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 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.

Variation of a Persistent Primitive Hypoglossal Artery (PPHA) as Incidental Finding in the Diagnostic Clarification of Cerebral Vasculopathy Associated with Intracranial Vasculitis

We present a very rare variation of a persistent primitive hypoglossal artery (PPHA) arising from the internal carotid artery, detected during a diagnostic angiography. A 50-year-old female patient was admitted with an atypical intracranial hematoma in the left frontal lobe. Catheter angiography revealed intracranial vasculopathy with segmental stenoses, a small aneurysm of the right internal carotid artery bifurcation and a "string of beads" appearance of the left carotid artery, consistent with fibromuscular disease. On the left side, a vertebral artery ending in the posterior inferior cerebellar artery (PICA) was detected, whereas on the right side the vertebral artery was aplastic. During selective angiography of the right common carotid artery, a persistent hypoglossal artery was seen supplying the basilar artery. The literature of persistent embryonal carotid-vertebrobasilar anastomosis and their anatomical variations is discussed with respect to clinical importance for ischemia, interventional procedures, and surgery.

Tandem symptomatic internal carotid artery and persistent hypoglossal artery stenosis treated by endovascular stenting and flow reversal

Persistence of the hypoglossal artery into adulthood is a rare vascular anomaly and, when present, provides the predominant vascular supply to the posterior circulation. We describe a case of vertebrobasilar insufficiency associated with severe high-grade stenosis of the persistent hypoglossal artery and tandem stenosis of the proximal ipsilateral internal carotid artery, treated by an endovascular approach. The unique anatomical and technical challenges associated with this case are reviewed in detail.