J Cerebrovasc Endovasc Neurosurg.  2023 Mar;25(1):75-80. 10.7461/jcen.2022.E2022.02.002.

Hydration-induced rapid growth and regression after indirect revascularization of an anterior choroidal artery aneurysm associated with Moyamoya disease: A case report

• Lee GY
• Cho BK
• Hwang SH
• Roh H
• Kim JH

• KMID: 2540810
• DOI: http://doi.org/10.7461/jcen.2022.E2022.02.002

Abstract

The prevalence of aneurysm formation in adults with Moyamoya disease (MMD) is higher than that in the general population. The treatment strategy is often individualized based on the patient’s disease characteristics. A 22-year-old man was diagnosed with MMD after presenting a small thalamic intracerebral and subarachnoid hemorrhage in the quadrigeminal cistern. Cerebral angiography revealed a small aneurysm (2.42 mm) in the left anterior choroidal artery. Since the hemodynamics in the left hemisphere was compromised, an indirect bypass surgery was performed. The patient’s condition deteriorated postoperatively because of poor perfusion of the internal carotid artery, and massive hydration was required. During neurocritical care, the aneurysm increased in size (5.33 mm). An observation strategy was adopted because of the distal aneurysmal location and the high risk involved. Subsequently, the patient recovered, and newly developed collateral flow appeared from the external carotid artery. Additionally, a dramatic size reduction of the aneurysm (1.51 mm) was noticed. Our case suggests that MMD-related dissecting aneurysms on a distal cerebral artery, which present a high risk of embolization, could be managed by indirectly reducing the hemodynamic burden. Massive hydration in such cases should be avoided or balanced to avoid the risk of rapid growth and aneurysm rupture.

Keyword

Moyamoya disease; Intracranial aneurysm; Anterior choroidal artery; Pseudoaneurysm

Figure

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  Fig. 1. Serial computed tomography (CT) images show from initial to Postoperative day 14 - Preoperative; Small amount of subarachnoid hemorrhage on the left quadrigeminal cistern on initial CT, Postoperative day 2; Clinical course got worsened (motor aphasia) and CT revealed the delayed postoperative hematoma on the epidural and subdural spaces, Postoperative day 6; Hematoma evacuation was performed due to the deep drowsy mentality with right hemiparesis (grade II). EDAS, encephalo-duro-arterio-synangiosis

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  Fig. 2. Chronological angiogram images – Preoperative; 2.42 mm sized saccular aneurysm was identified on his plexal segment of left anterior choroidal artery, Postoperative day 17, during massive hydration; Enlarged aneurysm of maximal diameter 5.33 mm, Postoperative day 35, after external carotid collateral formations; Dramatical size decrement of aneurysm.

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  Fig. 3. Computed tomography perfusion (CTP) images – in the postoperative images, perfusion delay of the right hemisphere has been restored. CBF, cerebral blood flow; CBV, cerebral blood volume; MTT, mean transit time; TTP, time-to-peak; EDAS, encephalo-duro-arteriosynangiosis

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