PMC5364928_01
A: The skin of the neck is thin and hard due to the radical neck dissection and irradiation, especially in the left side. Pulsation of the left carotid artery is seen just beneath the skin (arrowhead). B: Diffusion weighted magnetic resonance imaging (M R I) shows multiple infarction in the bilateral anterior cerebral artery (ACA) territories and the left middle cerebral artery (MCA) territory. C: MR angiogram shows occlusion of the bilateral internal carotid arteries (ICAs). Peripheral branches of the bilateral ICAs are revealed by collateral circulation. Distal segments of the bilateral ACAs are filled mainly by the left ICA. The signal of the left superficial temporal artery (STA) is unclear as compared to the right STA.
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F1
The surface of the skin was hard and thin, and carotid artery was seen just beneath it (Fig. 1A). Magnetic resonance imaging (MRI) of the brain showed multiple hyperintense spot on diffusion weighted image (DWI) in the bilateral cerebral hemisphere, predominantly in the left (Fig. 1B). Magnetic resonance angiography (MRA) of the intracranial vessels revealed occlusion of the bilateral internal carotid arteries (ICAs) (Fig. 1C). Signals of the left superficial temporal artery were diminished on MRA, as compared to the opposite side (Fig. 1C). Bilateral ACAs were predominantly supplied by left A1, as suggested also in MRA (Fig. 1C).
A: The left common carotid angiogram (CAG) shows occlusion at the orifice of the left internal carotid artery (ICA). Severe stenosis is also observed at the orifice of the left external carotid artery (ECA). B: The left external CAG shows decreased flow of the superficial temporal artery (STA) due to the stenosis at the orifice of the ECA. Collateral flow to the left distal ICA through the ophthalmic artery is observed. C: The right vertebral angiogram shows collateral flow to the bilateral ICA territories through posterior communicating arteries (Pcoms).
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F2
Bilateral intracranial ICAs were filled mainly by vertebral angiogram (VAG) through posterior communicating arteries (Pcoms) (Fig. 2C) and also by carotid angiogram (CAG) through ophthalmic arteries (OAs) (Fig. 2B). In addition, left CAG showed severe stenosis of the ECA at the orifice (Fig. 2A) and left superficial temporal artery (STA) was poorly revealed (Fig. 2B).
A, B: Pre-operative single photon emission tomography (SPECT) shows reduced cerebral blood flow (CBF) at rest (A) and decreased cerebral vascular reserve (CVR) at the acetazolamide challenge (B) in the left hemisphere and also in the right anterior cerebral artery territory. C, D: One week after bypass surgery, CBF at rest (C) and CVR (D) recovered showing no laterality.
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F3
A-G: The left carotid angiogram shows occlusion at the orifice of the internal carotid artery (ICA), and severe stenosis at the orifice of the external carotid artery (A). Stenting was performed and the stenosis was resolved (B). One week later, restenosis was observed caused by plaque protrusion or acute in-stent thrombosis (C). Another stent is placed, which resulted in successful dilatation of the lesion (D). Another week later, signal defect caused by in-stent thrombus was observed (E), which was resolved by balloon angioplasty (F). Three months after bypass surgery, the flow in the stent is smooth and restenosis is no longer observed (G).
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F4
First, carotid artery stenting (CAS, Precise 9 x 40 mm, Cordis, Bridgewater, New Jersey, USA) for the orifice of the left ECA was performed (Fig. 4B). One week later, by follow-up angiography, plaque protrusion or thrombus was identified in the stent (Fig. 4C). We decided to deploy another stent (Carotid Wallstent 10 x 24 mm, Boston Scientific, Natick, Massachusetts, USA) (Fig. 4D). One more week later, plaque protrusion or thrombus was observed again by angiography (Fig. 4E), which was treated by balloon angioplasty (Fig. 4F). Although small plaque was identified in the stent placed at the ECA orifice in this angiography, it spontaneously disappeared in the 3 month later (Fig. 4G).
A: After stenting for the stenosis of the left external carotid artery (ECA), the left carotid angiogram reveals the left superficial temporal artery (STA) much better than before stenting (Fig. 2B). B, C: After bypass surgery, intracranial internal carotid artery (ICA) territory is clearly revealed through STA bypass graft.
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F5
The left STA was clearly revealed immediately after the procedure, suggesting recovery of the blood flow (Fig. 5A). Angiography performed on 6 days after surgery revealed patency of the bypass (Fig. 5B and 5C).