Surgical Treatment of Cerebral Aneurysms and Cerebral Arterial Ectasia with “Moyamoya” Vessels

Abstract

In this paper, we report on two cases of intracranial cerebral aneurysms and one case of cerebral arterial ectasia with moyamoya vessels.
A 43-year-old female experienced one episode of TIA. Angiograms showed elongated, ectatic vessels on the right internal cerebral artery, the left posterior cerebral artery and the right subclavian artry, which were diagnosed as arterial ectasia. The cerebral arterial ectasia on the right internal cerebral artery was accompanied with moyamoya vessels. Wrapping of the ectatic vessel and STA-MCA anastomosis was performed.
A 68-year-old female suffered from intracerebral hematoma in the right temporal lobe. Cerebral angiograms showed the typical appearance of Moyamoya disease. An aneurysm was identified on the left internal carotid artery. During the frontotemporal approach, the aneurysm was found unruptured and was clipped. The moyamoya vessels were few in this case and the operative procedures were easily performed.
A 54-year-old female suddenly suffered from headache and vomiting, falling into coma soon after. Moyamoya vessels were noticed on the left carotid angiogram. A vertebral angiogram showed an aneurysm on the top of the basilar artery. Because her conscious level gradually improved after ventricular drainage, a direct approach to the aneurysm was planned. Under hypotensive anesthesia, clipping of the aneurysm was performed with the retraction of the right internal carotid artery medially or laterally. She did not fully awaken from the anesthesia, and remarkable brain swelling was noticed on the postoperative CT scan. She died on the 14th postoperative day.
There are several problems in performing a direct attack on cerebral aneurysms with moyamoya vessels.
The first is whether there are many or few moyamoya vessels. If there are many moyamoya vessels, a direct approach to the aneurysmal neck might be prohibited, especially with a basilar aneurysm.
The second problem is that intraoperative hypotension and excessive retraction of the major vessels might be dangerous, because severe disturbance of the cerebral perfusion could occur in moyamoya disease if such procedures are followed.