Tandem occlusion involving accessory middle cerebral artery in acute ischaemic stroke: management strategies

Occlusion of both the limbs of accessory middle cerebral artery (AMCA) poses a unique challenge in management of acute ischaemic stroke by mechanical thrombectomy. The patient is a 30-year-old man, presenting with acute onset of left-sided hemiparesis for 4 hours. Non-contrast CT brain showed no bleed and three-dimensional CT angiogram of head and neck vessels showed dissection involving right carotid bulb and tandem occlusion of right MCA with presence of two MCA stumps. Aspiration thrombectomy was done using a reperfusion catheter, advanced separately into both the MCA stumps and complete recanalisation of both the limbs of MCAs was achieved, which was found to be AMCA. Balloon angioplasty for the internal carotid artery dissection was performed. Although occlusion of AMCA in acute ischaemic stroke is a chance occurrence, it is important to identify this variant as recanalisation of both the limbs by mechanical thrombectomy is required for favourable outcome after the procedure.

Acute middle cerebral artery stroke in a patient with a patent middle cerebral artery

Purpose of reviewKnowledge of cerebrovascular anatomical variants is vital for clinicians working with patients presenting with signs and symptoms of cerebral infarction, particularly in the era of endovascular clot retrieval.Recent findingsWe provide an overview of a cerebrovascular anatomical variation and detail a patient presenting with cerebral infarction secondary to occlusion of their anomalous vessel who underwent successful endovascular clot retrieval with excellent functional outcome. We also include technical descriptions.SummaryGiven the clinical importance of the areas supplied by the accessory middle cerebral artery, knowledge of this vessel is not only important for diagnosis but also for neurosurgical or endovascular management of patients with this variant.