Vascular Anomalies Impacting Acute Stroke Management and Secondary Prevention
Maria Dhinojwala1, Lakshmi Shankar2
1Pennsylvania State College of Medicine, 2Department of Neurology Division of Stroke, Pennsylvania State College of Medicine
Objective:
To highlight the importance of recognizing cerebrovascular anatomical variants through vessel imaging and to demonstrate how these anomalies can guide acute ischemic stroke management and prevention strategies.
Background:
Vessel imaging is a cornerstone in the diagnosis and management of acute ischemic strokes. While identifying vascular occlusions is central to acute stroke care, unrecognized vascular anomalies can lead to diagnostic errors. Common vascular variants, such as hypoplasia (~30%), fetal posterior cerebral arteries (PCAs, 20%-30%), accessory middle cerebral arteries (MCAs, 0.3%), and duplicated arteries, can significantly alter stroke management. This case series illustrates how cerebrovascular variants impact stroke etiology and intervention.
Design/Methods:
Case Series
Results:
Patient A presented with right-sided weakness, aphasia, and hemi-neglect. Magnetic resonance imaging (MRI) revealed acute infarction in the left MCA and anterior cerebral artery (ACA) territories, as well as the right caudate. Computed tomography angiography (CTA) revealed severe left internal carotid artery (ICA) disease and aplasia of the right A1 segment, with cross-filling from the left via the anterior communicating artery. This explained the bilateral involvement from left ICA disease, rather than a cardioembolic source, guiding intervention towards left ICA stenosis.
Patient B presented with a right PCA stroke. CTA showed fetal right PCA with severe right ICA stenosis, without atherosclerotic disease in the posterior circulation. Stroke etiology was determined to be large artery atherosclerosis due to symptomatic ICA disease for which the patient underwent carotid revascularization.
An editorial described two patients with acute left MCA syndrome where CTA showed a patent left MCA, but digital subtraction angiography (DSA) revealed occlusion of an accessory MCA originating from the ACA. Both patients underwent successful MCA recanalization.
Conclusions:
Recognition of vascular variants is essential for acute stroke management and determination of stroke etiology. Identifying these anomalies can help prevent misdiagnosis on standard imaging, guide targeted interventions, and inform secondary prevention strategies.
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