Persistent trigeminal artery aneurysm rupture inducing a carotid-cavernous fistula: its presentation and management. Illustrative case.

BACKGROUND: A carotid-cavernous fistula (CCF) is a well-recognized entity resulting from an abnormal connection between the internal carotid artery (ICA) or external carotid artery and the cavernous sinus. Typical CCF symptomology includes proptosis, chemosis, orbital bruit, headache, facial pain, and cranial nerve (CN) palsies. While CCFs most often occur posttraumatically, they can also occur spontaneously, secondary to cavernous ICA aneurysm rupture. Very rarely, they can occur secondary to the rupture of an anomalous persistent trigeminal artery (PTA) aneurysm. OBSERVATIONS: Herein, the authors describe the case of a 54-year-old woman who presented with a CN VI palsy and headache due to a CCF secondary to a PTA aneurysm rupture. The CCF was ultimately treated via coil embolization of the aneurysm and the parent PTA vessel. LESSONS: Though such occurrences are rare, clinicians should be vigilant in assessing for the presence of a PTA in patients with a CCF, as a PTA-associated CCF requires unique treatment considerations. In some cases where the PTA plays a crucial role in the posterior circulation supply, preservation of the parent vessel PTA is crucial. However, in cases in which an adequate posterior circulation collateral supply exists, embolization of the aneurysm and the parent vessel PTA is a reasonable treatment option for fistula closure. https://thejns.org/doi/10.3171/CASE24287.

Bilateral concurrent type I and type II persistent proatlantal arteries: A case report.

Transient embryonic carotid-vertebrobasilar anastomoses can intermittently persist beyond the embryonic period. These vascular anomalies are often serendipitously identified during evaluation for unrelated disease states and pathologies. The persistent proatlantal intersegmental artery is one such recognized rare fetal anastomotic connection, often arising unilaterally. Bilateral persistence of the proatlantal anastomosis is a rarer occurrence, seldom described in the literature. We report a case of bilateral concurrent type I and type II proatlantal arteries, describe the embryology of persistent carotid-vertebrobasilar anastomoses, and consider pertinent clinical implications.

Selective Transarterial Embolization for a Ruptured Persistent Trigeminal Artery Variant Aneurysm.

We report a male patient with a ruptured persistent primitive trigeminal artery variant aneurysm that resulted in a fistula with the cavernous sinus. He presented with left conjunctival hyperemia and exophthalmos. Cerebral angiography revealed a left direct carotid-cavernous fistula; however, a balloon occlusion test determined that the source was actually a ruptured aneurysm located on the trunk of a persistent primitive trigeminal artery. Endovascular trapping of the persistent primitive trigeminal artery was performed, which resulted in fistula occlusion and symptom resolution.

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.

The Relationship between the Permanent Trigeminal Artery and Cerebrovascular Disease: A Meta-Analysis.

Background: We aimed to analyze the variability of the permanent trigeminal artery (PTA) and its relationship with cerebrovascular disease. Methods: To analyze the variability of the PTA and its relationship with cerebrovascular disease by using the terms "primitive trigeminal artery", "persistent primitive trigeminal artery", " persistent trigeminal artery variant", "PPTA", "PTAV", "carotid- basilar anastomoses", "carotid-vertebrobasilar anastomoses", "persisting embryonic vessels" were used as keywords, and the English-language literature related to PTA and cerebrovascular diseases published in PubMed, EMBAS, and Web of Science databases from 2000 to 2022 were searched by using "subject terms + free words". A meta-analysis of the collected data was performed using stata14.0 statistical software to assess the relationship between the immortal trigeminal artery and cerebrovascular-related diseases. Results: A total of 1908 relevant articles were initially retrieved for this study. Ten papers were initially screened according to the inclusion and exclusion criteria, while the literature was then read one by one to exclude duplicates, reviews, case reports, and conference abstracts, and six papers were finally included for meta-analysis. The six papers included in this paper were all cross-sectional studies with 39,355 subjects, of which 206 subjects had PTA, with a variation rate of approximately 0.52%, including 77 males and 129 females, 117 left-sided variants and 87 right-sided variants. In contrast, of the 206 subjects with a PTA, 52 had cerebrovascular disease, with an overall prevalence of approximately 25.24%. Conclusion: The PTA could influence the development of cerebrovascular disease.

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.

Ruptured Anterior Inferior Cerebellar Artery Aneurysm From a Persistent Trigeminal Artery: A Case Report.

Persistent trigeminal artery (PTA) is the most common remnant of the primitive carotid-vertebrobasilar anastomoses, which typically form and obliterate during the early stages of human embryonic development. While PTA can be non-pathologic and is usually an incidental finding, it is also associated with various other vascular abnormalities, such as arteriovenous malformations and fistulae, but most commonly cerebral aneurysms. In these cases, aneurysms are usually reported in the anterior cerebral circulation or in the PTA trunk itself; to date, only one report exists of an associated aneurysm in the posterior circulation (basilar artery). These associated vascular pathologies are not only a source of morbidity and mortality but can also complicate subsequent endovascular treatment due to different flow patterns and increased vessel tortuosity. In this case report, we present the first reported case of PTA-associated aneurysm in the anterior inferior cerebellar artery and its resulting impact on the endovascular treatment of this aneurysm.

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.

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]. / Tserebral'nye persistiruyushchie primitivnye arterii. Klinicheskii sluchai sochetaniya s intrakranial'noi anevrizmoi i obzor literatury.

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.

Internal Carotid Artery Dissecting Aneurysm Associated with Persistent Trigeminal Artery: A Case Report.

BACKGROUND: Persistent trigeminal artery (PTA) is the most common vascular anastomosis between the carotid artery and vertebrobasilar systems. We report a very rare case of dissecting aneurysm in the right internal carotid artery (ICA) with ipsilateral PTA and discuss its clinical importance. CASE REPORT: A 38-year-old male presented to the emergency department with paroxysmal dysphasia for 6h. Brain magnetic resonance (MR) imaging showed acute cerebral infarction of the right corona radiata and right parietal lobe. Three-dimensional time-of-flight MR angiography (3D TOF MRA) revealed severe stenosis of the petrous segment (C1 portion) of the right internal carotid artery and a PTA originating from the right ICA cavernous segment (C4 portion), with a length of approximately 1.8cm and a diameter of approximately 0.2cm. The ICA segments are all named according to the Bouthilier classification. The basilar artery (BA) under union was well developed. The bilateral posterior communicating arteries were also present. One day later, the high-resolution vessel-wall MR demonstrated a dissecting aneurysm in the C1 portion of the right ICA. The length of the dissecting aneurysm is approximately 4.4cm, the diameter of the true lumen at the most severe stenosis is approximately 0.2cm, and the diameter of the false lumen is approximately 0.8cm. Subsequent digital subtraction angiography (DSA) confirmed a dissecting aneurysm in the C1 portion of the right ICA. The patient was treated conservatively and did not undergo interventional surgery. Four months later, head and neck MRA showed that the right ICA blood flow was smooth and that the dissecting aneurysm had disappeared. The Ethics Committee of Liaocheng People's Hospital approved the research protocol in compliance with the Helsinki Declaration. Written informed consent was obtained from the individual for the publication of any potentially identifiable images or data included in this article. CONCLUSION: Flow alteration with PTA may have influenced the formation of ICA dissection in this patient. Awareness of this is crucial in clinical practice because it can influence treatment options and intervention procedures.

Posterior Circulation Mechanical Thrombectomy through Primitive Trigeminal Artery: A Case Report.

Introduction: Primitive trigeminal artery (PTA) is a rare intracranial vascular malformation, and mechanical thrombectomy and revascularization via PTA are rarely reported. Case Presentation: We reported a case of mechanical thrombectomy through PTA in a patient who presented with sudden slurred speech and had a National Institutes of Health Stroke Scale score of 12. Digital subtraction angiography of the cerebral vasculature showed PTA formation in the right internal carotid artery cavernous segment, with acute occlusion of the distal basilar artery at the PTA junction, and bilateral vertebral arteries and proximal basilar artery were underdeveloped. Therefore, we chose mechanical thrombectomy via PTA, but unfortunately, the vessel failed to recanalize. Follow-up at 1-month post-procedure indicated that the patient had passed away. We present the endovascular process and analyze and summarize the reasons for the failure to provide a reference for subsequent mechanical thrombectomy via PTA. Conclusions: PTA increases the risk of ischemic stroke and adds to the complexity of mechanical thrombectomy post-stroke. However, in certain situations, PTA can be used as a thrombectomy channel to increase the first-line possibility of timely endovascular treatment to save ischemic brain tissue.

Persistent trigeminal artery in a patient with moyamoya disease:a case report and literature review.

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.

Persistent trigeminal artery variant and presumed ophthalmic artery simultaneously arising from the inferolateral trunk incidentally diagnosed by magnetic resonance angiography.

PURPOSE: To describe a case of persistent trigeminal artery variant (PTAV) and presumed ophthalmic artery (OA) simultaneously arising from the inferolateral trunk (ILT). METHODS: A 53-year-old woman with an initial episode of convulsion underwent cranial magnetic resonance imaging (MRI) and MR angiography (MRA) of the intracranial region for the evaluation of brain and vascular lesions. The MR machine was a 3-T scanner. RESULTS: MRI revealed no pathological brain lesions. On MRA, the left anterior inferior cerebellar artery (AICA) arose from the cavernous segment of the internal carotid artery (ICA), indicative of the PTAV. The arising point was more distal than the usual point, and the presumed OA also arose simultaneously from the short common trunk, which was considered the ILT. CONCLUSION: There are two types of PTA: lateral (usual) and medial (intrasellar) PTA. The lateral-type PTA and PTAV arise from the ICA of the distal precavernous-proximal cavernous segment and take a course similar to that of the posterior fossa. The medial type arises slightly more in the distal cavernous segment than in the lateral type. The OA rarely arises from the cavernous segment of the ICA and enters the orbit via the superior orbital fissure. The origin of this type of OA is considered to be the ILT. We herein report a case of a PTAV and presumed OA arising simultaneously from an ILT. No similar case has been reported in the relevant English language literature.

Trigeminal neuralgia caused by a persistent primitive trigeminal artery variant passing through Meckel's cavity: a case report.

BACKGROUND: Persistent primitive trigeminal artery variant (PPTAv) is a rare remnant of the primitive intracranial embryonic anastomotic arteries, and its persistence has an unknown etiology. Trigeminal neuralgia attributed to a PPTAv passing through Meckel's cavity is extremely uncommon. CASE PRESENTATION: A 73-year-old woman presented with right-sided facial pain for 10 years that had failed to respond to medication. Magnetic resonance angiography suggested the presence of a PPTAv compressing the trigeminal nerve, as the abnormal artery originated from the right internal carotid artery. During microvascular decompression (MVD), the offending vessel was inferred to be a PPTAv, as it continued to become the anterior inferior cerebellar artery after passing through Meckel's cavity. Postoperative computed tomography angiography showed the PPTAv continuing posteriorly as the anterior inferior cerebellar artery and supplying the cerebellar hemisphere, which confirmed the intraoperative judgment. The pain resolved after MVD and has not recurred in 12 months of follow-up. CONCLUSION: MVD is the best surgical choice for trigeminal neuralgia combined with a PPTAv. For patients with neurovascular conflicts, particularly those with suspected vascular variations, preoperative imaging examinations play a critical role in meticulously evaluating the anatomical locations of the nerves and blood vessels. Semilunar puncture (for radiofrequency ablation or percutaneous balloon compression) is contraindicated in patients with a PPTAv.

Medial-type persistent trigeminal artery and ipsilateral posterior communicating artery supplying bilateral posterior cerebral arteries combined with an aberrant right subclavian artery and bicarotid trunk.

PURPOSE: To describe a case of a medial-type persistent trigeminal artery (PTA) associated with multiple arterial variations. METHODS: A 34-year-old woman with multiple sclerosis underwent cranial magnetic resonance (MR) angiography from the aortic arch to the neck region and intracranial region for the evaluation of an unruptured cerebral aneurysm that was previously detected on MR imaging. The MR machine was a 3-T scanner. RESULTS: There was an aberrant right subclavian artery and bicarotid trunk, medial-type left PTA and ipsilateral posterior communicating artery (PCoA) supplying bilateral posterior cerebral arteries (PCAs). The unruptured aneurysm was located at the paraclinoid segment of the left internal carotid artery and was treated successfully by coil embolization via a transfemoral approach. CONCLUSION: Only 10% of PTAs are classified as the medial type. The association with extremely large ipsilateral PCoA, which supplies the bilateral PCAs, has not been previously reported. Aberrant right subclavian arteries are common and are frequently associated with a bicarotid trunk. Before catheterization of the cerebral arteries, the aortic arch and its branches must be evaluated by MR angiography or computed tomography angiography to prevent catheterization failure via the right transradial approach.

Parent Artery Occlusion for Symptomatic Large Internal Carotid Artery Aneurysm with Primitive Trigeminal Artery Variant: A Case Report.

Objective: To report a case of symptomatic large cerebral aneurysm of the internal carotid artery (ICA), associated with a primitive trigeminal artery variant (PTAv), which was treated with a balloon occlusion test (BOT) to evaluate ischemic tolerance. Case Presentation: A 79-year-old woman was diagnosed with a symptomatic large cerebral aneurysm of the ICA bifurcating the PTAv due to diplopia. After confirming the ischemic tolerance of the perfusion area and PTAv by BOT, we performed ICA parent artery occlusion with selective embolization of the PTAv. Postoperative MRI showed no ischemic lesion and the diplopia was resolved. Conclusion: ICA parent artery occlusion with PTAv selective embolization after evaluation by BOT is useful in the treatment of large aneurysms.

Persistent trigeminal artery-superior cerebellar artery segmental fusion diagnosed using magnetic resonance angiography.

PURPOSE: To describe a case of persistent trigeminal artery (PTA)-superior cerebellar artery (SCA) segmental fusion incidentally diagnosed on magnetic resonance (MR) angiography. CASE REPORT: A 53-year-old woman with a history of facial pain underwent cranial MR imaging and MR angiography. MR angiography showed a left lateral-type PTA arising from the precavernous portion of the left internal carotid artery (ICA). PTA branched into the left distal SCA and showed segmental fusion with the proximal SCA at the distal part of the PTA. We also diagnosed an unruptured cerebral aneurysm at the junction between the left ICA and PTA. DISCUSSION: PTA is the most frequent type of carotid-vertebrobasilar anastomosis. The reported prevalence rate is 0.2% by angiography and 0.34% by MR angiography. There are two types of PTA-lateral (usual) and medial (intrasellar). SCA arising from the lateral-type PTA has rarely been reported. Further, a PTA from which the distal SCA branches and segmentally fuses with the proximal SCA at the distal part of the PTA has not been reported. CONCLUSION: Using MR angiography, we diagnosed a rare type of PTA that fused segmentally with SCA. No similar case has been reported in relevant English-language literature.

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.

Interventions and imaging in patients with anatomic variations of cerebral circulation: a pictorial review.

The cerebral arterial system shows a wide spectrum of variations. Minor degrees of anatomic differences can be seen in almost all patients. Recognition of these anatomic variants is essential for the following: evaluating collateral circulation; some anatomic variants may mimic pathology; increased risk for aneurysm formation with some variants (e.g. fenestration, persistent trigeminal artery); dealing with pathologies that can arise with these variations; and for preoperative planning. The anterior and posterior groups of intracranial circulation show numerous anastomoses that play a major role in maintaining adequate blood supply to the cerebral parenchyma. This review focuses on the imaging features of these variants as seen on computed tomography and magnetic resonance imaging with relevant digital subtraction angiography imaging. We also present some case illustrations where understanding of these variants contributed to providing appropriate management.