PMC5609634_01
Patient A, a 44-year-old woman with bilateral moyamoya disease, symptomatic on the right side. In panel (A), magnetic resonance imaging demonstrates multiple embolic-appearing ischemic infarcts in the right middle cerebral artery territory. Panel (B) demonstrates cerebral angiogram with severe right ICA stenosis with collateralization.
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Magnetic Resonance Imaging (MRI) showed acute right middle cerebral artery (MCA) territory infarcts in addition to multiple bilateral chronic infarcts (Figure 1A). Conventional angiogram demonstrated diffusely narrowed bilateral paraclinoid and supraclinoid ICAs, ACAs, and MCAs with numerous collaterals (Figure 1B). A portion was removed and sent for histological analysis, where it was interpreted as non-specific proteinaceous material (Figure S1 in Supplementary Material).
Intra-operative photos taken during right superficial temporal artery-middle cerebral artery bypass of patient A, demonstrating intraluminal embolic material traveling in a distal-to-proximal direction, observed on two occasions (A,B).
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On two occasions, embolic material was observed passing through the recipient artery in a distal-to-proximal direction (Figure 2; Video S1 in Supplementary Material).
Transcranial Doppler displaying a high-intensity transient signal (HITS) in the right middle cerebral artery territory of patient A.
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On post-operative day 1, a surveillance TCD showed 8-10 HITS in the right MCA (Figure 3).
PMC5609634_02
Patient B, a 37-year-old woman with left-sided moyamoya syndrome. (A) Magnetic resonance imaging demonstrates multiple embolic-appearing ischemic infarcts in the left middle cerebral artery (MCA) territory. (B) Cerebral angiogram with severe left ICA stenosis with collateralization. (C) Transcranial Doppler displaying HITS in the left MCA territory.
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Brain MRI demonstrated embolic-appearing infarcts of various ages in her left frontal, temporal, and parietal lobes (Figure 4A). Conventional angiography showed occlusion of the left MCA M1 segment with local proliferation of collaterals and a normal right ICA (Figure 4B). Transcranial Doppler demonstrated 26 HITS in the left MCA during a 30-min period (Figure 4C).