Ischemic stroke in azygos anterior cerebral artery: a case report

Context: The azygos anterior cerebral artery (azygos-ACA) is a rare variant that involves a common trunk in segment A2 (above the anterior communicating artery). Its prevalence is 0.3–2%. Case report: Male patient, 59 years old, diabetic, smoker, with congenital heart disease (long congenital QT) was admitted to the hospital on 01/07/2020 with traumatic brain injury followed by a seizure crisis (1st episode). Upon admission, he had Glasgow 13 and a cranial tomography showing small left frontal hemorrhage, then conservative treatment with phenytoin 100mg every 8 hours was initiated. The following day, there was a decrease in the level of consciousness (Glasgow 7), with orotracheal intubation being performed and a new skull tomography was performed revealing a slightly enlarged left frontal contusion area, right subdural hematoma, bifrontal hypodensity and left caudate nucleus. Mannitol (100ml / 6h) was indicated and phenytoin (100mg/ 8h) was maintained. On 16/07/2020, the cranial angiotomography showed hypoflow of the anterior cerebral artery and an anatomical variant showing that such artery emerged from a single trunk. The next day, he was still intubated, with Glasgow 6 and no interaction with an examiner. Conclusions: It is concluded that the patient had a bifrontal ischemic stroke (evidenced by the 2nd tomography) and this, occurred due to an obstruction of the azygos-ACA (rare variant), explaining its bilaterality. This situation led to traumatic brain injury, syncope and a severe decrease in the level of consciousness. Given the possible repercussions, the anatomical recognition of this variant becomes important.