Moyamoya disease in a patient with brain tumor: case report

A 40-year-old male presented to emergency room with epileptic grand mal seizure. He had untreated hypertension, and prior diagnostic investigation showed duplex renal arteries of the right kidney with hyperreninemia in the left renal vein. He was nonsmoker, with moderate alcohol intake. Neurologic examination was normal except for high blood pressure and tongue bite. Electroencephalogram was nonspecific. Nuclear magnetic resonance (NMR) showed vascular lesions in the white matter and infratentorially an expansive lesion with no postcontrast imbibition in the right cerebellar hemisphere. Neurosonography revealed hypoplasia of both internal carotid arteries (ICA), mean diameter <2 mm, subtotal stenosis at the origin of both ICA, and development of collateral path, typical for moyamoya disease. Magnetic resonance angiography (MRA) and digital subtraction angiography (DSA) confirmed the neurosonography diagnosis. Immunologic tests for vasculitis were negative, while hematologic examination showed 4G allele for PAI-1. Serum lipids were elevated. We recommended neurosurgical operation of brain tumor. Histopathologic finding showed meningioma. This case is interesting because of the rare complex cerebrovascular disease, i.e. coexistence ofhypoplasia of both ICA, bilateral subtotal stenosis of ICA, intracranial moyamoya disease, and brain tumor.