PMC9873458_01
Preoperative radiological examinations. (a) Computed tomography (CT) showed subcortical temporoparietal hemorrhage (arrow) and subdural hematoma (arrowheads) with midline shift of the cerebrum as well as uncal herniation. (b) Three-dimensional CT angiography indicated scarcely enhanced the left middle cerebral artery (arrow heads): (left) anterior-posterior and (right) posterior-anterior view.
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Coma Scale score was 4, and anisocoria and decorticate position of extremities were observed. Computed tomography (CT) demonstrated an acute subdural hematoma associated with left temporoparietal subcortical hemorrhage (Figure 1(a)). Three-dimensional CT angiography (3DCTA) indicated a round shift of the bilateral anterior cerebral artery and a scarcely enhanced left middle cerebral artery (MCA) (Figure 1(b)).
Images of the initial procedure. (a) Photograph showing a huge subdural hematoma after opening the dura mater. (b) Photograph after evacuation of the hematoma showing a swollen brain surface. (c) Intraoperative microscopic photograph showing the left internal carotid artery (arrow) and M1 segment of the hypoplastic left middle cerebral artery (MCA) (arrowheads). (d) Intraoperative microscopic showing a narrow M2 segment of the hypoplastic left MCA (arrowheads). (e) Computed tomography immediately after surgery, confirming adequate decompression and removal of the hematoma.
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Subsequently, we performed external decompression and hematoma evacuation (Figures 2(a) and 2(b)). During the procedure, we could not identify any aneurysms or arteriovenous malformations but observed marked stenosis of the MCA vessels, indicating hypoplastic MCA of the ipsilateral side (Figures 2(c) and 2(d)). Adequate evacuation of the hematoma and decompression was confirmed on postoperative CT (Figure 2(e)).
Images after initial procedure. (a) Digital subtraction angiography (DSA) of the right common carotid artery (CCA) after the initial surgery showing no remarkable abnormality. (b) DSA of the left CCA showed stenosis of the middle cerebral artery and moyamoya vessels (arrowheads). (c) Intraoperative photograph demonstrating encephalo-arterio-synangiosis between the brain surface and the parietal branch of the superficial temporal artery (STA) (arrowheads). (d) Three-dimensional computed tomography after the second surgery showing the structure of the implanted bone flap and STA.
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Postoperative digital subtraction angiography (DSA) three days after the initial surgery revealed severe stenosis of the MCA and moyamoya vessels on the left side; therefore, we diagnosed the patient with unilateral moyamoya disease (Figures 3(a) and 3(b)). We simply placed the end of the STA onto the surface of the M4 segment of the MCA with sutures using 10-0 nylon (Figure 3(c)). After indirect revascularization, cranioplasty using the patient's skull flap was performed (Figure 3(d)).
PMC9873458_02
Radiological findings after the second surgery. (a) Repeat magnetic resonance angiography showing the patent vessel of encephalo-arterio-synangiosis (arrow). The patent superficial temporal artery (STA) (arrow) and revascularized M4 segment of the middle cerebral artery (MCA) (arrow heads) were confirmed by digital subtraction angiography (DSA) of the external carotid artery (ECA); (b) left anterior-oblique and (c) lateral view. Three-dimensional DSA of the ECA verified good patency of the parietal branch of the STA (arrow) and the collateralized MCA (arrow heads); (d) left anterior-oblique view.
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Rankin Scale score of the patient one year after the treatment was 1, and regular magnetic resonance angiography (MRA) indicated increased blood flow in the revascularized STA (Figure 4(a)); there was no recurrence of stroke. Repeat DSA three years after the treatment showed good patency of the indirectly anastomosed STA and collateral formation, which was evaluated as "B" score of the Matsushima scale; with A being more than 2/3 of the MCA distribution, B in between 2/3 and 1/3 of the MCA distribution, and C being slight or none (Figures 4(b)-4(d)).