Abstract
Introduction: The twig-like middle cerebral artery (TL-MCA) constitutes an uncommon vascular anomaly characterized by the substitution of the M1 segment with a plexiform network of diminutive, delicate vessels. Due to its rarity and similarities in radiological features, it is frequently misdiagnosed as Moyamoya disease or arteriovenous malformation. This publication presents three cases of TL-MCA identified at a single center, providing detailed insights into the radiological and clinical findings, and discussing management strategies through illustrative cases.
Material and methods: We conducted a retrospective review of the records of patients referred for the management of Moyamoya disease. A total of 24 patients diagnosed with either Moyamoya disease or syndrome were included, with assessments encompassing clinical presentation, symptoms at the initial consultation, and findings from angiography and MRI.
Results: Between 2019 and 2022, a total of 24 patients referred for Moyamoya disease were evaluated. Of these, three patients exhibited the terminal segment of the middle cerebral artery (TL-MCA). The cohort included two females and one male, aged between 20 and 54 years, with a mean age of 41 years. Clinical presentations varied: two patients experienced only headaches, while one patient reported dysarthria and hemiparesis. Angiographic assessment revealed that the TL-MCA was on the left side in two patients and on the right side in one patient. In one patient, a distinguishable MCA trunk was observed, whereas in the other two patients, no trunk was identified; instead, a web-like plexiform structure was present in all cases.
Discussion: Moyamoya and TL MCA are two distinct entities that are frequently conflated owing to their comparable radiological characteristics. Since Moyamoya disease and TL-MCA both cause hypoperfusion of cerebral tissue, consideration should be given to direct extra-intracranial revascularization through bypass surgery, supplemented by indirect techniques.
Conclusion: LT-MCA and Moyamoya disease differ in their pathophysiology and radiological criteria. However, they share similarities in inducing cerebral hypoperfusion and clinical presentation. Consequently, decision-making and management strategies for Moyamoya are also applicable to LT-MCA, and bypass surgery is recommended in specific situations.
