{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,18]],"date-time":"2026-05-18T20:16:11Z","timestamp":1779135371907,"version":"3.51.4"},"reference-count":27,"publisher":"Vilnius University Press","issue":"2","license":[{"start":{"date-parts":[[2025,9,29]],"date-time":"2025-09-29T00:00:00Z","timestamp":1759104000000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["AML"],"abstract":"<jats:p>The bifurcation of the\u00a0Common Carotid Artery\u00a0(CCA) is a pivotal anatomical landmark in head and neck surgeries, particularly affecting procedures such as carotid endarterectomy. Typically occurring around the C3-C4 intervertebral disc, variations in its location can complicate surgical access and pose risks of nerve injury. In this case report, three rare bilateral high bifurcations of the CCA at the C2 and C2\/3 vertebrae levels are documented. Additionally, an unusual pentafurcation of the\u00a0External Carotid Artery\u00a0(ECA) and bilateral superior thyroid artery are observed, arising directly from the CCA. The high bifurcation presents challenges due to its proximity to nerves such as the hypoglossal nerve, potentially leading to complications such as dysphagia or speech impairment. Furthermore, it complicates procedures like carotid endarterectomy, necessitating additional techniques for adequate exposure and increasing risks of\u00a0Internal Carotid Artery\u00a0(ICA) thrombosis. Detailed preoperative imaging before surgery is important for effective planning and minimizing the surgical risk. Anatomical variation, such as the vascular structure, can significantly affect surgical and interventional outcomes. Identifying these differences through meticulous evaluation enables surgeons to anticipate potential challenges, reduce complications, and enhance patient outcomes.<\/jats:p>","DOI":"10.15388\/amed.2025.32.2.12","type":"journal-article","created":{"date-parts":[[2025,9,29]],"date-time":"2025-09-29T06:45:46Z","timestamp":1759128346000},"page":"12","source":"Crossref","is-referenced-by-count":1,"title":["High Bifurcation of the Common Carotid Artery with Pentafurcation of the External Carotid Artery: Case Series with Review of Literature"],"prefix":"10.15388","volume":"32","author":[{"given":"Aarthi","family":"Manokaran","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Manisha R","family":"Gaikwad","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Baskar","family":"A","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Murugan","family":"Gopalakrishnan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9494-9468","authenticated-orcid":false,"given":"Praveen Kumar","family":"Ravi","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"6097","published-online":{"date-parts":[[2025,9,29]]},"reference":[{"key":"ref0","doi-asserted-by":"publisher","unstructured":"Mirjalili SA, McFadden SL, Buckenham T, Stringer MD. Vertebral levels of key landmarks in the neck. Clin Anat. 2012;25(7):851-857. doi:10.1002\/ca.22124","DOI":"10.1002\/ca.22124"},{"key":"ref1","doi-asserted-by":"publisher","unstructured":"Michalinos A, Chatzimarkos M, Arkadopoulos N, Safioleas M, Troupis T. Anatomical Considerations on Surgical Anatomy of the Carotid Bifurcation. Anat Res Int. 2016;2016:1-8. doi:10.1155\/2016\/6907472","DOI":"10.1155\/2016\/6907472"},{"key":"ref2","doi-asserted-by":"publisher","unstructured":"Rockley M, Ryan SE, Nagpal S. Endarterectomy of carotid artery bifurcation in the setting of a persistent hypoglossal artery and anomalous collateral vascular supply. J Vasc Surg Cases Innov Tech. 2020;6(4):520-523. doi:10.1016\/j.jvscit.2020.08.007","DOI":"10.1016\/j.jvscit.2020.08.007"},{"key":"ref3","unstructured":"Standring S. Gray's anatomy: the anatomical basis of clinical practice. 41st ed. Elsevier Churchill Livingstone; 2016."},{"key":"ref4","doi-asserted-by":"publisher","unstructured":"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):244-247. doi:10.4314\/eamj.v85i5.9619","DOI":"10.4314\/eamj.v85i5.9619"},{"key":"ref5","unstructured":"Badhe P, Dabharde P, Kapadnis AS, Ravi Kiran D. Anatomical Variation of Common Carotid Artery Bifurcation In Relation To Cervical Vertebra on CT Angiogram. IOSR Journal of Dental and Medical Sciences (IOSR-JDMS). 2018;17(2):58-66. doi:10.9790\/0853-1712085866"},{"key":"ref6","unstructured":"Radha K. Bifurcation levels of the common carotid arteries- A cadaveric study in South Indian population. Int J Anat Res. 2014;2(3):511-514."},{"key":"ref7","unstructured":"Tong H, Sili Z, Xu S, Jie J, Jun B, Jianjin W, Liang W, Qingjun J, Lefeng Q. [Evaluation of the level of carotid bifurcation and the morphology of extracranial internal carotid artery in patients with carotid stenosis by color doppler ultrasound and digital subtraction angiography]. Natl Med J China. 2022;102(11):781-786. doi:10.3760\/cma.j.cn112137-20210605-01285"},{"key":"ref8","doi-asserted-by":"publisher","unstructured":"Z\u00fcmre \u00d6, Salbacak A, \u00c7i\u00e7ekciba\u015fi 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 Anat. 2005;187(4):361-369. doi:10.1016\/j.aanat.2005.03.007","DOI":"10.1016\/j.aanat.2005.03.007"},{"key":"ref9","doi-asserted-by":"publisher","unstructured":"Jitpun E, Wattanasen Y, Tirakotai W. Do Asians have Higher Carotid Bifurcation? A Computed Tomographic Angiogram Study of the Common Carotid Artery Bifurcation and External Carotid Artery Branching Patterns. Asian J Neurosurg. 2019;14(4):1082-1088. doi:10.4103\/ajns.AJNS_162_19","DOI":"10.4103\/ajns.AJNS_162_19"},{"key":"ref10","doi-asserted-by":"publisher","unstructured":"Kurkcuoglu A, Aytekin C, Oktem H, Pelin C. Morphological variation of carotid artery bifurcation level in digital angiography. Folia Morphol (Warsz). 2015;74(2):206-211. doi:10.5603\/FM.2015.0032","DOI":"10.5603\/FM.2015.0032"},{"key":"ref11","doi-asserted-by":"publisher","unstructured":"Woldeyes Bahir D, Dh W. Anatomical Variations of the Common Carotid Artery Bifurcations in Relation to the Cervical Vertebrae in Ethiopia 2014. Anat Physiol. 2014;4(3):1000143. doi:10.4172\/2161-0940.1000143","DOI":"10.4172\/2161-0940.1000143"},{"key":"ref12","doi-asserted-by":"publisher","unstructured":"Chalise U, Pradhan A, Lama CP, Dhungel S. Bifurcation of Common Carotid Artery in Relation to Vertebral Level in Nepalese: A Cadaveric Study. Nep Med Coll J. 2021;23(3):223-227. doi:10.3126\/nmcj.v23i3.40380","DOI":"10.3126\/nmcj.v23i3.40380"},{"key":"ref13","doi-asserted-by":"publisher","unstructured":"Amarttayakong S, Amarttayakong P, Munkong W, Laup A, Chaiyamoon A, Suwannakhan A, Sangkhano S. Is low carotid bifurcation determined by vertebral level always convenient for surgical approach? PLoS One. 2024;19(2):e0294072. doi:10.1371\/journal.pone.0294072","DOI":"10.1371\/journal.pone.0294072"},{"key":"ref14","doi-asserted-by":"publisher","unstructured":"Manta MD, Rusu MC, Hostiuc S, Tudose RC, Manta BA, Jianu AM. The vertical topography of the carotid bifurcation - original study and review. Surg Radiol Anat. 2024;46(8):1253-1263. doi:10.1007\/s00276-024-03404-y","DOI":"10.1007\/s00276-024-03404-y"},{"key":"ref15","doi-asserted-by":"publisher","unstructured":"Gulsen S, Caner H, Altinors N. An anatomical variant: Low-lying bifurcation of the common carotid artery, and its surgical implications in anterior cervical discectomy. J Korean Neurosurg Soc. 2009;45(1):32-34. doi:10.3340\/jkns.2009.45.1.32","DOI":"10.3340\/jkns.2009.45.1.32"},{"key":"ref16","doi-asserted-by":"publisher","unstructured":"McNamara JR, Fulton GJ, Manning BJ. Three-dimensional Computed Tomographic Reconstruction of the Carotid Artery: Identifying High Bifurcation. Eur J Vasc Endovasc Surg. 2015;49(2):147-153. doi:10.1016\/j.ejvs.2014.10.006","DOI":"10.1016\/j.ejvs.2014.10.006"},{"key":"ref17","doi-asserted-by":"publisher","unstructured":"Kazantsev AN, Korotkikh AV, Lider RY, et al. An alternative anatomical classification for carotid bifurcation and impact on outcome of carotid endarterectomy: a multicenter study. Cardiothorac Surg. 2023;31:6. doi:10.1186\/s43057-023-00097-8","DOI":"10.1186\/s43057-023-00097-8"},{"key":"ref18","doi-asserted-by":"publisher","unstructured":"Keshelava G, Kovziridze D, Robakidze Z. 180-degre carotid bifurcation with an internal carotid artery aneurysm. Surg Radiol Anat. 2023;45(6):769-771. doi:10.1007\/s00276-023-03136-5","DOI":"10.1007\/s00276-023-03136-5"},{"key":"ref19","doi-asserted-by":"publisher","unstructured":"Conte Neto N, Gon\u00e7alves TT, Louis C, Ikikame J, G\u00f3es Junior AMO. Surgical access to the distal cervical segment of the internal carotid artery and to a high carotid bifurcation - integrative literature review and protocol proposal. J Vasc Bras. 2022;21:e20210193. doi:10.1590\/1677-5449.202101931","DOI":"10.1590\/1677-5449.202101931"},{"key":"ref20","doi-asserted-by":"publisher","unstructured":"Galyfos G, Chamzin A, Sigala F, Filis K. Postcarotid Endarterectomy Hematoma Induced Arrhythmia: Report of a Rare Case. Case Rep Vasc Med. 2023;2023:4633731. doi:10.1155\/2023\/4633731","DOI":"10.1155\/2023\/4633731"},{"key":"ref21","doi-asserted-by":"publisher","unstructured":"Comerota AJ, Difiore R, Tzilinis A, Chahwan S. Cervical hematoma following carotid endarterectomy is morbid and preventable: A 12-year case-controlled review. Vasc Endovascular Surg. 2012;46(8):610-616. doi:10.1177\/1538574412465480","DOI":"10.1177\/1538574412465480"},{"key":"ref22","doi-asserted-by":"publisher","unstructured":"Brown CR, Brown ND, Brown MR. Surgical Considerations and Strategies for Anatomically Variant and Diseased Carotid Arteries. In: Kurt G, \u00d6zer A, eds. Carotid Arteries - Function, Pathology and Treatment. IntechOpen. 2024:1-29. doi:10.5772\/intechopen.114969","DOI":"10.5772\/intechopen.114969"},{"key":"ref23","doi-asserted-by":"publisher","unstructured":"Moraru L, Rusu MC, Popescu \u015eA. True terminal pentafurcation of the external carotid artery and terminal trifurcation of the contralateral one, occipitoauricular trunk, retropharyngeal internal carotid artery. Surg Radiol Anat. 2021;43(11):1895-1900. doi:10.1007\/s00276-021-02812-8","DOI":"10.1007\/s00276-021-02812-8"},{"key":"ref24","doi-asserted-by":"publisher","unstructured":"Tzortzis AS, Antonopoulos I, Pechlivanidou E, Chrysikos D, Pappas N, Troupis T. Anatomical variations of the superior thyroid artery: A systematic review. Morphologie. 2023;107(358):100597. doi:10.1016\/j.morpho.2023.03.002","DOI":"10.1016\/j.morpho.2023.03.002"},{"key":"ref25","doi-asserted-by":"publisher","unstructured":"Dessie MA. Variations of the origin of superior thyroid artery and its relationship with the external branch of superior laryngeal nerve. PLoS One. 2018;13(5):e0197075. doi:10.1371\/journal.pone.0197075","DOI":"10.1371\/journal.pone.0197075"},{"key":"ref26","doi-asserted-by":"publisher","unstructured":"Calot\u0103 RN, Rusu MC, Dumitru CC, Moraru L, Tudose RC. Retropharyngeal course of the superior thyroid artery - a novel finding. Surg Radiol Anat. 2025;47(1):115. doi:10.1007\/s00276-025-03627-7","DOI":"10.1007\/s00276-025-03627-7"}],"container-title":["Acta medica Lituanica"],"original-title":[],"link":[{"URL":"https:\/\/www.journals.vu.lt\/AML\/article\/download\/42240\/40528","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.journals.vu.lt\/AML\/article\/download\/42240\/40529","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.journals.vu.lt\/AML\/article\/download\/42240\/40528","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,29]],"date-time":"2025-09-29T06:46:27Z","timestamp":1759128387000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.journals.vu.lt\/AML\/article\/view\/42240"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,9,29]]},"references-count":27,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2025,7,29]]}},"URL":"https:\/\/doi.org\/10.15388\/amed.2025.32.2.12","relation":{},"ISSN":["2029-4174","1392-0138"],"issn-type":[{"value":"2029-4174","type":"electronic"},{"value":"1392-0138","type":"print"}],"subject":[],"published":{"date-parts":[[2025,9,29]]}}}