Endovascular Reconstruction of a Stenotic Persistent Primitive Trigeminal Artery Causing Hemodynamic Vertigo: A Case...

Atherosclerotic stenosis of a persistent primitive trigeminal artery is an exceptionally rare cause of posterior circulation hypoperfusion. A 48-year-old woman with hypertension and hyperlipidemia presented with recurrent, disabling rotational vertigo despite six weeks of aggressive medical therapy. Comprehensive neurological and otolaryngological evaluation, including a work-up to exclude common peripheral vestibular disorders, supported a vascular etiology for her persistent symptoms. Magnetic resonance angiography and digital subtraction angiography demonstrated a Saltzman type I persistent primitive trigeminal artery with severe ostial stenosis and coexisting 60%-70% stenosis of the ipsilateral cavernous internal carotid artery. The posterior circulation was predominantly dependent on the carotid-trigeminal axis because vertebrobasilar inflow was limited and the posterior communicating arteries were absent. Cervical vestibular evoked myogenic potential responses were absent bilaterally, supporting dysfunction of the sacculocollic pathway in the setting of suspected posterior circulation hypoperfusion. The persistent primitive trigeminal artery stenosis was treated first with sequential balloon angioplasty and deployment of a 2.0 mm × 8 mm zotarolimus-eluting balloon-expandable coronary stent, followed by angioplasty and self-expanding stent placement across the cavernous internal carotid artery stenosis. Final angiography demonstrated restoration of brisk flow through the carotid-trigeminal axis and basilar artery. At three months, the patient had near-complete resolution of vertigo, and bilateral cervical vestibular evoked myogenic potential responses were restored. This case illustrates that, following comprehensive clinical evaluation, exclusion of alternative causes of vertigo, and detailed assessment of collateral anatomy and procedural risk, individualized endovascular reconstruction may be considered in carefully selected patients with medically refractory symptoms and a hemodynamically dominant persistent primitive trigeminal artery.