Posterior trifurcation of the internal carotid artery — normal or pathological? (a case report)

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Abstract

INTRODUCTION: Currently, there is no unified classification of variant anatomy of cerebral vessels, which underlies the contradictory character of data on the prevalence and clinical picture of such developmental variants as the posterior trifurcation of the internal carotid artery (ICA).

AIM: To present a clinical case of diagnosis and confirm the anatomical norm of the posterior trifurcation of the ICA.

The article describes diagnostic search in a 51-year-old female patient with a chronic tension headache. On examination, a fusiform aneurysm of the left ICA was suspected, but it was not confirmed by computed angiography, which detected posterior trifurcation of the ICA.

CONCLUSION: The posterior trifurcation of the ICA in the analyzed clinical case is a finding not being a pathological condition. Anatomical differentiation of a complete posterior trifurcation and fusiform aneurysm of the ICA in chronic tension headache postulates the posterior trifurcation of the ICA being a variant of normal structure of the circle of Willis, which is of a principal clinical significance. For the first time the trifurcation of the ICA is presented as ontogenetic resource of the arterial system of the human brain, an ontogenetically determined variant of structure, and not ‘an embryonic type of structure’ of the circle of Willis, preserved due to delayed reduction of the posterior communicating arteries.

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About the authors

Alexey V. Gorbunov

Derzhavin Tambov State University

Email: alexey.gorbunov@mail.ru
ORCID iD: 0000-0002-6880-0472
SPIN-code: 2407-2777

MD, Dr. Sci. (Medicine), Professor

Russian Federation, Tambov

Dmitry S. Parshin

Astrakhan State Medical University

Author for correspondence.
Email: parshin.doc@gmail.com
ORCID iD: 0000-0002-1050-7716
SPIN-code: 8248-1975

MD, Dr. Sci. (Medicine), Professor

Russian Federation, Astrakhan

Angelina N. Khvorova

Tambov Regional Clinical Hospital named after V.D. Babenko

Email: ange.makon@gmail.com
ORCID iD: 0009-0000-3589-5834
Russian Federation, Tambov

Maria G. Kalugina

Derzhavin Tambov State University

Email: kaluginamg@yandex.ru
ORCID iD: 0000-0002-0764-4269
SPIN-code: 6355-3764
Russian Federation, Tambov

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2. Fig. 1. Magnetic resonance angiography of the brain of a 51-year-old woman in the horizontal (a) and frontal (b) planes: a section of the left internal carotid artery suspected of a fusiform aneurysm (thick arrow); posterior cerebral artery, which is a branch of internal carotid artery, without a clearly formed posterior communicating artery (narrow black arrow); a typically formed right posterior cerebral artery (short black arrow); anterior cerebral arteries (dotted black arrow); internal carotid artery on the right and left (white block arrows); basilar artery (short white arrow).

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3. Fig. 2. Magnetic resonance imaging of the brain of a 51-year-old woman in the sagittal plane — T1 mode (a), frontal plane — T1 mode (b) and horizontal plane — T1 mode (c): no pathology identified.

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4. Fig. 3. Computed tomographic angiography of brachiocephalic arteries of a 51-year-old woman, 3D reconstruction — structure of the circle of Willis in the horizontal plane: anterior communicating artery (short black arrow); basilar artery (thick black arrow); internal carotid artery on the right and left (white block arrows); typical variant of the posterior cerebral artery structure (narrow black arrow). Area of the origin of the posterior cerebral artery from the left internal carotid artery (posterior trifurcation of the internal carotid artery) (dotted black arrow).

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5. Fig. 4. Computed tomographic angiography of brachiocephalic arteries of a 51-year-old woman, 3D reconstruction — structure of the circle of Willis in the sagittal plane: basilar artery (thick black arrow); internal carotid artery on the left (white block arrow); area of origin of posterior cerebral artery from the left internal carotid artery (dotted black arrow); middle cerebral artery (narrow black arrow); anterior cerebral artery (short black arrow); posterior cerebral artery on the right (short white arrow).

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6. Fig. 5. Computed tomographic angiography of brachiocephalic arteries of a 51-year-old woman, 3D reconstruction — structure of the circle of Willis in the sagittal-horizontal plane: basilar artery (thick black arrow); branching area of internal carotid artery (posterior trifurcation of internal carotid artery) (white block arrow); posterior cerebral artery (cut off) (dotted white arrow); posterior cerebral artery on the left, a branch of left internal carotid artery (narrow black arrow); anterior cerebral arteries on the left and right (short black arrows); posterior cerebral artery on the right (short white arrow).

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7. Fig. 6. Schematic representation of the circle of Willis: a — prenatal stage of human ontogenesis; b — postnatal stage of human ontogenesis (posterior trifurcation of the internal carotid artery is shown on the left, and ‘classic’ structure of the circle of Willis is shown on the right). 1 — basilar artery; 2 — posterior cerebral artery; 3 — posterior communicating artery; 4 — internal carotid artery; 5 — middle cerebral artery; 6 — anterior cerebral artery; 7 — anterior communicating artery.

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