PMC5535565_01
CT scans on admission demonstrating subarachnoid hemorrhage, with a thick hematoma in the right sylvian cistern (a and b). CT scan showing increased hematoma on the day before surgery (c), and diffusion-weighted image revealing infarctions mainly in the right middle cerebral artery area (d)
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F1
On admission, her Glasgow Coma Scale score was 14, and CT demonstrated SAH, with a thick hematoma in the right sylvian cistern [Figure 1a and b]. On the day after admission, CT before surgery identified increased hematoma, indicating repeated hemorrhage, and diffusion-weighted imaging revealed infarctions mainly in the right MCA area [Figure 1c and d].
Preoperative DSA, left anterior oblique (a) and lateral (b) projections, showing severe stenosis and irregular aneurysmal dilatation in the M1 portion of the middle cerebral artery (MCA), and poor perfusion of the MCA territory compared with the anterior and posterior cerebral artery areas. Dissecting aneurysm with a purplish-red wall arising from the M1 trunk was found at surgery, just proximal to the lenticulostriate artery (LSA, arrow) and inferior trunk (arrowhead) of the MCA, part of the vessel wall was broken, and thrombus (asterisk) had protruded (c). Postoperative diffusion-weighted image revealing a new small infarction in the anterolateral part of the putamen (d, arrow), and DSA showing good patency of the radial artery graft (arrows), LSA, and inferior trunk of the MCA (arrowheads), and no flow to the dissecting lesion (e)
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F2
Digital subtraction angiography (DSA) of right carotid artery revealed severe stenosis and irregular aneurysmal dilatation in the M1 portion of the MCA, and poor perfusion of the MCA territory compared with the anterior and posterior cerebral artery areas [Figure 2a and b]. The large dissecting aneurysm with a purplish-red wall was identified arising from the M1 trunk, part of the vessel wall was broken, and thrombus had protruded [Figure 2c]. Postoperative magnetic resonance angiography showed good patency of the bypass, and diffusion-weighted imaging revealed a new small infarction in the anterolateral part of the putamen [Figure 2d]. The MCA distal to the dissection, including the M2 inferior trunk and LSA, was filled favorably by the high-flow bypass [Figure 2e].