Introduction Aneurysms of persistent primitive trigeminal artery (PPTAAs) are increasingly reported and commonly managed by endovascular (EN) techniques. There are no systematic reviews or meta-analyses which analyse outcomes and complications of treatment modalities for PPTAAs. We aim to highlight the change in trend of management of PPTAAs and to identify clinical and radiological parameters which may influence management paradigms. Methodology A systematic search of literature was done in PubMed, Embase, Google Scholar, Cochrane library and Medline using keywords ‘persistent primitive trigeminal artery’, ’aneurysms’, ‘embolization’, ‘surgical clipping’, etc. Only cases reporting aneurysms of PPTA were included. Three subgroups, such as conservative, open surgical (OS) and EN interventional, were studied for outcome evaluation. In the EN subgroup, relation of clinical and radiological parameters with outcome (complete/partial occlusion) was analysed using Microsoft Excel Data Analysis ToolPak. Results Of the 101 articles found eligible for assessment, 54 were analysed quantitatively. Mortality in the conservative group was 12.5% and OS group was 9.09%. After EN treatment, complete angiographic occlusion was seen in 88.89% PPTAAs and 5.5% warranted retreatment. In the EN subgroup, location ( p=0.17), shape ( p=0.69), Saltzman circulation ( p=0.26) or status of rupture ( p=0.08) did not significantly impact angiographic occlusion outcome. Multivariate regression analysis showed 6.6% influence of independent variables, that is, age, gender, aneurysm location, side, shape (saccular/fusiform), rupture status and type of Saltzman circulation on aneurysm occlusion outcome [F(7,27) =1.34] ( p=0.27). Total mortality reported in the EN group was 8.57%. Conclusion Clinical or radiological parameters do not influence angiographic occlusion outcome. Although EN techniques are successful, meticulous reporting of outcomes and complications is important.

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Background: The appearance of sequential bilateral aneurysms in patients with persistent primitive trigeminal artery (PTA) is not described in the literature. No clear guidelines on screening and follow-up of patients with incidental PTAs for the detection of associated lesions have been established. Case Description: A 55-year-old lady presented with occasional headaches. Detailed evaluation showed a left ophthalmic segment internal carotid artery (ICA) aneurysm measuring (11.2 × 5.5) mm. A bovine aortic arch configuration (type III) and a persistent left PTA were identified. A pipeline flex flow diverter was placed and aneurysm was coiled. Follow-up angiography after 6 months showed a completely occluded aneurysm with preserved PTA and a new aneurysm in the right ICA ophthalmic segment measuring 3.5 × 1.5 mm. It was followed up serially with angiography which revealed significant increase in 6 months. The base measured 5.4 mm and two blebs 3.1 mm and 2.5 mm had appeared on the dome. A SUPRASS flow diverter was placed across this aneurysm. Serial follow-up showed complete occlusion of the left aneurysm and significant reduction in filling of the right aneurysm. A review of the literature identified 34 cases of incidental PTAs associated with 50 aneurysms with increased prevalence of anterior circulation aneurysms in patients with incidental PTA. Conclusion: Sequential angiography of a patient with incidental PTA and an ICA aneurysm shows presence of a new aneurysm in contralateral circulation and its progression in size and morphology. Detailed large-scale studies are needed to assess the impact of incidental PTA on aneurysm development and management.

ObjectiveThere is a paucity in the literature regarding evidence‐based guidelines for the management of large placental chorioangiomas (≥ 4cm diameter). The objective of this study is to describe different thermal techniques that may improve the efficiency of in utero intervention for chorioangiomas.MethodsThis is a retrospective cohort study of 34 patients referred for the management of large placental chorioangiomas in a single center from January 2011 to December 2022, who were managed expectantly or with intervention. In utero intervention was performed when the fetus developed any signs of impending compromise including high combined cardiac output (CCO), worsening polyhydramnios, or abnormal fetal Doppler velocimetry findings. Interventions included radiofrequency ablation (RFA), interstitial laser surgery, single port FLP or two port fetoscopic laser photocoagulation (FLP). Treatment selection was dependent on the proximity of the tumor to the cord insertion and placental location. The two‐port technique was performed in patients with a chorioangioma with large feeder vessels (≥ 3 mm) located in the posterior placenta, where one port was for the bipolar occlusion and coagulation of the feeder vessels and the second port for laser photocoagulation of these vessels downstream. Single port technique was used in chorioangioma with small feeder vessels (< 3 mm) located in the posterior placenta. Interstitial laser ablation or RFA was performed in cases of anterior placenta. Supportive treatments like amnioreduction and intrauterine transfusion (IUT) were additionally performed for worsening polyhydramnios and suspected fetal anemia based on middle cerebral artery Doppler flow studies respectively. Comparative statistics between expectant management vs. in‐utero interventions were performed. Descriptive details are provided for patients who underwent in‐utero intervention.ResultsThirty‐four large chorioangiomas were evaluated, 25 (73.5%) were managed expectantly and 9 (26.4%) underwent intervention. The presence of polyhydramnios was significantly higher in the intervention group compared to the expectant group (67% vs 8%, p value <0.001). The live birth among expectantly managed chorioangiomas was significantly higher compared to intervention group (96% vs 56%, p value=0.01). In the intervention group, elevated CCO was present in all cases and hydrops was present in (n=3) 34% of cases. One patient experienced fetal demise following IUT but prior to planned FLP. Among the remaining 8 patients, 4 underwent the two‐port technique, 2 underwent a single‐port FLP, and 2 underwent interstitial laser ablation/RFA. The overall survival rate for fetuses undergoing interventions was 62.3% (5/8). All 3 cases where hydrops was present at the time of intervention ended with fetal demise.ConclusionFetoscopic laser photocoagulation of feeder vessels is a therapeutic option for the management of large chorioangiomas. A two‐port percutaneous fetoscopic technique appears to improve the efficiency of FLP when a large chorioangioma with large feeder vessels is located in the posterior placenta. We propose that in‐utero interventions for large chorioangioma should be initiated prior to the development of fetal hydrops.This article is protected by copyright. All rights reserved.