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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 3  |  Page : 321-322

Brainstem transient ischemic attacks due to compression of pons from a persistent primitive trigeminal artery


Department of Neurology, Sawai Man Singh Medical College Hospital, Jaipur, Rajasthan, India

Date of Submission01-Jun-2013
Date of Decision01-Jun-2013
Date of Acceptance06-Jun-2013
Date of Web Publication16-Jul-2013

Correspondence Address:
Raghavendra Bakki Sannegowda
Department of Neurology, Sawai Man Singh Medical College Hospital, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.115087

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How to cite this article:
Sannegowda RB, Srivastava T, Jain RS, Mathur T, Jain R. Brainstem transient ischemic attacks due to compression of pons from a persistent primitive trigeminal artery. Neurol India 2013;61:321-2

How to cite this URL:
Sannegowda RB, Srivastava T, Jain RS, Mathur T, Jain R. Brainstem transient ischemic attacks due to compression of pons from a persistent primitive trigeminal artery. Neurol India [serial online] 2013 [cited 2019 Sep 19];61:321-2. Available from: http://www.neurologyindia.com/text.asp?2013/61/3/321/115087


Sir,

Persistent primitive trigeminal artery (PPTA) is the most common type of persistent carotid-basilar arterial anastomosis. [1] Most cases have been incidentally detected [1],[2] but can present with brainstem symptoms. [2] Possible mechanisms of brain-stem ischaemia are low perfusion pressure in the vertebrobasilar system and embolisation from the stenotic carotid lesions. [2] Hemodynamic factors and dysautoregulation could also play a part in the pathogenesis of vertebrobasilar territory ischaemic attacks. [3]

A 17-year old girl noted sudden onset numbness of right side of her face and left hand for 15 min. Two months later she had a similar episode; this time it was associated with difficulty in walking, slipping of footwear from left foot which lasted for 45 min. On admission, neurological examination was essentially normal. Blood biochemistry and complete blood picture were normal. Brain magnetic resonance imaging (MRI) revealed indentation of the right ventral pons by an anomalous vessel [Figure 1]a. Magnetic resonance angiography (MRA) showed right PPTA (Saltzman type 1) with hypoplastic ipsilateral vertebral artery and basilar artery below PPTA [Figure 1]b and c. The postrerior communicating arteries were absent bilaterally. The posterior fossa circulation was almost independent from circle of Willis. Cerebral digital subtraction angiography (DSA) and therapeutic interventions were refused by the patient's relatives. She was treated with clopidogrel plus aspirin. She did not suffer from any transient ischemic attacks (TIAs) or stroke at 3-months follow-up.
Figure 1: (a) Brain MRI shows indentation of the right ventral pons by the right persistent primitive trigeminal artery. (b and c) MR angiography shows right persistent primitive trigeminal artery

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The documented incidental frequency of PPTA in cerebral angiograms was 0.02-0.6% of all cerebral angiograms. [4] It arises from the cavernous internal carotid artery near the posterior genu in the region where it leaves the carotid canal and enters the cavernous sinus to reach the basilar artery. Several anatomic variants of PPTA have been described. [1],[4] In Saltzman type I variant, the PPTA supplies the entire vertbrobasilar system distal to the anastomosis (both posterior cerebral arteries and superior cerebellar artery). Basilar artery proximal to the anastomosis is usually hypoplastic. Posterior communicating arteries are often absent. PPTA joins the basilar artery between the superior cerebellar artery and the anterior inferior cerebellar artery. In Saltzman type II variant, PPTA fills the superior cerebellar artery, but the posterior cerebral arteries are supplied via the patent posterior communicating arteries, and type III is a combination of both. [1],[4],[5] Numerous variations on these common patterns have also been described. [6]

PPTA may present with brainstem infarction, [2] trigeminal neuralgia, [7] and weber's syndrome. [8] PPTA may also present with TIAs in the distribution of the posterior fossa in cases of stenosis and ulcerative plaques at the carotid bifurcation. [9] Vertebrobasilar insufficiency in PPTA due to compression of brainstem has been sparingly reported. There is only one case in literature documenting compression of the pons by PPTA leading to recurrent, transient cerebellar ataxia. [10] We presume that brainstem TIAs in our patient probably were due to compression of the ventral lower pons by PPTA. We conclude that direct compression of the pons should be considered as one of the possible mechanism of symptom manifestation in PPTA along with other hemodynamic factors.

 
  References Top

1.Breutman ME, Fields WS. Persistent hypoglossal artery. Arch Neurol 1963;8:369-72.  Back to cited text no. 1
    
2.Okada Y, Shima T, Nishida M, Yamada T, Yamane K, Okita S, et al. Bilateral persistent trigeminal arteries presenting with brain-stem infarction. Neuroradiology 1992;34:283-6.  Back to cited text no. 2
[PUBMED]    
3.Naritomi H, Sakai F, Meyer IS. Pathogenesis of transient ischemic attacks within the vertebrobasilar arterial system. Arch Neurol 1979;36:121-28.  Back to cited text no. 3
    
4.Mckenzie JD, Dean BL, Flom RA. Trigeminal-cavernous fistula: Saltzman anatomy revisited. AJNR Am J Neuroradiol 1996;17:280-2.  Back to cited text no. 4
[PUBMED]    
5.Saltzman GF. Patent primitive trigeminal artery studied by cerebral angiography. Acta Radial 1959;51:329-36.  Back to cited text no. 5
    
6.Ohshiro S, Inoue T, Hamada Y, Matsuno H. Branches of the persistent primitive trigeminal artery: An autopsy case. Neurosurgery 1993;32:144-8.  Back to cited text no. 6
[PUBMED]    
7.De Bondt BJ, Stokroos R, Casselman J. Persistent trigeminal artery associated with trigeminal neuralgia: Hypothesis of neurovascular compression. Neuroradiology 2007;49:23-6.  Back to cited text no. 7
[PUBMED]    
8.Shioya H, Kikuchi K, Suda Y, Shindo K. Persistent primitive trigeminal artery presenting with Weber's syndrome: Report of a case with three-dimensional CT angiographic evaluations. No To Shinkei 2000;52:315-9.  Back to cited text no. 8
[PUBMED]    
9.Stern J, Correll JW, Bryan N. Persistent hypoglossal artery and persistent trigeminal artery presenting with posterior fossa transient ischemic attacks. Report of two cases. J Neurosurg 1978;49:614-9.  Back to cited text no. 9
[PUBMED]    
10.Yaginuma M, Miyake HA. Case of repetitive cerebellar ataxia with persistent primitive trigeminal artery. No To Shinkei 1997;49:343-7.  Back to cited text no. 10
    


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This article has been cited by
1 Acute Ischemic Stroke Involving Both Anterior and Posterior Circulation Treated by Endovascular Revascularization for Acute Basilar Artery Occlusion via Persistent Primitive Trigeminal Artery
Taichiro Imahori,Atsushi Fujita,Kohkichi Hosoda,Eiji Kohmura
Journal of Korean Neurosurgical Society. 2016; 59(4): 400
[Pubmed] | [DOI]



 

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