Surgical Revascularization: Ligation of Extracranial Internal Carotid Artery and Superficial Temporal Artery-to-Middle Cerebral Artery Bypass in Patient with Extracranial Internal Carotid Aneurysm and Hemorrhagic Moyamoya Disease

BACKGROUND: Extracranial internal carotid artery (EICA) aneurysm is regarded as a rare lesion. What is more, patients can suffer from EICA aneurysms and hemorrhagic moyamoya disease (MMD) simultaneously. CASE DESCRIPTION: A 38-year-old man was admitted to our hospital and underwent emergent tracheal intubation for hoarseness and breathing difficulty for 1 day. He had a pulsating mass of 2.5 cm in diameter in the left cervical area. Imaging examinations revealed the left EICA aneurysm and MMD. The patient underwent left superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass and ligation of the left EICA simultaneously. Computed tomography revealed hemorrhagic stroke in the right basal ganglia region 20 days after the bypass. The hematoma disappeared 20 days after the stroke. Right bypass was performed 6 months after the left bypass. The patient was discharged with no neurologic abnormalities 10 days after the right bypass. He lived a normal life, and no neurologic abnormalities were found at the 6-month follow-up. Imaging examinations indicated the efficacy of the bilateral STA-MCA bypass and verified the disappearance of the left EICA aneurysm after the ligation. CONCLUSIONS: We present a case of EICA aneurysm and hemorrhagic MMD. Ligation of the left ECA eliminates the EICA aneurysm with no neurologic abnormalities. STA-MCA bypass can be regarded as an effective choice for hemorrhagic MMD. Further studies should be performed to confirm the effectiveness of combined surgical revascularization.