PMC5926210_01
Diffusion weighted magnetic resonance imaging showed acute brain infarction at the bilateral cerebellar hemispheres and the right thalamus (a). Head MRA showed the bilateral VAs but posterior communicating arteries were not observed bilaterally (b). Neck MRA indicated the right VA but not the left VA (c)
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F1
Neck MRA indicated right VA but did not show left VA [Figure 1].
Posterior view of contrast-enhanced 3D-CTA before the operation (left) showed right VA severe stenosis at the origin (asterisk) and did not show the left VA from the ostia to the lower edge of the second cervical vertebra (white arrowheads). Whereas, 3D-CTA just after the operation (right) showed that the anastomosis was patent (white arrow) and the left VA was shown from the ostia to the union (black arrowheads)
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F2
Contrast-enhanced three-dimensional computed tomographic angiography (3D-CTA) showed right VA severe stenosis at the origin and did not show the left VA from the ostia to the lower edge of the second cervical vertebra [Figure 2, left]. On the day following the operation, the patient walked without assistance but watching and the bilateral ataxia improved. 3D-CTA just after the operation showed that the anastomosis was patent, and the left VA was observed from the ostia to the union [Figure 2, right].
Intraoperative findings of left OA to left extracranial VA anastomosis. After dissecting the OA and the VA (a), the OA was mobilized and anastomosed end-to-side to the VA (b). The VA was observed in the occipito-atlantal (C0-C1) level within the suboccipital triangle bounded by the rectus capitis posterior major muscle, obliquus capitis superior muscle, and obliquus capitis inferior muscle [Video 1]
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F3
The temporary occlusion time was 38 min and 40 s [Figure 3].