PMC10101701_01
Preoperative images.
. 
Preoperative images after infarctions (a-k) and for years prior to infarctions (l). a Diffusion-weighted image of the brain MRI showing acute infarctions within the right cerebral hemisphere in watershed distribution. b-g Catheter angiograms showing stenosis of the right MCA M1 (b), ACA A1 (b-c), VA (d), and cervical common carotid artery to the external carotid artery (f). Catheter angiograms of the right external carotid artery in the lateral view showing a very thin STA, which was insufficient for use as a graft in bypass surgery (e). Abdominal aortography showing moderate stenosis of the bilateral renal arteries (g). h FIESTA showing the preserved external diameter of the right MCA M1 (arrow). i-j A coronal slice (i) and a sagittal slice (j) of vessel wall imaging showing asymmetric wall thickening of the right MCA, with a narrowed internal diameter (arrow). k N-isopropyl-p-[123I]iodoamphetamine (123I-IMP) -SPECT showing hypoperfusion of the right hemisphere with rest (left) and acetazolamide (ACZ) stress (middle). Cerebrovascular reserve (CVR) showing a low degree of autoregulatory vasodilation in the right hemisphere (right). l MRA 4 years before infarctions showing no intracranial arterial stenosis.
2188-4226-10-0061-g001.jpg
PMC10101701_01_2188-4226-10-0061-g001.jpg
g001
Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) showed acute and subacute infarctions in the right watershed area (Fig. 1a) with multiple arterial stenoses. Digital subtraction angiography revealed severe stenosis in the M1 portion of the right MCA, A1 of the right anterior cerebral artery (ACA), right posterior cerebral artery, right vertebral artery (VA), and left cervical common carotid artery, without moyamoya vessels (Fig. 1b-g). Fast imaging employing steady-state acquisition (FIESTA) showed a preserved external diameter of the right MCA (Fig. 1h), and vessel wall imaging showed asymmetric wall thickening of the right MCA, with a narrowed internal diameter (Fig. 1i-j). Single-photon emission computerized tomography (SPECT) demonstrated severely low blood perfusion in the right MCA area (Fig. 1k). The MRI performed 4 years prior to this event revealed no arterial stenosis (Fig. 1l).
Intraoperative images.
. 
a, b Intraoperative cerebral angiogram in the lateral view (a) and three-dimensional reconstruction (b) showing good bypass flow through the radial artery graft. c MCA M1-M2-M3 appearance in the Sylvian fissure, whose external artery wall was not narrowed but was maintained, with sporadic yellow, shiny, and firm wall thickening that corresponded to atherosclerosis.
2188-4226-10-0061-g002.jpg
PMC10101701_01_2188-4226-10-0061-g002.jpg
g002
Therefore, a high-flow bypass was performed (Fig. 2a, b). The external wall of the artery was not narrowed but was maintained with sporadic yellow, shiny, and firm wall thickening, which corresponded to atherosclerosis (Fig. 2c).
Postoperative image.
. 
MRA showing good patency of the radial artery and right MCA M2 anastomosis.
2188-4226-10-0061-g003.jpg
PMC10101701_01_2188-4226-10-0061-g003.jpg
g003
Postoperative MRA showed a spastic change in the radial artery graft (Fig. 3), probably because the relatively short length of the harvested graft from her short arm forced us to stretch the graft to make the anastomosis.