neurosurgeryНейрохирургияRussian journal of neurosurgery1683-32952587-7569Издательский дом "МедИНК"10.17650/1683-3295-2022-24-4-95-100neurosurgery-1293Research ArticleНАБЛЮДЕНИЕ ИЗ ПРАКТИКИFROM PRACTICEАневризма примитивной тригеминальной артерии: случай из практики и обзор литературыAneurysm of the primitive trigeminal artery: a clinical case and a literature reviewhttps://orcid.org/0000-0001-7297-3213ГорощенкоС. А.GoroshchenkoS. A.

Сергей Анатольевич Горощенко

191014 Санкт-Петербург, ул. Маяковского, 12

Sergey Anatolevich Goroshchenko

12 Mayakovskogo St., Saint Petersburg 191014

goroschenkos@gmail.comhttps://orcid.org/0000-0002-0974-460XРожченкоЛ. В.RozhchenkoL. V.

191014 Санкт-Петербург, ул. Маяковского, 12

12 Mayakovskogo St., Saint Petersburg 191014

https://orcid.org/0000-0003-0956-6994БобиновВ. В.BobinovV. V.

191014 Санкт-Петербург, ул. Маяковского, 12

12 Mayakovskogo St., Saint Petersburg 191014

https://orcid.org/0000-0002-3904-2393КоломинЕ. Г.KolominE. G.

191014 Санкт-Петербург, ул. Маяковского, 12

12 Mayakovskogo St., Saint Petersburg 191014

https://orcid.org/0000-0002-3112-6584ПетровА. Е.PetrovA. E.

191014 Санкт-Петербург, ул. Маяковского, 12

12 Mayakovskogo St., Saint Petersburg 191014

Российский научно-исследовательский нейрохирургический институт им. проф. А. Л. Поленова – филиал ФГБУ «Национальный медицинский исследовательский центр им. В. А. Алмазова» Минздрава РоссииРоссияPolenov Russian Scienific Research Institute of Neurosurgery – a branch of the Almazov National Medical Research Centre, Ministry of Health of RussiaRussian Federation20222712202224495100Copyright © Горощенко С.А., Рожченко Л.В., Бобинов В.В., Коломин Е.Г., Петров А.Е., 20222022Горощенко С.А., Рожченко Л.В., Бобинов В.В., Коломин Е.Г., Петров А.Е.Goroshchenko S.A., Rozhchenko L.V., Bobinov V.V., Kolomin E.G., Petrov A.E.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.therjn.com/jour/article/view/1293Введение

Введение. Примитивная тригеминальная артерия – это фетальный анастомоз, связывающий каротидный и вертебробазилярный бассейны в эмбриональном периоде. После рождения данная артерия у ребенка в большинстве случаев облитерируется и редуцируется. Иногда облитерация не происходит, вследствие чего на этой артерии могут формироваться аневризмы (в связи с изменением привычной гемодинамики в каротидном бассейне), что, как следствие, влечет за собой риск развития субарахноидального кровоизлияния, резко ухудшающего прогноз течения заболевания. Привычные микрохирургические методы лечения к аневризмам данной локализации малоприменимы и высокотравматичны в связи с очень «низким» расположением шейки, что может потребовать применения расширенных базальных доступов, требующих резекции костей основания черепа. Также «открытая» хирургия влечет за собой риски повреждения перфорантных артерий, нередко отходящих от тригеминальной артерии и питающих ствол мозга, что незамедлительно приведет к его ишемическому повреждению. Именно поэтому предпочтительным методом при подобной патологии можно считать эндоваскулярное вмешательство как нереконструктивных, использующих только микроспирали, так и реконструктивных, требующих имплантации ассистирующих или поток‑перенаправляющих стентов.

Цель работы – демонстрация случая успешного лечения пациентки с аневризмой примитивной тригеминальной артерии.

Материалы и методы

Материалы и методы. Прооперирована пациентка с крупной аневризмой, расположенной на примитивной тригеминальной артерии, поступившая в клинику с жалобами на сходящееся косоглазие. По данным КТ‑ангиографии головного мозга выявлена крупная аневризма примитивной тригеминальной артерии справа, что в дальнейшем было подтверждено данными субтракционной селективной церебральной ангиографии. С учетом глазодвигательных расстройств у пациентки от использования микроспиралей было решено воздержаться в связи с возможностью сохранения масс‑эффекта. На фоне приема двойной дезагрегантной терапии (тикагрелор 90 мг 2 раза в день + ацетилсалициловая кислота 100 мг 1 раз вечером) и контроля функциональной активности тромбоцитов выполнена имплантация поток‑отклоняющего стента в правую внутреннюю сонную артерию.

Результаты

Результаты. Пациентка была выписана из стационара на 1‑е сутки после операции и вернулась к труду. При выполнении контрольной ангиографии через 3 года отмечено тотальное выключение аневризмы из кровотока, а также частичный регресс глазодвигательных расстройств. Внутрисосудистое лечение в данной ситуации послужило эффективным методом выбора и позволило надежно выключить аневризму из кровотока, не ухудшив при этом функциональный исход лечения пациентки.

Заключение

Заключение. Можно полагать, что внутрисосудистое вмешательство при подобных аневризмах служит эффективным методом выбора как минимально инвазивная и малотравматичная операция при лечении пациентов с данной патологией.

Background

Background. The primitive trigeminal artery is a fetal anastomosis connecting carotid and vertebrobasilar basins during embryonic period of development. After birth, this artery in the child is obliterated and reduced in most cases. Sometimes the obliteration does not occur and as a result the aneurysms may be formed on this artery (due to change in ordinary hemodynamics in carotid basin), as a consequence, it produces a risk of subarachnoid hemorrhage that sharply worsens prognosis of the disease outcome. The usual microsurgical treatment methods of aneurysms of such localization are of little use and are highly traumatic due to the very “low” location of the neck, because the surgery may need extended basal accesses requiring resection of skull base bones. Also, an “open” surgery produces risks of perforating arteries injury that often extend from trigeminal artery and feed the brain stem, the injury will immediately result in brain ischemic damage. That is why the preferred method for treatment of that kind of pathology may include endovascular intervention both of non‑reconstructive type employing microcoils only and those of reconstructive requiring implantation of assisting or flow‑redirecting stents.

Aim

Aim. To demonstrate a case of successful treatment of patient with a primitive trigeminal artery aneurysm.

Materials and methods

Materials and methods. A woman, who was admitted to clinic with complaints of convergent strabismus, undergone surgery for large aneurysm located on primitive trigeminal artery. CT brain angiography revealed large aneurysm of primitive trigeminal artery on the right, the result was later confirmed by data of selective cerebral subtraction angiography. Taking into account oculomotor disorders in the patient, it was decided to refrain from microcoils use due to risk of the mass‑effect preservation. Under double disaggregant therapy (ticagrelor 90 mg twice daily + acetylsalicylic acid 100 mg once daily in the evening) and monitoring the functional activity of platelets, a flow‑deflecting stent was implanted into the right internal carotid artery.

Results

Results. The patient was discharged from hospital on the 1st day after the surgery and returned to work. A control angiography performed 3 years later revealed a total shutdown of the aneurysm from bloodstream as well as a partial regression of oculomotor disorders. Intravascular treatment in this situation served as an effective method of choice and made it possible to reliably turn off the aneurysm from bloodstream without impairing the functional outcome of patient’s treatment.

Conclusions

Conclusions. It can be assumed that intravascular intervention in case of such aneurysms serves as an effective method of choice as minimally invasive and low‑traumatic surgery in the treatment of patients with that type of pathology.

аневризмапримитивная тригеминальная артериякаротидно‑базилярный анастомозпотокотклоняющий стентэндоваскулярное лечениеaneurysmprimitive trigeminal arterycarotid‑basilar anastomosisflow‑deflecting stentendovascular treatmentReferencesGeorge A.E., Lin J.P., Morantz R.A. Intracranial aneurysm on a persistent primitive trigeminal artery. Case report. J Neurosurg 1971;35(5):601–4. DOI: 10.3171/jns.1971.35.5.0601George A.E., Lin J.P., Morantz R.A. Intracranial aneurysm on a persistent primitive trigeminal artery. Case report. J Neurosurg 1971;35(5):601–4. DOI: 10.3171/jns.1971.35.5.0601Ishikawa T., Yamaguchi K., Anami H. et al. Treatment of large or giant cavernous aneurysm associated with persistent trigeminal artery: case report and review of literature. World Neurosurg 2017;108:996.e11–15. DOI: 10.1016/j.wneu.2017.09.033Ishikawa T., Yamaguchi K., Anami H. et al. Treatment of large or giant cavernous aneurysm associated with persistent trigeminal artery: case report and review of literature. World Neurosurg 2017;108:996.e11–15. DOI: 10.1016/j.wneu.2017.09.033Chen W.H., Tsai T.H., Shen S.C. et al. A case of giant thrombosed persistent primitive trigeminal artery aneurysm presenting with trigeminal neuralgia and successfully treated by a covered stent: case report and review of literature. Clin Neuroradiol 2015;25(2): 207–10. DOI: 10.1007/s00062-014-0314-6Chen W.H., Tsai T.H., Shen S.C. et al. A case of giant thrombosed persistent primitive trigeminal artery aneurysm presenting with trigeminal neuralgia and successfully treated by a covered stent: case report and review of literature. Clin Neuroradiol 2015;25(2): 207–10. DOI: 10.1007/s00062-014-0314-6Li M.H., Li W.B., Pan Y.P. et al. Persistent primitive trigeminal artery associated with aneurysm: report of two cases and review of the literature. Acta Radiol 2004;45(6):664–8. DOI: 10.1080/02841850410001196Li M.H., Li W.B., Pan Y.P. et al. Persistent primitive trigeminal artery associated with aneurysm: report of two cases and review of the literature. Acta Radiol 2004;45(6):664–8. DOI: 10.1080/02841850410001196Zhang C.W., Xie X.D., Yang Z.G. et al. Giant cavernous aneurysm associated with a persistent trigeminal artery and persistent otic artery. Korean J Radiol 2009;10(5):519–22. DOI: 10.3348/kjr.2009.10.5.519Zhang C.W., Xie X.D., Yang Z.G. et al. Giant cavernous aneurysm associated with a persistent trigeminal artery and persistent otic artery. Korean J Radiol 2009;10(5):519–22. DOI: 10.3348/kjr.2009.10.5.519Alcala-Cerra G., Tubbs R.S., Nino-Hernandez L.M. Anatomical features and clinical relevance of a persistent trigeminal artery. Surg Neurol Int 2012;3:111. DOI: 10.4103/2152-7806.101798Alcala-Cerra G., Tubbs R.S., Nino-Hernandez L.M. Anatomical features and clinical relevance of a persistent trigeminal artery. Surg Neurol Int 2012;3:111. DOI: 10.4103/2152-7806.101798Raybaud C. Normal and abnormal embryology and development of the intracranial vascular system. Neurosurg Clin N Am 2010;21(3):399–426. DOI: 10.1016/j.nec.2010.03.011Raybaud C. Normal and abnormal embryology and development of the intracranial vascular system. Neurosurg Clin N Am 2010;21(3):399–426. DOI: 10.1016/j.nec.2010.03.011Cloft H.J., Razack N., Kallmes D.F. Prevalence of cerebral aneurysms in patients with persistent primitive trigeminal artery. J Neurosurg 1999;90(5):865–7. DOI: 10.3171/jns.1999.90.5.0865Cloft H.J., Razack N., Kallmes D.F. Prevalence of cerebral aneurysms in patients with persistent primitive trigeminal artery. J Neurosurg 1999;90(5):865–7. DOI: 10.3171/jns.1999.90.5.0865O’uchi E., O’uchi T. Persistent primitive trigeminal arteries (PTA) and its variant (PTAV): analysis of 103 cases detected in 16,415 cases of MRA over 3 years. Neuroradiology 2010;52(12):1111–9. DOI: 10.1007/s00234-010-0669-6O’uchi E., O’uchi T. Persistent primitive trigeminal arteries (PTA) and its variant (PTAV): analysis of 103 cases detected in 16,415 cases of MRA over 3 years. Neuroradiology 2010;52(12):1111–9. DOI: 10.1007/s00234-010-0669-6Vasovic L., Jovanovic I., Ugrenovic S. et al. Trigeminal artery: a review of normal and pathological features. Childs Nerv Syst 2012;28(1):33–46. DOI: 10.1007/s00381-011-1622-7Vasovic L., Jovanovic I., Ugrenovic S. et al. Trigeminal artery: a review of normal and pathological features. Childs Nerv Syst 2012;28(1):33–46. DOI: 10.1007/s00381-011-1622-7Nishio A., Nishijima Y., Komiyama M., Hara M. Primitive trigeminal artery variant aneurysm treated with Guglielmi detachable coils – case report. Neurol Med Chir (Tokyo) 2001;41(9):446–9. DOI: 10.2176/nmc.41.446Nishio A., Nishijima Y., Komiyama M., Hara M. Primitive trigeminal artery variant aneurysm treated with Guglielmi detachable coils – case report. Neurol Med Chir (Tokyo) 2001;41(9):446–9. DOI: 10.2176/nmc.41.446Debrun G.M., Davis K.R., Nauta H.J. et al. Treatment of carotid cavernous fistulae or cavernous aneurysms associated with a persistent trigeminal artery: report of three cases. Am J Neuroradiol 1988;9(4):749–55.Debrun G.M., Davis K.R., Nauta H.J. et al. Treatment of carotid cavernous fistulae or cavernous aneurysms associated with a persistent trigeminal artery: report of three cases. Am J Neuroradiol 1988;9(4):749–55.Piotin M., Miralbes S., Cattin F. et al. MRI and MR angiography of persistent trigeminal artery. Neuroradiology 1996;38(8):730–3. DOI: 10.1007/s002340050337Piotin M., Miralbes S., Cattin F. et al. MRI and MR angiography of persistent trigeminal artery. Neuroradiology 1996;38(8):730–3. DOI: 10.1007/s002340050337Iancu D., Anxionnat R., Bracard S. Brainstem infarction in a patient with internal carotid dissection and persistent trigeminal artery: a case report. BMC Med Imaging 2010;10:14. DOI: 10.1186/1471-2342-10-14Iancu D., Anxionnat R., Bracard S. Brainstem infarction in a patient with internal carotid dissection and persistent trigeminal artery: a case report. BMC Med Imaging 2010;10:14. DOI: 10.1186/1471-2342-10-14Kwon J.Y., Lee E.J., Kim J.S. Brainstem infarction secondary to persistent trigeminal artery occlusion: successful treatment with intravenous rt-PA. Eur Neurol 2010;64(5):311. DOI: 10.1159/000321417Kwon J.Y., Lee E.J., Kim J.S. Brainstem infarction secondary to persistent trigeminal artery occlusion: successful treatment with intravenous rt-PA. Eur Neurol 2010;64(5):311. DOI: 10.1159/000321417Khodadad G. Trigeminal artery and occlusive cerebrovascular disease. Stroke 1977;8(2):177–81. DOI: 10.1161/01.str.8.2.177Khodadad G. Trigeminal artery and occlusive cerebrovascular disease. Stroke 1977;8(2):177–81. DOI: 10.1161/01.str.8.2.177Sato H., Haraguchi K., Takahashi Y. et al. Flow-diverter stent for an unruptured aneurysm at the junction of the internal carotid artery and persistent primitive trigeminal artery: case report and literature review. World Neurosurg 2019;132:329–32. DOI: 10.1016/j.wneu.2019.08.199Sato H., Haraguchi K., Takahashi Y. et al. Flow-diverter stent for an unruptured aneurysm at the junction of the internal carotid artery and persistent primitive trigeminal artery: case report and literature review. World Neurosurg 2019;132:329–32. DOI: 10.1016/j.wneu.2019.08.199Cekirge H.S., Saatci I. A New Aneurysm Occlusion Classification after the impact of flow modification. Am J Neuroradiol 2016;37(1):19–24. DOI: 10.3174/ajnr.A4489Cekirge H.S., Saatci I. A New Aneurysm Occlusion Classification after the impact of flow modification. Am J Neuroradiol 2016;37(1):19–24. DOI: 10.3174/ajnr.A4489Meckel S., Spittau B., McAuliffe W. The persistent trigeminal artery: development, imaging anatomy, variants, and associated vascular pathologies. Neuroradiology 2013;55(1):5–16. DOI: 10.1007/s00234-011-0995-3Meckel S., Spittau B., McAuliffe W. The persistent trigeminal artery: development, imaging anatomy, variants, and associated vascular pathologies. Neuroradiology 2013;55(1):5–16. DOI: 10.1007/s00234-011-0995-3Azab W., Delashaw J., Mohammed M. Persistent primitive trigeminal artery: a review. Turk Neurosurg 2012;22(4):399–406. DOI: 10.5137/1019-5149.JTN.4427-11.1Azab W., Delashaw J., Mohammed M. Persistent primitive trigeminal artery: a review. Turk Neurosurg 2012;22(4):399–406. DOI: 10.5137/1019-5149.JTN.4427-11.1Chen Y.C., Li M.H., Chen S.W. et al. Incidental findings of persistent primitive trigeminal artery on 3-dimensional time- of-flight magnetic resonance angiography at 3.0 T: an analysis of 25 cases. J Neuroimaging 2011;21(2):152–8. DOI: 10.1111/j.1552-6569.2010.00472.xChen Y.C., Li M.H., Chen S.W. et al. Incidental findings of persistent primitive trigeminal artery on 3-dimensional time- of-flight magnetic resonance angiography at 3.0 T: an analysis of 25 cases. J Neuroimaging 2011;21(2):152–8. DOI: 10.1111/j.1552-6569.2010.00472.xTubbs R.S., Verma K., Riech S. et al. Persistent fetal intracranial arteries: a comprehensive review of anatomical and clinical significance. J Neurosurg 2011;114(4):1127–34. DOI: 10.3171/2010.11.JNS101527Tubbs R.S., Verma K., Riech S. et al. Persistent fetal intracranial arteries: a comprehensive review of anatomical and clinical significance. J Neurosurg 2011;114(4):1127–34. DOI: 10.3171/2010.11.JNS101527Arraez-Aybar L.A., Fuentes-Redondo T., Millan J.M. Persistent trigeminal artery: a cross-sectional study based on over 3 years conventional angiography, CT angiography and MR angiography images. Surg Radiol Anat 2016;38(4):445–53. DOI: 10.1007/s00276-015-1578-5Arraez-Aybar L.A., Fuentes-Redondo T., Millan J.M. Persistent trigeminal artery: a cross-sectional study based on over 3 years conventional angiography, CT angiography and MR angiography images. Surg Radiol Anat 2016;38(4):445–53. DOI: 10.1007/s00276-015-1578-5Kai Y., Ohmori Y., Watanabe M. et al. Coil embolization of an aneurysm located at the trunk of the persistent primitive trigeminal artery. Neurol Med Chir (Tokyo) 2011;51(5):361–4. DOI: 10.2176/nmc.51.361Kai Y., Ohmori Y., Watanabe M. et al. Coil embolization of an aneurysm located at the trunk of the persistent primitive trigeminal artery. Neurol Med Chir (Tokyo) 2011;51(5):361–4. DOI: 10.2176/nmc.51.361Ohshiro S., Inoue T., Hamada Y., Matsuno H. Branches of the persistent primitive trigeminal artery – an autopsy case. Neurosurgery 1993;32(1):144–8. DOI: 10.1227/00006123-199301000-00025Ohshiro S., Inoue T., Hamada Y., Matsuno H. Branches of the persistent primitive trigeminal artery – an autopsy case. Neurosurgery 1993;32(1):144–8. DOI: 10.1227/00006123-199301000-00025Murai S., Sugiu K., Hishikawa T. et al. Endovascular treatment for unruptured aneurysm associated with persistent primitive trigeminal artery: a case report and literature review. Acta Neurochir (Wien) 2019;161(2):407–11. DOI: 10.1007/s00701-018-3767-6Murai S., Sugiu K., Hishikawa T. et al. Endovascular treatment for unruptured aneurysm associated with persistent primitive trigeminal artery: a case report and literature review. Acta Neurochir (Wien) 2019;161(2):407–11. DOI: 10.1007/s00701-018-3767-6Onizuka M., Kazekawa K., Tsutsumi M. et al. Hyperform remodeling balloon for the balloon occlusion test of persistent primitive trigeminal artery aneurysm – case report. Neurol Med Chir (Tokyo) 2006;46(11):541–3. DOI: 10.2176/nmc.46.541Onizuka M., Kazekawa K., Tsutsumi M. et al. Hyperform remodeling balloon for the balloon occlusion test of persistent primitive trigeminal artery aneurysm – case report. Neurol Med Chir (Tokyo) 2006;46(11):541–3. DOI: 10.2176/nmc.46.541Горощенко С.А., Ситовская Д.А., Петров А.Е. и др. Неблагоприятный исход течения гигантской аневризмы позвоночной артерии. Клиническое наблюдение и обзор литературы. Архив патологии 2021;83(4):45–51. DOI: 10.17116/patol20218304145Goroshchenko S.A., Sitovskaya D.A., Petrov A.E. et al. Unfavorable outcome of giant vertebral artery aneurysm. Clinical case and literature review. Archive of Pathology = Arkhiv patologii 2021;83(4):45–51. (In Russ.). DOI: 10.17116/patol20218304145Мамонов Н.А., Петров А.Е., Горощенко С.А. и др. Внутрисосудистое лечение экстракраниальных диссекционных аневризм брахиоцефальных артерий. Журнал «Вопросы нейрохирургии» им. Н.Н. Бурденко 2021;85(6):16–24. DOI: 10.17116/neiro20218506116Mamonov N.A., Petrov A.E., Goroshchenko S.A. et al. Endovascular treatment of extracranial dissecting aneurysms of cervical arteries. Zhurnal voprosy neirokhirurgii im. N.N. Burdenko = Burdenko’s Journal of Neurosurgery 2021;85(6):16–24. (In Russ., In Eng.). DOI: 10.17116/neiro20218506116Miyachi S., Ohnishi H., Hiramatsu R. et al. Innovations in endovascular treatment strategies for large carotid cavernous aneurysms – the safety and efficacy of a flow diverter. J Stroke Cerebrovasc Dis 2017;26(5):1071–80. DOI: 10.1016/j.jstrokecerebrovasdis.2016.12.023Miyachi S., Ohnishi H., Hiramatsu R. et al. Innovations in endovascular treatment strategies for large carotid cavernous aneurysms – the safety and efficacy of a flow diverter. J Stroke Cerebrovasc Dis 2017;26(5):1071–80. DOI: 10.1016/j.jstrokecerebrovasdis.2016.12.023

The authors declare that there are no conflicts of interest present.