Abstract
IntroductionMoyamoya disease is characterized by the gradualocclusion of distal internal carotid artery and thedevelopment of a collateral network of arteries torevascularize middle and anterior cerebral artery territo-ries. Similar collateral networks have also been describedin response to other occlusive vasculopathies differentfrom moyamoya disease. Rarely, aneurysms can formwithin these non-moyamoya collateral networks andpresent with hemorrhage. Overall, 12 cases of non-moyamoya occlusions revascularized by collateral arterialnetworks with an associated aneurysm have beenreported [1, 3–6, 9–14]. We report a case of a middlecerebral artery (MCA) occlusion with a collateral networkaneurysm. We also report two cases of aneurysm within acollateral arterial network arising from distal posteriorinferior cerebellar artery (PICA), which have not previ-ously been described. We present our management strategyand results in these three cases.Case reportsCase 1History and examinationA previously healthy 52-year-old man awoke with a severeright-sided headache, left-sided weakness, and difficultyambulating. His past medical history was not relevant. Onneurological exam, he was alert and oriented. He had a leftfacial droop and left hemiparesis with 4/5 strength in hisarm and leg.Diagnostic studiesHead CT scan revealed a right-sided 2.5-cm basal gangliahemorrhage. Cerebral angiography revealed a proximalocclusion of the right M1 MCA segment. A tangle of smallcaliber, tortuous arteries originating from the right A1anterior cerebral artery (ACA) segment reconstituted theM1 segment distally. The distal MCA and its branches hadnormalcaliberandcourse.A2-mmaneurysmwasseenwithinthat collateral network (Fig. 1a). Left internal carotid artery(ICA) angiography demonstrated normal left-sided vascula-ture with filling of the right-sided collateral network via apatent anterior communicating artery. Bilateral P1 segmentswere patent, and no arteriovenous shunting was observed.ManagementThe surgical plan was to perform a superficial temporalartery (STA) to MCA bypass to augment flow to the right
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