Tandem symptomatic internal carotid artery and persistent hypoglossal artery stenosis treated by endovascular stenting and flow reversal

Abstract

Persistence of the hypoglossal artery into adulthood is a rare vascular anomaly and, when present, provides the predominant vascular supply to the posterior circulation. We describe a case of vertebrobasilar insufficiency associated with severe high-grade stenosis of the persistent hypoglossal artery and tandem stenosis of the proximal ipsilateral internal carotid artery, treated by an endovascular approach. The unique anatomical and technical challenges associated with this case are reviewed in detail.

Keywords: Atherosclerosis; Intervention; Stenosis; Stent.

Figure 1

CT perfusion imaging showing no asymmetry and no evidence of perfusion deficit.

Figure 2

CT angiogram showing an anomalous vessel traveling through the hypoglossal canal with evidence of calcification and stenosis as it traverses the skull base. This is consistent with the diagnosis of persistent hypoglossal artery.

Figure 3

(A) Digital subtraction angiogram (lateral projection) showing the persistent hypoglossal artery (PHA) communicating the right internal carotid artery (ICA) with the basilar artery. Notice the high-degree stenosis at the PHA and the atherosclerotic plaque with stenosis of the proximal ICA. (B) The same angiographic view showing stenosis of the PHA measuring approximately 80%.

Figure 4

Roadmap guidance angiogram demonstrating the proximal (in the proximal internal carotid artery (ICA)) and distal (in the distal ICA) balloons of the GORE Flow-Reversal System. Inflation of the balloons creates anterograde flow arrest and, once the extracorporeal connection to the contralateral femoral vein is established, allows flow reversal through the persistent hypoglossal artery, essentially preventing any embolic debris from moving distally into the cerebral circulation.

Figure 5

The persistent hypoglossal artery and proximal internal carotid artery Wallstents have been deployed with excellent resolution of the vessel stenosis.

Figure 6

Final intracranial angiographic run, anteroposterior (A) and lateral (B) projections, demonstrating good filling of the intracranial circulation after successful tandem stenting. The territories of the carotid and basilar arteries are supplied by the right internal carotid artery through the persistent hypoglossal artery.