- Email: [email protected]
A rare case report of a mixed persistent proatlantal intersegmental artery
Journal of Clinical Neuroscience xxx (xxxx) xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case report
A rare case report of a mixed persistent proatlantal intersegmental artery Gao-Ting Ma a, Zi-Xian Zhang b, Yi-Ming Deng c, Feng Gao c, Zhong-Rong Miao c, Xuan Sun c,⇑ a
Department of Neurology, Qianfoshan Hospital Affiliated to Shandong University, China Department of Neurology, Zaozhuang Municipal Hospital, China c Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China b
a r t i c l e
i n f o
Article history: Received 8 October 2018 Accepted 12 November 2018 Available online xxxx Keywords: Proatlantal intersegmental artery Carotid artery stenting
a b s t r a c t Adults with persistent proatlantal intersegmental artery (PPIA) are rarely seen. We present a case of a special type of PPIA that was in a 57-year-old man who presented with dizziness and episodic vertigo of 9 months duration. The diagnosis relied on computed tomography angiography and digital subtraction angiography, by which a left internal carotid artery stenosis and an ipsilateral PPIA originating from the external carotid artery (ECA) was found. This special type of PPIA can be described as a ‘‘mixed PPIA’’ that originated as Type II from the ECA and coursed as Type I. The patient underwent carotid artery stenting and had no relapse during 3 months follow-up. In addition, the literatures on PPIA were reviewed. Ó 2018 Elsevier Ltd. All rights reserved.
1. Introduction The persistent proatlantal intersegmental artery (PPIA) is a rare anomalous communication between the carotid and vertebrobasilar system. Two types of PIA have been described according to embryological considerations, origin, and anatomic course: type I (the most common) originating from internal carotid artery (ICA), type II originating from external carotid artery (ECA) and the rarest form originating from common carotid artery (CCA). Here, we report a very rare case of ‘‘mixed PPIA’’ originated as Type II from the ECA and coursed as Type I. In addition, we present a brief review of previously reported cases for the PPIA.
2. Case report A 57-year-old man presented with dizziness and episodic vertigo of 9 months duration. His medical history included hyperlipidemia, intermittent claudication, smoking and alcoholism. Neurologic examination was unremarkable. Computed tomography angiography (CTA) revealed a left internal carotid artery stenosis and an ipsilateral PPIA originating from the external carotid artery (ECA). CTA also revealed bilateral absence of both cervical vertebral arteries. No other carotid-vertebrobasilar anastomoses ⇑ Corresponding author at: Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No. 119 Nansihuanxilu, Fengtai District, Beijing 100070, China. E-mail address: [email protected] (X. Sun).
were seen. Digital subtraction angiography (DSA) confirmed the 80% stenosis (NASCET criteria) of the left ICA, and a PPIA arising from the left ECA with a stenosis and bilateral absence of both cervical vertebral arteries (Fig. 1). In general, the anastomotic vessel arose from the posterior wall of the proximal ECA at C2 level. It coursed upward, then took a dorsal course, and continued as the vertebral artery, serving as the major contributor of the posterior circulation. It did not course through any cervical vertebra transverse foramen (Fig. 2). The ‘‘mixed PPIA” originated as Type II from the ECA and coursed as Type I. The patient underwent carotid angioplasty and stenting. The stent (Precise Pro Rx [Cordis, Fremont, CA], 8-mm 30-mm) was placed entirely in the ICA. He had no relapse during 3 months follow-up.
3. Discussion During early embryonic development, four transient arteries interconnect the anterior (carotid) and posterior (basilar) circulation systems, are known as the primitive carotid-vertebrobasilar anastomoses. The intracranial segmental arteries are accompanied by their corresponding nerves (trigeminal, otic, and hypoglossal) and resemble an intersegmental pattern [1]. From cranial to caudal, these are the trigeminal, otic, hypoglossal, and proatlantal intersegmental arteries [2]. These arteries are the main source of blood supply in the hindbrain during the 4 mm embryonic stage. By the 7–12 mm embryonic stage, these connections rapidly regress in about a week. The first to regress is the otic artery, followed by the hypoglossal artery. Proatlantal intersegmental
https://doi.org/10.1016/j.jocn.2018.11.028 0967-5868/Ó 2018 Elsevier Ltd. All rights reserved.
Please cite this article as: G.-T. Ma, Z. X. Zhang, Y. M. Deng et al., A rare case report of a mixed persistent proatlantal intersegmental artery, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.028
2
Case report / Journal of Clinical Neuroscience xxx (xxxx) xxx
Fig. 1. Catheter-based angiogram shows a PPIA arising from left ECA (arrowhead) and an approximately 80% stenosis (thick arrow) of the right ICA.
arteries persist until vertebral arteries (VA) develop [3]. The persistence and failure of involution of such connections contribute to ‘‘persistent fetal anastomoses’’ in adults [4]. Persistent fetal carotid-basilar anastomoses are rare. The most common persistent artery is the trigeminal (0.03%–2.2%), followed by the hypoglossal
one (0.027%–0.26%) [5]. There are no published data available on the incidence of PPIA and otic artery. In 1885, Gottschau first described a proatlantal intersegmental artery at autopsy, arising from the ICA [6]. Padget first named it proatlantal intersegmental artery [2]. The PPIA originated from the internal carotid artery (38%), external carotid artery (57%), or common carotid artery (5%) at the C2–4 cervical levels [7]. Lasjaunias and colleagues initially classified PPIA into two types [8]. The type I arises from the origin of the cervical ICA, ECA or the distal of common carotid artery (CCA), avoids the transverse foramen of cervical vertebrae, courses directly upward into the occipitoatlantal space, and joins the ipsilateral vertebral artery and travels intracranially through the foramen magnum. The type II arises laterally from the proximal ECA, follows a more lateral position than type I, courses posteriorly to the second cervical space, passes through the C1 transverse foramen before entering the foramen magnum [9]. However, Cohen et al. described a special type of PPIA. In their case, the PPIA arised from ECA, anteromedial along the ICA, turned in cranial-lateral-posterior direction, and finally connected with the terminal segment of the left vertebral artery (VA). Comparing with the classical type II PPIA, the upper cervical course differed significantly. The PPIA did not pass through any cervical vertebra transverse foramen (TF) but directly joined the ipsilateral VA and coursed intracranially through the foramen magnum [10], just as our case. This special type of PPIA can be also described as a ‘‘mixed PPIA’’ that originated as Type II from the ECA and coursed as Type I. Incidence rate of cerebrovascular abnormalities in patients with PPIA was as high as 59% [7]. Ipsilateral or bilateral vertebral arteries absence or hypoplasia were the most frequent anomalies, appearing in about 50% of cases [11]. Other anomalies included intracranial aneurysm (about 10%) [7], arteriovenous malformation [12], other persistent carotid-basilar anastomoses [13], vein of Galen malformation [14], multiple vascular anomalies of the aortic arch [15], left brachiocephalic trunk [16], fusiform aneurysm of the subclavian artery [17]. This was an indication that some changes in congenital hemodynamic factors caused by a PPIA might affect the pathogenesis of cerebrovascular abnormalities. Differentiation of PPIA from persistent hypoglossal artery (PHA) using imaging methods can be difficult because they can both
Fig. 2. Computed tomography angiogram (3-D reconstruction) of the left common carotid artery shows the course of the PPIA arising from the ECA and coursing over the vertebral artery groove of the posterior arch of C1 (arrowheads).
Please cite this article as: G.-T. Ma, Z. X. Zhang, Y. M. Deng et al., A rare case report of a mixed persistent proatlantal intersegmental artery, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.028
Case report / Journal of Clinical Neuroscience xxx (xxxx) xxx
origin from ICA. The main identifications include the following points: (1) The PHA has a higher origin only from the internal carotid artery at the C1 to C3 level; (2) The PHA has a more vertical course and lacks the suboccipital horizontal path which the PIA takes; (3) The PHA enters the skull through the hypoglossal canal rather than foramen magnum [18]. Most PPIAs were found incidentally without clinical symptoms. However, PPIAs have been associated with dizziness, pulsatile tinnitus, headache, ischemic and hemorrhagic stroke [4,17]. PPIAs were potentially at risk for injury during carotid endarterectomy, carotid artery stenting, embolization, carotid ligations, C1-2 fixations, or other neck surgeries. In our case, DSA revealed severe stenosis of the proximal internal carotid artery and only mild narrowing of the proximal PPIA. The stent was placed entirely in the ICA. This precaution taken to avoid coverage of the external carotid artery was such that it did not disrupt the blood supply to posterior circulation through PPIA. But it may entail the risk of delayed progression of the wall disease [19]. CTA reexamination had not found in-stent restenosis (ISR) after 3 months of regular drug treatment (asprin 100 mg per day, clopidogrel 75 mg per day). Even so, long-term follow up is necessary. 4. Conclusion We here report a mixed type of persistent proatlantal intersegmental artery that did not correspond to the traditional classification. Recognizing the variant is very important to surgeons. 5. Duality of interest No potential conflicts of interest relevant to this article were reported. Funding This research is supported by the National Key Research and Development Program of China; it is a part of the items (2016YFC1301501). Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jocn.2018.11.028.
3
References [1] Caldemeyer KS, Carrico JB, Mathews VP. The radiology and embryology of anomalous arteries of the head and neck. AJR Am J Roentgenol 1998;170:197–203. [2] Padget DH. Designation of the embryonic intersegmental arteries in reference to the vertebral artery and subclavian stem. Anat Rec 1954;119:349–56. [3] Luh GY, Dean BL, Tomsick TA, Wallace RC. The persistent fetal carotidvertebrobasilar anastomoses. AJR Am J Roentgenol 1999;172:1427–32. [4] Zarghouni M, Marichal D. Persistent bilateral proatlantal type II artery. Proc (Bayl Univ Med Cent) 2013;26:50–1. [5] Vasovic L, Jovanovic I, Ugrenovic S, Vlajkovic S, Jovanovic P, Stojanovic V. Trigeminal artery: a review of normal and pathological features. Childs Nerv Syst 2012;28:33–46. [6] Vasovic L, Mojsilovic M, Andelkovic Z, Jovanovic I, Arsic S, Vlajkovic S, et al. Proatlantal intersegmental artery: a review of normal and pathological features. Childs Nerv Syst 2009;25:411–21. [7] Kolbinger R, Heindel W, Pawlik G, Erasmi-Korber H. Right proatlantal artery type I, right internal carotid occlusion, and left internal carotid stenosis: case report and review of the literature. J Neurol Sci 1993;117:232–9. [8] Lasjaunias P, Theron J, Moret J. The occipital artery. anatomy–normal arteriographic aspects–embryological significance. Neuroradiology 1978;15:31–7. [9] Saito N, Uchino A, Ishihara S. Complex anomalies of type 1 proatlantal intersegmental artery and aortic arch variations. Surg Radiol Anat 2013;35:177–80. [10] Cohen JE, Grigoriadis S, Itshayek E. Type II proatlantal artery (occipital subtype) with bilateral absence of the vertebral arteries. Clin Anat 2011;24:950–2. [11] Gumus T, Onal B, Ilgit ET. Bilateral persistence of type 1 proatlantal arteries: report of a case and review of the literature. AJNR Am J Neuroradiol 2004;25:1622–4. [12] Arraez-Aybar LA, Navia-Alvarez P, Mendez-Cendon JC. A case of a type II proatlantal artery with arteriovenous malformation. Surg Radiol Anat 2011;33:85–9. [13] Tanaka Y, Hara H, Momose G, Kobayashi S, Kobayashi S, Sugita K. Proatlantal intersegmental artery and trigeminal artery associated with an aneurysm. Case Rep J Neurosurg 1983;59:520–3. [14] Purkayastha S, Gupta AK, Varma R, Kapilamoorthy TR. Proatlantal intersegmental arteries of external carotid artery origin associated with Galen’s vein malformation. AJNR Am J Neuroradiol 2005;26:2378–83. [15] Li TH, Lan MY, Liu JS, Tseng YL, Wu HS, Chang YY. Type II proatlantal intersegmental artery associated with objective pulsatile tinnitus. Neurology 2008;71:295–6. [16] Basekim CC, Silit E, Mutlu H, Pekkafali MZ, Ozturk E, Kizilkaya E. Type I proatlantal artery with bilateral absence of the external carotid arteries. AJNR Am J Neuroradiol 2004;25:1619–21. [17] Buljan K, Hegedus I, Gilman Kuric T, Salha T, Tomic S, Butkovic Soldo S, et al. Type I persistent proatlantal artery associated with fusiform subclavian artery aneurysm: report of one case. Rev Med Chil 2015;143:1081–4. [18] Bahsi YZ, Uysal H, Peker S, Yurdakul M. Persistent primitive proatlantal intersegmental artery (proatlantal artery I) results in ’top of the basilar’ syndrome. Stroke 1993;24:2114–7. [19] Bonaldi G. Angioplasty and stenting of the cervical carotid bifurcation: report of a 4-year series. Neuroradiology 2002;44:164–74.
Please cite this article as: G.-T. Ma, Z. X. Zhang, Y. M. Deng et al., A rare case report of a mixed persistent proatlantal intersegmental artery, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.028
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case report
A rare case report of a mixed persistent proatlantal intersegmental artery Gao-Ting Ma a, Zi-Xian Zhang b, Yi-Ming Deng c, Feng Gao c, Zhong-Rong Miao c, Xuan Sun c,⇑ a
Department of Neurology, Qianfoshan Hospital Affiliated to Shandong University, China Department of Neurology, Zaozhuang Municipal Hospital, China c Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China b
a r t i c l e
i n f o
Article history: Received 8 October 2018 Accepted 12 November 2018 Available online xxxx Keywords: Proatlantal intersegmental artery Carotid artery stenting
a b s t r a c t Adults with persistent proatlantal intersegmental artery (PPIA) are rarely seen. We present a case of a special type of PPIA that was in a 57-year-old man who presented with dizziness and episodic vertigo of 9 months duration. The diagnosis relied on computed tomography angiography and digital subtraction angiography, by which a left internal carotid artery stenosis and an ipsilateral PPIA originating from the external carotid artery (ECA) was found. This special type of PPIA can be described as a ‘‘mixed PPIA’’ that originated as Type II from the ECA and coursed as Type I. The patient underwent carotid artery stenting and had no relapse during 3 months follow-up. In addition, the literatures on PPIA were reviewed. Ó 2018 Elsevier Ltd. All rights reserved.
1. Introduction The persistent proatlantal intersegmental artery (PPIA) is a rare anomalous communication between the carotid and vertebrobasilar system. Two types of PIA have been described according to embryological considerations, origin, and anatomic course: type I (the most common) originating from internal carotid artery (ICA), type II originating from external carotid artery (ECA) and the rarest form originating from common carotid artery (CCA). Here, we report a very rare case of ‘‘mixed PPIA’’ originated as Type II from the ECA and coursed as Type I. In addition, we present a brief review of previously reported cases for the PPIA.
2. Case report A 57-year-old man presented with dizziness and episodic vertigo of 9 months duration. His medical history included hyperlipidemia, intermittent claudication, smoking and alcoholism. Neurologic examination was unremarkable. Computed tomography angiography (CTA) revealed a left internal carotid artery stenosis and an ipsilateral PPIA originating from the external carotid artery (ECA). CTA also revealed bilateral absence of both cervical vertebral arteries. No other carotid-vertebrobasilar anastomoses ⇑ Corresponding author at: Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No. 119 Nansihuanxilu, Fengtai District, Beijing 100070, China. E-mail address: [email protected] (X. Sun).
were seen. Digital subtraction angiography (DSA) confirmed the 80% stenosis (NASCET criteria) of the left ICA, and a PPIA arising from the left ECA with a stenosis and bilateral absence of both cervical vertebral arteries (Fig. 1). In general, the anastomotic vessel arose from the posterior wall of the proximal ECA at C2 level. It coursed upward, then took a dorsal course, and continued as the vertebral artery, serving as the major contributor of the posterior circulation. It did not course through any cervical vertebra transverse foramen (Fig. 2). The ‘‘mixed PPIA” originated as Type II from the ECA and coursed as Type I. The patient underwent carotid angioplasty and stenting. The stent (Precise Pro Rx [Cordis, Fremont, CA], 8-mm 30-mm) was placed entirely in the ICA. He had no relapse during 3 months follow-up.
3. Discussion During early embryonic development, four transient arteries interconnect the anterior (carotid) and posterior (basilar) circulation systems, are known as the primitive carotid-vertebrobasilar anastomoses. The intracranial segmental arteries are accompanied by their corresponding nerves (trigeminal, otic, and hypoglossal) and resemble an intersegmental pattern [1]. From cranial to caudal, these are the trigeminal, otic, hypoglossal, and proatlantal intersegmental arteries [2]. These arteries are the main source of blood supply in the hindbrain during the 4 mm embryonic stage. By the 7–12 mm embryonic stage, these connections rapidly regress in about a week. The first to regress is the otic artery, followed by the hypoglossal artery. Proatlantal intersegmental
https://doi.org/10.1016/j.jocn.2018.11.028 0967-5868/Ó 2018 Elsevier Ltd. All rights reserved.
Please cite this article as: G.-T. Ma, Z. X. Zhang, Y. M. Deng et al., A rare case report of a mixed persistent proatlantal intersegmental artery, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.028
2
Case report / Journal of Clinical Neuroscience xxx (xxxx) xxx
Fig. 1. Catheter-based angiogram shows a PPIA arising from left ECA (arrowhead) and an approximately 80% stenosis (thick arrow) of the right ICA.
arteries persist until vertebral arteries (VA) develop [3]. The persistence and failure of involution of such connections contribute to ‘‘persistent fetal anastomoses’’ in adults [4]. Persistent fetal carotid-basilar anastomoses are rare. The most common persistent artery is the trigeminal (0.03%–2.2%), followed by the hypoglossal
one (0.027%–0.26%) [5]. There are no published data available on the incidence of PPIA and otic artery. In 1885, Gottschau first described a proatlantal intersegmental artery at autopsy, arising from the ICA [6]. Padget first named it proatlantal intersegmental artery [2]. The PPIA originated from the internal carotid artery (38%), external carotid artery (57%), or common carotid artery (5%) at the C2–4 cervical levels [7]. Lasjaunias and colleagues initially classified PPIA into two types [8]. The type I arises from the origin of the cervical ICA, ECA or the distal of common carotid artery (CCA), avoids the transverse foramen of cervical vertebrae, courses directly upward into the occipitoatlantal space, and joins the ipsilateral vertebral artery and travels intracranially through the foramen magnum. The type II arises laterally from the proximal ECA, follows a more lateral position than type I, courses posteriorly to the second cervical space, passes through the C1 transverse foramen before entering the foramen magnum [9]. However, Cohen et al. described a special type of PPIA. In their case, the PPIA arised from ECA, anteromedial along the ICA, turned in cranial-lateral-posterior direction, and finally connected with the terminal segment of the left vertebral artery (VA). Comparing with the classical type II PPIA, the upper cervical course differed significantly. The PPIA did not pass through any cervical vertebra transverse foramen (TF) but directly joined the ipsilateral VA and coursed intracranially through the foramen magnum [10], just as our case. This special type of PPIA can be also described as a ‘‘mixed PPIA’’ that originated as Type II from the ECA and coursed as Type I. Incidence rate of cerebrovascular abnormalities in patients with PPIA was as high as 59% [7]. Ipsilateral or bilateral vertebral arteries absence or hypoplasia were the most frequent anomalies, appearing in about 50% of cases [11]. Other anomalies included intracranial aneurysm (about 10%) [7], arteriovenous malformation [12], other persistent carotid-basilar anastomoses [13], vein of Galen malformation [14], multiple vascular anomalies of the aortic arch [15], left brachiocephalic trunk [16], fusiform aneurysm of the subclavian artery [17]. This was an indication that some changes in congenital hemodynamic factors caused by a PPIA might affect the pathogenesis of cerebrovascular abnormalities. Differentiation of PPIA from persistent hypoglossal artery (PHA) using imaging methods can be difficult because they can both
Fig. 2. Computed tomography angiogram (3-D reconstruction) of the left common carotid artery shows the course of the PPIA arising from the ECA and coursing over the vertebral artery groove of the posterior arch of C1 (arrowheads).
Please cite this article as: G.-T. Ma, Z. X. Zhang, Y. M. Deng et al., A rare case report of a mixed persistent proatlantal intersegmental artery, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.028
Case report / Journal of Clinical Neuroscience xxx (xxxx) xxx
origin from ICA. The main identifications include the following points: (1) The PHA has a higher origin only from the internal carotid artery at the C1 to C3 level; (2) The PHA has a more vertical course and lacks the suboccipital horizontal path which the PIA takes; (3) The PHA enters the skull through the hypoglossal canal rather than foramen magnum [18]. Most PPIAs were found incidentally without clinical symptoms. However, PPIAs have been associated with dizziness, pulsatile tinnitus, headache, ischemic and hemorrhagic stroke [4,17]. PPIAs were potentially at risk for injury during carotid endarterectomy, carotid artery stenting, embolization, carotid ligations, C1-2 fixations, or other neck surgeries. In our case, DSA revealed severe stenosis of the proximal internal carotid artery and only mild narrowing of the proximal PPIA. The stent was placed entirely in the ICA. This precaution taken to avoid coverage of the external carotid artery was such that it did not disrupt the blood supply to posterior circulation through PPIA. But it may entail the risk of delayed progression of the wall disease [19]. CTA reexamination had not found in-stent restenosis (ISR) after 3 months of regular drug treatment (asprin 100 mg per day, clopidogrel 75 mg per day). Even so, long-term follow up is necessary. 4. Conclusion We here report a mixed type of persistent proatlantal intersegmental artery that did not correspond to the traditional classification. Recognizing the variant is very important to surgeons. 5. Duality of interest No potential conflicts of interest relevant to this article were reported. Funding This research is supported by the National Key Research and Development Program of China; it is a part of the items (2016YFC1301501). Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jocn.2018.11.028.
3
References [1] Caldemeyer KS, Carrico JB, Mathews VP. The radiology and embryology of anomalous arteries of the head and neck. AJR Am J Roentgenol 1998;170:197–203. [2] Padget DH. Designation of the embryonic intersegmental arteries in reference to the vertebral artery and subclavian stem. Anat Rec 1954;119:349–56. [3] Luh GY, Dean BL, Tomsick TA, Wallace RC. The persistent fetal carotidvertebrobasilar anastomoses. AJR Am J Roentgenol 1999;172:1427–32. [4] Zarghouni M, Marichal D. Persistent bilateral proatlantal type II artery. Proc (Bayl Univ Med Cent) 2013;26:50–1. [5] Vasovic L, Jovanovic I, Ugrenovic S, Vlajkovic S, Jovanovic P, Stojanovic V. Trigeminal artery: a review of normal and pathological features. Childs Nerv Syst 2012;28:33–46. [6] Vasovic L, Mojsilovic M, Andelkovic Z, Jovanovic I, Arsic S, Vlajkovic S, et al. Proatlantal intersegmental artery: a review of normal and pathological features. Childs Nerv Syst 2009;25:411–21. [7] Kolbinger R, Heindel W, Pawlik G, Erasmi-Korber H. Right proatlantal artery type I, right internal carotid occlusion, and left internal carotid stenosis: case report and review of the literature. J Neurol Sci 1993;117:232–9. [8] Lasjaunias P, Theron J, Moret J. The occipital artery. anatomy–normal arteriographic aspects–embryological significance. Neuroradiology 1978;15:31–7. [9] Saito N, Uchino A, Ishihara S. Complex anomalies of type 1 proatlantal intersegmental artery and aortic arch variations. Surg Radiol Anat 2013;35:177–80. [10] Cohen JE, Grigoriadis S, Itshayek E. Type II proatlantal artery (occipital subtype) with bilateral absence of the vertebral arteries. Clin Anat 2011;24:950–2. [11] Gumus T, Onal B, Ilgit ET. Bilateral persistence of type 1 proatlantal arteries: report of a case and review of the literature. AJNR Am J Neuroradiol 2004;25:1622–4. [12] Arraez-Aybar LA, Navia-Alvarez P, Mendez-Cendon JC. A case of a type II proatlantal artery with arteriovenous malformation. Surg Radiol Anat 2011;33:85–9. [13] Tanaka Y, Hara H, Momose G, Kobayashi S, Kobayashi S, Sugita K. Proatlantal intersegmental artery and trigeminal artery associated with an aneurysm. Case Rep J Neurosurg 1983;59:520–3. [14] Purkayastha S, Gupta AK, Varma R, Kapilamoorthy TR. Proatlantal intersegmental arteries of external carotid artery origin associated with Galen’s vein malformation. AJNR Am J Neuroradiol 2005;26:2378–83. [15] Li TH, Lan MY, Liu JS, Tseng YL, Wu HS, Chang YY. Type II proatlantal intersegmental artery associated with objective pulsatile tinnitus. Neurology 2008;71:295–6. [16] Basekim CC, Silit E, Mutlu H, Pekkafali MZ, Ozturk E, Kizilkaya E. Type I proatlantal artery with bilateral absence of the external carotid arteries. AJNR Am J Neuroradiol 2004;25:1619–21. [17] Buljan K, Hegedus I, Gilman Kuric T, Salha T, Tomic S, Butkovic Soldo S, et al. Type I persistent proatlantal artery associated with fusiform subclavian artery aneurysm: report of one case. Rev Med Chil 2015;143:1081–4. [18] Bahsi YZ, Uysal H, Peker S, Yurdakul M. Persistent primitive proatlantal intersegmental artery (proatlantal artery I) results in ’top of the basilar’ syndrome. Stroke 1993;24:2114–7. [19] Bonaldi G. Angioplasty and stenting of the cervical carotid bifurcation: report of a 4-year series. Neuroradiology 2002;44:164–74.
Please cite this article as: G.-T. Ma, Z. X. Zhang, Y. M. Deng et al., A rare case report of a mixed persistent proatlantal intersegmental artery, Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2018.11.028