Endovascular Therapy of Ruptured Aneurysms on Moyamoya Collateral Vessels: Two Cases

Abstract

Background: Using two case reports of adult women with moyamoya disease presenting with intracranial hemorrhage from ruptured aneurysms on moyamoya collateral vessels, we aim to demonstrate the potential for effective endovascular treatment navigated by CT angiography, digital subtraction angiography, and flat panel CT. Case 1 Presentation: A 45-year-old female patient with sudden onset of headache, followed by somnolency. CT scan showed a four-ventricle hematocephalus caused by a 27 × 31 × 17 mm hematoma located in the left basal ganglia. Angiography revealed a 3 mm aneurysm on hypertrophic lenticulostriate artery bridging the M1 occlusion. Selective catheterization and distal embolisation with acrylic glue was done. Case 2 Presentation: A 47-year-old woman was admitted for a sudden onset of severe headache, CT scan showed four-ventricle hematocephalus. A 4 mm aneurysm on the collateral vessel-anterior chorioidal artery bridging the closure of the terminal segment of the internal carotid artery was diagnosed as the source of bleeding. Selective catheterization and distal embolisation with acrylic glue was done. Conclusions: Selective embolisation of ruptured aneurysms on moya moya collaterals is a simple, effective, and safe procedure when relevant microcatheters are used with imaging software navigation such as 3D DSA, 3D road map and flat-panel CT.

Keywords: acute stroke; endovascular therapy; moyamoya.

Figure 1

(A) Case 1. Native CT scan showing an intraparenchymal hematoma (pair of arrowheads) that has spread into the lateral ventricle. (B) Case 1. The hemorrhage was caused by an aneurysm on the lenticulostriate collateral (arrowhead), which bridges a narrow stenosis of M1 section of the middle cerebral artery. (C) Case 1. Selective angiography of the lenticulostriate artery with an aneurysm filling distally the M2 branch of the middle cerebral artery. (D) Case 1. Final angiogram after embolisation, where the aneurysm does not fill. DSA after 10 months confirmed permanent closure of the bleeding aneurysm. (E) Case 1. CT scan demonstrating placement of the acrylic embolisation mixture cast.

Figure 2

(A) Case 2. CT angiogram showing an aneurysm (arrowhead) in the left lateral ventricle on moyamoya collateral, which was cause of hematocephalus. (B) Case 2. Three dimentional angiogram showing the hypertrophic anterior chorioidal artery (pair of arrows) as collateral bridging the left internal carotid artery intracranially. The contralateral arrow indicates the aneurysm seen on the CT angiogram. (C) Case 2. According to the 3D angiogram, the microcatheter was navigated through the anterior chorioidal artery to the vicinity of the aneurysm. The blood flow in the artery is slowed, so the aneurysm fills only partially and the contrast agent forms a level (arrow). (D) Case 2. Angiogram after acrylic and oily contrast mixture injection shows that the target aneurysm is no longer filling, as well as on control angiography 2 months later. (E) Case 2. Flat panel CT demonstrates embolic mixture penetration into the embolised aneurysm, which was not visible during injection of the embolising agent or on angiography immediately after embolisation. Symmetric calcifications within the lateral ventricles are in the chorioid plexus.