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Abstract: The patient, a 44-year-old male, was admitted to the hospital with the chief complaint of “sudden onset of slurred speech for 13 days”, and after admission, whole brain angiography and MRI of the head were performed, and a clear diagnosis of smog syndrome was made. After communicating with the patient and his family, we decided to perform right superficial temporal artery-middle cerebral artery bypass grafting combined with temporal muscle patching and drug treatment, and the patient had a successful operation and recovered well after the operation.
Basic information】Male, 44 years old
Type of disease】Smoke syndrome
Hospital】Liaoning Provincial People’s Hospital
Date of consultation】April 2021
Treatment plan】Surgical treatment (right superficial temporal artery-middle cerebral artery bypass combined with temporal muscle patching) + drug treatment (furosemide injection, olanzapine injection)
Treatment period] 14 days in hospital
Treatment effect】Surgery was successful and postoperative recovery was good
I. Initial consultation
The patient was admitted to the hospital with the complaint of “sudden onset of slurred speech for 13 days”. At the time of admission, the patient had clear consciousness, speech impairment, grade 5 muscle strength of the right limb, grade 0 muscle strength of the left upper limb, and grade 3 muscle strength of the left lower limb. Magnetic resonance angiography showed that the right middle cerebral artery was mostly unrevealed, the superficial temporal artery entered the skull with sparse and slender branches, and the left middle cerebral artery was narrowed at the beginning of the branches; 3D-ASL showed that the right frontoparietal occipitotemporal perfusion was reduced; whole brain angiography showed that the bilateral anterior cerebral and left middle cerebral arteries were both locally narrowed. The right middle cerebral artery was occluded, and the vascular morphology was consistent with the morphology of smog syndrome, so the diagnosis of smog syndrome was made.
(Magnetic resonance angiography)
Treatment history
In this case, the patient was relatively young, with slurred speech and hemiparesis, and the family was very anxious, and both the family and the patient were very anxious when they learned that it was smog syndrome. Because of the patient’s poor congenital vascular condition, there was a risk of cerebral infarction at a later stage. After learning that surgery could be done to improve the patient’s symptoms, the family actively cooperated and improved the preoperative examination. The patient then underwent right superficial temporal artery-middle cerebral artery bypass surgery combined with temporal muscle patching, which is to isolate the right superficial temporal artery, reach the frontal branch of middle cerebral artery through the temporal muscle, perform end-lateral anastomosis, and at the same time, patch the temporal muscle to the surface of cerebral cortex, and the surgery went smoothly.
III. Treatment effect
Postoperative CTA examination of the patient’s head showed that the operation went smoothly and blood entered the middle cerebral artery through the superficial temporal artery. The patient had no adverse complaints after the operation and had a good postoperative recovery, and was discharged after the removal of stitches from the head. Six months later, the patient was admitted to the hospital for re-examination, and his mental state was clear, but his speech function was improved, the muscle strength of the right limb was grade 5, the muscle strength of the left upper limb was grade 2, and the muscle strength of the left lower limb was grade 3, all of which were improved. The re-examination of head MRI revealed that the right frontoparieto-occipitotemporal hypoperfusion area was reduced, and the patient could continue rehabilitation exercises.
IV. Notes
We are very happy that the patient was discharged after treatment. Since it takes 3 months to 6 months for the bypass vessel to be fully formed, brain hemorrhage and cerebral infarction can easily occur during this period, so we should eat a scientific diet, mainly high protein and liquid food, and eat more light and easily digestible food to prevent constipation. Monitor the changes of blood pressure and blood sugar every day, avoid bad habits, avoid staying up too late, do not smoke and drink alcohol, and pay attention to temperature changes to avoid catching a cold. At the same time, the patient’s family should also provide appropriate psychological guidance to help the patient establish confidence to overcome the disease.
V. Personal insight
Smoke syndrome is a chronic progressive vaso-occlusive disease of the cerebral arteries. During whole brain angiography, the small blood vessels that form these cerebral vessels look like “smoke clusters” on the angiographic image, so it is called “smoke syndrome”. The damage is mainly caused by cerebral infarction or cerebral hemorrhage. As in the case of this patient, if the abnormal manifestations were detected and the patient was seen in time and underwent early surgery, the consequences of aphasia and hemiparesis, which should not have been suffered by him, could have been avoided. Therefore, I recommend that we all add the sequence MRA to our first MRI, which can screen for many vascular diseases, in addition to smog syndrome, and aneurysms, etc., and can effectively help to rule out potential risks.