• Marialuisa Zedde, Claudio Moratti, Claudio Pavone, Manuela Napoli, Franco Valzania, Thanh N Nguyen, Mohamad Abdalkader, and Rosario Pascarella.
• Neurology Unit, Stroke Unit, AUSL-IRCCS di Reggio Emilia, Reggio Calabria, Italy. Electronic address: zedde.marialuisa@ausl.re.it.
• World Neurosurg. 2024 Mar 1; 183: e11e21e11-e21.

ObjectivesTwig-like middle cerebral artery (MCA) is a rare anomaly where the M1 MCA is partially or completely replaced by a plexiform network. It has been described in angiographic series from Asian and South-American cohorts, but has not yet been reported in a European population.MethodsThe digital subtraction angiograms (DSAs) of adult patients referred to a single neurovascular center for a diagnostic hypothesis of moyamoya arteriopathy (MMA) from 2018 to 2023 were prospectively and retrospectively checked by experienced neuroradiologists for identifying patients with twig-like MCA. The angioarchitecture of twig-like MCA was systematically evaluated and described.ResultsFive of 30 (16.7%) male patients (mean age 55.8 + 14.7 years) of European ancestry were identified as having twig-like MCA. The clinical presentations were ischemic stroke (2 of 5), hemorrhagic stroke (1 of 5), and headache (2 of 5). All patients showed a unilateral involvement on DSA and in 1 of 5 (20%) an intracranial aneurysm was found. DSA was used to confirm the diagnosis of twig-like MCA and define the angioarchitecture and associated anomalies. An accessory MCA and recurrent artery of Heubner were found in 3 of 5 (60%) cases, feeding the network together with the anterior choroidal artery (4 of 5, 80%).ConclusionsTwig-like MCA is a rare vascular anomaly, but it seems to be less rare than expected among adult European patients with suspected MMA on noninvasive neuroimaging studies. DSA is fundamental for a reliable differential diagnosis and should not be omitted in these patients.Copyright © 2023 Elsevier Inc. All rights reserved.

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