PMC4697205_01
Preoperative computed tomography shows extensive high-intensity signal sign along middle cerebral artery (yellow allow) from the distal M1 portion (upper left) to the distal M2 (lower right)
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MCA from the M1 portion up to the distal M2 portion, suggesting long and extensive emboli [Figure 1]. MR angiography (MRA) demonstrated tandem occlusion of the left cervical ICA and intracranial MCA.
Preoperative intracranial magnetic resonance angiography (a) and left cervical magnetic resonance angiography (b) shows tandem occlusion of the cervical internal carotid artery and middle cerebral artery. Magnetization-prepared rapid acquisition gradient echo (c) reveals a high-intensity signal along the left cervical, middle cerebral artery. Arterial spin labeling (d) demonstrates decreased cerebral blood flow in the left middle cerebral artery area. Diffusion-weighted imaging (e) shows a high-intensity lesion in the left parasylvian area
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Arterial spin labeling (ASL) demonstrated decreased cerebral blood flow (CBF) in the entire left MCA area [Figure 2].
Intraoperative photographs demonstrate extensive bluish discoloration due to emboli in the M1-M2 bifurcation (a), up to the distal superior trunk (b) and distally into the inferior trunk (c). Cervical internal carotid artery with blue vessel tape (d) shows dark discoloration, suggestive of dissection
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After introduction of the microscope, the Sylvian fissure was opened to expose the M1-M2 portion of the MCA [Figure 3]. The cervical ICA showed discoloration suggestive of dissection [Figure 3].
Magnetic resonance imaging studies on postoperative day 1. Intracranial magnetic resonance angiography (upper left) shows complete recanalization of the left middle cerebral artery as well as a robustly patent superficial temporal artery-middle cerebral artery bypass. Arterial spin labeling (upper right) demonstrates slightly increased cerebral blood flow in the left middle cerebral artery area when compared with that on the contralateral side. Diffusion-weighted imaging (lower) shows a high-intensity lesion in the left parasylvian area and basal ganglia
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ASL showed slightly increased CBF in the left MCA area when compared with that on the contralateral side [Figure 4].
Magnetic resonance imaging studies at the 6th postoperative months. Intracranial magnetic resonance angiography (upper left) shows a robustly patent superficial temporal artery-middle cerebral artery bypass. Arterial spin labeling (upper right) demonstrates symmetrical cerebral blood flow in the bilateral middle cerebral artery area. T2-weighted imaging (lower) shows no additional ischemic lesion
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T2WI [Figure 5]. The patient subsequently experienced marked recovery from his aphasia and was able to resume his previous occupation.