Abstract
Objective: The twig?like middle cerebral artery (TL?MCA) is a rare congenital vascular anomaly in which the M1 segment is replaced by a plexiform network of primitive arterial twigs1. Because its angiographic appearance overlaps with Moyamoya disease and arteriovenous malformations, TL?MCA is frequently misdiagnosed. We report three cases initially referred to as Moyamoya disease and provide an expanded review of diagnostic criteria, embryological mechanisms, and management strategies.
Methods: A retrospective review of all patients referred to Al Azhar Clinic (Algiers, Algeria) between 2019 and 2024 for presumed Moyamoya disease was conducted. Among 24 patients diagnosed with Moyamoya disease or syndrome, three were ultimately identified as having TL?MCA. Clinical presentation, MRI findings, angiographic characteristics, and management decisions were analyzed.
Results: The three patients (two females, one male; mean age 41 years) presented with headaches (n=2) or transient neurological deficits (n=1). TL?MCA was left?sided in two cases and right?sided in one. An MCA trunk was present in one patient and absent in two. All demonstrated a plexiform arterial network replacing the M1 segment. Perfusion imaging was normal or showed no mismatch, and conservative management was favored.
Conclusions: TL?MCA is a non?progressive congenital anomaly that mimics Moyamoya disease radiologically and clinically. Accurate differentiation is essential to avoid unnecessary revascularization surgery. Combined MRI–angiography assessment is critical for diagnosis and management. Treatment should be individualized, with revascularization reserved for patients demonstrating perfusion–diffusion mismatch or progressive ischemia.
