Persistent carotid-vertebrobasilar anastomoses: How and why differentiating them?

doi:10.1016/S0150-9861(04)97022-8

Journal of Neuroradiology

Volume 31, Issue 5, December 2004, Pages 391-396

https://doi.org/10.1016/S0150-9861(04)97022-8 Get rights and content

Summary

The persistent carotid-vertebrobasilar anastomoses (PCVBA) can be explained by an interruption of the vertebrobasilar system (VBS) embryogenesis. We present two very rare cases of persistent anastomoses: a hypoglossal artery and a type I proatlantal artery, insisting on the angiographic criteria allowing differentiation.

After a brief review of the embryogenesis of the VBS, we describe the different types of persistent anastomoses (hypoglossal, type I and II proatlantal, trigeminal and otic arteries). We will insist on the potential risks, not well-known, but typical of each anastomosis. PCVBA usually are incidental findings but imaging follow-up may be required since aneurysms may develop.

Résumé

Les anastomoses carotido-vertébrales ou basilaires persistantes (ACVBP) s’expliquent par une interruption de l’embryogénèse du système vertébro-basilaire (SVB). Nous présentons deux cas très rares d’anastomose persistante: une artère hypoglosse et une artère pro-atantale de type I en insistant sur les critères angiographiques permettant de les différencier.

Après un rappel sur l’embryogénèse du SVB, nous décrivons les différents types d’anastomoses persistantes (artères hypoglosse, pro-atlantales type I et II, trigéminée et acoustique). Nous insistons sur leur potentiel pathogène, souvent méconnu, mais spécifique à chaque anastomose. De découverte le plus souvent fortuite, ces ACVBP justifieraient une surveillance radiologique en raison d’une évolution anévrysmale possible.

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Cited by (39)

Fatal Subarachnoid Hemorrhage from an Aneurysm of a Persistent Primitive Hypoglossal Artery: Case Series and Literature Overview
2018, World Neurosurgery
Persistent carotid–basilar connections have a prevalence of 0.14%. Recognizing such persistent fetal anastomoses between the carotid and the vertebrobasilar circulation is of great importance because they are reportedly associated with an increased prevalence of intracranial aneurysms.
We report the case of a 15-year-old female patient who presented with a World Federation of Neurosurgical Societies grade 5 subarachnoid hemorrhage from an aneurysm at the junction of a persistent primitive hypoglossal artery and the posterior inferior cerebellar artery origin. Supratentorially, unfortunately, there was no parenchymal blush or cortical venous return. Eventually, a multidisciplinary decision was made to withdraw care.
Fifty-seven cases were reported in the literature to date of persistent hypoglossal arteries, 16 of which presented with an associated aneurysm, 5 with an arteriovenous malformation, and 6 with a subarachnoid hemorrhage. Our case is the youngest patient reported so far. Hypoplasia or aplasia of the vertebral artery often were encountered (36 and 13 cases, respectively), as well as carotid artery stenosis (15 cases).
Although uncommon, it is important to recognize persistent carotid-basilar connections, since they have a considerable hemodynamic impact on the posterior cerebral circulation via the carotid system. A critical reduction in the carotid blood flow will, therefore, have ischemic consequences in the posterior cerebral territories. In addition, such connections might be associated with anomalies of the vessel wall and be predisposed to aneurysm formation. The endovascular neurointerventionalist, as well as the vascular and skull base neurosurgeon, need to be aware of their anatomy and variations.
Detection of Anomalous Cervical Internal Carotid Artery Branches by Colour Duplex Ultrasound
2017, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
The potential clinical implications of an ICA branch readily detectable on CDU, are documented in Table 3 and highlight that although rare, Kolbinger et al.'s31 case report and review of the literature found that there is a surprising association between a persistent proatlantal artery ICA branch and a 59% increase in intracranial cerebrovascular abnormalities including a 10% risk of having an intracranial aneurysm. Further studies support a theory that the persistence of carotid vertebrobasilar anastomoses is pathological and have an increased risk of cerebral aneurysms or compressive disorders.31,39–42 Although, Cloft et al.43 claim that the prevalence of cerebral aneurysms in this subset is no different from the general population and the associations are based solely on case reports and thus may be coincidental.
Conventional anatomical descriptions of the cervical internal carotid artery (ICA) report that no branches arise from this segment. However reports of ICA branches exist. The study aim was to determine the prevalence of anomalous branches of the ICA using colour duplex ultrasound (CDU).
Four hundred consecutive patients (800 carotid vessels) referred to a tertiary hospital vascular laboratory for investigation of carotid disease were included. A clear differentiation of a low resistive ICA and a high resistive external carotid artery (ECA) waveform was required. CDU was performed on a Philips IU22 ultrasound system with a 9–3 MHz linear array transducer employing a standard carotid imaging protocol. The origin of each ICA branch was identified using B-mode and CDU. Anatomical orientation of ICA branches and distance from bifurcation was recorded and spectral CDU analysis was performed.
Twenty ICA branches, tracking cephaladly, were detected in 16 patients (4%), or 2.5% (20/800) vessels. The median age was 73 years; 50% were female and 50% male. All patients demonstrated a single branch [unilateral anomaly (n = 12 patients), bilateral anomaly (n = 4) patients]. Eighty-five percent arose from the posterior wall of the ICA. The median distance from ICA bifurcation was 4 mm (range 0–18 mm). ICA branch diameters ranged from 1.2 mm to 2.4 mm (median 1.4 mm, mean 1.6 mm). Eighty percent of ICA branches had less than 50% stenosis. Spectral analysis revealed high resistive waveforms in all branches.
Branches from the ICA exist and can be characterised with CDU. Prevalence in a tertiary hospital referral cohort is 4%. Given their potential clinical implications, standard carotid imaging protocols should consider routine assessment and reporting of ICA branches.
Hypoglossal artery associated with homolateral internal carotid artery dissection
2011, Journal of Neuroradiology
Persistent trigeminal artery feeding a hemispheric branch of the posterior inferior cerebellar artery: A rare anatomic variant
2011, Journal of Neuroradiology
Citation Excerpt :
Occasionally, they may persist in adulthood. PTA is the most common carotid-basilar anastomosis, representing 85% of these primitive persistent anastomoses [1]. Usually, it originates from the ICA after its exit from the carotid canal and joins the upper third of basilar artery.
Persistent trigeminal artery is a rare persistent carotid-basilar anastomosis that usually connect the infracavernous segment of the ICA with the basilar artery. Rarely, PTA may feed cerebellar artery. We describe an exceptional case of PTA terminating in postero-inferior cerebellar artery (PICA) hemispheric branch. Angiographic and CTA features are presented and hypotheses regarding developmental origin of this variation are discussed.
Diagnosis and surgical management of extracranial PICA aneurysms presenting through subarachnoid haemorrhage: Case report and review of the literature
2009, Clinical Neurology and Neurosurgery
Citation Excerpt :
For further reference to the anatomy of the PICA's course we would refer to the excellent study of Lister et al. [24]. The variations of PICA origin have been explained with the persistence of different branches of the vertebrobasilar embryonic plexus or of the anastomotic channels connecting the vertebral system to the carotid system (trigeminal, otic, hypoglossal and proatlantal arteries) [33,34]. Aneurysms of the PICA are most common at their origin or just distal thereof and account for approximately 1% of all cerebral vasculature aneurysms [6–9].
We present a very unusual case in which a proximal posterior inferior cerebellar artery (PICA) aneurysm was located extracranially. We reviewed the PICA origin anatomy and pathology of aneurysms at this site.
A Caucasian woman, 52 years of age, presented with a lesion at the craniocervical junction. She complained only of headache off and on without other symptoms. Her physical examination was unremarkable. A CT angiography clearly visualized an approximately 9-mm wide aneurysm of the right PICA which lay intradurally in the spinal canal at the C₁-level. Surgery was planned. However, six weeks after her initial referral and just before her surgical date, the patient suffered a subarachnoid haemorrhage. Physical examination at that time showed a lethargic but conscious patient, with slight disorientation (Glasgow Coma Score 14; Hunt and Hess grade III).
The aneurysm was successfully treated by microneurosurgical techniques via a suboccipital craniotomy with laminectomy of C₁ as well. Temporary clipping of the PICA was feasible and the aneurysm could be dissected and clipped appropriately.
The present report underscores the anatomical variants of the PICA. Although uncommon, PICA aneurysms do occur and caretakers should be aware of this when treating patients with clinical signs or CT evidence of subarachnoid haemorrhage. Even extracranial PICA aneurysms can be encountered, either through a caudal loop or an early extracranial lateral medullary segment. We stress the use of four vessel angiography or CT angiography with thin cuts to rule out such aneurysms.
Posterior fossa transient ischemic attack in the setting of bilateral persistent hypoglossal arteries: A case report and literature review
2021, Medicine (United States)

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Original articlePersistent carotid-vertebrobasilar anastomoses: How and why differentiating them?Les anastomoses carotido-vertébrales ou basilaires persistantes. Comment et pourquoi les différencier?

Summary

Résumé

Ann Vasc Surg

J Neurol Sci

J Vasc Surg

Ann Chir Vasc

Unilateral hypoglossal nerve palsy due to aneurysm of the stump of persistent hypoglossal artery

J Neurol Neurosurg Psychiatry

Rare carotid-vertebrobasilar anastomoses with notes on the differentiation between proatlantal and hypoglossal arteries

Neuroradiology

Persistent primitive proatlantal intersegmental artery (proatlantal artery I) results in “top of the basilar” syndrome

Stroke

Eine seltene arterieanomalie (ursprung der a. basilaris aus des a. carotis internal)

Anat Anz

Intracranial aneurysm on a persistent primitive trigeminal artery

J Neurosurg

Zwei seltene varietäten der stamme des Stamme des aortenbogens

Arch Anat Entwickl Gesch

Anomalies congénitales des artères à destinée cérébrale

Persistant proatlantal artery

J Neurol Neurosurg Psychiatry

Trigeminal neuralgia, facial spasm intermedius and glossopharyngeal neuralgia with persistent carotid basilar anastomosis

J Neurosurg

Persistent primitive hypoglossal artery aneurysm – case report

No Shinkei Geka

The pharyngo-occipital system

Original article
Persistent carotid-vertebrobasilar anastomoses: How and why differentiating them?Les anastomoses carotido-vertébrales ou basilaires persistantes. Comment et pourquoi les différencier?