Treatment of ruptured cerebral aneurysm in moyamoya disease

Safety and effects of endovascular treatment of basilar tip aneurysms in patients with moyamoya diseases

The effect and safety of endovascular treatment of basilar tip aneurysms associated with moyamoya disease are unknown. This study was to investigate the safety and effect of endovascular treatment of basilar tip aneurysms associated with moyamoya disease. Patients with moyamoya disease concurrent with basilar tip aneurysms were retrospectively enrolled and treated with endovascular embolization. The clinical and angiographic data were analyzed. Thirty patients with a basilar tip aneurysm were enrolled, including 8 (26.67%) male and 22 (73.33%) female patients aged 38 to 72 years (mean 54.4 ± 8.15). Endovascular treatment was successfully performed in 29 (96.67%) patients but failed in 1 (3.33%). Immediately after embolization, aneurysm occlusion degree was Raymond-Roy grade I in 26 (89.66%), grade II in 2 (6.90%), and grade III in 1 (3.45%). Intraprocedural complications occurred in 2 (10%) patients, including aneurysm rupture in 1 (3.33%), leading to death of the patient, and stent thrombosis in 2 (6.67%) which was successfully treated with thrombolysis. At discharge, good clinical outcome (modified Rankin Scale 0-2) was achieved in 29 (96.67%) and death in 1 (3.03%). Follow-up was performed 6 to 26 months (median 15) in 27 (93.1%) patients. Aneurysm occlusion degree was Raymond-Roy grade I in 21 (77.78%) patients, grade II in 4 (14.81%), and grade III in 2 (7.41%), not significantly (P = .67) different from those immediately after embolization. Aneurysm recurrence was found in 4 patients (14.81%). The clinical outcome was modified Rankin Scale 0 to 2 in all 27 patients, not significantly different from that at discharge. Endovascular embolization can be performed safely and effectively for basilar tip aneurysms associated with moyamoya disease even though more advanced embolization techniques are necessary.

Management of non-vestibular schwannomas in adult patients: a systematic review and consensus statement on behalf of the EANS skull base section. Part I: oculomotor and other rare non-vestibular schwannomas (I, II, III, IV, VI)

BACKGROUND

Non-vestibular schwannomas are relatively rare, with trigeminal and jugular foramen schwannomas being the most common. This is a heterogeneous group which requires detailed investigation and careful consideration to management strategy. The optimal management for these tumours remains unclear, and there are several controversies. The aim of this paper is to provide insight into the main principles defining management and surgical strategy, in order to formulate a series of recommendations.

METHODS

A task force was created by the EANS skull base section along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumours on a European perspective. To achieve this, the task force performed an extensive systematic review in this field and had discussions within the group. This article is the first of a three-part series describing non-vestibular schwannomas (I, II, III, IV, VI).

RESULTS

A summary of literature evidence was proposed after discussion within the EANS skull base section. The constituted task force dealt with the practice patterns that exist with respect to pre-operative radiological investigations, ophthalmological assessments, optimal surgical and radiotherapy strategies and follow-up management.

CONCLUSION

This article represents the consensually derived opinion of the task force with respect to the treatment of non-vestibular schwannomas. For each of these tumours, the management of these patients is complex, and for those which are symptomatic tumours, the paradigm is shifting towards the compromise between function preservation and progression-free survival.

Management of non-vestibular schwannomas in adult patients: a systematic review and consensus statement on behalf of the EANS skull base section Part II: Trigeminal and facial nerve schwannomas (CN V, VII)

BACKGROUND

Non-vestibular schwannomas are relatively rare, with trigeminal and jugular foramen schwannomas being the most common. This is a heterogenous group which requires detailed investigation and careful consideration to management strategy. The optimal management for these tumours remains unclear and there are several controversies. The aim of this paper is to provide insight into the main principles defining management and surgical strategy, in order to formulate a series of recommendations.

METHODS

A task force was created by the EANS skull base section committee along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumours on a European perspective. To achieve this, the task force performed an extensive systematic review in this field and had discussions within the group. This article is the second of a three-part series describing non-vestibular schwannomas (V, VII).

RESULTS

A summary of literature evidence was proposed after discussion within the EANS skull base section. The constituted task force dealt with the practice patterns that exist with respect to pre-operative radiological investigations, ophthalmological assessments, optimal surgical and radiotherapy strategies, and follow-up management.

CONCLUSION

This article represents the consensually derived opinion of the task force with respect to the treatment of trigeminal and facial schwannoma. The aim of treatment is maximal safe resection with preservation of function. Careful thought is required to select the appropriate surgical approach. Most middle fossa trigeminal schwannoma tumours can be safely accessed by a subtemporal extradural middle fossa approach. The treatment of facial nerve schwannoma remains controversial.

Clinical features and prognostic analysis of moyamoya disease associated with intracranial aneurysms

OBJECTIVES

To explore clinical features and compare of the difference between conservative treatment and surgical treatmentin prognosis of intracranial aneurysms associated with moyamoya disease (MMD).

METHODS

104 patients with MMD a ssociated with intracranial aneurysms diagnosed by digital subtraction angiography (DSA) or computed tomography angiography (CTA) were retrospectively analyzed.

RESULTS

All patients of MMD with intracranial aneurysms had 129 aneurysms distributed at different sites. The distribution of the aneurysms was as follows: 28(21.71%) anterior communicating artery aneurysms, 21(16.28%) basilar artery aneurysms, 19(14.73%) middle cerebral artery aneurysms, 17(13.18%) posterior cerebral artery aneurysms, 12(9.30%)internal carotid artery aneurysms, 11(8.53%) posterior communicating artery aneurysms, 10(7.75%) anterior cerebral artery aneurysms, 5(3.88%) anterior choroidal artery aneurysms, 2(1.55%) moyamoya vessel aneurysms, and 4(3.1%) other location aneurysms. 82 cases (78.85%) had one aneurysm, and 21 cases (20.19%) had 2 or more aneurysms. 64 cases were treated surgically, and 40 cases were treated conservatively. 57 of 81 cases (70.37%) had a good outcome, 2 cases (2.47%) were in paralyzed, and 22 cases were died. The mortality rate was (27.16%). Death occurred in 16 (47.06%) of 34 patients with conservative treatment, and 6(12.77%) of 47 patients with surgical treatment. 7 cases (8.64%) had twice cerebral hemorrhage, and one case (1.23%) had third cerebral hemorrhage in the follow-up period. There were 5 deaths, two good outcomes, and one coma among 8 cases experienced re-hemorrhage.

CONCLUSION

Compared with conservative treatment, positive surgical treatment showed clinical significance for preventing cerebral hemorrhage and reducing mortality of MMD with intracranial aneurysms.

ABBREVIATIONS

MMD: moyamoya disease; DSA: digital subtraction angiography; CTA: computed tomography angiography.

Location-based treatment of intracranial aneurysms in moyamoya disease: a systematic review and descriptive analysis

We conducted a systematic review of the literature to evaluate the efficacy of various treatment modalities for intracranial aneurysms (IA) in patients with moyamoya disease (MMD) based on anatomical location of IA. A comprehensive review of studies documenting single cases or series of MMD patients with concomitant IA was conducted. Aneurysms were classified into two primary anatomical categories: those of the Circle of Willis (CoW) and those of peripheral "moyamoya" collateral vessels. Conservative, endovascular, and open surgical treatment modalities and their outcomes between each anatomical subgroup were descriptively compared. A total of 124 studies consisting of 275 patients with 313 IA were included. Of all IA, 59.6% were located on CoW vessels, 33.7% on peripheral vessels, and 6.7% in "other" locations. Of all CoW IA, 87.2% treated with endovascular techniques had no or minimal deficit at follow-up as compared with 56.7% of those treated with open surgery. Ninety-five percent of patients with peripheral aneurysms treated with endovascular therapy had no or minimal deficit, in contrast to open surgery (69.6%). Of peripheral IA treated conservatively with or without revascularization, 65.7% had spontaneous resolution as compared with 12.0% IA of the CoW. Our results support the use of endovascular techniques for direct treatment of both CoW and peripheral IA. Aneurysms of peripheral vessels respond well to indirect treatment through surgical revascularization as opposed to CoW aneurysms. The quality of evidence is limited due to heterogeneity of included studies and IA management in MMD patients should be considered in a case-specific manne.

Intracranial Aneurysms in White Patients with Moyamoya Disease: A U.S. Single-Center Case Series and Review

BACKGROUND

Intracranial aneurysms (IA) are associated with moyamoya disease (MMD). There are no clinically tested treatment guidelines. Reporting of cases is vital to better understand the underlying pathophysiology and potential ethnic predispositions and improve patient selection for intervention.

METHODS

Records of all patients diagnosed with MMD with concomitant IA who presented to our institution were retrospectively reviewed. Data related to demographic, clinical, MMD characteristics, aneurysm characteristics, surgical intervention, and follow-up were collected from the records of each patient. Aneurysm location was categorized into circle of Willis (CoW) aneurysms (originating from the CoW or its major branches) and peripheral aneurysms (arising from choroidal or lenticulostriate arteries).

RESULTS

Ten patients were found to have a total of 14 IA. All patients were white. Ten aneurysms (71%) were classified as CoW aneurysms and 4 (29%) were classified as peripheral. Seven of 10 CoW aneurysms (70%) were located in the anterior circulation, whereas 3 (30%) were located in the posterior circulation. Aneurysms of anterior and posterior circulations were most commonly treated with coil embolization, whereas peripheral artery aneurysms were most commonly treated with either cerebral revascularization alone or aneurysm excision.

CONCLUSIONS

Revascularization surgery seems to be an effective method of indirectly treating IA in patients with MMD. Previous literature in addition to our series shows that endovascular embolization is safe and efficacious in treating IA of most locations in patients with MMD. The use of open microsurgery for direct aneurysm treatment in this population poses many challenges.

Embolization of a peripheral cerebral aneurysm associated with intracranial major artery occlusion through a transdural anastomotic artery: Case report

A peripheral cerebral aneurysm is known to develop at collateral vessels as a result of hemodynamic stress by the occlusion of the intracranial major arteries. We report a case of successful embolization of a ruptured aneurysm through a transdural anastomotic artery. The aneurysm formed at the developed collateral vessel from the meningeal branch of the occipital artery (OA) to the posterior pericallosal artery. A 59-year-old man presented with acute-onset headache, and computed tomography revealed subarachnoid hemorrhage and intracerebral hemorrhage at the splenium of the corpus callosum with intraventricular hemorrhage. Digital subtraction angiography demonstrated a ruptured aneurysm located at a transdural anastomotic artery from the right OA to the posterior pericallosal artery. The patient underwent endovascular treatment for the aneurysm through the transdural anastomotic artery with a coil and n-butyl-2-cyanoacrylate. Because it was impossible to navigate a microcatheter to the aneurysm through the right anterior cerebral artery because of the occlusion of its proximal portion, it was advanced through the transdural anastomosis from the right OA. The aneurysm was completely occluded without complications. Endovascular embolization is a useful treatment option for a peripheral cerebral aneurysm developed at a collateral vessel with intracranial major artery occlusion.

Treatment of aneurysms in patients with moyamoya disease: a 10-year single-center experience

OBJECTIVE

Moyamoya disease (MMD) is occasionally accompanied by intracranial aneurysms. The purpose of this study was to delineate the efficacy of the authors’ current surgical strategy in the management of MMD-associated aneurysms of different types.

METHODS

Between January 2007 and March 2016, a consecutive cohort of 34 patients with 36 MMD-associated aneurysms was enrolled in this prospective single-center cohort study. The lesions were classified as peripheral (17 aneurysms) or main trunk aneurysms (13 in the anterior circulation and 6 in the posterior circulation). For the peripheral aneurysms, revascularization with or without endovascular treatment was suggested. For the main trunk aneurysms, revascularization alone, revascularization with aneurysm clipping, or revascularization with aneurysm embolization were used, depending on the location of the aneurysms.

RESULTS

Of the peripheral aneurysms, 4 were treated endovascularly with staged revascularization, and 13 were treated solely with cerebral revascularization. Of the 13 main trunk aneurysms in the anterior circulation, 10 were clipped followed by revascularization, and 3 were coiled followed by staged cerebral revascularization. Of the 6 main trunk aneurysms in the posterior circulation, 4 underwent endovascular coiling and 2 were treated solely with revascularization. One patient died of contralateral intracerebral hemorrhage 6 months after the operation. No other patients suffered recurrent intracranial hemorrhage, cerebral ischemia, or aneurysm rupture. An angiographic follow-up study showed that all the bypass grafts were patent. Complete occlusion was achieved in all 21 aneurysms that were clipped or embolized. Of the remaining 15 aneurysms that were not directly treated, 12 of 13 peripheral aneurysms were obliterated during the follow-up, whereas 1 remained stable; 1 of 2 posterior main trunk aneurysms remained stable, and the other became smaller.

CONCLUSIONS

The authors’ current treatment strategy may benefit patients with MMD-associated aneurysms.

Embolization with NBCA for Ruptured Aneurysm Located in the Moyamoya-like Collateral Network Associated with Isolated Middle Cerebral Artery Occlusion

Collateral vessel formation in moyamoya disease is a well-described phenomenon. However, the occurrence of unusual anastomosis pattern (moyamoya-like) associated with isolated middle cerebral artery (MCA) stenosis or occlusion has been reported very rarely and is not well known the relationship with aneurysm. We report a case of ruptured aneurysm treated with N-butyl cyanoacrylate (NBCA) located in moyamoya like collateral network with isolated MCA occlusion.

Ruptured posterior ethmoidal artery aneurysm and Moyamoya disease in an adult patient. Case report

The association between Moyamoya disease and intracranial aneurysms is well described. In our case, we describe a unique aneurismal location and its management. We report the case of a 74-year-old woman affected by a Moyamoya disease who displayed a frontal lobe hematoma. The origin of the bleeding came from the rupture of a posterior ethmoidal artery aneurysm that was treated surgically with favourable outcome. This case of a ruptured posterior ethmoidal artery aneurysm in a Moyamoya patient illustrates the polymorphism of the vascular complications encountered in this disease. It stresses the need to obtain information from an angiographic investigation in order to select the best therapeutic option and to reduce procedural complications.

Treatment strategies for aneurysms associated with moyamoya disease

The treatment of aneurysms associated with moyamoya disease (MMD) is difficult for neurosurgeons, and little is known of strategy options. This report constitutes a comprehensive review of the literature. We summarize the known treatments and their clinical outcomes according to the site of the aneurysm: in major arteries, peripheral arteries, moyamoya vessels, meningeal arteries, or at the site of anastomosis. The literature review indicates that the treatment of MMD-associated aneurysms varies according to the site of the aneurysm and its hemodynamic characteristics. In particular, the treatment for basilar tip aneurysms remains challenging, since both endovascular embolization and direct clipping are difficult. The potential risk for ischemia should be considered in selecting endovascular or surgical approaches. Revascularization surgery, which is important for the treatment of MMD, also determines the clinical treatment outcome of aneurysms associated with MMD.

Aneurysmal remodeling in the circle of Willis after carotid occlusion in an experimental model

Carotid occlusions are associated with de novo intracranial aneurysm formation in clinical case reports, but this phenomenon is not widely studied. We performed bilateral carotid ligation (n=9) in rabbits to simulate carotid occlusion, and sham surgery (n=3) for control. Upon euthanasia (n=3 at 5 days, n=6 at 6 months post ligation, and n=3 at 5 days after sham operation), vascular corrosion casts of the circle of Willis (CoW) were created. Using scanning electron microscopy, we quantified gross morphologic, macroscopic, and microscopic changes on the endocasts and compared findings with histologic data. At 5 days, CoW arteries of ligated animals increased caliber. The posterior communicating artery (PCom) increased length and tortuosity, and the ophthalmic artery (OA) origin presented preaneurysmal bulges. At 6 months, calibers were unchanged from 5 days, PComs further increased tortuosity while presenting segmental dilations, and the OA origin and basilar terminus presented preaneurysmal bulges. This exploratory study provides evidence that flow increase after carotid occlusion produces both compensatory arterial augmentation and pathologic remodeling such as tortuosity and saccular/fusiform aneurysm. Our findings may have considerable clinical implications, as these lesser-known consequences should be considered when managing patients with carotid artery disease or choosing carotid ligation as a therapeutic option.

Moyamoya disease associated with basilar tip aneurysm

Direct surgical intervention to treat ruptured basilar tip aneurysms in patients with moyamoya disease has rarely been attempted, and patients who have undergone such treatment have not fully recovered. We review six cases of surgically treated ruptured basilar tip aneurysm associated with moyamoya disease, including our own case to illustrate aspects of surgical intervention and the difficulties encountered. Patients who underwent surgery after 4 weeks of the onset of symptoms showed impressive results. Of the patients who underwent surgery in the acute stage, two died, including our patient, and one showed excellent recovery. It is emphasized that to achieve satisfactory surgical outcome, the following factors should be considered: (i) delayed operation is preferable, with extracranial-intracranial bypass in selected patients; (ii) careful preservation of moyamoyas and transdural collaterals is mandatory; (iii) intraoperative rupture of the aneurysm should be avoided; and (iv) using a neuroanaesthetic technique of induced hypothermia and hypertension may be preferable.

Incidental major artery aneurysms in patients with non-hemorrhagic moyamoya disease

BACKGROUND

Major artery aneurysms may be found incidentally while evaluating moyamoya disease (MMD). The purpose of this study was to delineate the prevalence and characteristics of these uncommon aneurysms with a brief mention of their management and outcomes.

METHODS

We conducted a retrospective review of 249 adult patients who were diagnosed with non-hemorrhagic MMD. Cerebral angiograms obtained at the time of initial diagnosis were carefully reviewed to identify incidental aneurysms located on a major intracranial artery or near its tributaries. Aneurysms originating from distal peripheral arteries or moyamoya vessels were ineligible for this study.

RESULTS

Nine patients (3.6%) were found to have 13 major artery aneurysms, 7 (54%) of which were located in the posterior circulation, especially in older patients with bilateral MMD. The sizes of all aneurysms were less than 10 mm. Surgical clipping was performed on two aneurysms, and endovascular coiling on six (five posterior circulation aneurysms). Ischemic complications occurred in two patients after clipping of an anterior communicating artery aneurysm and in one patient after the second coiling of a recanalized basilar tip aneurysm.

CONCLUSIONS

Incidental major artery aneurysms can be found in 3.6% of adult patients with non-hemorrhagic MMD, an observed frequency that increases with age. About half of these aneurysms are located in the posterior circulation, particularly in older patients with bilateral MMD. Considering the risks of treatment-related complications, more information about the natural course of these aneurysms is needed to design proper management strategies both for the aneurysms and MMD.

Paradoxical association of moyamoya syndrome with large middle cerebral artery aneurysm and subarachnoid hemorrhage. Case report

A 69-year-old woman was admitted to our hospital because of fluctuating dysarthria during the past 2 months. Magnetic resonance imaging revealed old cerebral infarction of the left cerebral hemisphere with acute subarachnoid hemorrhage in the left sylvian fissure. Cerebral angiography showed a large saccular aneurysm, 14 mm in diameter, at the bifurcation of the left middle cerebral artery (MCA) in association with moyamoya vasculopathy with atherosclerosis, including steno-occlusive changes at the bilateral terminal internal carotid arteries and abnormal net-like vessels at the base of the brain. She underwent microsurgical neck clipping of the large aneurysm followed by superficial temporal artery-MCA anastomosis without complication. Intraoperative findings showed no evidence of aneurysm rupture, suggesting that the subarachnoid hemorrhage was due to the intrinsic pathology of moyamoya vasculopathy. The postoperative course was uneventful, and the patient was discharged without neurological deficit. Association of moyamoya syndrome with large MCA aneurysm is extremely rare, and formation of large aneurysm at the vascular territory of an occluded vessel is apparently unique.

Endovascular treatment of intracranial aneurysms associated with moyamoya disease or moyamoya syndrome

Direct surgical clipping proves to be difficult and dangerous for intracranial aneurysms associated with moyamoya disease (MMD) or moyamoya syndrome (MMS). This study presents our clinical experience of endovascular embolization of intracranial aneurysms associated with these diseases. A total of 13 cases of intracranial aneurysms associated with MMD or MMS were treated by endovascular embolization between January 2001 and January 2009. Patients were divided into two groups: a saccular aneurysm group (n=10) and a pseudoaneurysm group (n=3). Different endovascular therapeutic strategies were employed for each type of case. Of the 13 cases, 11 received successful endovascular embolization and had an uneventful postoperative course during one to two years of follow-up. However, endovascular embolization failed in the other two cases, of whom one died from rebleeding after the five-month follow-up, while the other was conservatively treated and experienced no rebleeding during the two-year follow-up. A favorable prognosis may be secured through careful selection of endovascular treatment regimens for patients with intracranial aneurysms associated with MMD or MMS according to the site of intracranial aneurysms.

Treatment of ruptured lenticulostriate artery aneurysms

OBJECT

Lenticulostriate artery (LSA) aneurysms are rarely reported in the literature, making management decisions challenging. Conservative, endovascular, and surgical treatments have been described primarily through case reports and reports of individual authors' experiences. The purpose of this study is to report neurological outcomes in a single-institution experience of ruptured lenticulostriate aneurysms treated surgically.

METHODS

The authors have conducted a retrospective review of all cases involving patients with ruptured LSA aneurysms who presented to the Mt. Sinai Hospital neurosurgical service between September 2001 and January 2007.

RESULTS

Over 5.4 years, the authors treated 6 patients with 7 LSA aneurysms-6 ruptured and 1 unruptured. The Hunt and Hess grade on admission ranged from I to IV, with subarachnoid hemorrhage in 5 of the 6 patients. Catheter angiography confirmed the presence of the aneurysms, and all patients underwent a pterional craniotomy and clipping or resection of the aneurysm, performed by a single surgeon. Associated risk factors in our series of patients included hypertension, cocaine abuse, and intracranial occlusive disease suggestive of moyamoya disease. Two types of LSA aneurysms were identified. The mean size of the 6 ruptured aneurysms was 3.2 mm. The LSA was preserved in 3 of 6 patients, but LSA preservation did not correlate with development of a postoperative infarct, clinically or radiologically. In patients with ruptured aneurysms, the mean modified Rankin Scale score at discharge was 1.7. The 3 patients in whom the LSA was sacrificed had good outcomes, suggesting that loss of the artery is clinically well tolerated.

CONCLUSIONS

This case series demonstrates that surgical treatment of ruptured LSA aneurysms can be an appropriate, effective, and safe therapy.

Intracranial aneurysms associated with other lesions, disorders or anatomic variations

Intracranial aneurysms (IAs) can be related to or associated with some vascular anatomic variations, lesions, diseases, or systemic disorders in which a causative or predisposing factor(s) in aneurysm formation can be identified. This article includes flow-related, infectious, traumatic iatrogenic, and neoplastic aneurysms and aneurysms related to systemic disorders and drug abuse. In some conditions, IAs associated with other disorders are true aneurysms. Most of them, however, are false aneurysms. Characteristics and management of these unusual aneurysms are discussed.

Endovascular treatment of posterior cerebral aneurysm associated with moyamoya disease

PURPOSE

A patient with moyamoya disease associated with a ruptured posterior cerebral artery aneurysm treated by endovascular embolization is presented.

CASE REPORT

A 47-year-old woman was admitted with severe headache to our hospital. Computed tomography demonstrated subarachnoid haemorrhage. Cerebral angiography revealed evidence of moyamoya disease and a saccular aneurysm at the P1 segment of the left posterior cerebral artery.

CONCLUSION

Endovascular embolization was performed using Guglielmi detachable coil (GDC), and the aneurysm was completely occluded with preservation of the parent artery. Endovascular treatment using GDC seems comparatively safe and effective for the treatment of cerebral saccular aneurysms in patients with moyamoya disease.

Intraaneurysmal embolization of an unruptured basilar tip aneurysm associated with moyamoya disease

We describe a patient with moyamoya disease associated with an unruptured basilar tip aneurysm which was treated by endovascular embolization using Guglielmi detachable coils (GDCs). A 53-year-old man presented with left hemiparesis persisting for 3 mon ths before admission. Cerebral angiography revealed occlusion of the bilateral middle cerebral arteries and the left anterior cerebral artery, stenosis of the right anterior cerebral artery, and basal moyamoya vessels. In addition, a saccular small aneurysm was seen at the top of the basilar artery. The aneurysm was completely embolized by intraaneurysmal GDCs. Direct surgical clipping is often selected for the treatment of posterior fossa aneurysms in moyamoya disease. However, complete clipping is usually difficult due to the difficulties in operative technique associated with moyamoya disease. We suggest that the endovascular treatment using GDCs is comparatively safe and effective for the treatment of surgically difficult aneurysms in patients with moyamoya disease.

Endovascular treatment of a lenticulostriate artery aneurysm with N-butyl cyanoacrylate

BACKGROUND

Aneurysms arising from lenticulostriate artery branches in moyamoya-type disease are challenging lesions to treat, due to their fragility and deep location. Surgery is difficult and endovascular options may be limited.

METHODS

A 57-year-old woman presented with a right ganglionic parenchymal hemorrhage due to a ruptured lenticulostriate artery aneurysm associated with ipsilateral middle cerebral artery occlusion. The aneurysm and parent feeding artery were occluded using endovascular injection of N-butyl cyanoacrylate.

RESULTS

The aneurysm was successfully obliterated and although some glue did enter the more distal middle cerebral artery, there was no change in the patient's neurologic status.

CONCLUSIONS

In highly selected cases where lenticulostriate aneurysms cannot be directly accessed for surgery or endovascular coiling, obliteration with liquid acrylic glue may be considered as a therapeutic option.

Distal anterior choroidal artery aneurysm in a patient with moyamoya disease: case report

OBJECTIVE AND IMPORTANCE

Distal anterior choroidal artery (AChA) aneurysms in moyamoya disease are rare, with few surgically verified reported cases.

CLINICAL PRESENTATION

We report a rare case of distal AChA aneurysm associated with moyamoya disease in a 48-year-old man who presented with vomiting and severe headache. Computed tomographic scans revealed an intracerebral hematoma in the right temporoparietal lobe and a diffuse intraventricular hemorrhage.

INTERVENTION

The hematoma was removed via computed tomography-guided stereotactic aspiration and ventricular drainage. Cerebral angiography showed a saccular aneurysm located at the distal branch of the right AChA. By means of magnetic resonance imaging, a small signal void lesion was detected in the periventricular area lateral to the trigone of the right lateral ventricle. The aneurysm was accurately accessed via a parietal cortical incision by use of magnetic resonance imaging-guided stereotactic localization. The aneurysm was successfully resected after undergoing trapping of the parent artery, and when the patient was discharged, he had no evidence of neurological deficit. The aneurysm was histologically verified to be a true aneurysm.

CONCLUSION

Direct surgery should be considered in cases of ruptured distal AChA aneurysms located in the periventricular or intraventricular regions.

Long-term natural history of hemorrhagic moyamoya disease in 42 patients

OBJECT

The purpose of this study was to delineate the long-term natural history of hemorrhagic moyamoya disease (MMD).

METHODS

A retrospective review was conducted among 42 patients suffering from hemorrhagic MMD who had been treated conservatively without bypass surgery. The group included four patients who had undergone indirect bypass surgery after an episode of rebleeding. The follow-up period averaged 80.6 months. The clinical features of the first bleeding episode and repeated bleeding episodes were analyzed to determine the risk factors of rebleeding and poor outcome. Intraventricular hemorrhage with or without intracerebral hemorrhage was a dominant finding on computerized tomography scans during the first bleeding episode in 29 cases (69%). During the follow-up period, 14 patients experienced a second episode of bleeding, which occurred 10 years or longer after the original hemorrhage in five cases (35.7%). The annual rebleeding rate was 7.09%/person/year. The second bleeding episode was characterized by a change in which hemisphere bleeding occurred in three cases (21.4%) and by the type of bleeding in seven cases (50%). After rebleeding the rate of good recovery fell from 45.5% to 21.4% and the mortality rate rose from 6.8% to 28.6%. Rebleeding and patient age were statistically significant risk factors of poor outcome. All four patients in whom there was indirect revascularization after the second bleeding episode experienced a repeated bleeding episode within 8 years.

CONCLUSIONS

The occurrence of rebleeding a long time after the first hemorrhagic episode was not uncommon. Furthermore, the change in which hemisphere and the type of bleeding that occurred after the first episode suggested the difficulty encountered in the prevention of repeated hemorrhage.