Ruptured aneurysm at the origin of duplication of the middle cerebral artery--case report

Duplicated Middle Cerebral Artery Aneurysms Treated by Coil Embolization; A Report of Two Cases and Literature Review

BACKGROUND

Duplication of the middle cerebral artery (DMCA) is an anomalous vessel arising from the internal carotid artery (ICA). Aneurysms at the origin of a DMCA have been reported; however, most have been treated with clipping surgery. Here, we describe two cases of aneurysms at the origin of a DMCA treated with coil embolization.

CASE PRESENTATION

Case 1: A seventy-three year-old man presented with severe headache and was diagnosed with subarachnoid hemorrhage (SAH). Digital subtraction angiography (DSA) and 3-dimensional (3-D) DSA showed an aneurysm arising from a DMCA. Coil embolization was performed with DMCA patency. The patient had an uneventful postoperative course. CASE 1: A 44-year-old woman presented with a history of clipping for an IC-anterior choroidal artery (AchA) aneurysm 8 years prior. Magnetic resonance imaging (MRI) showed regrowth of the aneurysm. 3-D DSA showed an IC-DMCA aneurysm located laterally and distal to the AchA. The DMCA arose from the bottom of the aneurysm. Coil embolization was performed without DMCA occlusion and showed no postoperative ischemic changes.

CONCLUSION

An IC-DMCA aneurysm is rare and may be misdiagnosed as an AchA aneurysm. Clinicians should perform a 3D-DSA evaluation if the aneurysm arises from the lateral wall of the IC to obtain a precise diagnosis and to preserve the DMCA during coil embolization.

The Clinical Characteristics and Treatment Considerations for Intracranial Aneurysms Associated With Middle Cerebral Artery Anomalies: A Systematic Review

Background: As a result of their low incidence, most of the studies on intracranial aneurysms associated with middle cerebral artery (MCA) anomalies were presented as case reports or small case series. No systematic review on this specific entity has been conducted.

Methods: A PubMed search of the published studies was performed on April 6th, 2019 for patients who had intracranial aneurysms associated with MCA anomalies. The languages included in this study were English, Chinese, and Japanese.

Results: Finally, 58 articles reporting of 67 patients including 1 case in our center were included. The identified patients (37 females, 55.2%) aged from 4 to 81 (49.85 ± 15.22) years old. 50 (50/67, 74.6%) patients presented with hemorrhagic stroke either from the MCA anomalies associated aneurysms or other sources. 63 aneurysms (63/67, 94.0%) were saccular, 3 (4.5%) were dissecting or fusiform, and 1 (1.5%) was pseudoaneurysm. 32 (32/65, 49.2%) patients had other concurrent cerebrovascular anomalies. 56 (83.6%) patients underwent open surgeries, 8 (11.9%) patients underwent endovascular treatment, and 3 (4.5%) patients were conservatively managed. 56 (56/61, 91.8%) patients achieved a good recovery.

Conclusions: The pathophysiological genesis of intracranial aneurysms associated with MCA anomalies is still obscure. The inflicted patients tend to have other concurrent cerebrovascular anomalies, which denotes that congenital defect in cerebrovascular development might play a role in this process. Most of the affected patients could experience a good recovery after treatment.

An Aneurysm at the Origin of a Duplicated Middle Cerebral Artery Treated by Stent-Assisted Coiling Using the "Wrapped-Candy" Low-Profile Visualized Intraluminal Support (LVIS) Technique: A Technical Case Report and Review of the Literature

BACKGROUND

Aneurysms at the origin of a duplicated middle cerebral artery (DMCA) are quite rare. Here, we report a patient with such an aneurysm successfully treated endovascularly using our novel "wrapped-candy" low-profile visualized intraluminal support (LVIS) technique.

CASE DESCRIPTION

A 44-year-old woman underwent endovascular treatment for an unruptured wide-necked aneurysm at the origin of a DMCA that incorporated the origin of the DMCA into its neck. Stent-assisted coiling was performed using our newly developed "wrapped-candy" LVIS technique. To protect the origin of the DMCA and increase the stent metal density at the neck, an LVIS blue 3.5-mm × 22-mm stent was deployed by pushing the delivery wire aggressively to transform the visible wire components of the LVIS into a shape like "wrapped candy," maximizing the strut compaction at the neck of the aneurysm. Subsequently, the aneurysm component was coiled using a jailed microcatheter. The final procedural angiography demonstrated almost complete aneurysm occlusion with DMCA preservation.

CONCLUSIONS

Stent-assisted coiling can be a feasible treatment for an unruptured, usually wide-necked, aneurysm at the origin of a DMCA. The wrapped-candy LVIS technique may be useful in more challenging morphologies such as wide-necked aneurysms that incorporate the branch origin into the aneurysm neck.

Anomalies and Normal Variants of the Cerebral Arterial Supply: A Comprehensive Pictorial Review with a Proposed Workflow for Classification and Significance

Cerebral arteries may exhibit a wide range of variation from normal anatomy, which can be incidentally discovered during imaging. Knowledge of such variants is crucial to differentiate them from pathologies, to understand the etiology of certain pathologies directly related to a vascular variant, and to depict the changes in collateral circulation in patients with certain variants. Detection of particular variants may lead to the discovery of other nonvascular or vascular anomalies, especially aneurysms, and may also affect planning of endovascular or neurosurgical interventions. In this review, we summarize the variants and anomalies of cerebral arteries seen on cross-sectional imaging classified by a morphological approach and categorize their significance from a clinical perspective. This structured review is intended to serve as a guide for daily use in clinical practice.

An aneurysm at the site of the fenestration of the middle cerebral artery in a patient with multiple aneurysms: A case report

Background:

Middle cerebral artery (MCA) fenestration is a very rare anatomical variant of the MCA, incidentally found during magnetic resonance or computed tomography angiography. It has an incidence of 0.6%. Unlike fenestration of the posterior cerebral arterial circulation, fenestration of the anterior cerebral arterial circulation has not been well described.

Methods:

We present the rare case of a patient who was admitted for a ruptured aneurysm of the MCA arising at the site of the fenestration of the MCA and also an unruptured fusiform aneurysm of the right posterior communicating artery and a distal anterior cerebral artery (ACA) aneurysm.

Results:

The patient underwent craniotomy with microsurgical aneurysm clipping and the previously undiagnosed ruptured aneurysm, at the site of the fenestration of the MCA, arose immediately. Postoperatively, the patient awoke without a deficit. After treatment of postoperative bacterial meningitis, he was discharged on the 26^th postoperative day in good condition without any neurologic deficit. Six months after the first surgery, he was operated for the distal azygos ACA aneurysm.

Conclusion:

Anomalies of the intracranial vasculature are common, and we describe a rare case of left MCA fenestration with an associated ruptured aneurysm at the site of the fenestration. In the literature, cases of fenestration of the MCA are sporadically reported and are only incidental findings.

A rare case of supraclinoid internal carotid artery (ICA) fenestration in combination with duplication of the middle cerebral artery (MCA) originating from the ICA fenestration and an associated aneurysm

Fenestrations and duplications of the cervical and intracranial arteries are rare anatomic variants, reported to be associated with aneurysms or other vascular anomalies. We here present a patient with a supraclinoid ICA fenestration in combination with a duplication of the MCA originating from the ICA fenestration and an associated aneurysm.

Duplicated middle cerebral artery

Duplicated middle cerebral artery (DMCA) is an anomalous vessel arising from the internal carotid artery. The incidence DMCA is relatively law, and an association between this anomaly and cerebral aneurysms has been documented. There is a controversy whether DMCA may have perforating arteries. This is an important fact to consider in aneurysm surgery. We report the case of a 34-year-old black woman who suffered a subarachnoid hemorrhage and the angiography a left DMCA, and an aneurysm in an inferior branch of the main MCA. The DMCA and the MCA had perforating arteries. The aneurysm was clipped without complications. The observation of perforating arteries in our patient confirms that the DMCA may have perforating arteries. This is very important to be considered in cerebral aneurysms surgery. Moreover, the DMCA may potentially serve as a collateral blood supply to the MCA territory in cases of MCA occlusion.

Treatment of unruptured duplicated middle cerebral artery aneurysm: case report

BACKGROUND

Duplication of the middle cerebral artery (DMCA) is an anomalous vessel arising from the internal carotid artery (ICA). The origin of the DMCA lies between the anterior choroidal artery and the distal end of the ICA. The association of cerebral aneurysm and DMCA is rare.

CASE DESCRIPTION

In this 63-year-old woman, preoperative angiography and 3-dimensional computed tomography angiography revealed an aneurysm at the origin of the DMCA. The aneurysm was clipped and superficial temporal artery-DMCA anastomosis was performed. She was discharged with no neurologic deficits. Duplication of the middle cerebral artery can be divided into 2 types based on whether the site of separation from the ICA is at the top of the ICA (type A) or between the ICA top and the anterior choroidal artery (type B). The diameter of type A DMCA is comparable with that of the main middle cerebral artery trunk; in type B, it is smaller. In all 18 previously reported cases, the aneurysm was associated with type B DMCA.

CONCLUSION

For appropriate treatment planning, it is necessary to determine the DMCA type and the anatomic relationship between the aneurysm and the DMCA. In patients with type B DMCA, the possibility of aneurysm formation should be considered.

Multiple aneurysms arising from the origin of a duplication of the middle cerebral artery

Duplication of the middle cerebral artery is an anomalous vessel arising from the internal carotid artery. There have only been 14 reports of aneurysms arising from the origin of a duplication of the middle cerebral artery and 5 of these patients had multiple aneurysms. Aneurysms at this site have a high rupture rate compared to aneurysms in other locations and aggressive management is indicated.

Aneurysms in Twig-Like Middle Cerebral Artery

BACKGROUND

We report a vascular abnormality of the middle cerebral artery (MCA) that has not been described in the literature before.

METHODS

Two patients (1 male and 1 female; age 44 and 67 years, respectively) were found to have a vascular abnormality in which the main trunk of the MCA had a twig-like form. Both patients presented with intracranial hemorrhage.

RESULTS

In these 2 patients, the abnormality was seen before the genu of the MCA. They had an intracranial hemorrhage due to an associated aneurysm inside the twigs. The twig appeared to be a network between the bifurcation of internal carotid artery and insular segment of MCA, and it was different from the collateral circulation due to acquired occlusion or moyamoya disease.

CONCLUSION

This new type of vascular lesion of the MCA is not benign. It appears to be associated with the occurrence of an aneurysm, an important clinical aspect.