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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) Left external carotid artery DSA (AP view) post superficial temporal artery (STA) to MCA bypass. There is robust filling of the left MCA territories through the bypass graft. (b, c) Lateral VA DSA imaging and left ICA AP 7 months post left STA-MCA bypass showing complete regression of the aneurysm (arrow; site of the obliterated aneurysm)
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Figure 3: (a) Left external carotid artery DSA (AP view) post superficial temporal artery (STA) to MCA bypass. There is robust filling of the left MCA territories through the bypass graft. (b, c) Lateral VA DSA imaging and left ICA AP 7 months post left STA-MCA bypass showing complete regression of the aneurysm (arrow; site of the obliterated aneurysm)

Mentions: Consequently, a surgical approach was entertained; direct obliteration through surgical trapping was felt to be ill advised given the deep location and the continued concerns regarding placing the territory supplied by the aneurysmal collateral at risk. Direct STA–MCA bypass and EDAS was planned with the specific intention of revascularizing the territory supplied by the collateral arising from the aneurysmal vessel and with the additional premise that subsequent embolization could then be pursued safely if the aneurysm did not resolve with revascularization alone. Intraoperatively, direct STA to MCA bypass was performed over the frontal cortical surface. The STA cut flow intraoperatively was 89 ml/min and the final bypass flow was 45 ml/min, indicating a successful bypass patency with a cut flow index of 0.5.[1] Angiogram in the initial postoperative period showed a patent bypass and stable appearance of the left distal PCA choroidal branch aneurysm [Figure 3a]. A follow-up angiogram was planned 6 months later which revealed that the bypass remained patent. In addition, further vascular contribution from the EDAS, just deep and adjacent to the craniotomy site, to the left frontal lobe was now observed. Furthermore, the deep choroidal aneurysm was no longer seen, indicating complete regression [Figure 3b, c].


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) Left external carotid artery DSA (AP view) post superficial temporal artery (STA) to MCA bypass. There is robust filling of the left MCA territories through the bypass graft. (b, c) Lateral VA DSA imaging and left ICA AP 7 months post left STA-MCA bypass showing complete regression of the aneurysm (arrow; site of the obliterated aneurysm)
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 3: (a) Left external carotid artery DSA (AP view) post superficial temporal artery (STA) to MCA bypass. There is robust filling of the left MCA territories through the bypass graft. (b, c) Lateral VA DSA imaging and left ICA AP 7 months post left STA-MCA bypass showing complete regression of the aneurysm (arrow; site of the obliterated aneurysm)
Mentions: Consequently, a surgical approach was entertained; direct obliteration through surgical trapping was felt to be ill advised given the deep location and the continued concerns regarding placing the territory supplied by the aneurysmal collateral at risk. Direct STA–MCA bypass and EDAS was planned with the specific intention of revascularizing the territory supplied by the collateral arising from the aneurysmal vessel and with the additional premise that subsequent embolization could then be pursued safely if the aneurysm did not resolve with revascularization alone. Intraoperatively, direct STA to MCA bypass was performed over the frontal cortical surface. The STA cut flow intraoperatively was 89 ml/min and the final bypass flow was 45 ml/min, indicating a successful bypass patency with a cut flow index of 0.5.[1] Angiogram in the initial postoperative period showed a patent bypass and stable appearance of the left distal PCA choroidal branch aneurysm [Figure 3a]. A follow-up angiogram was planned 6 months later which revealed that the bypass remained patent. In addition, further vascular contribution from the EDAS, just deep and adjacent to the craniotomy site, to the left frontal lobe was now observed. Furthermore, the deep choroidal aneurysm was no longer seen, indicating complete regression [Figure 3b, c].

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