case_images: PMC11021110_01
case_images: (a) Computed tomography (CT) showed no signs of hemorrhage or early ischemia; (b) electrocardiogram showed the cardiogram feature of atrial fibrillation; (c) preoperative CT perfusion (CTP)-cerebral blood volume (CBV) image demonstrated acute cerebral infarction involving the brainstem; solid lines of squares represented the ischemic core area with CBV <1.2 mL/100 mL; (d) preoperative CTP-cerebral blood flow (CBF) image displayed an area of penumbra in the brainstem; solid lines of squares represented the penumbra area with CBF <27 mL/100 g/min.
case_images: SNI-15-93-g001.jpg
case_images: PMC11021110_01_SNI-15-93-g001.jpg
case_images: F1
case_images: Noncontrast computed tomography (CT) on admission showed no evidence of hemorrhage or early ischemia [Figure 1a]. Electrocardiogram findings confirmed the diagnosis of atrial fibrillation (AF) [Figure 1b]. The analysis revealed a significant volume of penumbra (70 mL), the region of potentially salvageable brain tissue, and ischemic core (10 mL), the irreversibly damaged brain tissue, in the brain stem and cerebellar hemispheres [Figures 1c and d].
case_images: (a) Digital subtraction angiography (DSA) image indicating the left posterior inferior cerebellar artery (PICA) with a red arrow; (b) DSA image illustrating the hypoplastic right PICA (red arrow); (c) DSA image displaying the right posterior cerebral artery(PCA) and middle cerebral artery(MCA); the red dotted square highlights the presence of the persistent primitive trigeminal artery (PPTA) arising from the cavernous Internal carotid artery( ICA). In (d), the red dotted square is enlarged to reveal the absence of the terminal portions of the PPTA, as indicated by the red dotted oval curve.
case_images: SNI-15-93-g002.jpg
case_images: PMC11021110_01_SNI-15-93-g002.jpg
case_images: F2
case_images: Emergent digital subtraction angiography (DSA) revealed the following results: the termination of both the left vertebral artery (VA) and the right VA was observed in the posterior inferior cerebellar artery [Figures 2a and b]. Based on the imaging features, we observed a PPTA arising from the cavernous ICA [Figure 2c] and occluded near its distal end [Figure 2d].
case_images: (a) Successful passage of a micro guidewire through the occlusion site, reaching the posterior cerebral artery (PCA); (b) images illustrating the basilar artery (BA) and PCA after deploying a revascularization with the embolization of a carotid occlusion (RECO) 4 x20 mm stent, leading to vessel reperfusion; (c) visualization of the recanalized BA after stent retrieval; (d) digital subtraction angiography image depicting the presence of the PPTA, BA, PCA, middle cerebral artery, and PCA following the successful recanalization of the persistent primitive trigeminal artery (PPTA) and BA; (e) extraction of a firm thrombus from the occluded PPTA.
case_images: SNI-15-93-g003.jpg
case_images: PMC11021110_01_SNI-15-93-g003.jpg
case_images: F3
case_images: This intricate setup allowed for precise access to the occluded area associated with the PPTA, as depicted in Figure 3a. Following this, we introduced a RECO 4 x 20 mm stent retriever (Medtronic, USA) into the XT-27 microcatheter, positioning it strategically across the thrombus [Figure 3b]. DSA confirmed the complete recanalization of the PPTA and the BA, achieving modified thrombolysis in cerebral infarction Grade 3 blood flow, as illustrated in Figures 3c and d. During the procedure, a substantial thrombus was successfully extracted from the occluded PPTA, as shown in Figure 3e.