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Management of Concomitant Moyamoya Disease, Arterial Venous Malformation, and Intracranial Aneurysm: Case
Mark T Mills1, Arif Zafar1, Kishor A Choudhari2
1Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, NHS Foundation Trust, Western Bank, Sheffield, UK.
Background:
Moyamoya disease (MMD), arterial venous malformations (AVMs), and intracranial aneurysms are distinct cerebrovascular disease processes that most commonly occur in isolation. The literature on the treatment algorithm of each individual condition is well established. An association between MMD and intracranial aneurysms is also known, but MMD in association with AVM is rare.
Case Descriptions:
The authors discuss various dilemmas in the multimodality management of these conditions when they coexist with an illustrative case of a 46-year-old woman who presented following a stroke, with 1) left-sided MMD, 2) left-sided frontal AVM, and 3) an aneurysm arising from the A1 segment of the right anterior cerebral artery. These were managed respectively by 1) the left external carotid artery to M2 segment of middle cerebral artery bypass using an autologous radial artery graft and left indirect superior temporal artery-encephaloduroarteriosynangiosis, 2) stereotactic radiosurgery, and 3) endovascular coiling of the aneurysm. Three years following intervention, cerebral angiography showed a patent bypass, complete obliteration of the AVM, and no residual filling of the coiled aneurysm.
Conclusions:
Our strategy of surgical revascularization for MMD, radiosurgery for AVM, and endovascular coiling for aneurysm resulted in a positive long-term clinical outcome. In view of the rarity of the condition, the authors propose a management algorithm for such patients.
Insights
Moyamoya disease (MMD), arterial venous malformations (AVMs), and intracranial aneurysms rarely coexist. A combined treatment strategy of surgical revascularization, radiosurgery, and endovascular coiling achieved positive long-term outcomes.
Area of Science:
- Cerebrovascular diseases
- Neurosurgery
- Interventional neuroradiology
Background:
- Moyamoya disease (MMD), arterial venous malformations (AVMs), and intracranial aneurysms are typically isolated conditions.
- While MMD and aneurysms can coexist, MMD associated with AVMs is exceptionally rare.
- Established treatment algorithms exist for each condition individually.
Observation:
- A 46-year-old woman presented with stroke due to coexisting left-sided MMD, left frontal AVM, and a right anterior cerebral artery aneurysm.
- The patient underwent a multimodality treatment approach.
- Management included bypass surgery for MMD, stereotactic radiosurgery for the AVM, and endovascular coiling for the aneurysm.
Findings:
- Post-intervention angiography at 3 years demonstrated a patent bypass graft.
- Complete obliteration of the AVM was confirmed.
- No residual filling of the treated aneurysm was observed.
Implications:
- A combined treatment strategy of surgical revascularization, radiosurgery, and endovascular coiling can lead to favorable long-term outcomes in complex cerebrovascular cases.
- The authors propose a management algorithm for rare instances of coexisting MMD, AVMs, and intracranial aneurysms.
- This case highlights the successful multimodality management of a rare and complex cerebrovascular presentation.
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