Case Report: Thrombectomy for left internal carotid artery occlusion with ipsilateral dual accessory middle cerebral arteries

Case Report: Thrombectomy for left internal carotid artery occlusion with ipsilateral dual accessory middle cerebral arteries | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Case Report: Thrombectomy for left internal carotid artery occlusion with ipsilateral dual accessory middle cerebral arteries Jota Tega, Yoshinobu Horio, Koichiro Suzuki, Yuta Oka, Koichiro Takemoto, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4872556/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Nov, 2024 Read the published version in Acta Neurochirurgica → Version 1 posted 10 You are reading this latest preprint version Abstract Accessory middle cerebral arteries (AMCAs) are found in 0.3-4.0% of cases, and ipsilateral dual AMCAs are rare. A seventy-three-year-old man presented with right hemiplegia and total aphasia. Magnetic resonance angiography showed left carotid artery occlusion. We infused him with tissue plasminogen activator. Digital subtraction angiogram showed revascularization of the left internal carotid artery. However, the left proximal anterior cerebral artery was occluded. We performed mechanical thrombectomy and achieved partial reperfusion. CT angiography on the tenth day showed ipsilateral dual AMCAs. Due to middle cerebral artery anomalies, we performed mechanical thrombectomy using contact aspiration which is safer than other techniques. Accessory MCA Triplicated MCA anomaly MCA Mechanical Thrombectomy Contact Aspiration Figures Figure 1 Figure 2 Introduction In 1962, Crompton 1) reported anomalous vessels arising from the ipsilateral anterior cerebral artery (ACA) proximal to the anterior communicating artery (AcoA) and from between the anterior choroidal artery and the internal carotid artery (ICA) terminal. In 1972, Teal et al. 2) defined anomalous vessels originating from the distal end of the ICA as duplicated middle cerebral arteries (DMCA) and those originating from the ACA as accessory middle cerebral arteries (AMCA). The presence of ipsilateral dual AMCAs was extremely rare. Mechanical thrombectomy was performed in an emergency. Therefore, it was often difficult to identify the occluded vessel in the presence of anomalies. We report here a case of mechanical thrombectomy for a patient with left internal carotid artery occlusion and dual ipsilateral AMCAs. Case description A seventy-three-year-old man with no known medical history collapsed at a baseball stadium. He was transferred to the closest hospital. He had right hemiplegia and total aphasia with an NIHSS score of 36. Electrocardiogram showed arterial fibrillation. Diffusion weighted imaging (DWI) showed an extensive high intensity area in the left middle cerebral artery (MCA) region (DWI- ASPECTS 5/10) and magnetic resonance angiography (MRA) showed occlusion of the left ICA (Fig. 1ABC). The patient was infused with tissue plasminogen activator and referred to our hospital for mechanical thrombectomy. On admission, the Glasgow Coma Scale was 12 (E4, V2, M6) He presented with complete right hemiplegia and severe motor aphasia. Endovascular procedure Left carotid angiogram revealed recanalized left ICA and two MCAs. The proximal MCA was completely recanalized. The distal MCA had a small diameter and was peripherally occluded. A large avascular area was observed in the left frontal lobe, which exceeded the perfusion area of the MCA that could be identified. Because the distal MCA was peripherally occluded, we did not attempt thrombectomy. Further, because the left ACA was occluded proximally, we performed contact aspiration for the occluded left ACA (Fig. 1 DEF). The third MCA originated from the A1-A2 junction. Thrombolysis in Cerebral Infarction grade was 2b. Because the third MCA was peripherally occluded, we did not attempt mechanical thrombectomy (Fig. 1 GHI). We considered the most proximal MCA to be the main trunk, and the remaining two MCAs to be AMCAs. Postoperative course The patient had a massive cerebral infarction in the left MCA region due to the length of time it took for him to be transferred from the referring hospital. The presence of an MCA anomaly made it difficult to identified occluded vessels. We performed a ten-day follow up CT angiography which showed spontaneous recanalization of dual AMCAs (Fig. 2AB). Since the patient still had severe right hemiplegia and motor aphasia, he was transferred to the rehabilitation ward with modified Rankin Scale 4 on the thirteenth day from onset. Discussion Padget et al. proposed that the development of the MCAs was thought to originate in the ICA cranial division at 7–12 mm of gestation, followed by the formation of the primitive anterior choroidal artery, primitive MCA, and ACA trunk, and that the AMCA and DMCA were generated by the remnants of primitive vascular networks and their formation process in later periods. 5) In 1970, Handa et al. claimed that the AMCA was an enlarged anomaly vessel of the recurrent artery of Heubner, which branches off from the ACA. However, this claim was rejected by Teals et al. 2,6) Komiyama et al. reported that AMCA was found in 0.3–4.0% of cases. It was an early anomaly branch of an MCA because it covered the perfusion area of the orbitofrontal, prefrontal, precentral, and / or central arteries. 3),15)-17) Uchiyama and Takahashi et al. considered AMCA to be a residual anastomosis between medial striate arteries from ACA and lateral striate arteries from MCA. 18) Uchino et al. 4) reported a case of triplicated MCA combined with DMCA and AMCA, but there have been only three reports on triplicated MCA combined with three MCAs in the English language literature 4),7–8) . This is the fourth case, and it is the first case of mechanical thrombectomy in a patient with ipsilateral dual AMCAs. It was often difficult to accurately diagnose and promptly treat acute ischemic stroke associated with DMCA and AMCA, which are such anomalous vessels. We reviewed several reports on mechanical thrombectomy for patients with a single anomaly MCA (Table 1). In the present study, we found six cases of MCA, three with AMCA and three with DMCA. 9)-14) Stent retriever was selected in two cases. One of two cases obtained a good result. However, in another case, vascular dissection was caused by mechanical stress of stent deployment and retraction. We consider contact aspiration to be safer than other techniques when we suspect the presence of MCA anomalies. 10,11) Conclusion We report here a case of acute revascularization for large vessel occlusion with triplicated MCA including dual AMCAs. When an avascular area wider than the perfusion area of the arteries that can be confirmed is observed during mechanical thrombectomy, we should suspect the anomaly MCAs. In such situations, ipsilateral dual AMCAs are rare anomalies. Contact aspiration is considered safer than other techniques when we suspect anomaly MCAs. Abbreviations AMCA; Accessory middle cerebral artery, MRI; magnetic resonance imaging, DSA; Digital subtraction angiogram, CT; Computed Tomography, ACA; anterior cerebral artery, Acom; anterior communicating artery, ICA; internal carotid artery, DMCA; duplicated middle cerebral artery, MCA; Middle Cerebral Artery, NIHSS; National Institutes of Health Stroke Scale, DWI; Diffusion weighted imaging, ASPECTS; Alberta Stroke Program Early CT Score, MRA; magnetic resonance angiography Declarations Conflicts of Interest The authors declare no conflicts of interest concerning the materials or methods used in this case report, or the findings of this study. Ethical Approval All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and / or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed Consent The patient and his family approved the writing of this paper. Funding This research received no specific grants from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution Jota Tega: conceptualization and writing of the original draft. Yoshinobu Horio: conceptualization, supervision, and writing of the original draft. Koichiro Suzuki: writing, review, and editing. Yuta Oka: writing, review, and editing. Koichiro Takemoto: supervision. Hiroshi Abe: supervision, writing review, and editing. References Crompton MR (1962) The pathology of ruptured middle-cerebral aneurysms with special reference to the differences between the sexes. Lancet 2:421–425 Teal JS, Rumbaugh CL, Bergeron RT, Segall HD (1973) Anomalies of the middle cerebral artery: accessory artery, duplication, and early bifurcation. AJR Am J Roentgenol 118:567–575 Masaki Komiyama H, Nakajima Misao Nishikawa, and Toshihiro Yasui. Middle Cerebral Artery Variations: Duplicated and Accessory Arteries. AJNR Am J Neuroradiol 19:45–49, January 1998 Uchino A, Tokushige K (2024) May. Triplicated middle cerebral arteries (duplicated and ipsilateral accessory) associated with triplicated anterior cerebral arteries (accessory) diagnosed by magnetic resonance angiography. Surgical and Radiologic Anatomy 14 Padget Dh (1948) The development of the cranial arteries in the human embryo. Contrib Embryol 212:207–261 Handa J, Shimizu y (1970) Matsuda m, Handa h: The accessory middle cerebral artery: report of further two cases. Clin Radiol 21:415–416 Masahiro, Kobari et al Triplication of the Middle Cerebral Artery Associated with Fenestration of the Anterior Cerebral Artery. Keio J Med 37: 429–433, 1988 M. Uchino S, Kitajimaet (2004) Ruptured aneurysm at a duplicated middle cerebral artery with accessory middle cerebral artery. Acta Neurochir (Wien) 146:1373–1375 Nirmalya, Ray et al (2020) Tandem occlusion involving accessory middle cerebral artery in acute ischaemic stroke: management strategies. BMJ Case Rep 13:e233287 10.Junpei Koge MD Vessel wall injury after stent retriever thrombectomy for internal carotid artery occlusion with a duplicated middle cerebral artery. World Neurosurg S1878-8750(18)32784-0 11.Tomoaki Akiyama,1,2 Tomohiro Okuda,2 and Satoshi Inoha. Lessons Learned from Mechanical Thrombectomy of an Acute Occlusion of a Duplicated Middle Cerebral Artery: A Case Report. J Neuroendovascular Therapy (2022) ; 16(10): 510–514 12.Ichiro Deguchi (2020) A case of acute cerebral infarction associated with an accessory middle cerebral artery in a patient who underwent thrombectomy. Acute Med Surg 7:e459 13.Tomoya Arakawa (2021) A Case of Acute Embolism of the Accessory Middle Cerebral Artery Treated Using ADAPT Thrombectomy without Lesion Passing. NMC Case Rep J 8:805–810 14.Pressman E, Amin S, Renati S et al (May 24, 2021) Middle Cerebral Artery Duplication: A Near Miss for Stroke Thrombectomy. Cureus 13(5): e15220 15.Umansky F, Dujovny M, Ausman JI, Diaz FG, Mirchandani HG (1988) Anomalies and variations of the middle cerebral artery: a micro- anatomical study. Neurosurgery 22:1023–1027 16.Marinkovic S, Milisavljevic M, Kovacevic M (1986) Anatomical bases for surgical approach to the initial segment of the anterior cerebral artery: microanatomy of Heubner’s artery and perforating branches of the anterior cerebral artery. Surg Radiol Anat 8:7–18 17.Tran-Dinh (1986) The accessory middle cerebral artery: a variant of the recurrent artery of Heubner (A. centralis longa)? Acta Anat 126:167–171 18.Takahashi S, hoshino F, Uemura K, Takahashi a, Sakamoto K (1989) accessory middle cerebral artery: is it a variant form of the recurrent artery of heubner? AJNR Am J Neuroradiol 10:563–568 19.Naoyuki Uchiyama (2017) Anomalies of the Middle Cerebral Artery. Neurol Med Chir (Tokyo) 57:261–266 【Figure legends】 Tables Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.jpg Cite Share Download PDF Status: Published Journal Publication published 06 Nov, 2024 Read the published version in Acta Neurochirurgica → Version 1 posted Editorial decision: Revision requested 12 Sep, 2024 Reviews received at journal 20 Aug, 2024 Reviewers agreed at journal 20 Aug, 2024 Reviews received at journal 18 Aug, 2024 Reviewers agreed at journal 18 Aug, 2024 Reviewers agreed at journal 15 Aug, 2024 Reviewers invited by journal 15 Aug, 2024 Editor assigned by journal 08 Aug, 2024 Submission checks completed at journal 08 Aug, 2024 First submitted to journal 07 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4872556","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":347703552,"identity":"6e63fc40-96f5-46a3-bbfd-a16216308105","order_by":0,"name":"Jota Tega","email":"","orcid":"","institution":"Fukuoka Seisyukai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jota","middleName":"","lastName":"Tega","suffix":""},{"id":347703553,"identity":"abbe4d65-a892-4df1-980b-1dff74ecefc9","order_by":1,"name":"Yoshinobu Horio","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABKElEQVRIiWNgGAWjYHACNoYEBhDiAbINgFz25oMPPoDE2YnVwsdzLNlwBkicGY8WBrgWIJCTyDETBrNxaDE43v7swcMdNnkGB3gPPq4osGFgk0hLY7b5tU2ej5mB8cPHHEwtZ86YGySeSSs2OMCXbHjGII2Bjefxsce5fbcN25gZmCVnbsPUciOHTSKx7XDihgM8ZpINBoeBvk5LN87tuc0I1MLGzItNS/ozNC0MOWbSlj237XFrSTBD08IB1MLw43YiLi2SZ86AtKQVSx7mMTZsMEjjYQMFcm/D7eQ2ZsZmbH7hA4aY5M82mzy+4z2GDxv+2MjJtwOj8sef27bzgYwPHzG1KByAsaCxAIkdxjYw2YChHgjksYoyMPzBLjwKRsEoGAUjEgAAatxquhUPy2IAAAAASUVORK5CYII=","orcid":"","institution":"Fukuoka Seisyukai Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yoshinobu","middleName":"","lastName":"Horio","suffix":""},{"id":347703554,"identity":"4f0f7907-7a6c-4f83-93be-351991ba6977","order_by":2,"name":"Koichiro Suzuki","email":"","orcid":"","institution":"Fukuoka Seisyukai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Koichiro","middleName":"","lastName":"Suzuki","suffix":""},{"id":347703555,"identity":"eb33b500-5d54-47f8-9e9f-37159c3e4fbe","order_by":3,"name":"Yuta Oka","email":"","orcid":"","institution":"Fukuoka Seisyukai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuta","middleName":"","lastName":"Oka","suffix":""},{"id":347703556,"identity":"a2121527-e670-42bc-bfee-701f6f2cb4f6","order_by":4,"name":"Koichiro Takemoto","email":"","orcid":"","institution":"Fukuoka University","correspondingAuthor":false,"prefix":"","firstName":"Koichiro","middleName":"","lastName":"Takemoto","suffix":""},{"id":347703557,"identity":"3d69d442-f639-46fa-bf50-9a476071a9e0","order_by":5,"name":"Hiroshi Abe","email":"","orcid":"","institution":"Fukuoka University","correspondingAuthor":false,"prefix":"","firstName":"Hiroshi","middleName":"","lastName":"Abe","suffix":""}],"badges":[],"createdAt":"2024-08-07 07:02:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4872556/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4872556/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00701-024-06338-x","type":"published","date":"2024-11-06T15:57:49+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":64604321,"identity":"879d5158-9977-4e27-a52e-342f340d5a0e","added_by":"auto","created_at":"2024-09-16 12:45:19","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":701235,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eInitial magnetic resonance imaging, intraoperative and postoperative digital subtraction angiogram\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDiffusion weighted imaging showed an extensive high intensity area in the left middle cerebral artery (MCA) region (A)(B) Magnetic resonance angiography showed internal carotid artery (ICA) occlusion (C). \u0026nbsp;Initial left ICA angiogram and three-dimensional rotational angiogram (3DRA) showed two MCAs (white arrowhead and asterisk) and a proximally occluded anterior cerebral artery (D)(E)(F). We performed mechanical thrombectomy. The final ICA angiogram showed partial recanalization(G)(H). 3DRA showed three MCAs. We considered the most proximal MCA to be the main trunk(asterisk) and the other two MCAs to be accessory middle cerebral artery (white arrow and white arrowhead) (I)\u003c/p\u003e","description":"","filename":"Fig.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4872556/v1/26e545eb07902d6fb2f2c5bc.jpg"},{"id":64604322,"identity":"dd1dc3a1-1d9a-415f-987f-dd548f003fb5","added_by":"auto","created_at":"2024-09-16 12:45:19","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":943077,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTen day follow up CT angiography\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCT angiography showed spontaneous recanalization of accessory middle cerebral arteries (AMCAs). The main trunk was asterisk, AMCAs (double asterisk and triple asterisk) run along the main trunk.\u003c/p\u003e\n\u003cp\u003eThis CT angiography was done on the tenth day after the operation. In addition to the middle cerebral artery (MCA) (*), which is the main trunk, A1 proximal (**) and distal (***) show that there are two accompanied by anomaly MCA.\u003c/p\u003e","description":"","filename":"Fig.2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4872556/v1/9ef9ec3bcc2399662059f6f9.jpg"},{"id":68749952,"identity":"7440dbf4-f673-4740-970d-660f5bfb4fb6","added_by":"auto","created_at":"2024-11-11 16:07:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1930569,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4872556/v1/57bb8999-3611-4f1c-9c38-398c84710c4f.pdf"},{"id":64604323,"identity":"a10d1da0-0f80-4a9b-aa25-7f9d5a3ae5d8","added_by":"auto","created_at":"2024-09-16 12:45:19","extension":"jpg","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":438486,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4872556/v1/0daf5c322ed47158505e3a67.jpg"}],"financialInterests":"No competing interests reported.","formattedTitle":"Case Report: Thrombectomy for left internal carotid artery occlusion with ipsilateral dual accessory middle cerebral arteries","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn 1962, Crompton\u003csup\u003e1)\u003c/sup\u003e reported anomalous vessels arising from the ipsilateral anterior cerebral artery (ACA) proximal to the anterior communicating artery (AcoA) and from between the anterior choroidal artery and the internal carotid artery (ICA) terminal. In 1972, Teal et al.\u003csup\u003e2)\u003c/sup\u003e defined anomalous vessels originating from the distal end of the ICA as duplicated middle cerebral arteries (DMCA) and those originating from the ACA as accessory middle cerebral arteries (AMCA). The presence of ipsilateral dual AMCAs was extremely rare. Mechanical thrombectomy was performed in an emergency. Therefore, it was often difficult to identify the occluded vessel in the presence of anomalies. We report here a case of mechanical thrombectomy for a patient with left internal carotid artery occlusion and dual ipsilateral AMCAs.\u003c/p\u003e"},{"header":"Case description","content":"\u003cp\u003eA seventy-three-year-old man with no known medical history collapsed at a baseball stadium. He was transferred to the closest hospital. He had right hemiplegia and total aphasia with an NIHSS score of 36. Electrocardiogram showed arterial fibrillation. Diffusion weighted imaging (DWI) showed an extensive high intensity area in the left middle cerebral artery (MCA) region (DWI- ASPECTS 5/10) and magnetic resonance angiography (MRA) showed occlusion of the left ICA (Fig.\u0026nbsp;1ABC). The patient was infused with tissue plasminogen activator and referred to our hospital for mechanical thrombectomy. On admission, the Glasgow Coma Scale was 12 (E4, V2, M6) He presented with complete right hemiplegia and severe motor aphasia.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEndovascular procedure\u003c/h2\u003e \u003cp\u003eLeft carotid angiogram revealed recanalized left ICA and two MCAs. The proximal MCA was completely recanalized. The distal MCA had a small diameter and was peripherally occluded. A large avascular area was observed in the left frontal lobe, which exceeded the perfusion area of the MCA that could be identified. Because the distal MCA was peripherally occluded, we did not attempt thrombectomy. Further, because the left ACA was occluded proximally, we performed contact aspiration for the occluded left ACA (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eDEF). The third MCA originated from the A1-A2 junction. Thrombolysis in Cerebral Infarction grade was 2b. Because the third MCA was peripherally occluded, we did not attempt mechanical thrombectomy (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e GHI). We considered the most proximal MCA to be the main trunk, and the remaining two MCAs to be AMCAs.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative course\u003c/h2\u003e \u003cp\u003eThe patient had a massive cerebral infarction in the left MCA region due to the length of time it took for him to be transferred from the referring hospital. The presence of an MCA anomaly made it difficult to identified occluded vessels. We performed a ten-day follow up CT angiography which showed spontaneous recanalization of dual AMCAs (Fig.\u0026nbsp;2AB). Since the patient still had severe right hemiplegia and motor aphasia, he was transferred to the rehabilitation ward with modified Rankin Scale 4 on the thirteenth day from onset.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003ePadget et al. proposed that the development of the MCAs was thought to originate in the ICA cranial division at 7\u0026ndash;12 mm of gestation, followed by the formation of the primitive anterior choroidal artery, primitive MCA, and ACA trunk, and that the AMCA and DMCA were generated by the remnants of primitive vascular networks and their formation process in later periods.\u003csup\u003e5)\u003c/sup\u003e In 1970, Handa et al. claimed that the AMCA was an enlarged anomaly vessel of the recurrent artery of Heubner, which branches off from the ACA. However, this claim was rejected by Teals et al. \u003csup\u003e2,6)\u003c/sup\u003e Komiyama et al. reported that AMCA was found in 0.3\u0026ndash;4.0% of cases. It was an early anomaly branch of an MCA because it covered the perfusion area of the orbitofrontal, prefrontal, precentral, and / or central arteries. \u003csup\u003e3),15)-17)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eUchiyama and Takahashi et al. considered AMCA to be a residual anastomosis between medial striate arteries from ACA and lateral striate arteries from MCA.\u003csup\u003e18)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eUchino et al.\u003csup\u003e4)\u003c/sup\u003e reported a case of triplicated MCA combined with DMCA and AMCA, but there have been only three reports on triplicated MCA combined with three MCAs in the English language literature\u003csup\u003e4),7\u0026ndash;8)\u003c/sup\u003e. This is the fourth case, and it is the first case of mechanical thrombectomy in a patient with ipsilateral dual AMCAs.\u003c/p\u003e \u003cp\u003eIt was often difficult to accurately diagnose and promptly treat acute ischemic stroke associated with DMCA and AMCA, which are such anomalous vessels. We reviewed several reports on mechanical thrombectomy for patients with a single anomaly MCA (Table\u0026nbsp;1). In the present study, we found six cases of MCA, three with AMCA and three with DMCA.\u003csup\u003e9)-14)\u003c/sup\u003e Stent retriever was selected in two cases. One of two cases obtained a good result. However, in another case, vascular dissection was caused by mechanical stress of stent deployment and retraction. We consider contact aspiration to be safer than other techniques when we suspect the presence of MCA anomalies.\u003csup\u003e10,11)\u003c/sup\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe report here a case of acute revascularization for large vessel occlusion with triplicated MCA including dual AMCAs. When an avascular area wider than the perfusion area of the arteries that can be confirmed is observed during mechanical thrombectomy, we should suspect the anomaly MCAs. In such situations, ipsilateral dual AMCAs are rare anomalies. Contact aspiration is considered safer than other techniques when we suspect anomaly MCAs.\u003c/p\u003e"},{"header":"Abbreviations","content":" \u003cp\u003eAMCA; Accessory middle cerebral artery, MRI; magnetic resonance imaging, DSA; Digital subtraction angiogram, CT; Computed Tomography, ACA; anterior cerebral artery, Acom; anterior communicating artery, ICA; internal carotid artery, DMCA; duplicated middle cerebral artery, MCA; Middle Cerebral Artery, NIHSS; National Institutes of Health Stroke Scale, DWI; Diffusion weighted imaging, ASPECTS; Alberta Stroke Program Early CT Score, MRA; magnetic resonance angiography\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflicts of Interest\u003c/h2\u003e \u003cp\u003eThe authors declare no conflicts of interest concerning the materials or methods used in this case report, or the findings of this study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical Approval\u003c/strong\u003e \u003cp\u003eAll procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and / or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed Consent\u003c/strong\u003e \u003cp\u003eThe patient and his family approved the writing of this paper.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no specific grants from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJota Tega: conceptualization and writing of the original draft. Yoshinobu Horio: conceptualization, supervision, and writing of the original draft. Koichiro Suzuki: writing, review, and editing. Yuta Oka: writing, review, and editing. Koichiro Takemoto: supervision. Hiroshi Abe: supervision, writing review, and editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCrompton MR (1962) The pathology of ruptured middle-cerebral aneurysms with special reference to the differences between the sexes. Lancet 2:421\u0026ndash;425\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTeal JS, Rumbaugh CL, Bergeron RT, Segall HD (1973) Anomalies of the middle cerebral artery: accessory artery, duplication, and early bifurcation. AJR Am J Roentgenol 118:567\u0026ndash;575\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMasaki Komiyama H, Nakajima Misao Nishikawa, and Toshihiro Yasui. Middle Cerebral Artery Variations: Duplicated and Accessory Arteries. AJNR Am J Neuroradiol 19:45\u0026ndash;49, January 1998\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUchino A, Tokushige K (2024) May. Triplicated middle cerebral arteries (duplicated and ipsilateral accessory) associated with triplicated anterior cerebral arteries (accessory) diagnosed by magnetic resonance angiography. Surgical and Radiologic Anatomy 14\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePadget Dh (1948) The development of the cranial arteries in the human embryo. Contrib Embryol 212:207\u0026ndash;261\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHanda J, Shimizu y (1970) Matsuda m, Handa h: The accessory middle cerebral artery: report of further two cases. Clin Radiol 21:415\u0026ndash;416\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMasahiro, Kobari et al Triplication of the Middle Cerebral Artery Associated with Fenestration of the Anterior Cerebral Artery. Keio J Med 37: 429\u0026ndash;433, 1988 M.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUchino S, Kitajimaet (2004) Ruptured aneurysm at a duplicated middle cerebral artery with accessory middle cerebral artery. Acta Neurochir (Wien) 146:1373\u0026ndash;1375\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNirmalya, Ray et al (2020) Tandem occlusion involving accessory middle cerebral artery in acute ischaemic stroke: management strategies. BMJ Case Rep 13:e233287\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e10.Junpei Koge MD Vessel wall injury after stent retriever thrombectomy for internal carotid artery occlusion with a duplicated middle cerebral artery. World Neurosurg S1878-8750(18)32784-0\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e11.Tomoaki Akiyama,1,2 Tomohiro Okuda,2 and Satoshi Inoha. Lessons Learned from Mechanical Thrombectomy of an Acute Occlusion of a Duplicated Middle Cerebral Artery: A Case Report. J Neuroendovascular Therapy (2022) ; 16(10): 510\u0026ndash;514\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e12.Ichiro Deguchi (2020) A case of acute cerebral infarction associated with an accessory middle cerebral artery in a patient who underwent thrombectomy. Acute Med Surg 7:e459\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e13.Tomoya Arakawa (2021) A Case of Acute Embolism of the Accessory Middle Cerebral Artery Treated Using ADAPT Thrombectomy without Lesion Passing. NMC Case Rep J 8:805\u0026ndash;810\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e14.Pressman E, Amin S, Renati S et al (May 24, 2021) Middle Cerebral Artery Duplication: A Near Miss for Stroke Thrombectomy. Cureus 13(5): e15220\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e15.Umansky F, Dujovny M, Ausman JI, Diaz FG, Mirchandani HG (1988) Anomalies and variations of the middle cerebral artery: a micro- anatomical study. Neurosurgery 22:1023\u0026ndash;1027\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e16.Marinkovic S, Milisavljevic M, Kovacevic M (1986) Anatomical bases for surgical approach to the initial segment of the anterior cerebral artery: microanatomy of Heubner\u0026rsquo;s artery and perforating branches of the anterior cerebral artery. Surg Radiol Anat 8:7\u0026ndash;18\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e17.Tran-Dinh (1986) The accessory middle cerebral artery: a variant of the recurrent artery of Heubner (A. centralis longa)? Acta Anat 126:167\u0026ndash;171\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e18.Takahashi S, hoshino F, Uemura K, Takahashi a, Sakamoto K (1989) accessory middle cerebral artery: is it a variant form of the recurrent artery of heubner? AJNR Am J Neuroradiol 10:563\u0026ndash;568\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e19.Naoyuki Uchiyama (2017) Anomalies of the Middle Cerebral Artery. Neurol Med Chir (Tokyo) 57:261\u0026ndash;266\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e【Figure legends\u0026amp;#12305\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"acta-neurochirurgica","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"anch","sideBox":"Learn more about [Acta Neurochirurgica](http://link.springer.com/journal/701)","snPcode":"701","submissionUrl":"https://submission.springernature.com/new-submission/701/3","title":"Acta Neurochirurgica","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Accessory MCA, Triplicated MCA, anomaly MCA, Mechanical Thrombectomy, Contact Aspiration","lastPublishedDoi":"10.21203/rs.3.rs-4872556/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4872556/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAccessory middle cerebral arteries (AMCAs) are found\u0026nbsp;in 0.3-4.0% of cases, and ipsilateral dual AMCAs are rare. A seventy-three-year-old man presented with right hemiplegia and total aphasia. Magnetic resonance angiography showed left carotid artery occlusion. We infused him with tissue plasminogen activator. Digital subtraction angiogram showed revascularization of the left internal carotid artery. However, the left proximal anterior cerebral artery was occluded. We performed mechanical thrombectomy and achieved partial reperfusion. CT angiography on the tenth day showed ipsilateral dual AMCAs. Due to middle cerebral artery anomalies, we performed mechanical thrombectomy using contact aspiration which is safer than other techniques.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Case Report: Thrombectomy for left internal carotid artery occlusion with ipsilateral dual accessory middle cerebral arteries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-16 12:45:14","doi":"10.21203/rs.3.rs-4872556/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-12T15:27:23+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-21T01:32:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98180558192480559533298718420958149290","date":"2024-08-21T01:09:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-18T14:45:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7721900107666189305866662081836240215","date":"2024-08-18T10:02:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"38557235079892927725465419880947491629","date":"2024-08-15T18:59:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-15T18:56:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-08T05:32:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-08T05:31:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Acta Neurochirurgica","date":"2024-08-07T07:01:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"acta-neurochirurgica","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"anch","sideBox":"Learn more about [Acta Neurochirurgica](http://link.springer.com/journal/701)","snPcode":"701","submissionUrl":"https://submission.springernature.com/new-submission/701/3","title":"Acta Neurochirurgica","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f1ab0fda-594f-4bf9-b848-f2ee8f34c486","owner":[],"postedDate":"September 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-11T16:02:15+00:00","versionOfRecord":{"articleIdentity":"rs-4872556","link":"https://doi.org/10.1007/s00701-024-06338-x","journal":{"identity":"acta-neurochirurgica","isVorOnly":false,"title":"Acta Neurochirurgica"},"publishedOn":"2024-11-06 15:57:49","publishedOnDateReadable":"November 6th, 2024"},"versionCreatedAt":"2024-09-16 12:45:14","video":"","vorDoi":"10.1007/s00701-024-06338-x","vorDoiUrl":"https://doi.org/10.1007/s00701-024-06338-x","workflowStages":[]},"version":"v1","identity":"rs-4872556","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4872556","identity":"rs-4872556","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}