A Case of a Ruptured Anterior Choroidal Artery Aneurysm Associated with Unilateral Moyamoya Disease Treated by Proximal Ligation and Direct/Indirect Bypass

Abstract

A 33-year-old man presented with subarachnoid hemorrhage (Hunt and Kosnik grade II, World Federation of Neurological Surgeons [WFNS] grade I, Fisher group 3). Cerebral angiography revealed two anterior choroidal arteries and an aneurysm in a distal branch, in addition to an occlusion at the beginning of the right middle cerebral artery (MCA) and ipsilateral moyamoya vessels (unilateral moyamoya disease). On day 5, proximal ligation and bypass (superficial temporal artery [STA]-MCA anastomosis and encephalo-myo-synangiosis [EMS]) was performed. After surgery, neither symptomatic cerebral vasospasm nor hydrocephalus occurred. The patient was discharged without any neurological deficits. According to several reports, in cases of ruptured aneurysms associated with main trunk artery occlusion, it is important to operate both the aneurysm and STA-MCA anastomosis simultaneously in the acute phase to prevent re-rupture of the aneurysm and improve the cerebral blood flow. Thus, combination surgery consisting of proximal ligation and direct/indirect bypass in the acute phase is considered useful for hemorrhagic moyamoya disease.