140

Dangerous Extracranial–Intracranial Anastomoses:

What the Interventionalist Must Know
Lorenzo Rinaldo, MD, PhD1 Waleed Brinjikji, MD1,2

1 Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota Address for correspondence Waleed Brinjikji, MD, Department of
2 Department of Radiology, Mayo Clinic, Rochester, Minnesota Radiology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55902
(e-mail: [email protected]).
Semin Intervent Radiol 2020;37:140–149

Abstract The extracranial and intracranial circulations are richly interconnected at numerous

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locations, a functional connectivity which underlies their impressive capacity for
adaptive plasticity in the setting of vasoocclusive disease. While evolutionarily benefi-
cial, these connections can also result in inadvertent communication with the
intracranial circulation during embolization of extracranial vessels, potentially resulting
Keywords in stroke or cranial nerve palsy. While these anastomoses are always present to a certain
► anatomy extent, flow through them occurs under predictable circumstances, and thus emboli-
► endovascular zation of the extracranial vasculature can be performed safely when knowledge of
procedures functional anatomy is combined with adherence to basic principles. Herein, we will
► external carotid review the anatomy of known extracranial–intracranial anastomoses and strategies for
artery avoidance of unwanted intracranial embolization. We will also review the vascular
► interventional supply to cranial nerves most at risk during common neurointerventional procedures,
radiology as well as blood supply to mucosal structures.

The external carotid artery (ECA) serves as the access route for these connections are always present to a certain extent,
numerous neurointerventional procedures, most commonly though they are often invisible on formal angiography. These
embolization of head and neck tumors, dural arteriovenous anastomotic channels underlie the cranial circulation’s rich
fistulae, and treatment of uncontrolled naso- and oropharyn- collateral network and potential for compensatory plasticity in
geal bleeding. Injection of embolic material into most ECA instances of chronic, and even acute, vascular occlusion.
branches is generally considered safe due to the redundant However, these anastomotic channels can result in dangerous
blood supply and noneloquent nature of extracranial soft and communication between the extracranial and intracranial
connective tissue structures. In certain circumstances, however, circulations in the setting of embolization procedures. Knowl-
this assumption is erroneous, the prompt recognition of which edge of these anastomoses, as well as the circumstances in
is necessary to avert potentially catastrophic complications. which blood flow is preferentially directed through them, is
Blood supply to early embryologic neural structures is essential for the neurointerventionalist. Herein, we will
delivered primarily by axially oriented segmental vessels describe the “dangerous” extracranial–intracranial anastomo-
stemming from the primordial dorsal and ventral aortae. ses through a presentation of illustrative cases. We will also
As the embryo develops, longitudinal connections between discuss the vascular supply to cranial nerves most relevant to
these segmental vessels form and mature, ultimately becom- common neurointerventional procedures and blood supply to
ing the great vessels constituting the adult circulation, specifi- mucosal structures important for the treatment of epistaxis.
cally the internal carotid, external carotid, and vertebral
arteries.1 Over time, the original segmental links between
Dangerous Anastomoses
these longitudinal vessels involute to varying degrees and can
uncommonly remain as one of the persistent carotid-verte- Prior to discussing specific extracranial–intracranial anasto-
brobasilar anastomoses, most commonly the persistent moses, it is worth reviewing the conditions under which
trigeminal artery.2 Even in patients with “normal” anatomy, these channels can open and become clinically relevant.

Issue Theme Neurointerventions; Guest Copyright © 2020 by Thieme Medical DOI https://doi.org/
Editors, Venu Vadlamudi, MD, RPVI, FSIR, Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0040-1709155.
FSVM, FASA and Martin Radvany, MD New York, NY 10001, USA. ISSN 0739-9529.
Tel: +1(212) 760-0888.
 Dangerous Extracranial–Intracranial Anastomoses Rinaldo, Brinjikji 141

Increased pressure on the feeding side of the anastomosis, for supply. In addition, the dural and extradural arteries with
example, during superselective or distal catheterization and which the OA has anastomotic connections are among those
instances in which the catheter is in a wedged position, can routinely embolized during neurointerventional procedures,
preferentially direct flow through these connections, as can and an anatomic understanding of these connections is critical
increased demand on the receiving side in instances of for avoidance of inadvertent extracranial–intracranial com-
arterial occlusion. In addition, high-flow pathologies, most munication. The choroidal blush, which is a reliable marker for
commonly dural arteriovenous fistulae or parenchymal retinal blood supply and best seen during the capillary phase
arteriovenous malformations, can sump blood through anas- on lateral angiographic views, is the most important visual cue
tomotic connections toward the location of arteriovenous that denotes significant collateralization with the OA, though
shunting.3 Recognition of these circumstances and appropri- its absence on ECA angiography does not necessarily preclude
ate modification of neurointerventional strategies can the potential for dangerous extracranial–intracranial commu-
greatly enhance procedural safety. Finally, it is important nication. In general, most anastomotic connections with the
to note that the arterioles constituting these anastomotic OA occur at or below the level of the sphenoid ridge, and thus
connections are generally 50 to 80 µm in diameter.3 As such, the likelihood for unwanted intracranial communication

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during particle embolization procedures, the use of larger diminishes as one moves distally past the lesser sphenoid
particles (150 µm) is generally considered safe and unlikely wing. While not strictly the subject of this review as it is an
to result in intracranial embolization due to traversal of anatomic variant as opposed to routinely occurring anasto-
angiographically occult anastomoses. On the other hand, motic connection, it is worth emphasizing that an OA origin
slowly polymerizing liquid embolic agents can pass through from the middle meningeal artery (MMA) is a strict contrain-
these connections with ease and their use should thus be dication to MMA embolization. The following cases depict the
employed with extreme caution, or avoided altogether, in the most clinically relevant extradural connections with the OA.
vicinity of known extracranial–intracranial connections.
These dangerous anastomoses can be considered as occur- Superior Temporal Artery to Ophthalmic Artery
ring within three semidiscrete anatomical subnetworks with- The supraorbital and supratrochlear arteries are terminal
in the broader extracranial and intracranial circulations, branches of the OA that supply structures of the anterior
specifically the orbital, petrocavernous, and occipital–cervical scalp. Together with the supraorbital nerve, the supraorbital
regions. We will discuss the specific anastomotic connections artery typically exits the orbit via the supraorbital foramen,
within each of these networks separately. while the supratrochlear artery exits the orbit more medially
with the supratrochlear nerve. The superficial temporal
Orbital Region artery, a terminal branch of the ECA along with the internal
The orbital contents and periorbital tissues are richly vascu- maxillary artery (IMAX), bifurcates into frontal and parietal
larized structures. The ophthalmic artery (OA), which typically branches, the former of which anastomoses with both su-
originates from the supraclinoid internal carotid artery (ICA) praorbital and supratrochlear arteries. In ►Fig. 1, we present
and gives rise to the central retinal artery, is unique in that it is angiographic images from a patient with bilateral carotid
the only pial artery with consistent dural and extradural occlusions. The left ICA was found to reconstitute distal to the

Fig. 1 Superior temporal artery to ophthalmic artery. (a) Angiographic and (b) 3D reconstructions from CT angiography demonstrating
reconstitution of the ICA from connections between the STA and OA via the SOA in a patient with left carotid occlusion. ICA, internal carotid
artery; OA, ophthalmic artery; SOA, superior orbital artery; STA, superficial temporal artery.

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142 Dangerous Extracranial–Intracranial Anastomoses Rinaldo, Brinjikji

occlusion from superior temporal artery supply via the additional route of communication between the OA and ECA is
supraorbital artery and OA. through the zygomaticotemporal artery, which departs from
the lacrimal artery as it courses along the upper border of the
Middle Meningeal Artery to Ophthalmic Artery lateral rectus muscle toward the lacrimal gland. This artery
The MMA is a frequent source of arterial supply to neuro- exits the orbit through the zygomaticotemporal foramen to
vascular pathology and thus is a common access route for reach the temporal fossa where it connects with the deep
neurointerventional procedures. While embolization of the temporal arteries originating from the IMAX.
MMA is generally well tolerated, a known potentially cata- In ►Fig. 2, we present a case of a giant supraclinoid artery
strophic complication of this procedure is inadvertent embo- aneurysm treated with carotid occlusion. ECA angiography
lization of the intracranial circulation, and/or central retinal performed after embolization demonstrated persistent fill-
artery, secondary to anastomoses with the OA. One potential ing of the aneurysm from the OA, which filled through its
route of communication is through the recurrent meningeal communication with the MMA via the RMA. Images from
artery (RMA), which originates from the lacrimal artery shortly magnetic resonance angiography demonstrate the close
after its departure from the OA. After its take-off, the RMA proximity of the RMA to the MMA in the region of the

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travels back toward the orbital apex and exits the lateral superior orbital fissure (►Fig. 2). In a second case, a patient
superior orbital fissure to vascularize local dura mater, where presented with an indirect carotid-cavernous fistula fed
clinically relevant communication with the MMA can occur. An predominantly by branches of the IMAX. At another

Fig. 2 Residual filling of supraclinoid aneurysm. (a) AP angiographic images demonstrating a large supraclinoid ICA aneurysm. After treatment
of the aneurysm with carotid sacrifice, residual aneurysm filling from anastomotic connections between the MMA and OA via the RMA could be
seen on (b) AP and (c) lateral views. (d) The anastomotic connection between the MMA and RMA could be seen on MR angiography. AP,
anteroposterior; ICA, internal carotid artery; OA, ophthalmic artery; MMA, middle meningeal artery; RMA, recurrent meningeal artery.

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 Dangerous Extracranial–Intracranial Anastomoses Rinaldo, Brinjikji 143

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Fig. 3 Inadvertent ICA embolization during treatment of carotid-cavernous fistula with a liquid embolic agent. (a) Lateral angiographic images
demonstrating an indirect carotid-cavernous fistula. Note the robust RMA. The fistula was treated with a combination of coil embolization of the
cavernous sinus through a transvenous route and embolization of IMAX branches with liquid embolic agent. (b) Lateral and (c) anteroposterior
anatomic views demonstrating reflux into the OA and ICA via the RMA. AP, anteroposterior; ICA, internal carotid artery; OA, ophthalmic artery;
RMA, recurrent meningeal artery.

institution, the patient underwent combined coil emboliza- Petrous Area

tion of the cavernous sinus and liquid embolization of The petrous ICA gives off relatively few and somewhat
feeding IMAX branches. The procedure was complicated by inconstant branches, which include the caroticotympanic,
complete right-sided visual loss, and postoperative angiog- mandibular, and vidian arteries. When it arises from the
raphy demonstrated embolization of the OA through its petrous ICA, the vidian artery exits the skull through the
communication with MMA via the RMA; embolic material foramen lacerum and courses toward the pterygopalatine
could be as far distally as the right ICA bifurcation (►Fig. 3). fossa, where it communicates with branches of the distal
This case reinforces the dangers associated with liquid IMAX. Along its course, the vidian artery provides blood to
embolization in the vicinity of known extracranial–intracra- both naso- and oropharyngeal mucosa, which results in
nial anastomoses. communication with mucosal branches of the ascending
pharyngeal artery (APhA) and accessory meningeal arter-
Petrocavernous Region ies, the latter of which is a more proximal branch of the
Extracranial–intracranial anastomoses in the petrocaver- IMAX. Finally, via the arteries of the foramen rotundum and
nous region can be further subdivided as occurring in the ovale, the vidian artery can anastomose with the infero-
petrous, clival, and cavernous sinus areas, though there is lateral trunk (ILT) of the cavernous ICA.4 These connections
significant overlap in the anastomotic pathways of these are best illustrated in the setting of pathology causing
regions. branch hypertrophy, which can occur in the setting of a

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144 Dangerous Extracranial–Intracranial Anastomoses Rinaldo, Brinjikji

juvenile nasopharyngeal angiofibroma (►Fig. 4). The car- Clival Area

oticotympanic artery originates from the petrous ICA and Extracranial–intracranial anastomoses in the vicinity of the
enters the middle ear where it anastomoses with the clivus occur through connections between the descending
inferior tympanic branch of the APhA; this connection clival branches of both ILT and meningohypophyseal trunks
forms the basis of the uncommon aberrant carotid artery (MHT) and ascending branches of the neuromeningeal trunk
variant in which the APhA essentially reconstitutes the ICA of the APhA. These connections are demonstrated in a
in the setting of cervical ICA agenesis.5 The mandibular patient with a chronic right ICA occlusion with reconstitu-
artery, which can originate with the vidian artery from a tion from the APhA (►Fig. 5).
common trunk, exits the temporal bone inferiorly to supply
pharyngeal structures and also connect with mucosal APhA Cavernous Area
branches. The highest density of extracranial–intracranial communi-
cations within the broader petrocavernous region occurs in
the vicinity of the cavernous sinus through extracranial
connections with the ILT and MHT. The potential anatomic

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configurations of the ILT are myriad, but in general anterior,
posterior, and superior branches have been described. The
anterior branch travels forward to the superior orbital fissure
to provide vascular supply to cranial nerves and also make
connections to the RMA and MMA. The posterior branch
vascularizes the second and third divisions of the trigeminal
nerve via the arteries of foramen rotundum and ovale,
respectively, though the artery of foramen rotundum often
originates from the anterior branch. Regardless of their site of
origin, these arteries are typically in hemodynamic balance
with similarly named branches of the IMAX and are a source
of extracranial–intracranial connection. Finally, the superior
branch, which is the most inconstant, provides vascular
supply to the cavernous sinus roof and connects with cav-
ernous sinus branches of the MMA.6,7 Relevant branches of
the MHT include the marginal tentorial artery (also known as
the artery of Bernasconi–Cassinari) coursing along the ten-
torial incisura, along which path this artery can anastomose
with the petrosquamosal branch of the MMA.8 Examples of
ICA reconstitution via ILT branches, specifically the artery of
foramen rotundum, in the setting of ICA occlusion can be
seen in ►Fig. 6.

Occipital–Cervical Region
Owing to the segmental origins of the extracranial and
intracranial circulations, the vertebral arteries, and hence
the intracranial posterior circulation, have numerous inter-
connections with branches of the ECA and other longitudinal
vessels of the neck, specifically APhA, occipital artery (OccA),
and ascending and deep cervical arteries.

Ascending Pharyngeal Artery to Vertebral Artery

The APhA typically originates from the posterior wall of the
ECA soon after the carotid bifurcation and ascends directly
superiorly until its division into pharyngeal and neurome-
ningeal trunks. The former travels anterosuperiorly to supply
structures of the pharynx, while the latter travels poster-
osuperiorly and ultimately divides into jugular and hypo-
glossal branches supplying the dura and cranial nerves of
Fig. 4 Juvenile nasopharyngeal angiofibroma. (a) Axial T1-weighted
their respective neural foramina. Prior to this division, the
contrast-enhanced image demonstrating a large JNA of the skull base. neuromeningeal trunk gives off one or two musculospinal
(b) Arterial blood supply to the tumor from the mandibulovidian branches feeding the adjacent cervical musculature that
artery (MVA) and artery of foramen ovale (AFOv) is seen on lateral form extensive connections with the vertebral arteries.
angiographic images. JNA, juvenile nasopharyngeal angiofibroma.
Another route of communication with the vertebral arteries

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 Dangerous Extracranial–Intracranial Anastomoses Rinaldo, Brinjikji 145

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Fig. 5 Reconstitution of ICA through the lateral clival artery. (a) AP and (b) lateral angiographic images demonstrating reconstitution of the ICA
from anastomotic connections between the APhA and ILT via the lateral clival artery in a patient with proximal right carotid occlusion. AP,
anteroposterior; APhA, ascending pharyngeal artery; ICA, internal carotid artery; ILT, inferolateral trunk; LCA, lateral clival artery.

Fig. 6 Reconstitution of the ICA from the ILT. (a) Lateral angiographic images demonstrating reconstitution of the right ICA from connections
between the IMAX and ILT via the artery of foramen rotundum. (b) A different case again demonstrating left ICA reconstitution via the artery of
foramen rotundum. Also seen is reconstitution from the MMA via the RMA and lacrimal arteries. AFRo, artery of foramen rotundum; AP,
anteroposterior; ICA, internal carotid artery; ILT, inferolateral trunk; LA, lacrimal artery; OA, ophthalmic artery; MMA, middle meningeal artery;
RMA, recurrent meningeal artery.

is through the prevertebral branch, which takes off from the Occipital Artery to Vertebral Artery
hypoglossal trunk and descends through the foramen mag- After branching from the ECA, the OccA travels posteriorly
num to connect with the odontoid arcade, an anastomotic along the inferolateral skull base to supply the musculature
network outlining the odontoid process formed by bilateral of the upper posterior cervical and suboccipital regions. It
prevertebral branches and segmental arteries emanating has a roughly horizontal orientation as it travels between
from the vertebral arteries (►Fig. 7). These connections the mastoid and transverse process of the atlas, along
are fairly constant, and thus caution should be employed which path it makes interconnections with the vertebral
whenever embolizing the APhA to avoid unwanted commu- artery through segmental arteries of C1 and C2. These
nication with the intracranial posterior circulation. connections are fairly robust and serve as a frequent source

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146 Dangerous Extracranial–Intracranial Anastomoses Rinaldo, Brinjikji

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Fig. 7 Odontoid arcade. (a) AP and (b) lateral angiographic images following selective catheterization and injection of the APhA demonstrating
filling of the odontoid arcade and vertebrobasilar system from the prevertebral branch of the APhA. Also seen is filling of the artery of the falx
cerebelli. AFCe, artery of falx cerebelli; AP, anteroposterior; APhA, ascending pharyngeal artery; BA, basilar artery; VA, vertebral artery.

of carotid reconstitution in the setting of proximal occlu- Ascending and Deep Cervical Artery to Vertebral Artery
sion (►Fig. 8). An additional anastomotic route is through The ascending and deep cervical arteries are longitudinal
the stylomastoid branch of the OccA, which enters into the vessels of the neck that originate from the thyro- and
stylomastoid foramen and connects with branches of the costocervical trunks, respectively. As they course parallel
posterior meningeal artery originating from the vertebral to the vertebral artery, numerous interconnections
artery. between these vessels are made by cervical radicular

Fig. 8 Reconstitution of carotid artery from the occipital artery. (a) Lateral and (b) AP angiographic images demonstrating reconstitution of an occluded left
common carotid artery from anastomotic connections between the VA and OccA. The C1 and C2 segmental arteries from the VA are seen to connect with
the musculospinal branch of the OccA, leading to carotid reconstitution. AP, anteroposterior; C1, C1 segmental artery; C2, C2 segmental artery; ECA,
external carotid artery; OccA, occipital artery; OccA MSB, musculospinal branch of occipital artery; VA, vertebral artery.

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 Dangerous Extracranial–Intracranial Anastomoses Rinaldo, Brinjikji 147

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Fig. 9 Connections between the deep cervical and vertebral arteries. (a) AP views following catheterization and injection of the DCA
demonstrating active extravasation (circles) from branches of the DCA in a patient with a history of head and neck cancer. Flash filling of the VA is
seen (arrow). (b) The patient was treated with a combination of coil embolization of the mid- to distal DCA followed by particle embolization with
polyvinyl alcohol particles. AP, anteroposterior; DCA, deep cervical artery; VA, vertebral artery.

arteries, with important clinical implications. In instances to a discussion of complication avoidance strategies in
of proximal vertebral artery occlusion, the distal artery is extracranial embolization procedures, specifically the fifth,
often reconstituted by one or both of these arteries seventh, and lower cranial nerves (IX–XII). As opposed to
(►Fig. 9). Embolization of either ascending or deep cervical providing an exhaustive description of cranial nerve supply,
arteries should thus be performed with caution due to the we will limit our discussion to cranial nerve segments with
risk of inadvertent vertebral artery embolization. Finally, it predominantly extracranial supply.
is important to note that the anterior spinal artery runs
longitudinally along with the vertebral and ascending and Trigeminal Nerve
deep cervical arteries, and thus is part of the same seg- The maxillary and mandibular divisions of the trigeminal
mental anastomotic network. Recognition of anterior spi- nerve egress from the Gasserian ganglion and pass through
nal artery filling during neurointerventional procedures is foramen rotundum and ovale, respectively. These segments
critical to avoid catastrophic spinal cord infarction during are supplied by the corresponding arteries of foramen
embolization procedures. rotundum and ovale that originate from branches of the
ILT, but are also in hemodynamic balance with IMAX
branches of the same name, which in many instances pro-
Cranial Nerve Vascular Supply
vides the dominant supply to these nerve segments. Embo-
While familiarity with the vascularization of all cranial lization of the IMAX thus carries the risk of incurring facial
nerves is obviously important, the blood supply to certain numbness in the maxillary and mandibular nerve distribu-
cranial nerves and their subdivisions is particularly relevant tions. Also noteworthy is the inferior alveolar artery, which

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148 Dangerous Extracranial–Intracranial Anastomoses Rinaldo, Brinjikji

originates from the proximal IMAX and runs in the mandib- review the literature on the incidence of and risk factors
ular canal alongside the inferior alveolar nerve, a branch of for tissue necrosis after embolization.
the mandibular division of the trigeminal nerve that provides
sensation to the lower teeth. Numbness in this distribution is Nose and Nasopharyngeal Mucosa
thus another potential complication of IMAX embolization. The nose and associated mucosa receives blood supply from
both the intracranial and extracranial circulations. The intra-
Facial Nerve cranial supply is from the OA via the anterior and posterior
The vascular supply to the tympanic and mastoid segments ethmoidal arteries, which descend through the cribriform plate
of the facial nerve is from an anastomotic network of arteries to vascularize the structures of the superior nasal cavity. From
originating from the extracranial circulation termed the the extracranial circulation, the predominant arterial supply
“facial arcade.” The predominant supply is from the petros- comes from the sphenopalatine artery, which derives from the
quamosal branch of the MMA, with additional supply from IMAX in the pterygopalatine fossa. The sphenopalatine artery
the posterior auricular artery via the stylomastoid branch, exits the pterygopalatine fossa via the sphenopalatine foramen
though this vessel can also take off from the horizontal and enters the nasal cavity just posterosuperiorly to the middle

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portion of the OccA. nasal concha, after which it bifurcates into posterolateral and
posterior medial, or septal, branches. Additional nasal arterial
Lower Cranial Nerves supply is from the greater palatine artery, a branch of the
The lower cranial nerves (9–12) receive significant blood supply descending palatine artery which vascularizes the nasal sep-
from the neuromeningeal trunk of the APhA via the jugular and tum, and superior labial artery, which is a terminal branch of
hypoglossal branches. Prior to its entry into the foramen the facial artery.
magnum, the previously mentioned musculospinal branch of Embolization of ECA branches for the treatment of intrac-
the neuromeningeal trunk also vascularizes the accessory table epistaxis is now a commonplace procedure.9 In general,
nerve. To illustrate the potential pitfalls of APhA embolization, unless a clear source of extravasation is identified, endovas-
we present a case of a hypoglossal palsy following an emboli- cular treatment of epistaxis involves embolization of some
zation procedure with a liquid embolic agent (►Fig. 10). combination of the sphenopalatine, greater palatine, and
distal facial arteries. The risk of tissue necrosis associated
with isolated, unilateral embolization of IMAX branches
Nasal and Oral Blood Supply
appears to be minimal,10 though it has been reported.11
Embolization of ECA branches vascularizing the structures of The authors of this study speculated that this particular
the nose and mouth for the treatment of uncontrolled case may have complicated by a heavy smoking habit and
bleeding is generally well tolerated due to the extensive poor oral hygiene in the patient, along with concomitant
collateral network of these tissues. A serious, yet fortunately treatment with nasal packing, which may have further
rare, complication of arterial embolization in these regions is compromised collateral blood flow. There are multiple series
tissue necrosis. We will discuss the vascular supply of both suggesting that bilateral IMAX embolization is generally well
the nose and tongue and associated mucosa and briefly tolerated, even when performed in combination with

Fig. 10 Hypoglossal palsy following treatment of condylar dural arteriovenous fistula (dAVF). (a) A patient with disabling pulsatile tinnitus was
found to have a condylar dAVF fed primarily by the neuromeningeal trunk of the ascending pharyngeal artery. (b) Anatomic and (c) angiographic
lateral images demonstrating obliteration of the dAVF following a combined transvenous and transarterial embolization with coils and liquid
embolic agent. The patient awoke with a right-sided hypoglossal nerve palsy that improved over time.

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 Dangerous Extracranial–Intracranial Anastomoses Rinaldo, Brinjikji 149

unilateral facial artery embolization,10,12,13 though nasal 3 Geibprasert S, Pongpech S, Armstrong D, Krings T. Dangerous
packing after bilateral IMAX should be performed judiciously extracranial-intracranial anastomoses and supply to the cranial
and for as little time as possible as it may dangerously nerves: vessels the neurointerventionalist needs to know. AJNR
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compromise collateral mucosal blood flow.14 The risk of
4 Osborn AG. The vidian artery: normal and pathologic anatomy.
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