Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 10 (2017) 28–31

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Interdisciplinary Neurosurgery: Advanced Techniques and

Case Management
journal homepage: www.inat-journal.com

Case Report

Resolution of persistent trigeminal artery aneurysm by coil embolization

Dan Zimelewicz Oberman a,⁎, Manuel Perez Akly b, Luis Ariel Miquelini b, Oscar Alfredo Peralta c,
Cristina Hilda Besada b, Matteo Baccanelli c
a
Hospital Italiano Universitary Institute, Buenos Aires, Argentina
b
Neuroradiology, Department of Radiology, Hospital Italiano, Buenos Aires, Argentina
c
Department of Neurosurgery, Hospital Italiano de Buenos Aires, Argentina

a r t i c l e i n f o a b s t r a c t

Article history: The persistent trigeminal artery (PTA) is the most common and most cephalic embryological vascular remnant
Received 21 December 2016 that persist in the adulthood. It is located between the internal carotid artery and the basilar artery. It is recog-
Revised 21 May 2017 nized on 0.1%–0.6% of cerebral angiography. In most cases is an incidental finding, but may be associate with
Accepted 28 May 2017
others cerebrovascular malformations, including arteriovenous malformations, aneurysms, and carotid-cavern-
Available online xxxx
ous fistulas, which cerebral aneurysms are the most common. We describe an extremely rare case of unruptured
Keywords:
aneurysm in the PTA trunk revealed by angiotomography successfully treated with endovascular embolization. A
Aneurysm proper diagnose prior to any surgical or radiological intervention is crucial to prevent possible complications.
Angiography © 2017 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
Coil embolization (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Neurosurgery
Persistent trigeminal artery

The persistent trigeminal artery (PTA) is a very rare anastomosis lo-
cated between the internal carotid artery (ICA) and the basilar artery
and is recognized on 0.1%–0.6% of cerebral angiography [1] with a
higher prevalence in females [2]. In most cases is an incidental finding,
but may be associate with others cerebrovascular malformations, in-
cluding arteriovenous malformations, aneurysms, and carotid-cavern-
ous fistulas. Aneurysms associated to PTA are relatively frequent, and
account for 14% of all cerebral aneurysms [3], although aneurysm aris-
ing from the trigeminal artery itself are extremely rare. We describe a
case of unruptured aneurysm in the PTA trunk revealed by
angiotomography successfully treated with endovascular embolization.
1. Case report
occupied the peritruncal cistern at the interpeduncular level. The
vertebrobasilar system proximal to the aneurysm was hypoplastic and
the posterior communicating artery were absent bilaterally. Due to the
size of the aneurysmal and the age of the patient, we decided an
endovascular treatment. The existence of perforating arteries associated
to the PTA made us initially think in placing a flow diverter, but the little
post-aneurysmal space of the trigeminal artery, prior to its union with
the basilar artery, would have made it difficult to anchor, so we chose
an embolization with coils (Trufill DCS orbit Detachable Codman J & J).
The patient tolerated successfully the endovascular procedure and had
a great evolution. At a follow-up 6 months after the surgery digital angi-
ography demonstrated sustained embolization of the aneurysm with no
recanalization (Fig. 3).

2. Discussion
A 56-year-old woman with a history of diabetes type 2, hyperten-
sion and dyslipidemia presented to our institution with headache and
PTA is the most cephalic and most common embryological vascular
nausea of 1 month of evolution. She suffered a traumatic brain injury
remnant that persist in the adulthood. It originates in the precavernous
without loss of consciousness 3 months prior to come to our hospital.
segment of the ICA, proximal to the origin of the meningohypophyseal
A cranial computed tomography (CT) scan was initially performed re-
trunk, to anastomose with the distal third of the basilar artery [4].
vealed a saccular vascular projection of the basilar artery (Fig. 1). The
Uchino et al. [5] divided the PTA into medial and lateral types, both
patient therefore underwent CT-angiography (CTA), showing a left per-
with a similar prevalence. The medial type courses posteromedially
sistent trigeminal artery measuring 3.8 mm in diameter and a saccular
through the cavernous sinus. The lateral travels between the trigeminal
aneurysm arising from the left-PTA, adjacent to the union with the bas-
nerve and the lateral side of the cavernous sinus to join the basilar artery
ilar trunk, measuring 15 × 12.6 mm of diameter (Fig. 2). The aneurysm
between the origins of the anterior inferior cerebellar arteries and the
⁎ Corresponding author at: Potosí 4234, 1199 Instituto Universitario, Hospital Italiano
superior cerebellar arteries. Due to the intimate relationship of PTA to
Buenos Aires, Argentina. the trigeminal nerve, it is an unusual cause trigeminal neuralgia [3]. In
E-mail address: dan.zimelewicz@hospitalitaliano.org.ar (D. Zimelewicz Oberman). our patient, CTA demonstrated that the PTA was lateral type.

http://dx.doi.org/10.1016/j.inat.2017.05.004
2214-7519/© 2017 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 D. Zimelewicz Oberman et al. / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 10 (2017) 28–31 29

Fig. 1. Computed tomography scan without contrast. Axial plane (a) where a slightly hyperdense saccular lesion is seen in the prepontine cistern, with a slight imprint on the protuberance.
Sagittal plane (b) that shows the close relation with the superior sector of the basilar trunk.

PTA was also characterized according to the configuration of the pos-
terior cerebral artery [6]: In two types: Saltzman type I there is an agen-
esis of the ipsilateral posterior communicating artery; and Saltzman
type II there is a variant of fetal origin of the posterior cerebral artery
that originates directly from the ACI, and the ipsilateral segment P1 is
absent. Our patient's PTA would therefore be classified as a lateral
variant Saltzman type 1. Besides, the proximal segment of the
vertebrobasilar system in our patient is hypoplastic and the posterior
communicating arteries are absent bilaterally. Secure flow preservation
is very important in patients treated for PTA trunk aneurysms because
insufficient flow in the main trunk of the PTA can compromise the pos-
terior circulation and generate significant post-treatment sequelae.

Fig. 2. Intracranial angiotomography. Axial plane (a) shows saccular dilation dependent on the left trigeminal trunk with imprint on the protuberance. Multiplane reconstruction of
maximum intensity (b) and volumetric reconstructions (c and d) showing the persistent left trigeminal artery associated with aneurysmal dilatation.
30 D. Zimelewicz Oberman et al. / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 10 (2017) 28–31
Fig. 3. Digital angiography oblique (a) and sagittal (b) prior to endovascular treatment. Post-embolization control with exclusion of circulatory aneurysm (c) and volumetric reconstruction
of intraoperative angiotomography (d) showing embolized aneurysm.
Aneurysm associated with PTA are relatively frequent, possible due
to turbulent flow. These aneurysms originate most frequently at the
junction in the cavernous segment of the ICA or the basilar being rare
in the trunk of the PTA. Aneurysms that originated from trigeminal ar-
tery itself have been reported in 1% to 2% of cases [7]. The pathogenesis
of these aneurysms is believed be due to a structural alteration in the
wall of persistent cerebral arterial vessels in addition to the hemody-
namic stress generated in the vessel wall [8]. Two cases of coil emboli-
zation of PTA aneurysm was found in literature, with only one was
successfully treated [4,9].
The first decision to be made when confronted with an asymptomat-
ic intracranial aneurysm is whether there is a need to treat it. The clini-
cal decision to intervene will therefore have to account for patient's age
and life expectancy in order to accurately gauge the risk of clinical ob-
servation. Statistically, studies have not shown any significant benefit
in repairing an aneurysm in patients with a life expectancy of b15 to
35 years or age between 45 and 70 years [10]. In our institution, the pro-
tocol is any incidental aneurysm N 7 mm in a patient younger than
73 years is surgical, because the expected survival time is at least
12 years and that “expires” at age 73 in our population. All aneurysm
N10 mm are operated, unless there are severe comorbidities in the
pre-surgical anesthetic evaluation. Patients with an anterior circulation
aneurysm are operated by clipping while aneurysms of posterior circu-
lation are operated via endovascular treatment.
Due to the deep location of the aneurysms of the trunk of the PTA
and their intimate relationship to the cranial nerves, direct surgery is
very difficult. PTA is usually an incidental finding; however, it presents
a high association with aneurysms. Aneurysm arising from the trigemi-
nal artery itself is extremely rare. Identification of this remnant and its
variants though CTA prior to any surgical or radiological intervention
is crucial to prevent possible complications.
Conflict of interest
The authors declare that they have no conflict of interest.
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