Critical carotid artery stenosis involving a persistent primitive hypoglossal artery

Percutaneous transluminal angioplasty for persistent primitive hypoglossal artery stenosis: illustrative case

BACKGROUND

We report a case of symptomatic, progressive stenosis of a persistent primitive hypoglossal artery (PPHA), which was successfully treated with percutaneous transluminal angioplasty (PTA) of the origin of the PPHA. The PPHA is a type of carotid-basilar anastomosis with an incidence of 0.02% to 0.10%. It originates from the internal carotid artery (ICA), passes through the hypoglossal canal, and merges with the basilar artery. In many cases, the ipsilateral vertebral artery is hypoplastic; therefore, PPHA stenosis causes cerebral infarction in the posterior circulation territory, as in this case.

OBSERVATIONS

The patient's right PPHA had severe and progressive stenosis; therefore, he experienced cerebral infarction despite medical treatment. Therefore, PTA for the stenosis was performed, which ceased the recurrence of cerebral infarction and dizziness by improving blood flow in the posterior circulation.

LESSONS

Several reports have described ICA stenosis accompanied by PPHA or PPHA stenosis in patients receiving endovascular treatments. Almost all cases were nonprogressive, and the treatment procedure was stenting. However, in our case, the PPHA stenosis was progressive, and we performed PTA because the patient experienced resistance to antiplatelet drugs and had poor collateral flow.

"Dual Internal Shunts Technique" for Carotid Endarterectomy with Carotid Vertebral Anastomosis: Technical Note

In revascularization of internal carotid stenosis with carotid vertebrobasilar anastomoses, attention should be paid not only to the anterior circulation but also to the posterior circulation cerebral infarction. A 74-year-old man was referred for treatment of carotid artery stenosis; NASCET 75% stenosis in the right internal carotid artery and acute cerebral infarction were confirmed. Occlusion of the left subclavian artery and vascular anastomosis between the right external carotid artery and the vertebral artery were indicated, such that the right external carotid artery may maintain blood flow to the vertebrobasilar artery. Therefore, dual shunts were used for the common and internal carotid arteries and the common and external carotid arteries to maintain blood flow during carotid endarterectomy. Management of the dual shunts is difficult due to the instable parallel placement of the common carotid artery shunt balloons. To solve this problem, the "dual internal shunts technique" was performed. The first shunt was inserted into the external and common carotid arteries, and the second into the internal and common carotid arteries. The shunt balloon on the common carotid artery side was placed distal to the first shunt balloon so that the dual balloons were placed in a tandem position. The proximal balloon was subsequently deflated gradually to improve flow in both shunts. The procedure is technically easy and safe.

Carotid Endarterectomy for Vertebrobasilar Insufficiency Caused by Severe Stenosis of Primitive Hypoglossal Artery: A Technical Case Report and Literature Review

Persistent primitive hypoglossal artery (PHA) originating from the external carotid artery (ECA) is a rare anomaly. Reports of carotid endarterectomy (CEA) for ECA stenosis associated with this anomaly are even rarer. A 76-year-old woman presented to a medical clinic with a major complaint of refractory dizziness. Carotid ultrasound study suggested severe stenosis of the left cervical carotid bifurcation; therefore, she was referred to our department for a possible CEA. The imaging results indicated severe stenosis of the left carotid bifurcation and that the ECA was a PHA and the origin of the dominant vertebrobasilar artery (VBA). CEA was performed with the special caution of providing VBA collateral flow during clamping and preventing microembolisms during declamping of the ECA. Postoperative head magnetic resonance imaging revealed no new findings of cerebral infarction, and her dizziness disappeared. CEA associated with stenosis of the PHA as the origin of a dominant VBA was safely performed with an appropriate understanding of possible collateral pathways during cross-clamping.

A case of carotid endarterectomy assisted with a three-way junction shunting tube for the internal carotid artery stenosis involving a persistent primitive hypoglossal artery

Only several cases of internal carotid artery (ICA) stenosis involving the persistent primitive hypoglossal artery (PPHA) have been treated with carotid endarterectomy (CEA) because of its extreme rarity. CEA was performed for an 87-year-old female with severe stenosis of the right ICA–PPHA bifurcation requiring shunting from CCA to both PPHA and ICA. We initially attempted to insert two intraluminal balloon shunts into the CCA, as previously reported. However, we found this procedure technically impossible to achieve. An improvised three-way junction tube was inserted distally into PPHA and ICA and proximally into CCA, securing blood flow during CEA. Unfortunately, the patient suffered post-operative ischemic brain lesions due to the prolonged ischemic time during our initial unsuccessful shunt attempt. A three-way junction shunting tube could be an effective shunt technique during an anatomically complicated CEA.

A fenestrated persistent primitive hypoglossal artery harboring a ruptured aneurysm: A case report

RATIONALE

Persistent primitive hypoglossal artery (PPHA) is a rare and permanent carotid-vertebrobasilar anastomoses. Patients with PPHA usually have higher changes of developing intracranial aneurysms due the high intracranial hemodynamics. Although cases of PPHA alone and PPHA with aneurysms have been reported in literature, cases of fenestrated PPHA harboring a ruptured aneurysm have seldomly be reported in literature. We present a rare occurrence of a fenestrated PPHA harboring a reputed aneurysm.

PATIENTS CONCERNS

A 43-year-old woman was presented with a sudden-onset severe headache and nausea.

DIAGNOSIS

Computerized tomography scan showed third, fourth, and bilateral ventricular hemorrhages. Computed tomographic angiogram showed a PPHA with fenestration malformation and a cystic protrusion consistent with an aneurysm.

INTERVENTION

The patient underwent a successful stent-assisted coil embolization via the trans-arterial route under general anesthesia.

OUTCOMES

Two years follow-up revealed no recurrence of her symptomatology and she is currently well and go about her normal daily life.

CONCLUSION

Fenestrated PPHAs harboring aneurysms may be more prone to rupture because of the fenestration and connective tissue weakness of the artery as well as changes in hemodynamics of the already malformed and weak artery.

Symptomatic internal carotid artery stenosis in the presence of a persistent primary hypoglossal artery

OBJECTIVES

Anatomic variations of the extracranial carotid artery are rare. Persistent primitive hypoglossal artery appears with a reported incidence between 0.03% and 0.2%. We report a case of recurrent transient ischemic attacks originating from proximal internal carotid artery stenosis associated with ipsilateral persistent primitive hypoglossal artery and give a review of the existing literature.

METHODS

A 78-year-old patient with a medical history of two previous transient ischemic attacks consulted our emergency department with an acute left hemispheric stroke. Intravenous thrombolysis permitted complete resolution of symptoms. Concurrent Computed Tomography (CT) and Magnetic Resonance (MR) angiography revealed an unstable plaque causing 50% stenosis of the left internal carotid artery with a persistent primitive hypoglossal artery dominantly perfusing the posterior circulation, and bilateral hypoplastic vertebral arteries.

RESULTS

Uneventful carotid artery stenting using a proximal protection device was performed, and the patient was discharged after 12 days. Six months follow-up was uneventful with a patent stent in the internal carotid artery.

CONCLUSIONS

Treatment of symptomatic carotid artery stenosis in the presence of persistent primitive hypoglossal artery is challenging. Management should be driven by patients' co-morbidities, the anatomical localization of the lesions and local expertise. In the case of a high origin of the persistent primary hypoglossal artery, carotid artery stenting with the use of a proximal cerebral protection device is probably the preferred and simplest approach.

Endarterectomy of carotid artery bifurcation in the setting of a persistent hypoglossal artery and anomalous collateral vascular supply

Presented is a patient with carotid artery stenosis resulting in crescendo anterior and posterior circulation transient ischemic attacks. Treatment was complicated by a rare persistent hypoglossal artery (HGA) arising from the left internal carotid artery in addition to severe contralateral carotid disease, hypoplastic vertebral arteries, and incomplete circle of Willis. A carotid endarterectomy with shunting was performed, maintaining perfusion of both the proper left internal carotid artery and HGA. This is a rare case of carotid stenosis in the setting of a persistent HGA with contralateral carotid disease and highlights the importance of planning intracranial perfusion before carotid surgery.