Carotid Endarterectomy for Internal Carotid Artery Stenosis Associated with Persistent Primitive Hypoglossal Artery: Efficacy of Intraoperative Multi-modality Monitoring

Abstract

Introduction: A persistent primitive hypoglossal artery (PPHA) is a rare vascular anomaly and is usually asymptomatic. However, the PPHA may cause multi-territorial infarction when complicated by internal carotid artery (ICA) stenosis.

Case Report: We describe a 73-year-old male who simultaneously developed cerebral infarction in both carotid and vertebrobasilar territories due to ICA stenosis associated with an ipsilateral PPHA. The PPHA mainly provided blood flow to the vertebrobasilar territory in this case, because the bilateral vertebral arteries were markedly hypoplastic. He underwent carotid endarterectomy under internal shunting. Intraoperative multi-modality monitoring including angiography, motor evoked potential, and near infrared spectroscopy was very useful to avoid ischemic complications during surgery. The postoperative course was uneventful.

Conclusion: It should be reminded that a persistent carotid-basilar anastomosis can cause multi-territorial cerebral infarction mimicking cardiogenic embolism and may be a candidate for aggressive prophylactic intervention, when occlusive lesions develop in the carotid artery. It is very important to monitor hemodynamic and/or electrophysiological status in both carotid and verebrobasilar territories in order to perform carotid endarterectomy safely in such cases.

persistent primitive hypoglossal artery - carotid stenosis - cerebral infarction - carotid endarterectomy - intraoperative angiography

References

• 1 Padget DH. The development of the cranial arteries in the human embryo.  Carnegie Institution of Washington Publication. 1948;  575 205-261
• 2 Lie T. Persistnet carotid-basilar and carotid-vertebral anastomoses. In: Lie T, ed. Congenital anomalies of the carotid arteries. Amsterdam: Excerpta Medica 1968: 52-94
• 3 Brismar J. Persistent hypoglossal artery, diagnostic criteria. Report of a case.  Acta Radiol Diagn (Stockh). 1976;  17 160-166
• 4 Matsumura M, Nojiri K, Yumoto Y. Persistent primitive hypoglossal artery associated with Arnold-Chiari type I malformation.  Surg Neurol. 1985;  24 241-244
• 5 Pyun HW, Lee DH, Kwon SU. et al . Internal carotid artery stenosis with ipsilateral persistent hypoglossal artery presenting as a multiterritorial embolic infarction: a case report.  Acta Radiol. 2007;  48 116-118
• 6 Jin K, Aihara N, Tsukamoto T. A case of medial medullary infarction with persistent primitive hypoglossal artery.  No To Shinkei. 2002;  54 341-345
• 7 Conforto AB, de Souza M, Puglia Jr P. et al . Bilateral occipital infarcts associated with carotid atherosclerosis and a persistent hypoglossal artery.  Clin Neurol Neurosurg. 2007;  109 364-367
• 8 Masaki T, Kanemaru K, Kuzuhara S. et al . Brainstem infarction caused by occlusion of the persistent primitive hypoglossal artery A case report.  Rinsho Shinkeigaku. 1988;  28 919-922
• 9 Elhammady MS, Baskaya MK, Sonmez OF. et al . Persistent primitive hypoglossal artery with retrograde flow from the vertebrobasilar system: a case report.  Neurosurg Rev. 2007;  30 345-349 discussion 349 
• 10 Sunada I, Yamamoto S, Matsuoka Y. et al . Endarterectomy for persistent primitive hypoglossal artery – case report.  Neurol Med Chir (Tokyo). 1991;  31 104-108
• 11 Hatayama T, Yamane K, Shima T. et al . Persistent primitive hypoglossal artery associated with cerebral aneurysm and cervical internal carotid artery stenosis case report.  Neurol Med Chir (Tokyo). 1999;  39 372-375
• 12 Yuasa H, Mitake S, Oguri T. et al . A case of transient blindness due to severe stenosis of the internal carotid artery with persistent primitive hypoglossal artery (PPHA).  Rinsho Shinkeigaku. 2005;  45 579-582
• 13 Cartier R, Cartier P, Hudan G. et al . Combined endarterectomy of the internal carotid artery and persistent hypoglossal artery: an unusual case of carotid revascularization.  Can J Surg. 1996;  39 159-162
• 14 McCartney SF, Ricci MA, Labreque P. et al . Persistent hypoglossal artery encountered during carotid endarterectomy.  Ann Vasc Surg. 1989;  3 257-260
• 15 Ouriel K, Green RM, DeWeese JA. Anomalous carotid-basilar anastomoses in cerebrovascular surgery.  J Vasc Surg. 1988;  7 774-777
• 16 Kashiwazaki D, Kuroda S, Terasaka S. et al . Detection of hemodynamic transient ischemic attack during hemodialysis with near-infrared monitoring in a patient with internal carotid artery occlusion.  Surg Neurol. 2007;  68 292-294; discussion 294–295 
• 17 Kuroda S, Houkin K, Abe H. et al . Near-infrared monitoring of cerebral oxygenation state during carotid endarterectomy.  Surg Neurol. 1996;  45 450-458
• 18 Quinones-Hinojosa A, Alam M, Lyon R. et al . Transcranial motor evoked potentials during basilar artery aneurysm surgery: technique application for 30 consecutive patients.  Neurosurgery. 2004;  54 916-924; discussion 924 

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