Development of Intracerebral Hemorrhage and Subarachnoid Hemorrhage Shortly after Cerebral Infarction Onset in an Adult Patient with Moyamoya Disease

Abstract

Here we describe the case of a patient with moyamoya disease who developed cerebral infarction followed shortly by subarachnoid hemorrhage and intracerebral hemorrhage. A 50-year-old woman presenting with sudden and transient weakness of the left lower limb was transferred to a local hospital. Magnetic resonance imaging(MRI)revealed cerebral infarction in the corpus callosum and in the bilateral frontal lobes induced by moyamoya disease. Pyramidal tract was not affected. The patient was treated with an anti-platelet agent(ozagrel sodium 160mg/day)and did not undergo intentional antihypertensive therapy. The patient's averaged blood pressure was 150/90mmHg. Six days after symptom onset, the patient's orientation deteriorated. Head computed tomography scans revealed a subarachnoid hemorrhage in the right sylvian fissure and in the bilateral frontal lobes and an intracerebral hemorrhage adjacent to the left corona radiata. In addition, MRI revealed a significant expansion of the cerebral infarction in the bilateral frontal lobes. Angiography with arterial catheterization confirmed that the patient's symptoms met diagnostic criteria of stage III moyamoya disease. Positron emission tomography revealed hemodynamic compromise in the left cerebral hemisphere. The patient underwent a superficial temporal artery-middle cerebral artery anastomosis with encephalo-duro-myo-synangiosis. The patient's postoperative course was uneventful. Postoperative T2^*-weighted MRI revealed multiple microbleeds in both cerebral hemispheres.