Persistent Trigeminal Artery in Endonasal Resection of Skull Base Tumors: A Systematic Review

Abstract

Background Primitive persistent trigeminal artery (PTA) is an uncommon embryologic vascular communication between the carotid and basilar arteries, which can be intimately involved by skull base tumors (SBT). Owing to its rarity, skull base surgeons should familiarize themselves with the anatomical variations of PTA to avoid catastrophic complications.

Objective To appraise and summarize the available evidence of PTA involved by SBTs while advocating a standardized algorithm for the surgical planning of these patients.

Methods MEDLINE and PubMed databases were searched using keywords pertaining to PTA and SBTs. Demographics, clinical presentation, radiographic findings, outcomes, and adverse events were extracted and analyzed.

Results A total of 13 cases between 1973 and 2015 were identified. The mean patient age at presentation was 43 years with predilections toward females and pituitary adenomas. Headaches and endocrine abnormalities were the most common symptoms. The tumors were more frequently associated with Salas medial-type PTA (70%) and Saltzman type-I PTA (31%) than seen in the general population in angiographic studies. We also present a new case of atypical meningioma with Saltzman type-1 PTA.

Conclusion With endoscopic approaches to SBTs becoming more commonplace, surgeons may encounter this anatomical abnormality more frequently. It is important for both otolaryngologists and neurosurgeons to gain a complete understanding of the anatomical variations and neurointerventional capabilities for the successful endoscopic management of these situations.

Level of Evidence: 4.

Keywords

persistent trigeminal artery - arterial variants - skull base surgery - skull base tumor - meningioma - arteriovenous malformation

• References

• 1 Lee KS, Kelly Jr DL. Intrasellar persistent trigeminal artery associated with a pituitary adenoma. Case report. J Neurosurg 1989; 70 (2) 271-273
• 2 Quain R. The Anatomy of the Arteries of the Human Body, with Its Applications to Pathology and Operative Surgery, in Lithographic Drawings with Practical Commentaries. London: Taylor and Walton; 1844
• 3 Sutton D. Anomalous carotid-basilar anastomosis. Br J Radiol 1950; 23 (274) 617-619
• 4 O'uchi E, O'uchi T. Persistent primitive trigeminal arteries (PTA) and its variant (PTAV): analysis of 103 cases detected in 16,415 cases of MRA over 3 years. Neuroradiology 2010; 52 (12) 1111-1119
• 5 Uchino A, Sawada A, Takase Y, Kudo S. MR angiography of anomalous branches of the internal carotid artery. AJR Am J Roentgenol 2003; 181 (5) 1409-1414
• 6 Uchino A, Saito N, Okada Y , et al. Persistent trigeminal artery and its variants on MR angiography. Surg Radiol Anat 2012; 34 (3) 271-276
• 7 Saltzman GF. Patent primitive trigeminal artery studied by cerebral angiography. Acta Radiol 1959; 51 (5) 329-336
• 8 Salas E, Ziyal IM, Sekhar LN, Wright DC. Persistent trigeminal artery: an anatomic study. Neurosurgery 1998; 43 (3) 557-561 , discussion 561–562
• 9 Meckel S, Spittau B, McAuliffe W. The persistent trigeminal artery: development, imaging anatomy, variants, and associated vascular pathologies. Neuroradiology 2013; 55 (1) 5-16
• 10 Navas M, Martinez P, Shakur SF , et al. Intrasellar chordoma associated with a primitive persistent trigeminal artery. Turk Neurosurg 2015; 25 (1) 146-153
• 11 Machado MC, Kodaira S, Musolino NR. Persistence of intrasellar trigeminal artery and simultaneous pituitary adenoma: description of two cases and their importance for the differential diagnosis of sellar lesions. Arq Bras Endocrinol Metabol 2014; 58 (6) 661-665
• 12 Komatsu F, Komatsu M, Di Ieva A, Tschabitscher M. Endoscopic anatomy of persistent trigeminal artery: a cadaveric study. Minim Invasive Neurosurg 2011; 54 (5–6) 223-227
• 13 Baltsavias G, Valavanis A. Endovascular occlusion of a lacerated primitive trigeminal artery during surgical resection of clival chordoma: a case report. Interv Neuroradiol 2010; 16 (2) 204-207
• 14 Murai Y, Kobayashi S, Tateyama K, Teramoto A. Persistent primitive trigeminal artery aneurysm associated with cerebellar hemangioblastoma. Case report. Neurol Med Chir (Tokyo) 2006; 46 (3) 143-146
• 15 Abe T, Fujita S, Ozawa H , et al. Haemorrhagic nonsecreting pituitary adenoma associated with persistent primitive trigeminal artery. Acta Neurochir (Wien) 2000; 142 (12) 1423-1424
• 16 Szeifert G, Lányi F, Czirják S, Pásztor E. Persistent trigeminal artery associated with pituitary adenoma [in Hungarian]. Orv Hetil 1991; 132 (26) 1433-1434
• 17 Minokura K, Hakuba A, Kurose K, Nishimura S. A variant of persistent trigeminal artery associated with a petroclival meningioma. Case report [in Japanese]. Neurol Med Chir (Tokyo) 1989; 29 (8) 767-771
• 18 Szdzuy D, Lehmann R, Feldmann H. Rare association of primitive persistent trigeminal artery with acoustic neurinoma [in German]. Fortschr Geb Rontgenstr Nuklearmed 1973; 118 (1) 98-100
• 19 Cahill DW, Salcman M, Hirsch D, Rao CV. Unilateral internuclear ophthalmoplegia due to angiographic embolism through a primitive trigeminal artery. Neurology 1981; 31 (6) 751-753
• 20 Piotin M, Miralbés S, Cattin F , et al. MRI and MR angiography of persistent trigeminal artery. Neuroradiology 1996; 38 (8) 730-733
• 21 Azab W, Delashaw J, Mohammed M. Persistent primitive trigeminal artery: a review. Turk Neurosurg 2012; 22 (4) 399-406
• 22 Bai M, Guo Q, Li S. Persistent trigeminal artery/persistent trigeminal artery variant and coexisting variants of the head and neck vessels diagnosed using 3 T MRA. Clin Radiol 2013; 68 (11) e578-e585
• 23 Ohshiro S, Inoue T, Hamada Y, Matsuno H. Branches of the persistent primitive trigeminal artery—an autopsy case. Neurosurgery 1993; 32 (1) 144-148
• 24 Hurst RW, Howard RS, Zager E. Carotid cavernous fistula associated with persistent trigeminal artery: endovascular treatment using coil embolization. Skull Base Surg 1998; 8 (4) 225-228
• 25 Ostrom QT, Gittleman H, Liao P , et al. CBTRUS statistical report: primary brain and central nervous system tumors diagnosed in the United States in 2007-2011. Neuro-oncol 2014; 16 (Suppl. 04) iv1-iv63
• 26 Brunworth J, Padhye V, Bassiouni A , et al. Update on endoscopic endonasal resection of skull base meningiomas. Int Forum Allergy Rhinol 2015; 5 (4) 344-352