Endovascular treatment of a ruptured aneurysm arising from the proximal end of a partial vertebrobasilar duplication with a contralateral prominent persistent primitive hypoglossal artery: illustrative case

BACKGROUND Ruptured aneurysms associated with a partial vertebrobasilar duplication or a persistent primitive hypoglossal artery (PPHA) have been reported. Only rarely has endovascular treatment of ruptured aneurysms in association with both vascular variations been reported. OBSERVATIONS A 66-year-old woman experienced the sudden onset of a severe headache caused by a subarachnoid hemorrhage. Cerebral angiograms demonstrated a prominent PPHA originating from the left internal carotid artery at the C2 vertebral level and a partial vertebrobasilar duplication between the hypoplastic right vertebral artery and proximal basilar artery with a small aneurysm at the proximal end of the duplication from where the anterior spinal artery originated. The left vertebral artery was aplastic. A microcatheter was introduced into the aneurysm via the PPHA under the control of high blood flow, using a balloon-assisted technique. The aneurysm was completely obliterated with a coil. Although small cerebellar and cerebral infarcts developed during the procedure, the patient was discharged without neurological symptoms. LESSONS To avoid serious neurological complications, precise analysis of the complex vascular anatomy, including the anterior spinal artery and hemodynamics, is clinically important for endovascular therapy of cerebral aneurysms in patients with an association between a partial vertebrobasilar duplication and a PPHA.

Case Report: Persistent Primitive Hypoglossal Artery Accompanied by a Basilar Bifurcation Aneurysm Treated by Y-Stent-Assisted Coil Embolization

Successful embolization of a basilar bifurcation aneurysm associated with a persistent primitive hypoglossal artery (PPHA) using Y-stent-assisted coiling.

Endovascular management of dissecting posterior cerebral artery aneurysm associated with persistent hypoglossal artery: A case report

Persistent embryological connections between the anterior and posterior circulations are rare entities. Persistent hypoglossal artery is the second most common persistent carotid-basilar anastomosis. As it is often associated with hypoplasia of vertebral arteries, it poses a challenge during endovascular interventions. We present a case of a 32-year-old woman who presented with occipital headache of four weeks’ duration. Magnetic Resonance Angiography showed hypoplastic vertebral arteries with a persistent hypoglossal artery arising from the cervical segment of the left internal carotid artery and supplying the entire posterior circulation, associated with a dissecting aneurysm of the right posterior cerebral artery. Endovascular parent vessel occlusion was performed for the dissecting posterior cerebral artery aneurysm by navigating the guide catheter, microwire, and microcatheter through the persistent hypoglossal artery because the vertebral arteries were hypoplastic. Post-intervention, the patient did not develop any neurological deficit and was discharged in a stable condition.

Symptomatic internal carotid artery stenosis in the presence of a persistent primary hypoglossal artery

Objectives Anatomic variations of the extracranial carotid artery are rare. Persistent primitive hypoglossal artery appears with a reported incidence between 0.03% and 0.2%. We report a case of recurrent transient ischemic attacks originating from proximal internal carotid artery stenosis associated with ipsilateral persistent primitive hypoglossal artery and give a review of the existing literature. Methods A 78-year-old patient with a medical history of two previous transient ischemic attacks consulted our emergency department with an acute left hemispheric stroke. Intravenous thrombolysis permitted complete resolution of symptoms. Concurrent Computed Tomography (CT) and Magnetic Resonance (MR) angiography revealed an unstable plaque causing 50% stenosis of the left internal carotid artery with a persistent primitive hypoglossal artery dominantly perfusing the posterior circulation, and bilateral hypoplastic vertebral arteries. Results Uneventful carotid artery stenting using a proximal protection device was performed, and the patient was discharged after 12 days. Six months follow-up was uneventful with a patent stent in the internal carotid artery. Conclusions Treatment of symptomatic carotid artery stenosis in the presence of persistent primitive hypoglossal artery is challenging. Management should be driven by patients’ co-morbidities, the anatomical localization of the lesions and local expertise. In the case of a high origin of the persistent primary hypoglossal artery, carotid artery stenting with the use of a proximal cerebral protection device is probably the preferred and simplest approach.