The brachiocephalic artery normally bifurcates into the right common carotid and subclavian artery behind the right sternoclavicular joint. A high-riding brachiocephalic trunk bifurcates above the level of the right sternoclavicular joint and is thought to be secondary to a persistent long portion of the proximal segment of the right fourth aortic arch.

Patients can be asymptomatic or may present with a pulsatile neck mass.

In this case, patient's age, underlying hypertension and atherosclerosis, in addition to a high-riding brachiocephalic artery are possible contributing factors to the tortuous retropharyngeal course of the right internal carotid artery.

It is imperative to report such vascular abberations in order to avoid devastating intraoperative hemorrhage .