title: Delayed intracerebral hemorrhage after superficial temporal artery-middle cerebral artery anastomosis in a patient with moyamoya disease: possible involvement of cerebral hyperperfusion and increased vascular permeability.
abstract: BACKGROUND
  Postoperative intracerebral hemorrhage is a rare complication after surgical revascularization for moyamoya disease, and its mechanism is totally undetermined.
  
  
  METHODS
  A 47-year-old woman with moyamoya disease, experiencing crescendo transient ischemic attack on her left hand, underwent STA-MCA anastomosis on the right hemisphere. Postoperative MR imaging 1 day after surgery demonstrated asymptomatic vasogenic edema without ischemic change at the subcortex under the site of the anastomosis that expanded the next day, and STA-MCA bypass was apparently patent with the strong high signal by MR angiography. N-isopropyl-p-[(123)I]iodo-amphetamine single-photon emission CT showed marked increase in the CBF on the hemisphere operated on. Four days after surgery, the patient complained of sudden headache and experienced severe monoparesis in her left hand due to the intracerebral hemorrhage at the corresponding lesion to the prior vasogenic edema. Edema around hematoma was prolonged for as long as a month; while intensive blood pressure control and the use of adrenocorticosteroid gradually relieved her symptoms. The patient completely recovered from her symptoms 2 months later, and she was discharged without neurologic deficit. Her transient ischemic attacks completely disappeared postoperatively.
  
  
  CONCLUSIONS
  Early increase in CBF associated with vasogenic edema formation at the site of the anastomosis could be the warning sign for subsequent hemorrhagic complication, and intensive blood pressure control is warranted in such patients. Alternatively, it would be necessary to elucidate the biochemical mechanism of the deleterious cascade during reperfusion in moyamoya disease to avoid this rare complication.
authors.affiliation: Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan. fujimur@nsg.med.tohoku.ac.jp
authors.forename: Miki
authors.initials: M
authors.lastname: Fujimura
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Shimizu
authors.forename: Shunji
authors.initials: S
authors.lastname: Mugikura
authors.forename: Teiji
authors.initials: T
authors.lastname: Tominaga
mesh_terms: D000714:Anastomosis, Surgical / Q000009:adverse effects; D002199:Capillary Permeability / Q000502:physiology*; D002543:Cerebral Hemorrhage / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D002548:Cerebral Revascularization / Q000009:adverse effects*; D002560:Cerebrovascular Circulation / Q000502:physiology*; D005260:Female; D006801:Humans; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000601:surgery; D009072:Moyamoya Disease / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D013699:Temporal Arteries / Q000601:surgery; D013997:Time Factors