Rete middle cerebral artery anomalies: a unifying name, case series, and literature review

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OBJECTIVE

Rete middle cerebral artery (MCA) is extremely rare and has not been frequently discussed. Rete MCA is a weblike anomaly of the MCA that does not coalesce and forms a prominent, large single branch from the plexiform vessels in the fetal stage. The purpose of this study was to further elucidate the clinical and radiological characteristics of patients with rete MCA.

METHODS

A total of 2262 cerebral digital subtraction angiography procedures were performed on 1937 patients at the authors’ institution from February 2013 to May 2017. Data analysis included age, sex, clinical symptoms, underlying diseases, coexisting cerebral arterial anomalies, and operative methods and findings.

RESULTS

Rete MCAs were found in 13 patients, and the incidence of this anomaly was 0.67% (13 of 1937) in this study. Of the 13 patients, 3 had hemorrhagic strokes, 6 had ischemic strokes, and 4 had no symptoms. Eight patients underwent conservative treatment, and 5 patients underwent surgical treatment. Rete MCA is considered a congenital disease of the cerebral vasculature with the possibility of an acquired abnormality, such as an aneurysm, caused by hemodynamic stress. Although an epidemiological survey of rete MCA was not conducted, it is assumed that rete MCA has a high prevalence in Asia. Ischemic and hemorrhagic stroke events are fairly common in rete MCA.

CONCLUSIONS

Clinicians should understand the radiological and clinical features of patients with rete MCA to avoid misdiagnosis and unnecessary treatment. This anomaly should be differentiated from other vascular diseases and patients presenting incidentally should be carefully monitored because of their vulnerability to both hemorrhagic and ischemic strokes.

ABBREVIATIONS ACA = anterior cerebral artery; ACoA = anterior communicating artery; DSA = digital subtraction angiography; ECA = external carotid artery; ICA = internal carotid artery; ICH = intracerebral hemorrhage; IVH = intraventricular hemorrhage; MCA = middle cerebral artery; SAH = subarachnoid hemorrhage; TIA = transient ischemic attack.

Article Information

Correspondence Yong Bae Kim: College of Medicine, Yonsei University, Gangnam Severance Hospital, Seoul, Korea. ybkim69@yuhs.ac.

INCLUDE WHEN CITING Published online August 3, 2018; DOI: 10.3171/2018.2.JNS1832.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. A: Initial brain CT reveals an SAH on the basal cistern, an ICH located in the right basal ganglia, and an IVH. B1 and B2: On initial DSA there is a rete MCA anomaly on the right M1 segment, but a bleeding focus, such as an aneurysm, is not noted (B1 = DSA, B2 = 3D rotational angiography). C1 and C2: On follow-up DSA, two small aneurysms are found near the rete (arrows; C1 = DSA, C2 = 3D rotational angiography). D: The surgical field shows a white, cordlike M1 segment that appears fragile (arrowheads). Figure is available in color online only.

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    Case 5. A: The MR image shows a small meningioma at the right sphenoid ridge (left). DSA (right) reveals the rete MCA anomaly at the right M1 segment and an associated small aneurysm (arrow). B: On follow-up DSA 30 months later, there is no major change in rete MCA features or aneurysmal size and shape. C: Surgical exploration shows atresia of the M1 segment, which exhibits a white, cordlike rudimentary appearance (arrowhead). Figure is available in color online only.

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    Case 9. A: Initial brain CT reveals ICH on the right temporal lobe. B: DSA reveals an M1 anomaly, but the distal MCA segments are intact in caliber, and the distal MCA is patent. Two regions suspected of an aneurysm are represented by an arrow and an arrowhead. C: On 3D rotational angiography, a weblike rete MCA anomaly is noted on the right M1 segment, and two aneurysms are observed (arrows). One aneurysm inside the rete is suspected to be bleeding (arrowheads). Another is seen on the right proximal ACA. D: Surgical exploration reveals a white, cordlike rudimentary rete MCA vessel (arrow). One aneurysm was clipped, and the hematoma beside the aneurysm was evacuated (arrowhead). The other one was not an aneurysm but a stump that was linked to the vessel, which no longer had flow and was similar to a thin, white straw. Figure is available in color online only.

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    Embryonic development of the MCA. A: Fetal type. The distal primitive ICA is divided into a large branch and numerous plexiform arterial networks. B: The primitive ACA is formed, but the primitive MCA has not yet formed. C: Rete MCA. Interruption by an unexplained cause during the coalescing period results in the persistence of the fetal arterial network except the distal MCA. D: Adult-type MCA.

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