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Case Reports
. 2022 May 30;3(22):CASE22121.
doi: 10.3171/CASE22121.

Aplastic or twiglike middle cerebral artery with contralateral middle cerebral artery stenosis showing transient ischemic attack: illustrative case

Hayato Takeda  1 , Kiyoyuki Yanaka  1 , Kuniyuki Onuma  1 , Kazuhiro Nakamura  1 , Kazuhiro Ishii  2 , Eiichi Ishikawa  3
Affiliations
Case Reports

Aplastic or twiglike middle cerebral artery with contralateral middle cerebral artery stenosis showing transient ischemic attack: illustrative case

Hayato Takeda et al. J Neurosurg Case Lessons. .

Abstract

Background: Aplastic or twiglike middle cerebral artery (Ap/T-MCA) is a rare anomaly characterized by a unilateral MCA occlusion with plexiform vessels that causes hemorrhagic and (less commonly) ischemic strokes. The reasons for this are rarely discussed, and thus optimal treatment for ischemic Ap/T-MCA remains controversial. Here, the authors report a case of Ap/T-MCA with transient ischemic attacks treated by bypass surgery and discuss the mechanism of ischemic development and treatment methods.

Observations: A 62-year-old hypertensive man with transient, recurrent left hemiparesis visited the authors' hospital. Magnetic resonance angiography showed proximal occlusion of the right MCA and stenosis in the left MCA. Digital subtraction angiography revealed occlusion of the right MCA and abnormal vascular networks, leading to a diagnosis of Ap/T-MCA with contralateral MCA stenosis. Antiplatelet therapy with aspirin was insufficient, and a superficial temporal artery-MCA bypass was performed. There were no ischemic or hemorrhagic events postoperatively.

Lessons: Atherosclerosis seems to have a significant impact on the development of ischemic stroke in patients with Ap/T-MCA, and the presence of coexisting atherosclerotic stenotic vascular lesions outside the Ap/T-MCA site is substantial in its development. Bypass surgery is a promising treatment option for ischemic Ap/T-MCA.

Keywords: Ap/T-MCA = aplastic or twiglike middle cerebral artery; CBF = cerebral blood flow; DSA = digital subtraction angiography; EMS = encephalomyosynangiosis; ICA = internal carotid artery; MMD = moyamoya disease; MRI = magnetic resonance imaging; SPECT = single-photon emission computed tomography; STA = superficial temporal artery; TIA = transient ischemic attack; aplastic or twiglike middle cerebral artery; atherosclerosis; bypass surgery; ischemia.

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Conflict of interest statement

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Figures

FIG. 1.
FIG. 1.
T2-weighted (A) and fluid-attenuated inversion recovery (B) MRI showing mild ischemic changes in the white matter. Magnetic resonance angiography (C) showing proximal occlusion of the right MCA and stenosis in the proximal portion of the left MCA.
FIG. 2.
FIG. 2.
DSA showing occlusion of the right M1 segment associated with plexiform collateral vessels (A) and stenosis of the left MCA (B). Blood flow from the right side also perfusing part of the left cerebral hemisphere (A). Three-dimensional rotational angiography showing abnormal vascular network around the occluded segment (C) of the right MCA.
FIG. 3.
FIG. 3.
99mTc-ethyl cysteinate dimer SPECT showing right-dominant decreases in the CBF and reactivity to acetazolamide (ACZ). Baseline (left panel) and after ACZ administration (right panel). Blood flow in part of the right frontal cortex decreasing after ACZ administration (arrow).
FIG. 4.
FIG. 4.
Postoperative MRA performed at 10 months after surgery, showing bypass patency. The right cerebral hemisphere is well perfused through the bypass.
See this image and copyright information in PMC

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