PMC4496833_01
Preoperative single photon emission computed tomography findings of cerebral blood flow before (a) and after intravenous injection of acetazolamide. (b) Cerebral blood flow was kept within normal, but the reactivity to acetazolamide was impaired in the left middle cerebral artery territory (arrows)
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F1
However, MR angiography demonstrated that the left CCA and left vertebral artery were completely occluded. 123I-IMP single photon emission computed tomography (SPECT) showed an impaired reactivity to acetazolamide in the territory of the left ICA [Figure 1].
Preoperative cerebral angiography. (a) Early arterial phase of left subclavian angiogram. Lateral view: The occipital artery (OA) was opacified through the deep cervical artery. Then the retrograde blood flow of the OA opacified the main trunk of the external carotid artery and then superficial temporal artery. (b) Late arterial phase of left subclavian angiogram. Lateral view: Note that the internal carotid artery was opacified through the retrograde blood flow of the ophthalmic artery (OphA, arrow)
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The blood flowed to the proximal part of the left ECA with a retrograde fashion, and then to the left ICA via the left ophthalmic artery [Figure 2]. At the same time, the left STA was opacified without a significant delay [Figure 2].
Ultrasound findings of left ophthalmic artery before (a) and after (b) superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis. Note the decrease in systolic velocity of retrograde blood flow in the ophthalmic artery (arrows)
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The peak systolic flow velocity was -40 cm/s, suggesting that ocular ischemia was closely related to severe neovascular glaucoma in this case [Figure 3]. Follow-up ultrasound examination also revealed that the reversed blood flow in the left ophthalmic artery improved from -40 cm/s to -20 cm/s at 6 days after surgery [Figure 3].
Postoperative single photon emission computed tomography findings of cerebral blood flow before (a) and after intravenous injection of acetazolamide. (b) Note that the reactivity to acetazolamide completely recovered in the left middle cerebral artery territory
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Postoperative SPECT study performed 2 weeks after surgery demonstrated that the reactivity to acetazolamide completely recovered in the territory of the left MCA [Figure 4].
Postoperative angiography. Early (a) and late arterial phase of left subclavian angiogram (b) revealed that superficial temporal artery to middle cerebral artery double anastomosis supplied enough collateral blood flow to the operated hemisphere
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Postoperative cerebral angiography demonstrated that STA-MCA anastomosis supplied enough blood flow to the operated hemisphere [Figure 5].