Combined extracranial-intracranial bypass surgery with stent-assisted coil embolization for moyamoya disease with a ruptured wide-necked basilar trunk aneurysm:a case report

Abstract

A ruptured wide-necked basilar trunk aneurysm is uncommon in patients with moyamoya disease. The optimal treatment is unclear. We report a safe and beneficial treatment modality for moyamoya disease with aneurysms located in the posterior circulation.A 37-year-old man presenting with subarachnoid hemorrhage was admitted to our hospital. Emergent cerebral angiography demonstrated moyamoya disease associated with a wide-necked basilar trunk aneurysm. We performed bilateral extracranial-intracranial bypass surgeries prior to stent-assisted coil embolization of the aneurysm after the acute phase. No complication occurred and the patient was discharged with no neurological deficit. Follow-up digital subtraction angiography (DSA) performed 6 months after the surgery showed that all the anastomosises were patent and bilateral collateral vascular compensation was fully established with no recanalization of the basilar trunk aneurysm post embolization.We also found that high-flow bypass did not contribute to cerebral revascularization as imagined despite the good patency.Combined extracranial-intracranial bypass surgery with endovascular treatment proved to be an efficient therapeutic modality for moyamoya disease with aneurysms located in the posterior circulation. High-flow bypass surgery was not essential due to the inefficiency and the high risk of postoperative cerebral hyperperfusion syndrome. KEywOrds: Extracranial-intracranial bypass, Coil embolization, Moyamoya disease, Basilar trunk aneurysm ÖZMoyamoya hastalıklı kişilerde rüptüre geniş boyunlu baziller trunkus anevrizması nadirdir. Optimum tedavi açık değildir. Posterior dolaşımda anevrizmalar bulunan moyamoya hastalığı için güvenli ve faydalı bir tedavi modalitesi bildiriyoruz.Subaraknoid kanamayla gelen 37 yaşında bir erkek hastaneye yatırıldı. Acil serebral anjiyografi geniş boyunlu bir baziller trunkus anevrizmasıyla ilişkili moyamoya hastalığı gösterdi. Akut fazdan sonra anevrizmanın stent yardımlı sarmal embolizasyonu öncesinde bilateral ekstrakraniyalintrakraniyal bypass cerrahisi gerçekleştirdik. Herhangi bir komplikasyon oluşmadı ve hasta nörolojik defisit olmadan taburcu edildi. Cerrahiden 6 ay sonra yapılan takip dijital subtraksiyon anjiyografisi (DSA) anastomozların açık olduğunu ve embolizasyondan sonra baziller trunkus anevrizmasının rekanalizasyonu olmadan bilateral, kollateral vasküler dengeleyici dolaşımın tam olarak tekrar oluştuğunu gösterdi. Ayrıca yüksek akışlı bypass işleminin, iyi açıklığa rağmen serebral revaskülarizasyona tahmin edildiği kadar katkıda bulunmadığını izlendi.Endovasküler tedaviyle kombine ekstrakraniyal-intrakraniyal bypass cerrahisi, posterior dolaşımda anevrizmalar bulunan moyamoya hastalığı için etkin bir terapötik modalite oldu. Yüksek akışlı bypass cerrahisi, etkin olmaması ve yüksek postoperatif serebral hiperperfüzyon sendromu riski nedeniyle şart değildir.

A Treatment Strategy for Basilar Bifurcation Aneurysm Associated with Moyamoya Disease: A Case Successfully Treated by Combined STA-MCA Anastomosis and Stent-assisted Coil Embolization

“…7) There have been few reports that evaluated the effects of hemodynamic load of MMD on major artery aneurysms. 4,[8][9][10][11] In this report, stent-assisted coiling (SAC) was performed after STA-MCA anastomosis as a treatment of an unruptured basilar bifurcation aneurysm associated with MMD. A treatment strategy for aneurysms associated with MMD is reported, along with a review of the literature.…”