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. 2009 Dec 3;2009:bcr06.2009.2035. doi: 10.1136/bcr.06.2009.2035

Duplicated middle cerebral artery

Jesus Perez 1, Calixto Machado 2, Claudio Scherle 3, Daniel Hierro 4
PMCID: PMC3028152  PMID: 22140405

Abstract

Duplicated middle cerebral artery (DMCA) is an anomalous vessel arising from the internal carotid artery. The incidence DMCA is relatively law, and an association between this anomaly and cerebral aneurysms has been documented. There is a controversy whether DMCA may have perforating arteries. This is an important fact to consider in aneurysm surgery. We report the case of a 34-year-old black woman who suffered a subarachnoid hemorrhage and the angiography a left DMCA, and an aneurysm in an inferior branch of the main MCA. The DMCA and the MCA had perforating arteries. The aneurysm was clipped without complications. The observation of perforating arteries in our patient confirms that the DMCA may have perforating arteries. This is very important to be considered in cerebral aneurysms surgery. Moreover, the DMCA may potentially serve as a collateral blood supply to the MCA territory in cases of MCA occlusion.

Background

Crompton in 1962 described in eight necropsies rupture of aneurysms of the accessory middle cerebral artery (MCA), which also included duplication of the MCA (DMCA).1 Teal et al in 1973 first proposed using the term MCA duplication to characterise the two vessels originating from the distal end of the internal carotid artery (ICA).2 Komiyama et al more precisely describe the origin of the DMCA between the anterior choroidal artery and the distal end of the ICA3; the term DMCA has been also widely used.3–9 Several authors have proposed different explanations regarding the origin of DMCA, but its embryologic origins is still an open question.3

Anomalies of the MCA occur less frequently than those of other major intracranial arteries.2,10,11 The incidence of DMCA is reported in necropsy studies and on angiography to be 0.7–2.9%1,12 and 0.24–1.5%,13–15 respectively. For example, Vincentelli et al reported only one case of real duplication of the MCA in 100 anatomical dissections of the basal brain arteries,16,17 whereas Komiyama et al found this cerebral artery anomaly in 0.4% of their series.3

An association between this anomaly and cerebral aneurysms has been documented, although it is not clear whether this relationship is a casual occurrence or whether they are related by an unknown mechanism.1,4,18,19

Moreover, there is controversy over whether DMCA is is a pure cortical vessel, or it has perforating arteries to the anterior perforated substance.20 This is an important fact to consider in aneurysm surgery, for avoiding cerebral ischaemia during surgical vessels manipulation.3,20,21

We present a case of DMCA associated with an ipsilateral distal MCA aneurysm.

Case presentation

A 34-year-old black woman suffered from severe headache and transient loss of consciousness. Computed tomography (CT) scan upon arrival to our hospital revealed diffuse subarachnoid haemorrhage with a gross clot in the left Sylvian cistern.

A digital subtraction angiographic study showed duplication of the left MCA and an aneurysm in the inferior division of the main MCA. The duplicated artery was smaller than the main vessel. The DMCA, as well as the main MCA, had perforating arteries (fig 1).

Figure 1.

Figure 1

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Digital subtraction angiography study showing a duplicated middle cerebral artery (DMCA), and an aneurysm of the inferior portion of the MCA. Single arrow indicates the DMCA. Both the main MCA and the DMCA have perforating arteries. Arrowhead shows a perforating artery that arises from the DMCA.

We discussed with neurosurgeons the presence of the DMCA with perforating arteries when planning surgery. The aneurysm was clipped 4 days after symptoms onset, and the patient was discharged without any neurologic deficit.

Discussion

Although some reports have affirmed that the DMCA is a pure cortical vessel without perforating arteries,22 other authors have reported that the DMCA and the main MCA have perforating arteries to the anterior perforated substance.3 The DMCA had perforating arteries in three of four cases studied by Komiyama et al, while the main MCA had perforating arteries in all four cases.3,20

The DMCA may play an important role in supplying collateral blood flow to the frontal lobe and basal ganglia through the perforating arteries.20 Abanou et al reported that the DMCA and the accessory MCA that originates near the anterior communicating artery provide cortical supplies to the orbito-frontal area, and sometimes to the anterior temporal area.22 Gibo et al described a patient who had both a duplicated and an accessory MCA in which the duplicated artery was distributed to the temporopolar, anterior, and middle temporal areas.23 Umansky et al reported a case in which the main MCA irrigated the frontal and parietal lobes, while the duplicated MCA provide blood supply to the temporal lobe.10,11 Komiyama et al affirmed that the DMCA consistently reached the temporopolar, as well as the anterior and/or middle temporal territories.20 Hence, the cortical areas supplied by the DMCA are similar to the early branches of the MCA, although the extent of vascular supply may vary.10,11,20,24–26

An association between the DMCA and cerebral aneurysms has been reported.27 There are few reports of aneurysms arising from the origin of a DMCA,19,28,29 and a small percentage of these patients had multiple aneurysms.27 Uchino et al recently reported a very rare case of subarachnoid haemorrhage due to rupture of a saccular aneurysm arising from trunk of this anomalous vessel.7

It is also important to consider that the DMCA and other MCA anomalies, and their potential relationship with cerebral aneurysms, can also be visualised by less invasive imaging techniques, such as CT angiography,30 and magnetic resonance angiography.31–33

The observation of perforating arteries in our patient confirms previous reports that the DMCA may have perforating arteries.3 Therefore, this important fact is to be considered during the opening of the Sylvian fissure for approaching the circle of Willis in cerebral aneurysms surgery, because manipulation of this vessel may lead to ischaemia and brain infarcts. Moreover, the DMCA may potentially serve as a collateral blood supply to the MCA territory in cases of MCA occlusion, and should be considered in the pathophysiology of brain infarcts in this arterial territory.3,20,34

Learning points

  • The observation of perforating arteries in our patient confirm that the DMCA may have perforating arteries.

  • The presence of perforating arteries in this MCA anomalous vessel seems to be relatively frequent.

  • This is important to consider during the opening of the Sylvian fissure for approaching the circle of Willis in cerebral aneurysms surgery, because manipulation of this vessel may lead to ischaemia and brain infarcts.

  • The DMCA may potentially serve as a collateral blood supply to the MCA territory in cases of MCA occlusion, and should be considered in the pathophysiology of brain infarcts in this arterial territory.

Footnotes

Competing interests: none.

Patient consent: Patient/guardian consent was obtained for publication

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