Managing intervention for severe intraventricular hemorrhage casting in moyamoya disease: Report of two cases

INTRODUCTION: When severe intraventricular hemorrhage (IVH) casting in moyamoya disease (MMD) is mentioned, experts advocate not to evacuate the IVH in acute phase. However, the devastating outcomes derived from this empirical rule have not been addressed. Herein, we report two MMD cases undergoing obliteration of ruptured aneurysm and early complete aspiration of severe IVH casting, and showed good outcomes. PRESENTATION OF CASES: Case 1: A 55-year-old woman was admitted to our hospital. Her initial Glasgow Coma Scale (GCS) was 4 and a computerized tomography (CT) scan showed severe IVH. Cerebral angiography (CAG) revealed MMD and an aneurysm. Direct surgery was performed for the ruptured aneurysm, followed by endoscopic complete aspiration of residual IVH. The modified Rankin Scale (mRS) was 1 at discharge. Case 2: A 44-year-old woman was admitted to our hospital. Her initial GCS was 4 and the CT scan showed a severe IVH. CAG revealed MMD and an aneurysm. Transcatheter arterial embolization was carried out for the aneurysm, followed by endoscopic complete aspiration of the residual IVH. The mRS was 2 at discharge. DISCUSSION: Performing only external ventricular drainage in acute phase for such IVH casting is generally preferred way, however, there are no scientific date supporting this empirical rule. Early surgical removal of severe IVH casting is an approach for severe IVH casting in MMD. CONCLUSION: Early aspiration of severe IVH casting is an option for managing MMD with critical intracranial pressure, and it has the potential to prevent poor outcomes in MMD patients with severe IVH.