[A case of moyamoya disease in the aged associated with cerebral embolism]

We reported a rare case of Moyamoya disease in the aged associated with cerebral embolism. A 76-year-old female was brought into our hospital by ambulance 30 min after an attack of fainting. She had no past history of cerebrovascular disease. On admission her consciousness level was JCS 3-IA and she showed Rt. hemiparesis ECG exhibited Af tachycardia. No abnormal region was recognized on brain CT. Emergency cerebral angiograms (AG) disclosed that unexpectedly she had Moyamoya disease. Stenotic or occluded lesions were seen from bilateral IC terminal portions to MCA and ACA, and basal moyamoya vessels were visualized. Transdural anastomosis was poor and posterior circulation was the main source of collateral flow. Mode of onset and neurological signs suggested that the cause of the attack was Lt. MCA occlusion at its sphenoidal portion by cardiogenic embolism. Superselective endovascular fibrinolysis was carried out by the use of urokinase and low molecular weight Dextran and Lt. MCA was able to be recanalized. She was recovered without neurological deficit. Lt. STA-MCA anastomosis and encephalo-myosynangiosis was performed in the chronic stage because stenosis had remained in Lt. MCA and hypo-perfusion in bilateral frontal lobes was presented on SPECT. Post-operative AG demonstrated that Lt. MCA was occluded but Lt. frontal lobe was supplied with plenty of blood flow from Lt. STA. During the next day morning, she had another attack of fainting and showed moderate consciousness disturbance and motor aphasia. No abnormal change was noticed on brain CT. Emergency AG revealed that Lt. STA had become stuffed up with embolic and bypass flow had disappeared. Superselective endovascular fibrinolysis was able to recanalize the blood flow imperfectly, but mild motor apasia remained due to Lt. frontal infarction.