{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,27]],"date-time":"2026-05-27T01:05:39Z","timestamp":1779843939120,"version":"3.53.1"},"reference-count":50,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"21","license":[{"start":{"date-parts":[[2026,5,25]],"date-time":"2026-05-25T00:00:00Z","timestamp":1779667200000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2026,5,25]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND<\/jats:title>\n                    <jats:p>The persistent proatlantal intersegmental artery (PPIA) arises from the cervical internal carotid artery (ICA) and joins the vertebral artery near the foramen magnum. In moyamoya syndrome (MMS), such embryonic carotid-vertebrobasilar channels may influence collateralization and procedural strategy. The authors report bilateral PPIA identified concurrently with bilateral MMS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>OBSERVATIONS<\/jats:title>\n                    <jats:p>A 28-year-old woman with Down syndrome presented with sudden severe headache and unresponsiveness. CT showed bilateral intraventricular hemorrhage, a small left periatrial hemorrhage, and obstructive hydrocephalus; an external ventricular drain was placed. CT angiography demonstrated bilateral distal ICA and proximal middle cerebral artery\/anterior cerebral artery narrowing concerning for MMS. Digital subtraction angiography revealed bilateral PPIA supplying the posterior circulation with extensive leptomeningeal and meningeal collateral vessels. A tortuous left posterior choroidal branch had no definite aneurysm or treatable lesion. The patient improved with CSF diversion and supportive care and was discharged on hospital day 19. Follow-up angiography confirmed advanced bilateral MMS and bilateral PPIA, and the choroidal finding was recharacterized as a vascular loop.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>LESSONS<\/jats:title>\n                    <jats:p>Bilateral PPIA in MMS is rare and clinically consequential. Precise angiographic mapping is essential due to the PPIA\u2019s potential to reshape anterior-posterior collateralization, affect bypass targeting and competitive flow risk, and influence endovascular access and surveillance planning.<\/jats:p>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/thejns.org\/doi\/10.3171\/CASE25974\">https:\/\/thejns.org\/doi\/10.3171\/CASE25974<\/jats:ext-link>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/case25974","type":"journal-article","created":{"date-parts":[[2026,5,20]],"date-time":"2026-05-20T14:52:30Z","timestamp":1779288750000},"source":"Crossref","is-referenced-by-count":0,"title":["Bilateral persistence of the proatlantal intersegmental arteries in moyamoya syndrome: illustrative case"],"prefix":"10.3171","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0009-0002-1455-2327","authenticated-orcid":true,"given":"Aaron","family":"Higginbotham","sequence":"first","affiliation":[{"name":"University of Kansas School of Medicine, Kansas City"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Domenico","family":"Napoletano","sequence":"additional","affiliation":[{"name":"University of Kansas School of Medicine, Kansas City"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Austin","family":"Reed","sequence":"additional","affiliation":[{"name":"University of Kansas School of Medicine, Kansas City"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Frank","family":"De Stefano","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0728-2242","authenticated-orcid":true,"given":"Lane","family":"Fry","sequence":"additional","affiliation":[{"name":"Radiology, University of Kansas Medical Center, Kansas City, Kansas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-6277-7480","authenticated-orcid":true,"given":"Ari","family":"Williams","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Koji","family":"Ebersole","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9421-5632","authenticated-orcid":true,"given":"Jeremy","family":"Peterson","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"11","key":"bib1","series-title":"Radiol Case Rep","first-page":"4832","article-title":"Bilateral concurrent type I and type II persistent proatlantal arteries: a case report","volume":"19","author":"Rahman","year":"2024","unstructured":"Rahman SFitzPatrick MRoychowdhury S.Bilateral concurrent type I and type II persistent proatlantal arteries: a case report. 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