Replaced posterior cerebral artery with early branching temporal artery diagnosed by magnetic resonance angiography

Replaced posterior cerebral artery with early branching temporal artery diagnosed by magnetic resonance angiography | 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 Research Article Replaced posterior cerebral artery with early branching temporal artery diagnosed by magnetic resonance angiography Akira Uchino, Nobusuke Tsuzuki This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4713906/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Aug, 2024 Read the published version in Surgical and Radiologic Anatomy → Version 1 posted 14 You are reading this latest preprint version Abstract Purpose To describe a case of replaced posterior cerebral artery (PCA) in which all branches of the PCA arose from the anterior choroidal artery (AChA) with an early branching temporal artery. Methods An 83-year-old man with cerebral infarctions underwent cranial magnetic resonance (MR) imaging and MR angiography using a 3-Tesla scanner. MR angiography was performed using a standard 3-dimensional time-of-flight technique. Results A large anomalous artery arose from the supraclinoid segment of the right internal carotid artery (ICA) and supplied all branches of the right PCA, mimicking fetal-type PCA. The temporal branch arose from the proximal segment of this artery and followed a course similar to that of the AChA in its proximal segment. In MR angiographic source images, a tiny artery arose from the right ICA proximal to the origin of the anomalous artery, indicating a hypoplastic right posterior communicating artery (PCoA). Thus, we concluded that the anomalous artery was a replaced PCA; all branches of the PCA arose from the AChA. Conclusion We present a case involving a replaced PCA with an early branching temporal artery, as seen on MR angiography. Careful observation of MR angiographic source images is useful for identifying small arteries. To our knowledge, this is the first report of this combined variation in the relevant English-language literature. Anterior choroidal artery Cerebral arterial variation Internal carotid artery Magnetic resonance angiography Posterior cerebral artery Posterior communicating artery Figures Figure 1 Figure 2 Figure 3 Introduction A branch of the posterior cerebral artery (PCA) rarely arises from the anterior choroidal artery (AChA). This variation is called the hyperplastic AChA [ 1 , 3 , 5 ], or accessory PCA [ 4 , 6 , 8 , 10 ]. Extremely rarely, all branches of the PCA arise from the AChA, and this is called a replaced PCA [ 2 , 7 , 8 ]. We herein report a case of a replaced PCA with an early branching temporal artery that was incidentally detected on magnetic resonance (MR) angiography. To our knowledge, this is the first case of such a variation reported in the relevant English-language literature. Case report An 83-year-old man with cerebral infarctions underwent cranial MR imaging and MR angiography using a 3-Tesla scanner (MAGNETOM Skyra; Siemens Healthineers, Erlangen, Germany) for evaluation of brain and cerebral arteries. MR angiography was performed using the standard 3-dimensional (3D) time-of-flight (TOF) technique. The imaging parameters were as follows: flip angle, 16°; repetition time, 30.0 s; echo time, 3.7 s; slice thickness, 0.6 mm; number of slices, 160; slab thickness, 96 mm; field of view, 28.0 × 20.0 cm; and imaging matrix, 320 × 272. MR imaging revealed multiple small infarctions and ischemic white matter lesions. Volume-rendering (VR) images of MR angiography images showed a large artery arising from the supraclinoid segment of the right internal carotid artery (ICA), mimicking fetal-type PCA. From the proximal segment of this artery, an arterial branch arose and followed a course similar to that of the AChA. This arterial branch supplied the temporal branch of the right PCA. There was also a fetal-type left PCA, basilar artery fenestration, and occlusion of the left vertebral artery (Fig. 1 ). On MR angiographic source images ( Supplemental files ) and reformatted images (Fig. 2 ), a tiny artery arose from the right ICA proximal to the origin of the large anomalous artery, indicating a hypoplastic right posterior communicating artery (PCoA). A normal-sized, tiny left AChA was also identified. Figure 3 shows a schematic illustration of the arterial system in this patient. Based on these findings, we made a diagnosis of replaced right PCA with an early branching temporal artery. Discussion Cerebral arterial variations may develop from failure of fusion/regression or abnormal fusion/regression during early embryonic stages. Traditionally, cerebral arterial variations have been reported in cadaver dissections, surgeries, and catheter angiographies. Recently, MR angiography has been widely used for the evaluation of cerebral arterial lesions, and its image quality has improved, especially in images obtained with a 3-Tesla scanner. Thus, the incidence of cerebral arterial variations incidentally diagnosed by MR angiography is increasing [ 6 ]. AChAs have a low incidence of hyperplasia and their prevalence on catheter angiography is reported to be 2.3% [ 5 ]. In contrast, the prevalence on MR angiography was reported to be only 0.55% [ 8 ]. This discrepancy between the prevalence on catheter and MR angiographic studies may be due to the low spatial resolution of MR angiography. Usually, one of the branches of the PCA arises from this hyperplastic AChA. The PCA usually has 4 major cortical branches: the anterior temporal, posterior temporal, calcarine, and parieto-occipital arteries. The hyperplastic uncal branch, which supplies part of the anterior temporal artery of the PCA, is relatively small in caliber. Thus, this type of variation may be overlooked on MR angiography. The majority of PCA branches arising from the AChA are temporal arteries [ 5 , 8 ]. Rarely, the parieto-occipital and calcarine arteries arise from the AChA [ 4 , 5 ]. In 2016, the term “hyperplastic AChA” was suggested to replace “accessory PCA” [ 8 ]. It is extremely rare for all branches of the PCA arise from an AChA. This type of variation is termed “replaced PCA” [ 2 , 7 , 8 ]. This variation may be misdiagnosed as transposition of the AChA and PCoA. The proximal segment of the replaced PCA takes a similar course to the cisternal segment of the AChA [ 7 ]. Catheter angiography can reveal the ventricular segment of the AChA arising from this large artery [ 2 ]. If a tiny artery arising from the supraclinoid segment of the ICA just proximal to the origin of the large anomalous artery is detected, it indicates a hypoplastic PCoA. Therefore, if a small PCoA is identified, as in our patient, a correct diagnosis can be obtained. Replaced PCAs have been reported to be associated with aneurysms [ 2 ] or infundibular dilatation [ 7 ] at the origin of the hypoplastic PCoA. The first large cortical branch of the PCA is the temporal artery, which rarely arises from the proximal segment of the PCA, forming an early bifurcated PCA. The prevalence of MR angiography was reported to be 0.34% [ 8 ]. Very rarely, the temporal artery arises from the PCoA of a fetal-type PCA [ 9 ]. Our patient had an extremely early branching temporal artery in the replaced PCA. To our knowledge, no similar cases have been reported in the relevant English-language literature. Accessory PCAs, including replaced PCAs, can be associated with other cerebral arterial variations. A case of accessory PCA associated with an accessory middle cerebral artery was recently reported [ 6 ]. PCA-accessory PCA anastomoses have been reported using CT or MR angiography [ 1 , 10 ]. There are several locations of anastomosis between the PCA and accessory PCA [ 3 ]. Two types of MR angiography reconstruction exist: maximum-intensity-projection (MIP) and VR images. MIP images are used more frequently than VR images in daily clinical practice. However, VR images are suitable for demonstrating arterial variations because they are 3-dimensional, which overcomes the superimposition of arterial branches (Fig. 1 ). Tiny arteries may not be identified on either MIP or VR images because of the limitation of the spatial resolution. Thus, careful observation of the source images and reformatted images is important and necessary for identifying tiny arteries ( Supplemental files , Fig. 2 ) Conclusions We encountered a case of a replaced PCA with an early branching temporal artery. Careful observation of the source images of MR angiography is important for identifying a small PCoA. Declarations Author contributions AU designed the study and drafted the manuscript. AU and NT critically reviewed the manuscript and read and approved the final manuscript. Funding The authors did not receive support from any organization for the submitted work. Data availability Not applicable. Declarations Conflict of interest The authors declare no competing interests. Ethical approval and consent to participate All procedures performed in studies 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. Consent for publication The patient gave his written informed consent for the publication of publishing of his data and figures. References Doi K, Mizuno T, Shigematsu Y, Kobayashi O, Takezaki T, Muta D, Nishi T (2018) A new type of hyperplastic anterior choroidal artery. J Clin Neurosci 51:72-74. doi: 10.1016/j.jocn.2018.02.002. Endo H, Ishikawa K, Ono H, Honjo K, Nakamura H (2024) Replaced posterior cerebral artery. Surg Radiol Anat 46:299-302. doi: 10.1007/s00276-023-03294-6. Hahm MH, Moon S (2021) Anomalous hyperplastic anterior choroidal artery and its mimicker: a case series. Surg Radiol Anat 43:1961-1965. doi: 10.1007/s00276-021-02777-8. Rusu MC, Vrapciu AD, Lazăr M (2023) A rare variant of accessory posterior cerebral artery. Surg Radiol Anat 45:523-526. doi: 10.1007/s00276-023-03127-6. Takahashi S, Suga T, Kawata Y, Sakamoto K (1990) Anterior choroidal artery: angiographic analysis of variations and anomalies. AJNR Am J Neuroradiol 11:719-729. Uchino A, Irie T (2024) Accessory posterior cerebral artery (hyperplastic anterior choroidal artery) associated with contralateral accessory middle cerebral artery incidentally diagnosed by magnetic resonance angiography. Surg Radiol Anat 46:313-316. doi: 10.1007/s00276-024-03298-w Uchino A, Kamide T, Kurita H (2019) Replaced posterior cerebral artery (PCA): origin of all branches of the PCA from the anterior choroidal artery diagnosed by MR angiography. Surg Radiol Anat 41:703-705. doi: 10.1007/s00276-019-02209-8. Uchino A, Saito N, Takahashi M, Okano N, Tanisaka M (2016) Variations of the posterior cerebral artery diagnosed by MR angiography at 3 tesla. Neuroradiology 58:141-146. doi: 10.1007/s00234-015-1614-5. Uchino A, Suzuki C (2016) Temporal branch of the posterior cerebral artery arising from the posterior communicating artery diagnosed by MR angiography. Surg Radiol Anat 38:153-155. doi: 10.1007/s00276-015-1518-4. Uchino A, Tokushige K (2024) Posterior cerebral artery (PCA)-accessory PCA (hyperplastic anterior choroidal artery) anastomosis detected on magnetic resonance angiography. Surg Radiol Anat 46:679-683. doi: 10.1007/s00276-024-03350-9. Additional Declarations No competing interests reported. Supplementary Files 00067.jpg 00068.jpg 00069.jpg 00070.jpg 00071.jpg 00072.jpg 00073.jpg 00074.jpg 00075.jpg 00076.jpg 00077.jpg 00078.jpg 00079.jpg 00080.jpg 00081.jpg 00082.jpg Cite Share Download PDF Status: Published Journal Publication published 05 Aug, 2024 Read the published version in Surgical and Radiologic Anatomy → Version 1 posted Editorial decision: Revision requested 23 Jul, 2024 Reviews received at journal 23 Jul, 2024 Reviews received at journal 22 Jul, 2024 Reviews received at journal 21 Jul, 2024 Reviewers agreed at journal 18 Jul, 2024 Reviewers agreed at journal 18 Jul, 2024 Reviewers agreed at journal 18 Jul, 2024 Reviews received at journal 16 Jul, 2024 Reviewers agreed at journal 16 Jul, 2024 Reviewers agreed at journal 16 Jul, 2024 Reviewers invited by journal 16 Jul, 2024 Editor assigned by journal 16 Jul, 2024 Submission checks completed at journal 15 Jul, 2024 First submitted to journal 09 Jul, 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. 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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-4713906","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":330916974,"identity":"84d2995d-70fd-4ef7-acc5-a785cb6ea44a","order_by":0,"name":"Akira Uchino","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYHACNoYEBgYe+/bmgw+APB4+YrXIGfAcSzYAaWEjSgsQGBtI5JhJwLn4AP+M5GcPHu6wSdzOkJZW+TXHToaNgfnhoxt4tEjcSDM3SDyTlriz4fCx27LbkoEOYzM2zsFnzY0cNonEtsOJDQfb0m5LbmMGauFhk8anRR6u5TCPWbHktnrCWgygWowNjvGYMX7cdpiwFsMzz8yAWtLkJHvYkqUZtx3nYWMm4Be548nPJH+22fDwyz8++PHntmp7fvbmh4/xeh8ZMPOASWKVgwDjD1JUj4JRMApGwYgBAKOfRxxHpWQSAAAAAElFTkSuQmCC","orcid":"","institution":"Saitama Sekishinkai Hospital","correspondingAuthor":true,"prefix":"","firstName":"Akira","middleName":"","lastName":"Uchino","suffix":""},{"id":330916975,"identity":"b8f0fbbc-dd25-4c42-9aa0-d3f7bc280edd","order_by":1,"name":"Nobusuke Tsuzuki","email":"","orcid":"","institution":"Saitama Sekishinkai Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nobusuke","middleName":"","lastName":"Tsuzuki","suffix":""}],"badges":[],"createdAt":"2024-07-09 18:05:58","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4713906/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4713906/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00276-024-03454-2","type":"published","date":"2024-08-05T15:57:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":62222035,"identity":"185eb0e9-b73d-42f3-8bac-d79b395b6b6a","added_by":"auto","created_at":"2024-08-11 12:35:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":925347,"visible":true,"origin":"","legend":"\u003cp\u003eRight lateral (\u003cstrong\u003ea\u003c/strong\u003e), posteroanterior (\u003cstrong\u003eb\u003c/strong\u003e) and inferosuperior (\u003cstrong\u003ec\u003c/strong\u003e) projections of volume-rendering images of cranial magnetic resonance (MR) angiography show a large artery arising from the supraclinoid segment of the right internal carotid artery (ICA) (\u003cem\u003elong arrows\u003c/em\u003e). From this artery, an arterial branch arises and takes a similar course to the anterior choroidal artery (AChA) (\u003cem\u003eshort arrows\u003c/em\u003e). This arterial branch supplies the temporal branch of the right posterior cerebral artery (PCA). The remaining main branch of the anomalous artery supplies other PCA territory. A fetal-type left PCA is present. Basilar artery fenestration is also present at its proximal segment. The left vertebral artery is occluded (\u003cstrong\u003eFig. 1b\u003c/strong\u003e). The right posterior communicating artery (PCoA), P1 segment of the right PCA, and left AChA are not identified probably due to small in caliber.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4713906/v1/2c52edae7524813699ca60a3.png"},{"id":62222041,"identity":"cf5f2a27-c9e3-4d80-b6df-e28a878d81b0","added_by":"auto","created_at":"2024-08-11 12:35:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":337666,"visible":true,"origin":"","legend":"\u003cp\u003eFour continuous reformatted MR angiographic source images of 3 mm in thickness (\u003cstrong\u003ea-d\u003c/strong\u003e) show a tiny right PCoA (\u003cem\u003esmall arrows\u003c/em\u003e). \u003cem\u003eSmall dotted arrows\u003c/em\u003e indicate the normal-sized tiny left AChA. \u003cem\u003eLong and short arrows\u003c/em\u003e indicate same arteries in \u003cstrong\u003eFigure 1\u003c/strong\u003e. Therefore, this patient has a replaced right PCA with an early branching temporal artery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplemental files\u003c/strong\u003e include MR angiographic source images.\u003c/p\u003e","description":"","filename":"Figure2.pptx.png","url":"https://assets-eu.researchsquare.com/files/rs-4713906/v1/e062021145edff9e5b19956e.png"},{"id":62222037,"identity":"c11a3935-6fbd-4979-9712-0580313b1940","added_by":"auto","created_at":"2024-08-11 12:35:11","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":29497,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic illustration of arterial system of our patient in inferosuperior projection.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFour types of arrows\u003c/em\u003e indicate same arteries in \u003cstrong\u003eFigures 1 and 2\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eACA, anterior cerebral artery; AChA, anterior choroidal artery; BA, basilar artery; ICA, internal carotid artery; MCA, middle cerebral artery; PCA, posterior cerebral artery; PCoA, posterior communicating artery; P1, P1 segment of the PCA; SCA, superior cerebellar artery; TA, temporal artery; VA, vertebral artery.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4713906/v1/ce35fcdd757c8d1cbaa19048.png"},{"id":62298283,"identity":"e35e4d02-a28c-4fd6-9e65-91ebe6c9dcaa","added_by":"auto","created_at":"2024-08-12 16:11:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1847793,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4713906/v1/ba42571f-95a0-4567-8cc6-1ca6e1329a79.pdf"},{"id":62222038,"identity":"c4be26c6-0e96-4d3d-89a4-e4e4ecff8c0c","added_by":"auto","created_at":"2024-08-11 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arises from the anterior choroidal artery (AChA). This variation is called the hyperplastic AChA [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], or accessory PCA [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Extremely rarely, all branches of the PCA arise from the AChA, and this is called a replaced PCA [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. We herein report a case of a replaced PCA with an early branching temporal artery that was incidentally detected on magnetic resonance (MR) angiography. To our knowledge, this is the first case of such a variation reported in the relevant English-language literature.\u003c/p\u003e"},{"header":"Case report","content":"\u003cp\u003eAn 83-year-old man with cerebral infarctions underwent cranial MR imaging and MR angiography using a 3-Tesla scanner (MAGNETOM Skyra; Siemens Healthineers, Erlangen, Germany) for evaluation of brain and cerebral arteries. MR angiography was performed using the standard 3-dimensional (3D) time-of-flight (TOF) technique. The imaging parameters were as follows: flip angle, 16\u0026deg;; repetition time, 30.0 s; echo time, 3.7 s; slice thickness, 0.6 mm; number of slices, 160; slab thickness, 96 mm; field of view, 28.0 \u0026times; 20.0 cm; and imaging matrix, 320 \u0026times; 272.\u003c/p\u003e \u003cp\u003eMR imaging revealed multiple small infarctions and ischemic white matter lesions. Volume-rendering (VR) images of MR angiography images showed a large artery arising from the supraclinoid segment of the right internal carotid artery (ICA), mimicking fetal-type PCA. From the proximal segment of this artery, an arterial branch arose and followed a course similar to that of the AChA. This arterial branch supplied the temporal branch of the right PCA. There was also a fetal-type left PCA, basilar artery fenestration, and occlusion of the left vertebral artery (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). On MR angiographic source images (\u003cb\u003eSupplemental files\u003c/b\u003e) and reformatted images (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), a tiny artery arose from the right ICA proximal to the origin of the large anomalous artery, indicating a hypoplastic right posterior communicating artery (PCoA). A normal-sized, tiny left AChA was also identified. Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows a schematic illustration of the arterial system in this patient. Based on these findings, we made a diagnosis of replaced right PCA with an early branching temporal artery.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCerebral arterial variations may develop from failure of fusion/regression or abnormal fusion/regression during early embryonic stages. Traditionally, cerebral arterial variations have been reported in cadaver dissections, surgeries, and catheter angiographies. Recently, MR angiography has been widely used for the evaluation of cerebral arterial lesions, and its image quality has improved, especially in images obtained with a 3-Tesla scanner. Thus, the incidence of cerebral arterial variations incidentally diagnosed by MR angiography is increasing [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAChAs have a low incidence of hyperplasia and their prevalence on catheter angiography is reported to be 2.3% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In contrast, the prevalence on MR angiography was reported to be only 0.55% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This discrepancy between the prevalence on catheter and MR angiographic studies may be due to the low spatial resolution of MR angiography. Usually, one of the branches of the PCA arises from this hyperplastic AChA. The PCA usually has 4 major cortical branches: the anterior temporal, posterior temporal, calcarine, and parieto-occipital arteries. The hyperplastic uncal branch, which supplies part of the anterior temporal artery of the PCA, is relatively small in caliber. Thus, this type of variation may be overlooked on MR angiography. The majority of PCA branches arising from the AChA are temporal arteries [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Rarely, the parieto-occipital and calcarine arteries arise from the AChA [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In 2016, the term \u0026ldquo;hyperplastic AChA\u0026rdquo; was suggested to replace \u0026ldquo;accessory PCA\u0026rdquo; [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is extremely rare for all branches of the PCA arise from an AChA. This type of variation is termed \u0026ldquo;replaced PCA\u0026rdquo; [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This variation may be misdiagnosed as transposition of the AChA and PCoA. The proximal segment of the replaced PCA takes a similar course to the cisternal segment of the AChA [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Catheter angiography can reveal the ventricular segment of the AChA arising from this large artery [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. If a tiny artery arising from the supraclinoid segment of the ICA just proximal to the origin of the large anomalous artery is detected, it indicates a hypoplastic PCoA. Therefore, if a small PCoA is identified, as in our patient, a correct diagnosis can be obtained. Replaced PCAs have been reported to be associated with aneurysms [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] or infundibular dilatation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] at the origin of the hypoplastic PCoA.\u003c/p\u003e \u003cp\u003eThe first large cortical branch of the PCA is the temporal artery, which rarely arises from the proximal segment of the PCA, forming an early bifurcated PCA. The prevalence of MR angiography was reported to be 0.34% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Very rarely, the temporal artery arises from the PCoA of a fetal-type PCA [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Our patient had an extremely early branching temporal artery in the replaced PCA. To our knowledge, no similar cases have been reported in the relevant English-language literature.\u003c/p\u003e \u003cp\u003eAccessory PCAs, including replaced PCAs, can be associated with other cerebral arterial variations. A case of accessory PCA associated with an accessory middle cerebral artery was recently reported [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. PCA-accessory PCA anastomoses have been reported using CT or MR angiography [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. There are several locations of anastomosis between the PCA and accessory PCA [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTwo types of MR angiography reconstruction exist: maximum-intensity-projection (MIP) and VR images. MIP images are used more frequently than VR images in daily clinical practice. However, VR images are suitable for demonstrating arterial variations because they are 3-dimensional, which overcomes the superimposition of arterial branches (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Tiny arteries may not be identified on either MIP or VR images because of the limitation of the spatial resolution. Thus, careful observation of the source images and reformatted images is important and necessary for identifying tiny arteries (\u003cb\u003eSupplemental files\u003c/b\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWe encountered a case of a replaced PCA with an early branching temporal artery. Careful observation of the source images of MR angiography is important for identifying a small PCoA.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e AU designed the study and drafted the manuscript. AU and NT critically reviewed the manuscript and read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e The authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e All procedures performed in studies 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\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e The patient gave his written informed consent for the publication of publishing of his data and figures.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDoi K, Mizuno T, Shigematsu Y, Kobayashi O, Takezaki T, Muta D, Nishi T (2018) A new type of hyperplastic anterior choroidal artery. J Clin Neurosci 51:72-74. doi: 10.1016/j.jocn.2018.02.002.\u003c/li\u003e\n\u003cli\u003eEndo H, Ishikawa K, Ono H, Honjo K, Nakamura H (2024) Replaced posterior cerebral artery. Surg Radiol Anat 46:299-302. doi: 10.1007/s00276-023-03294-6.\u003c/li\u003e\n\u003cli\u003eHahm MH, Moon S (2021) Anomalous hyperplastic anterior choroidal artery and its mimicker: a case series. Surg Radiol Anat 43:1961-1965. doi: 10.1007/s00276-021-02777-8.\u003c/li\u003e\n\u003cli\u003eRusu MC, Vrapciu AD, Lazăr M (2023) A rare variant of accessory posterior cerebral artery. Surg Radiol Anat 45:523-526. doi: 10.1007/s00276-023-03127-6.\u003c/li\u003e\n\u003cli\u003eTakahashi S, Suga T, Kawata Y, Sakamoto K (1990) Anterior choroidal artery: angiographic analysis of variations and anomalies. AJNR Am J Neuroradiol 11:719-729.\u003c/li\u003e\n\u003cli\u003eUchino A, Irie T (2024) Accessory posterior cerebral artery (hyperplastic anterior choroidal artery) associated with contralateral accessory middle cerebral artery incidentally diagnosed by magnetic resonance angiography. Surg Radiol Anat 46:313-316. doi: 10.1007/s00276-024-03298-w\u003c/li\u003e\n\u003cli\u003eUchino A, Kamide T, Kurita H (2019) Replaced posterior cerebral artery (PCA): origin of all branches of the PCA from the anterior choroidal artery diagnosed by MR angiography. Surg Radiol Anat 41:703-705. doi: 10.1007/s00276-019-02209-8.\u003c/li\u003e\n\u003cli\u003eUchino A, Saito N, Takahashi M, Okano N, Tanisaka M (2016) Variations of the posterior cerebral artery diagnosed by MR angiography at 3 tesla. Neuroradiology 58:141-146. doi: 10.1007/s00234-015-1614-5.\u003c/li\u003e\n\u003cli\u003eUchino A, Suzuki C (2016) Temporal branch of the posterior cerebral artery arising from the posterior communicating artery diagnosed by MR angiography. Surg Radiol Anat 38:153-155. doi: 10.1007/s00276-015-1518-4.\u003c/li\u003e\n\u003cli\u003eUchino A, Tokushige K (2024) Posterior cerebral artery (PCA)-accessory PCA (hyperplastic anterior choroidal artery) anastomosis detected on magnetic resonance angiography. Surg Radiol Anat 46:679-683. doi: 10.1007/s00276-024-03350-9.\u003c/li\u003e\n\u003c/ol\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":"surgical-and-radiologic-anatomy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sara","sideBox":"Learn more about [Surgical and Radiologic Anatomy](http://link.springer.com/journal/276)","snPcode":"276","submissionUrl":"https://submission.nature.com/new-submission/276/3","title":"Surgical and Radiologic Anatomy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Anterior choroidal artery, Cerebral arterial variation, Internal carotid artery, Magnetic resonance angiography, Posterior cerebral artery, Posterior communicating artery","lastPublishedDoi":"10.21203/rs.3.rs-4713906/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4713906/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo describe a case of replaced posterior cerebral artery (PCA) in which all branches of the PCA arose from the anterior choroidal artery (AChA) with an early branching temporal artery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAn 83-year-old man with cerebral infarctions underwent cranial magnetic resonance (MR) imaging and MR angiography using a 3-Tesla scanner. MR angiography was performed using a standard 3-dimensional time-of-flight technique.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA large anomalous artery arose from the supraclinoid segment of the right internal carotid artery (ICA) and supplied all branches of the right PCA, mimicking fetal-type PCA. The temporal branch arose from the proximal segment of this artery and followed a course similar to that of the AChA in its proximal segment. In MR angiographic source images, a tiny artery arose from the right ICA proximal to the origin of the anomalous artery, indicating a hypoplastic right posterior communicating artery (PCoA). Thus, we concluded that the anomalous artery was a replaced PCA; all branches of the PCA arose from the AChA.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWe present a case involving a replaced PCA with an early branching temporal artery, as seen on MR angiography. Careful observation of MR angiographic source images is useful for identifying small arteries. To our knowledge, this is the first report of this combined variation in the relevant English-language literature.\u003c/p\u003e","manuscriptTitle":"Replaced posterior cerebral artery with early branching temporal artery diagnosed by magnetic resonance angiography","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-11 12:35:06","doi":"10.21203/rs.3.rs-4713906/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-23T21:06:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-23T18:52:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-22T14:29:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-21T19:24:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"336320374425762185023113908653127713566","date":"2024-07-18T14:51:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"237528421013523671508302231493886593196","date":"2024-07-18T06:50:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"311534618529317434510093646465532287176","date":"2024-07-18T05:51:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-16T12:42:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190719830874664149909447650546342256567","date":"2024-07-16T09:11:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119995699724355514749843936701053497325","date":"2024-07-16T06:55:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-16T06:43:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-16T05:46:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-15T05:38:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"Surgical and Radiologic Anatomy","date":"2024-07-09T18:04:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"surgical-and-radiologic-anatomy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sara","sideBox":"Learn more about [Surgical and Radiologic Anatomy](http://link.springer.com/journal/276)","snPcode":"276","submissionUrl":"https://submission.nature.com/new-submission/276/3","title":"Surgical and Radiologic Anatomy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"59514b13-280a-41af-a43f-5ac7a3f1ca97","owner":[],"postedDate":"August 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-12T16:00:59+00:00","versionOfRecord":{"articleIdentity":"rs-4713906","link":"https://doi.org/10.1007/s00276-024-03454-2","journal":{"identity":"surgical-and-radiologic-anatomy","isVorOnly":false,"title":"Surgical and Radiologic Anatomy"},"publishedOn":"2024-08-05 15:57:14","publishedOnDateReadable":"August 5th, 2024"},"versionCreatedAt":"2024-08-11 12:35:06","video":"","vorDoi":"10.1007/s00276-024-03454-2","vorDoiUrl":"https://doi.org/10.1007/s00276-024-03454-2","workflowStages":[]},"version":"v1","identity":"rs-4713906","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4713906","identity":"rs-4713906","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}