PMC4109168_01
(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)
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F1
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. 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]. 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].
(a, b)Vertebral artery (VA) DSA AP and lateral views demonstrating an unruptured aneurysm (arrow) on a collateral from the left PCA to the left anterior cerebral artery (ACA) and left MCA. (c, d) Selective DSA imaging, AP and lateral views, through a microcatheter introduced through the left PCA. A small 3-mm aneurysm (long arrow) is seen supplied by the posterior choroidal branch of the PCA. There is reconstitution of ACA and MCA (short arrows) from the aneurysm feeding vessels
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F2
ICA with typical moya collaterals, in addition to the finding of a pseudoaneurysm arising from a collateral vessel just lateral to the third ventricle. In retrospect, it was noted that the lesion had likely been present previously but had become substantially more prominent [Figure 2a, b]. Subsequently, embolization was attempted; however, the aneurysm was originating from a deep choroidal branch arising from the left posterior cerebral artery (PCA), which was seen to be directly reconstituting cortical vasculature, including the distal MCA [Figure 2c, d].
(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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F3
Angiogram in the initial postoperative period showed a patent bypass and stable appearance of the left distal PCA choroidal branch aneurysm [Figure 3a]. Furthermore, the deep choroidal aneurysm was no longer seen, indicating complete regression [Figure 3b, c].