case_images: PMC10316151_01
case_images: Magnetic resonance image at the age of 41 (a) shows mild stenosis of bilateral middle cerebral arteries (MCAs). At ages 45 (b) and 49 (c), there are no significant changes in the MCAs. At the age of 53 (d), there is an occlusion of the right MCA.
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case_images: PMC10316151_01_SNI-14-192-g001.jpg
case_images: F1
case_images: Based on initial magnetic resonance imaging (MRI), mild stenosis in the bilateral MCA was suspected but there was neither stenosis in the ICA and no evidence of moyamoya vessels [Figure 1]. There were no imaging changes over approximately 10 years but MRI performed at the age of 53 showed a signal loss in M1 and its distal portion, suggestive of the right M1 occlusion [Figure 1].
case_images: 99 m-Tc single-photon emission computed tomography (SPECT) images at the age of 41 show no differences in cerebral blood flow (CBF) at rest (a) and no hemodynamic compromise after acetazolamide challenge (b).
case_images: SNI-14-192-g002.jpg
case_images: PMC10316151_01_SNI-14-192-g002.jpg
case_images: F2
case_images: In addition, 99m-Tc single-photon emission computed tomography (SPECT) showed stable cerebral hemodynamics without laterality [Figures 2a and b].
case_images: T1-weighted (a), T2-weighted (b), and fluid-attenuated inversion recovery (c) magnetic resonance imaging at the age of 53 show no abnormalities in the brain parenchyma.
case_images: SNI-14-192-g003.jpg
case_images: PMC10316151_01_SNI-14-192-g003.jpg
case_images: F3
case_images: No other vascular changes were found and there was no cerebral infarction [Figure 3].
case_images: SPECT images at the age of 53 show a subtle decrease in CBF in the right compared to the left hemisphere at rest (a) and hemodynamic compromise after acetazolamide challenge (b).
case_images: SNI-14-192-g004.jpg
case_images: PMC10316151_01_SNI-14-192-g004.jpg
case_images: F4
case_images: In addition, 99mTc-SPECT imaging showed a subtle decrease in resting cerebral blood flow in the right compared to the left hemisphere and imaging after acetazolamide challenge showed hemodynamic compromise in the right cerebral hemisphere [Figure 4].
case_images: Digital subtraction angiograms at the age of 53 show occlusion of the right middle cerebral arteries and the abnormal vascular network around the occluded segment. The vessel diameter of the M2 segment is almost normal. There is no stenosis in the supraclinoid portion of the internal carotid artery (a: Anterior-posterior [A-P] view, b: Lateral view). Left carotid angiogram in normal (c: A-P view, d: Lateral view). (e) Rotational angiograms clearly show a plexiform network formation replacing the M1 occlusion (arrow).
case_images: SNI-14-192-g005.jpg
case_images: PMC10316151_01_SNI-14-192-g005.jpg
case_images: F5
case_images: Digital subtraction angiography (DSA) revealed occlusion of the right M1 segment and a plexiform vascular network around the occluded segment [Figure 5].