Published: 2019-03-27

Variations, relations and clinical significance of carotid arterial system in anterior neck: a cadaveric study

Anasuya Ghosh, Subhramoy Chaudhury, Atin Datta


Background: The common carotid, internal and external carotid arteries and their branches serve as major source of blood supply in head-neck region of human and are often encountered during numerous surgical and clinical interventions of neck.

Methods: We dissected and examined both sides of neck in 49 well embalmed cadavers (98 sides). We recorded the following anatomical parameters of carotid arterial system-level of bifurcation, the relation between internal and external carotid arteries, branching pattern of anterior branches of external carotid artery, tortuosity in carotid arterial system, and relation of hypoglossal nerve with the carotid arteries.

Results: In 56.16 % cases, the common carotid arterial bifurcation took place at the upper border of thyroid cartilage though high bifurcation was quite common (43.88%). The external carotid artery was located antero-medial to internal carotid artery in most cases (93.87%). Abnormal tortuosity of carotid arterial system was detected in 2.04% cases only. In 86.73% cases, the hypoglossal nerve crossed the internal and external carotid artery superior to carotid bifurcation above the level of hyoid bone while in 1 case it crossed immediately inferior to carotid bifurcation. In branching pattern, following variations were observed- linguo-facial trunk in 15.3% cases, thyro-lingual trunk in 5.1% cases, origin of superior thyroid artery from common carotid in 10.02% cases and origin of superior thyroid from internal carotid in one case (1.02%).

Conclusions: The carotid arterial system has complex and variable anatomy in neck and this information should be kept in mind to avoid unwanted damage during surgical procedures of neck.


Carotid bifurcation and hypoglossal nerve, Carotid tortuosity, External carotid branching variation, Internal and external carotid relation

Full Text:



Al-Rafiah A, El-Haggagy AA, Aal IH, Zaki AI. Anatomical study of the carotid bifurcation and origin variations of the ascending pharyngeal and superior thyroid arteries. Folia Morphol. 2011;70(1):47-55.

Standring S. Gray’s anatomy: the anatomical basis of clinical practice. 39th Ed. Elsevier, Churchil Livingstone, New York; 2015.

Radha K. Bifurcation levels of the common carotid arteries: a cadaveric study in south Indian population. Int J Anat Res. 2014;2(3):511-14.

Vinaitha D, Anandhi KS, Saran RS, Ramanathan L, Subramaniam A. High bifurcation of the common carotid artery and looping of the external carotid artery-a case report. J Clin Diagn Res. 2012;6(3):462-4.

Anu VR, Pai MM, Rajalakshmi R, Latha VP, Rajanigandha V, D Costa S. Clinically-relevant variations of the carotid arterial system. Singapore Med J. 2007;48(6):566.

Kurkcuoglu A, Aytekin C, Oktem H, Pelin C. Morphological variation of carotid artery bifurcation level in digital angiography. Folia Morphol. 2015;74(2):206-11.

Woldeyes DH. Anatomical variations of the common carotid artery bifurcations in relation to the cervical vertebrae in Ethiopia. Anatomy Physiol. 2014;4:2161-0940.

Lo A, Oehley M, Bartlett A, Adams D, Blyth P, Al‐Ali S. Anatomical variations of the common carotid artery bifurcation. ANZ J Surg. 2006;76(11):970-2.

Michalinos A, Chatzimarkos M, Arkadopoulos N, Safioleas M, Troupis T. Anatomical considerations on surgical anatomy of the carotid bifurcation. Anatomy Res Int. 2016;1-8.

Brash JA. Cunningham’s Manual of practical anatomy, Head, neck and brain. 12th Ed. Oxford University: New York; 1958.

Trigaux JP, Delchambre F, Van Beers B. Anatomical variations of the carotid bifurcation: implications for digital subtraction angiography and ultrasonography. Brit J Radiol. 1990;63(747):181-5.

Ito H, Mataga I, Kageyama I, Kobayashi K. Clinical anatomy in the neck region. Okajimas Folia Anatomica Jap. 2006;82(4):157-68.

Kim T, Chung S, Lanzino G. Carotid artery-hypoglossal nerve relationships in the neck: an anatomical work. Neurol Res. 2009;31(9):895-9.

Imparato AM, Bracco A, Kim GE, Bergmann L. The hypoglossal nerve in carotid arterial reconstructions. Stroke. 1972;3(5):576-85.

Salame K, Masharawi Y, Rochkind S, Arensburg B. Surgical anatomy of the cervical segment of the hypoglossal nerve. Clin Anatomy. 2006;19(1):37-43.

Lučev N, Bobinac D, Marić I, Drešćik I. Variations of the great arteries in the carotid triangle. Otolaryngol Head Neck Surg. 2000;122(4):590-1.

Toni R, Della Casa C, Castorina S, Malaguti A, Mosca S, et al. A meta-analysis of superior thyroid artery variations in different human groups and their clinical implications. Ann Anatomy Anatomischer Anzeiger. 2004;186(3):255-62.

Troupis TG, Dimitroulis D, Paraschos A, Michalinos A, Protogerou V, Vlasis K, et al. Lingual and facial arteries arising from the external carotid artery in a common trunk. Am Surg. 2011;77(2):151-4.

Anangwe D, Saidi H, Ogeng’o J, Awori KO. Anatomical variations of the carotid arteries in adult Kenyans. East Afr Med J. 2008;85(5):244-7.

Lemaire V, Jacquemin G, Medot M, Fissette J. Thyrolingual trunk arising from the common carotid artery a case report. Surg Radiol Anatomy. 2001;23(2):135-7.

Hayashi N, Hori E, Ohtani Y, Ohtani O, Kuwayama N, Endo S. Surgical anatomy of the cervical carotid artery for carotid endarterectomy. Neurol Med Chirurgica. 2005;45(1):25-30.

Chan YC, Wong WH, Cheng SW. Successful carotid endarterectomy in a patient with an aberrant branch from the common carotid artery. Ann Royal Coll Surg Eng. 2013;95(2):e17-9.

Kaneko K, Akita M, Murata E, Imai M, Sowa K. Unilateral anomalous left common carotid artery; a case report. Ann Anatomy Anatomischer Anzeiger. 1996;178(5):477-80.

Kurkcuoglu A, Aytekin C, Oktem H, Pelin C. Morphological variation of carotid artery bifurcation level in digital angiography. Folia Morphol. 2015;74(2):206-11.

Phan TG, Beare RJ, Jolley D, Das G, Ren M, Wong K, et al. Carotid artery anatomy and geometry as risk factors for carotid atherosclerotic disease. Stroke. 2012;43(6):1596-601.

Yang X, Jin J, Xu M, Wu H, He W, Yuchi M, et al. Ultrasound common carotid artery segmentation based on active shape model. Computational Mathematical Methods Med. 2013;2013.

Klosek SK, Rungruang T. Topography of carotid bifurcation: considerations for neck examination. Surg Radiol Anatomy. 2008;30(5):383-7.

Zümre Ö, Salbacak A, Çiçekcibaşi AE, Tuncer I, Seker M. Investigation of the bifurcation level of the common carotid artery and variations of the branches of the external carotid artery in human fetuses. Ann Anatomy Anatomischer Anzeiger. 2005;187(4):361-9.

McNamara JR, Fulton GJ, Manning BJ. Three-dimensional computed tomographic reconstruction of the carotid artery: identifying high bifurcation. Euro J Vascul Endovascul Surg. 2015;49(2):147-53.

Stover S, Holtzman RB, Lottenberg L, Bass TL. Blunt innominate artery injury. Am Surg. 2001;67(8):757.

Prendes JL, McKinney WM, Buonanno FS, Jones AM. Anatomic variations of the carotid bifurcation affecting Doppler scan interpretation. J Clin Ultrasound. 1980;8(2):147-50.

Kaseff LG. Positional variations of the common carotid artery bifurcation: implications for digital subtraction angiography. Radiol. 1982;145(2):377-8.

Link J, Brossmann J, Penselin V, Glüer CC, Heller M. Common carotid artery bifurcation: preliminary results of CT angiography and color-coded duplex sonography compared with digital subtraction angiography. AJR. Am J Roentgenol. 1997;168(2):361-5.

Schwartz RB, Jones KM, Chernoff DM, Mukherji SK, Khorasani R, Tice HM, et al. Common carotid artery bifurcation: evaluation with spiral CT. Work in progress. Radiol. 1992;185(2):513-9.

Togay-Isikay C, Kim J, Betterman K, Andrews C, Meads D, Tesh P, Tegeler C, et al. Carotid artery tortuosity, kinking, coiling: stroke risk factor, marker, or curiosity?. Acta Neurol Belgica. 2005;105(2):68.

Dangas G, Laird Jr JR, Mehran R, Satler LF, Lansky AJ, Mintz G, et al. Carotid artery stenting in patients with high-risk anatomy for carotid endarterectomy. J Endovascular Therapy. 2001;8(1):39-43.

Ozgur Z, Govsa F, Ozgur T. Anatomic evaluation of the carotid artery bifurcation in cadavers: implications for open and endovascular therapy. Surg Radiol Anatomy. 2008;30(6):475.