Neuro-radiology
Neuroradiology (1991) 33:513-515
9 Springer-Veflag 1991
The posterior inferior cerebellar artery originating from the internal carotid artery, associated with multiple aneurysms H. Manabe 1, N. Oda 2' 3, M. Ishii 2, and A. IshiP 1 Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Japan Divisions of 2 Neurosurgery, 3 Neurology and 4 Ophthalmology, Ishii Hospital of Neurosurgery and Ophthalmology, Iwaki, Japan Received: 6 July 1991
Summary. We report the rare case of ipsilateral posterior inferior cerebellar artery originating from the carotid artery, and associated with multiple concurrent aneurysms. This is the 23rd reported case of carotid-cerebellar anastomosis and the first case with three concurrent aneurysms reported in the literature. Of the 23 cases, 6 had single aneurysms, 2 had double aneurysms and the present case had triple aneurysms.
artery originating directly from the ipsilateral carotid artery without opacification of the basilar artery. Since then, a total of 22 cases of variant carotid-basilar anastomosis [2] have been reported [1, 3-13]. We report here the 23rd case of variant carotid-basilar anastomosis: the posterior inferior cerebellar artery (PICA) originating from the ipsilateral internal carotid artery, complicated by multiple intracranial aneurysms.
Key words: Carotid-cerebellar anastomosis-Multiple aneurysms - A n a t o m y of arteries
Case report
Anomalous carotid-cerebellar anastomosis was first reported by Teal et al. [1] in 1972 as the superior cerebellar
This 38-year-old woman with severe headache for 6 days and left choked disc showed CT evidence of subarachnoid hemorrhage and mild hydrocephalus. Angiography
Fig.l.a,b. Right carotid angiogram shows the right P1-2 junction aneurysm (closed arrow), the right internal carotid-posterior communicating aneurysm (open arrow) and the right posterior inferior
cerebellar artery originating from the precavernous portion of the right internal carotid artery (arrowhead)
514
Fig.2.a,b. The left vertebral angiogram shows the right P1-2 junction aneurysm (arrow). The left carotid angiogram shows the left middle cerebral aneurysm (arrowhead) Table 1. Reported cases ofthe cerebellar artery originating from the carotid artery a
Cavernous Distal IC Precavernous Precavernous Cavernous Precavernous
Terminal portion SCA PICA PICA PICA AICA AICA
Complicating aneurysm None A corn An None None None A corn An
PTAV PTAV PTAV PTAV PTAV PTAV PTAV PTAV POAV PTAV
Precavernous Precavernous Precavernous Precavernous Cavernous Cavernous Cavernous Cavernous Pe~ous Cavernous
AICA AICA AICA AICA AICA AICA AICA AICA PICA AICA
None None None None 2MC Ans None None None None None
PTAV PTAV PTAV PTAV PTAV PTAV PTAV
Precavernous Presellar Presellar Cavernous Precavernous Precavernous Precavernous
AICA AICA AICA SCA SCA AICA PICA
Basilar top An IC-PC An A corn A n PC-P corn A n None PTA An, basilar An IC-PCAN, M C A n , P1-2 junction A n
Author
Age/sex
Type
Original site
Teal et al. (1972) [1] Teal et al. (1973) [11] Delinge and Heon (1974) [5] Chambers and Lukin (1975) [3] Scotti (1975) [10] Nutik and Dilenge (1976) [8]
31 F 41 M ? 59 F 58 F 22 F
PTAV PHAV PTAV PTAV PTAV PTAV
Haughton et al. (1978) [6]
? ? ? ? 56 M 19 F ?F ? 17 M 1M 51 F 20 F ?M 34 M 44 F 67 F 38 F
Tomsick et al. (1979) [12]
Ito et al. (1980) [7]
Cobb et al. (1983) [4] Okuno et al. (1988) [9] Watanabe et al. (1988) [13] Manabe et al. (1991; this report)
a Abbreviations: PTA, Primitive trigeminal artery; oph, ophthalmic;
anast, anastomosis; PTAV, primitive trigeminal artery variant; PHAV, primitive hypoglossal artery variant; SCA, superior cerebel-
Other anomaly None IC-AC anast None None None A com-IC anast, oph. A; origin from internal carotid artery None None None None None None None None PTA, AVM Sturge-Weber syndrome None None None Hypoplasia of Blt.IC None PTA None
lar artery; PICA, posterior inferior cerebellar artery; AICA, anterior inferior cerebellar artery; POAV, primitive otic artery variant
515 (Figs. 1, 2) showed an aneurysm of the left middle cerebral artery, an aneurysm of the right internal carotid-posterior communicating artery and aright P1-2 junction aneurysm. The right P I C A originated f r o m the precavernous portion of the right internal carotid artery without opacification of the basilar artery. The right vertebral artery was hypoplastic. Both superior cerebellar arteries (SCA) and the left anterior inferior cerebellar artery ( A I C A ) were opacified on left vertebral angiography. Neither the P I C A s nor the right A I C A were opacified. Radical operations were performed in two stages for the three aneurysms with a ventriculoperitoneal shunt. The postoperative course was uneventful.
Discussion The 23 reported cases of anomalous carotid-cerebellar anastomosis, including our case are listed in Table 1 [1, 3-12]. Nine of the 23 cases had associated aneurysms. Six of the 23 cases had one aneurysm, 2 had two concurrent aneurysms, and this case alone had three aneurysms. A total of 6 of the 23 cases had other vascular anomalies. According to Lie's classification, carotid-cerebellar anastomoses can be divided into three types [2]: the primitive otic artery variant (POAV) [12], the primitive hypoglossal artery variant (PHAV) [11], and the primitive trigeminal artery variant (PTAV) [3-13]. Our case can be classified as a PTAV. Since a structural defect has been reported in the arterial walls of the circle of Willis in cases of primitive trigeminal artery [14], the high incidence of vascular malformations in cases of persistent embryonic vessels might suggest a congenital disturbance of brain vessel developm e n t [15]. In the embryo, a n u m b e r of branches provide communication between the carotid system and the verteobrobasilar system, e.g., the primitive trigeminal artery [16]. As lateral vertebrobasilar anastomoses form cerebellar arteries, it might be possible for the primitive trigeminal artery originating from the internal carotid artery to form P I C A [2].
Acknowledgements. We express our appreciation to Professor Takashi Iwabuchi, Department of Neurosurgery, Hirosaki University School of Medicine for his encouragement in preparing this paper. We are also indebted to Mr. Yoshiichi Furukawa, Radiological technologist, Ishii Hospital of Neurosurgery and Ophthalmology, for his gentle assistance.
References 1. Teal JS, Rumbaugh CL, Bergeron RT, Scanlan RL, Segall HD (1972) Persistent carotid-superior cerebellar artery anastomosis: a variant of persistent trigeminal artery. Radiology 103:335-341 2. Lie TA (1983) Congenital anomalies of the carotid arteries. Variations in cerebrovascular anatomy. In: Fox JL (ed) Intracranial aneurysms. Springer, New York Berlin Heidelberg, pp 432-489 3. Chambers AA, Lukin RR (1975) Trigeminal artery connection to the posterior inferior cerebellar arteries. Ne~roradiology 9: 121-123 4. Cobb SR, Hieshima GB, Mehringer CM, Grinnell VS (1983) Persistent trigeminal artery variant. Surg Neuro119: 263-266 5. Dilenge D, Heon M (1974) The internal carotid artery. In: Newton TH, Potts DG (eds) Radiology of the skull and brain. Mosby, St Louis, pp 1202-1245 6. Hanghton VM, Rosenbaum AE, Pearce J (1978) Internal carotid artery origins of the inferior cerebellar arteries. Am J Roentgeno1130:1191-1192 7. Ito J, Takeda N, Suzuki Y, Takeuchi S, Osugi S, Yoshida Y (1980) Anomalous origin of the anterior inferior cerebellar arteries from the internal carotid artery. Neuroradiology 19:105-109 8. Nutik S, Dilenge D (1976) Carotid-anterior cerebral artery anastomosis. J Neurosurg 44:378-382 9. Okuno T, Nishiguchi T, Hayashi S, Miyamoto K, Terashita T, Itakura T, Moriwaki H, Komai N (1988) A case of carotid superior cerebellar artery anastomosis associated with bilateral hypoplasia of the internal carotid arteries. Represented as the rupture of posterior cerebral artery-posterior communicating artery aneurysm. No Shinkei Geka 16:1211-1217 10. Scotti G (1975) Anterior inferior cerebellar artery originating from the cavernous portion of the internal carotid artery. Radiology 116:93-94 11. Teal JS, Rumbaugh CL, Segall HD, Bergeron RT (1973) Anomalous branches of the internal carotid artery. Radiology 106: 567573 12. Tomsick TA, Lukin RR, Chambers AA (1979) Persistent trigeminal artery: unusual associated abnormalities. Neuroradiology 17:253-257 13. Watanabe T, Aoki A, Sn Ching Chan (1988) Two cases of persistent trigeminal artery variant. No Shinkei Geka 16:95-100 14, Wolpert SM (1966) The trigeminal artery and associated aneurysms. Neurology 16:610-614 15. Agnoli AL (1982) Vascular anomalies and subarachnoid haemorrhage. Associated with persisting embryonic vessels. Acta Neurochir 60:183-199 16. Padget DH (1948) The development of the cranial arteries in the human embryo. Contrib Embryo132:207-261 Dr. H. Manabe Department of Neurosurgery Hirosaki University School of Medicine 5 Zaifucho Hirosaki 036 Japan
Neuroradiology (1991) 33:513-515
9 Springer-Veflag 1991
The posterior inferior cerebellar artery originating from the internal carotid artery, associated with multiple aneurysms H. Manabe 1, N. Oda 2' 3, M. Ishii 2, and A. IshiP 1 Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Japan Divisions of 2 Neurosurgery, 3 Neurology and 4 Ophthalmology, Ishii Hospital of Neurosurgery and Ophthalmology, Iwaki, Japan Received: 6 July 1991
Summary. We report the rare case of ipsilateral posterior inferior cerebellar artery originating from the carotid artery, and associated with multiple concurrent aneurysms. This is the 23rd reported case of carotid-cerebellar anastomosis and the first case with three concurrent aneurysms reported in the literature. Of the 23 cases, 6 had single aneurysms, 2 had double aneurysms and the present case had triple aneurysms.
artery originating directly from the ipsilateral carotid artery without opacification of the basilar artery. Since then, a total of 22 cases of variant carotid-basilar anastomosis [2] have been reported [1, 3-13]. We report here the 23rd case of variant carotid-basilar anastomosis: the posterior inferior cerebellar artery (PICA) originating from the ipsilateral internal carotid artery, complicated by multiple intracranial aneurysms.
Key words: Carotid-cerebellar anastomosis-Multiple aneurysms - A n a t o m y of arteries
Case report
Anomalous carotid-cerebellar anastomosis was first reported by Teal et al. [1] in 1972 as the superior cerebellar
This 38-year-old woman with severe headache for 6 days and left choked disc showed CT evidence of subarachnoid hemorrhage and mild hydrocephalus. Angiography
Fig.l.a,b. Right carotid angiogram shows the right P1-2 junction aneurysm (closed arrow), the right internal carotid-posterior communicating aneurysm (open arrow) and the right posterior inferior
cerebellar artery originating from the precavernous portion of the right internal carotid artery (arrowhead)
514
Fig.2.a,b. The left vertebral angiogram shows the right P1-2 junction aneurysm (arrow). The left carotid angiogram shows the left middle cerebral aneurysm (arrowhead) Table 1. Reported cases ofthe cerebellar artery originating from the carotid artery a
Cavernous Distal IC Precavernous Precavernous Cavernous Precavernous
Terminal portion SCA PICA PICA PICA AICA AICA
Complicating aneurysm None A corn An None None None A corn An
PTAV PTAV PTAV PTAV PTAV PTAV PTAV PTAV POAV PTAV
Precavernous Precavernous Precavernous Precavernous Cavernous Cavernous Cavernous Cavernous Pe~ous Cavernous
AICA AICA AICA AICA AICA AICA AICA AICA PICA AICA
None None None None 2MC Ans None None None None None
PTAV PTAV PTAV PTAV PTAV PTAV PTAV
Precavernous Presellar Presellar Cavernous Precavernous Precavernous Precavernous
AICA AICA AICA SCA SCA AICA PICA
Basilar top An IC-PC An A corn A n PC-P corn A n None PTA An, basilar An IC-PCAN, M C A n , P1-2 junction A n
Author
Age/sex
Type
Original site
Teal et al. (1972) [1] Teal et al. (1973) [11] Delinge and Heon (1974) [5] Chambers and Lukin (1975) [3] Scotti (1975) [10] Nutik and Dilenge (1976) [8]
31 F 41 M ? 59 F 58 F 22 F
PTAV PHAV PTAV PTAV PTAV PTAV
Haughton et al. (1978) [6]
? ? ? ? 56 M 19 F ?F ? 17 M 1M 51 F 20 F ?M 34 M 44 F 67 F 38 F
Tomsick et al. (1979) [12]
Ito et al. (1980) [7]
Cobb et al. (1983) [4] Okuno et al. (1988) [9] Watanabe et al. (1988) [13] Manabe et al. (1991; this report)
a Abbreviations: PTA, Primitive trigeminal artery; oph, ophthalmic;
anast, anastomosis; PTAV, primitive trigeminal artery variant; PHAV, primitive hypoglossal artery variant; SCA, superior cerebel-
Other anomaly None IC-AC anast None None None A com-IC anast, oph. A; origin from internal carotid artery None None None None None None None None PTA, AVM Sturge-Weber syndrome None None None Hypoplasia of Blt.IC None PTA None
lar artery; PICA, posterior inferior cerebellar artery; AICA, anterior inferior cerebellar artery; POAV, primitive otic artery variant
515 (Figs. 1, 2) showed an aneurysm of the left middle cerebral artery, an aneurysm of the right internal carotid-posterior communicating artery and aright P1-2 junction aneurysm. The right P I C A originated f r o m the precavernous portion of the right internal carotid artery without opacification of the basilar artery. The right vertebral artery was hypoplastic. Both superior cerebellar arteries (SCA) and the left anterior inferior cerebellar artery ( A I C A ) were opacified on left vertebral angiography. Neither the P I C A s nor the right A I C A were opacified. Radical operations were performed in two stages for the three aneurysms with a ventriculoperitoneal shunt. The postoperative course was uneventful.
Discussion The 23 reported cases of anomalous carotid-cerebellar anastomosis, including our case are listed in Table 1 [1, 3-12]. Nine of the 23 cases had associated aneurysms. Six of the 23 cases had one aneurysm, 2 had two concurrent aneurysms, and this case alone had three aneurysms. A total of 6 of the 23 cases had other vascular anomalies. According to Lie's classification, carotid-cerebellar anastomoses can be divided into three types [2]: the primitive otic artery variant (POAV) [12], the primitive hypoglossal artery variant (PHAV) [11], and the primitive trigeminal artery variant (PTAV) [3-13]. Our case can be classified as a PTAV. Since a structural defect has been reported in the arterial walls of the circle of Willis in cases of primitive trigeminal artery [14], the high incidence of vascular malformations in cases of persistent embryonic vessels might suggest a congenital disturbance of brain vessel developm e n t [15]. In the embryo, a n u m b e r of branches provide communication between the carotid system and the verteobrobasilar system, e.g., the primitive trigeminal artery [16]. As lateral vertebrobasilar anastomoses form cerebellar arteries, it might be possible for the primitive trigeminal artery originating from the internal carotid artery to form P I C A [2].
Acknowledgements. We express our appreciation to Professor Takashi Iwabuchi, Department of Neurosurgery, Hirosaki University School of Medicine for his encouragement in preparing this paper. We are also indebted to Mr. Yoshiichi Furukawa, Radiological technologist, Ishii Hospital of Neurosurgery and Ophthalmology, for his gentle assistance.
References 1. Teal JS, Rumbaugh CL, Bergeron RT, Scanlan RL, Segall HD (1972) Persistent carotid-superior cerebellar artery anastomosis: a variant of persistent trigeminal artery. Radiology 103:335-341 2. Lie TA (1983) Congenital anomalies of the carotid arteries. Variations in cerebrovascular anatomy. In: Fox JL (ed) Intracranial aneurysms. Springer, New York Berlin Heidelberg, pp 432-489 3. Chambers AA, Lukin RR (1975) Trigeminal artery connection to the posterior inferior cerebellar arteries. Ne~roradiology 9: 121-123 4. Cobb SR, Hieshima GB, Mehringer CM, Grinnell VS (1983) Persistent trigeminal artery variant. Surg Neuro119: 263-266 5. Dilenge D, Heon M (1974) The internal carotid artery. In: Newton TH, Potts DG (eds) Radiology of the skull and brain. Mosby, St Louis, pp 1202-1245 6. Hanghton VM, Rosenbaum AE, Pearce J (1978) Internal carotid artery origins of the inferior cerebellar arteries. Am J Roentgeno1130:1191-1192 7. Ito J, Takeda N, Suzuki Y, Takeuchi S, Osugi S, Yoshida Y (1980) Anomalous origin of the anterior inferior cerebellar arteries from the internal carotid artery. Neuroradiology 19:105-109 8. Nutik S, Dilenge D (1976) Carotid-anterior cerebral artery anastomosis. J Neurosurg 44:378-382 9. Okuno T, Nishiguchi T, Hayashi S, Miyamoto K, Terashita T, Itakura T, Moriwaki H, Komai N (1988) A case of carotid superior cerebellar artery anastomosis associated with bilateral hypoplasia of the internal carotid arteries. Represented as the rupture of posterior cerebral artery-posterior communicating artery aneurysm. No Shinkei Geka 16:1211-1217 10. Scotti G (1975) Anterior inferior cerebellar artery originating from the cavernous portion of the internal carotid artery. Radiology 116:93-94 11. Teal JS, Rumbaugh CL, Segall HD, Bergeron RT (1973) Anomalous branches of the internal carotid artery. Radiology 106: 567573 12. Tomsick TA, Lukin RR, Chambers AA (1979) Persistent trigeminal artery: unusual associated abnormalities. Neuroradiology 17:253-257 13. Watanabe T, Aoki A, Sn Ching Chan (1988) Two cases of persistent trigeminal artery variant. No Shinkei Geka 16:95-100 14, Wolpert SM (1966) The trigeminal artery and associated aneurysms. Neurology 16:610-614 15. Agnoli AL (1982) Vascular anomalies and subarachnoid haemorrhage. Associated with persisting embryonic vessels. Acta Neurochir 60:183-199 16. Padget DH (1948) The development of the cranial arteries in the human embryo. Contrib Embryo132:207-261 Dr. H. Manabe Department of Neurosurgery Hirosaki University School of Medicine 5 Zaifucho Hirosaki 036 Japan
