Twig-like middle cerebral artery: Clinical and radiological features — a study of three patients from a single center

Twig-like middle cerebral artery (T-MCA) is a vascular anomaly in which the M1 segment of the MCA is replaced by a plexiform network of small vessels. It may present with hemorrhagic or ischemic stroke or be detected incidentally. In this paper, we report three rare cases of T-MCA and describe their clinical and radiological characteristics as well as their clinical courses. A secondary objective was to provide a rough estimate of the occurrence of T-MCA among patients who underwent cerebral angiography in our center. From 2019 to 2023, 810 patients underwent brain digital subtraction angiography (DSA) at our center, of which three (0.37%) had T-MCA. Two patients presented with subarachnoid hemorrhage, and one was incidentally diagnosed. None were candidates for bypass surgery due to comorbidities, overall clinical condition, or patient preference, and all received conservative management. Two patients were discharged alert and without deficits, while one had a poor outcome, remaining in a vegetative state after complications of hemorrhage, hydrocephalus, and meningitis. T-MCA is a rare congenital anomaly with an estimated occurrence of approximately 0.37% among patients undergoing cerebral angiography in our center. This study adds three new patients to the limited literature and highlights their clinical presentations, radiological features, management decisions, and short-term outcomes. Further studies are needed to clarify its epidemiology, natural history, and optimal management strategies.