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Navigation-guided clipping of a de novo aneurysm associated with superficial temporal artery-middle cerebral artery bypass combined with indirect pial synangiosis in a patient with moyamoya disease

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Abstract

De novo aneurysms associated with superficial temporal artery (STA)-middle cerebral artery (MCA) bypass are an extremely rare complication of direct revascularization surgery for moyamoya disease (MMD). The basic pathology of MMD includes fragility of the intracranial arterial wall characterized by medial layer thinness and waving of the internal elastic lamina. However, the incidence of newly formed aneurysms at the site of anastomosis currently remains unknown. Among 317 consecutive direct/indirect combined revascularization surgeries performed for MMD, we encountered a 52-year-old woman manifesting a de novo aneurysm adjacent to the site of anastomosis 11 years after successful STA-MCA bypass with encephalo-duro-myo-synangiosis (EDMS). Although the patient remained asymptomatic, the aneurysm gradually increased in diameter to more than 6 mm with the formation of a daughter sac, and a computational fluid dynamic study revealed low wall shear stress at the aneurysm dome. The patient underwent microsurgical clipping of the aneurysm using a neuro-navigation system that permitted the minimally invasive dissection of the temporal muscle flap used for EDMS at the site of the aneurysm without affecting pial synangiosis. The aneurysm was successfully occluded using a titanium clip without complications. The postoperative course was uneventful, and the patient was discharged without neurological deficits. De novo aneurysms associated with STA-MCA bypass for MMD may be safely treated with microsurgical clipping, even in cases initially managed by a combined revascularization procedure that includes complex pial synangiosis. We recommend the application of the neuro-navigation system for the maximum preservation of pial synangiosis during this procedure.

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Authors and Affiliations

  1. Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan

    Daiki Aburakawa, Miki Fujimura, Kuniyasu Niizuma, Hiroyuki Sakata & Teiji Tominaga

  2. Department of Neurosurgery, Kohnan Hospital, Sendai, Japan

    Hidenori Endo

Authors
  1. Daiki Aburakawa
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  2. Miki Fujimura
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  3. Kuniyasu Niizuma
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  4. Hiroyuki Sakata
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  5. Hidenori Endo
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  6. Teiji Tominaga
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Corresponding author

Correspondence to Miki Fujimura.

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Funding

This study was supported by JSPS KAKENHI Grant Number 26462150 from the Ministry of Health, Labour and Welfare, Japan.

Disclosure of the potential conflict of interest

The authors declare that they have no conflict of interest.

Research involving human participants and/or animals

The MRI/MRA and catheter angiography are routine postoperative examinations, which are all covered by medical insurance in Japanese healthcare system. All procedures are performed in accordance with the Declaration of Helsinki.

Informed consent

Informed consent was obtained from an individual participant included in the study.

Financial and material support

This study was supported by JSPS KAKENHI Grant Number 426462150 and AMED Grant Number J160001258.

No portion of this work has been presented previously.

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Aburakawa, D., Fujimura, M., Niizuma, K. et al. Navigation-guided clipping of a de novo aneurysm associated with superficial temporal artery-middle cerebral artery bypass combined with indirect pial synangiosis in a patient with moyamoya disease. Neurosurg Rev 40, 517–521 (2017). https://doi.org/10.1007/s10143-017-0866-4

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  • DOI: https://doi.org/10.1007/s10143-017-0866-4

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