A Ruptured Aneurysm of the Transdural Anastomotic Artery Occurring at the Temporal Base in Moyamoya Disease: Case Report and Literature Review.

A 24-year-old woman with hemorrhagic onset moyamoya disease received bilateral indirect bypass surgery 11 years ago. She presented with a life-threatening atraumatic acute right subdural hematoma with temporal lobe intracerebral hemorrhage due to a transdural anastomosis (TDA) aneurysm rupture. We reviewed six cases of rare TDA aneurysms, all of which occurred around the temporal base. TDA aneurysms may occur near the main trunk of the middle meningeal artery (MMA) where hemodynamic stress is high. Therefore, we must pay attention to skull base aneurysms that form near the MMA; otherwise, the prognosis would be poor if such an aneurysm ruptured.

Life-Threatening Hemorrhagic Moyamoya Disease: Report of Rare Case of Atraumatic Acute Subdural Hematoma Due to Ruptured Transdural Anastomosis.

BACKGROUND: Atraumatic acute subdural hematoma (ASDH) associated with moyamoya disease (MMD) is rare, and only a few studies have reported the bleeding origin. We present a case of atraumatic ASDH attributable to a transdural anastomosis that developed owing to the compensatory mechanisms involved in the pathogenesis of advanced MMD. This is the first case of life-threatening atraumatic ASDH associated with MMD in which the rupture point was clearly visualized using a 3-dimensional rotational reconstructed image. CASE DESCRIPTION: A 37-year-old woman presented with sudden-onset, serious, atraumatic ASDH requiring emergency decompressive craniectomy. The cerebral angiograms revealed that she had advanced MMD with transdural anastomosis that was classified as Suzuki stage V with a 5-mm saccular aneurysm in the middle meningeal artery on the affected side, which was suggested as the bleeding origin. Follow-up angiograms demonstrated that the aneurysm spontaneously disappeared and was inferred to be a pseudoaneurysm. We performed a left extraintracranial bypass to prevent recurrent hemorrhage. With intensive rehabilitation, the patient accordingly achieved stroke-free survival with a modified Rankin Scale score of 3 for 1 year. CONCLUSIONS: Atraumatic ASDH associated with MMD is a rare type of hemorrhagic MMD, and a 3-dimensional-rotational reconstructed image was useful to confirm the origin of the bleeding. The transdural anastomosis development most likely correlates with the occurrence of any type of hemorrhagic MMD. We should consider that the transdural anastomosis collapse can cause a life-threatening atraumatic ASDH and should plan a surgical strategy carefully so as not to destroy collateral supply through the transdural anastomosis in such cases.

Chronic subdural hematoma associated with moyamoya disease.

Chronic subdural hematomas (SDHs) associated with non-operated moyamoya disease are extremely rare. A 68-year-old woman underwent burr-hole surgery for a right SDH, which resolved completely. On day 3, however, the patient suffered cerebral infarction in the right parietal lobe. Cerebral angiography demonstrated total occlusion of the bilateral internal carotid arteries with transdural anastomoses via branches of the right occipital artery and middle meningeal artery, feeding the left parietal cortex. A branch of the right middle meningeal artery passed near the burr hole, but was preserved. The patient was diagnosed of moyamoya disease. We thought that the main cause of chronic SDH might be the disruption of transdural anastomoses. Furthermore, we also hypothesized that we might have coagulated the small vessels of the transdural anastomoses which were undetectable by postoperative angiography, and that cerebral infarction might occur.