PMC5562676_01
Neuroimaging. Figure 1 with axial CT head (A) and coronal CTA (B) on presentation, with repeat axial CT 3 h later (C,D) and axial images on posthemorrhage day 4 and 21 (E,H). Diagnostic cerebral angiogram (coronal view and sagittal view) is shown in images (F,G), respectively.
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F1
CT (Figure 1A) demonstrated a small ICH in the left periventricular white matter with significant intraventricular blood. CT angiogram of the head (Figure 1B) was suggestive of Moyamoya-like vasculopathy involving the left internal carotid artery (ICA) summit. Repeat head CT showed worsened IVH (Figure 1C) with hydrocephalus and apparent compression of the midbrain (Figure 1D). Based on this clinical improvement, the patient's husband requested that her code status be changed back to "full resuscitation." Repeat head CT on postbleed day 4 (Figure 1E) showed improved hydrocephalus, although still with ventricles "casted" from IVH. A diagnostic cerebral angiogram confirmed a Moyamoya syndrome characterized by (1) chronic occlusion of the left supraclinoid ICA above the origin of the anterior choroidal artery, (2) a meshwork of small vessels replacing the ICA summit, proximal ACA, and proximal MCA, and (3) robust collaterals supplying the L MCA vascular territory via a widely patent anterior communicating artery and leptomeningeal collaterals derived from the distal L PCA (Figures 1F,G).