Endovascular angioplasty for stenosis of the petrous segment of the internal carotid artery associated with moyamoya disease

Abstract

  The optimal treatment strategy for internal carotid artery (ICA) stenosis associated with moyamoya disease has not been fully established. There are few reports of endovascular angioplasty for this condition, and the outcomes suggest that this procedure is not recommended. We report a case of endovascular angioplasty for stenosis of the petrous segment of the ICA associated with moyamoya disease and ischemic stroke. The patient was a 78‒year‒old Japanese man who presented with conjugate eye deviation to the left, aphasia, severe right hemiparesis, and left lower extremity paresis after the gradual deterioration of a gait disturbance. Brain magnetic resonance imaging revealed an acute brain infarct in the left internal capsule with no involvement of the cerebral cortex. Magnetic resonance angiography showed poor blood flow in the left ICA, the left middle cerebral artery, and the bilateral anterior cerebral arteries. Angiography revealed a severe stenotic lesion in the petrous segment of the ICA, for which we attempted endovascular angioplasty. Despite repeated percutaneous transluminal angioplasty (PTA), refractory restenosis and dissection developed. However, a favorable angioplasty outcome was obtained using the Neuroform Atlas stent system (Stryker Neurovascular). Although blood flow distal to the stenotic lesion improved, the flow beyond the terminal segment of the ICA remained poor and typical moyamoya vasculature was seen around the basal ganglia. We then suspected moyamoya disease or moyamoya syndrome. The patient’s symptoms improved rapidly after this treatment. Angiography 1 month after the first treatment showed restenosis inside the stent, so we performed a repeat PTA. Restenosis reoccurred 3 months after the second treatment, and it was treated with the placement of a drug‒eluting stent within the Neuroform Atlas. Moderate restenosis was seen on angiography after the final treatment, but there was no recurrence of ischemic attack. In endovascular angioplasty for ICA stenosis associated with moyamoya disease, close observation is required because repeated recurrence after treatment often occurs.