Emergency Superficial Temporal Artery to Middle Cerebral Artery Bypass after Intravenous Recombinant Tissue Plasminogen Activator Administration for Acute Cerebral Ischemia in a Patient with Moyamoya Disease

There are few study data to help in the decision whether to perform aggressive surgical revascularization, such as emergency bypass, after intravenous recombinant tissue plasminogen activator (rt-PA) administration in patients with progressive symptoms due to acute cerebral ischemia. A 33-year-old healthy male with no known previous medical history developed right hemiparesis and motor aphasia. No acute lesion was observed on admission computed tomography. According to the treatment protocol, emergency intravenous rt-PA administration was indicated within 3 h. After rt-PA administration, symptoms progressed to complete right hemiplegia. Emergency magnetic resonance imaging (MRI) showed an acute ischemic lesion in the left basal ganglia. MR angiography showed severe stenosis of the bilateral terminal portion of the internal carotid artery and occlusion of the left middle cerebral artery (MCA). Obvious diffusion-perfusion mismatch was detected. We performed digital subtraction angiography and diagnosed this condition as acute cerebral ischemia induced by moyamoya disease. We decided to perform emergency superficial temporal artery (STA)-MCA bypass to prevent further damage. The operation began 7 h after the administration of rt-PA and successful bypass was achieved. Symptoms stabilized and improved postoperatively. The majority of the area with preoperative hypoperfusion was rescued. Four months after surgery, the patient resumed his previous employment and continues to do well after 1.5 years of follow-up. This is the first report of emergency STA-MCA bypass performed after intravenous rt-PA administration for acute cerebral ischemia in a patient with moyamoya disease. We conclude that emergency STA-MCA bypass is a viable option for patients with moyamoya disease even after administration of rt-PA.