Endoport-Assisted Microsurgical Treatment of a Ruptured Periventricular Aneurysm

Abstract

Background and Importance. Ruptured periventricular aneurysms in patients with moyamoya disease represent challenging pathologies. The most common methods of treatment include endovascular embolization and microsurgical clipping. However, rare cases arise in which the location and anatomy of the aneurysm make these treatment modalities particularly challenging. Clinical Presentation. We report a case of a 34-year-old female with moyamoya disease who presented with intraventricular hemorrhage. CT angiography and digital subtraction angiography revealed an aneurysm located in the wall of the atrium of the right lateral ventricle. Distal endovascular access was not possible, and embolization risked the sacrifice of arteries supplying critical brain parenchyma. Using the BrainPath endoport system, the aneurysm was able to be accessed. Since the fusiform architecture of the aneurysm prevented clip placement, the aneurysm was ligated with electrocautery. Conclusion. We demonstrate the feasibility of endoport-assisted approach for minimally invasive access and treatment of uncommon, distally located aneurysms.

Figure 1

Cerebral angiography, (a) lateral and (b) AP projections of a right internal carotid artery injection and (c) lateral projection of a right vertebral artery injection, shows an aneurysm (arrowhead) arising from the medial posterior choroidal artery branch of the right posterior cerebral artery, with stagnation of contrast in the late arterial phase. Preoperative CTA, (d) axial, (e) sagittal, and (f) coronal views, shows a 5 × 4 × 3 mm periventricular aneurysm (arrowhead), projecting into the atrium of the right lateral ventricle with multiple adjacent collateral vessels.

Figure 2

(a) Intraoperative view through the outer sheath of the BrainPath endoport system shows exposure of the proximal vessel (dashed arrow) and the partially thrombosed, fusiform periventricular aneurysm (solid arrow) within the atrium of the right lateral ventricle. (b) A temporary clip was placed on the inflow vessel to achieve proximal control prior to ligation of the aneurysm with electrocautery. Postoperative CTA, (c) axial, (d) sagittal, and (e) coronal views, shows interval decrease in the quantity of intraventricular hemorrhage and no evidence of residual aneurysm.