{"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":1779135371725,"version":"3.51.4"},"reference-count":32,"publisher":"Scientific Scholar","content-domain":{"domain":["surgicalneurologyint.com"],"crossmark-restriction":true},"short-container-title":[],"abstract":"<jats:sec id=\"st1\">\n<jats:title>Background: <\/jats:title>\n<jats:p>We have already introduced the visualization of the posterior belly of the digastric muscle, which is a major component of the styloid diaphragm (SD). This helped the carotid endarterectomy (CEA) simulation considering the carotid bifurcation or carotid plaque height and their accessibility. In CEA cases, we examined the relationship between the SD and carotid bifurcation to determine whether the high bifurcation cases have the specific clinical profiles.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"st2\">\n<jats:title>Methods: <\/jats:title>\n<jats:p>Eighty-seven consecutive CEA-treated Japanese patients were evaluated, and the location of the carotid bifurcation, thyroid cartilage (TC), hyoid bone (HB), and gonion was measured on the computed tomography angiography, referred to the heights of cervical vertebra bodies.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"st3\">\n<jats:title>Results: <\/jats:title>\n<jats:p>Mean vertebral levels of the carotid bifurcation, TC, HB, and gonion were 3.9 \u00b1 0.6, 5.5 \u00b1 0.6, 4.2 \u00b1 0.5, 3.9 \u00b1 0.6, and 2.9 \u00b1 0.6, respectively. Seven carotid bifurcations located higher than the SD. There were no statistical differences in the distribution of sex, age, and coexisting diseases except for coronary artery disease (<jats:italic>P<\/jats:italic> = 0.02) between normal (4.0 \u00b1 0.6) and high bifurcation (3.4 \u00b1 0.4) cases. The multivariate analyses revealed that the coronary artery disease (<jats:italic>P<\/jats:italic> = 0.04), twisted internal carotid artery (ICA) (<jats:italic>P<\/jats:italic> = 0.031), and TC levels (<jats:italic>P<\/jats:italic> = 0.007) were correlated with the high bifurcation.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"st4\">\n<jats:title>Conclusion: <\/jats:title>\n<jats:p>The high bifurcation correlates with the twisted ICA, high TC, and alternatively low gonion levels. The visualized SD could be the landmark for the CEA indication and preparation and enables meticulous surgical manipulation of the distal end of the carotid plaque.<\/jats:p>\n<\/jats:sec>","DOI":"10.25259\/sni_561_2025","type":"journal-article","created":{"date-parts":[[2025,8,8]],"date-time":"2025-08-08T06:59:46Z","timestamp":1754636386000},"page":"324","update-policy":"https:\/\/doi.org\/10.25259\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Analysis of the carotid bifurcation levels for carotid endarterectomy"],"prefix":"10.25259","volume":"16","author":[{"given":"Masaru","family":"Honda","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"10894","published-online":{"date-parts":[[2025,8,8]]},"reference":[{"key":"10.25259\/SNI_561_2025\/ref-1","doi-asserted-by":"crossref","first-page":"2575","DOI":"10.1161\/01.STR.0000035736.30488.7A","article-title":"Bilateral symmetry of human carotid artery atherosclerosis","volume":"33","author":"Adams","year":"2002","journal-title":"Stroke"},{"key":"10.25259\/SNI_561_2025\/ref-2","first-page":"e31715","article-title":"Topography of the anatomical landmarks of carotid bifurcation and clinical significance","volume":"14","author":"Ci","year":"2022","journal-title":"Cureus"},{"key":"10.25259\/SNI_561_2025\/ref-3","doi-asserted-by":"crossref","first-page":"1029","DOI":"10.1007\/s00276-022-02985-w","article-title":"Geometric morphometric study of anterior branches of external carotid artery and carotid bifurcation by 3D-CT angiography","volume":"44","author":"Demirta\u015f","year":"2022","journal-title":"Surg Radiol Anat"},{"key":"10.25259\/SNI_561_2025\/ref-4","doi-asserted-by":"crossref","first-page":"1675","DOI":"10.1016\/j.jvs.2020.08.149","article-title":"Carotid endarterectomy remains safe in high-risk patients","volume":"73","author":"Droz","year":"2021","journal-title":"J Vasc Surg"},{"key":"10.25259\/SNI_561_2025\/ref-5","doi-asserted-by":"crossref","first-page":"1751","DOI":"10.1161\/01.STR.30.9.1751","article-title":"The North American symptomatic carotid endarterectomy trial: Surgical results in 1415 patients","volume":"30","author":"Ferguson","year":"1999","journal-title":"Stroke"},{"key":"10.25259\/SNI_561_2025\/ref-6","doi-asserted-by":"crossref","first-page":"865","DOI":"10.3109\/02688697.2015.1071331","article-title":"Access to the carotid artery bifurcation: Cadaveric study with application to nasotracheal intubation as a technique to improve access to a high carotid artery bifurcation","volume":"29","author":"Foreman","year":"2016","journal-title":"Br J Neurosurg"},{"key":"10.25259\/SNI_561_2025\/ref-7","doi-asserted-by":"crossref","first-page":"123","DOI":"10.1007\/s00276-001-0123-x","article-title":"High bifurcation of common carotid artery, anomalous origin of ascending pharyngeal artery and anomalous branching pattern of external carotid artery","volume":"23","author":"Gluncic","year":"2001","journal-title":"Surg Radiol Anat"},{"key":"10.25259\/SNI_561_2025\/ref-8","first-page":"676692","article-title":"The carotid system of arteries","volume-title":"Gray\u2019s anatomy","author":"Gray","year":"1980","edition":"36th ed"},{"key":"10.25259\/SNI_561_2025\/ref-9","doi-asserted-by":"crossref","first-page":"25","DOI":"10.2176\/nmc.45.25","article-title":"Surgical anatomy of the cervical carotid artery for carotid endarterectomy","volume":"45","author":"Hayashi","year":"2005","journal-title":"Neurol Med Chir (Tokyo)"},{"key":"10.25259\/SNI_561_2025\/ref-10","doi-asserted-by":"crossref","first-page":"147","DOI":"10.25259\/SNI_601_2019","article-title":"Analysis of twisted internal carotid arteries in carotid endarterectomy","volume":"11","author":"Honda","year":"2020","journal-title":"Surg Neurol Int"},{"key":"10.25259\/SNI_561_2025\/ref-11","doi-asserted-by":"crossref","first-page":"121","DOI":"10.2535\/ofaj.86.121","article-title":"Anomalous bifurcation and island formation of the carotid artery","volume":"86","author":"Iimura","year":"2010","journal-title":"Okajimas Folia Anat Jpn"},{"key":"10.25259\/SNI_561_2025\/ref-12","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1177\/1591019915581941","article-title":"Usefulness of the fusion imaging of 3D-CT and MRA for carotid artery stenting with minimum use of contrast medium in patient with renal dysfunction","volume":"21","author":"Inoue","year":"2015","journal-title":"Interv Neuroradiol"},{"key":"10.25259\/SNI_561_2025\/ref-13","doi-asserted-by":"crossref","first-page":"157","DOI":"10.2535\/ofaj.82.157","article-title":"Clinical anatomy in the neck region--the position of external and internal carotid arteries may be reversed","volume":"82","author":"Ito","year":"2006","journal-title":"Okajimas Folia Anat Jpn"},{"key":"10.25259\/SNI_561_2025\/ref-14","doi-asserted-by":"crossref","first-page":"96","DOI":"10.2335\/scs.50.96","article-title":"Carotid fat pad flip method: Improving carotid endarterectomy by exploiting fat tissue in the carotid triangle","volume":"50","author":"Kaji","year":"2020","journal-title":"Surg Cereb Stroke (Jpn)"},{"key":"10.25259\/SNI_561_2025\/ref-15","first-page":"963","article-title":"Relationship between the cervical carotid artery and the stylohyoid-thyroid chain","volume":"48","author":"Kawahara","year":"2020","journal-title":"No Shinkei Geka (Jpn)"},{"key":"10.25259\/SNI_561_2025\/ref-16","doi-asserted-by":"crossref","first-page":"295","DOI":"10.3995\/jstroke.11097","article-title":"Hyoid bone-related vasculopathy","volume":"45","author":"Kawahara","year":"2023","journal-title":"Jpn J Stroke (Jpn)"},{"key":"10.25259\/SNI_561_2025\/ref-17","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1186\/s43057-023-00097-8","article-title":"An alternative anatomical classification for carotid bifurcation and impact on outcome of carotid endarterectomy: A multicenter study","volume":"31","author":"Kazantsev","year":"2023","journal-title":"Cardiothoracic Surg"},{"key":"10.25259\/SNI_561_2025\/ref-18","doi-asserted-by":"crossref","first-page":"e1075","DOI":"10.1016\/j.wneu.2023.04.071","article-title":"Preoperative novel magnetic resonance fusion imaging for carotid endarterectomy patients with contrast contraindications: A pilot study","volume":"175","author":"Kikuchi","year":"2023","journal-title":"World Neurosurg"},{"key":"10.25259\/SNI_561_2025\/ref-19","doi-asserted-by":"crossref","first-page":"383","DOI":"10.1007\/s00276-008-0337-2","article-title":"Topography of carotid bifurcation: Considerations for neck examination","volume":"30","author":"Klosek","year":"2008","journal-title":"Surg Radiol Anat"},{"key":"10.25259\/SNI_561_2025\/ref-20","doi-asserted-by":"crossref","first-page":"384","DOI":"10.1007\/978-3-662-10172-8","article-title":"Surgical neuroangiography 1","volume-title":"Clinical Vascular Anatomy and Variations","author":"Lasjaunias","year":"2001","edition":"2nd ed"},{"key":"10.25259\/SNI_561_2025\/ref-21","doi-asserted-by":"crossref","first-page":"344","DOI":"10.1053\/ejvs.2002.1725","article-title":"Assessment of voice quality after CEA","volume":"24","author":"Lazaris","year":"2002","journal-title":"Eur J Vasc Endovasc Surg"},{"key":"10.25259\/SNI_561_2025\/ref-22","doi-asserted-by":"crossref","first-page":"1253","DOI":"10.1007\/s00276-024-03404-y","article-title":"The vertical topography of the carotid bifurcation-original study and review","volume":"46","author":"Manta","year":"2024","journal-title":"Surg Radiol Anat"},{"key":"10.25259\/SNI_561_2025\/ref-23","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1016\/j.ejvs.2014.10.006","article-title":"Three-dimensional computed tomographic reconstruction of the carotid artery: Identifying high bifurcation","volume":"49","author":"McNamara","year":"2015","journal-title":"Eur J Vasc Endovasc Surg"},{"key":"10.25259\/SNI_561_2025\/ref-24","first-page":"6907472","article-title":"Anatomical considerations on surgical anatomy of the carotid bifurcation","volume":"2016","author":"Michalinos","year":"2016","journal-title":"Anat Res Int"},{"key":"10.25259\/SNI_561_2025\/ref-25","doi-asserted-by":"crossref","first-page":"851","DOI":"10.1002\/ca.22124","article-title":"Vertebral levels of key landmarks in the neck","volume":"25","author":"Mirjalili","year":"2012","journal-title":"Clin Anat"},{"key":"10.25259\/SNI_561_2025\/ref-26","doi-asserted-by":"crossref","first-page":"484","DOI":"10.1160\/th15-07-0597","article-title":"Atherosclerosis at arterial bifurcations: Evidence for the role of haemodynamics and geometry","volume":"115","author":"Morbiducci","year":"2016","journal-title":"Thromb Haemost"},{"key":"10.25259\/SNI_561_2025\/ref-27","doi-asserted-by":"crossref","first-page":"380","DOI":"10.2335\/scs.38.380","article-title":"Surgical anatomy of styloid diaphragm for carotid endarterectomy in patients with high cervical carotid artery stenosis","volume":"38","author":"Narumi","year":"2010","journal-title":"Surg Cereb Stroke (Jpn)"},{"key":"10.25259\/SNI_561_2025\/ref-28","first-page":"246","article-title":"Anatomy of the suprahyoid muscles","volume":"53","author":"Saigusa","year":"2010","journal-title":"Otorhinolaryngology"},{"key":"10.25259\/SNI_561_2025\/ref-29","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1007\/BF00337533","article-title":"On the symmetry and asymmetry of the bifurcation of the common carotid artery: A study of bilateral carotid angiograms in 100 adults","volume":"17","author":"Smith","year":"1979","journal-title":"Neuroradiology"},{"key":"10.25259\/SNI_561_2025\/ref-30","doi-asserted-by":"crossref","first-page":"1182","DOI":"10.1016\/j.jvs.2022.11.063","article-title":"Prevalence, risk factors, and clinical effect of coronary artery disease in patients with asymptomatic bilateral carotid stenosis","volume":"77","author":"Squizzato","year":"2023","journal-title":"J Vasc Surg"},{"key":"10.25259\/SNI_561_2025\/ref-31","first-page":"633","article-title":"Angiographical evaluation of extracranial carotid artery: Comparison between Japanese and Hungarian","volume":"49","author":"Toyota","year":"1997","journal-title":"No To Shinkei (Jpn)"},{"key":"10.25259\/SNI_561_2025\/ref-32","first-page":"143","article-title":"Anatomical variations of the common carotid artery bifurcations in relation to the cervical vertebrae in Ethiopia","volume":"4","author":"Woldeyes","year":"2014","journal-title":"Anat Physiol"}],"container-title":["Surgical Neurology International"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/surgicalneurologyint.com\/analysis-of-the-carotid-bifurcation-levels-for-carotid-endarterectomy\/","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/surgicalneurologyint.com\/surgicalint-articles\/analysis-of-the-carotid-bifurcation-levels-for-carotid-endarterectomy\/","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,8]],"date-time":"2025-08-08T06:59:51Z","timestamp":1754636391000},"score":1,"resource":{"primary":{"URL":"http:\/\/surgicalneurologyint.com\/surgicalint-articles\/analysis-of-the-carotid-bifurcation-levels-for-carotid-endarterectomy\/"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,8,8]]},"references-count":32,"alternative-id":["10.25259\/SNI_561_2025"],"URL":"https:\/\/doi.org\/10.25259\/sni_561_2025","relation":{},"ISSN":["2152-7806","2229-5097"],"issn-type":[{"value":"2152-7806","type":"electronic"},{"value":"2229-5097","type":"print"}],"subject":[],"published":{"date-parts":[[2025,8,8]]},"article-number":"324"}}