Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 130-132

Can Internal Carotid Artery Occlusion Produce Simultaneous Anterior and Posterior Circulation Stroke?


Department of Neurology, PSG Institute of Medical Science and Research, Coimbatore, Tamil Nadu, India

Date of Web Publication8-Oct-2015

Correspondence Address:
Prasanna Venkatesan Eswaradass
Department of Neurology, PSG Institute of Medical Science and Research, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-0820.166934

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  Abstract 

Collateral circulation in the brain is important for maintaining a sufficient cerebral blood flow in case of obstructive disease of arteries. In case of hemodynamic compromise to the anterior circulation, the posterior circulation supplies the anterior circulation via the collaterals. Simultaneous anterior and posterior circulation stroke is a very rare occurrence. It can occur due to cardioembolic stroke or due to anatomical variants of the circle of Willis. Fetal origin of the posterior cerebral artery (PCA) from the internal carotid artery (ICA), persistent trigeminal artery, and persistent hypoglossal artery are known to present with posterior circulation stroke due to occlusive disease of ICA. Here we report a 85-year-old man who presented to us with left hemiparesis. On evaluation, he had right middle cerebral artery (MCA), anterior cerebral artery (ACA), and PCA infarct. Our case most likely had fetal PCA, which can readily explain the PCA infarction in ICA occlusion. Although cases of simultaneous MCA and PCA infarction had been reported in past, we report the first case with simultaneous ACA, MCA, and PCA infarction secondary to fetal PCA.

Keywords: Anatomical variants, circle of Willis, fetal origin, posterior cerebral artery, internal carotid artery occlusion


How to cite this article:
Eswaradass PV, Ramasamy B, Ramadoss K, Gnanashanmugham G. Can Internal Carotid Artery Occlusion Produce Simultaneous Anterior and Posterior Circulation Stroke?. Indian J Vasc Endovasc Surg 2015;2:130-2

How to cite this URL:
Eswaradass PV, Ramasamy B, Ramadoss K, Gnanashanmugham G. Can Internal Carotid Artery Occlusion Produce Simultaneous Anterior and Posterior Circulation Stroke?. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2019 Oct 21];2:130-2. Available from: http://www.indjvascsurg.org/text.asp?2015/2/3/130/166934


  Introduction Top


Collateral circulation in the brain is important for maintaining a sufficient cerebral blood flow in case of obstructive disease of arteries. In case of hemodynamic compromise to the anterior circulation, the posterior circulation supplies the anterior circulation via the collaterals. The circle of Willis plays a major role in the redistribution of blood between anterior and posterior circulation. Leptomeningeal collaterals are an important source of connection between anterior and posterior circulation. There are many variants in the circle of Willis, and the most important one is the fetal origin of the posterior cerebral artery (PCA) from the internal carotid artery (ICA). In this variant leptomeningeal collateral between the ICA and the vertebrobasilar system impossible to develop since both the middle and the PCA are connected to the internal carotid system and not to the vertebrobasilar system. Here, we describe a patient with simultaneous anterior and posterior circulation stroke due to fetal PCA.


  Case Report Top


An 85-year-old right handed male was admitted with a history of sudden onset of left hemiparesis. The patient was apparently normal the previous day when he went to bed. He woke up in the morning with the inability to move right upper and lower limb. He was then brought to the emergency department. His past medical history included 40 years of hypertension, 30 years of diabetes mellitus and dyslipidemia. There was no previous history of transient ischemic attacks or stroke. He had suffered acute myocardial infarction 20 years back. He was on regular treatment with insulin, metformin, ramipril, atorvastatin, nitrates, and metoprolol. He was a smoker and consumed alcohol twice a week for 40 years but quit smoking 10 years ago.

On examination in the emergency department, patient was drowsy but arousable. He responded only to painful stimuli by moving his right upper and lower limb. His eyes were deviated to the right side, and doll's eye reflex was intact. Patient's vitals were stable except for blood pressure which was 170/100 mm of Hg. His initial computed tomography (CT) scan of the brain was normal. We proceeded with magnetic resonance (MR) imaging brain with MR angiogram (MRA), which showed diffusion restriction along right-sided anterior cerebral artery, middle cerebral artery, and PCA territory (ACA, MCA, PCA) [Figure 1] and [Figure 2]. The MRA revealed right ICA occlusion [Figure 3] and [Figure 4]. His electrocardiogram showed left ventricular hypertrophy and did not reveal any atrial fibrillation. Within few hours patient's condition deteriorated. He developed massive brain swelling and died due to transtentorial herniation and brainstem compression.
Figure 1: Magnetic resonance imaging brain axial view shows diffusion restriction along middle cerebral artery territory

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Figure 2: Magnetic resonance imaging brain axial view shows diffusion restriction along anterior cerebral artery, middle cerebral artery and posterior cerebral artery territory

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Figure 3: Magnetic resonance imaging brain axial view shows diffusion restriction along middle cerebral artery and posterior cerebral artery territory

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Figure 4: Magnetic resonance imaging brain shows complete occlusion of right internal carotid artery and absent P1 segment of posterior cerebral artery probably due to fetal posterior cerebral artery

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  Discussion Top


Simultaneous anterior and posterior circulation stroke is a very rare occurrence. It can occur due to cardioembolic stroke or due to anatomical variants of the circle of Willis. Fetal origin of the PCA from the ICA, persistent trigeminal artery and persistent hypoglossal artery are known to present with posterior circulation stroke due to occlusive disease of ICA. Fetal PCA is a common variant of the circle of Willis with a prevalence of 15–32%.[1] There are two types of fetal PCA: Partial fetal PCA is characterized by small, atretic PCA connecting basilar with posterior communicating artery (PCOM) of ICA whereas full or complete fetal PCA has absent P1 segment and PCA directly arises from PCOM of ICA.

In patients with fetal-type PCA, the lack of proper collaterals may pose an increased risk for ischemic stroke. Arjal et al. in a study of 202 patients who underwent multislice CT angiogram concluded that the odds of having ischemic strokes in patients with full and partial fetal-type posterior were 1.448 and 3.027. There are many proposed mechanisms leading to stroke in partial fetal PCA.[2] The cerebral circulation is plastic, and there is a constant change in flow dynamics. Redistribution of blood flow can result in “steal” phenomenon leading to hypoperfusion and ischemic stroke. Incomplete fetal PCA there is lack of development of leptomeningeal vessels as both the anterior and the posterior circulations are derived from the ICA, and the tentorium prevents the cerebellar circulations from forming the collaterals with the PCA territory. A full fetal PCA can adapt to altered hemodynamics efficiently by developing collaterals, unlike partial fetal PCA. Atherosclerosis can result in apparent partial fetal PCA which increases the risk of stroke.

Simultaneous MCA and PCA infarction has been reported in the literature by van Raamt et al. and Yang et al. due to fetal PCA.[3],[4] In fetal PCA, leptomeningeal vessels fails to develop between anterior and posterior circulation and hence they are more prone to develop stroke.[5] Our case most likely had fetal PCA, which can readily explain the PCA infarction in ICA occlusion. Although cases of simultaneous MCA and PCA infarction had been reported in past, we report the first case with simultaneous ACA, MCA, and PCA infarction secondary to fetal PCA.


  Conclusion Top


Simultaneous anterior and posterior circulation stroke although rare can occur due to cardioembolism and fetal PCA.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Liebeskind DS. Collateral circulation. Stroke 2003;34:2279-84.  Back to cited text no. 1
    
2.
Arjal RK, Zhu T, Zhou Y. The study of fetal-type posterior cerebral circulation on multislice CT angiography and its influence on cerebral ischemic strokes. Clin Imaging 2014;38:221-5.  Back to cited text no. 2
    
3.
van Raamt AF, Mali WP, van Laar PJ, van der Graaf Y. The fetal variant of the circle of Willis and its influence on the cerebral collateral circulation. Cerebrovasc Dis 2006;22:217-24.  Back to cited text no. 3
    
4.
Yang JH, Choi HY, Nam HS, Kim SH, Han SW, Heo JH. Mechanism of infarction involving ipsilateral carotid and posterior cerebral artery territories. Cerebrovasc Dis 2007;24:445-51.  Back to cited text no. 4
    
5.
Schomer DF, Marks MP, Steinberg GK, Johnstone IM, Boothroyd DB, Ross MR, et al. The anatomy of the posterior communicating artery as a risk factor for ischemic cerebral infarction. N Engl J Med 1994;330:1565-70.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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