The Neuroradiology Journal 21: 401-405, 2008
www. centauro. it
Persistent Trigeminal Artery with Bilateral Ophthalmoplegia and Contralateral Internal Carotid Artery Occlusion A Case Report S. PURKAYASTHA Department Imaging Sciences and Interventional Radiologo, AMRI Hospital; Kolkata, India
Key words: PTA, ophthalmoplegia, carotid occlusion
SUMMARY – The most frequent persistent embryonic communication between the vertebrobasilar and carotid systems in adult life is a persistent trigeminal artery (PTA). Several anatomic variants of PTA have been described. The other associations of PTA mainly include aneurysm and vascular steal phenomena between basilar and carotid systems. We describe an interesting case of PTA with bilateral ophthalmoplegia and contralateral occlusion of the internal carotid artery.
Case Report
Discussion
This 52-year-old man presented with coronary symptoms. He had one episode of vertigo and on examination he showed bilateral ophthalmoplegia. He was then subjected to MRA examination which revealed left sided PTA arising from the posterolateral aspect of left ICA and joining the basilar artery just proximal to the superior cerebellar artery. Left posterior communicating artery was also visualized. Right ICA was not seen (figure 1). CT scan disclosed a bony carotid canal (figure 2). Digital subtraction angiogram confirmed left sided PTA (figure 3). Atherosclerotic complete occlusion of the right ICA noted. Right external carotid artery faintly filled the right carotid siphon via retrograde circulation through the ophthalmic artery (figure 4). Thin atherosclerotic plaque was noted at the origin of the left ICA. Vertebral injection also showed opacification of whole basilar artery (figure 5).
During fetal development (approximately 35 gestational days) the craniocerebral circulation is characterized by temporary connections between the primitive carotid and the paired dorsal longitudinal neural arteries (precursors of the vertebrobasilar system). They include trigeminal, otic, hypoglossal and proatlantic intersegmental arteries. Normal embryonic development underwrites the regression of all these vessels totally. PTA is the most frequent persistent communication of these primitive carotid-basilar anastomoses 2,3. Several anatomic variants of PTA have been described. The other associations of PTA mainly include aneurysm and vascular steal phenomena between basilar and carotid systems 2. Congenital absence and acquired occlusion of the internal carotid artery associated with PTA are rare: a Pubmed search revealed only three reports of such association 4,5,6. Ohta et Al reported 401
Persistent Trigeminal Artery with Bilateral Ophthalmoplegia and Contralateral Internal Carotid Artery Occlusion
A
S. Purkayastha
B
↑
Figure 1 A,B MR angiogram shows persistent trigeminal artery on left side. The artery takes its origin from the posterolateral aspect of the left internal carotid artery (ICA) and joins the basilar artery proximal to superior cerebellar artery. Right ICA is not visualized.
←
Figure 2 CT scan bone window shows persistent bilateral carotid canal.
↓
Figure 3 A) Anteroposterior and B) lateral views of left carotid artery injection show the trigeminal artery arising from the junction of lateral and cavernous segments of the ICA and joining the basilar artery just proximal to the superior cerebellar artery.
A
402
B
www. centauro. it
The Neuroradiology Journal 21: 401-405, 2008
A
B
C
D
Figure 4 A,B) Right common carotid artery injection shows complete occlusion of right ICA. C,D) Right external carotid artery shows filling of the right ICA siphon through retrograde flow through the ophthalmic artery.
an extremely rare case of PTA associated with multiple cerebral aneurysms and a contralateral occluded IC 5. Ophthalmoplegia associated cranial nerve palsy is also described with PTA 7,8 . The PTA can take either a lateral or medial course regarding its relationship with the abducens nerve. When the PTA originates from the posterolateral aspect of the posterior bend of the cavernous carotid artery (C4 segment),
it crosses underneath and distorts the abducens nerve, continuing between the abducens and trigeminal nerves. When taking a medial course, the PTA arises from the posteromedial aspect of the posterior bend of the cavernous carotid at the same segment and pierces the clival dura at the dorsum sellae. Cranial nerve displacement or distortion are less likely in this variation. 403
Persistent Trigeminal Artery with Bilateral Ophthalmoplegia and Contralateral Internal Carotid Artery Occlusion
A
B
C
D
S. Purkayastha
Figure 5 A.B) Right vertebral artery shows complete opacification of the basilar artery. C,D) Left vertebral artery predominantly ends in posterior inferior cerebellar artery, however minimal distal flow is also noted.
In our case, bilateral ophthalmoplegia was noted. The PTA here originated from the posterolateral aspect of the left internal carotid artery accounting for the left sided ophthalmoplegia. Right ICA was occluded and the right hemispheric vessels were filling from the contralateral side through the anterior communicating 404
artery. Ischaemia probably is the cause of right sided ophthalmoplegia. Bony carotid canal was seen in our case suggesting the etiology to be acquired occlusion of right ICA. We feel this is a unique combination, but the cause of right sided ophthalmoplegia remains speculative.
www. centauro. it
The Neuroradiology Journal 21: 401-405, 2008
References 1 Salas E, Ziyal IM, Sekhar LN et Al: Persistent trigeminal artery: an anatomic study. Neurosurgery 43: 55761, 1998. 2 Anne G. Osborn: The Internal Carotid Artery: Cavernous, clinoid, ophthalmic &communicating segments In: Diagnostic Cerebral Angiography, (2nd ed): Lippincott Williams & Wilkins: Philadelphia1999: 91-3. 3 Saltzman GF: Patent Persistent Trigeminal Artery studied by cerebral angiography. Acta Radiol 51: 32936, 1959. 4 Lewis VL, Cail WS: Persistent trigeminal artery with internal carotid artery occlusion. Neurosurgery 13: 314-5, 1983. 5 Ohta H, Genmoto T, Yokota A: Multiple cerebral aneurysms and a contralateral occluded internal carotid artery associated with persistent primitive trigeminal artery. No Shinkei Geka 32: 1045-8, 2004. 6 Hattori T, Kobayashi H, Inoue S et Al: Persistent primitive trigeminal artery associated with absence of internal carotid artery. Surg Neurol 50: 352-5, 1998.
7 Olivares J, Alonso-Verdegay G: Persistent trigeminal artery and isolated sixth cranial nerve. Rev Neurol 44: 685-6, 2007. 8 Chidambaranathan N, Sayeed Zaheer Ahmed, Sunder K et Al: Persistent trigeminal artery: A rare cause of trigeminal neuralgia - MR imaging. Neurology India 54: 226-227, 2006.
Dr Sukalyan Purkayastha Department Imaging Sciences and Interventional Radiology AMRI Hospital Dhakuria Kolkata, 700029 India E-mail: [email protected]
405
www. centauro. it
Persistent Trigeminal Artery with Bilateral Ophthalmoplegia and Contralateral Internal Carotid Artery Occlusion A Case Report S. PURKAYASTHA Department Imaging Sciences and Interventional Radiologo, AMRI Hospital; Kolkata, India
Key words: PTA, ophthalmoplegia, carotid occlusion
SUMMARY – The most frequent persistent embryonic communication between the vertebrobasilar and carotid systems in adult life is a persistent trigeminal artery (PTA). Several anatomic variants of PTA have been described. The other associations of PTA mainly include aneurysm and vascular steal phenomena between basilar and carotid systems. We describe an interesting case of PTA with bilateral ophthalmoplegia and contralateral occlusion of the internal carotid artery.
Case Report
Discussion
This 52-year-old man presented with coronary symptoms. He had one episode of vertigo and on examination he showed bilateral ophthalmoplegia. He was then subjected to MRA examination which revealed left sided PTA arising from the posterolateral aspect of left ICA and joining the basilar artery just proximal to the superior cerebellar artery. Left posterior communicating artery was also visualized. Right ICA was not seen (figure 1). CT scan disclosed a bony carotid canal (figure 2). Digital subtraction angiogram confirmed left sided PTA (figure 3). Atherosclerotic complete occlusion of the right ICA noted. Right external carotid artery faintly filled the right carotid siphon via retrograde circulation through the ophthalmic artery (figure 4). Thin atherosclerotic plaque was noted at the origin of the left ICA. Vertebral injection also showed opacification of whole basilar artery (figure 5).
During fetal development (approximately 35 gestational days) the craniocerebral circulation is characterized by temporary connections between the primitive carotid and the paired dorsal longitudinal neural arteries (precursors of the vertebrobasilar system). They include trigeminal, otic, hypoglossal and proatlantic intersegmental arteries. Normal embryonic development underwrites the regression of all these vessels totally. PTA is the most frequent persistent communication of these primitive carotid-basilar anastomoses 2,3. Several anatomic variants of PTA have been described. The other associations of PTA mainly include aneurysm and vascular steal phenomena between basilar and carotid systems 2. Congenital absence and acquired occlusion of the internal carotid artery associated with PTA are rare: a Pubmed search revealed only three reports of such association 4,5,6. Ohta et Al reported 401
Persistent Trigeminal Artery with Bilateral Ophthalmoplegia and Contralateral Internal Carotid Artery Occlusion
A
S. Purkayastha
B
↑
Figure 1 A,B MR angiogram shows persistent trigeminal artery on left side. The artery takes its origin from the posterolateral aspect of the left internal carotid artery (ICA) and joins the basilar artery proximal to superior cerebellar artery. Right ICA is not visualized.
←
Figure 2 CT scan bone window shows persistent bilateral carotid canal.
↓
Figure 3 A) Anteroposterior and B) lateral views of left carotid artery injection show the trigeminal artery arising from the junction of lateral and cavernous segments of the ICA and joining the basilar artery just proximal to the superior cerebellar artery.
A
402
B
www. centauro. it
The Neuroradiology Journal 21: 401-405, 2008
A
B
C
D
Figure 4 A,B) Right common carotid artery injection shows complete occlusion of right ICA. C,D) Right external carotid artery shows filling of the right ICA siphon through retrograde flow through the ophthalmic artery.
an extremely rare case of PTA associated with multiple cerebral aneurysms and a contralateral occluded IC 5. Ophthalmoplegia associated cranial nerve palsy is also described with PTA 7,8 . The PTA can take either a lateral or medial course regarding its relationship with the abducens nerve. When the PTA originates from the posterolateral aspect of the posterior bend of the cavernous carotid artery (C4 segment),
it crosses underneath and distorts the abducens nerve, continuing between the abducens and trigeminal nerves. When taking a medial course, the PTA arises from the posteromedial aspect of the posterior bend of the cavernous carotid at the same segment and pierces the clival dura at the dorsum sellae. Cranial nerve displacement or distortion are less likely in this variation. 403
Persistent Trigeminal Artery with Bilateral Ophthalmoplegia and Contralateral Internal Carotid Artery Occlusion
A
B
C
D
S. Purkayastha
Figure 5 A.B) Right vertebral artery shows complete opacification of the basilar artery. C,D) Left vertebral artery predominantly ends in posterior inferior cerebellar artery, however minimal distal flow is also noted.
In our case, bilateral ophthalmoplegia was noted. The PTA here originated from the posterolateral aspect of the left internal carotid artery accounting for the left sided ophthalmoplegia. Right ICA was occluded and the right hemispheric vessels were filling from the contralateral side through the anterior communicating 404
artery. Ischaemia probably is the cause of right sided ophthalmoplegia. Bony carotid canal was seen in our case suggesting the etiology to be acquired occlusion of right ICA. We feel this is a unique combination, but the cause of right sided ophthalmoplegia remains speculative.
www. centauro. it
The Neuroradiology Journal 21: 401-405, 2008
References 1 Salas E, Ziyal IM, Sekhar LN et Al: Persistent trigeminal artery: an anatomic study. Neurosurgery 43: 55761, 1998. 2 Anne G. Osborn: The Internal Carotid Artery: Cavernous, clinoid, ophthalmic &communicating segments In: Diagnostic Cerebral Angiography, (2nd ed): Lippincott Williams & Wilkins: Philadelphia1999: 91-3. 3 Saltzman GF: Patent Persistent Trigeminal Artery studied by cerebral angiography. Acta Radiol 51: 32936, 1959. 4 Lewis VL, Cail WS: Persistent trigeminal artery with internal carotid artery occlusion. Neurosurgery 13: 314-5, 1983. 5 Ohta H, Genmoto T, Yokota A: Multiple cerebral aneurysms and a contralateral occluded internal carotid artery associated with persistent primitive trigeminal artery. No Shinkei Geka 32: 1045-8, 2004. 6 Hattori T, Kobayashi H, Inoue S et Al: Persistent primitive trigeminal artery associated with absence of internal carotid artery. Surg Neurol 50: 352-5, 1998.
7 Olivares J, Alonso-Verdegay G: Persistent trigeminal artery and isolated sixth cranial nerve. Rev Neurol 44: 685-6, 2007. 8 Chidambaranathan N, Sayeed Zaheer Ahmed, Sunder K et Al: Persistent trigeminal artery: A rare cause of trigeminal neuralgia - MR imaging. Neurology India 54: 226-227, 2006.
Dr Sukalyan Purkayastha Department Imaging Sciences and Interventional Radiology AMRI Hospital Dhakuria Kolkata, 700029 India E-mail: [email protected]
405
