Fetal anastomotic variants can create misleading clinical findings in the patients presenting with stroke syndromes. Arterial emboli originating from a fetal anastomotic vessel can result in stroke that can mimic a cardio-embolic source due to ischemia in multiple vascular territories typically supplied by separate vessels. Timely identification of pathology including atherosclerotic plaque associated with these vascular variants on non-invasive imaging like computerized tomography angiogram is critical to identify the source of stroke and in guidance of potential therapy including surgical or endovascular intervention.

From the manuscript

Bilateral persistent primitive hypoglossal arteries associated with unilateral symptomatic carotid thromboembolism

Abstract
We report the fifth case of bilateral persistent primitive hypoglossal arteries in the literature. This is also the first such case to be demonstrated on computerized tomography angiogram (CTA) and the first case to be associated with a symptomatic carotid thrombus. The sub-occlusive thrombus was distal to the take-off of the dominant persistent hypoglossal artery (PHA) from the internal carotid artery, thus sparing involvement of posterior circulation. Timely identification of the internal carotid artery thromboembolism in the setting of a PHA is important to allow for thrombectomy. Any intervention was not done in this case as the patient was out of the window and at an additional risk of inducing intracranial thromboembolism. Symptomatic carotid stenosis at the PHA take-off is typically treated with endovascular angioplasty and stenting due to the typically high level of the bifurcation in the neck.