PMC4533381_01
A: Diffusion weighted imaging (DWI) during the initial attack showing small cerebral infarctions in both cerebral hemispheres. B: Magnetic resonance angiography showing occlusion of the terminal portion of the internal carotid artery bilaterally and moyamoya vessels. C, D: Preoperative single-photon emission computed tomography with (C) and without (D) acetazolamide showing decreased cerebral blood flow and impaired vascular reserve capacity in both cerebral hemispheres. E: DWI after the second attack showing cerebral infarction in the right parietal and posterior cerebral lobe. A: anterior, P: posterior.
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F1
Magnetic resonance imaging (MRI) demonstrated cerebral infarction in his left frontal and parietal lobes and occlusion of the terminal portion of the bilateral internal carotid artery (Fig. 1A, B). Spontaneous Occlusion of the Circle of Willis of the Ministry of Health, Labor, and Welfare, Japan. Single-photon emission computed tomography with N-isopropyl[123I]-p-iodoamphetamine (IMP-SPECT) with and without acetazolamide showed marked decrease in cerebral blood flow (CBF) and impaired cerebral vascular reserve capacity (CVRC) in both cerebral hemispheres (Fig. 1C, D). However, while waiting for the surgery, the patient suffered from a common cold, which was followed by new cerebral infarction in his right temporal and occipital lobes (Fig. 1E).
A: Before the anastomosis, the cortical branch (M4) of the middle cerebral artery on the temporal lobe (arrow) was exposed. B: Photograph at 5 minutes after declamping the superficial temporal artery (STA). Parietal branch of the STA (asterisk) was anastomosed to the recipient in an end to side fashion (arrowhead). Cortical veins near the anastomosis site reddened a few seconds after declamping the STA (arrows) and the dilated arterioles are also observed.
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F2
After the exposure of the cortical branch of the MCA (M4) on the temporal lobe (Fig. 2A), the recipient artery was temporarily interrupted and the parietal branch of the STA was anastomosed in an end to side fashion (Fig. 2B). The total interrupting time of the recipient artery was 22 minutes A few seconds after declamping the STA, the cortical veins near the anastomosis site gradually changed its color from blue to red (Fig. 2B) and the arterioles around the anastomosis site dilated.
A: Computed tomography (CT) scan one day after operation showing no new lesions. B: CT scan 3 days after operation showing subarachnoid hematoma at the anastomosis site. C: Single-photon emission computed tomography (SPECT) 2 days after the operation demonstrating increased cerebral blood flow (CBF) at the anastomosis site (arrow) D: Follow-up SPECT 8 days after the operation showing mildly increased CBF in the right cerebral hemisphere and disappearance of local hyperperfusion. E: Magnetic resonance angiogram 14 days after the operation showing well-developed STA (arrow). A: anterior, P: posterior.
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F3
CT scan, the day after the operation, showed no new lesions (Fig. 3A). However, SPECT two days after the operation demonstrated marked increase in CBF around the anastomosis site in his right temporal lobe (Fig. 3C) and CT scan three days after the operation showed subarachnoid hemorrhage in the same region (Fig. 3B). He did not complain of any new symptoms and follow-up SPECT eight days after the operation demonstrated normalized CBF in his right cerebral hemisphere indicating the remission of the syndrome (Fig. 3D). MRA 14 days after the operation demonstrated a well-developed STA (Fig. 3E).