PMC3700478_01
CT brain showing left posterior parietal encephalomalacia.
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Non-contrast computerized tomography of brain showed an area of decreased density consistent with encephalomalacia in left parietal cortex (Figure 1).
MRI brain with gadolinium showing old left parietal cortical infarct with prominence of blood vessels in basal ganglia and thalami bilaterally.
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Magnetic resonance imaging (MRI) brain with contrast showed an old ischemic infarct involving left parietal cortex with attenuation and narrowing of cavernous and supra-clinoid internal carotid arteries bilaterally as well as horizontal portion of middle cerebral arteries bilaterally with increased prominence and enhancement of lenticulo-striate and thalamo-perforating arteries bilaterally favoring a diagnosis of MMD (Figure 2).
(A) Left common carotid angiography showing extensive external carotid lepto-meningeal collateralization (occipital artery-ethmoidal branch of maxillary division-middle meningeal-anterior falcine). There is complete occlusion of internal carotid proximal to ophthalmic segment. (B) Right common carotid angiography showing attenuation of internal carotid with developed deep lenticulo-striate vessels as well as lepto-meningeal collaterals from external carotid. There is also crossover flow from right to left into the contralateral anterior cerebral artery.
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A trans-femoral four vessel cerebral angiogram showed extra-cranial intracranial collateral anastomoses derived from branches of the external carotid artery to bypass internal carotid obstruction in both sides especially left side. (Figures 3A,B and 4A,B).
(A) Right vertebral angiography showing extracranial origin of PICA. There is patent left posterior communicating artery with flow into middle cerebral artery distribution and evidence of choroidal vessel hypertrophy. (B) Left vertebral angiography showing typical findings with vertebral and posterior cerebral arteries poorly visualized.
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A trans-femoral four vessel cerebral angiogram showed extra-cranial intracranial collateral anastomoses derived from branches of the external carotid artery to bypass internal carotid obstruction in both sides especially left side. (Figures 3A,B and 4A,B).