Duplication of the middle cerebral artery in a neonate: case report

Middle Cerebral Artery Duplication: A Near Miss for Stroke Thrombectomy

Middle cerebral artery (MCA) duplication is a rare anatomical arrangement where an anomalous MCA arises from the distal end of the internal carotid artery. If occluded, a duplicated MCA can present with significant deficits comparable to an occlusion of the M2 vessel without obvious findings on vessel imaging via computed tomography angiography (CTA) or magnetic resonance angiography. A female in her 30s with no past medical history presented with suspected acute stroke 8 hours after last known normal-featuring new-onset right-sided weakness, facial droop, and slurred speech, which corresponds to a National Institutes of Health Stroke Scale score of 13. Head CTA was interpreted as preserved patency of intracranial vessels. CT perfusion was suggestive of a large area of penumbra. Emergent cerebral angiography demonstrated MCA duplication on the left side with proximal occlusion of the M1 branch supplying the traditional M2 territory. Mechanical thrombectomy achieved grade TICI 2b reperfusion. Throughout her hospital stay, her aphasia started to resolve, and the patient was discharged to inpatient rehabilitation. This case presents a diagnostic challenge and learning point in identifying similar patients in the future. We suggest the clinician, given a high clinical suspicion for large vessel occlusion, even if CTA is negative, to continue with CT perfusion to not miss stroke in patients with MCA duplication. If CT perfusion shows substantial deficit in an MCA distribution, one must consider that the patient may have an MCA duplication.

Epidemiologic and anatomic aspects comparing incidental and ruptured intracranial aneurysms: A single centre experience

The feasibility of multicentric international data such as integrated in the PHASES score for patient counseling in unruptured intracranial aneurysms has recently been challenged. To determine, whether this data is applicable to local populations in a restricted catchment area, we performed a retrospective mono-centric analysis comparing patients with ruptured aneurysms to patients with incidental aneurysms. 200 patients with unruptured aneurysms and 197 patients after aneurysmal subarachnoid hemorrhage were analyzed for risk factors differing between the groups and to the general German population. Subgroup analysis was performed for 25 patients harboring multiple aneurysms, in 19 patients with intracavernous aneurysms and in 77 women of childbearing potential. While the preponderance of female patients was confirmed, significantly more men figured in the patient group with subarachnoid hemorrhage (36.4%) than among unruptured aneurysms (25%). Patients with bleeding events were significantly younger (51.6 years) than patients with incidental aneurysms (57.8 years). The rupture risk prediction of the PHASES score concerning aneurysm size below 7 mm and patient age over 70 years could not be confirmed, instead score points correlated to the clinical outcome after rupture. In our population, pregnant women were not overrepresented. Intracavernous carotid aneurysms contributed to the low risk profile of giant aneurysms. Thus, recommendations from pooled international data have to be adapted cautiously to local circumstances. We retained seven items with predictive value for outpatient counseling: age, smoking, hypertonus and concurrent vascular aberrations as patient characteristics and irregular shape, (increasing) largest diameter and the harboring vessel for the aneurysm.