Posterior Cerebral Circulation Stroke Secondary to Foetal Origin of Posterior Communicating Artery: An Indication for Carotid Endarterectomy

Abstract

Introduction: Posterior cerebral circulation strokes are most commonly caused by posterior vasculature in situ thrombosis, cardiac emboli, or arterial dissection. However, the foetal origin of the posterior communicating artery is an anatomical variant of the cerebral circulation that results in communication between the internal carotid and posterior cerebral circulation. Therefore, rarely this can result in posterior cerebral territory infarction from internal carotid artery thrombo-embolism. This is the report of a case in which a patient suffered posterior circulation stroke secondary to this anatomical variation of the circle of Willis.

Report: A 71 year old male patient was admitted to the stroke team with seizures, headache, and confusion. Examination revealed a left sided homonymous hemianopia. Diffusion weighted magnetic resonance imaging (MRI) of the brain 36 hours into his admission revealed an acute right posterior circulation infarct with extensive haemorrhagic transformation. Duplex ultrasound three days later revealed a heavily calcified right internal carotid artery mixed echogenicity plaque with 80%-90% stenosis. Subsequent computed tomography angiography showed a large right foetal variant posterior communicating artery. Following improvement in functional status, the patient underwent uneventful carotid endarterectomy to reduce risk of future stroke.

Discussion: In patients presenting with posterior circulation infarction, clinicians should consider embolism from an atheromatous internal carotid artery via the variant foetal origin of posterior communicating artery. If detected, consideration should be given to undertaking carotid endarterectomy to reduce future stroke risk if no other source is detected.

Keywords: Carotid artery disease; Circle of Willis; Foetal origin of posterior communicating artery; Stroke.

Figure 1

(A) Normal configuration of the complete Circle of Willis. (B) A partial foetal type posterior communicating artery (PComA) with a hypoplastic P1 posterior cerebral artery segment as seen in this patient. (C) The true foetal PComA with an absent P1 segment.

Figure 2

(A) Arrow showing magnetic resonance imaging of a brain with acute right posterior cerebral artery territory infarct. (B) Arrow showing computed tomography angiogram demonstrating the large right PComA.

Figure 3

Carotid doppler of right internal carotid artery (ICA).