Table of Contents  
Year : 2019  |  Volume : 11  |  Issue : 1  |  Page : 65-70

Cone Beam Computed Tomography Detection of Extracranial Vertebral Artery (EVA) Calcification and Ectasia

1 Department of Diagnostic Sciences, Rutgers School of Dental Medicine, Newark, NJ
2 Department of Radiology, University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA

Date of Web Publication9-Aug-2019

Correspondence Address:
Mel Mupparapu
Professor and Director of Radiology, University of Pennsylvania School of Dental Medicine, 240 S 40th Street, Philadelphia, PA 19104
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jofs.jofs_130_18

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Carotid artery calcification is frequently noted in panoramic dental radiographs but more evident on cone beam computed tomography (CBCT) examinations. Vertebral artery calcification and ectasia, although rare, can place the patient for equal risk for a cerebrovascular accident (stroke). The aim of this article is to radiographically identify calcified atheromatous plaque, as well as, atresia related to vertebral artery in large field of view CBCT examinations. This article presents two patients with radiographic diagnosis of vertebral artery disease. In case 1, the large field of view CBCT volume was obtained for evaluation of the temporomandibular joints. A curvilinear high-density structure was seen within the left transverse foramen of C3. Based on the density, location, and shape, a radiographic diagnosis of calcified atheromatous plaque was made. The patient was referred to her physician for management. In case 2, irregularly shaped, small, high-density structures were noted on the CBCT examination close to the left carotid bifurcation at the level of C3–C4. It was also noted that the left transverse foramen of C4 was enlarged. A diagnosis of calcified atheroma of left carotid was made in patient 1, and calcified atheromatous plaque in the left carotid bifurcation area and concomitant vertebral artery ectasia was made in patient 2. Both the patients were referred to their physicians for management. Although prevalence of carotid artery stenosis and calcification is noted more frequently in CBCT examinations, vertebral artery calcification or ectasia is rare but because of its potential risk for causation of stroke, identification is paramount.

Keywords: Calcification, calcified plaques, cone beam CT, ectasia, stroke, vertebral artery

How to cite this article:
Singer SR, Mupparapu M. Cone Beam Computed Tomography Detection of Extracranial Vertebral Artery (EVA) Calcification and Ectasia. J Orofac Sci 2019;11:65-70

How to cite this URL:
Singer SR, Mupparapu M. Cone Beam Computed Tomography Detection of Extracranial Vertebral Artery (EVA) Calcification and Ectasia. J Orofac Sci [serial online] 2019 [cited 2023 Jun 9];11:65-70. Available from:

  Introduction Top

Calcified atheromatous plaque is most often noted extracranially, in the common carotid artery at the bifurcation, or intracranially, within the internal carotid artery in the region of sella turcica.[1] Calcified atheromatous plaque in the vertebral arteries has been reported less often, although vertebral artery ectasia is more commonly reported.[1] The vertebral arteries are paired vessels arising from the subclavian artery and ascending in the neck supplying vasculature to the occipital lobes and posterior cranial fossa [Figure 1]. The vertebral arteries branch off from the first part of the subclavian artery and ascend via the transverse foramina of cervical vertebrae to join the contralateral vertebral artery and form the basilar artery[2] [Figure 1]. Calcification within the atheromatous plaques is a pathophysiological process that is not a rarity. The calcification is a slow process and becomes a major risk factor if the lumen of the vessel becomes narrow and eventually when its very patency is challenged. Unlike atheromatous calcifications of the carotid artery, extracranial vertebral artery (EVA) atheromatous calcifications are rare.
Figure 1 Drawing depicting the anatomical position and branching of vertebral artery in the neck.

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The American College of Cardiology Foundation and the American Heart Association published the study[3] entitled “Guidelines on the management of patients with extracranial carotid and vertebral artery disease.” Based on the published management guidelines of atherosclerotic risk factors in patients with vertebral artery disease, vascular imaging of patients with suspected or known vertebral artery disease can be performed using CT angiography or magnetic resonance imaging (MR) angiography.[3] Periodic imaging of the EVA is recommended to assess progression of atherosclerotic disease and exclude the development of new lesions for patients who are at a high risk for cerebrovascular events. If a stenosis is suspected, catheter-based contrast angiography is recommended when noninvasive imaging fails to define the location or severity of stenosis. In patients who have had prior vertebral artery revascularization, periodic imaging of the EVA is recommended at intervals like those for carotid revascularization.[3] Due to its rarity and importance for the dental clinicians, a case of calcified atheroma in the vertebral artery is presented, along with an additional case of vertebral artery ectasia with concomitant finding of extracranial carotid atherosclerosis.

  Case report 1 Top

A 62-year-old female presented to her dentist with a main complaint of pain in the temporomandibular joint areas on chewing. The pain had grown progressively worse over the past few months. The patient’s medical history was otherwise noncontributory. After the clinical examination, which revealed bilateral tenderness in the area on palpation and mildly reduced interincisal opening, a large field of view (FOV) CBCT examination was obtained. The dentist sent her CBCT volumes for radiology review. The interpretation of the CBCT volume revealed a 4 mm × 1 mm × 5.5 mm irregularly shaped high-density structure noted within the left transverse foramen of C3. When viewed in the axial reconstruction, the structure appeared curvilinear. The structure was not seen to be in contact with the bony structure of C3 in any of the multiplanar reconstructions, leading to a radiographic diagnosis of calcified atheromatous plaque within the lumen of the left vertebral artery at the level of C3 [Figure 2] and [Figure 3]. Other findings included missing, endodontically treated, and restored teeth in both the maxilla and mandible. Marginal periodontitis was also noted. Persistent or resolving apical inflammatory lesions were seen at the apices of endodontically treated tooth #19. Flattening of the anterior articulating surfaces of the condylar heads and osteophyte formation indicated degenerative joint disease in both temporomandibular joint (TMJs). Additionally, deviation of the nasal septum was noted. Calcification of the pineal gland, a finding that is generally associated with normal aging, was also present. It was recommended that the patient be referred to her physician for management of the vertebral artery calcified atheroma while continuing her dental care at the primary care dentist.
Figure 2 Noncontrast axial, coronal, and sagittal views of the maxillofacial CBCT demonstrating the curvilinear radiodensity (arrows) within the transverse foramen of C3 suggestive of calcified atherosclerotic plaque within vertebral artery. CBCT: cone beam computed tomography.

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Figure 3 Three-dimensional reconstruction of the neck area showing the radiodense structure within the left transverse foramen of C3 indicating the calcification of vertebral artery at this level.

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  Case report 2 Top

A 77-year-old female presented to her dentist for routine care. Periapical radiographs revealed a large noncorticated lesion in the mandibular anterior teeth, apical and lateral to the left canine and lateral incisors. A CBCT of the mandible was obtained. The dentist sent her CBCT volumes for radiology review. The interpretation of the volume revealed a moderately corticated hypodense lesion noted at the apex of left canine. In addition, a 8 mm × 8 mm × 5.5 mm well-demarcated, noncorticated lesion was noted in the interdental bone between left lateral incisor and canine. The lesion surrounded the roots of both the teeth displacing the roots. Both the buccal and lingual cortices were thinned and slightly expanded in the area of the lesion. A biopsy of this area was recommended for definitive diagnosis of the mandibular lesion. The examination revealed the following additional findings in the area of the neck and cervical spine. Calcifications, consistent in appearance with calcified carotid artery atheromas, were present in the vicinity of left carotid bifurcation at the level of C3–C4 [Figure 4]. Diminished joint space, cortical erosion of the articulating surfaces of the vertebral bodies, and osteophyte formation were noted. Further, C3 and C4 appeared to be fused. These changes are consistent with significant degenerative joint disease. Additionally, the left transverse foramen in C4 was enlarged [Figure 4], suggesting a diagnosis of vertebral artery ectasia. The patient was referred to her physician for further investigation and management. Additional findings included missing and endodontically treated teeth. The dentition was restored with a fixed prosthesis. Periodontal bone loss with horizontal and vertical defects was noted. Mild-to-moderate ridge atrophy was noted in the edentulous areas.
Figure 4 Noncontrast axial CBCT views of neck at the level of the epiglottis (left) and slightly below the epiglottis (right) showing the ectasia of left carotid canal (long arrow) and calcification of the left common carotid artery (short arrows). CBCT: cone beam computed tomography.

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  Diagnosis Top

A diagnosis of calcified atheromatous plaque was made in the left vertebral artery at the level of C3. In addition, a diagnosis of calcified atheromatous plaque in the left carotid bifurcation and concomitant vertebral artery ectasia was made. Both the patients were at a high risk for stroke and sent to their primary care physicians for management of their risk factors as well as necessary interventions.

  Discussion Top

Although it is known that high blood pressure, high cholesterol, smoking, obesity, and diabetes are the leading causes of stroke,[4] calcified atheromatous plaques that may be detected radiographically have been associated with increase stroke risk.[5] Although this association solely based on panoramic radiographic detection remains controversial,[6] reporting of findings of calcified atheromas and referral to the patient’s physician for follow-up is considered to be the acceptable standard of care.[7] Although all of the preceding statements are true with regard to the carotid artery calcifications, similar standards can be attributed to the EVA detection, reporting, and referral. Large FOV cone beam computed tomography (CBCT) examinations, as used in dental settings, often display the structures of the head and neck, including the cervical vertebrae to the level of fourth cervical vertebra (C4) inferior to the level of hyoid bone. Superiorly, most large FOV scans are designed to capture structures to the level of the pituitary fossa. While reviewing these volumes, calcifications in the areas of the carotid bifurcation, as well as within the intracranial course of internal carotid arteries, are commonly noted. These findings are more common in older patients because of increased prevalence of atherosclerosis.[8] Calcified atheromas in the vertebral arteries are less commonly noted possibly due to the anatomic location of the vertebral arteries obscured by the cervical vertebrae. In comparison to the appearance of calcified carotid artery atheromas on panoramic radiographs, EVA calcifications are not captured on these radiographs. It is only the volumetric captures of CBCT that led to the visualization of neck in three dimensions including the cervical vertebrae, the foramina, and their calcified contents. While the vessels are not directly seen in noncontrast CBCT reconstructions, a radiographic diagnosis of calcified atheromas can be made based on the location and other radiographic features of the calcifications within these vessels.

Although there are several published studies in the literature on the intracranial vertebral atherosclerotic plaques presenting as calcifications, EVA calcifications are not noted as frequently.[9],[10],[11] Katada et al.[11] reviewed a series of 3648 multidetector computed tomographic scans to identify the frequency of intracranial vertebral artery calcifications. The authors concluded that CT imaging is highly sensitive for detection of calcified plaques intracranially and extracranially. Cloud and Markus[12] noted that “the gold standard for the diagnosis of vertebral artery stenosis is digital subtraction angiography and the primary noninvasive investigation of choice for EVA disease is ultrasound.”[12] In a study conducted by de Bray et al.,[13] the authors noted that when transcranial Doppler ultrasound was used to detect intracranial vertebral artery stenosis, the sensitivity was high (80%) and the specificity was even higher (80%–97%) compared with digital subtraction angiography. This study supports the value of transcranial Doppler ultrasonography in the detection of intracranial vertebral artery disease.As per the American Heart Association and American Stroke Association guidelines[14] for the prevention of stroke, the broad medical management of EVA stenosis include antiplatelet therapy, use of statins, and risk factor modification. If symptoms persist in spite of medical treatment, then endovascular and surgical treatment is recommended for patients with EVA stenosis.[14] Early detection of carotid artery (internal, external, or common) or vertebral artery stenosis is of paramount importance to institute early preventative measures, timely interventions, and management. In dental practice, due to the availability of CBCT and its regularity in use for various maxillofacial applications, the area of carotids and vertebral vessels are frequently imaged. In conclusion, when calcifications are noted on the CBCT reconstructions, appropriate referral to the medical specialist will prevent catastrophic medical emergencies such as a major cerebrovascular event (stroke).

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Conflicts of interest

There are no conflicts of interest.

  References Top

Mokin M, Dumont TM, Kass-Hout T, Levy EL. Carotid and vertebral artery disease. Prim Care Clin Office Pract 2013;40:135-51.  Back to cited text no. 1
Choic IS. Functional vascular anatomy of the head and neck. Interv Neuroradiol 2003; 9(suppl 2):29-30.  Back to cited text no. 2
American College of Cardiology Foundation and American Heart Association. Guidelines on the management of patients with extracranial carotid and vertebral artery disease. 2011, pp. 11-2. Available at: [Accessed October 18, 2018].  Back to cited text no. 3
Centers for Disease Control and Prevention. Stroke facts. Available at: [Accessed October 18, 2018].  Back to cited text no. 4
Carter LC, Tsimidis K, Fabiano J. Carotid calcifications on panoramic radiography identify an asymptomatic male patient at risk for stroke. Oral Surg Oral Med Oral Pathol Oral Radiol 1998;85:119-22.  Back to cited text no. 5
Mupparapu M, Kim IH. Calcified carotid artery atheroma and stroke: a systematic review. JADA 2007;138:483-92.  Back to cited text no. 6
Mupparapu M, Creanga AG, Singer SR. Interpretation of cone beam computed tomography volumetric data: How to report findings? Quintessence Int 2017;48:733-41.  Back to cited text no. 7
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Summary health statistics. Available at: [Accessed October 18, 2018].  Back to cited text no. 8
Narwal P, Cutting S, Prabhakaran S, Yaghi S. Diagnosis and management of active intracranial atherosclerotic disease: a case study. Stroke 2018;49:e221-3.  Back to cited text no. 9
Pikija S, Magdič J, Hojs-Fabjan T. Calcifications of vertebrobasilar arteries on CT: detailed distribution and relation to risk factors in 245 ischemic stroke patients. Biomed Res Int 2013;2013:918970.  Back to cited text no. 10
Katada K, Kanno T, Sano H, Shinomiya Y, Koga S. Calcification of the vertebral artery. AJNR Am J Neuroradiol 1983;4:450-3.  Back to cited text no. 11
Cloud GC, Markus HS. Diagnosis and management of vertebral artery stenosis. QJM 2003;96:27-54.  Back to cited text no. 12
de Bray JM, Missoum A, Dubas F, Emile J, Lhoste P. Detection of vertebrobasilar intracranial stenosis: transcranial Doppler sonography versus angiography. J Ultrasound Med 1997;16:213-8.  Back to cited text no. 13
Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American heart association/American stroke association. Stroke 2011;42:227-76.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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