Limits...
Resolution of bilateral moyamoya associated collateral vessel aneurysms: Rationale for endovascular versus surgical intervention.

Amin-Hanjani S, Goodin S, Charbel FT, Alaraj A - Surg Neurol Int (2014)

Bottom Line: Management of aneurysms associated with deep collateral vessels in moyamoya disease is challenging both from an endovascular and a surgical standpoint.Alternatively, superficial temporal artery-middle cerebral artery bypass is another potential strategy for resolution of these aneurysms.Presented are the findings and management for a patient with moyamoya disease and bilateral deep collateral vessel aneurysms, successfully treated with endovascular obliteration following a right-sided hemorrhage and subsequently with bypass for an unruptured but growing contralateral aneurysm.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, University of Illinois at Chicago, 912 S. Wood St., M/C799, Chicago, IL, USA.

ABSTRACT

Background: Management of aneurysms associated with deep collateral vessels in moyamoya disease is challenging both from an endovascular and a surgical standpoint. Difficulties with access or localization, and compromise of the collateral circulation with subsequent ischemia are the primary concerns, making direct obliteration potentially unfeasible or risky. Alternatively, superficial temporal artery-middle cerebral artery bypass is another potential strategy for resolution of these aneurysms.

Case description: Presented are the findings and management for a patient with moyamoya disease and bilateral deep collateral vessel aneurysms, successfully treated with endovascular obliteration following a right-sided hemorrhage and subsequently with bypass for an unruptured but growing contralateral aneurysm.

Conclusions: A rationale and approach to management is outlined, as derived from review of the current literature and the illustrative case with bilateral collateral vessel aneurysms.

No MeSH data available.


Related in: MedlinePlus

(a) CT scan of the brain demonstrating diffuse subarachnoid hemorrhage with intraventricular extension into the right temporal horn. (b, c) Right internal carotid artery (ICA) digital subtraction angiography (DSA) anterio-posterior (AP) view and lateral view, demonstrating advanced moyamoya disease with right middle cerebral artery (MCA) occlusion and collaterals originating from the ICA partially reconstituting the MCA. There is a 3-mm aneurysm seen on one of the thalamostriate vessels (arrow). (d) Fluoroscopic image of the skull (AP view) post n-BCA glue embolization of the thalamostriate aneurysm along with the feeding vessel. The aneurysm is filled with n-BCA glue cast (arrow). (e) AP view of right ICA DSA post n-BCA embolization. The aneurysm is completely obliterated (arrow: location of obliterated aneurysm)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4109168&req=5

Figure 1: (a) CT scan of the brain demonstrating diffuse subarachnoid hemorrhage with intraventricular extension into the right temporal horn. (b, c) Right internal carotid artery (ICA) digital subtraction angiography (DSA) anterio-posterior (AP) view and lateral view, demonstrating advanced moyamoya disease with right middle cerebral artery (MCA) occlusion and collaterals originating from the ICA partially reconstituting the MCA. There is a 3-mm aneurysm seen on one of the thalamostriate vessels (arrow). (d) Fluoroscopic image of the skull (AP view) post n-BCA glue embolization of the thalamostriate aneurysm along with the feeding vessel. The aneurysm is filled with n-BCA glue cast (arrow). (e) AP view of right ICA DSA post n-BCA embolization. The aneurysm is completely obliterated (arrow: location of obliterated aneurysm)

Mentions: A 43-year-old female presented to the hospital after being found unresponsive with preceding complaints of headaches and dizziness. Upon arrival, a computed tomographic (CT) scan of the head revealed a deep right-sided hemorrhage in the region of the posterior limb of the internal capsule with extensive intraventricular extension [Figure 1a] and parenchymal extension. Her examination demonstrated dense left hemiparesis, affecting the arm more than the leg. An angiogram demonstrated findings of advanced MMD and a small 5 mm right distal thalamostriate branch aneurysm, which was consistent with the source of the hemorrhage [Figure 1b, c]. It was felt that the distal territory of this perforator branch had already been affected by the hemorrhagic event and, thus, no longer providing indispensable supply to a functional brain area. The aneurysm was accessed using a Marathon microcatheter (Covidien, Irvine, CA, USA) with the help of a Mirage guidewire (Covidien), and embolized with 20% n-butyl cyanoacrylate glue (n-BCA) (Cordis-Codman, Raynham, MA, USA) in ethiodol oil [Figure 1d]. This resulted in complete obliteration of the aneurysm along with the feeder vessel [Figure 1e]. No further intervention was pursued at that time given the absence of hemodynamic compromise and successful obliteration of the hemorrhage source. The patient demonstrated gradual neurological improvement and was discharged home with stable left hemiparesis, which improved over the course of a year to the ability to ambulate independently with 3/5 distal and 4/5 proximal left upper extremity strength.


Resolution of bilateral moyamoya associated collateral vessel aneurysms: Rationale for endovascular versus surgical intervention.

Amin-Hanjani S, Goodin S, Charbel FT, Alaraj A - Surg Neurol Int (2014)

(a) CT scan of the brain demonstrating diffuse subarachnoid hemorrhage with intraventricular extension into the right temporal horn. (b, c) Right internal carotid artery (ICA) digital subtraction angiography (DSA) anterio-posterior (AP) view and lateral view, demonstrating advanced moyamoya disease with right middle cerebral artery (MCA) occlusion and collaterals originating from the ICA partially reconstituting the MCA. There is a 3-mm aneurysm seen on one of the thalamostriate vessels (arrow). (d) Fluoroscopic image of the skull (AP view) post n-BCA glue embolization of the thalamostriate aneurysm along with the feeding vessel. The aneurysm is filled with n-BCA glue cast (arrow). (e) AP view of right ICA DSA post n-BCA embolization. The aneurysm is completely obliterated (arrow: location of obliterated aneurysm)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4109168&req=5

Figure 1: (a) CT scan of the brain demonstrating diffuse subarachnoid hemorrhage with intraventricular extension into the right temporal horn. (b, c) Right internal carotid artery (ICA) digital subtraction angiography (DSA) anterio-posterior (AP) view and lateral view, demonstrating advanced moyamoya disease with right middle cerebral artery (MCA) occlusion and collaterals originating from the ICA partially reconstituting the MCA. There is a 3-mm aneurysm seen on one of the thalamostriate vessels (arrow). (d) Fluoroscopic image of the skull (AP view) post n-BCA glue embolization of the thalamostriate aneurysm along with the feeding vessel. The aneurysm is filled with n-BCA glue cast (arrow). (e) AP view of right ICA DSA post n-BCA embolization. The aneurysm is completely obliterated (arrow: location of obliterated aneurysm)
Mentions: A 43-year-old female presented to the hospital after being found unresponsive with preceding complaints of headaches and dizziness. Upon arrival, a computed tomographic (CT) scan of the head revealed a deep right-sided hemorrhage in the region of the posterior limb of the internal capsule with extensive intraventricular extension [Figure 1a] and parenchymal extension. Her examination demonstrated dense left hemiparesis, affecting the arm more than the leg. An angiogram demonstrated findings of advanced MMD and a small 5 mm right distal thalamostriate branch aneurysm, which was consistent with the source of the hemorrhage [Figure 1b, c]. It was felt that the distal territory of this perforator branch had already been affected by the hemorrhagic event and, thus, no longer providing indispensable supply to a functional brain area. The aneurysm was accessed using a Marathon microcatheter (Covidien, Irvine, CA, USA) with the help of a Mirage guidewire (Covidien), and embolized with 20% n-butyl cyanoacrylate glue (n-BCA) (Cordis-Codman, Raynham, MA, USA) in ethiodol oil [Figure 1d]. This resulted in complete obliteration of the aneurysm along with the feeder vessel [Figure 1e]. No further intervention was pursued at that time given the absence of hemodynamic compromise and successful obliteration of the hemorrhage source. The patient demonstrated gradual neurological improvement and was discharged home with stable left hemiparesis, which improved over the course of a year to the ability to ambulate independently with 3/5 distal and 4/5 proximal left upper extremity strength.

Bottom Line: Management of aneurysms associated with deep collateral vessels in moyamoya disease is challenging both from an endovascular and a surgical standpoint.Alternatively, superficial temporal artery-middle cerebral artery bypass is another potential strategy for resolution of these aneurysms.Presented are the findings and management for a patient with moyamoya disease and bilateral deep collateral vessel aneurysms, successfully treated with endovascular obliteration following a right-sided hemorrhage and subsequently with bypass for an unruptured but growing contralateral aneurysm.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, University of Illinois at Chicago, 912 S. Wood St., M/C799, Chicago, IL, USA.

ABSTRACT

Background: Management of aneurysms associated with deep collateral vessels in moyamoya disease is challenging both from an endovascular and a surgical standpoint. Difficulties with access or localization, and compromise of the collateral circulation with subsequent ischemia are the primary concerns, making direct obliteration potentially unfeasible or risky. Alternatively, superficial temporal artery-middle cerebral artery bypass is another potential strategy for resolution of these aneurysms.

Case description: Presented are the findings and management for a patient with moyamoya disease and bilateral deep collateral vessel aneurysms, successfully treated with endovascular obliteration following a right-sided hemorrhage and subsequently with bypass for an unruptured but growing contralateral aneurysm.

Conclusions: A rationale and approach to management is outlined, as derived from review of the current literature and the illustrative case with bilateral collateral vessel aneurysms.

No MeSH data available.


Related in: MedlinePlus