J Korean Neurosurg Soc.  2016 Jul;59(4):400-404. 10.3340/jkns.2016.59.4.400.

Acute Ischemic Stroke Involving Both Anterior and Posterior Circulation Treated by Endovascular Revascularization for Acute Basilar Artery Occlusion via Persistent Primitive Trigeminal Artery

• Imahori T
• Fujita A
• Hosoda K
• Kohmura E

• KMID: 2315977
• DOI: http://doi.org/10.3340/jkns.2016.59.4.400

Abstract

We report a case of acute ischemic stroke involving both the anterior and posterior circulation associated with a persistent primitive trigeminal artery (PPTA), treated by endovascular revascularization for acute basilar artery (BA) occlusion via the PPTA. An otherwise healthy 67-year-old man experienced sudden loss of consciousness and quadriplegia. Magnetic resonance imaging showed an extensive acute infarction in the right cerebral hemisphere, and magnetic resonance angiography showed occlusion of the right middle cerebral artery (MCA) and BA. Because the volume of infarction in the territory of the right MCA was extensive, we judged the use of intravenous tissue plasminogen activator to be contraindicated. Cerebral angiography revealed hypoplasia of both vertebral arteries and the presence of a PPTA from the right internal carotid artery. A microcatheter was introduced into the BA via the PPTA and revascularization was successfully performed using a Merci Retriever with adjuvant low-dose intraarterial urokinase. After treatment, his consciousness level and right motor weakness improved. Although persistent carotid-vertebrobasilar anastomoses such as a PPTA are relatively rare vascular anomalies, if the persistent primitive artery is present, it can be an access route for mechanical thrombectomy for acute ischemic stroke.

Keyword

Endovascular revascularization; Mechanical thrombectomy; Acute ischemic stroke; Basilar artery occlusion; Persistent primitive trigeminal artery; Persistent carotid-vertebrobasilar anastomosis

MeSH Terms

Aged
Arteries*
Basilar Artery*
Carotid Artery, Internal
Cerebral Angiography
Cerebrum
Consciousness
Humans
Infarction
Magnetic Resonance Angiography
Magnetic Resonance Imaging
Middle Cerebral Artery
Quadriplegia
Stroke*
Thrombectomy
Tissue Plasminogen Activator
Unconsciousness
Urokinase-Type Plasminogen Activator
Vertebral Artery
Tissue Plasminogen Activator
Urokinase-Type Plasminogen Activator

Figure

• 

  Fig. 1 A: Magnetic resonance diffusion-weighted imaging on admission showing an extensive acute infarction in the right cerebral hemisphere. B: Magnetic resonance angiography on admission showing occlusion of the right middle cerebral artery and basilar artery (BA). Bilateral extra-cranial vertebral arteries are comparatively well visualized, but bilateral intracranial VAs and the BA are poorly visualized. An unusual branch arising from the precavernous portion of the right internal carotid artery can be seen (white arrow).

• 

  Fig. 2 A: Right innominate angiography showing a relatively hypoplastic right VA (left). Left vertebral angiography showing occlusion of the BA (right). The intracranial left VA is relatively hypoplastic. B and C: Right carotid angiography showing the occluded right middle cerebral artery and a persistent primitive trigeminal artery arising from the precavernous portion of the right internal carotid artery. D: Simultaneous angiography from the guiding catheter and the microcatheter indicating the location of the clot. E: Radioscopic image showing the Merci Retriever inserted into the left posterior cerebral artery. F and G: Final angiography after the endovascular treatment showing recanalization of the BA. VA: vertebral artery, BA: basilar artery.

• 

  Fig. 3 A: Magnetic resonance DWI at 24 hours after treatment showing new, relatively small infarctions in the left occipital lobe, left thalamus, and midbrain compared with DWI on admission. B: MRA after treatment showing good patency of the BA after the endovascular revascularization. DWI: diffusion-weighted imaging, BA: basilar artery.

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