Abstract 194: Angioplasty and Stenting of Persistent Primitive Trigeminal Artery Stenosis in Acute Ischemic Stroke

IntroductionA persistent primitive trigeminal artery (PPTA) is the most common remnant of carotid‐vertebrobasilar anastomosis during embryonic development. The PPTA usually arises from the cavernous or pre‐cavernous portion of the Internal Carotid Artery (ICA). Based on cerebral angiography and magnetic resonance angiography (MRA) data, PPTA has been identified in between 0.1% and 0.6% of the population. Amongst most cases with PPTA, the Basilar Artery (BA) is exclusively supplied from the ICA with the PPTA. There have been multiple reports of acute strokes secondary to embolism to the ICA presenting with top of the BA syndrome. Successful revascularization of the PPTA has been reported with Aspiration and Stent retriever with Thrombolysis in Cerebral Infarction (TICI) score between 2B‐3. There have also been reports of stenting to the PPTA in cases of unruptured aneurysms. Here, we describe a case where severe stenosis to the PPTA due to Intracranial Atherosclerotic Disease presented as top of the BA syndrome, requiring urgent angioplasty and stenting.MethodsA 78‐year‐old female with no past medical history presented with altered mental status to the emergency department. During the evaluation by the Neurology team, she appeared grossly encephalopathic. On arrival, the National Institutes of Health Stroke Scale (NIHSS) was 3, with workup largely unremarkable. The patient's NIHSS worsened to 25, and code stroke was activated. CTA Head/Neck and CT Perfusion were obtained. Imaging revealed BA occlusion and decreased posterior circulation perfusion, likely due to a PPTA (Figure). The patient was outside the window for IV thrombolytics and was taken for Mechanical Thrombectomy.ResultsFollowing initial vascular access, the Catheter Angiography revealed a Left PPTA with 80% stenosis at the midsegment, with slow filling to the top of BA and patent flow to the left PICA territory via a hypoplastic left vertebral artery. The stenosis was crossed using an SL‐10 and Gateway microcatheter, followed by angioplasty with a Gateway balloon and deployment of a Neuroform Atlas 4times21mm stent across the stenosis (Figure). Final angiography demonstrated TICI 3 flow. Post‐procedure NIHSS improved to 14, and she was started on DAPT. MRI of the Brain revealed bilateral PCA strokes as well as central pontine. She was discharged to subacute rehabilitation for the rest of her care.ConclusionThis case illustrates successful revascularization with angioplasty and stenting for a PPT