Persistent Trigeminal Artery and Posterior Circulation Stroke: A Rare Presentation

Abstract

The persistent trigeminal artery is a rare embryonic developmental anomaly which is encountered frequently. In embryonic life it maintains posterior blood circulation before the development of posterior circulation blood vessels and once normal circulation gets stabilized it undergoes natural regression. The persistent trigeminal artery originates from the cavernous segment of the internal carotid artery and connects the basilar artery. This study reports an accidental finding during evaluation for the cause of posterior fossa stroke. It is also associated with various vascular pathologies like aneurysms, vascular nerve compression, trigeminal cavernous fistulas, and thromboembolic ischemia like ischemic stroke or transient ischemic attack. In large artery stroke, it also acts as collateral and maintains perfusion. We describe the case of a patient who presented with complaints of giddiness, diplopia, vomiting, and imbalance while walking, in which the infarction may have been limited by a persistent trigeminal artery.

 

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Keywords

anatomical variation - persistent trigeminal artery - stroke

Introduction

The trigeminal artery (TA) is normally present in embryonic life and maintains blood circulation in the basilar artery before the development of the vertebral artery and posterior communicating artery. Generally, it appears at the age of 6 days of embryogenesis[1] and maintains its patency up to 7 to 10 days after that its TA undergoes regression, and if it fails to regress and persists after 10 days of embryogenesis then it is defined as persist TA.[1] In persistent TA (PTA), the main cavernous segment of the internal carotid artery (ICA) communicates with the basilar artery (BA) between the anterior inferior cerebellar artery and superior cerebellar artery[2] [3] [4] and the incidence varies from 0.1 to 0.6%[5] with different anatomical variation.[6] PTA and its relationship with the abducens nerve are the basic criteria for its variations.[7]

Classification of Persistent Trigeminal Artery

1. Salas classification

2. Saltzman angiographic classification

 

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Salas Classification

• The medial type: Also known as sphenoidal type persistent primitive trigeminal artery (PPTA), it may be a different carotid-basilar anastomosis of the PTA, and the remnant of this vessel may form the future meningohypophyseal trunk of the ICA.[8]

• The lateral type: Also known as petrosal type of PPTA, this is true PTA. In this variety pontine perforating arteries along with branches to the trigeminal ganglion may arise from the PTA, embryogenesis.

Saltzman angiographic classification: This is a widely accepted classification.

Our case depicts a lateral variation of the PTA and angiographically is a Saltzman type 1 ([Fig. 1] and [2]). Assessment of presence of collaterals are best evaluated by digital subtraction angiography (DSA) and presence of collateral shows less extension of infarct.[9]

Fig. 1 (A) Diffusion magnetic resonance imaging (MRI) shows the pinpoint area of diffusion restriction in the dorsal pon near the 6th nerve nuclei. (B) MRI angiography shows poor visualization of the proximal 2/3 of the basilar artery.

Fig. 2 (A) Digital subtraction angiography (DSA) showing the origin of the lateral type of persistent trigeminal artery which originates from the left internal carotid artery (ICA) and good flow in distal 1/3 of the basilar artery. (B) It shows type 1 TPA with no anterograde filling of the basilar artery.

 

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Case Report

A 60-year-old male brought on casualty with complain of sudden-onset giddiness, imbalance left facial numbness, and double vision. Urgent magnetic resonance imaging (stroke protocol) was done which was suggestive of acute pontine infarct. Dual antiplatelet was started and planed for DSA. Cerebral angiography identified the presence of left PTA, hypoplastic bilateral vertebral artery, and minimal stenosis of the right supraclinoid ICA ([Table 1]). After angiographic finding dual antiplatelet was started along with physiotherapy and lifestyle modification was advised. With medical management the patient gradually improved and was discharged after 4 days.

Table 1 Saltzman[18] and Wollschlaeger[1] angiographic classification of PTA

Type 1	Type 2	Type-3
Known as fetal PTA	Adult type PTA	Rare variant
Absent Pcom	Maintain blood flow in SCA and PCA	Never terminate in BA
Hypoplastic/absent distal BA with hypoplastic vertebral arteries	It predominantly received blood flow from Pcom A	It directly supplies SCA, AICA, and PICA

Abbreviations: AICA, anterior inferior cerebellar artery; BA, basilar artery; PCA, posterior cerebral artery; Pcom, posterior communicating artery; PICA, posterior inferior cerebellar artery; PTA, persistent trigeminal artery; SCA, superior cerebellar artery.

 

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Discussion

During embryogenesis PTA maintains posterior brain blood circulation until vertebra-basilar system develops[10] [11] and after that it undergo natural regression. But in some cases it fails to regress and manifest in the form of PTA. This is very rare with documented anatomical developmental variation with a reported incidence of between 0.1 and 0.68%.[10] [11] [12] [13] The presence of ischemic stroke associated with PTA is a rarely reported event and its contribution to stroke is understood. Hypoplastic proximal BA and bilateral vertebral arteries may have some role in posterior circulation stroke. PTA can act as the site for thrombus formation with distal migration which directly contributes to posterior circulation stroke. The majority of case reports show that PTA may increase the risk of ischemic stroke[14] [15] [16] and it also leads to brainstem transient ischemia stroke.[17]

 

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Conflict of Interest

None declared.

• References

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Publikationsverlauf

Artikel online veröffentlicht:
29. Mai 2025