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Case Reports
. 2020 Aug;162(8):1861-1865.
doi: 10.1007/s00701-020-04335-4. Epub 2020 Apr 19.

Transcallosal, transchoroidal clipping of a hypothalamic collateral vessel aneurysm in Moyamoya disease

Wing Mann Ho  1 , Alice Stephanie Görke  1 , Florian Dazinger  2 , Bettina Pfausler  3 , Elke R Gizewski  2 , Ondra Petr  4 , Claudius Thomé  1
Affiliations
Case Reports

Transcallosal, transchoroidal clipping of a hypothalamic collateral vessel aneurysm in Moyamoya disease

Wing Mann Ho et al. Acta Neurochir (Wien). 2020 Aug.

Abstract

Peripheral collateral vessel aneurysms in Moyamoya disease (MMD) remain difficult to treat due to their deep location, small size, and vascular fragility. We report the case of an aneurysm localized in the hypothalamus, which was rapidly increasing in size with repeated hemorrhage despite revascularization surgery. Aneurysm clipping was performed to prevent further progress and rerupture with favorable outcome. To our best knowledge, this is the first description of a hypothalamic aneurysm in MMD being clipped via a transcallosal, transchoroidal approach through the third ventricle.

Keywords: Aneurysm; Clipping; Collateral vessel; Moyamoya; Transcallosal approach.

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Conflict of interest statement

The authors have no disclosures to declare.

The patient’s consent has been obtained for this publication.

Figures

Fig. 1
Fig. 1
a The initial CT scan demonstrating ICH in the right hypothalamus with IVH and SAH in the basal cisterns, scored as Hunt and Hess 3/Fisher 4. Additionally, signs of diffuse leukoencephalopathy in both hemispheres with spotty calcification were observed. b The CT angiogram demonstrated stenosis of both distal internal carotid arteries (ICA) and a proximally dilated posterior communicating artery, which appeared occluded after the P1 segment. The middle (MCA) and anterior cerebral arteries (ACA) were partially fed by collaterals with a rete of collateral moyamoya vessels
Fig. 2
Fig. 2
The initial DSA confirming the network of moyamoya-pattern collateral vessels. The arrow points to the aneurysm and suspected bleeding source. Severe stenosis of both ICA and the A1 segments and moderate stenosis of the left MCA were obvious with pronounced collaterals between the ICAs, both proximal ACAs and the right posterior communicating artery (PCOM). The dilated perforating vessels in the basal ganglia and hypothalamus were supposed to be caused by hypoperfusion due to MMD. One distinctive large collateral vessel was present between the reticular collaterals of the distal right-sided ICA and the ACA territory bearing a small aneurysm
Fig. 3
Fig. 3
The 3D reconstruction of the follow-up CT angiogram showing the configuration of the collateral vessel aneurysm
Fig. 4
Fig. 4
Intraoperative pictures via the third ventricular approach shows the aneurysm a in situ and b after microsurgical clipping
Fig. 5
Fig. 5
The arrow in the DSA points to a the aneurysm before surgery, b the aneurysm clip, and c the complete obliteration of the aneurysm
See this image and copyright information in PMC

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