PMC3432552_01
Preoperative magnetic resonance imaging axial T2-weighted image (a) and coronal FLAIR image (b). Cerebral infarction of the left fronto-parietal watershed area was noted.
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Preoperative head magnetic resonance imaging indicated cerebral infarction of the frontoparietal watershed area (Figures 1(a) and 1(b)).
Preoperative cervical echograms (a, b) and left cervical angiogram (c). The lumen of the internal carotid artery (ICA) in echograms is indicated by arrowheads, and the left ICA in angiogram is indicated by arrows. The left cervical common carotid artery (CCA)-ICA echogram indicated severe stenosis towards the distal end of the left ICA without wall thickening (interna-media thickness = 0.8) (b) compared with the right CCA-ICA echogram (a). The lateral view of the left cervical angiography also indicated stenosis and winding of left ICA towards the distal intracranial region (c).
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Carotid echogram indicated shrinkage of the left ICA towards the distal end, starting at the level of carotid bifurcation without vascular wall thickening (Figure 2(b)), compared with the right ICA (Figure 2(a)); the possibility of steroid-induced atherosclerosis as the cause of this left ICA occlusion was dismissed. And, left cervical digital subtraction angiography (DSA) also indicated stenosis and winding of the left cervical ICA towards the distal intracranial lesion (Figure 2(c)).
Preoperative head angiograms. Anteroposterior view (b) and lateral view of the left common carotid angiogram (c) indicating occlusion of the left internal carotid artery (ICA) at the C1 segment, leptomeningeal (transdural) anastomosis from the left external carotid artery to the left anterior cerebral artery (ACA) and middle cerebral artery (MCA) area (arrowheads), and formation of basal moyamoya vessels (arrows), and the lateral view of the right carotid angiogram (a) indicating no abnormality. Lateral view of left vertebral angiography (d) showing leptomeningeal anastomosis (arrow heads) and anastomosis to the ACA and MCA area via the left posterior cerebral artery (arrows).
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Head DSA of the right ICA indicated no abnormality (Figure 3(a)). However, DSA of the left common carotid artery indicated the occlusion of the left ICA just after the bifurcation of the posterior communicating artery, deficit of the left anterior cerebral artery and the left middle cerebral artery, development of moyamoya-like vessels in the left basal ganglia (Figures 3(b) and 3(c)), and leptomeningeal anastomosis from the left posterior cerebral artery to the perfusion area of the left anterior and middle cerebral artery (Figure 3(d)).
Evaluation of the increase rate of cerebral blood flow (CBF) under diamox stress using a three-dimensional stereotactic region of interest template analysis of 99mTechnetium-ethyl-cysteinate-dimer CBF single-photon emission computed tomography (preoperative (a); postoperative (b)). Preoperative CBF increase rate under diamox stress was impaired more around the central sulcus than on the ipsilateral side (2.2% and 10.8%, resp.). Postoperative CBF increase rate by acetazolamide stress around the left central sulcus was improved (5.7%, green circle) compared with that observed during the preoperative study.
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Analysis of 99mTechnetium-ethyl-cysteinate-dimer single-photon emission computed tomography (99mTc-ECD SPECT) imaging of the cerebral blood flow (CBF) using three-dimensional stereotactic region of interest template highlighted a reduced level of CBF in the left hemisphere under acetazolamide loading, compared with the right hemisphere (Figure 4(a)). Postoperative SPECT imaging of the CBF under acetazolamide loading indicated improvement in cerebrovascular reserve capacity of the left hemisphere, particularly around the central sulcus (Figure 4(b)).
Postoperative digital subtraction angiography. Anteroposterior view (a) and lateral view (b) of the left common carotid angiogram indicating marked neovascularization from the graft compared with preoperative angiography (Figures 3(b) and 3(c)).
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A postoperative DSA study indicated marked neovascularization from the graft (Figures 5(a) and 5(b)).