case_images: PMC6764047_01
case_images: Preoperative diagnosis of MMD.. (A-C) Preoperative DSA showing occlusion of the terminal portions of left
  ICA and the occurrence of abundant moyamoya vessels in the brain base
  unilaterally. (D) Preoperative CTA revealing occlusion change
  (dotted circles) at the terminal portions of left
  ICA.. CTA, computed tomography angiography; DSA, digital subtraction
  angiography; ICA, internal carotid artery; MMD, moyamoya disease.
case_images: 10.1177_1756286419878343-fig1.jpg
case_images: PMC6764047_01_10.1177_1756286419878343-fig1.jpg
case_images: fig1-1756286419878343
case_images: Surgical view of left STA-MCA anastomosis.. STA-MCA anastomosis with EDMS in the left hemisphere (the temporal lobe
  area) was performed. The MCA (M4 segment) was temporarily occluded (A)
  to perform left STA-MCA anastomosis (arrow in B). (C)
  Indocyanine green video-angiography demonstrated apparent patent bypass
  with the favorable distribution of bypass flow.. EDMS, encephalo-duro-myo-synangiosis; STA-MCA, superficial temporal
  artery-middle cerebral artery.
case_images: 10.1177_1756286419878343-fig2.jpg
case_images: PMC6764047_01_10.1177_1756286419878343-fig2.jpg
case_images: fig2-1756286419878343
case_images: Briefly, the patient underwent general anesthesia, during the temporary occlusion time (29 min) (Figure 2A), the stump of the frontal branch of STA was anastomosed to MCA (M4 segment) (arrow in Figure 2B). The patency of the bypass was promptly confirmed by indocyanine green video-angiography (Figure 2C).
case_images: (A) MRA showing the patency of left STA-MCA bypass 2 days after surgery
  (arrow). (B) CT 2 days after surgery showing
  low-density lesion at left frontotemporal lobes without subdural
  hematoma.. CT, computerized tomography; MRA, magnetic resonance angiography;
  STA-MCA, superficial temporal artery-middle cerebral artery.
case_images: 10.1177_1756286419878343-fig3.jpg
case_images: PMC6764047_01_10.1177_1756286419878343-fig3.jpg
case_images: fig3-1756286419878343
case_images: Magnetic resonance angiography (MRA) showed an apparently patent bypass (arrow in Figure 3A), while postoperative computerized tomography (CT) revealed a newly developed low-density region at left frontotemporal lobes (Figure 3B), as well as a hyperintensity area on T2-weighted magnetic resonance imaging (MRI) (Figure 4A, B), which led to the diagnosis of cerebral edema. The patient did not suffer from postoperative seizure and the mechanical compression by extra-axial lesion (such as subdural hematoma and compression by temporal muscle used for indirect bypass) have also been ruled out by CT (Figure 3B) and MRA scanning (Figure 4D, E, F).
case_images: Temporal profile of 123I-IMP-SPECT images and MRI.. Quantitative local CBF values (dotted circles) (A)
  before surgery, (B) 2 days after surgery, and (C) 15 days after surgery.
  Preoperative SPECT showing decreased CBF in left frontal, temporal,
  parietal and occipital lobes; combined bypass surgery resulted in
  prominent hypoperfusion at left frontotemporal lobes 2 days after
  surgery, which improved 15 days after surgery. High-signal-intensity
  lesion on T2-weighted magnetic resonance images (D) before surgery, (E)
  2 days after surgery, and (F) 15 days after surgery. Preoperative MRI
  showing no abnormal lesion at left frontotemporal lobes; combined bypass
  surgery resulted in prominent high-signal-intensity lesion on T2 left
  frontotemporal lobes 2 days after surgery, which improved 15 days after
  surgery. The low signal on T2 images of the sticking temporal muscle
  suggesting that there was no edema in temporal muscle and no obvious
  compression of brain tissue in the hypoperfusion area.. CBF, cerebral blood flow; MRI, magnetic resonance imaging; Pre-op,
  preoperative; POD, postoperative day; SPECT, single-photon emission
  computed tomography; STA-MCA, superficial temporal artery-middle
  cerebral artery.
case_images: 10.1177_1756286419878343-fig4.jpg
case_images: PMC6764047_01_10.1177_1756286419878343-fig4.jpg
case_images: fig4-1756286419878343
case_images: Magnetic resonance angiography (MRA) showed an apparently patent bypass (arrow in Figure 3A), while postoperative computerized tomography (CT) revealed a newly developed low-density region at left frontotemporal lobes (Figure 3B), as well as a hyperintensity area on T2-weighted magnetic resonance imaging (MRI) (Figure 4A, B), which led to the diagnosis of cerebral edema. Postoperative 123I N-isopropyl-p-iodoamphetamine single-photon emission computed tomography (123I-IMP-SPECT) showed relevant improvement of perfusion status at left parietal and occipital lobes [cerebral blood flow (CBF) value of 57.64 ml/min/100 g and 54.53 ml/min/100 g] than preoperative (39.76 ml/min/100 g and 35.41 ml/min/100 g), while a lower CBF at left frontotemporal lobes (14.88 ml/min/100 g) than preoperative (48.14 ml/min/100 g) (Figure 4C, D). The patient did not suffer from postoperative seizure and the mechanical compression by extra-axial lesion (such as subdural hematoma and compression by temporal muscle used for indirect bypass) have also been ruled out by CT (Figure 3B) and MRA scanning (Figure 4D, E, F).