A 58-year-old Hispanic man with a history of coronary artery disease and three episodes of strokes with residual left upper and lower extremity weakness presented to our facility with a new onset left-sided facial droop. He reported facial numbness, dysarthria, and blurred vision. His neurological examination revealed left-sided facial droop, positive pronator drift, and left-sided hemiparesis, as well as positive left Babinski sign. Brain magnetic resonance imaging (MRI) without contrast described a patchy region of acute ischemia in the mid and posterior right frontal lobe, predominantly peripherally and cortically based, measuring 3.8 cm x 3 cm (Figure ).\nNeck and head computed tomography (CT) angiography revealed bilateral supraclinoid ICA occlusions (Figure ).\nCerebral angiography demonstrated diffuse intracranial vascular irregularity with stenosis, more pronounced above the bilateral supraclinoid ICAs and on the right middle cerebral artery (MCA) (Figure ).\nImaging findings were suggestive of moyamoya phenomenon. Superficial temporal artery (STA)-MCA vascular bypass was not an option due to the lack of right MCA patency. Therefore, he underwent right-sided EDAS procedure. STA was dissected inferiorly to see it at just above the root of the zygoma. Superiorly, three branches were identified: one frontally, one temporally, and one superiorly. Even after full dissection, the STA was still not completely movable. The smallest posterior branch was bipolared and cut, and therefore there was more mobility in the STA. The other branches were all dopplerable. The STA was then again dissected completely free and moved anteriorly. Subperiosteal dissection was done. A perforator drill was used to makde a bur hole at the superior portion of the incision, and then one at the inferior portion of incision along the course of the STA. The burr holes were connected with a footplate, and the bone was removed in one piece. The dura was tented up and opened. The STA was brought on top of the brain. There was still some tension on the STA. Therefore, STA was further dissected at the level of the root of zygoma and at the superior branches. There was still tension on the STA, and therefore again it was dopplered inferiorly and superiorly. The frontal branch of the STA was bipolared and cut. At this point, the STA was completely free superiorly and inferiorly with good Doppler signals superiorly and inferiorly. The STA was brought in and laid down on top of the brain. The STA was on top of the pia without tension. No complications noted intraoperatively. Postoperatively, his facial droop gradually improved, but the residual left-sided weakness remained unchanged. He was discharged home with levetiracetam and aspirin. Follow-up of nine months later revealed no evidence of new stroke recurrence.
A 36 year old African American female presented to the Out Patient Office with headache which was on and off for last 4–6 months. The headache presented was of piercing type with moderate intensity not relieved by butalbital, acetaminophen. It was associated with weakness on right hand side for last few days, which evolved into dizziness and speech difficulty. There was no associated fever, night sweats, loss of consciousness, vomiting, ataxia, photophobia, tingling, numbness, difficulty swallowing, difficulty hearing, neck stiffness, vision problems. Her family history was significant for hypertension, diabetes and coronary artery disease. General physical examination showed no abnormalities. She is obese with BMI of 36.4; Vitals include [Heart Rate = 93/min, Blood Pressure = 165/75 mm Hg, Temp. = 36.67°C, Resp. Rate = 18/min]. Neurological examination showed intact 2–12 cranial nerve function, motor strength grossly intact with strength 3/5 on the right side of hand. No pronator drift, normal muscular tone, and gait was normal. Laboratory investigations, complete blood count, electroencephalogram and echocardiogram were normal.\nA CT angiogram head with contrast shows one sagittal [\n] and two axial views [\n,\n] at the level of the lateral ventricle and Circle of Willis, demonstrate mild proliferation of collateral vessels emanating from the distal internal carotid artery particularly on the left side. In addition, the visualized portion of the distal internal carotid artery and M1 segment of the left middle cerebral arteries appeared somewhat diminutive in caliber. Findings were generally compatible with progressive vascular occlusive process which can be seen in Moyamoya disease.\nSince the patient was refractory to the pain medications, surgical revascularization was done and the procedure involved left superficial temporal artery-left middle cerebral artery bypass without any complications. Following surgery, she was prescribed 81mg aspirin and discharged home and was followed up initially after surgery once every three months for one year followed by every 6 months for next four years. She did not complain of any headaches or focal neurological symptoms.