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Simultaneous anterior and posterior circulation stroke secondary to large-vessel atherosclerotic disease associated with persistent trigeminal artery: a case report

Context: Cardioembolic events are the main cause of simultaneous anterior and posterior circulation stroke. Anatomical variants of the circle of Willis represent another rare mecanism. Persistent trigeminal artery is a carotid–vertebrobasilar anastomosis related to an increased risk of aneurysms, vascular malformations and stroke. Case report: A 67-year-old diabetic man was brought to the emergency department with a history of sudden onset of left hemiparesis. Neurologic finginds showed a hemiparesis, hemianesthesia and heminegligence (all left sided), right hemiataxia and a dysarthria. Brain Magnetic Resonance study revealed a isquemic stroke in right middle cerebral artery, right posterior cerebral artery (PCA) and bilateral superior cerebellar arteries (SUCA). Computed tomography angiography showed a right internal carotid artery oclusion and a persistent trigeminal artery. Causitive Classification System (CCS) revealed a large-vessel atherosclerotic stroke. A non-habitual simultaneous affection of PCA and SUCA resulted from a carotid artery embolization associated with anterior and posterior territories anostomosis by the persistent trigeminal artery. Secondary prevention consisted of aspirin 100mg/day and cardiovascular risk factor control. The patient remained free from others cardiovascular events, in rehabilitation, at the moment, in category 3 from the Ranking Modified Scale. Conclusions: The presence of a persistent trigeminal artery, in the context of a internal carotid oclusion, can chance our stroke-mecanism interpretation. Simultaneous anterior and posterior circulation stroke are compatible with large-vessel aterosclerotic disease.