case_images: PMC10927214_01
case_images: (a) Magnetic resonance imaging of the head showing acute cerebral infarction in the white matter of the right cerebral hemisphere. (b and c) Magnetic resonance angiography (MRA) of the head and digital subtraction angiography (DSA) show unclear delineation beyond the peripheral portions of the bilateral internal carotid arteries. (d) Left external carotid angiography shows that the superficial temporal artery is very thin (arrows). (e) Single-photon emission computed tomography with N-isopropyl-p-[123I] iodoamphetamine showed reduced blood flow at rest in the bilateral anterior and middle cerebral artery regions. (f) MRA and DSA at three months postoperatively showed good blood flow in the bypass area and collateral blood flow development (arrows, dashed circle).
case_images: SNI-15-72-g001.jpg
case_images: PMC10927214_01_SNI-15-72-g001.jpg
case_images: F1
case_images: Magnetic resonance imaging of the head revealed acute cerebral infarction in the white matter of the right cerebral hemisphere [Figure 1a]. Magnetic resonance angiography (MRA) of the head and digital subtraction angiography (DSA) showed unclear delineation beyond the peripheral portions of the bilateral internal carotid arteries, and a diagnosis of MMD was made [Figures 1b and c]. The results of external carotid arteriography showed a very thin superficial temporal artery (STA) on both sides [Figure 1d]. Single-photon emission computed tomography with N-isopropyl-p-[123I] iodoamphetamine (123I-IMP) showed reduced blood flow at rest in bilateral anterior and middle cerebral artery (MCA) regions [Figure 1e]. Three months postoperatively, MRA and DSA showed adequate bilateral blood flow in the bypass area and well-developed collateral blood flow [Figure 1f].
case_images: (a) Before treatment, a peripherally inserted central venous catheter was inserted to avoid ischemic attacks due to dehydration, chirping, and malnutrition (arrows). (b) A semicircular arcuate skin incision was made around the parietal branch of the superficial temporal artery (STA) (the yellow line indicates the STA). (c and d) The STA graft was detached by approximately 4 cm, and the thicker branches were ligated using an 8-0 nylon thread, coagulated and cut. (e) The temporal muscle was incised in the middle along the STA graft run. (f) Craniotomy was performed with only one burr hole for the graft tunnel in children aged <1 year. (g) A cross incision was made in the dura mater to avoid obstructing the passage of the STA graft.
case_images: SNI-15-72-g002.jpg
case_images: PMC10927214_01_SNI-15-72-g002.jpg
case_images: F2
case_images: All examinations and procedures that would be stressful to the patient, such as blood examinations, were performed using the PICC or under sedation [Figure 2a]. To perform a single bypass, a semicircular skin incision was made on a semicircular arc with its base on the auricular side, centered on the parietal branch of the STA, without damaging the main trunk of the frontal branch [Figure 2b]. Therefore, grafts should be harvested using a combination of low-power coagulation and sharp incision, paying attention to coagulation heat and tear damage during dissection [Figure 2c]. STA grafts should be detached by approximately 4 cm, and thick branches should be ligated using an 8-0 nylon thread, coagulated, and cut [Figure 2d]. The temporal muscle was incised medially along the STA graft run, and a Y-shaped incision was made where the graft passed through the muscle to avoid compression during closure [Figure 2e]. Once the bony surface is exposed, craniotomy is performed with only one burr hole for the graft tunnel to minimize bone defects in children aged <1 year [Figure 2f]. A dural incision should also be made in the midline to avoid interfering with the passage of the STA graft, and a cross incision should be made in the middle to go straight through [Figure 2g].
case_images: (a) A silicone super micro sheet K was inserted under the recipient. (b) Gelfoam, cut into small pieces of 10 mm x 10 mm, was placed on the brain surface around the recipient. (c) Approximately 1-2 cm of the tissue attached to the superficial temporal artery (STA) graft end was removed, and the graft tip was trimmed. (d and e) The diameter of the recipient and STA graft was 1.2 mm and 0.8 mm, respectively. (f) Before anastomosis, a stay suture needle was threaded through both ends of the STA graft in advance using an 11-0 monofilament nylon thread.
case_images: SNI-15-72-g003.jpg
case_images: PMC10927214_01_SNI-15-72-g003.jpg
case_images: F3
case_images: After carefully incising the surrounding arachnoid membrane and securing the recipient, a silicone Super Micro Sheet K (Kono Seisakusyo, Tokyo, Japan) was inserted under the recipient to lift the planned anastomosis area to facilitate anastomosis [Figure 3a]. Gelfoam (Pfizer, Tokyo, Japan), cut into small pieces of 10 mm x 10 mm, was placed on the brain surface around the recipient to protect the brain surface and provide space for needle placement [Figure 3b]. Approximately 1-2 cm of tissue attached to the STA graft end was removed, and the tip of the graft was trimmed [Figure 3c]. The diameter of the recipient and STA graft was 1.2 mm and 0.8 mm, respectively [Figures 3d and e]. Before anastomosis, a stay suture needle was threaded through both ends of the STA graft in advance using an 11-0 monofilament nylon thread (BEAR Medic Co., Ibaraki, Japan) [Figure 3f].
case_images: (a and b) After marking the anastomotic site of the recipient and the position where the clip is to be applied with biological pigment, the clip was used to block blood flow. (c) After suturing the planned anastomosis with one stitch using an 11-0 monofilament nylon thread, the thread was lifted upward, and the arterial wall was incised. (d) A stay suture was first performed at both ends. (e and f) Anastomosis was performed with interrupted sutures. Anastomosis was performed with 2-4 stitches on each side. (g and h) After anastomosis, micro-Doppler and indocyanine green were used to confirm adequate blood flow in the bypass area. (i) The dura mater was folded back to the brain's surface for encephalo-duro-synangiosis. The dural defect was replaced by harvesting of the temporal fascia. (j) The bone flap was fixed using an absorbable osteosynthesis plate in the infant.
case_images: SNI-15-72-g004.jpg
case_images: PMC10927214_01_SNI-15-72-g004.jpg
case_images: F4
case_images: After marking the anastomotic site of the recipient and the position where the clip was to be applied with biological pigment, the clip was used to block the blood flow [Figures 4a and b]. After suturing the planned anastomosis with one stitch using an 11-0 monofilament nylon thread, the thread was lifted upward, and the arterial wall was incised [Figure 4c]. The lumen was rinsed with heparinized saline, and after confirming that there was no leakage of arterial blood, a stay suture was first performed at both ends [Figure 4d]. Anastomosis was performed with 2-4 stitches on each side [Figures 4e and f]. After anastomosis, micro-Doppler and indocyanine green were used to confirm adequate blood flow in the bypass area [Figure 4g and h]. The dural defect was replaced by harvesting of the temporal fascia [Figure 4i]. The bone flap was fixed using an absorbable osteosynthesis plate in infants [Figure 4j].