Persistent trigeminal artery in a patient with posterior circulation stroke treated with rt-PA: case report

Abstract

BackgroundA persistent trigeminal artery (PTA) is a non-involuted embryonic vessel that connects the cavernous part of the internal carotid artery with the posterior circulation. In the adult it is associated with multiple pathological conditions including trigeminal neuralgia, ophthalmoplegia, hypopituitarism, intracavernous fistula, brain aneurysms and posterior circulation strokes. The latter may occur through steal phenomena or thrombosis in the anterior circulation. PTA associated vertebrobasilar hypoplasia has yet to be associated to TIA like events, however, in the reported case, that seems to be the case with reported vertigo being probably linked to vertebrobasilar insufficiency.Case reportWe present a case of an 82-year-old man with sudden onset neurological deficits, including left hemiparesis with crural predominance, vertical nystagmus, right internuclear ophthalmoplegia, dysarthria and dysmetria on the left arm. CT angiography disclosed basilar artery hypoplasia in the proximal two thirds and a persistent trigeminal artery. He was diagnosed with acute ischemic stroke. He was submitted to rt-PA with partial reversion of deficits.ConclusionThe ischemic events related to PTA remain a rare cause of stroke with specific pathophysiological mechanisms and implications. They may occur through steal phenomena or thrombosis in the anterior circulation. Upon literature review, in the described case both mechanisms seem possible, however the transient episodes of vertigo could have been the first sign of vertebrobasilar insufficiency.

Persistent trigeminal artery incidentally found in a patient with brain posterior system infarction: a rare case report

“…According to Da-Ping et al (5), it is unclear whether PTA is associated with ischemic cerebrovascular disease. However, Ferreira et al (3) reported that patients with PTA and basilar hypoplasia had hypoperfusion in the posterior fossa, and therefore were more susceptible to ischemic events. Engelhardt et al ( 4) stated that as the number of collaterals increased, infarction became smaller.…”

“…PTA accounts for approximately 85% of all persistent presegmental arteries (2). In digital subtraction angiography (DSA), PTA is observed at a rate ranging from 1 in a 1,000 to 6 in 1,000, and it is usually unilateral (2,3). In radiological examinations, almost all cases are detected incidentally.…”

Persistent trigeminal artery as a rare cause of vertebrobasilar insufficiency

“…The PTA has been identified as a rare cause of cranial nerves dysfunction, including incomplete oculomotor and abducens nerve palsies, trigeminal neuralgia and hemifacial spasm. The ischemic events related to the PTA are rare and can occur through the steal phenomenon or thrombosis in anterior circulation [16,21]. Typically, persistent trigeminal artery aneurysms (PTAA) are discovered incidentally in patients with subarachnoid hemorrhage (SAH) due to the rupture of a simultaneous aneurysm in another localization.…”

Persistent trigeminal artery detected on computed tomography angiography

“…It has been reported that the presence of PTA may also be associated with ischemic stroke [18][19][20]. In patients with PTA and vertebrobasilar hypoplasia, the vascular supply to the posterior fossa may tend to decrease.…”

“…Arra'ez-Aybar et al reported that most of the PTAs originated from the posterior wall of the cavernous segment of the ICA (C4) and a small number of PTAs originated from the petrous segment [9]. The C4 segment is often reported as the origin of PTAs [9,[17][18][19][20][21]. Most of the PTA cases in the present study (85%) originated from the posterior wall of the cavernous segment (C4) of the ICA, and few (15%) originated from the petrous part.…”