
Oph, ophthalmic artery; PCOM, posterior communicating artery;
PLL, petrolingual ligament.

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JHON E. BOCANEGRA-BECERRA ET AL.
relied on highly variable anatomic
structures.14 Hence, this novel system
aimed to understand the ICA anatomy
from a ventral endonasal perspective,
provide a relevant classification to the
expanded endoscopic approaches, and
identify landmarks for each ICA
segment. Thus, helping to improve
technical dexterity and diminishing the
risk of ICA injury.
The course of the ICA was carefully
observed through bilateral endoscopic
endonasal dissections of 33 cadaveric
specimens. Morphometric analyses were
made in 24 ICAs. The common carotid
arteries, vertebral arteries, and internal
jugular veins were injected with colored
siloxane/silicone material. As a result, the
ICA was divided into 6 segments in the
direction of blood flow, starting from the
bifurcation of the carotid artery and
ending at the distal dural ring. The
nomenclature referred to cranial base
compartments surrounding the ICA as
viewed from a ventral perspective. Named
from proximal to distal: the para-
pharyngeal, petrous, paraclival, parasellar,
paraclinoid, and intradural segments
(Figures 1H and 2H).
First, the parapharyngeal segment ari-
ses from the common carotid artery
bifurcation, runs within the carotid
sheath, and ends at the external orifice of
the carotid canal of the petrous bone.
Corresponding surgical landmarks include
the eustachian tube (ET), the fossa of
Rosenmüller, and levator veli palatini.
The petrous segment extends from the
external orifice of the carotid canal, travels
vertically, and continues on 3 planes:
posterior-to-anterior, inferior-to-superior,
and lateral-to-medial towards the postero-
lateral edge of the exocranial surface of the
foramen lacerum. Along with this segment,
key landmarks include the pterygoid wedge,
the mandibular division of the trigeminal
nerve, and the vidian nerve/artery.
The paraclival segment extends from
the posterolateral aspect of the foramen
lacerum to the superior limit of the medial
petrous apex. This segment has 5 surfaces:
anterior, medial, posterior, lateral, and
inferior. Important landmarks include the
ICA sock, the roof of the fossa of Rose-
nmüller, paraclival protuberance, and fo-
ramen rotundum.
The parasellar segment, embedded in
the cavernous sinus, extends from the
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superior limit of the medial petrous apex
and the upper edge of the petroclival
fissure up to the level of the proximal
dural ring of the ICA. The sellar floor is
highlighted as a key landmark.
The paraclinoid segment originates
from the proximal to the distal dural ring.
The bony landmarks in this short segment
include the lateral tubercular recess, the
medial opticocarotid recess, the distal
osseous arch, and the lateral opticocarotid
recess. Importantly, these osseous pa-
rameters are crucial during the resection
of intradural lesions.
Finally, the intradural segment of the
ICA travels from the distal dural ring,
within the subarachnoid space, and ends
at the bifurcation into the anterior and
medial cerebral arteries.
Although this system brought a clear
understanding of the ICA anatomy under
an endoscopic perspective, it also created
new terminology. In parallel, DePowell
et al. re-examined Bouthillier et al.‘s
classification,4 which had already achieved
widespread use, under the transnasal
endoscopic approach to preserve the
existing terminology and expand its
universal application. Upon testing their
hypothesis, the authors suggested the
preservation of the terminology could be
extrapolated to the endoscopic approach
and avoid new terms.5
A System With Potential Use in
Microsurgical and Endoscopic
Approaches
Abdulrauf et al. provided a clinical meth-
odology to the uniform application of skull
base surgical approaches, including lateral
microsurgical and ventral endoscopic
procedures. Additionally, this nomencla-
ture proposes the extrapolation of clinical
information to potential surgical injuries
involving structures proximal to the ICA.9
Anatomic and radiologic aspects were
considered. Anatomically, the authors
used 5 human head cadaveric dissections
of the ICA (10 sides in total), which un-
derwent formalin fixation. Visualization of
arterial and venous systems was enhanced
via red and blue latex inoculation via the
cervical segment of the ICA and internal
jugular vein at vertebral level C6. Micro-
scopy aided in the inspection and demar-
cation of the ICA anatomical course.
Associations between the ICA were
appraised against the following landmark
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structures: the styloid process, cochlea,
the ET, PLL, abducens nerve, trigeminal
nerve, Gasserian ganglion, the MHT, the
trochlear nerve, and the oculomotor nerve.
Radiologically, 324 (648 sides) adult
consecutive axial computed tomography
angiography images (excluding cases with
noted pathology) from the author’s
respective institutional radiology database
in conjunction with the skeletal associa-
tions of the ICA to the styloid process
base, clivus, sella, vidian canal, cochlea,
and sphenoid sinus were analyzed. Studies
with limited image quality for analysis
were excluded.
The ICA was divided into 8 segments
according to cadaveric and radiologic im-
aging findings. Such segments were
identified according to anatomical land-
marks that correlated to each ICA por-
tion’s origin and termination (Figures 1I
and 2I). Thus, the cervical segment
constitutes the first subdivision and
follows the analog course of previous
microsurgical classification systems.
Then, the cochlear segment (the
ascending segment of the ICA in the
temporal bone) starts from the base of
the styloid process towards the ET. The
petrous segment (the horizontal segment
of the ICA in the temporal bone) begins
at the crossing of the ET superolateral to
the ICA turn, from vertical to horizontal
at the genu. The Gasserian-Clival
segment (the ascending segment of ICA
in the cavernous sinus) starts at the
proximal portion of the PLL and ends at
the MHT. The sellar segment (the medial
loop of ICA in the cavernous sinus) starts
at MHT. Then, the sphenoid segment (the
lateral loop of ICA within the cavernous
sinus) continues after crossing the troch-
lear nerve on the lateral aspect of the
cavernous ICA located directly lateral to
the sphenoid sinus. The ring segment,
composed between the 2 dural rings,
starts at the crossing of the oculomotor
nerve on the lateral aspect of the ICA.
Finally, the cisternal segment continues at
the distal dural ring.
DISCUSSION
This illustrative review described the his-
torical attempts to create a unified
nomenclature version of the ICA.
Although the pioneered ICA system from
Fischer had anatomical limitations and
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lacked broad clinical applicability, it
motivated the subsequent development of
nomenclatures addressing different
radiographic, endovascular, and neuro-
endoscopic needs. At the same time, the
sophistication of neurosurgical technology
has shaped the ICA anatomy from
different perspectives, which has resulted
in heterogeneous denominations and
confusion among health care pro-
fessionals, trainees, and students.
While the classifications mentioned
above offer unique and invaluable insight
into the structure and path of the ICA,
they also meet with some difficulties in
finding the best method to subdivide it
into segments in a way that is anatomically
accurate, physiologically meaningful,
clinically applicable to more than 1 surgi-
cal approach, as well as reliable in cases of
anatomic variations. Fischer’s numerical
segmentation of the ICA against the di-
rection of blood flow, the disregard for
topographic relations to the artery, and the
limited source of information he used to
create the first ICA classification have only
marked a small number struggles that
future author would encounter. Another
significant point for concern has proven to
be the limited application of the classifi-
cations from Gibo et al., Bouthillier et al.,
and Ziyal et al. as they do not consider the
ICA anatomy through a ventral perspec-
tive, nor do they account for the differ-
ences in the view through a microscope
and an endoscope such as the altered
depth-perception and the barrel type
spatial distortion created by the bi-
dimensional view of an endoscope. This
makes the previously mentioned classifi-
cations inapplicable to endoscopic endo-
nasal surgical approaches and limits them
to be only relevant to transcranial micro-
surgical approaches. On the other hand,
the ICA classifications from Labib et al.
and Shapiro et al. were explicitly designed
to be applicable to endoscopic surgeries,
as those were primarily based on endo-
scopic endonasal dissections and cerebral
angiograms, which in turn made them not
precise enough to be used in transcranial
surgical interventions.
Furthermore, some ICA classifications
have failed to recognize essential land-
marks for their description of the ICA
course, such as the clinoid segment,
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which is important for marking the tran-
sition from intradural to extradural space.
It has also been neglected since it is not
visible on any clinical imaging modalities
and only localized microsurgically,
requiring additional research sources
other than radiologic imaging. These as-
pects are some of the considerations that
should made when using the different ICA
classifications. Further potential issues
that could arise when applying each ICA
classification are listed in Table 1.
CONCLUSIONS
Our graphical description of multiple ICA
systems provides a rapid neuroanatomic
consultation tool and highlights the
importance of effective communication in
academic settings. We also believe the
future application of augmented reality
software for improved visuospatial orien-
tation of the ICA systems might help in
providing a more entertaining learning
experience, although useful 3-dimensional
models are already available.15
Ultimately, the knowledge of the ICA
anatomy based on a single system may be
both convenient and suboptimal; however,
understanding it through our comparative
description will help to sum up the
strengths of each nomenclature for better
anatomic appraisal, operative perfor-
mance, and easier communication.
ACKNOWLEDGMENTS
We would like to thank “Cura Canaz
Medical Arts” for its essential and indis-
pensable role in illustrating this work.
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Conflict of interest statement: Dr. G. Canaz is affiliated with
“Cura Canaz Medical Arts.” The authors declare no other
conflict of interest.
Received 19 January 2022; accepted 26 March 2022
Citation: World Neurosurg. (2022) 163:41-49.
https://doi.org/10.1016/j.wneu.2022.03.116
Journal homepage: www.journals.elsevier.com/world-
neurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2022 Elsevier Inc. All
rights reserved.
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