title: Color-coded digital subtraction angiography in the management of a rare case of middle cerebral artery pure arterial malformation. A technical and case report.
abstract: The advent of flow dynamics and the recent availability of perfusion analysis software have provided new diagnostic tools and management possibilities for cerebrovascular patients. To this end, we provide an example of the use of color-coded angiography and its application in a rare case of a patient with a pure middle cerebral artery (MCA) malformation. A 42-year-old male chronic smoker was evaluated in the emergency room due to sudden onset of severe headache, nausea, vomiting and left-sided weakness. Head computed tomography revealed a right basal ganglia hemorrhage. Cerebral digital subtraction angiography (DSA) showed a right middle cerebral artery malformation consisting of convoluted and ectatic collateral vessels supplying the distal middle cerebral artery territory-M1 proximally occluded. An associated medial lenticulostriate artery aneurysm was found. Brain single-photon emission computed tomography with and without acetazolamide failed to show problems in vascular reserve that would indicate the need for flow augmentation. Twelve months after discharge, the patient recovered from the left-sided weakness and did not present any similar events. A follow-up DSA and perfusion study using color-coded perfusion analysis showed perforator aneurysm resolution and adequate, albeit delayed perfusion in the involved vascular territory. We propose a combined congenital and acquired mechanism involving M1 occlusion with secondary dysplastic changes in collateral supply to the distal MCA territory. Angiographic and cerebral perfusion work-up was used to exclude the need for flow augmentation. Nevertheless, the natural course of this lesion remains unclear and long-term follow-up is warranted.
authors.affiliation: Department of Surgery-Neurosurgery Section, University of Puerto Rico-Medical Sciences Campus; San Juan, Puerto Rico - Neuroendovascular Surgery and Stroke Program, Puerto Rico Medical Services Administration; San Juan, Puerto Rico - caleb.feliciano@upr.edu.
authors.forename: Caleb E
authors.initials: CE
authors.lastname: Feliciano
authors.affiliation: Department of Surgery-Neurosurgery Section, University of Puerto Rico-Medical Sciences Campus; San Juan, Puerto Rico.
authors.forename: Eva
authors.initials: E
authors.lastname: Pamias-Portalatin
authors.affiliation: Neuroendovascular Surgery and Stroke Program, Puerto Rico Medical Services Administration; San Juan, Puerto Rico.
authors.forename: Jorge
authors.initials: J
authors.lastname: Mendoza-Torres
authors.affiliation: Neuroendovascular Surgery and Stroke Program, Puerto Rico Medical Services Administration; San Juan, Puerto Rico.
authors.forename: Euclides
authors.initials: E
authors.lastname: Effio
authors.affiliation: University District Hospital; San Juan, Puerto Rico.
authors.forename: Yadira
authors.initials: Y
authors.lastname: Moran
authors.affiliation: Department of Surgery-Neurosurgery Section, University of Puerto Rico-Medical Sciences Campus; San Juan, Puerto Rico - Neuroendovascular Surgery and Stroke Program, Puerto Rico Medical Services Administration; San Juan, Puerto Rico.
authors.forename: Rafael
authors.initials: R
authors.lastname: Rodriguez-Mercado
mesh_terms: D000328:Adult; D015901:Angiography, Digital Subtraction / Q000379:methods*; D020145:Basal Ganglia Hemorrhage / Q000000981:diagnostic imaging / Q000628:therapy; D020785:Central Nervous System Vascular Malformations / Q000000981:diagnostic imaging* / Q000628:therapy*; D002533:Cerebral Angiography; D003116:Color; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D008297:Male; D020768:Middle Cerebral Artery / Q000002:abnormalities* / Q000000981:diagnostic imaging*; D012907:Smoking / Q000009:adverse effects; D015899:Tomography, Emission-Computed, Single-Photon; D014057:Tomography, X-Ray Computed; D057832:Watchful Waiting
chemical_list: D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors
keywords: arterial malformation; color-coded angiography; intracerebral hemorrhage