- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
DOI:10.4103/2152-7806.127890Copyright: © 2014 Noguchi K. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Noguchi K, Aoki T, Komaki S, Takeuchi Y, Hirohata M, Morioka M. Unusual hemodynamic stroke related to an accessory middle cerebral artery: The usefulness of fusion images from three-dimensional angiography. Surg Neurol Int 26-Feb-2014;5:26
How to cite this URL: Noguchi K, Aoki T, Komaki S, Takeuchi Y, Hirohata M, Morioka M. Unusual hemodynamic stroke related to an accessory middle cerebral artery: The usefulness of fusion images from three-dimensional angiography. Surg Neurol Int 26-Feb-2014;5:26. Available from: http://sni.wpengine.com/surgicalint_articles/unusual-hemodynamic-stroke-related-to-an-accessory-middle-cerebral-artery-the-usefulness-of-fusion-images-from-three-dimensional-angiography/
Background:Ischemic stroke associated with an anomaly of the middle cerebral artery (MCA) is a rare occurrence. The diagnosis is very difficult when there are steno-occlusive lesions associated with an accessory middle cerebral artery (AMCA).
Case Description:A 77-year-old female with hypertension and hyperlipidemia experienced repeated transient ischemic attacks (TIAs) of motor aphasia and dysarthria. Although angiography showed only left intracranial occlusion, the fusion images of three-dimensional digital subtraction angiography (3-D DSA) showed complex steno-occlusive lesions and an AMCA related with the TIA. The cerebral blood flow (CBF) to the left frontal lobe was supplied by the AMCA, via the anterior communicating artery from the right internal carotid artery. The left temporal and parietal lobes were supplied by the stenotic MCA, via the left posterior communicating artery from the left posterior cerebral artery. Single-photon emission computed tomography showed a marked decrease in CBF to both the left frontal and temporal lobes. A left superficial temporal artery (STA)-to-left MCA double anastomosis was performed, in which each branch of the STA supplied branches of the AMCA and MCA.
Conclusion:This is the first reported case of ischemic stroke in a patient with an AMCA. The exact diagnosis could be made only by using fusion images of 3-D DSA, which were useful for understanding the complicated CBF pattern and for the choice of recipient artery in bypass surgery.
Keywords: Accessory middle cerebral artery, revascularisation, transient ischemic attack, 3D-DSA
Intracranial vascular anomalies involving the middle cerebral artery (MCA) are rare. Among this group, an accessory middle cerebral artery (AMCA) has been reported to have an incidence of approximately 0.3-4%.[
A 77-year-old female experienced repeated TIAs of motor aphasia and dysarthria. On admission, she was alert and well oriented. She had no cranial nerve deficits or focal neurological signs. Magnetic resonance (MR) imaging revealed no evidence of acute cerebral infarction [
Magnetic resonance (MR) imaging on admission showed no acute infarction (a) T2WI, T2-weighted images; DWI, diffusion weighted images. MR angiography showed an occlusion of the left internal carotid artery (b and c, arrow) and stenosis of the bilateral middle cerebral artery (arrowhead). Some anomalous arteries were also suspected (b), but the detailed anatomy was unclear
Conventional angiography of the right internal carotid artery (a and b) and left vertebral artery (c and d). Anterior-to-posterior view (a and c) and lateral view (b and d). The arrow (c) indicates stenosis of the left proximal segment (M1) of the middle cerebral artery (MCA), which is supplied via the left posterior communicating artery. Note that the left accessory MCA supplied only the left frontal lobe (arrowhead in a and b), while the left MCA supplied the area beneath the Sylvian fissure (arrowheads in c and d)
Fusion images of three-dimensional angiography of the right internal carotid artery (brown) and left vertebral artery (red). To clearly illustrate the distal part of the middle cerebral artery (MCA), the right side of all images was intentionally eliminated. The left accessory MCA and left MCA run independently, and the areas they supply are clearly distinguished. The arrowhead (b) indicates the site of occlusion of the left anterior cerebral artery. The stenosis of the left MCA is indicated by the arrow (d)
Three-dimensional DSA revealed the characteristic cerebral blood flow (CBF) supply pattern. The AMCA supplied CBF to the frontal lobe alone. The AMCA was perfused by the right ICA via the ACoA. In addition, the left MCA, which was perfused by the left posterior cerebral artery via the left posterior communicating artery, supplied CBF to the temporal and parietal lobes [Figures
It was concluded that bypass surgery was needed for the territory of both the AMCA and MCA. A double anastomosis was performed that consisted of: (1) the frontal branch of the left superficial temporal artery (STA) to the cortical artery of the left AMCA; and (2) the parietal branch of the STA to the cortical branch of the left MCA. Prior to anastomosis, intraoperative indocyanine green video angiography was performed and demonstrated bidirectional flow in the left frontal cortical artery [
The intraoperative findings (a and b) of the left superficial temporal artery-to-middle cerebral artery double anastomosis and magnetic resonance angiography after operation (c). Intraoperative indocyanine green video angiography showed the time delay of blood flow and bidirectional flow. The arrows indicate the anastomosis sites (a and b)
Intracranial vascular anomalies involving the MCA are relatively rare. There are two known types of double-M1 segments of the MCA, including a duplicated middle cerebral artery (DMCA) and an AMCA. Teal et al.[
The clinical presentation in this case likely represents a TIA due to a hemodynamic mechanism. There were three stenotic lesions contributing to cerebral ischemia: (1) occlusion of the left ICA, (2) occlusion of the ipsilateral A1 of the ACA, and (3) severe stenosis of the ipsilateral MCA. The stenosis in the left MCA caused the decrease in blood flow, while the occlusion of A1 of the ACA reduced the blood flow through the AMCA. Together, these obstructions resulted in a decrease in blood flow through the MCA [
AMCA is well-established anomalous artery originates from the ACA.[
Because the frontal and temporal areas clearly had separate blood supplies in this case and only CBF decrease could explain this patient's symptoms, an STA–MCA double bypass was performed to the frontal and temporal areas. Furthermore this patient is free from ischemic attack without antiplatelet medication. Now EC-IC bypass surgery was not accepted in worldwide evidence, however, there are some studies supporting the effectiveness of EC-IC bypass in Japan,[
The authors thank Mr. Kenzo Kamachi and Ms. Keiko Suematsu for their technical assistance. This work was supported by Grants-in-Aid for Scientific Research from the Ministry of Education, Sports, Science and Culture of Japan and there is no conflict of interest.
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