Single-stage aneurysm clipping and revascularization for moyamoya disease with ruptured aneurysm: a case report

• First comprehensively documented case of single-stage aneurysm clipping combined with STA-MCA bypass in the acute phase of ruptured aneurysm associated with moyamoya disease. • Individualized decision-making is critical—bypass addition reduces postoperative ischemia risk, but requires careful evaluation of cerebral hemodynamics and intracranial pressure status. The optimal treatment strategy for moyamoya disease (MMD) complicated by ruptured intracranial aneurysms remains controversial. Most studies recommend addressing the aneurysms in the first stage and treating the MMD in a delayed fashion. Reports of simultaneous surgical interventions are exceptionally rare. A 58-year-old male patient was admitted for a spontaneous left frontal hemorrhage. Preoperative computed tomography angiography (CTA) revealed aneurysm in the left middle cerebral artery (LMCA). Subsequent digital subtraction angiography (DSA) showed an occlusion of the main trunk of the LMCA accompanied by moyamoya vessel formation. The aneurysm originated from the atretic LMCA trunk. The patient underwent microsurgical clipping of the aneurysm. Concurrently, a left superficial temporal artery–middle cerebral artery (STA–MCA) bypass combined with encephalo-duro-myo-synangiosis (EDMS) was performed for the MMD. The patient recovered well after the surgery, and follow-up CTA confirmed patency of the bypass graft with no filling of the aneurysm. For patients with moyamoya disease complicated by an ipsilaterally ruptured intracranial aneurysm (IA), a simultaneous clipping of the aneurysm with revascularization procedures is a technically feasible treatment option, yet surgical indications must be carefully evaluated.