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Table of Contents    
NEUROIMAGES
Year : 2018  |  Volume : 66  |  Issue : 3  |  Page : 881-883

Persistent primitive trigeminal artery- a study of two cases


Department of Radiodiagnosis and Imaging, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

Date of Web Publication15-May-2018

Correspondence Address:
Dr. Musaib Ahmad Dar
Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar - 190 011, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.232285

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How to cite this article:
Dar MA, Shafi F, Suhail JM, Wani MA, Wani MY, Choh NA. Persistent primitive trigeminal artery- a study of two cases. Neurol India 2018;66:881-3

How to cite this URL:
Dar MA, Shafi F, Suhail JM, Wani MA, Wani MY, Choh NA. Persistent primitive trigeminal artery- a study of two cases. Neurol India [serial online] 2018 [cited 2018 May 20];66:881-3. Available from: http://www.neurologyindia.com/text.asp?2018/66/3/881/232285




Multiple foetal arterial anastomoses exist between the internal carotid artery (ICA) and the vertebro-basilar system during the early stages of embryogenesis. These anastomoses include the persistence of the trigeminal, otic, hypoglossal or proatlantal arteries between the two systems of circulation. All these primitive arterial connections regress and then disappear when definitive cerebral circulation forms. One or more of these anastomoses may persist in postnatal life and may result in one of the many insignificant variations in the cerebral circulation. These arterial anastomoses are most often found incidentally during cerebrovascular imaging done for unrelated causes. Out of these, the persistence of the trigeminal artery is the most common variation and is seen in 0.1-1% of the healthy population.[1-6]

Case 1

A 34-year old male patient was referred to our clinic for the evaluation of chronic headache from the last 2 years. The patient had a normal neurological, ophthalmological and otorhinolaryngological examination.

The computed tomographic (CT) examination was performed on a 64-slice CT scanner (Siemens Healthcare, Germany). The non-contrast CT (NCCT) scan of the head did not reveal any abnormality. On computed tomographic angiogram (CTA), there was a definite vascular connection (the presence of a persistent trigeminal artery) [Figure 1]a, [Figure 1]b, [Figure 1]c between the cavernous segment of the left ICA and the basilar artery. The basilar artery proximal to this vascular connection was hypoplastic. The left PCA also had a fetal origin from the posterior communicating artery.
Figure 1: (a) Axial CT angiogram brain showing the persistent vascular connection between cavernous part of left ICA and basilar artery, consistent with persistent trigeminal artery (arrow). (b) Coronal CT angiogram brain showing the persistent vascular connection between cavernous part of left ICA and basilar artery, consistent with persistent trigeminal artery (arrow). (c) Sagittal CT angiogram brain showing a persistent vascular connection between cavernous part of left ICA and basilar artery, consistent with persistent trigeminal artery (arrow)

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Based on the CTA examination and the clinical symptoms, it was concluded that the patient may have had headache due to the persistent trigeminal artery. Currently, the patient is taking non-steroidal anti-inflammatory druds (NSAIDS) intermittently for his headache.

Case 2

A 23-year old male patient was referred to our clinic with ataxia, vertigo and dizziness for the last 1 month. The patient had a normal otological examination.

The MRI examination was performed on a 1.5 Tesla magnetic resonance imaging (MRI) scanner (Magneton Avanton Siemens). On MRI, no abnormality was detected. However, on post-contrast T1 weighted and time of flight images, there was a vascular connection between the cavernous part of ICA and the basilar artery [Figure 2]a and [Figure 2]b. The basilar artery proximal to this vascular connection was hypoplastic. Sagittal magnetic resonance imaging (MRA) showed the characteristic Tau sign [Figure 3].
Figure 2: (a) Post contrast T1W MR image showing the persistent trigeminal artery (arrow). (b) MR TOF images showing the persistent trigeminal artery (arrow)

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Figure 3: Sagittal MRA showing the classical Tau sign (arrow)

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As all other causes of tinnitus were ruled out, it is possible that the tinnitus that the patient was having was probably attributable to this persistent abnormal vascular connection.

In the majority of cases, persistent trigeminal artery is an incidental finding; however, it is often implicated as a rare cause of various neurological symptoms like headache, tinnitus, ataxia or vertigo. The etiology of vertebrobasilar insufficiency may occasionally be the embolism from the ICA to the posterior circulation via the persistent trigeminal artery.

Based upon its configuration, a persistent trigeminal artery has been classified into 2 types by Saltzman:[4]

Type I: The persistent trigeminal artery reconstitutes the distal basilar artery while the proximal basilar artery is usually hypoplastic, and the ipsilateral posterior communicating artery is absent.

Type II: The persistent trigeminal artery is supplying the superior cerebellar artery, and ipsilateral posterior cerebral artery has an origin from the posterior communicating artery.

In conclusion, we present two cases of trigeminal artery with different symptomology. Both of them can be classified as Saltmanz's Type II persistent trigeminal artery. Thus, a persistent trigeminal artery can be associated with a myriad of neurological symptoms; the course of this persistent artery should be well delineated before undertaking any surgical intervention around this area; and, embolism from the carotid artery can involve the posterior cerebral circulation in patients with a persistent trigeminal artery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
O'Uchi E, O'Uchi T. Persistent primitive trigeminal arteries (PTA) and its variants (PTAV): Analysis of 103 cases detected in 16,415 cases of MRA over 3 years. Neuroradiology 2010;52:1111-19.   Back to cited text no. 1
    
2.
Quain, R. The anatomy of the arteries of the human body and its applications to pathology and operative surgery, with a series of lithographic drawings, London: Taylor and Walton, 1844, pp. 510-1.   Back to cited text no. 2
    
3.
Sutton, D. Anomalous carotid-basilar anastomosis. Br J Radiol 1950; 23:617-61.   Back to cited text no. 3
    
4.
Saltzman, G. Patent primitive trigeminal artery studied by cerebral angiography. Acta Radiol 1959;51:329-36.   Back to cited text no. 4
    
5.
Weon, YC, Choi, SH, Hwang, JC. Classification of persistent primitive trigeminal artery (PPTA): A reconsideration based on MRA. Acta Radiol 2011;52:1043-151.  Back to cited text no. 5
    
6.
Azab, W, Delashaw, J, Mohammed, M. Persistent primitive trigeminal artery: A review. Turk Neurosurg 2012;22:399-406.  Back to cited text no. 6
    


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