This document summarizes a presentation on treating ruptured choroidal artery aneurysms in patients with Moyamoya disease. It describes a literature search that found 30 relevant cases, most involving posterior choroidal artery aneurysms. Of the patients treated conservatively, two re-hemorrhaged. Among those who underwent treatment, some experienced postoperative deficits, but no significant difference in outcomes was reported between surgical clipping and endovascular coiling approaches. The search was challenging due to the need for multiple search terms and large number of duplicates found across databases.

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Presented by Dr Chris Davidoff
in collaboration with Dr Markus Wiedmann
and Prof Marcus Stoodley
EBS Presentation 16/3/17
Treatment of ruptured choroidal artery aneurysms in the setting
of Moyamoya disease

2. Case Presentation
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TREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING
OF MOYAMOYA DISEASE
• 34yr old female presents with sudden onset headache
• associated with nausea and vomitting
• 10 days post-partum

3. Case Presentation
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TREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING
OF MOYAMOYA DISEASE

4. Case Presentation
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TREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING
OF MOYAMOYA DISEASE

5. Case Presentation
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TREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING
OF MOYAMOYA DISEASE

6. Case Presentation
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TREATMENT OF RUPTURED CHOROIDAL ARTERY ANEURYSMS IN THE SETTING
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7. P – patients who have a ruptured choroidal artery aneurysm in the setting of
Moyamoya disease
I – surgical treatment or interventional embolisation
C – patients conservatively managed
O – morbidity and mortality
Question: “What is the morbidity and mortality of treating a patient with a
ruptured choroidal artery aneurysm in the setting of Moyamoya
disease”
Searchable Question (PICO)
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8. • Medline
• Embase
• Scopus
Search Strategy
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9. Search Results
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Initial Medline Search

10. Search Results
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Revised Medline Search

11. Search Results
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Revised Medline Search – Database Updated

12. Search Results
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Embase Search

13. Search Results
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Scopus Search

14. Search Results
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Markus’ Scopus Search

15. Search Results
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Medline 194 articles Embase 362 articles Scopus 362 articles
Total papers 918
Abstracts reviewed 397
Excluded 8
Articles retrieved 21
Excluded 376
Duplicates removed 521
Articles reviewed 13

16. Results
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Authors Year No. of
Patients
Aneurysm
Location
Intervention Follow Up Morbidity&
Mortality
Ali et al 2004 1 R PChoA + L thalamo
perforator
clipping 6 month *re-haemorrhage
prior to treatment
Chen et al 1988 1 L AChoA N/A lost to follow
up
N/A
Chong et al 2007 1 R AChoA AChoA trapping +
aneurysm excision
12 months reduced speech
fluency, impaired fine
motor, higher
cognitive dysfunction
Choulakian et al 2010 1 L AChoA nBCA embolisation 6 months N/A
Hamada et al 1994 2 L PChoA
R AChoA
clipping
clipping + STA-MCA
6 months
3 weeks
hemiparesis –
improved
hemiparesis –
transient
He et al 2013 3 L PChoA
L PChoA
Bilateral AChoA
clipping + STA-MCA
+ EDMS
clipping + STA-MCA
+ EDMS
N/A
34 months
21 months
4 months
N/A, GOS 5
N/A, GOS 5
re-haemorrhage

17. Results
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Authors Year No. of
Patients
Aneurysm
Location
Intervention Follow Up Morbidity&
Mortality
Kawaguchi et al 1996 2 Basilar tip + PChoA
PChoA
clipping + STA-MCA
ventricular drainage +
bilateral STA-MCA
3 months
3 months
GOS 5
GOS 4
Kawai et al 1997 1 R AChoA N/A 18 months re-haemorrhage
Kim et al 2009 7 R PChoA
L ACho A
R PChoA
R PChoA
L PChoA
R PChoA
R PChoA
nBCA embolisation
nBCA embolisation
nBCA embolisation
nBCA embolisation
nBCA embolisation
nBCA embolisation
nBCA embolisation
11-60 months,
mean 4
months
“Stupor”
N/A
N/A
N/A
N/A
N/A
“Stupor”
Kodama et al 1978 3 L PChoA
R PChoA
L PChoA
N/A
N/A
N/A
6 weeks
11 months
3.5 months
not reported
not reported
not reported

18. Results
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Authors Year No. of
Patients
Aneurysm
Location
Intervention Follow Up Morbidity&
Mortality
Liu et al 2016 5 PChoA
PChoA
PChoA
AChoA
PChoA
Onyx embolistion
N/A
N/A
Onyx embolistion
N/A
3-11 years,
mean 6.4
years
all cases reported as
mRS of
0 or 1 (but not
individually specified)
Okawa et al 2013 1 R lateral PChoA -
pseudoaneurysm
trapping + resection of
pseudoaneurysm
3 months N/A
Yang et al 2010 2 L AChoA
L AChoA
Glubran 2
embolisation
coil embolisation
1 year
1 year
N/A
N/A

19. Results Summary
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Overall summary of patients
• 30 patients that match criteria
- 10 AChoA, 20 PChoA
• most studies are case reports, few case series
• 9 patients treated conservatively – 2 re-haemorrhaged
• 12 patients underwent endovascular treatment
- 2 patients had deficits post-op (?severe)
• 9 patients underwent surgical treatment
- 3 patients had deficits post-op

20. • balance between keeping search broad and trying to focus in on area of
interest
• multiple search terms needed for ruptured aneurysms
• had to keep search broad to avoid missing cases
• large number of papers to manually sort through
• large number of duplicates – Endnote X8 does not filter these well
Difficulties of Search
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21. • ruptured posterior choroidal artery aneurysms are twice as common as
anterior choroidal artery aneurysms in the setting of Moyamoa disease
• in the setting of a ruptured aneurysm, the majority of patients are treated
• 2 of 9 reported conservatively treated cases re-haemorrhaged*
• majority of reported cases were treated endovascularly
• no significant difference in the morbidity and mortality between surgical and
endovascular treatment reported
Conclusions
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