PMC10159324_01
(a and b) Computed tomography revealing thalamic hemorrhage. (c) Anterior-posterior and (d) lateral angiography of the right internal carotid artery before bypass surgery showing Suzuki grade 4 moyamoya disease. (e) Anterior-posterior and (f) lateral angiography of the right vertebral artery demonstrating development of the thalamic channel.
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Computed tomography revealed right thalamic hemorrhage with ventricular hemorrhage [Figures 1a and b]. Digital subtraction angiography (DSA) showed MMD (Suzuki grade 4) development of the thalamic channel with hemorrhage in the ipsilateral hemisphere [Figures 1c-f].
(a) Anterior-posterior angiography before revascularization surgery. (b) Lateral angiography of the right external carotid artery at 3 months after revascularization surgery. The angiogram shows a pseudoaneurysm (arrowheads, b) at the middle meningeal artery (arrows, a and b). The diameter of the middle meningeal artery at 6 months after the superficial temporal artery-to-middle cerebral artery (STAMCA) bypass and encephalo-duro-myo-arterio-pericranio-synangiosis (EDMAPS) was larger than that before surgery. (c) Fusion image of computed tomography and right external carotid artery angiography. The pseudoaneurysm is located at the edge of the craniotomy (black arrow). (d) Intraoperative photo of STA-MCA bypass and EDMAPS. The arrow is location of pseudoaneurysm hereafter.
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In addition, a pseudoaneurysm was observed in the right posterior branch of the MMA [Figures 2a and b]. The pseudoaneurysm was located immediately under the edge of the craniotomy site [Figure 2c]. Figure 2d demonstrated the intraoperative photo of STAMCA bypass and EDMAPS on ipsilateral hemisphere of pseudoaneurysm development.
(a) Right middle meningeal artery (MMA) angiography shows the indirect bypass to the parietal and occipital lobe. The pseudoaneurysm is located at the posterior branch of the MMA (black arrow). (b) The working angle of coil embolization. The aneurysm size is 4.2 mm x 3.9 mm and neck length is 1.1 mm (black arrow) (c) Intra-aneurysmal embolization using platinum coils. (d) Post-embolization angiography of the MMA reveals patency of the posterior branch of the MMA. (e and f) Follow-up angiography at 1 month after pseudoaneurysm embolization. Complete occlusion of the aneurysm and patency of the middle meningeal artery is observed.
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Medical Products, Japan) and microcatheter (Echelon-10, Medtronic, USA) were navigated into the right MMA. Microangiography of the posterior trunk of MMA revealed transdural anastomosis by indirect bypass [Figure 3a]. The aneurysm size was 4.2 mm x 3.9 mm and neck length was 1.1 mm [Figure 3b]. The microcatheter was navigated into the pseudoaneurysm, and the pseudoaneurysm was embolized using five platinum coils (Optima Coil System , BALT, USA) [Figure 3c]. Angiography after embolization showed complete occlusion of the pseudoaneurysm, patency of the MMA, and transdural anastomosis [Figure 3d]. Follow-up DSA performed 1 month after the endovascular treatment showed no recanalization of the pseudoaneurysm [Figures 3e and f].