Treatment Strategies for Aneurysms Associated with Moyamoya Disease

Abstract

The treatment of aneurysms associated with moyamoya disease (MMD) is difficult for neurosurgeons, and little is known of strategy options. This report constitutes a comprehensive review of the literature. We summarize the known treatments and their clinical outcomes according to the site of the aneurysm: in major arteries, peripheral arteries, moyamoya vessels, meningeal arteries, or at the site of anastomosis. The literature review indicates that the treatment of MMD-associated aneurysms varies according to the site of the aneurysm and its hemodynamic characteristics. In particular, the treatment for basilar tip aneurysms remains challenging, since both endovascular embolization and direct clipping are difficult. The potential risk for ischemia should be considered in selecting endovascular or surgical approaches. Revascularization surgery, which is important for the treatment of MMD, also determines the clinical treatment outcome of aneurysms associated with MMD.

Transcallosal, transchoroidal clipping of a hypothalamic collateral vessel aneurysm in Moyamoya disease

“…Cases of aneurysm formation localized close to the anastomosis after bypass surgery have been documented [1,7,8,16,19], but to date, only few cases of aneurysm formation and progression in collateral MMD vessels have been reported [10,12,21]. The treatment of deep-seated peripheral artery aneurysms is technically challenging [22]. Either the feeding artery is hardly accessible for endovascular coiling due to the small size of the vessel, the fusiform character of the lesion and the fragile vascular structure, or the surgical approach may entail parenchymal damage of eloquent brain areas.…”

Paediatric arterial ischemic stroke: acute management, recent advances and remaining issues

“…The existence of different patterns of Moyamoya disease and the rarity of this condition, solicit an individualized decision making and the patient should be referred for evaluation to a centre with expertise in evaluating patients for surgical revascularisation [ 34 ]. Despite a vast literature about Moyamoya, the need of controlled clinical trials to guide the decision of therapy persists [ 24 , 80 , 81 ].…”

Regression of moyamoya-associated weak spots on the distal anterior choroidal artery following surgical revascularization

“…The ideal therapeutic strategy for hemorrhagic-type moyamoya disease is to obliterate the bleeding source before conducting a revascularization procedure in order to prevent early re-rupture [ 3 ]. However, owing to multiple factors, direct surgical or endovascular obliteration of the bleeding source is not always feasible [ 3 ].…”

“…The ideal therapeutic strategy for hemorrhagic-type moyamoya disease is to obliterate the bleeding source before conducting a revascularization procedure in order to prevent early re-rupture [ 3 ]. However, owing to multiple factors, direct surgical or endovascular obliteration of the bleeding source is not always feasible [ 3 ]. Surgical revascularization alone is considered effective in preventing re-rupture from moyamoya collaterals, but its role as the primary treatment for ruptured weak points arising from choroidal arteries is less clear [ 4 ].…”