PMC6174737_01
Pre- and postoperative cerebrovascular examinations. (a) and (b) Preoperative digital subtraction angiography showing narrowing in the M1 portion of MCA. (c) Preoperative 3D-CT angiography showing narrowing in the M1 portion of MCA. (d) Postoperative 3D-CT angiography showing the patency of STA-MCA anastomosis. (e) Preoperative magnetic resonance angiography (MRA) showing stenosis of M1 portion of left middle cerebral artery (MCA) and poor visualization of peripheral MCA. (f) Postoperative MRA showing the patency of STA-MCA anastomosis and improvement of blood flow in peripheral MCA.
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Screening head magnetic resonance imaging (MRI) at this time revealed stenosis of the left MCA with no brain parenchymal lesions (Figure 1(e)), why she was consulted to our department. We performed angiography, confirming moderate M1 portion stenosis (Figures 1(a) and 1(b)). On operation, left temporal craniotomy was performed, and the parietal branch of the STA was anastomosed with the M4 portion on the temporal lobe (Figures 1(d) and 1(f)).
Pre- and postoperative neuroradiologic examinations. (a) Arterial spin labelling (ASL) of MRI showing decrease of CBF in the left brain when the patient presented with right hand weakness and numbness; (b) ASL on postoperative day (POD) 5 showing an increase of CBF in the left cerebrum; (c) preoperative single-photon emission computed tomography (SPECT) showing no apparent laterality in CBF. (d) SPECT on POD12 showing remarkable increase of CBF in the left cerebrum; (e) MRI T2WI on POD16 showing slightly hypointense change in the subcortex of the left cerebrum (arrows). (f) SPECT on POD33 showing normalization of CBF.
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Although MRI showed no apparent ischemic change in her brain, arterial spin labelling (ASL) of MRI detected the decrease of CBF in the left cerebrum (Figure 2(a)), which was thought to well correspond for her symptoms. Preoperative SPECT showed no apparent laterality in CBF (Figure 2(c)). MRI and CT showed no ischemic or hemorrhagic changes, but ASL and SPECT revealed remarkable increase of CBF in the left cerebrum (Figures 2(b) and 2(d)), by which the symptoms were diagnosed as CHPS. MRI showed no abnormality except slightly hypointense changes on T2 weighted images and FLAIR (Figure 2(e)). One month after the surgery, the patient started to utter words that were not fluent, when SPECT and MRI showed normalization (Figure 2(f)).