Ruptured aneurysm of a persistent primitive hypoglossal artery treated by endovascular approach—case report and literature review

Persistence of a hypoglossal artery: Case report

Persistent primitive hypoglossal artery (PPHA) is a rare embryological carotid-basilar anastomosis. Diagnosis is by imaging and computed tomography angiography is the most common methods employed. Herein we present a case of a 51 years-old Indian male, who admitted with midnight nonwitnessed syncope. CT angiogram of the brain revealed a very rare caroto-basilar anastomoses anomaly with PPHA.

Concurrence of multiple aneurysms, extreme coiling of the extracranial internal carotid artery and ipsilateral persistent primitive hypoglossal artery: A case report and literature review

Background

The primitive hypoglossal artery (PHA) is an anastomotic vessel of the carotid-basilar artery system that is prevalent only transiently during the embryonic period. Persistent primitive hypoglossal artery (PPHA) is a rare vessel variation in which PHA exists persistently in adulthood and occurs in approximately 0.02-0.1% of the population. Tortuosity of the extracranial internal carotid artery (ICA) is relatively common, impacting 10-43% of the population, and is caused by either congenital or acquired factors. It is still unknown whether PPHA and tortuosity of extracranial ICA are associated. Here, we present a case report of the concurrence of three types of pathologies of the carotid artery: extreme coiling of the extracranial internal carotid artery, multiple aneurysms and persistent primitive hypoglossal artery.

Case description

A 66-year-old woman suffered intermittent headaches, dizziness and numbness of the right eyelid for 5 years. Magnetic resonance angiography performed in a local hospital reported an aneurysm of the posterior communicating artery segment of the left ICA and a left PPHA. Digital subtraction angiography conducted after admission showed a PPHA originating from the left cervical ICA and an extremely coiling segment of the ICA distal to the beginning of PPHA. Except for the aneurysm of the posterior communicating artery segment of the left ICA, multiple aneurysms were found at the coiling segment of the ICA.

Conclusion

To the best of our knowledge, this is the first report of PPHA accompanied by an adjacent, extremely coiling ICA. There are no reports of similar tortuous ICAs to this extent or at this position. Including aneurysms, three types of pathologies suggest their congenital origin, and a review of the literature infers the probable association of these lesions.

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.

A persistent primitive hypoglossal artery-posterior inferior cerebellar artery convergence aneurysm treated by stent-assisted coil embolization: A case report

RATIONALE

Persistent primitive hypoglossal artery (PPHA) is often associated with intracranial anomalies such as aneurysms. Surgical treatment of aneurysms on the PPHA is challenging due to that the posterior circulation depends solely on PPHA.

PATIENT CONCERNS

A case of an 83-year-old woman with a large aneurysm on PPHA presented with vertigo was reported.

DIAGNOSIS

Three-dimensional angiogram revealed a wide-neck aneurysm on the PPHA.

INTERVENTIONS

The aneurysm was successfully treated using a novel low-profile visualized intraluminal support stent-assisted coiling technique.

OUTCOMES

No complications occurred during the procedure. The final angiogram confirmed the patency of the posterior inferior cerebellar artery and the parent artery and its distal branches.

LESSONS

Our case suggests that stent-assisted coil embolization is safe and effective for the treatment of aneurysms on the PPHA.

Persistent hypoglossal artery aneurysm: Case report and qualitative systematic review

A persistent hypoglossal artery was first described in 1889 and is one of the more common anatomical variations arising from aberration in normal development. Endovascular coiling has been recognised as a robust treatment for acutely ruptured intracranial arterial aneurysms, although specific data regarding an aneurysm arising from a persistent hypoglossal artery is lacking due to the low incidence. Here we report both the oldest patient reported to be treated with a persistent hypoglossal artery-associated aneurysm and also explicitly report endovascular treatment of a persistent hypoglossal artery aneurysm arising at the posterior inferior cerebellar artery origin. Qualitative systematic review of the available medical literature demonstrates limited evidence regarding treatment of persistent hypoglossal artery-associated aneurysms with the majority being carried out via open surgery. Ruptured posterior inferior cerebellar artery aneurysm arising from a persistent hypoglossal artery can be successfully and safely treated by endovascular therapy via the persistent hypoglossal artery. Randomised study of this situation is unlikely to be feasible; however, qualitative review of the literature reveals six such aneurysms that have been treated surgically, and this case appears to be the first via an endovascular means.

Fatal Subarachnoid Hemorrhage from an Aneurysm of a Persistent Primitive Hypoglossal Artery: Case Series and Literature Overview

BACKGROUND

Persistent carotid-basilar connections have a prevalence of 0.14%. Recognizing such persistent fetal anastomoses between the carotid and the vertebrobasilar circulation is of great importance because they are reportedly associated with an increased prevalence of intracranial aneurysms.

METHODS

We report the case of a 15-year-old female patient who presented with a World Federation of Neurosurgical Societies grade 5 subarachnoid hemorrhage from an aneurysm at the junction of a persistent primitive hypoglossal artery and the posterior inferior cerebellar artery origin. Supratentorially, unfortunately, there was no parenchymal blush or cortical venous return. Eventually, a multidisciplinary decision was made to withdraw care.

RESULTS

Fifty-seven cases were reported in the literature to date of persistent hypoglossal arteries, 16 of which presented with an associated aneurysm, 5 with an arteriovenous malformation, and 6 with a subarachnoid hemorrhage. Our case is the youngest patient reported so far. Hypoplasia or aplasia of the vertebral artery often were encountered (36 and 13 cases, respectively), as well as carotid artery stenosis (15 cases).

CONCLUSIONS

Although uncommon, it is important to recognize persistent carotid-basilar connections, since they have a considerable hemodynamic impact on the posterior cerebral circulation via the carotid system. A critical reduction in the carotid blood flow will, therefore, have ischemic consequences in the posterior cerebral territories. In addition, such connections might be associated with anomalies of the vessel wall and be predisposed to aneurysm formation. The endovascular neurointerventionalist, as well as the vascular and skull base neurosurgeon, need to be aware of their anatomy and variations.

Endovascular Treatment of an Aneurysm of a Persistent Primitive Hypoglossal Artery With Complete Resolution of Brainstem Compressive Symptoms: Case Report

BACKGROUND AND IMPORTANCE:

Aneurysms of the posterior circulation may manifest with neurological deficits related to mass effect on the brainstem. We present an unusual case of an aneurysm resulting in selective lower-extremity weakness and gait instability.

CLINICAL PRESENTATION:

A 61-year-old man presents with progressively worsening gait instability over the course of several months. A magnetic resonance image and computed tomographic angiogram demonstrate a persistent hypoglossal artery associated with an aneurysm invaginating into the pontomedullary junction. The patient manifested only lower-extremity symptoms. An endovascular approach through the right internal carotid artery and persistent primitive hypoglossal artery was assayed, coiling off the aneurysm with complete angiographic occlusion. One month after the procedure, the patient reported marked improvement in symptoms with residual difficulty walking. At the 1-year postprocedure interval, he reported nearly complete resolution of symptoms.

CONCLUSION:

Endovascular therapy of an aneurysm invaginating into the brainstem is safe and efficacious.

Persistent primitive olfactory artery aneurysm

A hypertensive 69-year-old man presented with an incidentally discovered non-ruptured aneurysm of the persistent primitive olfactory artery (POA). The POA originates at the terminal portion of the internal carotid artery, runs along the olfactory tract anteriorly toward the crista galli, and forms an acute angle with the distal anterior cerebral artery. The aneurysm was located at this characteristic acute angle. The persistent POA aneurysm associated with an anterior communicating artery aneurysm with wide neck was successfully treated by clipping surgery.

A case of aneurysm on a persistent hypoglossal artery treated by endovascular coiling

SUMMARY

We describe a 22-year-old woman admitted to hospital in emergency with nuchal headache and vomiting. CT scan disclosed subarachnoid hemorrhage. Digital subtraction angiography with three-dimensional rotational acquisitions showed a ruptured aneurysm of a right persistent primitive hypoglossal artery as the cause of symptoms and hemorrhage. The patient was successfully treated with endovascular coiling of the aneurysm. This is the second literature report describing endovascular treatment in this unusual condition.