• Qasim Bashir
  • Aamir Badruddin
  • Saeed Arif
  • Tamir Hersonsky


We present a case of a 41-year-old woman who carried the misdiagnosis of multiple sclerosis for 13 years while on disease modifying therapy [DMT]. Her neurologic work-up showed an extremely rare type of bilateral middle cerebral artery occlusive disease, a basilar apex aneurysm and paroxysmal atrial fibrillation. A thorough search for alternative neurologic diagnosis is recommended before patients are given a definitive diagnosis and committed to DMT


Gailloud P, Albayram S, Fasel JH, Beauchamp NJ, Murphy KJ. Angiographic and embryologic considerations in five cases of middle cerebral artery fenestration. Am J Neuroradiol 2002;23:585–7.

Sanders WP, Sorek PA, Mehta BA. Fenestration of intracranial arteries with special attention to associated aneurysms and other anomalies. Am J Neuroradiol 1993;14:675–80.

Amagasaki K, Yagishita T, Kawataki T, Kase M, Nukui H. Middle cerebral artery aplasia associated with an aneurysm of the proximal anterior cerebral artery. Acta Neurochir (Wein) 1998;140:1313–4.

Seo BS, Lee YS, Lee HG, Lee JH, Ryu KY, Kang DG. Clinical and radiological features of patients with aplastic or twiglike middle cerebral arteries. Neurosurgery 2012;70:1472–80.

Liu HM, Lai DM, Tu YK, Wang YH. Aneurysms in twig-like middle cerebral artery. Cerebrovasc Dis 2005;20(1):1–5.

Padget DH. The development of the cranial arteries in the human embryo. Contrib Embryol 1948;32:205–61.

Yeon JY, Shin HJ, Kong DS, Seol HJ, Kim JS, Hong SC, et al. The prediction of contralateral progression in children and adolescents with unilateral moyamoya disease. Stroke 2011;42:2973–6.

Katzan I, Rudick RA. Guidelines to avoid errors in diagnosis of multiple sclerosis. Ann Neurol 1996;40(Suppl 3):554.

Nawashiro H, Wada K, Kita H. Decerebrate posture following bilateral middle cerebral artery occlusion. Intern Med 2011;50:2063