Carotid artery stenting to treat internal carotid artery stenosis with persistent primitive hypoglossal artery: a case report

Abstract

Persistent primitive hypoglossal artery (PPHA) is a rare embryonic carotid-vertebrobasilar artery anastomosis, which has been often found accidentally. The PPHA is a unique anastomosis, among all the embryonic persistent fetal anastomosis, to act as a sole supply to the vertebrobasilar circulations. Here, we experienced a case of thrombotic cerebral infarction caused by atherosclerotic internal carotid artery (ICA) stenosis from which a concurrent PPHA arise. The case involved a 79-year-old male who had suffered from thrombotic strokes twice within a half year. Since the oral medication of anti-platelets drug failed to prevent stroke events, the ICA lesion was treated by carotid artery stenting (CAS). There have been several publications with respect to the surgical treatment for the ICA stenosis coinciding with a PPHA, where especially concerns for the inherent risks to damage the whole central nervous system were debated. After careful consideration and planning, CAS using a distal filter protection was successfully performed without complications. We report the details of the case along with literature reviews.

Strategy of cerebral endovascular treatment for cervical internal carotid artery stenosis with a persistent primitive hypoglossal artery

“…Distal filter (DF) type EPDs can be used to maintain intracranial blood flow, and there have been reports of DF type EPDs being used in patients with ICA stenosis and PPHA. [ 1 , 13 , 14 ] Silva et al . [ 13 ] and Ebiko et al .…”

“…Tonegawa et al . [ 14 ] reported a case in which a DF-type EPD was placed at the bifurcation between the ICA and PPHA, resulting in successful CAS without ischemic complications. This method can be used even in patients with low ischemic tolerance.…”

“…ere are 12 reported cases of CAS for ICA stenosis accompanied by PPHA, including ours. [1,2,[5][6][7][8]10,[12][13][14]18] However, in each case, the site of stenosis was different, as was the treatment method [Table 1]. When CAS is performed, proximal protection using a balloon guide catheter (BGC) has been used in several cases due to concerns about the dispersal of the plaque from the site of stenosis.…”

“…Distal filter (DF) type EPDs can be used to maintain intracranial blood flow, and there have been reports of DF type EPDs being used in patients with ICA stenosis and PPHA. [1,13,14] Silva et al [13] and Ebiko et al [1] performed CAS without ischemic complications by implanting a DF type EPD in both the ICA and PPHA. e problem with this technique is that since the EPD is not coaxial with the stent, it might get stuck in between the stent and the vessel wall, making its retrieval difficult.…”

“…ere are only four previously reported cases of stent placement for ICA stenosis associated with PPHA. [1,2,[5][6][7][8]10,[12][13][14]18] We report a strategy using a CASPER stent and Spider FX and compare it with the methods described in the previous reports.…”