Rare case of duplicated middle cerebral artery and
acute ischaemic stroke managed successfully with
mechanical thrombectomy
Subash Phuyal,1 Lekhjung Thapa ‍ ‍,2 Biswa Mohan Mishra,3
Manoj Kumar Nayak ‍ ‍4
1

Neuroimaging and
Interventional Radiology,
Upendra Devkota Memorial
National Institute of
Neurological and Allied
Sciences, Kathmandu, Nepal
2
Neurology, National Neuro
Centre, Kathmandu, Nepal
3
Departemnt of Neurology,
All india institute of Medical
sciences, New Delhi, Delhi, India
4
Radiodiagnosis, AIIMS
Bhubaneswar, Bhubaneswar,
Orissa, India
Correspondence to
Dr Manoj Kumar Nayak;
​tuna.​manoj@​gmail.​com
Accepted 17 October 2023

© BMJ Publishing Group
Limited 2023. No commercial
re-­use. See rights and
permissions. Published by BMJ.
To cite: Phuyal S, Thapa L,
Mishra BM, et al. BMJ Case
Rep 2023;16:e251221.
doi:10.1136/bcr-2022251221

SUMMARY
A man in his early 80s presented with acute onset
aphasia and right-­sided weakness with an NIH Stroke
Scale (NIHSS) of 17. He was last seen normal 9 hours
before the presentation. MRI of the brain showed
acute infarcts in the left caudate, lentiform nucleus
and corona radiata. MRI angiogram (MRA) revealed an
occluded left main middle cerebral artery (MCA) and an
associated ipsilateral patent duplicated middle cerebral
artery (DMCA). Mechanical thrombectomy (MT) was
performed, and he was discharged with an NIHSS of 8. In
this report, we review and discuss the challenges during
the intervention of MCA occlusion in the presence of
duplicated MCA, a rare anomaly.

BACKGROUND
Among the intracranial vessel anomalies, duplicated middle cerebral artery (DMCA) is rare.
Other common anomalies of middle cerebral
artery (MCA) include aplasia or twig-­
like MCA,
MCA fenestration and accessory middle cerebral
artery (AMCA).1 In angiographic and anatomical
studies, AMCA and DMCA have an incidence of
0.3%–4.0% and 0.2%–2.9%, respectively.2 Existing
literature shows DMCA associations with intracranial aneurysms,3–5 but its association with ischaemic
stroke is rarely reported.6 7 In a published report,8
AMCA-­associated ischaemic stroke has been inappropriately interpreted as DMCA-­associated stroke.
This is likely due to the confusing classification by
Crompton, who first used the terminology ‘accessory middle cerebral artery’ in 1962.9 We believe
using ‘accessory MCA’ and ‘duplicated MCA’
appropriately is of utmost importance as these two
variants of MCA have unique characteristics. They
originate at different sites, supply different territories, have different haemodynamic properties and
are predisposed to different vascular pathology.
Literature search did not reveal any report of
thrombolysis in patients with DMCA. Nevertheless, there are few reports of thrombectomy in
DMCA-­associated stroke.10 Here, we report a rare
and unusual case of a successfully managed MCA
occlusion associated with DMCA by mechanical
thrombectomy.

CASE PRESENTATION
A man in his early 80s with a medical history of
hypertension and diabetes mellitus for 7 years

presented with an acute onset of weakness in the
right upper and lower limbs, facial deviation to the
left side and inability to speak. These symptoms
occurred 9 hours before the presentation.
During the examination, the patient appeared to
be of average build. His pulse rate was 66 beats per
minute and irregularly irregular, with all peripheral
pulses palpable. His blood pressure was measured
at 138/70 mm Hg, respiratory rate at 22minute and
oxygen saturation at 97% without needing oxygen
support.
Neurological examination revealed a conscious
patient with a Glasgow Coma Scale (GCS) score of
10 and a National Institutes of Health Stroke Scale
(NIHSS) score of 17. The patient had right hemiparesis, right upper motor neuron (UMN) facial palsy
and global aphasia.

INVESTIGATIONS

The routine blood investigations, blood sugar, renal
function test, liver function test, lipid profile and
tests for HIV, hepatitis B and hepatitis C yielded
normal results. ECG revealed atrial fibrillation.
MRI showed an acute infarct in the left caudate,
lentiform nucleus and corona radiata (figure 1A–C).
Time of flight (TOF) MRA revealed a thin calibre
(compared with right-­sided normal MCA) MCA-­
like vessel originating from the left terminal ICA
coursing towards the left insula (figure 1D). A
stump of an occluded left-­sided true MCA immediately distal to the MCA-­like vessel (DMCA) was
also noticed (figure 1D white arrow). Echocardiography showed moderate aortic regurgitation and
mild mitral, tricuspid regurgitation without intracardiac clots.

TREATMENT

A mechanical thrombectomy was planned with
a triaxial approach as the patient was eligible.
Informed consent was obtained from the family.
Right-­sided femoral artery access was obtained, and
a 6F neuro-­sheath was placed into the left proximal cervical internal carotid artery (ICA). Diagnostic digital subtraction angiogram (DSA) showed
an occluded true MCA (figure 1E). A smaller bore
ACE 60 reperfusion catheter was advanced through
the neuro-­sheath over a guidewire. With the help
of a microcatheter/microguidewire assembly, the
ACE 60 catheter was advanced until the level
of the clot (figure 1F). Thrombo-­
aspiration was
performed using a penumbra aspiration pump.

Phuyal S, et al. BMJ Case Rep 2023;16:e251221. doi:10.1136/bcr-2022-251221

1

BMJ Case Rep: first published as 10.1136/bcr-2022-251221 on 3 November 2023. Downloaded from http://casereports.bmj.com/ on April 18, 2024 at The Francis Countway Library of
Medicine. Protected by copyright.

Case report

Figure 1 MRI and digital subtraction (DSA) images of the stroke
patient with left duplicated MCA axial diffusion weighted imaging
(DWI). (A) Apparent diffusion coefficient (ADC) (B) and FLAIR (C)
showed restriction on the left caudate, lentiform nucleus and corona
radiate. TOF MR-­angiography (D) showed complete cut-­off of distal
larger trunk of proximal MCA (white arrow), with smaller proximal
trunk. DSA run of left internal carotid artery (E) showed complete cut-­
off of distal larger trunk of proximal MCA (white arrow), the smaller
proximal trunk with normal flow. Fluoroscopy image (F) showed ACE
60 aspiration at the occlusion site (white arrow). Final angiogram (G)
showed complete recanalisation of the distal occluded trunk (white
arrow) with duplicated left MCA. Follow-­up CT scan (H) after 1 month
showed gliotic changes in the previous infarct.
After a single pass, recanalisation of the occluded true MCA
was achieved. The check angiogram showed complete recanalisation of the left-­sided true MCA (figure 1G). After the procedure, the patient was shifted to the ward. He was treated with
atorvastatin, amlodipine, telmisartan, metformin and acarbose
for management of hypertension and diabetes mellitus. He also
received physiotherapy during his hospital stay and was advised
to continue at home after discharge.

OUTCOME AND FOLLOW-UP

He was discharged on the ninth day with an NIHSS of 8. On
follow-­up at 2 weeks, his neurological condition has remained
stable.

DISCUSSION

We considered the MCA-­like artery as DMCA and the occluded
vessel as true MCA in agreement with the classification by Teal.11
Post-­
thrombectomy, the anatomy of both arteries was visible
with the presence of a duplicated MCA. DMCA has critical clinical implications. First, the occluded MCA may be missed. This
can happen because patent DMCA can be erroneously considered a true MCA. Missed vessels may be discovered only after
thrombectomy.12 Intriguingly, a smaller stump may be confused
with an aneurysm.13 Misdiagnosis can delay or stop patients
from undergoing thrombectomy, one of the established treatments for stroke.14 Second, the size of true MCA may vary in the
presence of DMCA. Normative data on MCA diameter in our
population is lacking. In a study involving participants from the
Indian subcontinent, an examination of 340 MCAs revealed the
normal outer diameter of the middle of the trunk of MCA to be
between 2 and 5 mm (mean 3 mm).15 In our case, during DSA,
the measurements just after the origin of the vessels revealed
the main MCA to be 2.4 mm and the DMCA to be 2.17 mm,
nearly half the size of the healthy right-­sided MCA (4.2 mm).
Considering the relatively lesser size of the occluded MCA, we
2

used an ACE 60 catheter with a distal outer diameter (OD) of
5.4 F (French) instead of an ACE 68 catheter with distal OD of
6 F. A recent meta-­analysis has established that the direct aspiration technique is safe, efficient and an alternative to primary
stent retriever.16 We were fortunate to achieve complete recanalisation without complication after a single-­pass aspiration.
However, there is a lack of strong evidence regarding the types
of thrombectomy techniques used in this setting.
Third, DMCA supplies a territory, typically the anterior
temporal lobe. This knowledge can help better interpretation
of clinical syndrome, utilise appropriate rehabilitation protocols, prognosticate a case and, importantly, allow communication effectively with patient’s relatives. Moreover, if MT fails
and the associated anomalous vessel is injured, there may be a
life-­threatening complication because of the expected extensive
infarct. Although our patient substantially improved, residual
neurological deficits were inevitable due to delayed presentation. We believe early intervention in cases like ours will have a
more favourable outcome.

Patient’s perspective
We are very thankful to the hospital and the team of doctors
involved in our case. Being in a developing country, we initially
considered going for treatment to our neighbour country. It’s
a pride for our country that this type of advanced emergency
treatment is available and patients are getting benefits. We
are fortunate to go home after successful treatment for such a
devastating disease.
Learning points
► Recognition of true middle cerebral artery (MCA) occlusion

in the presence of a duplicated MCA is essential in stroke for
the early institution of the best treatment, such as mechanical
thrombectomy.
► Aspiration thrombectomy effectively removes clots from
occluded MCA in the presence of duplicated vessels.
► Smaller bore catheters can be used in smaller calibre vessels
in duplicated MCA.
Contributors The following authors were responsible for drafting of the text,
sourcing and editing of clinical images, investigation results, drawing original
diagrams and algorithms and critical revision for important intellectual content:
drafting of the text and sourcing and editing of clinical images, BMM and MKN;
investigation results, SP; and critical revision for important intellectual content, LT.
The following authors gave final approval of the manuscript: LT and SP.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests None declared.
Patient consent for publication Consent obtained directly from patient(s).
Provenance and peer review Not commissioned; externally peer reviewed.
Case reports provide a valuable learning resource for the scientific community and
can indicate areas of interest for future research. They should not be used in isolation
to guide treatment choices or public health policy.
ORCID iDs
Lekhjung Thapa http://orcid.org/0000-0001-5206-0740
Manoj Kumar Nayak http://orcid.org/0000-0002-1146-2302

REFERENCES

1 Cilliers K, Page BJ. Anatomy of the middle cerebral artery: cortical branches, branching
pattern and anomalies. Turk Neurosurg 2017;27:671–81.

Phuyal S, et al. BMJ Case Rep 2023;16:e251221. doi:10.1136/bcr-2022-251221

BMJ Case Rep: first published as 10.1136/bcr-2022-251221 on 3 November 2023. Downloaded from http://casereports.bmj.com/ on April 18, 2024 at The Francis Countway Library of
Medicine. Protected by copyright.

Case report

2 Komiyama M, Nakajima H, Nishikawa M, et al. Middle cerebral artery variations:
duplicated and accessory arteries. AJNR Am J Neuroradiol 1998;19:45–9.
3 Hayashi K, Matsuo Y, Hayashi Y, et al. A ruptured aneurysm at the origin of a
duplicated middle cerebral artery, treated by coil embolization:a case report. No
Shinkei Geka 2017;45:391–6.
4 Kim JS, Lee C-­H, Park H, et al. An unruptured cerebral aneurysm at the origin
of the duplicated middle cerebral artery. J Cerebrovasc Endovasc Neurosurg
2015;17:223–6.
5 Miyamoto J, Mineura K. Unruptured middle cerebral artery aneurysm associated with
a duplicated middle cerebral artery and a dolichoectasic anterior cerebral artery. J
Stroke Cerebrovasc Dis 2010;19:503–6.
6 Chang HY, Kim MS. Middle cerebral artery duplication: classification and clinical
implications. J Korean Neurosurg Soc 2011;49:102–6.
7 Vila Moriente N, Millán Torné M, Capellades Font J, et al. [Anatomical variations
of the middle cerebral artery: duplication and accessory artery implications in the
treatment of acute stroke]. Rev Neurol 2004;38:732–5.
8 Gómez-­Choco M, Nedelmann M, Valdueza JM. Stenosis in middle cerebral artery
duplication: assessment with transcranial color-­coded duplex sonography. J
Ultrasound Med 2016;35:2053–6.
9 CROMPTON MR. The pathology of ruptured middle-­cerebral aneurysms with special
reference to the differences between the sexes. Lancet 1962;2:421–5.

10 Koge J, Kato S, Hashimoto T, et al. Vessel wall injury after stent retriever thrombectomy
for internal carotid artery occlusion with duplicated middle cerebral artery. World
Neurosurg 2019;123:54–8.
11 Teal JS, Rumbaugh CL, Bergeron RT, et al. Anomalies of the middle cerebral artery:
accessory artery, duplication, and early bifurcation. Am J Roentgenol Radium Ther
Nucl Med 1973;118:567–75.
12 Bayer-­Karpinska A, Lutz J, Birnbaum T, et al. Severe MCA stroke without MCA
occlusion? Thrombectomy Uncovers accessory middle cerebral artery. Neurology
2015;85:831–2.
13 Khrlobyan M, Olivas E, Feng L, et al. Severe left MCA syndrome with an occluded
accessory MCA. Neurol Clin Pract 2019;9:279–81.
14 Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management
of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the
early management of acute ischemic stroke: a guideline for Healthcare professionals
from the American Heart Association/American Stroke Association. Stroke
2019;50:e344–418.
15 Gunnal SA, Farooqui MS, Wabale RN. Study of middle cerebral artery in human
cadaveric brain. Ann Indian Acad Neurol 2019;22:187–94.
16 Primiani CT, Vicente AC, Brannick MT, et al. Direct aspiration versus stent retriever
thrombectomy for acute stroke: a systematic review and meta-­analysis in 9127
patients. J Stroke Cerebrovasc Dis 2019;28:1329–37.

Copyright 2023 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit
https://www.bmj.com/company/products-services/rights-and-licensing/permissions/
BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission.
Become a Fellow of BMJ Case Reports today and you can:
► Submit as many cases as you like
► Enjoy fast sympathetic peer review and rapid publication of accepted articles
► Access all the published articles
► Re-use any of the published material for personal use and teaching without further permission
Customer Service
If you have any further queries about your subscription, please contact our customer services team on +44 (0) 207111 1105 or via email at support@bmj.com.
Visit casereports.bmj.com for more articles like this and to become a Fellow

Phuyal S, et al. BMJ Case Rep 2023;16:e251221. doi:10.1136/bcr-2022-251221

3

BMJ Case Rep: first published as 10.1136/bcr-2022-251221 on 3 November 2023. Downloaded from http://casereports.bmj.com/ on April 18, 2024 at The Francis Countway Library of
Medicine. Protected by copyright.

Case report