Recurrent Transient Ischemic Attacks due to Aplastic or Twig‐Like Middle Cerebral Artery

A 38‐year‐old, right‐handed woman presented with transient left hemiplegia and dysarthria. Brain magnetic resonance imaging showed no infarction, but magnetic resonance angiography and computed tomography angiography confirmed right middle cerebral artery (MCA) M1 occlusion. Despite dual antiplatelet therapy, she experienced recurrent transient ischemic attacks. Digital subtraction angiography revealed right M1 occlusion with a twig‐like collateral network to the M2 segment, leading to the diagnosis of aplastic or twig‐like MCA (Ap/T‐MCA). Single‐photon emission computed tomography showed reduced perfusion in the right MCA territory. Superficial temporal artery (STA)‐MCA bypass was performed 38 days after the initial attack and 12 days after diagnosis, resolving her symptoms. Postoperative imaging confirmed bypass patency and blood flow to the MCA cortical branches and suggested reduced perfusion asymmetry. She remained recurrence‐free for 2 years. STA‐MCA bypass may be a treatment option for Ap/T‐MCA patients with recurrent ischemic symptoms despite medical treatment.