Rare Presentation of Moyamoya Disease with an Acute Subdural Hemorrhage from a Rare Location of Aneurysm-Related Moyamoya Disease

Abstract

Spontaneous acute subdural hematoma is uncommon and usually caused by coagulopathy or other bleeding disorders, malignancy, intracranial hypotension, and abnormal intracranial vessels. We present unique cases of acute spontaneous subdural hematoma from moyamoya disease. There are a few cases reported, and we review previous literature and describe bleeding sources from aneurysms related to moyamoya disease in highly unusual locations.

Keywords: aneurysm-related moyamoya disease; anterior ethmoidal artery; moyamoya disease; subdural hematoma; transdural anastomosis.

Fig. 1

Noncontrast computed tomography (CT) brain in axial view demonstrated acute subdural hematoma at the left frontoparietotemporal convexity ( A – D ) and left parafalcine region (arrow in C – E ), which caused mild subfalcine herniation. Acute hematoma at the left gyrus rectus is observed ( F ). Old infarctions at the right caudate head and right periventricular white matter are detected (arrowhead in B and C ). The axial fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) ( G , H ) and coronal FLAIR MRI ( I ) showed old infarctions at the right periventricular white matter.

Fig. 2

Coronal maximal intensity projection (MIP) of the contrast-enhanced magnetic resonance angiography (MRA) ( A ) and coronal fluid-attenuated inversion recovery (FLAIR) fat saturation (FS) ( B ) over the next 2 months demonstrated a round shape outpouching lesion at the previous hemorrhagic area at the left gyrus rectus, which is suspected as aneurysm.

Fig. 3

Lateral view of the left internal carotid artery (ICA) angiogram in early arterial phase ( A ) and late arterial phases ( B ), three-dimensional (3D) left ICA angiogram ( C ) with axial ( D ) and coronal ( E ) maximal intensity projection (MIP) images in the next 2 weeks demonstrated left supraclinoid ICA occlusion with collateral vessels from the left ophthalmic artery, left posterior choroidal artery, left splenial artery, and left posterior cerebral artery (PCA) cortical vessels with intracranial aneurysm of the dilated left anterior ethmoidal artery (arrow). The aneurysm of the left parieto-occipital artery is also detected (arrowhead in A – C ). The right supraclinoid ICA occlusion with multiple collateral supplied by the dilated lenticulostriate arteries and parieto-occipital branches of the right PCAs are demonstrated on the right ICA angiogram in anteroposterior (AP) ( F ) and lateral views ( G ).