A 48-year-old woman presented with intermittent headaches for 3 years. Cerebral computed tomography angiography showed irregular vessels resembling a moyamoya pattern involving the left middle cerebral artery (MCA), and found an aneurysm in the ophthalmic segment of the right internal carotid artery (Fig 1A). Digital subtraction angiography showed the absence of the normal left M1 segment, replaced by a serpentine vascular tangle that connects the carotid termination to the normal distal M1 segment, consistent with twig-like MCA (T-MCA; Fig 1B). This structure differs from the moyamoya pattern, and may be related to the persistence of the fetal arterial network that ultimately developed into the main trunk of the MCA. Cinematic rendering of computed tomography angiography provides a clear depiction of T-MCA anatomy, facilitating communication between the doctor and the patient, and adding value to existing medical images in preoperative planning (Fig 1C, Video S1). In general, aneurysms associated with T-MCA should be prioritized for targeted therapy, especially ruptured aneurysms. In T-MCA with recurrent stroke, bypass intervention may be a last resort. T-MCA can be found incidentally, or it can present with hemorrhagic or ischemic stroke, but most patients with T-MCA in previous studies have had hemorrhagic stroke. Hemorrhagic stroke in T-MCA may be related to rupture of aneurysms, the twig-like network, or other abnormal collateral vessels. Ischemic stroke in T-MCA may be mainly caused by hemodynamic compromise, artery-to-artery embolism, or a combination of both. Although aneurysm formation, hemorrhage, and ischemia are known clinical consequences, many cases of T-MCAs may remain clinically and radiologically stable for at least several years.1 Therefore, given the absence of hemorrhagic or severe ischemic complications, the patient in the present study was treated conservatively and underwent regular imaging monitoring. T-MCA is a rare vascular anomaly characterized by a plexiform network of small vessels replacing the M1 segment of the MCA.1 The incidence of T-MCA has been widely assessed in Asian populations, ranging from 0.11% to 1.17% in angiographic studies.2 However, due to the similarity of the imaging manifestations of T-MCA and moyamoya disease, up to 69% of patients with T-MCA are initially diagnosed with moyamoya disease.3 Moyamoya is a progressive, predominantly bilateral steno-occlusive disorder that typically involves the internal carotid artery termini with involvement of the proximal anterior cerebral artery and MCA. However, T-MCA does not involve the distal internal carotid artery. Although typical moyamoya disease is angiographically bilateral and symmetric, T-MCA is a unilateral anomaly. Additionally, in T-MCAs, there are no transdural collateral vessels, as are seen in most cases of moyamoya disease. In moyamoya disease, distal MCA vessels have the appearance of a "puff of smoke." However, in T-MCA, the caliber of the distal MCA and flow are maintained. This is the most important difference from moyamoya disease.4 Cinematic rendering techniques have significantly improved the ability to generate photorealistic 3D images from computed tomography data, providing a remarkable level of realism that better shows the imaging characteristics of T-MCA, thereby reducing misdiagnosis rates, and avoiding unnecessary evaluation and treatment. Both authors contributed to the conception and design of the study; the acquisition and analysis of data; and drafting the text and preparing the figure. We thank Siemens Healthineers engineer, Dr X. Zhao, for his support in rendering film technology. Nothing to report. Video S1. Cinematic rendering from CT angiography in a 48-year-old woman with a twig-like left middle cerebral artery. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Linggen Dong

Ming Lv

Annals of Neurology

《神经病学年鉴》发表了对神经病学具有广泛兴趣的文章，尤其是那些对理解人类神经系统疾病的机制和治疗有重大影响的文章。尽管 ANNALS 使用多种临床和基本神经科学方法发表论文，但我们最感兴趣的是学术神经学家普遍感兴趣的那些手稿，包括临床试验和其他为医学实践提供信息的大规模研究。纯粹的基础研究，没有很强的临床或转化潜力，不太可能有足够的优先发表权。

The Annals of Neurology publishes articles on a wide range of topics relevant to neurology, particularly those that have a significant impact on understanding the mechanisms and treatments of human neurological diseases. While the Annals employs various clinical and basic neuroscience methods for publication, we are particularly interested in manuscripts that are of general interest to academic neurologists, including clinical trials and large-scale studies that provide valuable information for medical practice. Purely basic research, lacking strong clinical or translational potential, is less likely to receive priority for publication.

《Annals of Neurology》发表了与神经病学相关的广泛主题文章，特别是那些对理解人类神经系统疾病的机制和治疗具有重要影响的研究。虽然《Annals of Neurology》采用多种临床和基础神经科学方法来发表论文，但我们特别关注那些学术神经学家普遍感兴趣的稿件，包括临床试验和其他为医学实践提供重要信息的大规模研究。纯粹的基础研究，若缺乏明显的临床或转化潜力，通常不具备优先发表的条件。

Category	Quartile
医学	1
医学, 临床神经病学	1
医学, 神经科学	1

Cinematic Rendering of Twig‐Like Middle Cerebral Artery

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