Evaluation of Middle Cerebral Artery Symmetry: A Pilot Study for Clinical Application in Mechanical Thrombectomy

Endovascular mechanical thrombectomy (MT) has now evolved to become the standard treatment for acute ischemic stroke due to large vessel occlusion. Arterial perforation is a potential complication of MT, and the risk of this event during blind crossing the occlusion site has been elucidated. The intracranial arterial system shows morphological structural symmetry, so we investigated the utility of the bilateral symmetry of the proximal middle cerebral artery (MCA) as a preprocedural evaluation to predict hidden running course distal to the thrombus.

This study retrospectively analyzed 191 consecutive patients (mean age, 67.5 ± 15.5 years; 100 women) who underwent time-of-flight-magnetic resonance angiography in our institution. Four landmarks of the MCA were assessed: division pattern, early branching pattern, length, and course pattern. Each geometric property was compared between cerebral hemispheres. Frequencies of symmetry and symmetry breaking were assessed.

In 91% (bifurcation type, 87%; trifurcation type, 4%), branching patterns of the left and right M1 were symmetrical. Early frontal and/or temporal branches were observed in 31%, and the presence/absence of early branches was symmetrical in 70% cases. In 19%, M1 was classified as short M1, and classifications were identical between hemispheres in 74%. Running course of the M1 was symmetrical in 63%. Two or more parameters were symmetrical in 181 cases (95%).

The symmetry of bilateral M1-2 structures was demonstrated in most cases from the perspectives of 4 parameters. The MCA symmetry can predict the running course of the MCA before crossing the occlusion site and shows potential benefits for neurointerventionalists.