Persistent Trigeminal Artery: Neuroanatomic and Clinical Relevance

Watershed cerebral infarction in a patient with a persistent primitive trigeminal artery and contralateral internal carotid artery stenosis: A case report

Patients with a persistent primitive trigeminal artery frequently have a poorly developed vertebrobasilar arterial system. However, they are not at higher risk of stroke and most are asymptomatic. Left cerebral watershed infarction was identified in a 75-year-old man who presented with aphasia and disorientation on magnetic resonance image (MRI). Additional imaging studies also demonstrated a right persistent primitive trigeminal artery, aplastic basilar artery, and 47% left internal carotid artery stenosis. Antiplatelet medication was administered and he was discharged 2 weeks after admission on aspirin. At the 4-month follow-up, cerebral blood flow in the left watershed territory was still decreased; however, no recurrent stroke had occurred. Although the indication for surgical or endovascular intervention for internal carotid artery stenosis is primarily determined by the degree of stenosis, cerebral blood flow evaluation is recommended in patients with internal carotid artery stenosis and a persistent primitive trigeminal artery.

A Case of Cerebral Infarction due to Internal Carotid Artery Occlusion Accompanied by Persistent Primitive Trigeminal Artery

An 85-year-old woman with a history of diabetes mellitus became aware of motor weakness of the left lower extremity. Magnetic resonance imaging showed multiple small cerebral infarctions in the right corona radiata. Angiography revealed persistent primitive trigeminal artery (PPTA) originating from the right internal carotid artery (ICA) and connecting to basilar artery, and the right ICA occluded distal to PPTA. Collateral blood circulation had developed, and sufficient collateral blood flow was expected. From these findings, the right ICA was considered to show stenosis due to atherosclerotic changes before occlusion. Conservative treatment was conducted with the transoral administration of rivaroxaban. It is important to correctly diagnose the anatomy and existence of an anomalous vessel in a stroke patient, not only when endovascular treatment is planned, but also for conservative medical treatment. Rapid and accurate radiological examinations facilitate safe and effective treatment.

Incidental Finding of Persistent Trigeminal Artery in a Young Woman: A Case Report

Persistent trigeminal artery disease is one of the most common types of persistent carotid-vertebrobasilar anastomoses. Usually, it is unilateral, and it can be discovered with a magnetic resonance angiography (MRA), computed tomography angiography (angioCT), or classic angiography exam. It can be associated with non-specific symptoms, such as headaches, or more specific ones, such as III or VI nerve palsy or trigeminal neuralgia, but most of the time it goes undetected, being an incidental finding and not causing any symptoms. On MRA and angioCT, it has the characteristic "tau" sign. We present the case of a young woman who, incidentally, discovered this malformation after undergoing an MRA. She had been experiencing a persistent headache without a known cause, which did not improve despite medication.

Successful endovascular thrombectomy using solitaire FR stent with intermediate catheter assisting technique for acute persistent primitive trigeminal artery and basilar artery occlusion: A case report and literature review

Background

The persistent primitive trigeminal artery (PPTA) is a persistent embryological carotid-basilar connection. Endovascular thrombectomy (EVT) for hypoplastic PPTA occlusion is a challenge. This case report aims to describe the successful recanalization of simultaneous occlusions in both the PPTA and basilar artery (BA) using the Solitaire FR (RECO SR)/Stent and Intermediate Catheter Assisting (SWIM) technique in a patient with acute cardiogenic cerebral embolism. To the best of our knowledge, this is the first report of such a case.

Case Description

We present a case of a 70-year-old female patient who presented with acute right-sided hemiparesis and altered consciousness. Digital subtraction angiography confirmed the occlusion of both the distal portion of the PPTA and the BA. The patient underwent EVT using the SWIM technique, resulting in successful recanalization and significant improvement in the patient's condition.

Conclusion

This case report demonstrates the successful application of the SWIM technique in achieving recanalization and improving outcomes in a patient with simultaneous occlusion of the acute PPTA and BA. These findings support the potential use of EVT in similar cases.

[Cerebral persistent primitive arteries. Clinical case of combination with intracranial aneurysm and review of the literature]

Cerebral persistent primitive arteries are uncommon and associated with cerebrovascular diseases, like cerebral aneurysms. They can cause vertebrobasilar ischemia and neuropathy of the cranial nerves. The authors present a patient with trigeminal artery associated with giant partially thrombosed cavernous internal cerebral artery aneurysm.

An anatomical study of persistent trigeminal artery detected by computed tomography angiography and magnetic resonance angiography: proposal for a modified classification and a novel basilar artery grading system

PURPOSE

The purpose of this study is to investigate the anatomical characteristics of persistent trigeminal artery (PTA) detected by computed tomography angiography (CTA) and magnetic resonance angiography (MRA), propose a modified classification and a novel grading system for basilar artery (BA).

METHODS

Patients who underwent head CTA or MRA in our hospital between August 2014 and August 2022 were reviewed retrospectively. The prevalence, sex, and course of PTA were evaluated. PTA types were modified based on Weon's classification. Type I to IV were similar to those in Weon's classification except the presence of intermed fetal-type posterior cerebral artery (IF-PCA). Type V was the same as that in Weon's classification. Type VI included subtypes of VIa (concomitant IF-PCA based on type I to IV) and VIb (other variants). BA was assessed based on a scale of 0 to 5 compared with PTA's caliber (0, BA aplasia; 1 and 2, BA non-dominant; 3, equilibrium; 4 and 5, BA dominant).

RESULTS

A total of 57 patients (0.06%) with PTA, including 36 females and 21 males, were detected in 94,487 patients. Six patients (10.5%) were medial type and 51 patients (89.5%) were lateral type. Thirty-seven patients (64.9%) were type I, 1 (1.8%) as type II, 13 (22.8%) as type III, 3 (5.3%) as type IV, 1 (1.8%) as type V, and 2 (3.5%) as type VI. For BA grading, 4 (7.0%), 21 (36.8%), 17 (29.8%), 6 (10.5%), 6 (10.5%), and 3 (5.3%) of the patients were grade 0, 1, 2, 3, 4, and 5, respectively. Fifteen patients (26.3%) had intracranial aneurysms. One cases (1.8%) had a fenestration of the PTA.

CONCLUSION

The prevalence of PTA in our study was lower than that in most previous reports. The modified PTA classification and BA grading system can be used to better understand the vascular structure of PTA patients.

Case report: Spontaneous carotid-cavernous fistula associated with persistent primitive trigeminal artery aneurysm rupture

Background

The incidence of carotid cavernous fistula (CCF) associated with persistent primitive trigeminal artery (PPTA) aneurysm rupture is extremely rare. We presented a case about a spontaneous CCF secondary to a ruptured PPTA aneurysm, which was successfully embolized with coils and onyx-18 by a trans-arterial approach.

Case presentation

A 55-year-old female suffered a sudden onset of headache, left orbital pain, and pulsatile exophthalmos for a month without any history of trauma. Angiography revealed a left-sided CCF associated with a ruptured PPTA aneurysm, with major drainage to the ipsilateral superior ophthalmic vein. Through a trans-arterial approach, the fistula and ruptured PPTA aneurysm were embolized with coils and onyx-18, while the cavernous sinus and PPTA were well-preserved. However, the preserved PPTA vanished at 4 month follow-up. The patient had no neurological deficit from hospitalization to 1 year follow-up period.

Conclusion

Trans-arterial approach was a reasonable choice for spontaneous CCF associated with ruptured PPTA aneurysm. The requirement for PPTA preservation depended on individual evaluation.

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.

Ruptured peripheral superior cerebellar artery dissecting aneurysms associated with primitive trigeminal artery: a case report

Background

Persistent primitive trigeminal artery (PPTA) is a remnant of the carotid-vertebrobasilar anastomoses in the embryo. Although PPTAs are discovered incidentally in most cases, altered hemodynamics may lead to increased risk of stroke. To the best of our knowledge, no reports of PPTA associated with superior cerebellar artery (SCA) dissecting aneurysms have been published in the English language.

We describe the case of a patient who presented with subarachnoid hemorrhage (SAH) due to ruptured peripheral SCA dissecting aneurysms in association with PPTA. Additionally, we discuss the relationship between PPTA and peripheral SCA aneurysms and the treatment of peripheral SCA aneurysms.

Case presentation

A 43-year-old woman presented with acute onset of headache and nausea and admitted to our hospital. She was diagnosed with SAH due to ruptured left SCA dissecting aneurysm(s) and had undergone digital subtraction angiography. The left vertebral angiography showed aneurysmal dilatations of the left S2 segment (lateral pontomesencephalic segment) along with dissection through the segments of S2 and S3 (cerebellomesencephalic segment). It also showed ipsilateral PPTA. The left vertebral artery (VA) had normal caliber and the basilar artery segment proximal to the orifice of the left PPTA was not hypoplastic. The patient underwent proximal parent artery occlusion at the S2 segment via the left VA and was successfully treated with no neurological deficits having lasted 5 months.

Conclusions

The flow alteration with PPTA may have influenced the formation of SCA dissection in this patient. Further studies are needed to understand the etiology and treatment outcomes of peripheral SCA aneurysms better.

Microvascular Decompression for Trigeminal Neuralgia with Concomitant Persistent Primitive Trigeminal Artery

Background and Introduction

Apersistent primitive trigeminal artery (PPTA) is an embryonic vessel that connects the cavernous part of the internal carotid artery with the posterior circulation. Though many are incidental, it is associated with conditions such as trigeminal neuralgia (TN).

Objective

In this video, we present a case of TN due to neurovascular conflict with associate PPTA. The close association of PPTA with trigeminal nerve results in increased incidence of TN. Surgical view and technique of surgery are described in the video.

Surgical Technique

A 55-year-old male presented with medically refractory TN with imaging suggestive of neurovascular conflict. During surgery, the superior cerebellar artery was visibly causing compression of nerve and on inspection, the PPTA was in close association with the trigeminal nerve near the entry to Meckel's cave. Microvascular decompression was done using Teflon to separate the nerve from both SCA and PPTA.

Conclusion

TN with PPTA is rare, and surgery and its nuances have rarely been described. This video shows the operative findings as well as describes the surgical technique.

Persistent Trigeminal Artery as Collateral Circulation in Ischemic Stroke

The persistent trigeminal artery is the most frequent of the persistent embryonic carotid-basilar artery anastomoses. In the literature, it has most often been described in relation to cerebrovascular pathologies such as aneurysms, vascular nerve compression, trigeminal cavernous fistulas, and thromboembolic ischemia. Its role as collateral circulation, thus supplying brain perfusion during main arterial trunk occlusion, has seldom been described. We describe the case of a patient who presented with a stroke due to a traumatic dissection of the internal carotid artery at the neck, in which the infarction may have been limited by a persistent trigeminal artery.