A fusiform aneurysm of a persistent trigeminal artery variant: case report and literature review

Selective Transarterial Embolization for a Ruptured Persistent Trigeminal Artery Variant Aneurysm

We report a male patient with a ruptured persistent primitive trigeminal artery variant aneurysm that resulted in a fistula with the cavernous sinus. He presented with left conjunctival hyperemia and exophthalmos. Cerebral angiography revealed a left direct carotid-cavernous fistula; however, a balloon occlusion test determined that the source was actually a ruptured aneurysm located on the trunk of a persistent primitive trigeminal artery. Endovascular trapping of the persistent primitive trigeminal artery was performed, which resulted in fistula occlusion and symptom resolution.

Management paradigms of persistent primitive trigeminal artery aneurysms: A systematic review and analysis of techniques and complications from 1960s to 2022: From conservative to surgical to endovascular, how far along the right path are we?

INTRODUCTION

Aneurysms of persistent primitive trigeminal artery (PPTAAs) are increasingly reported and commonly managed by endovascular (EN) techniques. There are no systematic reviews or meta-analyses which analyse outcomes and complications of treatment modalities for PPTAAs. We aim to highlight the change in trend of management of PPTAAs and to identify clinical and radiological parameters which may influence management paradigms.

METHODOLOGY

A systematic search of literature was done in PubMed, Embase, Google Scholar, Cochrane library and Medline using keywords 'persistent primitive trigeminal artery', 'aneurysms', 'embolization', 'surgical clipping', etc. Only cases reporting aneurysms of PPTA were included. Three subgroups, such as conservative, open surgical (OS) and EN interventional, were studied for outcome evaluation. In the EN subgroup, relation of clinical and radiological parameters with outcome (complete/partial occlusion) was analysed using Microsoft Excel Data Analysis ToolPak.

RESULTS

Of the 101 articles found eligible for assessment, 54 were analysed quantitatively. Mortality in the conservative group was 12.5% and OS group was 9.09%. After EN treatment, complete angiographic occlusion was seen in 88.89% PPTAAs and 5.5% warranted retreatment. In the EN subgroup, location (p=0.17), shape (p=0.69), Saltzman circulation (p=0.26) or status of rupture (p=0.08) did not significantly impact angiographic occlusion outcome. Multivariate regression analysis showed 6.6% influence of independent variables, that is, age, gender, aneurysm location, side, shape (saccular/fusiform), rupture status and type of Saltzman circulation on aneurysm occlusion outcome [F(7,27) =1.34] (p=0.27). Total mortality reported in the EN group was 8.57%.

CONCLUSION

Clinical or radiological parameters do not influence angiographic occlusion outcome. Although EN techniques are successful, meticulous reporting of outcomes and complications is important.

Parent Artery Occlusion for Symptomatic Large Internal Carotid Artery Aneurysm with Primitive Trigeminal Artery Variant: A Case Report

Objective

To report a case of symptomatic large cerebral aneurysm of the internal carotid artery (ICA), associated with a primitive trigeminal artery variant (PTAv), which was treated with a balloon occlusion test (BOT) to evaluate ischemic tolerance.

Case Presentation

A 79-year-old woman was diagnosed with a symptomatic large cerebral aneurysm of the ICA bifurcating the PTAv due to diplopia. After confirming the ischemic tolerance of the perfusion area and PTAv by BOT, we performed ICA parent artery occlusion with selective embolization of the PTAv. Postoperative MRI showed no ischemic lesion and the diplopia was resolved.

Conclusion

ICA parent artery occlusion with PTAv selective embolization after evaluation by BOT is useful in the treatment of large aneurysms.

Clinical Importance of the Persistent Primitive Trigeminal Artery in Vascular Lesions and Its Role in Endovascular Treatment

The persistent primitive trigeminal artery (PPTA) extends from the internal carotid artery to the basilar artery between the origins of the anterior inferior cerebellar artery and superior cerebellar artery. PPTAs have complex anatomical characteristics. Salas and Saltzman classifications are most often used in PPTAs. The PPTA can play many roles in vascular lesions, including intracranial aneurysms, brain arteriovenous malformations, trigeminal artery-cavernous fistulas, Moyamoya disease, and large vessel occlusion. For these lesions, surgical treatment is difficult due to the deep location and complex anatomy of the PPTA, but endovascular treatment (EVT) has emerged as a good alternative. Currently, a complete review of the clinical importance of the PPTA in terms of its role in the development and EVT of vascular lesions is lacking. Therefore, we conducted a PubMed search, performed a review of the relevant extracted literature and cataloged our experience with PPTAs. By review, we found that a thorough understanding of the anatomical and angiographic features of this PPTA is of utmost importance when making therapeutic decisions for any of these pathological conditions.

Persistent trigeminal artery variant associated with ipsilateral hypoplasia of the internal carotid artery

A persistent trigeminal artery is the most common persistent carotid-vertebrobasilar anastomosis, while persistent trigeminal artery variants involve termination at the cerebellar artery without connecting to the basilar artery. Internal carotid artery hyperplasia is also a rare congenital anomaly. To the best of our knowledge, there are no reports of persistent trigeminal artery variant associated with ipsilateral hypoplasia of the internal carotid artery. Herein, we report a case of a 44 year-old woman who visited a neurosurgical clinic because of chronic headaches. Magnetic resonance angiography showed impaired delineation of the left internal carotid artery, and she was referred to our hospital for catheter angiography. Angiogram revealed left internal carotid artery hypoplasia and a left persistent trigeminal artery variant that terminated at the left anterior inferior cerebellar artery. Computed tomography bone images showed a narrow left carotid canal. We diagnosed congenital hypoplasia of the left internal carotid artery concomitant with ipsilateral persistent trigeminal artery variant. Careful imaging assessment is important for identifying persistent trigeminal artery variant when associated with ipsilateral internal carotid artery hypoplasia.

Persistent trigeminal artery aneurysms: case report and systematic review

Background

The persistent trigeminal artery (PTA) is an adult carotid-basilar anastomosis with debated pathologic aspects, such as its association with brain aneurysms. True trigeminal artery aneurysms are rare vascular anomalies, reported in a few case reports.

Objective

To report our experience with a ruptured trigeminal artery aneurysm and to provide a systematic review of the literature in order to analyse potential links between the anatomic configuration of the PTA and PTA aneurysm (PTAA) type, and implications of each PTAA type for the diagnostic and therapeutic approach.

Methods

We reviewed the medical literature on trigeminal artery aneurysms according to the PRISMA guidelines. Population characteristics, aneurysms features, and PTA type and side were assessed.

Results

40 previously published cases of PTAAs were included in the analysis. The mean age of subjects was 55 years, with a strong female predominance (77%). Four PTAAs were accidentally discovered, while 16 caused compressive symptoms and 20 were ruptured. Successful endovascular treatment was performed in 62% of cases.

Conclusions

PTAAs are rare vascular anomalies, underdiagnosed in the presence of a trigemino-cavernous fistula. Parent vessel occlusion seems to be the best therapeutic option for ruptured or symptomatic unruptured PTAAs in Saltzman type II and III PTAs. Patency of the parent vessel is the main target in Saltzman type I PTA.

Double-balloon remodeling for coil embolization of a primitive trigeminal artery variant aneurysm. A case report

Here we describe the case of a patient with a wide-necked unruptured aneurysm arising at origin of a persistent primitive trigeminal artery (PTA) variant from the right internal carotid artery (ICA), supplying the territory of the right superior cerebellar artery and the anterior inferior cerebellar artery. To preserve the ICA and the PTA variant, coil embolization of the aneurysm was performed using a double-balloon remodeling technique (HyperForm™ and HyperGlide™ Occlusion Balloon Systems; ev3 Endovascular Inc., Irvine, CA, USA). The association of a PTA variant with an aneurysm is very rare. To our knowledge, this is the first description of the use of coil embolization using double-balloon remodeling to treat a PTA variant aneurysm. This technique permits complete embolization and reduces the risk of cerebral and cerebellar ischemia.

Anatomical features and clinical relevance of a persistent trigeminal artery

Background:

Although persistent trigeminal artery (PTA) is uncommonly identified, knowledge of this structure is essential for clinicians who interpret cranial imaging, perform invasive studies of the cerebral vasculature, and operate this region.

Methods:

A review of the medical literature using standard search engines was performed to locate articles regarding the PTA, with special attention with anatomical descriptions.

Results:

Although anatomical reports of PTA anatomy are very scarce, those were analyzed to describe in detail the current knowledge about its anatomical relationships and variants. Additionally, the embryology, classification, clinical implications, and imaging modalities of this vessel are extensively discussed.

Conclusions:

Through a comprehensive review of isolated reports of the PTA, the clinician can better understand and treat patients with such an anatomical derailment.

Bilateral persistent trigeminal artery variants diagnosed by MR angiography

A persistent trigeminal artery (PTA) is the most common anastomosis between the carotid and vertebrobasilar system. A PTA variant (PTAV) is a rare anomaly in which the cerebellar artery arises from the internal carotid artery (ICA) without connection with the basilar artery (BA). I present what I believe is the first report of bilateral PTAVs diagnosed using magnetic resonance (MR) angiography and briefly discuss the embryology of this rare anomaly. An 81-year-old woman with small infarctions underwent cerebral MR imaging and MR angiography with a 1.5-tesla imager for the evaluation of brain lesions. An MR angiography was obtained using the standard noncontrast three-dimensional time-of-flight technique. The MR angiographic demonstration of bilateral anterior inferior cerebellar arteries arising from the precavernous segment of the ICA without anastomosis to the BA indicated bilateral PTAVs. This is the first report of bilateral PTAVs diagnosed by MR angiography. The literature review indicates that an estimated prevalence of bilateral PTAVs is about 0.0012%.

Ruptured cerebral aneurysm associated with a persistent primitive trigeminal artery variant

Background:

Primitive trigeminal artery variants (PTAVs) are one of the rare persistent fetal anastomoses between the carotid and vertebrobasilar circulations. They originate from the internal carotid artery and join one of the cerebellar arteries instead of the basilar artery.

Case Description:

We present an 82-year-old woman with subarachnoid hemorrhage due to a ruptured aneurysm originating at a PTAV. Three-dimensional computed tomography angiogram and cerebral angiography revealed bilateral PTAV and two aneurysms originating at the left PTAV. The proximal and distal aneurysms were saccular and fusiform, respectively. She underwent surgical treatment and her postoperative course was uneventful.

Conclusion:

Our case demonstrates that extremely rare cerebral aneurysms associated with PTAV can be addressed successfully by surgical intervention.

Persistent fetal intracranial arteries: a comprehensive review of anatomical and clinical significance

As fetal intracranial vessels may persist into adulthood, knowledge of their anatomy and potential clinical and surgical complications should be borne in mind by the surgeon. A comprehensive review of these vessels, however, is not easily identified in the literature. Therefore, the present analysis was undertaken so that such information is available to the clinician and morphologist.