Treatment Strategy for Symptomatic Internal Carotid Artery Stenosis with Persistent Primitive Hypoglossal Artery

Abstract

The persistent primitive hypoglossal artery (PPHA) is the second most common of the remnant embryonic arteries. We describe a case of carotid endarterectomy for symptomatic internal carotid artery (ICA) stenosis with ipsilateral PPHA. A 68-year-old man presented to a local hospital with weakness in his left lower extremity and was referred to our hospital after carotid ultrasonography revealed severe stenosis of the right ICA. Head magnetic resonance imaging (MRI) revealed small infarcts in the right cerebellar hemisphere, bilateral occipital lobes, and right frontal lobe, whereas cervical vascular MRI revealed an unstable plaque at the site of stenosis. Angiography demonstrated 70% stenosis of the right ICA, according to North American Symptomatic Carotid Endarterectomy Trial criteria, with the PPHA branched posteriorly from the ICA and anastomosing with the vertebral artery. Under somatosensory evoked potential, electroencephalography, and auditory brainstem response monitoring, an internal shunt was placed between the distal end of the plaque and PPHA bifurcation, and carotid endarterectomy was performed. The patient was discharged postoperatively without any new findings of cerebral infarction or neurological deficits. There are several variations in ICA stenosis with the PPHA, including collateral blood circulation and the height of the PPHA bifurcation. Therefore, individual strategies should be determined to ensure safe treatment for each case.