PMC4533378_01
A: Preoperative 3D-CTA showed a left thyroid tumor involving the left CCA. B: Preoperative DSA showed that there was cross-flow through the anterior communicating artery filling the MCA territory. C: The thyroid tumor was resected with reconstructive ECA-RA-CCA bypass using an RA graft. D, E: Postoperative DSA showed that the left STA was filling in a retrograde fashion from the right STA over the midline of the head. F: A reversed single STA-MCA bypass was performed using a naturally formed "bonnet" STA. G: The left STA was anastomosed to a cortical artery in the left frontal lobe so that the cerebral blood flow in the left STA was supplied in a retrograde fashion. H: Postoperative 3D-CTA showed that the anastomosed bonnet STA perfused the MCA territory. CCA: common carotid artery, DSA: digital subtraction angiography, ECA: external carotid artery, MCA: middle cerebral artery, RA: radial artery, STA: superficial temporal artery, 3D-CTA: three dimensional-computed tomography angiography.
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F1
A 76-year-old female was admitted to our hospital because of a left thyroid tumor involving the left CCA (Fig. 1A). The balloon occlusion test (BOT) showed that she could tolerate a 30-minute occlusion (Fig. 1B). The thyroid tumor was resected with the left CCA due to its involvement, and reconstructive ECA-CCA bypass using an RA graft was performed (Fig. 1C). Postoperative DSA showed that the left STA was filling in a retrograde fashion from the right STA over the midline of the head (Fig. 1D, E). A reversed single STA-MCA bypass was performed using a naturally formed "bonnet" STA (Fig. 1F). The left STA was anastomosed to a cortical artery in the left frontal lobe so that the cerebral blood flow in the left STA was supplied in a retrograde fashion (Fig. 1G). Postoperative 3D-CTA showed that the anastomosed bonnet STA perfused the MCA territory (Fig. 1H).
A computed tomography (CT) perfusion study after removal of the thyroid tumor with common carotid occlusion showed an increase of cerebral vascular volume (CBV), and a prolongation of the mean transient time (MTT) and time to peak (TTP) in the extent frontal lobe and -left side (A-I). After reverse single bypass, postoperative CT perfusion showed a decrease of CBV, a normalization of MTT and TTP in the extent frontal lobe and -left side (J-R).
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F2
A CT perfusion study showed an increase of cerebral vascular volume (CBV), and a prolongation of the mean transient time (MTT) and time to peak (TTP) in the extent frontal lobe and -left side (Fig. 2A-I). Postoperative CT perfusion study showed a decrease of CBV, and a normalization of MTT and TTP in the extent frontal lobe and -left side (Fig. 2J-R).