J Cerebrovasc Endovasc Neurosurg.  2022 Jun;24(2):154-159. 10.7461/jcen.2021.E2021.06.011.

A Ruptured lenticulostriate artery aneurysm in moyamoya disease treated with Onyx embolization

• Byeon Y
• Kim HB
• You SH
• Yang K

• KMID: 2531658
• DOI: http://doi.org/10.7461/jcen.2021.E2021.06.011

Abstract

Lenticulostriate artery (LSA) aneurysms are uncommon. Here, we report one case of ruptured LSA aneurysm which is related to Moyamoya disease (MMD). Surgical treatment of this aneurysm is challenging because of its deep location and complex neural structures around the LSA. We report one case treated with endovascular Onyx embolization, successfully and review LSA aneurysm associated with MMD.

Keyword

Lenticulostriate artery; Ruptured aneurysm; Moyamoya disease; Onyx; Embolization

Figure

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  Fig. 1. Axial view of brain computed tomography (CT) image is showing acute intraventricular hemorrhage (IVH) with focal hemorrhage in the body of the corpus callosum.

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  Fig. 2. Axial view of enhanced T1-weight magnetic resonance image (MRI) is showing abnormal vascular spot point which can be origin of intraventricular hemorrhage in lateral wall of the right frontal horn (white arrow).

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  Fig. 3. Left internal carotid artery (ICA) digital subtraction angiography (A) frontal and (B) lateral projections are confirming a total occlusion of distal ICA segment with numerous basal collaterals and the distal ACA territory was supplied with ethmoidal collateral vessels which is compatible with moyamoya disease. ACA; anterior cerebral artery.

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  Fig. 4. Preoperative right internal carotid artery (ICA) digital subtraction angiography (A) frontal and (B) trans-orbital oblique projections are showing a ruptured saccular aneurysm (white arrow head) was originated in the lenticulostriate artery (LSA) arising from proximal one third of right middle cerebral artery (MCA). The LSA was too tortuous and acute angle (white arrow) made by MCA to advance the guidewire. Unlike the left ICA, which showed typical MMD findings in Fig. 3, the right ICA showed almost normal distal patency. So, we diagnosed this case as probable MMD.

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  Fig. 5. “Balloon bumping guidewire advancing technique”: We positioned the Gateway PTA Balloon Catheter (white arrow heads: proximal & distal markers of balloon) in the middle cerebral artery (MCA) just distal to the ostium of the targeted lenticulostriate artery (LSA). The Mirage-10 micro-wire (white arrow) was bumped against the balloon and advanced along the LSA (A: plane image) and the Marathon 10 micro-catheter (black arrow head: marker of tip) was positioned just proximal to the LSA aneurysm (B: roadmap image). We fixed the micro-catheter with balloon, firstly and removed the micro-wire, gently. There was no change in position of micro-catheter tip (C: plane image). With Onyx (black arrow) injection, the distal LSA aneurysm was embolized (D: reverse-roadmap image).

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  Fig. 6. Postoperative right internal carotid digital subtraction angiography (A) frontal and (B) trans-orbital oblique projections were done after embolization. Those demonstrate no aneurysmal filling and maintained patency of parent lenticulostriate artery (white arrow).

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