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.

Abstract

A 69-year-old woman with hypertension presented to the emergency room with severe pulsatile pain around the left orbital area and diplopia for 2 days. Neurological examination revealed paresthesia over the upper two-thirds of left face innervated by the ophthalmic and maxillary divisions of trigeminal nerve and diplopia secondary to left abducens nerve palsy. Brain noncontrast computed tomography (CT) showed a 2.5 × 2.5 × 2.0 cm hyperdense mass over left cavernous sinus suggestive of thrombus formation (Fig. 1a). CT angiography (CTA) showed a giant, partially thrombosed aneurysm arising from the intracavernous internal carotid artery (ICA) (Fig. 1b). Digital subtraction angiography (DSA) showed a large persistent primitive trigeminal artery (PPTA) connecting the ICA to the distal part of the hypoplastic middle basilar artery (BA), with a 1.2 × 1.2 × 1.0 cm aneurysm sac at the origin of PPTA and hypoplasia in the left vertebral artery (VA). (Fig. 1c–f) Steroid therapy was prescribed initially and endovascular surgery was arranged. Aspirin (400 mg) and clopidogrel (300 mg) were administered before the treatment. All procedures were performed under general anesthesia and full heparinization. The covered stent, Jostent stent graft (previously JoMed, Helsingborg, Sweden; now Abbott Vascular, Redwood City, California, USA), was successfully deployed at left ICA to cover the orifice of persistent primitive trigeminal artery (Fig. 2). The postoperative course was uneventful. Trigeminal neuralgia improved immediately after treatment but diplopia persisted. One-year follow-up of left ICA DSA showed ICA patency was preserved and there was no recurrent aneurysm. In addition, the right VA DSA showed a small remnant of PPTA supplied by the vertebrobasilar artery (Fig. 3). The clinical situation at one-year follow-up showed complete resolution of trigeminal neuralIntroduction