Presentation
Headache. No history of previous brain insult or chronic disease.
Patient Data
MRI study shows few non-specific white matter foci of high signal in T2/FLAIR; otherwise normal brain parenchyma. The right MCA is poorly visualized in axial T2 with in-situ multiple signal void foci.
MRA shows absence/ discontinuity of the right middle cerebral artery with in-situ multiple small vessels reconstituting the artery and presenting a "twig-like" appearance. The distal MCA branches could be seen however they are perhaps fewer compared to the left side.
No evidence of distal internal carotid artery stenosis.
Case Discussion
Here is a case of a twig-like middle cerebral artery, a rare vascular anomaly. It should be differentiated from other pathological vascular conditions including moyamoya disease, vasculitis, and stenoocclusive disease considering the patient clinical history and the radiological features of these conditions.
Checking of the cerebral arteries in T2WI should be done routinely in the MR brain studies aiming to pick up small aneurysms or vascular defects; however, overcalling should be avoided.