Duplicated middle cerebral artery origin with an aneurysm

RATIONALE: Middle cerebral artery (MCA) anomalies are relatively rare and often related to aneurysms. Familiarity with these anomalies is important in resolving problems that arise in the complex angioarchitecture. Reports often describe that aneurysms that are related to accessory or duplicated MCA are often located at its origin. PATIENT CONCERNS: A 59-year-old man presented with a headache for 10 days, without nausea and vomiting. The physical examination was negative. DIAGNOSIS: A computed tomography (CT) scan revealed an intracerebral hematoma in the deep right frontal lobe, near the caudate nucleus. Digital subtraction angiography (DSA) revealed an anomalous duplicated origin of the right MCA, with occlusion of the main MCA trunk as well as twisting and dilation of the accessory MCA trunk. A wide-necked aneurysm was located at a sharp curve of the tortuous accessory MCA trunk. A ruptured aneurysm related to a duplicated MCA origin was diagnosed. INTERVENTIONS: Open surgery was rejected by the patient; hence, palliative endovascular coil embolization of the larger daughter sac was performed. OUTCOMES: The postoperative course was uneventful. There was no rebleeding at 8-months follow-up. LESSONS: MCA anomalies are relatively rare and often related to aneurysms. It is important to be familiar with these anomalies as related lesions often manifest within a complex angioarchitecture. Aneurysms at the trunk of an anomalous MCA are a rare entity and open surgery may be recommended.