A Ruptured Aneurysm Associated with Ischemia of Anterior Cerebral Artery Territory in Moyamoya Disease Treated by Proximal Clipping and Direct/Indirect Bypass: A Case Report

Abstract

A 41-year-old woman with Moyamoya disease (MMD) who had undergone bilateral indirect bypass during childhood presented with intracerebral hemorrhage in the genu of the corpus callosum. Digital subtraction angiography (DSA) revealed an occluded right anterior cerebral artery (ACA) and a small aneurysm in the frontal lobe, which arose on an unusual collateral artery from the M3 portion of the right middle cerebral artery. Since the aneurysm was still present on day 15, we performed proximal clipping using the navigation-guided trans-sulcal approach. Superficial temporal artery (STA)-ACA bypass with an indirect procedure was also performed to prevent further aneurysmformation. The aneurysm disappeared on DSA, and the patient fully recovered without neurological deficits.

Aneurysm formation at this site is extremely rare. Single-stage proximal clipping and bypass surgery to reduce hemodynamic stress can be a potentially effective therapeutic strategy.