J Cerebrovasc Endovasc Neurosurg.  2023 Mar;25(1):87-92. 10.7461/jcen.2022.E2022.07.001.

Pseudoaneurysm formation or dural arteriovenous fistula formation at the middle meningeal artery following revascularization surgery in Moyamoya disease

• Seo D
• Yoon BH
• Byun J
• Park W
• Park JC
• Ahn JS

• KMID: 2540812
• DOI: http://doi.org/10.7461/jcen.2022.E2022.07.001

Abstract

Moyamoya disease (MMD) is a rare progressive steno-occlusive cerebrovascular disorder. Currently, revascularization surgery is used as optimal treatment to overcome MMD. However, revascularization for MMD has reported several complications. Also, iatrogenic complications such as pseudoaneurysms formation or dural arteriovenous fistulas (dAVFs) formation—has been identified in rare cases after the surgical intervention for revascularizations.
We describe two cases. In first case, the patency of the anastomosis site was good and saccular type pseudoaneurysm formation was found at parietal branch of posterior middle meningeal artery (MMA) in transfemoral cerebral angiography (TFCA) performed on the twelfth day after surgery. We decided to treat pseudoaneurysm by endovascular embolization the next day, but the patient was shown unconsciousness and anisocoria during sleep at that day. Computed tomography showed massive subdural hemorrhage at the ipsilateral side, thus we performed decompressive craniectomy and hematoma evacuation.
In second case, the patency of the anastomosis site was good and dAVF formation at right MMA was found in TFCA performed on the sixth day after surgery. We performed endovascular obliteration of the arteriovenous fistula under local anesthesia.
Pseudoaneurysm formation or dAVF formation after revascularization surgery is an exceptional case. If patients have such complications, practioner should carefully screen the patients by implementing digital subtraction angiogram to identify anatomic features; as well as consider immediate treatment in any way, including embolization or other surgery

Keyword

Moyamoya disease; Arteriovenous fistula; Pseudoaneurysm; Revascularization

Figure

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  Fig. 1. Pseudoaneurysm at proximal part of anastomosis site of STA. Pseudoaneurysm from middle meningeal artery on digital subtraction angiogram (white arrow heads) (A) anterior-posterior view and (B) lateral view. (C) Brain computed tomography (CT) showed epidural hemorrhage due to ruptured pseudoaneurysm. (D) Brain CT showed parenchymal low density at ipsilateral hemisphere after hematoma evacuation. STA, superficial temporal artery

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  Fig. 2. dAVF formation at right middle meningeal artery (MMA). dAVF occurring between MMA and middle meningeal vein on digital subtraction angiogram (white arrow heads) (A) anterior-posterior view and (B) lateral view. (C) Occluded dAVF beside black arrows on digital subtraction angiogram after glue embolization. dAVF, dural arteriovenous fistula

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