Incidental bilateral accessory middle cerebral arteries on MR imaging and MR angiography

Intracranial vascular variations involving the middle cerebral artery are rarely seen. Herein, we report an 11-year-old girl with incidental bilateral accessory middle cerebral arteries, an extremely rare variation, which is the first case in the related literature demonstrated by cranial magnetic resonance imaging and magnetic resonance angiography.

Bilateral accessory middle cerebral arteries associated with an aneurysm of the anterior circulation

An accessory middle cerebral artery is one variation of the intracranial vasculature that may be a source of misinterpretation by clinicians dealing with cerebrovascular diseases. We report a case of an elderly female found to have bilateral accessory middle cerebral arteries, who presented with the rupture of an aneurysm of the anterior part of the circle of Willis. Accessory middle cerebral arteries are rare anatomical findings and the bilateral occurrence is exceedingly rare. We believe this to be the first report of bilateral accessory middle cerebral arteries associated with an aneurysm of the anterior cerebral-anterior communicating arteries. The anatomical and clinical relevance of this variation is described.

Integrated monitoring of fetal growth restriction by computerized cardiotocography and Doppler flow velocimetry

OBJECTIVE

To investigate the correlations between Doppler flow velocimetry and computerized cardiotocography (cCTG) in fetal growth restriction.

STUDY DESIGN

Fifty growth-restricted foetuses with abdominal circumference below the 10th percentile and no major abnormalities were studied. A total of 186 cCTG tracings (at least two per patient) analysed using the HP2CTG system were compared with the corresponding umbilical artery pulsatility index (PI), the PI ratio of umbilical artery to middle cerebral artery, and the ductus venosus systolic/atrial ratio.

RESULTS

Worsening in umbilical artery Doppler velocimetry parameters was associated with a significant reduction of short- and long-term variability indices and accelerations. When end-diastolic umbilical artery flow was preserved, a reversed ratio between umbilical artery and middle cerebral artery PIs was not correlated with a worsening of cCTG parameters; in the presence of umbilical artery absent or reversed flow, ductus venosus Doppler velocimetry abnormalities were correlated with a significant reduction of variability. When end-diastolic umbilical artery flow was preserved, there was a progressive increase in variability indices and accelerations with advancing gestational age. In the more compromised fetuses this "maturation" process of cCTG patterns was not found.

CONCLUSION

There is a strict correlation between Doppler velocimetry abnormalities and cCTG parameter deterioration, in particular between ductus venosus and variability.

Schizencephaly with occlusion or absence of middle cerebral artery

In a study of 160 infants with prenatal and/or perinatal risk factors for brain damage, we observed three cases of schizencephaly. All cases were unilateral, and the clefts had open lips. In two cases, magnetic resonance angiography showed occlusion or absence of the middle cerebral artery (MCA) on the affected side. Two of the patients, including one with absent flow in the MCA of the affected side, had ipsilateral cerebellar atrophy.

[Surgical treatment of anterior circulation aneurysm via pterion keyhole approach]

OBJECTIVE

To investigate the feasibility of pterion keyhole approach with minimal invasion for treatment of the anterior circulation aneurysm.

METHOD

Aneurysm clipping through the pterion keyhole approach was performed in patients with anterior circulation aneurysms, including 9 with posterior communication artery aneurysms, 3 with middle cerebral artery aneurysms and 6 with anterior communication artery aneurysms, who were in stages I to III according to Hunt-Hess scale.

RESULT

All the aneurysms were clipped successfully. One patient with a left posterior communication artery aneurysm developed transient sensory aphasia and motor aphasia after surgery due to intraoperative aneurysm rupture. No facial paralysis occurred due to damage of the facial nerve.

CONCLUSION

The pterion keyhole approach is a very useful surgical approach for treatment of anterior circulation aneurysms on the basis of cautious determination of indications and careful operation planning.

Persistent carotid-vertebral anastomosis associated with contralateral accessory middle cerebral artery

An exceptional case is reported of a complex anomaly of the brain arteries including low left carotid bifurcation, persistent carotid-vertebral anastomosis on the left and accessory middle cerebral artery on the right; the whole posterior circulation was only filled through the anomalous anastomotic vessel which joined with the vertebral artery because of a contralateral hypoplasic vertebral artery and the absence of both posterior communicating arteries. This association has not been previously reported in the literature. The embryological processes leading to these arterial anomalies are discussed. Risks related to a severe carotid stenosis or occlusion and to surgical or endovascular procedures in patients harboring these arterial anomalies are emphasized.

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.

Normal variants of the intracranial circulation demonstrated by MR angiography at 3T

Magnetic resonance angiography (MRA) at 3T offers increased signal to noise ratio with better background suppression, leading to exquisite depiction of the intracranial circulation. We present a pictorial review of the normal variations and anomalies of the intracranial circulation detected on MRA performed on a high field 3T clinical scanner using parallel imaging techniques. The salient imaging features of these anomalies and normal variations are discussed with relevance to clinical practice.

Endovascular treatment of an "anterior cerebral artery" aneurysm in a patient with "embryonic unfused middle cerebral artery" anomaly: a case report

We report a unique case of an anterior cerebral artery aneurysm in a patient with embryonic unfused middle cerebral artery anomaly. The arterial twigs of the middle cerebral artery supply the entire middle cerebral artery territory including the lenticulostriate branches. There was a vessel incorporated into the aneurysm, which was referred to as an accessory middle cerebral artery and it gave rise to a lenticulostriate branch. The aneurysm was occluded with detachable coils using a remodeling technique. After successful occlusion of the aneurysm the so-called accessory middle cerebral artery including its lenticulostriate branch started to fill from the anomalous middle cerebral artery network and the patient did not experience any ischemic injury.

Ruptured aneurysm at a duplicated middle cerebral artery with accessory middle cerebral artery

Although many cerebral vascular anomalies are widely recognized, others are less well known or unclassified. Accessory middle cerebral artery (MCA) and duplicated MCA are among uncommon anomalies. We present a very rare case of subarachnoid haemorrhage due to rupture of a saccular aneurysm arising from a duplicated middle cerebral artery which was associated with an accessory middle cerebral artery.

[Cervical myelopathy in a patient with congenital cervico-cerebral vascular malformation]

We report a 50 year-old woman with cervical myelopathy. The patient, who had cutaneous angiomas in the right orbital area, became aware of left upper limb weakness when she woke up, followed by painful abnormal sensation in both axilla and arms. MRI revealed an intramedullar lesion mainly located in cervical cord at the level of C3-C4. Angiography showed that serpentine left vertebral artery entered the canalis vertebralis at C3 and fed the blood flow of bilateral middle cerebral arteries. In this case, the upper cervical spinal cord ischemia might be induced by hemodynamic insufficiency of the anterior spinal artery ascribed to congenital cervico-cerebral vascular malformation.

[Frequency of vascular variations and anomalies accompanying intracranial aneurysms]

PURPOSE

Investigation of the sites of intracranial aneurysms and incidence of associated congenital variations or anomalies.

MATERIALS AND METHODS

One hundred and ninety cerebral angiography examinations that were positive for aneurysm were evaluated retrospectively. Fourteen cases with vasospasm were excluded and the remaining 176 patients were assessed for the location of the aneurysm and co-incidental vascular variations and/or anomalies. There were two observers in the study, one of whom was an experienced vascular radiologist.

RESULTS

The most frequent locations of aneurysms were the supraclinoid internal carotid artery (32%, n=74), anterior communicating artery (30%, n=68), and middle cerebral artery bifurcation (23%, n=52). Twenty-eight patients (17%) had multiple aneurysms. Ninety-one (52%) patients had a vascular anomaly or variation. Hypoplasia or agenesis of A1 segment of the anterior cerebral artery was found in 48 patients, an azygous anterior cerebral artery in 1, a frontoorbital artery in 1, a duplicated middle cerebral artery in 1, early bifurcation of the middle cerebral artery in 9, persistent fetal origin of the posterior cerebral artery in 26, fenestration of P1 segment of posterior cerebral artery in 1, agenesis of P1 segment of posterior cerebral artery in 1, fenestration of vertebral artery in 1, double trunk visualization of superior cerebellar artery in 2 patients.

CONCLUSION

Due to an increased hemodynamic stress, congenital anomalies of the intracranial arteries predispose to the formation of saccular aneurysms. Nomalies such as A1 hypoplasia or agenesis, azygous anterior cerebral artery, accessory middle cerebral artery and persistent trigeminal artery are detected more frequently in patients with cerebral aneurysms compared to the normal population. The location of aneurysms and the frequency of arterial variations and anomalies in this study correlated well with data found in previous studies.

[Multiple intracranial aneurysms and vascular abnormalities associated with neurofibromatosis type 1: a case report]

We present an unusual case of multiple intracranial aneurysms, persistent primitive trigeminal artery (PPTA), and fenestration of the middle cerebral artery (MCA), associated with type 1 neurofibromatosis (NF 1). The patient was a 55-year-old woman in a state of semicoma. We observed widespread neurofibromas and café au lait spots on her trunk and limbs. Computed tomography (CT) scan revealed diffuse subarachnoid hemorrhage and right frontal intracerebral hemorrhage (WFNS grade IV, Fisher's classification group 4). Cerebral angiography showed two intracranial aneurysms at the anterior communicating artery, an aneurysm at the cavernous portion of the right carotid artery, a PPTA, and MCA fenestration. The patient remained in an apallic state, even after successful clipping of the anterior communicating artery aneurysms.

[Trombosis of the middle cerebral artery as the cause of cerebrovascular insult (CVI) and recognition of the etiologic factors for CVI]

In the paper is shown the case of the patient of the CVI life, age of 40 years. It was about the vascular lesion left of the temperoparienal MRA shew the amputation of amputation of the temporal branches art. cerebri medii from the left side. The patient 6 years before she suffered of CVI infract myocard after which she recovered well. After the performed neurologic and physiatric treatment it came to the strength of the rude motor strength with the normalization of the speech.

Microsurgical anatomy of the early branches of the middle cerebral artery: morphometric analysis and classification with angiographic correlation

OBJECT

The cortical arteries arising from the main trunk of the middle cerebral artery, proximal to its bifurcation or trifurcation, are called "early branches." The purpose of this study was to characterize these early branches.

METHODS

The early branches were characterized according to their sites and patterns of origin, diameters, and relative proximity to the internal carotid artery bifurcation, as well as the course and area of supply of their cortical branches based on an examination of 50 hemispheres. Special attention was directed to the perforating arteries that arose from the early branches and entered the anterior perforated substance. The anatomical findings were compared with data obtained from 109 angiograms.

CONCLUSIONS

Early branches directed to the temporal and frontal lobes were found in 90 and 32% of the hemispheres, respectively. The early branches that arose more proximally from the M1 segment were larger than those arising distally. Lenticulostriate arteries arose from 81% of the early frontal branches (EFBs) and from 48% of the early temporal branches (ETBs). An average of two cortical arteries arose from the EFBs and 1.3 from the ETBs, the most common of which supplied the temporopolar and orbitofrontal areas. Although the microsurgical anatomy of the early branches demonstrates abundant diversity, they can be classified into clearly defined patterns based on anatomical features. These patterns can prove helpful in evaluating angiographic data and in planning an operative procedure.

Transient third nerve palsy in a young patient with intracranial arteriovenous malformation

PURPOSE

To describe a patient with transient third nerve palsy as the possible presenting sign of intracranial arteriovenous malformation.

METHOD

Case report.

RESULT

A 24-year-old female presented to ophthalmic casualty with sudden onset binocular diplopia and was diagnosed to have right sided partial third nerve palsy. Within 30 hours the third nerve palsy had recovered completely. A MRI scan and subsequent carotid angiogram revealed a large, high flow, trans-cortical Spetzler-Martin grade 4 arteriovenous malformation. The feeder vessel of the AVM originated from the right middle cerebral artery. Superficial venous drainage was via the superficial middle cerebral vein to the right transverse sinus. The deep venous drainage was via thalamostriate veins into markedly dilated internal cerebral vein and vein of Galen (Great cerebral vein). Venous reflux was noted around the midbrain from the vein of Galen.

CONCLUSIONS

Transient third nerve palsy may rarely occur secondary to intracranial arteriovenous malformation. Ophthalmologists should consider neuroimaging in the investigations for transient cases of III nerve palsy in young patients.

Relationship between the Oxfordshire Community Stroke Project classification and vascular abnormalities in patients with predominantly intracranial atherosclerosis

BACKGROUND

The Oxfordshire Community Stroke Project (OCSP) classification is a stroke classification based on clinical features collected at bedside. Previous studies reported good correlation between vascular abnormalities and OCSP mainly in populations not at risk of intracranial atherosclerosis. There have been limited data on the relationship between intracranial atherosclerosis and the OCSP classification.

METHODS

Consecutive Chinese patients admitted to a regional hospital with acute ischemic stroke were studied in Hong Kong. Stroke subtype was classified as total or partial anterior circulation infarct (TACI or PACI), posterior circulation infarct (POCI), or lacunar infarct (LACI), according to the OCSP method. Transcranial Doppler (TCD) was performed whenever possible to evaluate the intracranial arteries as well as the carotid arteries. National Institute of Health Stroke Scale (NIHSS) was used to assess the severity of stroke on admission.

RESULTS

Six hundred and ninety-nine consecutive patients were studied. On admission, 24 patients were classified as TACI (3.4%), 96 PACI (13.7%), 111 POCI (15.9%), and 468 LACI (67.0%). Of the 345 patients who had TCD evidence of intracranial or carotid artery abnormalities, 75% had intracranial involvement only, 5% extracranial involvement only and 20% had both intracranial and extracranial involvement. The frequencies of arterial abnormalities were found in 58% of TACIs, 48% of PACIs, 48% of POCIs and 50% of LACIs. There was no evidence that the frequencies of arterial abnormalities were different between the OCSP groups (P=0.8). Middle cerebral artery velocity was abnormal in 9 TACIs (38%), 32 PACIs (33%), 35 POCIs (32%) and 177 LACIs (38%) (P=0.6). Vertebrobasilar velocities were abnormal in 4 TACIs (17%), 20 PACIs (21%), 29 (26%) and 87 LACIs (19%) (P=0.3). The OCSP subtypes were associated with POCIs the severity of stroke. NIHSS score of > or =9 was found in 83% of TACIs, 18% of PACIs, 9% of POCIs, and 12% of LACIs (P<0.0001).

CONCLUSIONS

OCSP classification is not significantly related to the presence of vascular abnormalities among patients with predominantly intracranial atherosclerosis.

Size, course, distribution and anomalies of the middle cerebral artery in adult Nigerians

OBJECTIVE

To determine the size, course, distribution and anomalies of the middle cerebral artery in adult Nigerians.

DESIGN

A retrospective study.

SETTING

Department of pathology, University College Hospital, Ibadan between April and September 1999.

SUBJECTS

One hundred middle cerebral arteries from patients' asymptomatic for central nervous system lesions, obtained at autopsy from fifty adult Nigerians were examined.

RESULTS

The MCA arose as the wider of the two terminal branches of the internal carotid artery (ICA). Its mean diameter was 3.49 mm (CI = 3.39-3.59 mm), while the mean pre-division length was 15.43 mm (CI = 14.59-16.27 mm). In 92% of specimens, the first branches were perforators. The early branches were destined solely to the temporal lobe pole in most hemispheres (85%). In most specimens, (81%) the main trunk bifurcated while in 13% it trifurcated. One accessory MCA, and the early branches were given off before the perforators in two middle cerebral arteries, making an incidence of anomalies of 3%. There was no aneurysm.

CONCLUSION

These results are similar to what has been described in the literature for Caucasians. It buttresses the assertion that anatomical anomalies of the MCA are rare. The rarity at autopsy of aneurysms of the MCA in asymptomatic Nigerian Africans is not explained by the gross morphology of this vessel.

Angiographic and embryologic considerations in five cases of middle cerebral artery fenestration

Five cases of unilateral middle cerebral artery fenestration were observed during the prospective evaluation of 1466 consecutive cerebral angiograms (0.43% of 1170 patients) between January 1999 and July 2001. In each case, an early branching temporopolar artery was seen to arise from the inferior limb of the fenestrated segment. This finding suggests that early branching temporopolar arteries may participate in the formation of middle cerebral artery fenestration by interfering with the normal fetal development of the middle cerebral artery.

Association of cerebral arteriovenous malformation with cerebral arterial fenestration

Cerebral arteriovenous malformations (AVMs) are rarely associated with other vascular lesions. Our goal was to examine the incidence of the coexistence of cerebral AVMs and cerebral arterial fenestrations. During the past 18 years, 51 patients with a cerebral AVM were examined with selective cerebral angiography in our institution. We retrospectively reviewed these cerebral angiographies and noted associated cerebral arterial fenestrations. We found five fenestrations distributed among 3 patients. In each patient one fenestration was located in the vertebral artery (VA). In 1 patient there were additional basilar and left middle cerebral artery fenestrations. Vertebral artery angiography was performed in 43 of the 51 patients; thus, the frequency of coexistence of AVM and VA fenestration was 7% (3 of 43). Although the clinical significance may not be great, we found a noteworthy incidence of associated VA fenestrations in AVM cases.