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Case Reports
. 2025 Apr 1;17(4):e81562.
doi: 10.7759/cureus.81562. eCollection 2025 Apr.

Symptomatic Common Carotid Artery Stenosis With a Persistent Primitive Hypoglossal Artery Presenting With Posterior Circulation Symptoms and Technical Challenges in Stenting

Keisuke Kadooka  1 , Roselyn Pamatmat  2 , Kotaro Ueda  1 , Shimpei Tsuboki  3   1 , Takafumi Mitsutake  1 , Michihiro Tanaka  1
Affiliations
Case Reports

Symptomatic Common Carotid Artery Stenosis With a Persistent Primitive Hypoglossal Artery Presenting With Posterior Circulation Symptoms and Technical Challenges in Stenting

Keisuke Kadooka et al. Cureus. .

Abstract

The persistent primitive hypoglossal artery (PPHA) is a rare variant of the persistent carotid-vertebrobasilar anastomoses. When PPHA coexists with carotid artery stenoses, it typically presents ischemic symptoms of the anterior circulation. However, we report a unique case of common carotid artery (CCA) stenosis with PPHA presenting exclusively ischemic symptoms of the posterior circulation, which posed significant diagnostic challenges and required innovative modifications in embolic protection strategies during carotid artery stenting. A 65-year-old woman experienced recurrent bilateral ptosis, diplopia, and transient bilateral visual loss, suggestive of posterior circulation ischemia. Imaging revealed significant left CCA stenosis with a PPHA supplying the posterior circulation. Due to the large diameter of the CCA, standard distal protection was unfeasible. Instead, distal balloon protection was innovatively applied at the bifurcation of the PPHA and the internal carotid artery, where the slightly narrower diameter facilitated successful stenting. The postoperative course was favorable, with no recurrence of symptoms. PPHA-associated carotid stenosis can cause posterior circulation symptoms, complicating diagnosis. Understanding anatomical and hemodynamic variations like PPHA is crucial for effective treatment and ensuring optimal outcomes.

Keywords: carotid artery stenosis; carotid artery stenting; embolic protection; persistent primitive hypoglossal artery; posterior circulation.

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Conflict of interest statement

Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. Preoperative MRI and CT angiography. (A) DWI showing hyperintensity at the left parietooccipital area (white arrows). (B) MR angiography showing PPHA running through the left hypoglossal canal (white arrow). (C) CT angiography revealing CCA stenosis (white arrow). PPHA originates from the ICA at the level of the mandibular angle (white dotted arrow)
DWI: diffusion-weighted imaging; PPHA: persistent primitive hypoglossal artery; CCA: common carotid artery
Figure 2
Figure 2. Treatment and cone beam CT of the PPHA. (A) Preoperative left CCA injection showing CCA stenosis. The caliber of the distal CCA is too large to occlude with a distal balloon protection device. Note the narrow segment at the bifurcation (white arrow). (B) Intraoperative roadmap. The distal balloon (white arrow) protection device is located at the ICA and PPHA bifurcation, where its diameter is small enough for the distal balloon protection devices. (C) Postoperative injection showing successful stenting. Cone beam CT revealing left PPHA (white arrows) running through the hypoglossal canal: (D) axial, (E) coronal, and (F) sagittal
CT: computed tomography; PPHA: persistent primitive hypoglossal artery; CCA: common carotid artery
See this image and copyright information in PMC

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