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1 . 2024

Symptomatic stenosis of the internal carotid artery combined with persistent primitive hypoglossal artery separately forming the basilar artery (case report)

Abstract

Background. The persistent primitive hypoglossal artery is an anastomosis between the internal carotid artery and the basilar artery, being a rarely encountered developmental anomaly of vessels supplying the brain. The presence of the persistent primitive hypoglossal artery in a combination with atherosclerotic stenosis of the internal carotid artery substantially increases the risk of developing vascular catastrophes and a lethal outcome. In this clinical case report, we describe a situation with successful open endarterectomy performed from the ostium of the internal carotid artery and the presence of the persistent primitive hypoglossal artery completely forming the basilar artery.

Objective. We herein present a rare clinical case concerning surgical management of a patient with significant stenosis of the internal carotid artery in a combination with the persistent primitive hypoglossal artery separately forming the basilar artery.

Patients and methods. The persistent primitive hypoglossal artery is a branch of the carotid artery, located in the canal of the hypoglossal nerve. In our patient, this artery was the only one forming the basilar artery, with both vertebral arteries being aplastic. The patient was operated on for significant stenosis of the internal carotid artery.

Conclusion. The presence of abnormal carotid-basilar anastomoses is a rare pathology most often found incidentally. Currently, there is no specific screening to identify this pathology, but once revealed, it requires thorough differential diagnosis for an appropriate therapeutic decision to be made.

Funding. The study had no financial support.

Conflict of interest. The authors declare no conflicts of interest.

Authors’ contribution. Study conception and design – Shevtsov Yu.N.; data collection and handling – Arkhipov I.S., Bugaeva S.R., Bykov P.M., Storozhenko S.Yu.; draft manuscript preparation – Arkhipov I.S., Bugaeva S.R..; manuscript revision – Shevtsov Yu.N., Mikhailova Yu.A., Bobrovskaya Е.А.

For citation: Shevtsov Yu.N., Arkhipov I.S., Bugaeva S.R., Mikhailova Yu.A., Bykov P.M., Storozhenko S.Yu., Bobrovskaya Е.А. Symptomatic stenosis of the internal carotid artery combined with persistent primitive hypoglossal artery separately forming the basilar artery (case report). Angiology and Vascular Surgery. Journal named after Academician A.V. Pokrovsky. 2024; 30 (1): 88–93. DOI: https://doi.org/10.33029/1027-6661-2024-30-1-88-93

Keywords: carotid endarterectomy; persistent primitive hypoglossal artery; internal carotid artery stenos; stroke; atherosclerosis

References

1. Kawamura K., Tokugawa J., Watanabe M., et al. Persistent primitive hypoglossal artery with ipsilateral symptomatic carotid artery stenosis and cerebral aneurysm. Journal of Stroke & Cerebrovascular Diseases. 2021; 30 (11): 106099. DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.106099

2. Huynh-Le P., Matsushima T., Muratani H., et al. Persistent primitive hypoglossal artery associated with proximal posterior inferior cerebellar artery aneurysm. Surgical Neurology. 2004; 62 (6): 546–551. DOI: https://doi.org/10.1016/j.surneu.2004.03.018

3. Srinivas M.R., Vedaraju K.S., Manjappa B.H., Nagaraj B.R. Persistent primitive hypoglossal artery (PPHA) – a rare anomaly with literature review. Journal of Clinical and Diagnostic Research. 2016; 10 (1): Td13–14. DOI: https://doi.org/10.7860/JCDR/2016/15556.7116

4. Tse G.H., Martin A., Dyde R.A., Coley S.C. Persistent hypoglossal artery aneurysm: Case report and qualitative systematic review. Interventional Neuroradiology. 2019; 25 (2): 164–171. DOI: https://doi.org/10.1177/1591019918809087

5. Telianidis S., Westcott M.J., Ironfield C.M., Sanders L.M. Case of Amaurosis Fugax in the Setting of a Persistent Primitive Hypoglossal Artery Requiring Carotid Endarterectomy with Regional Anesthesia. American Journal of Clinical Case Reports. 2023; 24: e939450. DOI: https://doi.org/10.12659/AJCR.939450

6. Mutlu D., Mutlu Z.Ö.P., Kültürsay B., Karagöz A. An Unusual Cause of Syncope: Persistent Hypoglossal Artery, A Case Report. Türk Kardiyoloji Derneği Arşivi. 2023; 51 (4): 286–289. DOI: https://doi.org/10.5543/tkda.2022.8056

7. Yasin S., Tasdemir R., Cihan O.F. A rare occurrence of persistent hypoglossal artery and its clinical significance. Folia Morphologica (Warsz). 2023; 82 (4): 953–956. DOI: https://doi.org/10.5603/FM.a2022.0105

8. Tubbs R.S., Verma K., Riech S., et al. Persistent fetal intracranial arteries: a comprehensive review of anatomical and clinical significance. Journal of Neurosurgery. 2011; 114 (4): 1127–1134. DOI: https://doi.org/10.3171/2010.11.JNS101527

9. Kimball D., Ples H., Miclaus G.D., et al. Persistent hypoglossal artery aneurysm located in the hypoglossal canal with associated subarachnoid hemorrhage. Surgical and Radiologic Anatomy. 2015; 37 (2): 205–209. DOI: https://doi.org/10.1007/s00276-014-1285-7

10. Varvari I., Bos E.M., Dinkelaar W., et al. Fatal Subarachnoid Hemorrhage from an Aneurysm of a Persistent Primitive Hypoglossal Artery: Case Series and Literature Overview. World Neurosurgery. 2018; 117: 285–291. DOI: https://doi.org/10.1016/j.wneu.2018.06.119

Обсуждение

Каротидно-базилярные анастомозы - это важная составляющая кровотока в головном мозге, которая обеспечивает перфузию его базальных отделов в интранатальном периоде. В норме в постнатальном периоде эти анастомозы начинают редуцироваться, но у ряда пациентов их сохранение приводит к гипоплазии подъязычной артерии (ПА) и недоразвитию или отсутствию задних соединительных артерий (ЗСА) [7].

Среди персистирующих артерий можно выделить тройничную, ушную, подъязычную и проатлантную. Это важно учитывать при оценке состояния кровообращения в головном мозге и при выборе тактики лечения. ПЭПА - ветвь сонной артерии, располагающаяся в канале подъязычного нерва и являющаяся второй по частоте встречаемости. Она проходит через полость черепа и соединяется с базилярной артерией [8].

Наличие функционирующей ПЭПА может приводить к разным осложнениям, но симптомы, связанные с этим заболеванием, бывают неявными. К примеру, заболевание может проявляться как головные боли или головокружения, которые не вызывают больших опасений у пациентов.

Однако у ряда пациентов наличие ПЭПА может приводить к развитию аневризм [9] и ишемическим инсультам [7].

В 2018 г. в журнале World Neurosurgery опубликована статья, в которой описывается наблюдение обнаружения аневризмы ПЭПА у 15-летней пациентки, которая была госпитализирована по поводу диффузного субарахноидального кровоизлияния, закончившегося гибелью мозга [10].

Наличие таких клинических наблюдений подтверждает высокий риск развития ОНМК у данной когорты больных, особенно при необходимости выполнения им оперативного лечения. Мы полагаем, что в таких ситуациях необходимо использование разных вариантов интраоперационного внутрипросветного шунтирования. В представленном наблюдении применение временного шунта было осуществлено в варианте "ОСА-ВСА" (до места разделение на ВСА и ПЭПА).

Заключение

Выявление у больного перед операцией каротидной эндартерэктомии такой редкой патологии, как аномальные каротидно-базилярные анастомозы, предполагает тщательное операционное планирование, направленное прежде всего на определение необходимости интраоперационного использования внутрипросветного шунта.

Литература/References

1. Kawamura K., Tokugawa J., Watanabe M., et al. Persistent primitive hypoglossal artery with ipsilateral symptomatic carotid artery stenosis and cerebral aneurysm. Journal of Stroke & Cerebrovascular Diseases. 2021; 30 (11): 106099. DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.106099

2. Huynh-Le P., Matsushima T., Muratani H., et al. Persistent primitive hypoglossal artery associated with proximal posterior inferior cerebellar artery aneurysm. Surgical Neurology. 2004; 62 (6): 546-551. DOI: https://doi.org/10.1016/j.surneu.2004.03.018

3. Srinivas M.R., Vedaraju K.S., Manjappa B.H., Nagaraj B.R. Persistent primitive hypoglossal artery (PPHA) - a rare anomaly with literature review. Journal of Clinical and Diagnostic Research. 2016; 10 (1): Td13-14. DOI: https://doi.org/10.7860/JCDR/2016/15556.7116

4. Tse G.H., Martin A., Dyde R.A., Coley S.C. Persistent hypoglossal artery aneurysm: Case report and qualitative systematic review. Interventional Neuroradiology. 2019; 25 (2): 164-171. DOI: https://doi.org/10.1177/1591019918809087

5. Telianidis S., Westcott M.J., Ironfield C.M., Sanders L.M. Case of Amaurosis Fugax in the Setting of a Persistent Primitive Hypoglossal Artery Requiring Carotid Endarterectomy with Regional Anesthesia. American Journal of Clinical Case Reports. 2023; 24: e939450. DOI: https://doi.org/10.12659/AJCR.939450

6. Mutlu D., Mutlu Z.Ö.P., Kültürsay B., Karagöz A. An Unusual Cause of Syncope: Persistent Hypoglossal Artery, A Case Report. Türk Kardiyoloji Derneği Arşivi. 2023; 51 (4): 286-289. DOI: https://doi.org/10.5543/tkda.2022.8056

7. Yasin S., Tasdemir R., Cihan O.F. A rare occurrence of persistent hypoglossal artery and its clinical significance. Folia Morphologica (Warsz). 2023; 82 (4): 953-956. DOI: https://doi.org/10.5603/FM.a2022.0105

8. Tubbs R.S., Verma K., Riech S., et al. Persistent fetal intracranial arteries: a comprehensive review of anatomical and clinical significance. Journal of Neurosurgery. 2011; 114 (4): 1127-1134. DOI: https://doi.org/10.3171/2010.11.JNS101527

9. Kimball D., Ples H., Miclaus G.D., et al. Persistent hypoglossal artery aneurysm located in the hypoglossal canal with associated subarachnoid hemorrhage. Surgical and Radiologic Anatomy. 2015; 37 (2): 205-209. DOI: https://doi.org/10.1007/s00276-014-1285-7

10. Varvari I., Bos E.M., Dinkelaar W., et al. Fatal Subarachnoid Hemorrhage from an Aneurysm of a Persistent Primitive Hypoglossal Artery: Case Series and Literature Overview. World Neurosurgery. 2018; 117: 285-291. DOI: https://doi.org/10.1016/j.wneu.2018.06.119

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CHIEF EDITOR
CHIEF EDITOR
Yuri V. Belov
Academician of the Russian Academy of Sciences Doctor of Medical Sciences, Professor, President of the Russian Society of Angiologists and Vascular Surgeons

 

In accordance with the decision of the Presidium of the Russian Society of Angiologists and Vascular Surgeons, the journal "Angiology and Vascular Surgery" will be named after Academician A.V. Pokrovsky starting from No. 2/2022.

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