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      <h1 class="highwire-cite-title" id="page-title">Aortic Arch Origin of the Left External Carotid Artery and Type II Proatlantal Fetal Anastomosis</h1>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">Michael Horowitz</span>, <span class="highwire-citation-author" data-delta="1">Surendra Bansal</span> and <span class="highwire-citation-author" data-delta="2">Kush Dastur</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">March 2003,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">24 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(3) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">323-325; </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-10727--6840218433" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">Michael Horowitz </div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=Michael%2BHorowitz%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Horowitz%20M&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AMichael%2BHorowitz%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">Surendra Bansal </div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=Surendra%2BBansal%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Bansal%20S&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3ASurendra%2BBansal%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-2"><div class="author-tooltip-name">Kush Dastur </div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=Kush%2BDastur%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Dastur%20K&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AKush%2BDastur%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div></div></div>  </div>

  
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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article fulltext-view"><span class="highwire-journal-article-marker-start"></span><div class="section abstract" id="abstract-1"><h2>Abstract</h2><p id="p-1">Summary: This case report demonstrates a rare vascular pattern of a left external carotid artery (ECA) that arises directly from the aortic arch (AA), along with a type II proatlantal-vertebral artery anastomosis. Our research shows no report of an ECA arising from the AA. This, in association with a type II proatlantal anastomosis, is interesting because of its apparent rarity.</p></div><p id="p-2">A variety of aortic arch (AA) branch anomalies have been reported, but we found no report of an external carotid artery (ECA) that arises directly from the AA. Such an aberrant origin in association with a type II proatlantal artery must be so rare as to be reportable. This case documents such a vascular pattern.</p><div class="section" id="sec-1"><h2>Case Report</h2><p id="p-3">A 50-year-old woman presented with transient ischemic events. An arteriogram was requested by the referring physician to evaluate for the presence of hemodynamic abnormalities or sources of emboli. The study showed a left ECA and left internal carotid artery (ICA) arising separately from the aortic arch (<a id="xref-fig-1-1" class="xref-fig" href="#F1">Figs 1</a>–<a id="xref-fig-3-1" class="xref-fig" href="#F3">3</a>). A type II proatlantal intersegmental artery was also identified (<a id="xref-fig-4-1" class="xref-fig" href="#F4">Figs 4</a>–<a id="xref-fig-5-1" class="xref-fig" href="#F5">5</a>).</p><div id="F1" class="fig pos-float odd"><div class="highwire-figure"><div class="fig-inline-img-wrapper"><div class="fig-inline-img"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F1.large.jpg?width=800&amp;height=600&amp;carousel=1" title="Oblique view of the AA shows the left ECA (solid arrow) and the left ICA (open arrow) arising separately from the AA." class="highwire-fragment fragment-images colorbox-load" rel="gallery-fragment-images-1412240981" data-figure-caption="&lt;div class=&quot;highwire-markup&quot;&gt;Oblique view of the AA shows the left ECA (solid arrow) and the left ICA (open arrow) arising separately from the AA.&lt;/div&gt;" data-icon-position="" data-hide-link-title="0"><span class="hw-responsive-img"><img class="highwire-fragment fragment-image lazyload" alt="Fig 1." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" data-src="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F1.medium.gif" width="440" height="438"/><noscript><img class="highwire-fragment fragment-image" alt="Fig 1." src="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F1.medium.gif" width="440" height="438"/></noscript></span></a></div></div><ul class="highwire-figure-links inline"><li class="download-fig first"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F1.large.jpg?download=true" class="highwire-figure-link highwire-figure-link-download" title="Download Fig 1." data-icon-position="" data-hide-link-title="0">Download figure</a></li><li class="new-tab"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F1.large.jpg" class="highwire-figure-link highwire-figure-link-newtab" target="_blank" data-icon-position="" data-hide-link-title="0">Open in new tab</a></li><li class="download-ppt last"><a href="/highwire/powerpoint/33079" class="highwire-figure-link highwire-figure-link-ppt" data-icon-position="" data-hide-link-title="0">Download powerpoint</a></li></ul></div><div class="fig-caption" xmlns:xhtml="http://www.w3.org/1999/xhtml"><span class="fig-label">F<span class="sc">ig</span> 1.</span> <p id="p-7" class="first-child">Oblique view of the AA shows the left ECA (<em>solid arrow</em>) and the left ICA (<em>open arrow</em>) arising separately from the AA.</p><div class="sb-div caption-clear"></div></div></div><div id="F2" class="fig pos-float odd"><div class="highwire-figure"><div class="fig-inline-img-wrapper"><div class="fig-inline-img"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F2.large.jpg?width=800&amp;height=600&amp;carousel=1" title="Anteroposterior (AP) view of the nonbranching ICA." class="highwire-fragment fragment-images colorbox-load" rel="gallery-fragment-images-1412240981" data-figure-caption="&lt;div class=&quot;highwire-markup&quot;&gt;Anteroposterior (AP) view of the nonbranching ICA.&lt;/div&gt;" data-icon-position="" data-hide-link-title="0"><span class="hw-responsive-img"><img class="highwire-fragment fragment-image lazyload" alt="Fig 2." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" data-src="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F2.medium.gif" width="440" height="309"/><noscript><img class="highwire-fragment fragment-image" alt="Fig 2." src="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F2.medium.gif" width="440" height="309"/></noscript></span></a></div></div><ul class="highwire-figure-links inline"><li class="download-fig first"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F2.large.jpg?download=true" class="highwire-figure-link highwire-figure-link-download" title="Download Fig 2." data-icon-position="" data-hide-link-title="0">Download figure</a></li><li class="new-tab"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F2.large.jpg" class="highwire-figure-link highwire-figure-link-newtab" target="_blank" data-icon-position="" data-hide-link-title="0">Open in new tab</a></li><li class="download-ppt last"><a href="/highwire/powerpoint/33044" class="highwire-figure-link highwire-figure-link-ppt" data-icon-position="" data-hide-link-title="0">Download powerpoint</a></li></ul></div><div class="fig-caption"><span class="fig-label">F<span class="sc">ig</span> 2.</span> <p id="p-8" class="first-child">Anteroposterior (AP) view of the nonbranching ICA.</p><div class="sb-div caption-clear"></div></div></div><div id="F3" class="fig pos-float odd"><div class="highwire-figure"><div class="fig-inline-img-wrapper"><div class="fig-inline-img"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F3.large.jpg?width=800&amp;height=600&amp;carousel=1" title="Lateral view of the nonbranching left ICA." class="highwire-fragment fragment-images colorbox-load" rel="gallery-fragment-images-1412240981" data-figure-caption="&lt;div class=&quot;highwire-markup&quot;&gt;Lateral view of the nonbranching left ICA.&lt;/div&gt;" data-icon-position="" data-hide-link-title="0"><span class="hw-responsive-img"><img class="highwire-fragment fragment-image lazyload" alt="Fig 3." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" data-src="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F3.medium.gif" width="440" height="309"/><noscript><img class="highwire-fragment fragment-image" alt="Fig 3." src="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F3.medium.gif" width="440" height="309"/></noscript></span></a></div></div><ul class="highwire-figure-links inline"><li class="download-fig first"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F3.large.jpg?download=true" class="highwire-figure-link highwire-figure-link-download" title="Download Fig 3." data-icon-position="" data-hide-link-title="0">Download figure</a></li><li class="new-tab"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F3.large.jpg" class="highwire-figure-link highwire-figure-link-newtab" target="_blank" data-icon-position="" data-hide-link-title="0">Open in new tab</a></li><li class="download-ppt last"><a href="/highwire/powerpoint/33135" class="highwire-figure-link highwire-figure-link-ppt" data-icon-position="" data-hide-link-title="0">Download powerpoint</a></li></ul></div><div class="fig-caption"><span class="fig-label">F<span class="sc">ig</span> 3.</span> <p id="p-9" class="first-child">Lateral view of the nonbranching left ICA.</p><div class="sb-div caption-clear"></div></div></div><div id="F4" class="fig pos-float odd"><div class="highwire-figure"><div class="fig-inline-img-wrapper"><div class="fig-inline-img"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F4.large.jpg?width=800&amp;height=600&amp;carousel=1" title="Lateral view of left the ECA (bottom solid arrow), type II proatlantal intersegmental artery (top solid arrow), and vertebral artery (open arrow)." class="highwire-fragment fragment-images colorbox-load" rel="gallery-fragment-images-1412240981" data-figure-caption="&lt;div class=&quot;highwire-markup&quot;&gt;Lateral view of left the ECA (bottom solid arrow), type II proatlantal intersegmental artery (top solid arrow), and vertebral artery (open arrow).&lt;/div&gt;" data-icon-position="" data-hide-link-title="0"><span class="hw-responsive-img"><img class="highwire-fragment fragment-image lazyload" alt="Fig 4." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" data-src="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F4.medium.gif" width="440" height="276"/><noscript><img class="highwire-fragment fragment-image" alt="Fig 4." src="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F4.medium.gif" width="440" height="276"/></noscript></span></a></div></div><ul class="highwire-figure-links inline"><li class="download-fig first"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F4.large.jpg?download=true" class="highwire-figure-link highwire-figure-link-download" title="Download Fig 4." data-icon-position="" data-hide-link-title="0">Download figure</a></li><li class="new-tab"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F4.large.jpg" class="highwire-figure-link highwire-figure-link-newtab" target="_blank" data-icon-position="" data-hide-link-title="0">Open in new tab</a></li><li class="download-ppt last"><a href="/highwire/powerpoint/33028" class="highwire-figure-link highwire-figure-link-ppt" data-icon-position="" data-hide-link-title="0">Download powerpoint</a></li></ul></div><div class="fig-caption"><span class="fig-label">F<span class="sc">ig</span> 4.</span> <p id="p-10" class="first-child">Lateral view of left the ECA (<em>bottom solid arrow</em>), type II proatlantal intersegmental artery (<em>top solid arrow</em>), and vertebral artery (<em>open arrow</em>).</p><div class="sb-div caption-clear"></div></div></div><div id="F5" class="fig pos-float odd"><div class="highwire-figure"><div class="fig-inline-img-wrapper"><div class="fig-inline-img"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F5.large.jpg?width=800&amp;height=600&amp;carousel=1" title="Nonsubtracted image of Figure 4 shows the relationship of the arteries to the spinal levels." class="highwire-fragment fragment-images colorbox-load" rel="gallery-fragment-images-1412240981" data-figure-caption="&lt;div class=&quot;highwire-markup&quot;&gt;Nonsubtracted image of Figure 4 shows the relationship of the arteries to the spinal levels.&lt;/div&gt;" data-icon-position="" data-hide-link-title="0"><span class="hw-responsive-img"><img class="highwire-fragment fragment-image lazyload" alt="Fig 5." src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" data-src="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F5.medium.gif" width="440" height="276"/><noscript><img class="highwire-fragment fragment-image" alt="Fig 5." src="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F5.medium.gif" width="440" height="276"/></noscript></span></a></div></div><ul class="highwire-figure-links inline"><li class="download-fig first"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F5.large.jpg?download=true" class="highwire-figure-link highwire-figure-link-download" title="Download Fig 5." data-icon-position="" data-hide-link-title="0">Download figure</a></li><li class="new-tab"><a href="http://ajnr-stage2.stage.highwire.org/content/ajnr/24/3/323/F5.large.jpg" class="highwire-figure-link highwire-figure-link-newtab" target="_blank" data-icon-position="" data-hide-link-title="0">Open in new tab</a></li><li class="download-ppt last"><a href="/highwire/powerpoint/33216" class="highwire-figure-link highwire-figure-link-ppt" data-icon-position="" data-hide-link-title="0">Download powerpoint</a></li></ul></div><div class="fig-caption"><span class="fig-label">F<span class="sc">ig</span> 5.</span> <p id="p-11" class="first-child">Nonsubtracted image of <a id="xref-fig-4-2" class="xref-fig" href="#F4">Figure 4</a> shows the relationship of the arteries to the spinal levels.</p><div class="sb-div caption-clear"></div></div></div></div><div class="section" id="sec-2"><h2>Discussion</h2><p id="p-4">The AA and great vessels develop secondary to the formation and selective regression of paired vascular arches that connect the embryonic aortic sac (ventral aorta) with the paired dorsal aortae (<a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a>). During the first 35 days of fetal development, the primitive carotid arteries provide most of the intracranial blood flow (<a id="xref-ref-1-2" class="xref-bibr" href="#ref-1">1</a>). The proximal part of the primitive carotid arteries arises from the ventral aorta and third AAs and gives rise to the common carotid arteries. The distal segments of the primitive carotid arteries arise from the paired dorsal aortae and give rise to the ICAs (<a id="xref-ref-1-3" class="xref-bibr" href="#ref-1">1</a>). The ECAs arise as outgrowths from the third AAs (<a id="xref-ref-1-4" class="xref-bibr" href="#ref-1">1</a>). The ECA ultimately supplies those regions originally supplied by the ventral pharyngeal arteries, which arise from the ventral aorta and supplied the pharyngeal pouches.</p><p id="p-5">While the AA and carotid circulation are developing, the future vertebrobasilar system is developing. The vertebral arteries are formed from plexiform longitudinal anastomoses between the cervical intersegmental arteries (<a id="xref-ref-1-5" class="xref-bibr" href="#ref-1">1</a>). Connections between the paired plexiform longitudinal neural arteries and the carotid system exist and form what we know as the persistent fetal anastomoses (proatlantal intersegmental, hypoglossal, otic, and trigeminal arteries) (<a id="xref-ref-1-6" class="xref-bibr" href="#ref-1">1</a>, <a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2</a>). These anastomoses eventually regress in most individuals; the only connection between the anterior and posterior circulations is the posterior communicating arteries.</p><p id="p-6">The case described in this report is unique in several aspects. We have not encountered any other reports in the literature demonstrating a left ECA arising directly from the AA nor have we seen any literature describing such an ECA giving rise to a type II proatlantal intersegmental artery (proatlantal intersegmental artery arising from the ECA). It is clear that the anomalies found in this patient developed within the first 4–6 weeks of gestation. We speculate that they are due to abnormal regression of the ventral aorta, the third AA, the ventral pharyngeal arteries, and the proatlantal intersegmental artery anastomoses. Aside from being an angiographic curiosity, this finding reminds us of the complex nature of human development.</p></div><div class="section ref-list" id="ref-list-1"><h2>References</h2><ol class="cit-list"><li><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1 in text" id="ref-1">↵</a><div class="cit ref-cit ref-other" id="cit-24.3.323.1"><div class="cit-metadata"><cite>Osborn AG. <strong>The aortic arch, external carotid artery and internal carotid artery.</strong> In: Osborn AG, ed. <span class="cit-source">Diagnostic Cerebral Angiography.</span> 2nd ed. New York: Lippincott, Williams &amp; Wilkins;<span class="cit-pub-date">1999</span> :<span class="cit-fpage">1</span>–83</cite></div><div class="cit-extra"></div></div></li><li><a class="rev-xref-ref" href="#xref-ref-2-1" title="View reference 2 in text" id="ref-2">↵</a><div class="cit ref-cit ref-other" id="cit-24.3.323.2"><div class="cit-metadata"><cite>Lasjaunias P, Berenstein A. <strong>Arterial anatomy: introduction.</strong> In: Lasjaunias P, Berenstein A, eds. <span class="cit-source">Surgical Neuro-angiography Functional Anatomy of Craniofacial Arteries.</span> New York: Springer-Verlag.<span class="cit-pub-date">1987</span> :<span class="cit-fpage">1</span>–11</cite></div><div class="cit-extra"></div></div></li></ol></div><ul class="history-list"><li xmlns:hwp="http://schema.highwire.org/Journal" class="received" hwp:start="2002-08-05"><span class="received-label">Received </span>August 5, 2002.</li><li xmlns:hwp="http://schema.highwire.org/Journal" class="accepted" hwp:start="2003-08-21"><span class="accepted-label">Accepted after revision </span>August 21, 2003.</li></ul><ul class="copyright-statement"><li class="fn" id="copyright-statement-1">Copyright © American Society of Neuroradiology</li></ul><span class="highwire-journal-article-marker-end"></span></div><span class="related-urls"></span></div><a href="http://ajnr-stage2.stage.highwire.org/content/24/3/323.abstract" class="hw-link hw-link-article-abstract" data-icon-position="" data-hide-link-title="0">View Abstract</a></div>  </div>

  
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      <div class="highwire-cite-title">Aortic Arch Origin of the Left External Carotid Artery and Type II Proatlantal Fetal Anastomosis</div>  
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