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Manea A, Laszlo SȘ, Stoian A, Cocuz IG, Halmaciu I. Incidental Finding of Persistent Trigeminal Artery in a Young Woman: A Case Report. Cureus 2024; 16:e61060. [PMID: 38915981 PMCID: PMC11195812 DOI: 10.7759/cureus.61060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2024] [Indexed: 06/26/2024] Open
Abstract
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.
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Affiliation(s)
- Andrei Manea
- Department of Radiology, Mureș County Emergency Hospital, Târgu Mureș, ROU
| | | | - Adina Stoian
- Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology, Târgu Mureș, ROU
- Mures County Clinical Emergency Hospital, 1st Neurology Clinic, Târgu Mureș, ROU
| | - Iuliu Gabriel Cocuz
- Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology, Târgu Mureș, ROU
- Pathology Department, Mures Clinical County Hospital, Târgu Mureș, ROU
| | - Ioana Halmaciu
- Department of Radiology, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology, Târgu Mureș, ROU
- Department of Radiology, Mures County Clinical Emergency Hospital, Târgu Mureș, ROU
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Sun T, Huang L, Sun J, Wu Z, Chen C, Wang H. Persistent trigeminal artery in a patient with moyamoya disease:a case report and literature review. BMC Neurol 2024; 24:54. [PMID: 38308221 PMCID: PMC10835905 DOI: 10.1186/s12883-024-03545-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/18/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUNDS Persistent trigeminal artery (PTA) is a rare anastomosis between internal carotid artery (ICA) and basilar artery. In rare conditions, the PTA could be combined with others cerebrovascular anomalies, moyamoya disease (MMD) is one of them. CASE PRESENTATION Here, we reported one rare case of MMD associated with PTA, the patient admitted to our department for severe dizziness and headache, imaging examination suggested MMD combined with right PTA, which arising from the ipsilateral cavernous portion of ICA. The patient received phased bilaterral revascularization with no any complication. In the subsequent follow-up, the patient's symptoms and intracranial vascular condition gradually improved. Moreover, we conducted a literature review of coexistence of PTA and MMD, the results of a web of science regarding such condition, and a deep discussion providing brief insight into the status of co-occurrence of PTA and MMD, including its manifestation, treatment and outcome. CONCLUSIONS The coexistence of PTA and MMD was rarely reported, the pathogenesis of such condition remains unknown. We found that the features of the coexistence of PTA and MMD were diverse, revascularization might be a feasible for such patient.
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Affiliation(s)
- Tao Sun
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-Sen University, No. 600th Tianhe Road, Guangzhou, 510630, Guangdong, China
| | - Lixin Huang
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-Sen University, No. 600th Tianhe Road, Guangzhou, 510630, Guangdong, China
| | - Jun Sun
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-Sen University, No. 600th Tianhe Road, Guangzhou, 510630, Guangdong, China
| | - Zhimin Wu
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-Sen University, No. 600th Tianhe Road, Guangzhou, 510630, Guangdong, China
| | - Chuan Chen
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-Sen University, No. 600th Tianhe Road, Guangzhou, 510630, Guangdong, China.
| | - Hui Wang
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-Sen University, No. 600th Tianhe Road, Guangzhou, 510630, Guangdong, China.
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Alnafie MA. New variant of persistent primitive trigeminal artery associated with duplicated basilar artery: a radiological case report. Surg Radiol Anat 2023; 45:321-326. [PMID: 36656340 DOI: 10.1007/s00276-023-03082-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/07/2023] [Indexed: 01/20/2023]
Abstract
PURPOSE This article reports a new variant of the persistent primitive trigeminal artery. This variant does not exist in Salas and Saltzman classifications. METHODS We analyzed CTA images of a 39-year-old male patient using RadiAnt. This work had clinical and research purposes. RESULTS A persistent primitive trigeminal artery arose from left internal carotid artery termination. Its course was atypical, superior, and lateral to the sella turcica. At its end, it joined a duplicated basilar artery. These morphological features are new compared to Salas and Saltzman's variants. CONCLUSION Anatomists, radiologists, and neurosurgeons must know this new variant. Angiographic analysis of this variant will keep the patient safe and perform the surgery. This new variant deserves to be considered in Salas and Saltzman classifications as a new type.
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Affiliation(s)
- Mohammed Assaad Alnafie
- Faculty of Medicine of Oran, University of Oran 1 Ahmed Ben Bella, BP 1510 El'Mnaouer, 31000, Oran, Algeria.
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Sun P, Chai Y, Fang W, Chen H, Long Q, Zhao Z, Zhang T. Case report: Spontaneous carotid-cavernous fistula associated with persistent primitive trigeminal artery aneurysm rupture. Front Neurol 2022; 13:923186. [PMID: 36147047 PMCID: PMC9485939 DOI: 10.3389/fneur.2022.923186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/20/2022] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Peng Sun
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Yuan Chai
- Department of Neurosurgery, Xi'an Central Hospital, Xi'an, China
| | - Wei Fang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Hu Chen
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Qianfa Long
- Department of Neurosurgery, Xi'an Central Hospital, Xi'an, China
| | - Zhenwei Zhao
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Tao Zhang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
- *Correspondence: Tao Zhang
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Wang L, Li J, Li Z, Chai S, Chen J, Xiong N, Yang B. Hybrid surgery for coexistence of cerebral arteriovenous malformation and primitive trigeminal artery: A case report and literature review. Front Surg 2022; 9:888558. [PMID: 35959118 PMCID: PMC9360567 DOI: 10.3389/fsurg.2022.888558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
The primitive trigeminal artery (PTA), an abnormal carotid-basilar anastomosis, forms the vascular anomaly connection between the internal carotid artery and vertebrobasilar system. Rarely, PTA can be complicated by several other cerebrovascular disease, including arteriovenous malformations (AVMs), intracranial aneurysms, moyamoya disease, and carotid-cavernous malformations. Herein, we reported a rare case of PTA combined with an AVM in a male patient. The patient was a 28-year-old male with epileptic seizures at the onset of symptoms. Magnetic resonance imaging showed abnormal signal foci and localized softening foci formation with gliosis in the right parietal temporal lobe. Furthermore, using a digital subtraction angiogram (DSA), it was found that an abnormal carotid-basilar anastomosis had developed through a PTA originating from the cavernous portion of the right internal carotid artery (ICA) and a large AVM on the surface of the right carotid artery. The lesion of AVM tightly developed and draining into superior sagittal sinus. A hybrid operating room was used for the surgery. The main feeding arteries of the AVM originating from three major arteries, including the right middle cerebral artery, the right anterior cerebral artery, and the right posterior cerebral artery, were clipped and subsequently, then the AVM was thoroughly removed. The intraoperative DSA showed that the AVM had been resected completely. Postoperative pathological examination of the resected specimen indicated the presence of an AVM. The patient recovered well after surgery and has been symptom-free for more than 3 months. In summary, the pathogenesis of the coexistence of PTA and AVM remains unknown. As highlighted in this case report, hybrid surgery can be used to remove AVMs and can improve the patients' prognosis. To our best knowledge, this is the first case in the literature of successful AVM treatment using hybrid surgery.
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Affiliation(s)
- Lesheng Wang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Brain Research Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jieli Li
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhengwei Li
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Songshan Chai
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Nanxiang Xiong
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Correspondence: Bangkun Yang Nanxiang Xiong
| | - Bangkun Yang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Correspondence: Bangkun Yang Nanxiang Xiong
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A Study on the Persistent Trigeminal Artery and Its Classification Based on Magnetic Resonance Angiograph Images. J Comput Assist Tomogr 2022; 46:645-650. [PMID: 35675665 DOI: 10.1097/rct.0000000000001309] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The persistent trigeminal artery (PTA) is the most common remnant of primitive circulation, communicating the developing carotid and vertebrobasilar junction. PURPOSE This study aimed to evaluate the implementation of magnetic resonance angiography for the detection of PTA and to reclassify the variations based on Weon typing. Moreover, the correlation of various Weon types with the posterior cerebral artery (PCA), Willis ring, basilar artery (BA) dysplasia, and the relationship between PTA and arteriosclerosis were analyzed. METHODS From November 2017 to October 2019, a total of 48,184 patients underwent magnetic resonance angiography examination in our hospital, and 79 patients were diagnosed with PTA. Of these, 70 patients with complete radiological and clinical information were included in this study. RESULTS Among the 70 patients with complete data, 27 were classified as Weon type I (38.6%), 7 as type II (10%), 14 as type III (20%), 8 as type IV (11.4%), and 3 as type V (4.3%: type Va, 1 case; type Vb, 2 cases). The remaining 11 cases were PCA with mixed blood supply, so the new type VI was divided into 3 subtypes: type VIa, type VIb, and type VIc, and each subtype of type V was further refined into 4 subtypes. There were 32 cases of PTA with BA dysplasia, including 14 with type I (51.9%), 5 with type II (71.4%), 2 with type III (14.3%), 5 with type IV (62.5%), and 6 with type VI (54.5%). Cerebral infarction was found in 55 cases (78.6%) of PTA, among which 11 had a cerebral infarction in the posterior circulation blood supply area. There were 46 cases (65.7%) accompanied by intracranial arteriosclerosis, and in 6 cases, arteriosclerosis mainly occurred in the posterior circulation. CONCLUSIONS We redefined the classification of PTA based on Weon typing for a better understanding of clinical symptoms and surgical risks. Moreover, PTA was correlated with the fetal origin of PCA, BA dysplasia, and posterior circulation arteriosclerosis. These factors may increase the incidence of cerebral infarction in the posterior circulation blood supply area.
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Hoang TT, Nguyen CN, Nguyen AQ, Nguyen HL, Subramanian PS, Pham VT. Contralateral Ocular Manifestations of a Carotid Cavernous Fistula Associated With Primitive Persistent Trigeminal Artery. J Neuroophthalmol 2021; 41:e803-e805. [PMID: 33449487 DOI: 10.1097/wno.0000000000001181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Tung Thanh Hoang
- Ophthalmology Department (TTH, VTP), Hanoi Medical University, Vietnam; Ophthalmology Unit (TTH), Hanoi Medical University Hospital, Vietnam; Save Sight Institute (TTH), the University of Sydney School of Medicine, Australia ; Radiology Department (CNN), Hanoi Medical University Hospital, Vietnam; Oculoplastic and Cosmesis Surgery Department (AQN), Vietnam National Eye Hospital; Cardiology Center (HLN), Hanoi Medical University Hospital, Vietnam; and Ophthalmology Department (PSS), University of Colorado School of Medicine
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A rare case of pituitary TSH secreting microadenoma (TSHoma) complicated with sellar primitive persistent trigeminal artery; an operative implication and radiologic emphasis. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Castle-Kirszbaum M, Uren B, Goldschlager T. Anatomic Variation for the Endoscopic Endonasal Transsphenoidal Approach. World Neurosurg 2021; 156:111-119. [PMID: 34610448 DOI: 10.1016/j.wneu.2021.09.103] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 10/20/2022]
Abstract
Knowledge of anatomy and its variations is the key to safe and efficient surgery. The endoscopic endonasal route to the sella has evolved to become the preferred route to access a wide variety of diseases. We describe the skeletal, vascular, and neural anatomic variations that could be encountered from the nasal phase, through the sphenoid phase, to the sellar phase of the operative exposure. A preoperative checklist is also provided.
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Affiliation(s)
| | - Brent Uren
- Department of Ear, Nose and Throat Surgery, Monash Health, Melbourne, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Health, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia
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Tamaki A, Heilingoetter A, Kang SY. Enhancing Skull Base Structure Along the Carotid Sheath in a Patient With Oropharyngeal Squamous Cell Carcinoma. JAMA Otolaryngol Head Neck Surg 2021; 146:960-961. [PMID: 32816000 DOI: 10.1001/jamaoto.2020.2260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Akina Tamaki
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus
| | - Ashley Heilingoetter
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus
| | - Stephen Y Kang
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus
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Sakai S, Hatano T, Ando M, Chihara H, Ogura T, Suzuki K, Yamagami K, Kondo D, Kamata T, Higashi E, Sakamoto H, Nagata I. Treatment of Aneurysms in Persistent Primitive Trigeminal Arteries with Stent-Assisted Coil Embolization. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 15:150-156. [PMID: 37502730 PMCID: PMC10370667 DOI: 10.5797/jnet.cr.2020-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/22/2020] [Indexed: 07/29/2023]
Abstract
Objective Persistent primitive trigeminal artery (PPTA) is a rare condition in which a fetal carotid-basilar anastomosis persists into adulthood. PPTA aneurysms often necessitate endovascular treatment and adjunctive techniques, such as stent- or balloon-assisted techniques, are sometimes selected. This case report describes two women in their sixties with unruptured right PPTA aneurysms who underwent stent-assisted coil embolization procedures, with consideration of the anatomical features in each case. Case Presentations One patient presented with an aneurysm at the bifurcation of the PPTA and the basilar artery (BA), which was classified as Saltzman type 1 with a hypoplastic vertebral artery (VA)-BA system. A stent was deployed from the BA to the PPTA to cover the neck of the aneurysm and coil embolization was performed. The second patient presented with an aneurysm at the bifurcation of the PPTA and the internal carotid artery (ICA), which was classified as Saltzman type 2 with a hypoplastic VA-BA system. A stent was deployed from the PPTA to the petrous segment of the ICA covering the neck of the aneurysm and coil embolization was performed. In both patients, the 1-year follow-up digital subtraction angiography (DSA) showed that the aneurysms had not recurred. Conclusion The PPTA aneurysms were successfully treated with stent-assisted coil embolization. The treatment strategy should be devised in accordance with both the lesion site and the PPTA variant.
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Affiliation(s)
- Shota Sakai
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Taketo Hatano
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Mitsushige Ando
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Hideo Chihara
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Takenori Ogura
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Keita Suzuki
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Keitaro Yamagami
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Daisuke Kondo
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Takahiko Kamata
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Eiji Higashi
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Hiroki Sakamoto
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Izumi Nagata
- Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
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Ramaswamy S, Surendran D, Bammigatti C, Palamalai SR. A Rare Variant of the Lateral Medullary Syndrome with Craniovertebral Junction and Vascular Anomalies. Neurol India 2020; 68:934-936. [PMID: 32859848 DOI: 10.4103/0028-3886.293463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Srinath Ramaswamy
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Deepanajali Surendran
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Channaveerappa Bammigatti
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Miller PA, Oberg KC, Sun A, Achiriloaie A. A unique variant of a right persistent hypoglossal artery arising from the common carotid artery with complex cardiovascular anomalies in a female neonatal patient. J Radiol Case Rep 2020; 13:28-35. [PMID: 32184928 DOI: 10.3941/jrcr.v13i9.3601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Persistent primitive hypoglossal artery is a carotid-vertebrobasilar anastomosis, which commonly arises from the internal carotid artery at the level of the C (cervical) 1-3 vertebrae. We describe a unique case of a female infant patient with this anomaly that has an unusually low origin from the distal common carotid artery just below the bifurcation at the level of roughly C5 and supplies the entire vertebrobasilar system. Additional cardiovascular anatomical variations were present: Tetralogy of Fallot and a right-sided aortic arch with mirror image branching. These singular variations are rare in the general population, but even rarer when combined. Awareness of these unusual vascular variants is clinically significant, as they may predispose the patients to early ischemic injury, hemorrhage, aneurysm formation, and can be essential in surgical planning. Therefore, radiographic imaging is of importance in proper diagnosis of such variants.
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Affiliation(s)
- Paul A Miller
- School of Medicine, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Kerby C Oberg
- Department of Human Anatomy, Loma Linda University Medical Center, Loma Linda, Ca, USA
| | - Alex Sun
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, Ca, USA
| | - Adina Achiriloaie
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, Ca, USA
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Lyu DP, Wang Y, Wang K, Yao M, Wu YF, Zhou ZH. Acute Cerebral Infarction in a Patient with Persistent Trigeminal Artery and Homolateral Hypoplasia of Internal Carotid Artery Distal Anastomosis: A Case Report and a Mini Review of the Literature. J Stroke Cerebrovasc Dis 2019; 28:104388. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104388] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/22/2019] [Accepted: 08/28/2019] [Indexed: 11/16/2022] Open
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Tyagi G, Sadashiva N, Konar S, Aravinda HR, Saini J, Shukla D, Devi BI. Persistent Trigeminal Artery: Neuroanatomic and Clinical Relevance. World Neurosurg 2019; 134:e214-e223. [PMID: 31627002 DOI: 10.1016/j.wneu.2019.10.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Persistent trigeminal artery (PTA) is the most common remnant of primitive circulation communicating the developing carotid and vertebrobasilar junction. Although discovered incidentally, an altered hemodynamic may lead to an increased association of aneurysms, vascular malformations, and stroke. Neurosurgeons should be aware of the presence and significance of PTA when interpreting imaging and planning interventions. METHODS We retrospectively reviewed all magnetic resonance angiography and cerebral digital subtraction angiography performed between 2012 and 2017 for the presence of PTA. The radiologic and anatomic details were noted and analyzed along with the clinical profiles. We categorized the radiologic findings with respect to the available classification systems. A review of the available literature was done comparing our results. RESULTS We found 33 cases of incidentally detected PTA. The average age of the patients was 45.42 years. The lateral surface of the proximal cavernous internal carotid artery was the most common origin (n = 23). Only 3 cases had a medial/transsellar course. Most cases were Saltzman/Weon type I (19/33). Intracranial aneurysms were associated with 6 patients (18.18%). Trigeminal neuralgia (TN) was a presenting feature in 5 patients. None had a direct neurovascular conflict at the root entry zone. CONCLUSIONS Our study is one of the largest to describe the incidence of PTA. We emphasized the importance of PTA to the neurosurgeons; increased association of aneurysms, as a route for intervention in occlusive disease of the posterior fossa; risk of injury and bleeding during transsphenoidal surgery; and the association with TN. However, we found that only PTA variants are likely to be associated with TN because of their cisternal course causing NV conflict.
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Affiliation(s)
- Gaurav Tyagi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Nishanth Sadashiva
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India.
| | - Subhas Konar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | | | - Jitender Saini
- Department of Neuroradiology and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Bhagavatula Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
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Nunes M, Ullah A, Rios J, Garg A. Persistent Trigeminal Artery Playing a Protective Role in a Case of Vertebral Artery Dissection and Stenosis. Cureus 2019; 11:e5327. [PMID: 31598434 PMCID: PMC6777932 DOI: 10.7759/cureus.5327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Several fetal anastomoses have been described between the carotid and vertebrobasilar circulations. These anastomoses usually revert while the P1 segment (posterior cerebral artery segment 1) develops. However, these primitive intracranial embryonic anastomes can occasionally persist in adult age. Persistence of the primitive trigeminal artery (PPTA) is the most common of these persistent fetal anastomoses. Although uncommonly identified, knowledge of this structure is crucial for clinicians who analyze cranial imaging. PPTA has been associated with intracranial aneurysms and arteriovenous malformations but it is not very clear whether or not PPTA can also play a protective role in certain cases. We present the case of a 31-year-old female who suffered from a medullary stroke due to vertebral artery dissection and the persistent trigeminal artery (PTA) possibly played an important protective role since blood flow to the brainstem was preserved via a robust collateral flow from the right internal carotid artery (ICA).
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Affiliation(s)
- Michelle Nunes
- Neurology, University of Central Florida/Osceola Regional Medical Center, Orlando, USA
| | - Aqsa Ullah
- Neurology, University of Central Florida/Osceola Regional Medical Center, Orlando, USA
| | - Joseph Rios
- Neurology, University of Central Florida/Osceola Regional Medical Center, Orlando, USA
| | - Ankur Garg
- Vascular Neurology, Orlando Neurosurgery, Winter Park, USA
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Ishiguro T, Satow T, Okada A, Hamano E, Ikeda G, Chikuie H, Koiso T, Hashimura N, Nishimura M, Takahashi JC. Spontaneous Persistent Primitive Trigeminal Artery−Cavernous Sinus Fistula Successfully Treated by Multipronged Coil Embolization: Case Report and Literature Review. World Neurosurg 2019; 128:122-126. [DOI: 10.1016/j.wneu.2019.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/30/2019] [Accepted: 05/02/2019] [Indexed: 10/26/2022]
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Lam JJH, Shah MTBM, Chung SL, Ho CL. Persistent primitive trigeminal artery associated with a cavernous carotid aneurysm. Case report and literature review. J Radiol Case Rep 2019; 12:1-11. [PMID: 30647831 DOI: 10.3941/jrcr.v12i11.3500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The persistent primitive trigeminal artery is the most common persistent carotid-vertebrobasilar anastomosis. Patients are usually asymptomatic and the persistent primitive trigeminal artery is commonly found incidentally on imaging. Rarely, they may present with symptoms of neurovascular conflict or cranial nerve compression syndromes as the artery may be intimately related to the cranial nerves. The basilar artery is often hypoplastic in this condition and blood supply to the posterior circulation is predominantly via the persistent primitive trigeminal artery. Recognizing the persistent primitive trigeminal artery is imperative as disease of the artery may result in ischemia of the posterior circulation. To date, there is no clear association between this artery and cerebral aneurysms. We present a rare case of a patient with a persistent primitive trigeminal artery and a concomitant cavernous carotid aneurysm together with a literature review.
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Affiliation(s)
| | - Mohammad Taufik Bin Mohamed Shah
- Department of Radiology, Sengkang General Hospital, Singapore
- Duke-NUS (National University of Singapore) Graduate Medical School, Singapore
| | - Siok Li Chung
- Department of Radiology, Sengkang General Hospital, Singapore
| | - Chi Long Ho
- Department of Radiology, Sengkang General Hospital, Singapore
- Duke-NUS (National University of Singapore) Graduate Medical School, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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19
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Ma S, Agarwalla PK, van Loveren HR, Agazzi S. Successful Microvascular Decompression For Trigeminal Neuralgia Secondary to a Persistent Trigeminal Artery. Oper Neurosurg (Hagerstown) 2019; 16:18-22. [PMID: 29554372 DOI: 10.1093/ons/opy043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 02/14/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Persistent trigeminal artery (PTA) is a rare but important anatomic variant that contributes to trigeminal neuralgia (TN). Microvascular decompression (MVD) of the responsible vessel(s) away from the trigeminal nerve provides the most complete and durable relief from TN. The role and technique of MVD for TN associated with a PTA has not been fully defined in the literature. Furthermore, assessment of PTA anatomy intraoperatively with a microscope is challenging. We report the first 3-dimensional (3D) microscopic video and first intraoperative endoscopic video of a successful MVD of the trigeminal nerve in a patient who suffered TN from a tortuous, compressive PTA. CLINICAL PRESENTATION A 66-yr-old right-handed female presented with right facial pain in V2 and V3 distributions with a clinical picture of TN. Imaging demonstrated trigeminal nerve compression secondary to a PTA and MVD was performed with a 3D operative microscope and an endoscope. The PTA appeared to compress the nerve directly at the trigeminal porus and also had compressive superior cerebellar artery variant branches. The nerve was decompressed at all points of compression with Teflon pledgets along its entire cisternal length. Postoperatively, she is free with trigeminal pain episodes at 4-mo follow-up. CONCLUSION In cases of TN associated with a PTA, we recommend decompression along the entire length of the nerve wherever there is compression. Furthermore, we find both the operative microscope and particularly the endoscope useful to assess vascular anatomy intraoperatively.
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Affiliation(s)
- Shunchang Ma
- Department of Neurosurgery, Capital Medical University, Beijing, China.,Department of Neurosurgery, University of South Florida, Tampa, Florida
| | | | | | - Siviero Agazzi
- Department of Neurosurgery, University of South Florida, Tampa, Florida
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20
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Conventional MRI. HANDBOOK OF CLINICAL NEUROLOGY 2018. [PMID: 29903441 DOI: 10.1016/b978-0-444-63956-1.00013-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Conventional magnetic resonance imaging (MRI) allows for a detailed noninvasive visualization/examination of posterior fossa structures and represents a fundamental step in the diagnostic workup of many cerebellar disorders. In the first part of this chapter methodologic issues, like the correct choice of hardware (magnets, coils), pro and cons of the different MRI sequences, and patient management during the examination are discussed. In the second part, the MRI anatomy of the cerebellum, as noted on the various conventional MRI sequences, as well as a detailed description of cerebellar maturational processes from birth to childhood and into adulthood, are reported. Volumetric studies on the cerebellar growth based on three-dimensional MRI sequences are also presented. Moreover, we briefly discuss two main topics regarding conventional MRI of the cerebellum that have generated some debate in recent years: the differentiation between cerebellar atrophy, hypoplasia, and pontocerebellar hypoplasia, and signal changes of dentate nuclei after repetitive gadolinium-based contrast injections. The advantages and benefits of advanced neuroimaging techniques, including 1H magnetic resonance spectroscopy, diffusion-weighted imaging, diffusion tensor imaging, and perfusion-weighted imaging are discussed in the last section of the chapter.
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Hakim A, Gralla J, Rozeik C, Mordasini P, Leidolt L, Piechowiak E, Ozdoba C, El-Koussy M. Anomalies and Normal Variants of the Cerebral Arterial Supply: A Comprehensive Pictorial Review with a Proposed Workflow for Classification and Significance. J Neuroimaging 2017; 28:14-35. [PMID: 28945289 DOI: 10.1111/jon.12475] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 12/13/2022] Open
Abstract
Cerebral arteries may exhibit a wide range of variation from normal anatomy, which can be incidentally discovered during imaging. Knowledge of such variants is crucial to differentiate them from pathologies, to understand the etiology of certain pathologies directly related to a vascular variant, and to depict the changes in collateral circulation in patients with certain variants. Detection of particular variants may lead to the discovery of other nonvascular or vascular anomalies, especially aneurysms, and may also affect planning of endovascular or neurosurgical interventions. In this review, we summarize the variants and anomalies of cerebral arteries seen on cross-sectional imaging classified by a morphological approach and categorize their significance from a clinical perspective. This structured review is intended to serve as a guide for daily use in clinical practice.
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Affiliation(s)
- Arsany Hakim
- University Institute of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Christoph Rozeik
- Radiology Department, Lörrach District Hospital, Lörrach, Germany
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Lars Leidolt
- University Institute of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Eike Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Christoph Ozdoba
- University Institute of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Marwan El-Koussy
- University Institute of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
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Petik B, Colak D, Sirik M, Erturk SM. Rare Variants of Carotid-Vertebrobasilar Anastomoses. J Belg Soc Radiol 2016; 100:74. [PMID: 30151473 PMCID: PMC6100572 DOI: 10.5334/jbr-btr.1167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Carotid-vertebrobasilar anastomoses generally disappear during embryogenesis. However, if a problem exists during regression, these arteries persist in adult period and are named as persistent arteries. Their persistence in adult patients is sometimes pathological and may result in the development of an aneurysm or a compressive syndrome. These anastomoses are frequently associated with proximal or distal arterial pathology. Herein, we present three rare variants of carotid-vertebrobasilar anastomoses: a persistent trigeminal artery, persistent hypoglossal artery, and a persistent otic artery. These variants should be kept in mind to avoid errors both in clinical reporting and surgical procedures.
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Parthasarathy R, Derksen C, Saqqur M, Khan K. Isolated intermittent vertigo: A presenting feature of persistent trigeminal artery. J Neurosci Rural Pract 2016; 7:161-3. [PMID: 26933370 PMCID: PMC4750321 DOI: 10.4103/0976-3147.165430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Embryonic carotid – basilar anastomosis when persistent in adult life can present with a variety of neurological symptoms. We present a patient with isolated intermittent vertigo attributable to the embryonic anastomosis and describe the different types of persistent trigeminal artery. A 76-year-old Caucasian man presented with isolated intermittent vertigo and symptoms suggestive of anterior and posterior circulation strokes. Impaired vasomotor reactivity was demonstrated on insonation of the anterior and posterior cerebral arteries in this patient with a persistent left trigeminal artery and 75% stenosis of the left internal carotid artery (ICA). The symptom of intermittent vertigo resolved with carotid endarterectomy. Decreased flow across the stenotic segment of the ICA which subserved the posterior circulation resulted in basilar insufficiency. Hypoperfusion to the flocculonodular lobe supplied by the anterior inferior cerebellar artery is a likely cause for the intermittent vertigo.
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Affiliation(s)
- Rajsrinivas Parthasarathy
- Department of Neurointerventional Surgery, Institute of Neurosciences, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Carol Derksen
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Maher Saqqur
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Khurshid Khan
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Persistent trigeminal artery: a cross-sectional study based on over 3 years conventional angiography, CT angiography and MR angiography images. Surg Radiol Anat 2015; 38:445-53. [DOI: 10.1007/s00276-015-1578-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 10/16/2015] [Indexed: 10/22/2022]
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Pseudo subclavian steal syndrome: Case report. Int J Surg Case Rep 2015; 16:177-80. [PMID: 26479783 PMCID: PMC4643450 DOI: 10.1016/j.ijscr.2015.09.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 09/21/2015] [Accepted: 09/22/2015] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Vertebrobasilar insufficiency (VBI) is a condition that results from restricted blood flow to the posterior portions of the brain, which are primarily served by the vertebral and basilar arteries. It is the most common cause of vertigo in the elderly and is usually accompanied by impaired vision and sensation. Congenital abnormalities, atherosclerosis, stroke and/or trauma may all lead to decreased vertebrobasilar circulation. A syndrome called Subclavian Steal Syndrome (SSS), which manifests with similar neurological symptoms but with a different pathophysiology, may also cause VBI. CASE PRESENTATION A middle-aged female presented with gradual onset fainting and vertigo attacks. Cardiac, auditory and autonomic etiologies were investigated and excluded. Clinical findings and presentation were highly suggestive of subclavian steal. However, subsequent CT angiography showed normal subclavian arteries. Instead, findings included a persistent right trigeminal artery (PTA), stenosis of the right proximal internal carotid artery, atresis of the left vertebral artery and distal segment of right vertebral artery, congenitally compromised changes in vertebral circulation (bilateral absence of the posterior communicating arteries (PCOMs)) and an absent anterograde vertebrobasilar circulation. Symptoms resolved after carotid endarterectomy. DISCUSSION Due to the absence of a normally developed posterior circulation, the PTA was the main source of blood supply for the patient. Development of recent artheromatous changes in the right internal carotid artery, however, resulted in decreased blood through PTA, further compromising posterior circulation. This resulted in vertebrobasilar insufficiency, and manifested in symptomology similar to SSS. CONCLUSIONS This clinical encounter illustrates the relative contribution of anatomical and vasoocclusive factors in closely mimicking symptoms of subclavian steal syndrome.
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Mohammad LM, Carlson AP. Unusual persistent primitive trigeminal artery with a superior duplicated basilar system. Surg Radiol Anat 2015; 38:605-7. [PMID: 26404778 DOI: 10.1007/s00276-015-1559-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/20/2015] [Indexed: 11/30/2022]
Abstract
A 67-year-old patient who presented with a right cerebellar hemorrhage underwent vascular workup for suspicion of underlying vascular anomalies. A diagnostic cerebral angiogram demonstrated a duplicated basilar system fed solely by a persistent primitive trigeminal artery. The findings proved to be incidental and unrelated to the patient's hemorrhage. These developmental abnormalities are consistent with embryological development.
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Affiliation(s)
- Laila Malani Mohammad
- Department of Neurosurgery, The University of New Mexico, 1 University of New Mexico, Albuquerque, NM, 87131, USA.
| | - Andrew Phillip Carlson
- Department of Neurosurgery, The University of New Mexico, 1 University of New Mexico, Albuquerque, NM, 87131, USA
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Wenz H, Wenz R, Förster A, Fontana J, Kerl HU, Groden C, Scharf J. Missing relationship of moyamoya and persistent primitive artery in Europeans. Another distinctive feature or artifact? Surg Radiol Anat 2015; 37:1079-85. [DOI: 10.1007/s00276-015-1457-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 03/03/2015] [Indexed: 11/30/2022]
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28
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Seltzer J, He S, Shiroishi MS, Lucas JW, Hwang DH, Zada G. Coincident intrasellar persistent trigeminal artery and craniopharyngioma: case report and implications for transsphenoidal surgery. INTERDISCIPLINARY NEUROSURGERY 2014. [DOI: 10.1016/j.inat.2014.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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29
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Vrselja Z, Brkic H, Mrdenovic S, Radic R, Curic G. Function of circle of Willis. J Cereb Blood Flow Metab 2014; 34:578-84. [PMID: 24473483 PMCID: PMC3982101 DOI: 10.1038/jcbfm.2014.7] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 12/31/2013] [Accepted: 01/06/2014] [Indexed: 12/21/2022]
Abstract
Nearly 400 years ago, Thomas Willis described the arterial ring at the base of the brain (the circle of Willis, CW) and recognized it as a compensatory system in the case of arterial occlusion. This theory is still accepted. We present several arguments that via negativa should discard the compensatory theory. (1) Current theory is anthropocentric; it ignores other species and their analog structures. (2) Arterial pathologies are diseases of old age, appearing after gene propagation. (3) According to the current theory, evolution has foresight. (4) Its commonness among animals indicates that it is probably a convergent evolutionary structure. (5) It was observed that communicating arteries are too small for effective blood flow, and (6) missing or hypoplastic in the majority of the population. We infer that CW, under physiologic conditions, serves as a passive pressure dissipating system; without considerable blood flow, pressure is transferred from the high to low pressure end, the latter being another arterial component of CW. Pressure gradient exists because pulse wave and blood flow arrive into the skull through different cerebral arteries asynchronously, due to arterial tree asymmetry. Therefore, CW and its communicating arteries protect cerebral artery and blood-brain barrier from hemodynamic stress.
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Affiliation(s)
- Zvonimir Vrselja
- 1] Department of Anatomy and Neuroscience, Medical School of J. J. Strossmayer University in Osijek, Osijek, Croatia [2] Department of Radiology, Osijek University Medical Center, Osijek, Croatia
| | - Hrvoje Brkic
- Department of Biophysics, Medical Statistics and Medical Informatics, Medical School of J. J. Strossmayer University in Osijek, Osijek, Croatia
| | - Stefan Mrdenovic
- Department of Hematology, Osijek University Medical Center, Osijek, Croatia
| | - Radivoje Radic
- Department of Anatomy and Neuroscience, Medical School of J. J. Strossmayer University in Osijek, Osijek, Croatia
| | - Goran Curic
- 1] Department of Chemistry and Biochemistry, Laboratory for DNA Analysis, Medical School of J. J. Strossmayer University in Osijek, Osijek, Croatia [2] Department of Pathology and Legal Medicine, Osijek University Medical Center, Osijek, Croatia
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