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Angiography of left internal carotid artery showed a caudad left PTA and the trigeminal artery to cavernoussinus fistula. The left fetal-type PCA is also noted. The superimposition of the caudad PTA and the precavernous internal-carotid artery led to an initial incorrect impression of an indirect carotid-cavernous sinus fistula.
Source publication
A 59-year-old man who denied a history of trauma presented with left pulsatile tinnitus and left orbital swelling for six months. Digital subtraction angiography showed a left persistent trigeminal artery (PTA) with a trigeminal artery to cavernous sinus (trigeminal-cavernous sinus) fistula and a right PTA. Transarterial detachable coil embolizatio...
Contexts in source publication
Context 1
... also exist of PTAs originating from the precavernous ICA, approximately 1.5 cm below the carotid siphon 17 . Other authors have described PTAs originating from the supracli- noid internal carotid artery 17,27 . The left PTA in our patient was particularly caudad because it originated from between the lacerum and petrous segments of the left ICA ( Figure 2). An anomalous branch emerging from the petrous ICA may be a persistent otic artery. However, this was excluded in our patient because the ar- terial branch followed the trigeminal nerve, rather than passing through the internal audi- tory canal [18][19][20] . Moreover, an anomalous ...
Context 2
... months later, the patient presented to our hospital. DSA imaging demonstrated that a right PTA originated from the cavernous seg- ment of the right internal carotid artery (ICA), forming an anastomosis with the mid-basilar artery (Figure 1). Bilateral fetal-type posterior- cerebral arteries (PCAs) were also noted (Fig- ures 1 and 2), suggesting that the right PTA was Saltzman type 2 11 . An anomalous arterial branch emerged between the lacerum and petrous segments of the left ICA, which coursed upward along the left ICA, and connected to the left cavernous sinus, forming a fistula (Fig- ure ...
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Citations
... Davis rst reported the coexistence of a persistent primitive trigeminal artery (PPTA) and an intracranial aneurysm (IA) in 1956 [14] . Cerebral angiography studies indicate that unilateral PPTA aneurysms occur in approximately 0.1% to 0.6% of cases [2] , and bilateral cases are exceedingly uncommon [15] . In an 18-year review of the literature, Cloft found that the prevalence of IA was around 3% among 34 PPTA cases, comparable to the 3.7% in the general population [7] . ...
Background and Importance: Persistent primitive trigeminal artery aneurysms are clinically rare, especially with carotid cavernous fistula caused by their rupture. At present, endovascular treatment is of choice for carotid cavernous fistula, including by detachable balloon / coil, coil combined with Onyx glue, covered stent and so on. We cured a patient harbored carotid cavernous fistula caused by a ruptured primitive trigeminal artery aneurysm by detachable coil combined with endovascular electrothrombosis with a good result.
Clinical Presentation: The patient was admitted with a history of head trauma over two months ago and had experienced right eye protrusion for the past three weeks. Physical examination revealed protrusion of the right eye, along with conjunctival congestion and swelling. Digital subtraction angiography (DSA) confirmed a diagnosis of an incomplete Cavernous Carotid Fistula (CCF) on the right side, associated with a Persistent Primitive Trigeminal Artery (PPTA) on the same side. We cured by a ruptured primitive trigeminal artery aneurysm by detachable coil combined with endovascular electrothrombosis with a good result. It effectively avoided the mass effect associated with excessive coil filling and mitigated the risk of unintended embolization.
Conclusion: The combination of mechanical detachable bare metal coil embolization and electrocoagulation presents a novel and innovative approach for addressing CCF resulting from a ruptured PPTA aneurysm. This approach brings several notable advantages, including cost-effectiveness, reduced mass effect from embolic materials, and avoidance of potential complications associated with the use of medical glue for embolization.
... In fact, most types have been published in the literature as case reports. In a recent large-scale study conducted with DSA, MRA or CTA, the incidence of PTA was in the range between 0.2 and 0.76% [1,2,11,12,14,15]. ...
... Though the overall incidence of the PTA is low, it occurs mostly on one side, usually on the left one [1,2,5,11]. Bilateral presence of PTA is an extremely rare condition [12]. ...
... The posterior communicating arteries are absent or poorly opacified. Also, the entire basilar artery system distal to the anastomosis is filled through PTA which becomes the main supply to the distal BA, PCA, and SCA territories [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16]. ...
Persistent trigeminal artery is the most common primitive carotid basilar anastomosis that persists in adulthood. The overall incidence of persistent trigeminal artery is between 0.2 to 0.76%. PTA are known to be associated with a wide range of pathology. The aim of this study was to describe the morphological characteristics of the PTA and to emphasize its clinical significance. We examined radiographs from patients who had CT angiography undertaken for a variety of clinical reasons, performed as a part of their medical treatment at the University Institute for Radiology in Skopje, RN Macedonia. The study population included 234 patients, 130 male and 104 females, mean age 57.8 years. In one patient we found PTA with overall incidence of 0.42%. CTA revealed a left PTA that arise from the internal carotid artery and communicate with the basilar artery between the origin of the anterior inferior cerebellar artery and the superior cerebellar artery. Although anatomically interesting, an awareness of the anatomy and variations of the brain arteries is clinically important for radiologists and surgeons for save performance of procedures, and forensic pathologists since variants may have forensic consequences. Key words: anatomy, persistent trigeminal artery, computed tomography.
... Thus, this case turned out to be a unilateral PPTA causing bilateral ophthalmic findings with late onset of the ipsilateral abnormality. Chen et al described a case with bilateral PPTA, but only one fistula was identified (2). In addition, Demartini reported a patient suffering from traumatic unilateral CCF with contralateral ophthalmic manifestations (3). ...
... Both contralateral (4) and bilateral (5) findings have been described in association with direct CCF from ICA injury. Similarly, there are prior case reports of traumatic CCF with PPTA involvement (6) and ipsilateral orbital bruit (1) as well as spontaneous CCFs associated with PPTA inducing the manifestations of the ipsilateral side (7,8). However, this patient seems to be the first reported case to have a CCF fed by PPTA on one side causing ophthalmic manifestations solely on the contralateral side. ...
A 41-year-old woman developed binocular diplopia and redness of her right eye after a motorcycle accident. She was diagnosed with a left carotid cavernous fistula causing contralateral manifestations through intercavernous sinus venous connections related to ruptured persistent primitive trigeminal artery. She underwent a coil embolization pro- cedure to fix the fistula. Her ophthalmic manifestations improved after the intervention. This case serves as a reminder of the complex anatomy of venous drainage path- ways at the skull base and the potential for traumatic lesions
to cause contralateral or even bilateral symptoms.
... Due to its anatomical proximity to the trigeminal nerve, there have been some case reports on its association with trigeminal neuralgia. Similarly, there are also some reports on the associations between the PTA with intracranial aneurysms and carvernous sinus fistulas [2,3]. Moreover it is rarely reported in the setting of acute ischemia stroke, especially with the internal carotid artery (ICA) occlusion. ...
Background:
Almost all case reports related to persistent trigeminal artery indicated that the existence of persistent trigeminal artery may increase the risk of ischemic stroke. However our case demonstrated that the persistent trigeminal artery may also play a protective role in preventing severe ischemic stroke by functioning as collateral circulation.
Case presentation:
We reported a patient with left internal carotid artery occlusion with persistent trigeminal artery manifesting only as a minor acute ischemia stroke exhibiting acute onset of dizziness and difficulty in walking. Brain MRI showed two small areas of restricted diffusion on diffusion-weighted imaging in the left hemisphere. The digital subtraction angiography showed his left middle cerebral artery and bilateral anterior cerebral artery were supplied by the basilar artery via a persistent trigeminal artery. Furthermore, CT perfusion showed no remarkable difference between the two hemispheres.
Conclusions:
Persistent trigeminal artery may have a protective role in the setting of an acquired occlusion of homolateral internal carotid artery. Therefore, it is important to fully assess the presence of the persistent trigeminal artery in acute ischemic stroke.
... Angiographic anatomy and classification of the PPTA in two types, as cited (16), was given by Saltzman almost sixty years before. In Saltzman type 1 PPTA, the BA proximal to the junction with the PPTA may be hypoplastic, and the bilateral PCoAs may be absent; the junction of Saltzman type 2 PPTA with the BA is below the origin of the SCA, and the PCA receives blood predominantly through the patent PCoAs, whereas the BA was completely filled by one or both VAs (1,16). The type 3 can have the junction above or below the SCA where the PPTA supplies the SCA and the contralateral PCA, while the PCoA supplies the ipsilateral PCA (5,16). ...
Simultaneous presence of the persistent primitive trigeminal artery and so-called intermediate communicating artery in a 77-years-old cadaver autopsied due to the myocardial infarction was discovered. Many vascular variants and abnormalities such as an aplasia of the right vertebral artery (VA), a presence of two right posterior cerebral arteries (PCAs), partial duplication of the right superior cerebellar artery, hypoplasia of the pre-communicating part (A1) of the right anterior cerebral artery and the right PCA of basilar origin, a special configuration of the anterior communicating artery (ACoA), and a small aneurysm at the right A1-ACoA junction were associated. The finding of an incipient cerebral aneurysm at the junction of the hypoplastic A1 and embryonal configuration of the ACoA in eight decade of life indicates that its development was caused by long-term pressure of blood flow at branching points of this artery independent from its caliber. However, it is not yet clear whether the persistence of the first and/or the second carotid-basilar anastomoses in this case was the condition for an aplasia of one VA or vice versa.
... PTA has an estimated prevalence of about 0.1-0.6 % (see Table 1), higher in females [5,16,20,29] although Uchino et al. [27] did not find statistically significant differences. Some cases of bilateral PTA have been reported [6] but its presence, according to the authors, is mostly unilateral, with right [5,16], left [20] or none-sided predominance [27,29,30]. PTA extends from the cavernous internal carotid artery (ICA) to the upper part of the basilar artery (BA) between the origin of the anterior inferior cerebellar artery (AICA) and the superior cerebellar artery (SCA) [28] and often perforates the dorsum sellae. ...
... In almost half of the cases published, PTA is found to be accompanied by other vascular anomalies that might suggest its presence [5] such as basilar hypoplasia, carotidcavernous fistulas or aneurysms. Nearly 25 % of the patients with PTA suffer from cerebrovascular diseases (CVD), being headache the most frequent symptom referred [1,6,28]. ...
... In about 25 % of the cases, PTA might be a major cause of CVD such as transient ischemic attack (TIA), brainstem ischemia, vertebrobasilar insufficiency, ICA occlusion and hemorrhagic events [1,7,10]. Hence, a prior recognition of the PTA and its directional flow must be taken into account in surgical procedures on the cavernous sinus or the posterior fossa because ''fetal type'' PTAs should be spared to prevent ischemia while ''adult type'' PTAs can be embolized [6,29]. Samra et al. [25] reported that spontaneous acute subarachnoid hemorrhage can occur without any other source of bleeding found. ...
Purpose:
The trigeminal artery is one of the four primitive anastomosis established between the internal carotid artery and the vertebrobasilar system that regresses at the sixth week of embryonic development. Its persistence in adult life (PTA) is usually found incidentally. The aim of this study is to determine its prevalence, main characteristics and clinical significance.
Methods:
A cross-sectional study was performed over the last 3 years, 2012-2014, to analyze images performed on conventional angiography, CT angiography and MR angiography of patients who attended the Neuroradiology Department of the Hospital Universitario Doce de Octubre in Madrid, Spain, to control their underlying pathology.
Results:
Nine cases of PTA were found (prevalence 0.37 %, two men, seven women; three right, six left; age range 13-88 years). Eight PTA emerged from the cavernous ICA and one from the petrous segment. Six cases were lateral or petrosal type and one was medial or sphenoidal type. The whole PTAs anastomosed the BA, six at the middle third and three at the distal third. Weon et al.'s type 3 was predominant. CVD incidence was 55.6 % and aneurysm incidence was 22 %.
Conclusions:
PTA prevalence was similar to those previously reported, being commonly left-sided, Salas et al.'s lateral or petrosal type, Weon et al.'s type 3 and with no gender predominance. CVD and aneurysms incidence in the presence of a PTA were higher than in general population. Its anatomical relations make it essential to consider its presence and directional blood flow when planning endovascular and neurosurgical treatments.
... 1,2 The advances in neuroimaging techniques have led to the increased detection of PPTA and prompted considerable research interest in its clinical significance. 3,4 Studies have shown that in approximately 25% of the cases, PPTA occurs in combination with other cerebrovascular lesions, such as aneurysms, 5 cavernous fistula, and arteriovenous malformation, 6,7 which are clinically manifested as trigeminal neuralgia, paralysis of the oculomotor nerve or abducens nerve, or palsy of the trochlear nerve. 2 These conditions can lead to compression of the brain stem and, eventually, cerebral ischemia. 8 The detection of the PTA is also important from the standpoint of the safety of surgical and interventional procedures performed on the affected population. ...
In this paper, we present 2 rare cases of persistent embryonic anastomoses. In one case, the patient presented with persistent trigeminal artery along with multiple foci of cerebral infarction as well as central retinal artery thrombosis. In the other case, the patient had direct anastomosis of the vertebral artery with ipsilateral external carotid artery as well as pontine infarction, aneurysm, and unilateral hypoplasia of the vertebral artery. The findings in these cases may shed light on the clinical presentation of such persistent anastomoses and aid their detection in clinical settings.
Background: The persistent trigeminal artery (PTA) is an adult carotid-basilar anastomosis with debated pathologic aspects, such as its association with brain aneurysms. True trigeminal artery aneurysms are rare vascular anomalies, reported in a few case reports.
Objective: To report our experience with a ruptured trigeminal artery aneurysm and to provide a systematic review of the literature in order to analyse potential links between the anatomic configuration of the PTA and PTA aneurysm (PTAA) type, and implications of each PTAA type for the diagnostic and therapeutic approach.
Methods: We reviewed the medical literature on trigeminal artery aneurysms according to the PRISMA guidelines. Population characteristics, aneurysms features, and PTA type and side were assessed.
Results: 40 previously published cases of PTAAs were included in the analysis. The mean age of subjects was 55 years, with a strong female predominance (77%). Four PTAAs were accidentally discovered, while 16 caused compressive symptoms and 20 were ruptured. Successful endovascular treatment was performed in 62% of cases.
Conclusions: PTAAs are rare vascular anomalies, underdiagnosed in the presence of a trigemino-cavernous fistula. Parent vessel occlusion seems to be the best therapeutic option for ruptured or symptomatic unruptured PTAAs in Saltzman type II and III PTAs. Patency of the parent vessel is the main target in Saltzman type I PTA.
Background:
Rupture of a persistent trigeminal artery associated with development of a cavernous sinus fistula in a traumatic setting is rare. They are typically treated with coil embolization of the cavernous sinus.
Case description:
We present the case of a 42-year-old woman who developed a direct cavernous carotid fistula after a motor-vehicle accident. Angiographic imaging revealed a rupture point of a persistent trigeminal artery as it connected with the cavernous segment of the internal carotid artery (ICA), causing a cavernous sinus fistula. Coiling of the cavernous sinus was abandoned after placement of one coil because of coil herniation into the ICA. A Pipeline embolization device (PED) was placed to oppose the coil against the intima and keep the lumen open. The combination of coil embolization and flow diversion acutely decreased the fistulous flow. Surprisingly, an angiographic follow-up at six month showed complete fistula occlusion despite placement of only one coil into the cavernous sinus.
Conclusions:
We report a rare case where undercoiling of the cavernous sinus occluded a cavernous-sinus fistula because of the adjunct use of a PED in the presence of a traumatic rupture of a persistent trigeminal artery.
