Abstract 77: Circulating miRNome in Moyamoya Discordant MZ Twins - Implications for Endothelial Biofunctions

Objective: We aim to investigate circulating genome-wide microRNA (miRNome) profiles in Moyamoya disease-discordant monozygotic (MZ) twins with the RNF213 founder mutation (rs112735431), since the etiology remains unclear even after the identification of RNF213.

Methods: Circulating miRNome was screened in a pair of Moyamoya-discordant MZ twins and a validation cohort (unrelated 9 cases and 8 normal controls) using microarray and validated by quantitative real-time PCR. Differential plasma microRNAs were quantified in endothelial cells differentiated from iPS cell line (iPSECs) derived from unrelated 3 cases and 3 controls. Gene expressions targeted by the significant microRNAs in iPSECs was studied using published iPSEC-transcriptome and bioinformatics tool.

Results: A total of 537 circulating microRNAs were detected in the Moyamoya-discordant MZ twins and the validation cohort. Unsupervised cluster analysis demonstrated 2 discrete miRNome, predominantly by disease, but the MZ twins showed similar miRNome profiles, regardless of phenotypic discordance (Fig. 1A). Across the 143 and 98 differential microRNAs in the MZ twins and validation cohort, 23 microRNAs were overlapped (Fig. 1B). A cluster of plasma hsa-miR-6722-3p/-328-3p/150-5p was significantly up-regulated in patients in the validation cohort (p < 0.05) (Fig. 1C). In iPSECs, hsa-miR-6722-3p/-328-3p cluster was up-regulated with a greater than 3.0-fold change in patients. Bioinformatics analysis revealed that 94 target genes involving organismal injuries and cell survival/maintenance were significantly down-regulated in Moyamoya-iPSECs (p < 0.05, q < 0.1), suggesting the regulatory role of the miR-6722/-328 cluster in endothelial gene expression (Fig. 1D).

Conclusions: Differential plasma-miRNAs in Moyamoya-discordant MZ twins may potentially serve as a diagnostic biomarker in Moyamoya disease and regulate endothelial gene expression.

Preparing Japanese surgeons for potential mass casualty situations will require innovative and systematic programs

INTRODUCTION

The ongoing state of global geo-political instability means that it is prudent to prepare civilian surgeons to manage major military-type trauma. Japan has enjoyed a prolonged period of peace and consequently it is unlikely that surgeons will have been exposed to a sufficient volume of cases. This study reviews the state of trauma training and preparedness in Japan and reviews the trauma workload of a major Japanese emergency medical center and compared with a major South African trauma center with the intention of quantifying and comparing the time needed to gain adequate exposure to major trauma at the two centers.

MATERIALS AND METHODS

The literature describing the surgical burden from a number of recent military missions was reviewed and the core surgical skills to manage military-type injuries were identified. We then went on to review all patients admitted to both Kurashiki Central Hospital (KCH) and Pietermaritzburg Metropolitan Trauma Service (PMTS) following trauma between the period September 2015 and August 2016. The burden of trauma at each center was quantified and the number of core surgical competencies or procedures performed at each center was then reviewed. These were then compared with the number of the core procedures which were performed on the reported military missions.

RESULTS

Three reports on military surgical missions were reviewed. These came from the Dutch, French and British military surgical services. The average number of each core procedures performed on each reported military surgery mission are tabulated in the text. The most common procedures were wound debridement and orthopedic fixation, followed by trauma laparotomy, neck exploration and thoracotomy. During the 12 month study period, 309 trauma patients were admitted to KCH. Of which 206 (67%) were male, and the mean age was 57 years. There were 10 penetrating injuries and 299 blunt injuries. Of the penetrating injuries there were no gunshot wounds. The mechanisms of injury for blunt trauma were as follows: Road traffic accidents (RTAs); 141 (47%), fall; 136 (46%) and other injuries; 22 (7%). In the same period, 2887 trauma patients were admitted by the PMTS. There were 1244 cases (43%) of penetrating trauma and 1644 cases (57%) of blunt trauma in PMTS. The mechanisms of injury for penetrating trauma were as follows: stab wounds (SWs); 955 (77%), gunshot wounds (GSWs); 252 (20%), and other injuries; 37 (3%) and for blunt trauma were as follows: assault; 739 (45%), RTAs; 669 (41%), fall; 166 (10%), and other injuries; 70 (4%). The exposure to all the key competencies required to manage trauma is overwhelmingly greater in South Africa than in Japan. The length of time needed to obtain an equivalent trauma exposure to that achieved in South Africa, working in Japan is prohibitively long.

CONCLUSION

Trauma training in Japan is hamstrung by a lack of clinical material as well as by systematic factors. Training a trauma surgeon is difficult. Developing a trauma system in the country may help address some of these deficits. South Africa in contrast has a huge burden of trauma and sufficient infrastructure to ensure that surgeons working there have adequate exposure to major trauma. Developing an academic exchange program between Japan and South Africa may allow for the transfer of trauma experience and skills between the two countries.

Novel insights into symptomatology of moyamoya disease in pediatric patients: survey of symptoms suggestive of orthostatic intolerance

OBJECTIVE A specific population of young patients with moyamoya disease (MMD) persistently experience physical symptoms not attributable to focal ischemia. These symptoms, highly suggestive of orthostatic intolerance (also termed "orthostatic dysregulation"), were investigated and reported as potential determinants of quality of life in young MMD patients. METHODS Forty-six patients (6-30 years of age) were selected from a group of 122 patients who were diagnosed with MMD before 18 years of age. The authors administered a structured questionnaire consisting of 11 items based on screening checklists published in the Japanese clinical guidelines for juvenile orthostatic dysregulation in young patients. The results were tabulated, and correlations with clinical data were explored. RESULTS Thirty-seven (80%) patients (mean age 15.9 years) responded to the questionnaire. Frequent headache, vertigo/dizziness on standing, fatigue, difficulty with getting out of bed, and motion sickness were the top 5 symptoms, resulting in 57% of patients being unable to attend school. Forty-three percent of the patients demonstrated multiple symptoms suggestive of orthostatic intolerance, even as long as 5 years after revascularization surgery. The number of symptoms was inversely associated with the number of years after surgery (p = 0.028). The number of symptoms was not associated with a history of surgery, clinical presentations, vascular involvement, cerebral perfusion, brain lesions, or history of transient ischemic attacks. CONCLUSIONS The present study provided novel insight into the symptomatology of young patients with MMD. Failure to notice nonfocal physical symptoms can significantly impair quality of life in young patients with MMD even years after successful revascularization surgery. These symptoms may serve as independent clinical markers used to assess disease outcome, although the underlying mechanisms of this disease are, as of yet, unclear.

Downregulation of Apolipoprotein-E and Apolipoprotein-J in Moyamoya Disease-A Proteome Analysis of Cerebrospinal Fluid

BACKGROUND AND PURPOSE

Genetic factors are closely involved in the etiology of moyamoya disease (MMD). However, its postgenomic mechanisms are still unknown. This study was aimed to identify specific biomarkers in the cerebrospinal fluid (CSF) of patients with MMD, using quantitative proteome technique.

METHODS

This study included 10 patients with MMD and 4 controls. The CSF was collected without blood contamination during surgery. A comparative 2-dimensional gel electrophoresis study (2D-PAGE) was performed. Protein spots that showed significant differences between moyamoya patients and controls were selected for further analysis by mass spectrometry.

RESULTS

On 2D-PAGE, 2 proteins were significantly upregulated, and 2 other proteins were downregulated in the CSF of MMD. Further mass spectrometry analysis revealed that haptoglobin and α-1-B-glycoprotein (A1BG) were upregulated. On the other hand, apolipoprotein-E (apoE), apoE precursor, and apolipoprotein-J (apoJ) were significantly downregulated in the CSF of MMD. The observed probability-based MOWSE score was 72 for haptoglobin (P <.05), 521 for A1BG (P <.05), 62 for apoE (P <.05), 72 for apoE precursor (P <.05), and 112 for apoJ (P <.05).

CONCLUSION

Although the role of A1BG in the central nervous system is still unknown, the overexpressed haptoglobin may indicate the inflammation and/or angiogenesis in MMD. The downregulation of apoE and apoJ strongly suggests a critical role of lipid metabolism in the development and progression of MMD. These proteins may be novel biomarkers in shedding light on the pathogenesis of MMD, although further studies would be warranted.

Mapping altered brain connectivity and its clinical associations in adult moyamoya disease: A resting-state functional MRI study

Detection of subtle ischemic injuries in moyamoya disease may enable optimization of timing of revascularization surgery, and could potentially improve functional outcomes. Resting-state functional magnetic resonance imaging (rs-fMRI) is widely used to study functional organization of the brain, but it remains unclear whether rs-fMRI could elucidate distinct characteristics in moyamoya disease. Here, we aimed to determine changes in a conventional rs-fMRI measure and analyze any associations with clinical symptoms and cerebral hemodynamics. Thirty-one adults with moyamoya disease and 25 adult controls underwent rs-fMRI, in which we measured brain connectivity via temporal correlations of low-frequency BOLD signals. We identified the extent of between-group differences with multivoxel pattern analysis. Seed-based analysis was performed to determine associations with vascular lesions, symptoms, and regional cerebral blood flow (rCBF). There was significantly altered connectivity in the precentral gyrus, operculo-insular region, precuneus, cingulate cortex, and middle frontal gyrus in moyamoya disease. There was reduced connectivity in the left insula, left precuneus, right precentral, and right middle frontal regions, which form part of the salience, default mode, motor, and central executive networks, respectively. Patients with ischemic motor-related symptoms showed significantly decreased connectivity in precentral homotopic regions compared with those without, while there were no differences in vascular lesions or rCBF. Connectivity between the right occipital and left hippocampus was significantly associated with cognitive performance and posterior cerebral artery involvement. Our results demonstrate distinct alterations in the temporal correlations of low-frequency BOLD signals, predominantly in resting-state networks in moyamoya disease. Additionally, rs-fMRI measures were associated with ischemic motor-related symptoms and cognitive performance in the patients. Thus, rs-fMRI may offer a useful non-invasive method of acquiring additional information beyond cerebral perfusion as part of clinical investigations in patients with moyamoya disease.

Proposal for a Prospective Registry for Moyamoya Disease in Japan

The number of clinical research papers published worldwide on moyamoya disease (MMD) has increased recently. However, the majority of the literature comprises retrospective single-center studies collecting data on small numbers of patients. Several multi-center studies are ongoing in Japan; however, the current data are insufficient for comprehensively outlining the various characteristics of MMD. To enhance our knowledge on epidemiologic, vascular, and genetic aspects of MMD, a prospective multicenter registry will be established in Japan that will help to streamline clinical research as well as improve clinical treatments and long-term outcomes. Patients with MMD or secondary moyamoya syndrome referred to the participating centers will be invited to the registry. Demographic and physiological parameters, along with neuroimaging data will be collected chronologically. Clinical events, including neurological, medical, and surgical interventions will be recorded. Whole blood samples will be collected. Extra- and intracranial vascular tissue, and/or cerebrospinal fluid will also be collected from patients who undergo surgical revascularization. These biospecimens will be stored at the repositories and utilized for genome-wide association studies for identifying genetic variants, as well as tissue-specific proteomic, and/or molecular analyses. Ethics approval will be obtained at all facilities collecting biospecimens. The registry will provide descriptive statistics on functional outcomes, surgical techniques used, medications, and neurological events stratified according to patients’ clinical characteristics. We expect this study to provide novel insights in the management of MMD patients and design better therapies.

Abstract TP448: Genome-wide CNV Array Analysis Following Post-hoc Targeted Amplicon Sequencing Revealed Genetic Anticipation in Parent-offspring Pairs with Moyamoya Disease

Introduction: Molecular mechanisms underlying clinical observation of progressively earlier age of onset of Moyamoya disease (MMD) as it is passed on to the next generation, as known as clinical anticipation, is still obscure. This study investigates copy number variation (CNV) in parent-offspring pairs with MMD with and without clinical anticipation using genome-wide CNV array following high-throughput DNA sequencing.

Methods: Fifteen out of 25 consecutive Japanese parent-offspring pairs with MMD treated at our institute since 1980 were enrolled. Demographics, inheritance pattern, angiographical stage, disease type at onset were reviewed. Using genomic DNA from whole blood, rs112735431 in RNF213 gene was genotyped, then genome-wide CNV analysis was conducted using a 2.6 M oligonucleotide array to compare CNV profile in parent-offspring pairs with and without clinical anticipation. Amplicon Sequencing was further conducted using Miseq.

Results: Clinical anticipation was observed in 10 pairs (67%) and was not in 5 pairs (33%). In clinical anticipation group, mean age at onset was significantly lower in the offsprings than in the parents (p<0.001). There were no significant differences in other clinical and genetic backgrounds, including the genotype in RNF213 between the generations and between the groups with and without clinical anticipation. Genome-wide CNV profiling revealed that 10 CNV in chr7q, 8p, 9q, 14q, 16p, 19p, 20q, and 22q were overlapped for more than 3 individuals in the whole studied population. Of these CNV, copy number was different only in chr16p13.3 between the generations in clinical anticipation group (P=0.06). Fourteen genes were observed in this locus, including GNPTG gene, whose mutation is known to be associated with mucolipidosis. Amplicon sequence targeting these 14 genes revealed significant copy number loss at GNPTG gene locus, in the offsprings compared to their parent (P = 0.02, copy number = 1.8 and 2.0, respectively).

Conclusion: These data suggest clinical anticipation of MMD in Japanese population can be observed regardless of the RNF213 genotype. This is the first genome-wide CNV profiling, suggesting the CNV in chr16p13.3 might be underlying mechanism for anticipation in familial MMD by reducing gene dosage.

Abstract TP133: Interactive Development of Direct and Indirect Bypass After Combined Revascularization for Moyamoya Disease: The Significance of Indirect Bypass

Background & Purpose: The additional effects of indirect bypass on combined revascularization surgery in moyamoya disease (MMD) remain unclear. Our purpose in this study is to evaluate how direct and indirect bypass in combined revascularization change through long term follow up and to analyze the clinical factors or hemodynamic parameters involved in these changes.

Methods: A retrospective survey was conducted with a sample size of 97 hemispheres from 69 consecutive patients (43 adults and 26 children) with MMD treated by combined revascularization. We used magnetic resonance angiography (MRA) to evaluate bypass development with the diameters of superior temporal artery (STA) for the direct bypass and middle meningeal artery (MMA) and deep temporal artery (DTA) for the indirect bypass. A multivariate logistic regression analysis was used to study the related multiple variables on bypass development.

Results: Good indirect bypass indicated by MMA development was seen 78% of the adult hemispheres and 95% of the pediatric ones. Dual development of direct and indirect bypasses was most frequently observed (47% and 56% of the adult and pediatric hemispheres, respectively). When indirect bypasses developed, 28% of the STAs reduced in diameter reciprocally from the acute to the chronic phases after surgery. The development of indirect bypass was significantly better in the adult hemispheres at Suzuki stage 4 or greater ( P =0.02; odds ratio 7.4, 95% confidence interval, 1.4-39.4). The disease onset type and the hemodynamic parameters were not associated with the development of surgical revascularization.

Conclusions: Indirect bypass developed effectively in both adult and pediatric patients, even in the presence of direct bypass. The universal application of indirect bypass is considered an optimal surgical strategy to maximize revascularization in MMD.

Abstract TP447: Edaravone Reduces Hyperperfusion-related Neurological Deficits After Direct Bypass in Adult Moyamoya Disease

Background and Purpose: Postoperative hyperperfusion-related transient neurological deficits (TNDs) are frequently observed in adult patients with moyamoya disease (MMD) who undergo direct bypass procedures. The present study evaluated the effect of the free radical scavenger edaravone on postoperative hyperperfusion in adult MMD.

Methods: This study included 92 hemispheres in 72 adult patients who underwent direct bypass for MMD. Serial measurements of cerebral blood flow were conducted immediately after surgery and on postoperative days 2 and 7. In 40 hemispheres in 36 patients, edaravone (60 mg/day) was administered from the day of surgery until postsurgical day 7. The incidence of postoperative hyperperfusion and associated TNDs were compared with a control group that included 52 hemispheres in 36 patients.

Results: Radiological hyperperfusion was observed in 28/40 (70.0%) and 39/52 (75.0%) hemispheres in the edaravone and control groups, respectively (P = 0.30). Hyperperfusion-related TNDs incidences were significantly lower in the edaravone group compared with the control group (12.5% vs. 32.7%, P = 0.024). Multivariate analysis demonstrated that edaravone administration (P = 0.009) and left-sided surgery (P = 0.037) were significantly correlated with hyperperfusion-related TNDs (odds ratios, 0.3 and 4.2, respectively).

Conclusions: Perioperative administration of edaravone reduced the incidence of hyperperfusion-related TNDs after direct bypass procedures in adult patients with MMD.

Synergistic Interactions Between Direct and Indirect Bypasses in Combined Procedures: The Significance of Indirect Bypasses in Moyamoya Disease

BACKGROUND: Whether additional indirect bypasses effectively contribute to revascularization in combined procedures remains unclear in patients with moyamoya disease.

OBJECTIVE: To evaluate the longitudinal changes associated with combined procedures while following up pediatric and adult patients long term and to assess whether any other clinical factors or hemodynamic parameters affected these changes to determine an optimal surgical strategy.

METHODS: We studied 58 hemispheres in 43 adults and 39 hemispheres in 26 children who underwent combined revascularization for moyamoya disease. To evaluate bypass development, we assessed the sizes of the superficial temporal artery and middle meningeal artery using magnetic resonance angiography. Multivariate analysis determined the effects of multiple variables on bypass development.

RESULTS: Indirect bypass (middle meningeal artery) development occurred in 95% and 78% of the pediatric and adult hemispheres, respectively. Of these, dual development of direct and indirect bypasses occurred in 54% of the pediatric hemispheres and in 47% of the adult hemispheres. Reciprocal superficial temporal artery regression occurred in 28% of the hemispheres during the transition from the postoperative acute phase to the chronic phase during indirect bypass development. Good indirect bypass development was associated with adult hemispheres at Suzuki stage 4 or greater (odds ratio, 7.4; 95% confidence interval, 1.4-39.4; P = .02). Disease onset type and preoperative hemodynamic parameters were not considered predictors for the development of surgical revascularization.

CONCLUSION: Simultaneous direct and indirect bypass development was most frequently observed, regardless of patient age and hemodynamic status. Applying indirect bypass as an adjunct to direct bypass could maximize revascularization in adults and children.

Topographic changes in cerebral blood flow and reduced white matter integrity in the first 2 weeks following revascularization surgery in adult moyamoya disease

OBJECTIVE After revascularization surgery, hyperperfusion and ischemia are associated with morbidity and mortality in adult moyamoya disease (MMD). However, structural changes within the brain following revascularization surgery, especially in the early postsurgical period, have not been thoroughly studied. Such knowledge may enable improved monitoring and clinical management of hyperperfusion and ischemia in MMD. Thus, the objective of this study was to investigate the topographic and temporal profiles of cerebral perfusion and related white matter microstructural changes following revascularization surgery in adult MMD. METHODS The authors analyzed 20 consecutive surgeries performed in 17 adults. Diffusion imaging in parallel with serial measurements of regional cerebral blood flow (rCBF) using SPECT was performed. Both voxel-based and region-of-interest analyses were performed, comparing neuroimaging parameters of postoperative hemispheres with those of preoperative hemispheres at 4 different time points within 2 weeks after surgery. RESULTS Voxel-based analysis showed a distinct topographic pattern of cerebral perfusion, characterized by increased rCBF in the basal ganglia for the first several days and gradually increased rCBF in the lateral prefrontal cortex over 1 week (p < 0.001). Decreased rCBF was also observed in the lateral prefrontal cortex, occipital lobe, and cerebellum contralateral to the surgical hemisphere (p < 0.001). Reduced fractional anisotropy (FA) and axial diffusivity (AD), as well as increased radial diffusivity (RD), were demonstrated in both the anterior and posterior limbs of the internal capsule (p < 0.001). Diffusion parameters demonstrated the greatest changes in both FA and RD on Days 1-2 and in AD on Days 3-6; FA, RD, and AD recovered to preoperative levels on Day 14. Patients with transient neurological deteriorations (TNDs), as compared with those without, demonstrated greater increases in rCBF in both the lateral prefrontal cortex and striatum as well as smaller FAs in the posterior limb of the internal capsule (p < 0.05). CONCLUSIONS The excessively increased rCBF and the recovery process were heterogeneous across brain regions, demonstrating a distinct topographic pattern during the initial 2 weeks following revascularization surgery in MMD. Temporary impairments in the deep white matter tract and immediate postoperative ischemia were also identified. The study results characterized postoperative brain perfusion as well as the impact of revascularization surgery on the brain microstructure. Notably, rCBF and white matter changes correlated to TNDs, suggesting that these changes represent potential neuroimaging markers for tracking tissue structural changes associated with hyperperfusion during the acute postoperative period following revascularization surgery for MMD.

Characteristics of Diffusional Kurtosis in Chronic Ischemia of Adult Moyamoya Disease: Comparing Diffusional Kurtosis and Diffusion Tensor Imaging

BACKGROUND AND PURPOSE

Detecting microstructural changes due to chronic ischemia potentially enables early identification of patients at risk of cognitive impairment. In this study, diffusional kurtosis imaging and diffusion tensor imaging were used to investigate whether the former provides additional information regarding microstructural changes in the gray and white matter of adult patients with Moyamoya disease.

MATERIALS AND METHODS

MR imaging (diffusional kurtosis imaging and DTI) was performed in 23 adult patients with Moyamoya disease and 23 age-matched controls. Three parameters were extracted from diffusional kurtosis imaging (mean kurtosis, axial kurtosis, and radial kurtosis), and 4, from DTI (fractional anisotropy, radial diffusivity, mean diffusivity, and axial diffusivity). Voxelwise analysis for these parameters was performed in the normal-appearing brain parenchyma. The association of these parameters with neuropsychological performance was also evaluated.

RESULTS

Voxelwise analysis revealed the greatest differences in fractional anisotropy, followed, in order, by radial diffusivity, mean diffusivity, and mean kurtosis. In patients, diffusional kurtosis imaging parameters were decreased in the dorsal deep white matter such as the corona radiata and superior longitudinal fasciculus (P < .01), including areas without DTI abnormality. Superior longitudinal fasciculus fiber-crossing areas showed weak correlations between diffusional kurtosis imaging and DTI parameters compared with tissues with a single-fiber direction (eg, the corpus callosum). Diffusional kurtosis imaging parameters were associated with general intelligence and frontal lobe performance.

CONCLUSIONS

Although DTI revealed extensive white matter changes, diffusional kurtosis imaging additionally demonstrated microstructural changes in ischemia-prone deep white matter with abundant fiber crossings. Thus, diffusional kurtosis imaging may be a useful adjunct for detecting subtle chronic ischemic injuries.

Direct Anastomosis Using Occipital Artery for Additional Revascularization in Moyamoya Disease After Combined Superficial Temporal Artery–Middle Cerebral Artery and Indirect Bypass

BACKGROUND: The posterior cerebral artery (PCA) is involved in approximately 30% of moyamoya disease (MMD) cases. However, there have been insufficient reports describing revascularization techniques in the posterior portion of the brain, particularly of direct anastomosis.

OBJECTIVE: To perform a technical assessment in patients with MMD who underwent either occipital artery (OA)–PCA bypass or OA–middle cerebral artery (MCA) bypass.

METHODS: A total of 428 revascularization procedures in 368 patients were retrospectively assessed by reviewing clinical charts and radiological data.

RESULTS: Ten patients (3.5%) were treated with direct bypass after the anterior revascularization with a median interval of 30 months (range, 5 months-16 years). Seven patients were &lt; 18 years of age (average age, 17.5 ± 15.6 years). Preoperative symptoms included transient motor deficits involving the lower extremities (n = 5), visual disturbances (n = 6), and cerebral infarctions (n = 6). A favorable outcome (modified Rankin Scale score &lt; 3) was achieved in 9 of these 10 patients. Direct anastomosis was performed in 3 hemispheres with an OA-MCA bypass and in 8 hemispheres with an OA-PCA bypass. Patency of the direct bypass was confirmed on angiogram in 7 of 7 patients who underwent conventional angiogram performed within 1 year after the surgery. None of the 10 patients demonstrated cerebral infarctions after the posterior revascularization.

CONCLUSION: In MMD, symptomatic PCA regression after anterior revascularization was found predominantly in children and young adults. Direct anastomosis in the posterior portion of the brain can be successfully achieved and is effective in preventing ischemic events.

Edaravone Reduces Hyperperfusion-Related Neurological Deficits in Adult Moyamoya Disease

Background and Purpose—

Postoperative hyperperfusion-related transient neurological deficits (TNDs) are frequently observed in adult patients with moyamoya disease who undergo direct bypass procedures. The present study evaluated the effect of the free radical scavenger edaravone on postoperative hyperperfusion in adult moyamoya disease.

Methods—

This study included 92 hemispheres in 72 adult patients who underwent direct bypass for moyamoya disease. Serial measurements of cerebral blood flow were conducted immediately after surgery and on postoperative days 2 and 7. In 40 hemispheres for 36 patients, edaravone (60 mg/d) was administered from the day of surgery to postsurgical day 7. The incidence of postoperative hyperperfusion and associated TNDs were compared with a control group that included 52 hemispheres in 36 patients.

Results—

Radiological hyperperfusion was observed in 28 of 40 (70.0%) and 39 of 52 (75.0%) hemispheres in the edaravone and control groups, respectively ( P =0.30). Hyperperfusion-related TND incidences were significantly lower in the edaravone group compared with the control group (12.5% versus 32.7%; P =0.024). Multivariate analysis demonstrated that edaravone administration ( P =0.009) and left-sided surgery ( P =0.037) were significantly correlated with hyperperfusion-related TNDs (odds ratios, 0.3 and 4.2, respectively).

Conclusions—

Perioperative administration of edaravone reduced the incidence of hyperperfusion-related TNDs after direct bypass procedures in adult patients with moyamoya disease.

Familial moyamoya disease in two Turkish siblings with same polymorphism in RNF213 gene but different clinical features

BACKGROUND

Moyamoya disease is an uncommon, progressive, and occlusive cerebrovascular disorder, predominantly affecting the terminal segment of the internal carotid arteries and its main branches. This occlusion results at the formation of a compensatory collateral arterial network (moyamoya vessels) developing at the base of the brain. The c.14576G>A variant in ring finger protein 213 (RNF213) was recently reported as a susceptibility gene for moyamoya disease.

METHODS

We describe two Turkish pediatric siblings with moyamoya disease born to consanguineous, unaffected Turkish parents.

RESULTS

The first patient (proband) is a 2-year-old boy who presented with afebrile focal seizures, moderate psychomotor retardation, paresis in the left upper and lower extremity, multiple infarctions of the brain, stenosis of the bilateral internal carotid artery and the middle cerebral artery, and stenosis of the right posterior cerebral artery. The second patient is a 10-year-old girl who is an elder sister of proband. She showed normal psychomotor development, millimetric signal enhancement without diffusion limitation of the brain, and stenosis of the bilateral internal carotid artery.

CONCLUSION

We herein report pediatric sibling patients of moyamoya disease who have homozygous wild-type c.14576G>A variant in RNF213, showing different clinical course and disease severity. This is the first report of pediatric siblings with moyamoya disease from Turkey validating the genetic background of most frequent variant in East Asian patients with moyamoya disease.

Abstract WP61: A Novel Application of Four-dimensional Magnetic Resonance Angiography Using Arterial Spin Labeling for Assessment of Postoperative Cerebral Hemodynamic Changes in Moyamoya Disease

Introduction: Recently, four-dimensional magnetic resonance angiography without contrast enhancement using arterial spin labeling (ASL-4D MRA) has become available to visualize the intracranial arteries. However, few reports are available about the efficacy of ASL-4D MRA in moyamoya disease (MMD).

Hypothesis: We hypothesized that postoperative hemodynamic changes in MMD patients could be evaluated using ASL-4D MRA.

Methods: This study included 26 hemispheres of 21 patients who underwent combined direct and indirect revascularization for MMD. ASL-4D MRA was serially performed before and after surgery. We assessed the time phases where signals of the arteries were detected on ASL-4D MRA in order to analyze perioperative changes in cerebral hemodynamics.

Results: The signals of the anastomosed arteries on ASL-4D MRA were detected and disappeared at significantly earlier time phase after surgery than before. This change in acute period was moderated in chronic period after surgery. Postoperative hyperperfusion was observed in 12 of 26 hemispheres within 7 days after surgery. The signals of the arteries were detected significantly earlier in hemispheres with hyperperfusion than those without. In cases with hyperperfusion, ASL-4D MRA demonstrated high intensity of peripheral middle cerebral artery (MCA) around anastomosed region in early time phase (Figure). This “early hyperintensity of MCA” was observed in all cases with hyperperfusion and corresponded to the timing of the occurrence of hyperperfusion. Furthermore, this hyperperfusion-specific sign could not be detected by routine TOF MRA.

Conclusions: Noninvasive ASL-4D MRA successfully evaluated perioperative dynamic changes of cerebral blood flow and the effect of surgical revascularization in MMD. This next generation modality could also visualize cerebral hemodynamics in cases with postoperative hyperperfusion and would be quite useful for appropriate postoperative management.

Postoperative Acute Submandibular Sialadenitis after Neurosurgery: Two Case Reports and a Review of the Literature

This article details two case reports and reviews the extant literature concerning acute postoperative submandibular sialadenitis occurring in the side contralateral to the operated site after neurosurgery. Although its precise pathogenesis remains to be elucidated, it is likely related to intraoperative compression of the submandibular gland and surrounding tissues, caused by head positioning and the endotracheal tube. Submandibular swelling rapidly deteriorates after surgery, and emergent airway protection is required in most cases in order to avoid fatal airway obstruction. To avoid serious sequelae, we should be aware of acute submandibular sialadenitis that occurs contralateral to the surgical side, which, although rare, is more probable after posterior fossa surgery. When it occurs, early airway protection is crucial, and the following conservative treatment could provide a good prognosis.

Insulin and the Brain: A Sweet Relationship With Intensive Care

BACKGROUND

Insulin receptors (IRs) in the brain have unique molecular features and a characteristic pattern of distribution. Their possible functions extend beyond glucose utilization. In this systematic review, we explore the interactions between insulin and the brain and its implications for anesthesiologists, critical care physicians, and other medical disciplines.

METHODS

A literature search of published preclinical and clinical studies between 1978 and 2014 was conducted, yielding 5996 articles. After applying inclusion and exclusion criteria, 92 studies were selected for this systematic review.

RESULTS

The IRs have unique molecular features, pattern of distribution, and mechanism of action. It has effects on neuronal function, metabolism, and neurotransmission. The IRs are involved in neuronal apoptosis and neurodegenerative processes.

CONCLUSION

In this systematic review, we present a close relationship between insulin and the brain, with discernible effects on memory, learning abilities, and motor functions. The potential therapeutic effects extend from acute brain insults such as traumatic brain injury, brain ischemia, and hemorrhage, to chronic neurodegenerative diseases such as Alzheimer and Parkinson disease. An understanding of the wider effects of insulin conveyed in this review will prompt anaesthesiologists and critical care physicians to consider its therapeutic potential and guide future studies.

A novel application of four-dimensional magnetic resonance angiography using an arterial spin labeling technique for noninvasive diagnosis of Moyamoya disease

BACKGROUND

Noncontrast-enhanced time-resolved four-dimensional magnetic resonance angiography using an arterial spin labeling technique (ASL-4D MRA) is emerging as a next generation angiography for the management of neurovascular diseases. This study evaluated the feasibility of ASL-4D MRA for the diagnosis of Moyamoya disease (MMD) and MMD staging by using digital subtraction angiography (DSA) and time-of-flight MRA (TOF MRA) as current standards.

METHODS

Eleven consecutive non-operated patients who underwent DSA for the diagnosis of MMD were recruited. Two independent observers evaluated the three tests. The data were analyzed for inter-observer and inter-modality agreements on MMD stage. Nine of 22 hemispheres underwent surgical revascularization and ASL-4D MRA was repeated postoperatively.

RESULTS

Time-resolved inflow of blood through the cerebral vessels, including moyamoya vessels, was visualized in all the 22 non-operated hemispheres. MMD stages assessed by DSA and ASL-4D MRA were completely matched in 18 hemispheres, with a significant positive correlation between these modalities (r=0.93, P<0.001). Inter-observer agreement with ASL-4D MRA (κ=0.91±0.04, P<0.001) and inter-modality agreement between ASL-4D MRA and DSA (κ=0.93±0.04, P<0.001) were both excellent. MMD stages assessed by ASL-4D MRA have also a significant positive correlation with those assessed by TOF MRA (r=0.68, P=0.004). Repeated ASL-4D MRA clearly demonstrated the bypassed arteries and changes in the dynamic flow patterns of cerebral arteries in all the nine hemispheres after surgical revascularization. Of these, postoperative focal hyperperfusion was detected by single photon emission tomography in 7 hemispheres. In five of the seven hemispheres (71%) with postoperative hyperperfusion, ASL-4D MRA demonstrated focal hyperintense signals in the bypassed arteries, although TOF MRA did not.

CONCLUSIONS

Noninvasive ASL-4D MRA is feasible for the diagnosis of MMD staging. This next generation angiography may be useful for monitoring disease evolution and treatment response in cerebral arteries after revascularization surgery in MMD.

Molecular and functional characterization of choline transporter in the human trophoblastic cell line JEG-3 cells

INTRODUCTION

Choline is essential for the synthesis of the major membrane phospholipid phosphatidylcholine (PC), the methyl donor betaine and the neurotransmitter acetylcholine (ACh), which is involved in several vital biological functions that play key roles in fetal development. In this study, we examined the molecular and functional characteristics of choline uptake in the human trophoblastic cell line JEG-3.

METHODS

We examined [(3)H]choline uptake in the human trophoblastic cell line JEG-3. The expression of CTL1 and CTL2 was evaluated by quantitative real-time PCR, western blotting and immunocytochemistry.

RESULTS

We demonstrated that JEG-3 cells take up [(3)H] choline by a saturable process that is mediated by a Na(+)-independent and pH-dependent transport system. The cells have two different [(3)H] choline transport systems, high- and low-affinity, with Km values of 28.4 ± 5.0 μM and 210.6 ± 55.1 μM, respectively. Cationic compounds and hemicholinium-3 (HC-3) inhibited choline uptake. Choline transporter-like protein 1 (CTL1) and CTL2 mRNA and protein were highly expressed in JEG-3 cells and were localized to the plasma membrane.

DISCUSSION

The present results suggest that choline is mainly transported via a high-affinity choline transport system (CTL1) and a low-affinity choline transport system (CTL2) in human trophoblastic JEG-3 cells. These transporters play an important role in the growth of the fetus.

Abstract 136: Prediction of Postoperative Hyperperfusion by Intraoperative Assessment of Indocyanine Green Videoangiography in Moyamoya Disease

Background: Postoperative hyperperfusion is a potential complication of the direct bypass procedure for moyamoya disease (MMD). However, no reliable modality is available yet for the prediction of postoperative hyperperfusion during surgery for MMD. This study aimed to investigate whether semiquantitative analysis of indocyanine green (ICG) videoangiography could contribute to the prediction of postoperative hyperperfusion in MMD.

Methods: This study included 12 hemispheres from 10 patients who underwent surgical revascularization for MMD. Intraoperative ICG videoangiography was performed before and after a direct bypass procedure. The ICG intensity-time curves were semiquantitatively analyzed to evaluate cortical perfusion by calculating the blood flow index (BFI). Using single-photon emission computed tomography (SPECT), postoperative cerebral blood flow measurements were performed thrice: immediately and 2 and 7 days after surgery.

Results: BFI significantly increased from 21.3 ± 10.5 to 38.4 ± 20.0 after bypass procedures in all the hemispheres (p < 0.01). The ratio of BFI before and after the bypass procedure was 2.4 ± 2.0, ranging from 0.5 to 8.0. Postoperative hyperperfusion was observed in 9 of the 12 operated hemispheres within 7 days after surgery. Of these, 3 hemispheres developed hyperperfusion immediately after surgery. In the adult cases, the increase in the ratio of BFI after bypass was significantly greater in those who developed hyperperfusion immediately after surgery than in those who did not (6.5 ± 0.5 vs. 1.8 ± 2.1, p < 0.01). In contrast, no significant increase in BFI was observed in the pediatric MMD patients who experienced immediate hyperperfusion. No correlation between the changes in BFI and the occurrence of delayed hyperperfusion was observed.

Conclusions: Our results suggest that semiquantitative analysis of BFI by intraoperative ICG videoangiography is useful in evaluating changes in cortical perfusion after bypass procedures for MMD and can predict the occurrence of early-onset hyperperfusion in MMD patients after direct bypass.