Abstract
Middle cerebral artery (MCA) anatomy is essential to prevent catastrophe during intravascular procedures such as thrombolysis and cerebral angiography and neurosurgical practices, example – stent insertion, bypass grafting, etc. Eighty percent of blood supply to the brain is through MCA. The motor and sensory homunculus of brain representing arm and face receive blood supply from MCA. MCA consists of four segments. M1 is between the origin of MCA and the genu of insula (sphenoidal); M2 runs from limen insula to insula’s circular sulcu (insular) s; M3 from circular sulcus to Sylvian fissure surface (opercular). Cortical branches of MCA territory can be divided into 13 areas orbitofrontal, prefrontal, precentral, central, postcentral, anterior parietal, posterior parietal, angular, temporo-occipital, posterior temporal, middle temporal, anterior temporal, and temporopolar arteries. MCA with bifurcated termination is seen in 64.70%. Bilateral bifurcation of MCA is present in 50%. Unilateral bifurcation of MCA is present in 25.45% on the left side and in 24.54% on the right side. MCA with trifurcated termination is seen in 12.35%. Bilateral trifurcation is present in 14.28%. Unilateral trifurcation is seen in 28.57% on the left side and 57.14% on the right side. Quadrifurcated type of termination is seen in 2.35%, four on the right side and four on the left side. Different sites of accessory MCA are at the level of proximal A1, at the level of middle A1, at the level of distal A1, at the level of Anterior communicating artery (AComA) at the level of A2. M1 segment (sphenoidal) of MCA is either straight or curved, where it is more curved than straight. The volume of this segment is more on the left side in males as compared to females. Average length of M1 segment is 17.30 ± 0.07 mm. Length is more on the left side as compared to the right side; it is more on nonaneurysmal side as compared to aneurysmal side. Again, the average diameter of M1 segment of MCA is 2.37 ± 0.33 mm, which is more on the left side and in male populations, diameter is more on aneurysmal side as compared to nonaneurysmal side. Diameter of M2 segment is more on left side (0.8–2.6 mm), and it is also more in case of females as compared to males. The M3 segment has been found to be more on the left side (1.5 mm as compared to right side1.4 mm. MCA fenestration is the name given to a fusion defect in the main trunk of the MCA after its origin, such that it emerges as a single trunk, branches, and then re-fuses. CRD number-420251052884.
Keywords: Accessory branches, bifurcation, fenestration, middle cerebral artery, trifurcation
Résumé
L’anatomie de l’artère cérébrale moyenne (MCA) est essentielle pour prévenir les catastrophes lors d’Interventions intravasculaires telles que la thrombolyse, l’angiographie cérébrale et les pratiques neurochirurgicales, par exemple – insertion de stent, pontage, etc. Quatre-vingts pour cent de l’apport sanguin au cerveau provient de l’ACM. L’homoncule moteur et sensoriel du cerveau, représentant le bras et le visage, reçoit un apport sanguin de l’ACM. Le MCA se compose de quatre segments. M1 se situe entre l’origine de l’ACM et le gène de l’insula (sphénoïdale) ; M2 va de l’insula limen au sulcu circulaire (insulaire) de l’insula ; M3 du sillon circulaire à la surface de fissure sylvienne (operculaire). Les branches corcales du territoire MCA peuvent être divisées en 13 zones : orbitofrontale, préfrontale, précentrale, centrale, postcentrale, pariétale antérieure, pariétale postérieure, angulaire, temporo-occipitale, temporale postérieure, temporale moyenne, temporale antérieure et temporopolaire. L’ACM avec terminaison bifurquée est enregistrée à 64,70 %. La bifurcaon bilatérale de l’ACM est présente à 50 %. La bifurcation unilatérale de l’ACM est présente à 25,45 % du côté gauche et à 24,54 % du côté droit. L’ACM avec terminaison trifurquée est enregistrée à 12,35 %. La trifurcaon bilatérale est présente à 14,28 %. La trifurcation unilatérale se manifeste à 28,57 % du côté gauche et à 57,14 % du côté droit. Le type de terminaison quadrifurquée se retrouve à 2,35 %, quatre sur le côté droit et quatre sur le côté gauche. Les différents sites de MCA accessoire se trouvent au niveau de l’A1 proximal, de l’A1 central, de l’A1 distal, et de l’artère communicante antérieure (AComA) au niveau de l’A2. Le segment M1 (sphénoïdal) de MCA est soit droit, soit courbé, où il est plus courbé que droit. Le volume de ce segment est plus à gauche chez les mâles que chez les femelles. La longueur moyenne du segment M1 est de 17,30 ± 0,07 mm. La longueur est plus du côté gauche que du côté droit ; C’est plutôt du côté non anévrisque que du côté anévrisque. Encore une fois, le diamètre moyen du segment M1 de MCA est de 2,37 ± 0,33 mm, ce qui est plus du côté gauche et, chez les hommes, le diamètre est plus du côté anévrismaque que du côté non anévrisque. Le diamètre du segment M2 est plus du côté gauche (0,8–2,6 mm), et il est également plus important chez les femelles que chez les mâles. Le segment M3 a été constaté plus sur le côté gauche (1,5 mm comparé au côté droit) 1,4 mm. La fenestraon MCA est le nom donné à un défaut de fusion dans le tronc principal du MCA après son origine, de sorte qu’il émerge sous forme d’un seul tronc, se ramifie, puis refusionne.CRD-420251052884.
Mots-clés: Branches accessoires, bifurcation, fenestration, artère cérébrale moyenne, trifurcation
INTRODUCTION
Sharma et al. have mentioned that middle cerebral artery (MCA) anatomy has become essential to prevent catastrophe during intravascular procedures such as thrombolysis and cerebral angiography, and neurosurgical practices example, stent insertion, bypass grafting, etc. Eighty percent of blood supply to the brain is via MCA. The motor and sensory homunculus of brain representing arm and face receive blood supply from MCA. MCA comprises four segments [Figure 1] M1 is between the origin of MCA and genu of insula (sphenoidal); M2 runs from limen insula to insula’s circular sulcu (insular) s; M3 from circular sulcus to the Sylvian fissure surface (opercular). M4 segment from Sylvian fissure to branches in lateral convexity (cortical). M1 segment, from the internal carotid artery (ICA), travels toward insula. Sometimes, there may be 5 segments, where M4 and M5 were parainsular and terminal segments. M1 is most crucial as branching occurs here.[1]
Figure 1.
Coronal section of the brain showing different sections of the middle cerebral artery
Wade Kane et al.[9] say that the cortical branches of MCA territory can be divided into 13 areas [Figure 2]: orbitofrontal, prefrontal, precentral, central, postcentral, anterior parietal, posterior parietal, angular, temporo-occipital, posterior temporal, middle temporal, anterior temporal, and temporopolar arteries. The smallest cortical arteries arise at the anterior end and the largest one at the posterior end of the Sylvian fissure. The largest cortical arteries supply the temporo-occipital and angular areas.
Figure 2.
The cortical branches of middle cerebral artery
According to him regarding the histological structure of cerebral circulation, the wall of cerebral arteries and arterioles consist of three concentric layers: The innermost layer is the tunic intima, which consists of a single layer of endothelial cells and the internal elastic lamina (IEL); the next layer out is the tunica media, which contains mostly smooth muscle cells with some elastin and collagen fibers; and the outermost layer is the tunica adventitia, composed mostly of collagen fibers, fibroblasts, and associated cells such as perivascular nerves (in large and small pial arteries) and pericytes and astrocytic end-feet (in parenchymal arterioles and capillaries). Unlike systemic arteries, cerebral arteries have no external elastic lamina, but instead have a well-developed IEL. Other differences from systemic arteries include a paucity of elastic fibers in the medial layer and a very thin adventitia. The number of smooth muscle cell layers varies depending on the size of the vessels and species, with large arteries such as the ICA having as many as 20 layers. Smaller pial arteries contain approximately two to three layers of smooth muscle, whereas the penetrating and parenchymal arterioles contain just one layer of smooth muscle. In addition, smooth muscle in the medial layer of cerebral arteries and arterioles is circularly arranged and oriented perpendicular to blood flow with essentially a zero-degree pitch.[2]
Embryological development of middle cerebral artery
Ota and Komiyama et al. have also mentioned the development of cranial arteries, published in 1948, which provides useful information about the embryology of MCA. When the embryo is 28–30 days old (crown-rump length 4–5 mm), ICA divides into a cranial and a caudal branch [Figure 3a]. The anterior cerebral artery (ACA) is a continuation of the cranial branch, and MCA is one of its collaterals. The caudal branch later develops into a posterior communicating artery. When the embryo is 31–33 days old (7–12 mm), the primary cranial branch of ICA gives rise to several branches. The largest of these is the primitive anterior choroidal artery (AChoA) [Figure 3b]. At 34–36 days of the embryonal stage (12–14 mm), the AChoA becomes quite prominent. Just distal to the AChoA, multiple plexiform arterial twigs appear, which later develop into lateral striate arteries and the trunk of MCA by fusion and regression [Figure 3c]. The terminal end of the cranial division of the carotid constitutes the primitive olfactory artery (POA). It has two branches, a primary branch to the nasal fossa, and a secondary branch passing more medially to the emerging olfactory nerve root. The latter is the medial olfactory artery (MOA), which joins with the artery from the contralateral side, in the mid-line region of the future Anterior communicating artery (Acom A). By 39–41 days of the embryo (16–18 mm), the MCA becomes a prominent stem, with plexiform arteries, which enter the lateral part of the anterior perforated substance, for supply to the striatum. At 43–45 days of the embryo (20–24 mm), the POA dwindles. On the other hand, larger derivatives of the POA extend laterally to enter the mesial part of the anterior substance, for supplying the basal ganglia [Figure 3d]. They are the recurrent artery of Heubner and medial striate arteries, which may have potential anastomosis with lateral striate groups [Figure 3e]. Finally, at 40 mm stage of the embryo, the MCA attains an approximate adult configuration [Figure 3f].[3]
Figure 3.
Schematic representation of the formation of the middle cerebral artery (MCA). (a) Internal carotid artery divides into a cranial branch (CR) and a caudal branch. (b) Anterior choroidal artery (AChoA) arises from the CR. (c) Multiple plexiform arterial twigs appear just distal to the AChoA. (d) Development of arterial twigs for recurrent artery of Haeubner’s (RAH) and MCA, AChOA. (e) Multiple plexiform arterial twigs evolve into RAH, a single MCA trunk. (f) Adult configuration of cerebral arteries of anterior circulation. MCA = Middle cerebral artery, AChoA = Anterior choroidal artery, RAH = Recurrent artery of Haeubner, CR = Cranial branch, CD = Caudal branch
MATERIALS AND METHODS
A literature search was carried out using the Boolean operator AND to search for literature containing all keywords and OR to search for literature containing alternative keywords.(“Middle Cerebral Artery” OR “MCA”) AND (“Neuroangiography” OR “Angiography” OR “Digital Subtraction Angiography” OR “DSA”) AND (“Patterns” OR “Variations” OR “Anomalies”) from literature searches on PubMed, the Cochrane Library, Directory of Open Access Journals, and EBSCOhost. English literature was collected, and no time restriction was applied in the search criteria.
Inclusion criteria
All clinical trials, cohort, prospective, retrospective, and observational mentioning patterns and variations or anomalies of MCA in neuroangiography, as well as cadaveric studies were included in the study.
Exclusion criteria
All review articles or consensus statements that did not have clinical information mentioning patterns and variations or anomalies of MCA in neuroangiography, as well as studies, were excluded from the study.
Online journal databases used in the search included PubMed (22 studies), Cochrane (0 studies), DoAJ (0 study), and EBSCO (0 study), scimago (1 study), web of science (1 study) others (4 studies) for a total of 28 articles. Duplication screening revealed 7 duplicate articles. Screened titles and abstracts were then screened, resulting in the remaining 21 articles. Full texts of the 21 articles were further screened. Five articles were excluded because further reading of the full text showed that the methodology and results did not follow the research we conducted. A total of 16 articles met the inclusion criteria of the study. A flowchart of the research literature search results is presented by Prisma chart [Figure 4].
Figure 4.
Preferred reporting items for systematic reviews and meta-analyses flow diagram. (Prisma chart)
Zurada et al. have mentioned that the M1 segment had a mean internal diameter of 2.23 mm and was greater in men. M1 asymmetry was identified in 23.4% of the individuals and was more common in women. The mean length was 15.62 mm, and the left M1 segments were a little longer. The mean volume of the M1 segments was 63.92 mm3, and this was typically greater in men and on the left sides. M1 segments are only slightly curved or straight in their course. In addition, the longest vascular M1 segments are more deviated (curved) and more tortuous.[4] Sharma et al. say that the M1 segment length was maximum in patients over 60 years and diameter was maximum in young patients (20–40 years).[1] According to Reci and Bexheti, this segment is arch-shaped, in (64%) arteries, rarely S-shaped, in (24%) arteries, much less straight alignment, in (12%) arteries. The average length of the M1 segment of the S shape is 20.6 ± 3.31 mm, with a 19.8 mm 4.41 mm arch shape, whereas the straight shape is 16.9 ± 3.62 mm. The average S-shaped diameter is 2.7 ± 0.51 mm, arched 2.6 ± 0.47 mm, straight form 2.6 ± 0.36 mm. Variations of M1 branching are: Common in 38 cases, early branching in 12 cases, joint trunk with cortical branch in 9 cases, lateral cortical branch in 21 cases, final bifurcation in 24 cases, final trifurcation in 13 cases, duplication in 1 case and M1 accessory in just 1 case out of 105 cases.[5] Hema and Sharieff found in their study that the mean of length of M1 was found slightly more on the left side (2.09 cm) in comparison to right side (1.90 cm). The mean diameter of M1 segment of MCA was more on the left side (0.352 cm), in comparison to right side (0.317 cm). The mean diameter of left MCA (0.352 cm) and left ICA (0.359 cm) were of the same size. The mean diameter of right MCA (0.317 cm) and right ICA (0.323 cm) were almost of the same size.[6] Siedlecki et al. the mean length of segment M1 was 24.1 ± 2.43 mm on the nonaffected side and 23.6 ± 2.21 mm on the affected side. The mean width measured in the proximal end of the MCA was 2.19 ± 0.19 mm on the nonaffected side and 2.21 ± 0.17 mm on the affected side. The mean width of the middle part of M1 was 1.99 ± 0.12 mm on the nonaffected side (nonaneurysmal side) and 2.02 ± 0.14 mm on the affected side (aneurysmal side).[7]
From the Table 1, it has been found that the M1 segment (sphenoidal) of MCA is either straight or curved, where it is more curved than straight. The volume of this segment is more on the left side in males as compared to females. The average length of M1 segment is 17.30 ± 0.07 mm. Length is more on the left side as compared to the right side; it is more on nonaneurysmal side as compared to aneurysmal side. Again, the average diameter of M1 segment of MCA is 2.37 ± 0.33 mm, which is more on the left side, and in male populations, diameter is more on aneurysmal side as compared to nonaneurysmal side.
Table 1.
Volume, length and diameters of M1 segment of middle cerebral artery along with its different morphological patterns using various modes of studies
| Authors | Mode of study | Morphology | Volume (mm3) | Length, mean±SD | Width, mean±SD | Sample size |
|---|---|---|---|---|---|---|
| Zurada et al., 2011 | CTA (computed tomographic study) | Slight curve/straight | 63.92 mm3 | 15.62 mm | 2.23 mm | 115 |
| Male > female | Left > right | Male > Female | 40=Male | |||
| Left > right | 75=Female | |||||
| Urvi et al., 2023 | CT cerebral angiography | 14.32±1.27 mm | 3.33±0.62 | 289 | ||
| Left > Right | Left > right | 180=Male | ||||
| P<0.05 | P=0.832 | 109=Female | ||||
| Reci et al., 2019 | Brain autopsy | Arch (64%) | 19.8±4.41 mm | 2.6±0.47 | ||
| S Shaped (24%) | 20.6±3.31 mm | 2.7±0.51 | ||||
| Straight (12%) | 16.9±3.62 mm | 2.6±0.36 | ||||
| Hema and Sharieff, 2018 | Brain autopsy | 2.0 cm/20 mm | 0.335 cm/3.35 mm | 140 | ||
| Left > right | Left > right | |||||
| Siedlecki et al., 2021 | CTA | 23.85±2.32 mm | 2.10±0.15 mm | 45 | ||
| Nonaneurysm > aneurysm | Aneurysm > nonaneurysm |
SD=Standard deviation, CTA=CT angiography, CT=Computed tomography
According to Halama et al., with DSA study of MCA, it has been found that the diameter of M2 segment is more on left side (0.8–2.6 mm) and it is also more in case of females as compared to males.[8] Wade-Kane et al.[9] have stated that on MRI study of MCA, the luminal diameter of the artery on the left cerebral hemisphere is more (2.2 mm) as compared to right side (2.1 mm) [Table 2].
Table 2.
Diameters of M2 segment of middle cerebral artery with various moods of studies
| Authors | Mode of study | Diameters of M2 | Sample size |
|---|---|---|---|
| Halama et al., 2022 | DSA | 0.9–2.4 mm <0.8–2.6 mm | Female=306 |
| Right < left | Male=146 | ||
| Male < female | Total=452 | ||
| Wade-Kane et al., 2022 | MRI | 2.1 mm | 40 |
| 2.2 mm | |||
| Left > right |
DSA=Data structures and algorithms, MRI=Magnetic resonance imaging
Wade-Kane et al. also demonstrated that on MRI study of MCA diameter of the M3 segment has been found to be more on the left side (1.5 mm as compared to right side 1.4 mm) [Table 3].[9] Pillai et al. have mentioned that on computed tomography angiography (CTA) study, luminal diameter of M3 segment of MCA is found to be 1.1–2.1 mm.[10]
Table 3.
Length and diameters of M3 segment of middle cerebral artery with various moods of studies
| Authors | Mode of study | Length of M3 | Diameters ofM3 | Sample size |
|---|---|---|---|---|
| Wade-Kane et al., 2022 | MRI | 1.5 mm | 40 | |
| 1.4 mm | ||||
| Left > right | ||||
| Pillai et al., 2023 | CTA | 1.1–2.1 mm |
MRI=Magnetic resonance imaging, CTA=Computed tomography angiography
Gunnal et al., MCA with bifurcated termination is seen in 64.70%. Bilateral bifurcation of MCA is present in 50%. Unilateral bifurcation of MCA is present in 25.45% on the left side and in 24.54% on the right side. MCA with trifurcated termination is seen in 12.35%. Bilateral trifurcation is present in 14.28%. Unilateral trifurcation is seen in 28.57% on the left side and 57.14% on the right side. Quadrifurcated type of termination is seen in 2.35%, four on the right side and four on the left side. When the main stem of MCA runs from its origin up to the posterior end of lateral cerebral fissure, it is referred as the complete MCA with a single trunk. In this type, no secondary trunk formation is seen. All cortical branches arise from the main single stem of MCA.[11]
Different branching pattern of accessory middle cerebral artery
Branches sprouting from the main artery had different termination patterns, including bifurcation [Figure 7b], trifurcation [Figure 7c], or primary trunk [Figure 7a]; of these, bifurcation was the most common (72%), consistent with previous reports. Early bifurcation, defined as occurring within 1 cm of the MCA origin, was observed in 3% and should be distinguished from double MCA. Early bifurcation was more likely to be associated with perforating branches arising from the postbifurcation segment of MCA. The presence of both early bifurcation and perforators from the postbifurcation segment in the same hemisphere was observed in 1% of specimens.[12]
Figure 7.
(a) Single main trunk of middle cerebral artery (MCA) and its cortical branches. (b) Bifurcation of MCA into upper (a) and lower trunks (b) with other branching patterns. (c) Trifurcation of MCA and its cortical branches. OA = Orbital artery, OFA = Orbitofrontal artery, FA = Frontal artery, PCA = Precentral artery, CA = Central artery, POCA = Postcentral artery, APA = Anterior parietal artery, PPA = Posterior parietal artery, TPA = Temporopolar artery, ATA = Anterior temporal artery, MTA = Middle temporal artery, PTA = Posterior temporal artery, OTA = Occipito temporal artery, MS = Mainstem of middle cerebral artery, ICA = Internal carotid artery, A = Upper trunk, B = Lower trunk, MCA = Middle cerebral artery, POCA = Post central artery, AA = Angular artery, ACoA = Anterior communicating artery, ACA = Anterior cerebral artery, PCOA = Posterior communicating artery, Achoa = Anterior choroidal artery, PFA = Prefrontal artery, POCA = Posterior cerebral artery, AA = Angular artery
Accessory middle cerebral artery
Gunnal et. al, in a cadaveric study, found that accessory MCA (AMCA) has been found in 2.05%. It is arising from the postcommunicating part of ACA. Out of the total specimens maximum number is seen in the right cerebral hemisphere [Figures 5 and 6].[11] According to Takahashi et al., in a CTA study, AMCA arise from AComA level with an average incidence of 4%.[13] Kim et. al., in both CTA and magnetic resonance angiography (MRA) study found that the incidence of AMCA as 0.45% (CTA) and 0.14% (MRA) at A1 or AComA level which is more on left side.[14] Nomura et al. established in his DMRI study that with. 3%–4% incidence rate AMCA is arising mostly at A1 level, more on left side[15] [Table 4, Figures 7 and 8].
Figure 5.
Bifurcation pattern of middle cerebral artery (upper branch dominance) (a) upper division before Genu (dark red ink) (b) upper division at the level of genu (dark red ink) (c) upper division after Genu (dark red ink). MCA = Middle cerebral artery
Figure 6.
Middle cerebral artery bifurcation (lower branch dominance) (a) Lower division dominance before genu (dark red ink). (b) Lower division dominance at the level of the genu (dark red ink). (c) Lower division after genu (dark red ink)
Table 4.
Incidence of accessory middle cerebral artery and its site of origin with various study pattern
| Case number | Authors | Incidence | Site of origin | Side of origin | Investigations |
|---|---|---|---|---|---|
| 1 | Gunnal et al. | 2.05% | A2 | Right - 5 Left - 2 |
Cadaveric study |
| 2 | CilliersK, JohnPageB | 0.1%–9.1% | A1, AComA, A2 | Cadaveric study | |
| 3 | Lucifero et al. | 0.5% | A1 | Cadaveric study | |
| 4 | Takahashi et al. | 4% | AComA | One AMCA - 7 Paired AMCA - 1 |
CTA |
| 5 | Kim et al. | 0.45% - CTA 0.14% - MRA |
Prox A1, AComA | Left | CTA, MRA |
| 6 | Brzegowy et al. | 2%–2.7% | A1 | Left | CTA |
| 7 | Nomura et al. | 0.3%–4% | A1 | Left | DMRI |
AMCA=Accessory middle cerebral artery, Acom=Anterior communicating artery, CTA=Computer tomography angiography, MRA=Magnetic resonance angiography, DMRI=Digital subtraction magnetic resonance imaging
Figure 8.
Different sites of accessory middle cerebral artery. (a) At the level of proximal A1, (b) At the level of middle A1, (c) At the level of distal A1, (d) At the level of Anterior communicating artery (AComA) (e) At the level of A2. AMCA = Accessory middle cerebral artery, ICA = Internal carotid artery, ICA = Internal carotid artery, MCA = Middle cerebral artery, POCA = Post central artery, AChoa = Anterior choroidal artery
Fenestrations of middle cerebral artery
MCA fenestration is the name given to a fusion defect in the main trunk of the MCA after its origin, such that it emerges as a single trunk, branches, and then re-fuses.[16]
CONCLUSION
From various quantitative and qualitative studies carried out, one can approach with angiographic stent placement after thrombectomy in the occlusion of this artery by clot.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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