case_images: PMC3994683_01
case_images: Magnetic resonance (MR) imaging on admission showed no acute infarction (a) T2WI, T2-weighted images; DWI, diffusion weighted images. MR angiography showed an occlusion of the left internal carotid artery (b and c, arrow) and stenosis of the bilateral middle cerebral artery (arrowhead). Some anomalous arteries were also suspected (b), but the detailed anatomy was unclear
case_images: SNI-5-26-g001.jpg
case_images: PMC3994683_01_SNI-5-26-g001.jpg
case_images: F1
case_images: Magnetic resonance (MR) imaging revealed no evidence of acute cerebral infarction [Figure 1a]. MR angiography showed an occlusion of the left internal carotid artery (ICA) and stenosis of the right MCA [Figure 1b and c].
case_images: Conventional angiography of the right internal carotid artery (a and b) and left vertebral artery (c and d). Anterior-to-posterior view (a and c) and lateral view (b and d). The arrow (c) indicates stenosis of the left proximal segment (M1) of the middle cerebral artery (MCA), which is supplied via the left posterior communicating artery. Note that the left accessory MCA supplied only the left frontal lobe (arrowhead in a and b), while the left MCA supplied the area beneath the Sylvian fissure (arrowheads in c and d)
case_images: SNI-5-26-g002.jpg
case_images: PMC3994683_01_SNI-5-26-g002.jpg
case_images: F2
case_images: ICA and stenosis of both the proximal segments (M1) of the MCA [Figure 2]. In addition, a left AMCA, originating from near the anterior communicating artery (ACoA), was identified [Figures 2 and 3]. ICA via the ACoA. In addition, the left MCA, which was perfused by the left posterior cerebral artery via the left posterior communicating artery, supplied CBF to the temporal and parietal lobes [Figures 2-4].
case_images: Fusion images of three-dimensional angiography of the right internal carotid artery (brown) and left vertebral artery (red). To clearly illustrate the distal part of the middle cerebral artery (MCA), the right side of all images was intentionally eliminated. The left accessory MCA and left MCA run independently, and the areas they supply are clearly distinguished. The arrowhead (b) indicates the site of occlusion of the left anterior cerebral artery. The stenosis of the left MCA is indicated by the arrow (d)
case_images: SNI-5-26-g003.jpg
case_images: PMC3994683_01_SNI-5-26-g003.jpg
case_images: F3
case_images: ICA and stenosis of both the proximal segments (M1) of the MCA [Figure 2]. In addition, a left AMCA, originating from near the anterior communicating artery (ACoA), was identified [Figures 2 and 3]. ICA via the ACoA. In addition, the left MCA, which was perfused by the left posterior cerebral artery via the left posterior communicating artery, supplied CBF to the temporal and parietal lobes [Figures 2-4].
case_images: Schematic drawing of the anomalous arteries and steno-occlusive changes found in this patient, showing the blood flow in the right internal carotid artery angiography (b) and the left vertebral artery angiography (c) as seen on Figures 2 and 3
case_images: SNI-5-26-g004.jpg
case_images: PMC3994683_01_SNI-5-26-g004.jpg
case_images: F4
case_images: ICA via the ACoA. In addition, the left MCA, which was perfused by the left posterior cerebral artery via the left posterior communicating artery, supplied CBF to the temporal and parietal lobes [Figures 2-4]. Because the proximal segment (A1) of the left ACA was occluded, the flows of the AMCA and MCA were clearly separate [Figure 4].
case_images: Single-photon emission computed tomography showed a marked decline in cerebral blood flow at the left fronto-temporo-parietal lesion, and cerebral vascular reactivity was impaired by acetazolamide loading
case_images: SNI-5-26-g005.jpg
case_images: PMC3994683_01_SNI-5-26-g005.jpg
case_images: F5
case_images: Single-photon emission computed tomography (SPECT) showed a marked decline in the CBF to the left fronto-temporo-parietal lesion at rest, while cerebral vascular reactivity was impaired by acetazolamide loading [Figure 5].
case_images: The intraoperative findings (a and b) of the left superficial temporal artery-to-middle cerebral artery double anastomosis and magnetic resonance angiography after operation (c). Intraoperative indocyanine green video angiography showed the time delay of blood flow and bidirectional flow. The arrows indicate the anastomosis sites (a and b)
case_images: SNI-5-26-g006.jpg
case_images: PMC3994683_01_SNI-5-26-g006.jpg
case_images: F6
case_images: Prior to anastomosis, intraoperative indocyanine green video angiography was performed and demonstrated bidirectional flow in the left frontal cortical artery [Figure 6].