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Teaching NeuroImages: Rete-like middle cerebral artery

A 72-year-old woman underwent neuroimaging for evaluation of bilateral vertex headaches. Brain MRI was unremarkable but intracranial magnetic resonance angiography and CT angiography (figure) revealed unilateral, plexiform appearance of the proximal right middle cerebral artery (MCA). The constellation of imaging findings in absence of clinical correlates is consistent with a rete anomaly of the MCA (previously referred to as unfused or twig-like MCA).1 Unilateral involvement, exclusive involvement of proximal MCA, and otherwise normal intracranial vasculature ruled out moyamoya syndrome. The etiopathology of rete MCA anomaly is unknown. Recognition of rete anomaly is important to differentiate it from other vascular diseases and avoid unnecessary treatment.