PMC7398410_01
Preoperative investigations. (a) Magnetic resonance imaging (MRI) on admission shows a small infarction in the left parietal lobe on diffusion-weighted imaging (DWI). (b) MR angiography on admission shows occlusion of the M2 inferior trunk of the middle cerebral artery (MCA). (c) Serial MRI shows expansion of cerebral infarction on DWI. D, E: Lateral view of right carotid angiograms. (d) In the early phase, there is an avascular area in the territory of the M2 inferior trunk. (e) In the late phase, vessels that belong to the M2 inferior trunk are represented by retrograde flow from the anterior cerebral artery. (f) Arterial spin labeling (ASL) perfusion imaging showed decreased intensity in the M2 inferior trunk of the right MCA territory
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Fig1
Magnetic resonance imaging (MRI) showed a small acute cerebral infarction of the deep white matter in the right parietal lobe (Fig. 1a). MR angiography showed occlusion of the M2 inferior trunk of the right MCA (Fig. 1b). MRI showed expansion of the cerebral infarction (Fig. 1c). Digital subtraction angiography (DSA) showed occlusion of the M2 inferior trunk of the MCA with retrograde flows from the anterior cerebral artery (ACA) (Fig. 1d, e). Arterial spin labeling (ASL) perfusion imaging showed decreased intensity in the M2 inferior trunk of the right MCA territory (Fig. 1f).
A, B, C: Intraoperative microscopic photographs. (a) After dissection of the Sylvian fissure, the M1-2 bifurcation of the middle cerebral artery is exposed (asterisk: M2 inferior trunk). (b) After dissection of the M2 inferior trunk from the proximal side, the occluded portion is long. (c) There are several M4 cortical arteries on the brain surface (arrows: Sylvian fissure, F: frontal lobe, T: temporal lobe). D, E, F: Intraoperative indocyanine green video angiography in the same view as C. (d) In the early phase, M4 cortical arteries fed by the superior trunk show luminescence. (e) A short time later, M4 cortical arteries fed by the inferior trunk show luminescence. (f) In the late phase, M4 cortical arteries fed by the inferior trunk still show luminescence. (arrows: M4 cortical arteries fed by the inferior trunk)
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Fig2
Unexpectedly, the occluded portion was so long that deep dissection of the Sylvian fissure was necessary (Fig. 2a, b). However, selecting the recipient arteries was difficult, because it was not obvious which M4 arteries were fed by the inferior trunk in the operative field (Fig. 2c). On intraoperative ICG-VA, the M4 arteries of the inferior trunk showed delayed luminescence (Fig. 2d-f).
Postoperative investigations. (a) Postoperative magnetic resonance angiography showed visualization of the M2 inferior trunk of the right middle cerebral artery (MCA) connected with the superficial temporary artery. (b) Postoperative arterial spin labeling perfusion imaging showed increased intensity in the M2 inferior trunk of the right MCA territory
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Fig3
MR angiography showed visualization of the M2 inferior trunk of the right MCA connected with the STA (Fig. 3a). Moreover, postoperative ASL perfusion imaging showed increased intensity in the M2 inferior trunk of the right MCA territory (Fig. 3b).