case_images: PMC7451180_01
case_images: PMC7451180_02
case_images: Intraoperative photographs. The site of bypass anastomosis was initially morphologically expanded (a), and the good blood flow from the bypass was confirmed (b). All five stitches on one side of anastomosis were removed to confirm the lumen of anastomosis site (c). In the lumen, a white thrombus was revealed, as expected (d). The superficial temporal artery was anastomosed to the occluded recipient at the end of the surgery (e and f).
case_images: SNI-11-220-g001.jpg
case_images: PMC7451180_02_SNI-11-220-g001.jpg
case_images: F1
case_images: After removing the temporary clips, the site of bypass anastomosis was morphologically expanded [Figure 1a], and good blood flow from the bypass was initially confirmed using Doppler echo. However, blood flow on echo was attenuated within 10 min, and the blood flow through the bypass could not be confirmed on the following intraoperative indocyanine green angiography [Figure 1b]. In the lumen, a white thrombus was revealed, as expected [Figure 1c and d]. STA remained to be anastomosed to the occluded site in the hope of postoperative reopening of bypass due to heparin and aspirin [Figure 1e and f]. Subsequently, hemostasis of the brain surface, subdural and epidural space, was confirmed, and the incised dura mater was folded inside subdural space as to be used as an encephalo-duro-synangiosis.
case_images: PMC7451180_03
case_images: Serial follow-up magnetic resonance angiography (MRA). Preoperative MRA (a). Intraoperative occluded bypass vessel was not visualized on magnetic resonance imaging (MRI) at 2 days (b), 2 weeks (c), and 6 weeks (d). However, the bypass vessel was detected on MRI performed 4 months after surgery (e). Furthermore, the bypass vessels became more clearly visible on MRI performed 10 months (f) and 19 months (g and h (from caudal)) after surgery (d). (Lt.: left, ICA: Internal carotid artery, STA: Superficial temporal artery, br.: Branch, OA: Occipital artery, EMS (encephalo-myo-synangiosis).
case_images: SNI-11-220-g002.jpg
case_images: PMC7451180_03_SNI-11-220-g002.jpg
case_images: F2
case_images: The intraoperative occluded bypass vessels (using parietal branch of STA [Figure 2a] as donor) were not visualized on MRI at 2 days [Figure 2b], 2 weeks [Figure 2c] and 6 weeks [Figure 2d] after surgery. However, the bypass vessels were detected on MRI performed 4 months [Figure 2e] after surgery. Furthermore, the bypass vessels became more clearly visible half a year later (10 months after surgery) [Figure 2f], and 19 months after surgery [Figure 2g and h].