Treatment of Unruptured Aneurysm of Duplication of the Middle Cerebral Artery
Abstract and Figures
A 60-year-old woman presented with a rare unruptured aneurysm of duplication of the middle cerebral artery (DMCA) identified at examination for headache. Preoperative cerebral angiography revealed the DMCA and a small aneurysm at its origin. Surgical clipping was performed successfully via the trans-sylvian approach. DMCA aneurysms have a tendency to bleed even if small, but the anatomical configuration causes some technical difficulties.
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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.
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.
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.
Objective: Treatment of an unruptured aneurysm at the origin of duplicated middle cerebral artery (DMCA) by coil embolization using balloon remodeling has not been reported. We report a case of coil embolization using balloon remodeling for an unruptured aneurysm at the origin of DMCA.
Case Presentation: A 71-year-old female was found to have an unruptured aneurysm at the origin of DMCA during an examination for headache. Coil embolization using balloon remodeling for the wide neck aneurysm to preserve both the internal carotid artery (ICA) and DMCA was successful. The perioperative course was uneventful.
Conclusion: This treatment enables complete embolization, and preserves both the ICA and DMCA. Thus, it is useful for aneurysms at the origin of DMCA.
Aneurysm at the origin of a duplication of the middle cerebral artery (DMCA) is very rare, and only 29 treated cases have been reported. All of the cases were treated by direct surgery except a ruptured case treated by intentional partial coil embolization. We report the first unruptured case treated by coil embolization and review the previously published cases. Coil embolization can be alternative treatment for an unruptured aneurysm at the origin of the DMCA. Stable framing to spare the origin of it and prevention of thromboembolic complications are keys for safe treatment.
Objective:
To review the management of aneurysms arising at the origin of a duplicated middle cerebral artery (DMCA), which is an extremely rare entity.
Methods:
Four patients with internal carotid artery-DMCA aneurysms are presented, and 24 previously published cases are reviewed.
Results:
Of the 28 internal carotid artery-DMCA aneurysms, 17 were ruptured, and 11 were unruptured. The aneurysms were equally distributed on the right and left sides and were small in size (≤6 mm) except for two that were of medium size. All aneurysms were treated surgically except for two very small aneurysms, which have been managed conservatively and followed for 9 years.
Conclusions:
Although all previously published clinical cases of internal carotid artery-DMCA aneurysms were treated surgically, conservative management with follow-up is a viable option in very small unruptured aneurysms.
A 62-year-old female complaining of sudden severe headache was referred to our stroke center in consultation. Computed tomography showed diffuse spread of thick subarachnoid hemorrhage to the basal cistern and both sylvian fissures, and digital subtraction angiography showed kissing aneurysms arising in the left lateral and occipital directions in the C(1) portion of the internal carotid artery (ICA). The anterior choroidal artery was situated between the two aneurysms, and another small branch originating from the dome of the distal aneurysm was confirmed as a duplicated middle cerebral artery (MCA). Endovascular treatment was successfully performed to spare the two vessels involved. This case of kissing aneurysms and ICA-duplicated MCA is very rare, and presents difficulties for both surgical and endovascular treatments.
We experienced three cases of duplication of the middle cerebral artery among 750 cases by angiography in our institute. One case showed a saccular aneurysm at its origin. The rest were detected during examinations for cerebral infarction. One had an accessory middle cerebral artery in itself. We discuss our clinical findings with some reference to the literature.
A case of duplication of the middle cerebral artery and an aneurysm at its origin is described. The patient, a 74-year-old male, was hospitalized following a head injury. A computed tomography scan showed intraventricular and subarachnoid hemorrhages. Carotid and vertebral angiograms revealed no vascular abnormalities causative of the hemorrhages. However, duplication of the middle cerebral artery and a saccular aneurysm at its origin were coincidentally observed on the right side. Craniotomy was performed 3 weeks later, and the duplication was confirmed. The neck of the unruptured aneurysm was clipped. Of the 55 reported cases of duplication of the middle cerebral artery, only six were associated with an aneurysm at the origin. The possible etiologies of such aneurysms are discussed.
Two cases of intracranial aneurysms, arising from the origin of anomalous middle cerebral arteries were reported. One case showed a rather classical history of subarachnoid hemorrhage and duplication of the middle cerebral artery beside the ruptured aneurysm. The other case was found incidentally with chronic subdural hematoma while performing carotid angiography, and an accessory middle cerebral artery was seen originating from the A1 portion of the anterior cerebral artery as well as an IC-PC aneurysm. According to Teal's definition, an anomalous middle cerebral artery arising from the anterior cerebral artery should be termed as the accessory middle cerebral artery, whereas the duplication of the middle cerebral artery should originate from the internal carotid artery proximal to the Al-M1 origin. Twenty-three cases of aneurysms associated with those anomalous middle cerebral arteries have been reported, among which 8 cases were found to have the accessory middle cerebral artery and 15 cases were with duplication of the middle cerebral artery. Location of these aneurysms suggested both congenital and acquired factors as the etiology.
: The microvascular anatomy of the main trunk and divisions of the middle cerebral artery was studied in 104 unfixed brain hemispheres injected with polyester resin and dissected under the operating microscope. The following anomalies and variations of the middle cerebral artery were found: fenestration (1 case; 1%), located on the first 4 mm of the main trunk of the middle cerebral artery; duplication (1 case; 1%), with vessels arising from the internal carotid artery; accessory middle cerebral artery (2 cases; 2%), originating on the A1 segment of the anterior cerebral artery; single-trunk type of middle cerebral artery (4 cases; 4%), with no division of its main trunk; quadrifurcation (4 cases; 4%), in which the main trunk of the middle cerebral artery divided into four secondary trunks. The clinical implications of these anatomical findings are discussed, and photographs of representative specimens illustrate the anomalies. (Neurosurgery 22:1023-1027, 1988)
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We report a very rare case of subarachnoid hemorrhage associated with fenestration of the anterior cerebral artery (ACA), the accessory middle cerebral artery (A-MCA) and the duplication of the middle cerebral artery (D-MCA). It seems that this is the first report of these combined intracranial vascular anomalies, although many authors have reported each anomaly in isolation. A 50-year-old male visited a local physician complaining of the sudden onset of a severe pulsating headache. A lumbar puncture showed bloody cerebrospinal fluid, and he was transferred to our institution. An emergency CT scan showed no apparent subarachnoid hemorrhage, but the left internal carotid angiography showed a saccular aneurysm at the origin of the D-MCA. Other anomalies, such as the fenestration of the ACA and the A-MCA, were also apparent during angiography. The ruptured aneurysm was safely clipped on the next day and the patient was discharged with no neurological deficits three weeks after the operation. The incidence of fenestration of the ACA is 0.2% in the angiographic series, and 0.1-7.2% at autopsy. Fenestration of the ACA is thought to be less than that of the vertebral artery. Ever since it was proposed by Teal et al, the term A-MCA has been restricted to an artery that arises from the ACA, and a branch arising from the internal carotid artery has been termed as the D-MCA. These anomalous vessels supply the cortex in the distribution of the middle cerebral artery. The angiographic incidence of A-MCA is about 4%, and six cases of aneurysm located at the origin of the A-MCA have been reported so far.(ABSTRACT TRUNCATED AT 250 WORDS)
The microvascular anatomy of the main trunk and divisions of the middle cerebral artery was studied in 104 unfixed brain hemispheres injected with polyester resin and dissected under the operating microscope. The following anomalies and variations of the middle cerebral artery were found: fenestration (1 case; 1%), located on the first 4 mm of the main trunk of the middle cerebral artery; duplication (1 case; 1%), with vessels arising from the internal carotid artery; accessory middle cerebral artery (2 cases; 2%), originating on the A1 segment of the anterior cerebral artery; single-trunk type of middle cerebral artery (4 cases; 4%), with no division of its main trunk; quadrifurcation (4 cases; 4%), in which the main trunk of the middle cerebral artery divided into four secondary trunks. The clinical implications of these anatomical findings are discussed, and photographs of representative specimens illustrate the anomalies.
Unlabelled:
Branching patterns of middle cerebral artery (MCA) were angiographically analyzed in 704 cases with cerebral aneurysms. The mean age was 53 years old and the men-to-women ratio was 1.1. In addition, 13 vascular anomalies of MCA were reported and their correlation with the occurrence of cerebral aneurysm was studied.
Results:
MCA branching patterns were classified in 6 types. Each type was further studied by dividing into 2 subgroups, namely one with MCA aneurysms at their side and the other without MCA aneurysms. There were no differences statistically between each two groups. Vascular anomalies were consisted of 5 duplications of MCA, 4 fenestrations, 3 accessories and one case of combination of duplication and accessory in the same side. Duplications and accessories did not have any evidence of developing aneurysm more frequently at their bifurcation than any one of normal MCA branching patterns. So we concluded that duplications and accessories should be thought to have similar meanings with the ordinary branching patterns of MCA in the occurrence of aneurysms. A postmortem case of accessory MCA without aneurysm revealed that the origin of the anomaly was pathologically normal. We suggested that the origin of accessory MCA could both be an enlarged Heubner artery and a rare branching pattern of MCA. The fenestration should be a true anomaly but at this point we do not have any suggestive clue for that. Finally, we thought that the combination of duplication and accessory in a single MCA was very rare morphologically, and worthwhile to report.
Two cases of accessory middle cerebral artery arising from the internal carotid artery are described, both being demonstrated by carotid angiography. In one case there was an aneurysm at the origin of the anomalous vessel. Only four previous angiographic demonstrations of the anomaly could be found in the literature, although there is a reported post-mortem incidence of 3 per cent.