- Department of Vascular Neurosurgery, Instituto Nacional de Neurología y Neurocirugía “Manuel Velasco Suárez,” Ciudad de México, Mexico.
Correspondence Address:
Edgar Nathal, Department of Vascular Neurosurgery, Instituto Nacional de Neurología y Neurocirugía “Manuel Velasco Suárez,” Ciudad de México, Mexico.
DOI:10.25259/SNI_678_2022
Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.How to cite this article: Alejandro Serrano-Rubio, Bill Roy Ferrufino-Mejia, Juan C. Balcázar-Padrón, Héctor A. Rodríguez-Rubio, Edgar Nathal. Ruptured aneurysm associated with a twig-like middle cerebral artery: An illustrative case report. 07-Oct-2022;13:456
How to cite this URL: Alejandro Serrano-Rubio, Bill Roy Ferrufino-Mejia, Juan C. Balcázar-Padrón, Héctor A. Rodríguez-Rubio, Edgar Nathal. Ruptured aneurysm associated with a twig-like middle cerebral artery: An illustrative case report. 07-Oct-2022;13:456. Available from: https://surgicalneurologyint.com/?post_type=surgicalint_articles&p=11922
Abstract
Background: Anomalies of the middle cerebral artery (MCA) are rare; among the different types of anomalies, the aplastic or twig-like (Ap/T) MCA is extremely rare and has been reported under various names, including aplastic, unfused, or rete type anomaly. The occurrence of a brain aneurysm associated with this anatomic variant is an even rare event, and probably their development and rupture are related to hemodynamic stress of the tinny wall of vessels forming the network.
Case Description: We present a 43-year-old male patient with an explosive and persistent right orbitofrontal headache. A computed tomography showed a right frontobasal hematoma with intraventricular disruption. Magnetic resonance angiography showed a right MCA aneurysm and what seems to be a MCA trunk stenosis. Cerebral digital subtraction angiography demonstrated a plexiform arterial network and one aneurysm arising from the network. The patient was successfully treated by surgical clipping to evacuate the hematoma and to prevent further intracranial hemorrhages.
Conclusion: The Ap/T-MCA may be associated with hemodynamic stress with a significant effect through the tinny wall of the vessels causing hemorrhage or leading to the formation and rupture of cerebral aneurysms. Based on a correct diagnosis of the anomaly, treatment can be completed successfully through different standard methods.
Keywords: Aneurysm, Clipping surgery, MCA anomaly, Middle cerebral artery, Twiglike MCA
INTRODUCTION
Aplastic or twig-like middle cerebral artery (Ap/T-MCA), also called “unfused MCA,” “rete MCA” or “anomalous collateral artery,” is a rare anatomic anomaly with a very low prevalence among population (0.11–0.88%),[
CASE DESCRIPTION
This 43-year-old male with a history of systemic arterial hypertension was admitted to the hospital because a sudden onset of severe headache of 7 days evolution accompanied by nausea, vomiting, and a right-side hemiparesis.
Computed tomography (CT) revealed a frontobasal hematoma with ventricular disruption [
Figure 1:
Illustrative case (a) A right frontobasal hematoma with ventricular extension is seen on noncontrast Computed tomography (CT) scan. (b and c) Cerebral DSA with rotational 3-D show the presence of a saccular aneurysm in the middle of the vascular network. (d) Intraoperative view. After evacuating the hematoma, the vascular network is exposed (T-MCA). Under the superficial vessels of the anomaly, the dome of the aneurysm is just visible. Distal M2 segment seems normal. (e) Postoperative DSA. The aneurysm is not visible. (f) CT-angio displays the clip position and the complete exclusion of the aneurysm. (g) Perfusion MRI showing the mean transit time (MTT) and regional cerebral blood volume (rCBV) images without ischemic areas (h) Illustration of the Ap/T MCA anomaly depicting the plexiform arterial network replacing the proximal M1 segment.
The patient was operated on 3 weeks after ictus, through a right side pterional approach. After opening the Sylvian fissure, the vessels network was visualized, formed by numerous tinny and fragile vessels, with the aneurysm located in the middle of this network with old clots and hemosiderin surrounding the lesion [
A straight 7 mm Yasargil type clip was used for neck clipping. We verified total occlusion using intraoperative fluorescein videoangiography and intraoperative Doppler. The postoperative course was uneventful and the patient showed a total recovery of the initial preoperative neurologic deficit in the next days. Postoperative cerebral DSA and CT- angio showed the disappearance of the aneurysm without associated low-density areas [
Video 1
DISCUSSION
Ap/T-MCA is a rare vascular anomaly. It has been considered that embryological interruption of the MCA trunk genesis is the cause, being replaced by the formation of a plexiform arterial anomaly [
Due to the difficulty of diagnosing this anomaly on noninvasive imaging modalities such as CT and MR angiography, it is often misdiagnosed as arteriovenous malformation or pseudo-occlusion of the MCA. In patients that underwent a DSA, the Ap/T-MCA was present 0.11% and 1.17% of them.[
Akkan et al. described three types of “Ap/T-MCA” presentations, where the entire MCA is composed of a vascular network; in another presentation, the vascular network terminates at the bifurcation. In the last case, the vascular plexiform network ends before the beginning of the bifurcation.[
The twig-like appearance of the vessels may be confused with the MMD; however, there is no evidence of a progressive internal carotid artery occlusion leading to the formation of the Moyamoya vessels, as occurs in MMD.[
At present, there are 42 cases in the international literature of aneurysms associated with the Ap/T-MCA anomaly, of which 26 presented as SAH,[
In this case, our patient had a Fisher Grade IV subarachnoid hemorrhage. During surgery, after evacuating the surrounding hematoma, we found many fragile vessels of the network around the aneurysm that bleed easily. Compression of the bleeding points with surgical patties quickly stopped the hemorrhage without the need of cauterization with the bipolar forceps, assuming the thrombotic mechanism of the vessel.
Ap/T-MCA can present with hemorrhagic stroke in 27–40% of the cases, of which up to 26.6–46% were associated with aneurysm rupture. On the other hand, ischemic stroke can be present in 33–46% of cases.[
Endovascular coil embolization and surgical clipping are procedures that have been associated with success in managing ruptured aneurysms. However, in the presence of a hematoma causing a mass effect, as occurred in this case, the surgical approach is mandatory. Endovascular coiling has been used mainly in aneurysms located lateral to the twig-like anomaly. In cases associated with ischemic events, cerebral revascularization surgery may be used whenever a perfusion study was done showing hypoperfusion in the MCA territory of the Ap/T-MCA. In our case, this procedure was unnecessary since there were not ischemic events or neurological deficits.[
CONCLUSION
The Ap/T-MCA is a rare anomaly. There is a lack of knowledge and information about it due to the scarcity of reports in the literature. However, when present, it should be diagnosed correctly to avoid unnecessary therapeutic considerations in patients with acute symptomatology. DSA remains as the gold standard for diagnoses. The occurrence of cerebral aneurysms associated with this anomaly requires additional considerations. In case of unruptured aneurysms, an endovascular or surgical procedure has been reported as effective methods, but in ruptured cases associated with brain hematomas, surgical treatment is mandatory. This case gives rise to a complete opening in both diagnosis and treatment of aneurysms in variants of the MCA as the twig-like type. More detailed clinical studies with a large population are required to determine the optimal treatment of Ap/T-MCA associated with aneurysms or ischemic events.
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Declaration of patient consent
Patient’s consent not required as patient’s identity is not disclosed or compromised.
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Conflicts of interest
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