Rare Cause of Basal Ganglionic Haematoma: Rete Anomaly of Middle Cerebral Artery

Abstract

ABSTRACT A 52-year-old female without co-morbidities presented to us with a history of sudden onset of severe headache and vomiting followed by drowsiness. Computed tomography brain plain was done which showed left capsuloganglionic bleed with intraventricular haemorrhage. In view of normal blood pressure and no co-morbidities, we suspected a vascular pathology and hence planned for digital subtraction angiogram (DSA). DSA showed rete anomaly of the middle cerebral artery (MCA) with aneurysm arising from the one of the anterior branches. The patient was taken up for surgery and left pterional craniotomy and evacuation of haematoma with clipping of aneurysm was done. Rete anomaly of MCA is an extremely rare entity with the incidence of 0.11%. It is web-like anomaly of MCA that does not coalesce to form a prominent, large single branch from the plexiform vessels in the foetal stage. The most common form of presentation is haemorrhagic stroke. The scan mimics a hypertensive basal ganglionic haematoma. Any non-hypertensive patient with a basal ganglionic haematoma needs an angiogram to look for other causes. In cases with rete anomaly with aneurysm, clipping is advocated over endovascular procedures as it is difficult to negotiate through these tiny vessels.