Narrative review suggests endovascular therapy is preferable for persistent primitive hypoglossal artery lesions

The persistent primitive hypoglossal artery (PPHA) is a rare and anatomically complex cerebrovascular variant. Although typically asymptomatic, its presence is associated with various cerebrovascular pathologies, including intracranial aneurysms, carotid artery stenosis, acute large vessel occlusion, moyamoya disease, brain arteriovenous malformations, and other vascular anomalies. When such lesions involve the PPHA, therapeutic intervention may be necessitated. Surgical management is particularly challenging due to the artery's deep anatomical location and intricate surrounding vasculature. Consequently, endovascular therapy (EVT) has emerged as a preferable alternative to open surgery, offering a favorable safety profile and reduced technical complexity. Despite this, a substantial need remains in the literature regarding systematic evaluations of the PPHA's clinical significance in vascular pathology and the efficacy of EVT. This review aims to address this need through a comprehensive narrative synthesis of available literature and clinical experience in managing these complex cases. This review found that when EVT is required, the PPHA can serve as an access route. However, given that it often provides the sole blood supply to the posterior circulation—particularly in the context of bilateral hypoplastic vertebral arteries—the vessel must be meticulously preserved during interventions for associated conditions.