Moyamoya disease in adults: the role of cerebral revascularization

Clinical and angiographic findings in Moya Moya

Patient: Female, 40

Final Diagnosis: Moya-Moya Disease

Symptoms: Blurred vision • headache • lethargy

Medication: —

Clinical Procedure: —

Specialty: Neurology

Treatment of Moyamoya disease in the adult population with pial synangiosis

OBJECT

Surgical treatment of moyamoya disease in the adult population commonly uses direct revascularization, the superficial temporal artery (STA) to middle cerebral artery (MCA) bypass (STA-MCA). Pial synangiosis, a method of indirect revascularization, has been used in adult patients with moyamoya when STA-MCA bypass was not technically feasible. Although the effectiveness of pial synangiosis has been well described in children, only limited reports have examined its role in adult patients with moyamoya disease. In this study the authors report on their experience with pial synangiosis revascularization for this population.

METHODS

The authors reviewed the clinical and radiographic records of all adult patients (≥ 18 years of age) with moyamoya disease who underwent cerebral revascularization surgery using pial synangiosis at a single institution.

RESULTS

From 1985 to 2010, 66 procedures (6 unilateral, 30 bilateral) were performed on 36 adult patients with moyamoya disease. The mean age at surgery was 28.3 years, and 30 patients were female. Twenty-eight patients (77.8%) presented with transient ischemic attacks (TIAs), 24 (66.7%) with stroke, and 3 (8.3%) with hemorrhage. Preoperative Suzuki stage was III or higher in 50 hemispheres (75.8%) and 3 patients had undergone prior treatments to the affected hemisphere before pial synangiosis surgery. Clinical follow-up was available for an average of 5.8 years (range 0.6-14.1 years), with 26 patients (72.2%) followed for longer than 2 years. Postoperative angiography was available for 24 patients and 46 revascularized hemispheres, and 39 (84.8%) of the 46 hemispheres demonstrated good collateral formation (Matsushima Grade A or B). Postoperative complications included 3 strokes, 5 TIAs, and 2 seizures, and there was no hemorrhage during the follow-up period. One patient required additional revascularization surgery 8 months after pial synangiosis.

CONCLUSIONS

Pial synangiosis is a safe and durable method of cerebral revascularization in adult patients with moyamoya and can be considered as a potential treatment option for moyamoya disease in adults.

History of the development of surgical treatments for moyamoya disease

Many surgical treatments for moyamoya disease have been developed over the past 40 years. The optimum treatment for ischemic-type moyamoya disease is almost established. The first surgical treatment for the disease was the superficial temporal artery to middle carotid artery (STA-MCA) anastomosis. The discovery of spontaneous collateral formation following the STA-MCA anastomosis surgery led to the development of various indirect bypass procedures. Collateral formation and clinical outcomes from direct and indirect procedures have been compared to assess the merits and limitations of each technique. Experience and a greater understanding of the surgical effects of moyamoya disease have led to the development of surgical procedures combining various direct and indirect bypass techniques for optimal restoration of perfusion. This review of the historical development and efficacy of each procedure will aid surgeons in selecting the most appropriate surgical procedure for patients of different ages with different symptoms and disease severities.

Effectiveness of burr holes for indirect revascularization in patients with moyamoya disease-a review of the literature

OBJECTIVE

Moyamoya disease (MMD) has inspired the development and refinement of numerous surgical techniques to induce revascularization in hypoperfused territories. Over the last 3 decades, the use of burr hole surgery has progressively gained popularity. Used either in combination with another direct or indirect procedure or as the sole method for revascularization, burr hole surgery can be tailored to each patient's specific needs. We reviewed the conceptual progress, the technical evolution, and the clinical and radiological data following burr hole surgery.

METHODS

Pubmed and Medline databases were searched for publications from 1970 to 2012 relating to the use of burr holes in the surgical management of MMD. The reference sections of each article were reviewed, and pertinent articles were identified.

RESULTS

A review of case reports and case series using burr hole surgery for MMD testifies to the progressive refinement in the decision process and key technical aspects of this procedure. Favorable clinical and angiographic results have been documented in the pediatric and adult MMD population after burr holes, used either in combination with direct or indirect revascularization techniques, or more recently alone in the setting of multiple burr holes. The superficial temporal artery and middle meningeal artery have both been found to contribute to revascularization via burr holes.

CONCLUSIONS

Burr hole surgery is an important and versatile tool in the armamentarium of surgeons treating children and adults with MMD, allowing tailoring of the revascularization. Further studies should help to determine factors that may help predict optimal revascularization from this surgical technique.

Moyamoya disease: a case of vanishing cerebral vessels

PURPOSE

To provide an overview of moyamoya disease (MMD) including pathophysiology, epidemiology, clinical presentation, diagnosis, treatment, and prognosis.

DATA SOURCES

Selected clinical and epidemiological studies, review articles, and diagnostic guidelines for MMD.

CONCLUSIONS

MMD is a rare cerebrovascular disease characterized by progressive stenosis of the distal internal carotid arteries and their major branches. The dilated and fragile basal collateral circulations display a "puff of smoke" appearance and thus are called moyamoya vessels. Other unique features of MMD include 2:1 female preponderance and its peak incidence in two age groups: early childhood and adults in their mid-40s. The pathophysiology of MMD is unclear and possible causes include genetic linkage, angiogenesis, autoimmune disease, cranial radiation, and infection of the head and neck. Most patients are symptomatic and may present with ischemic or hemorrhagic strokes, seizure, or headache. The diagnosis depends on clinical presentation and radiographic imaging, and disease progression may be halted with direct or indirect cerebral revascularization.

IMPLICATIONS FOR PRACTICE

It is important to make a correct diagnosis and provide appropriate treatment to reduce the morbidity and mortality associated with MMD. A prompt referral for possible surgical revascularization offers the best chance to reduce additional cerebral injuries and improve clinical outcomes.

Moyamoya syndrome associated with hemoglobin Southampton (Casper)

When moyamoya vasculopathy results from an associated disease, this vasculopathy is then referred to as moyamoya syndrome. Moyamoya syndrome has been reported in association with sickle cell disease, neurofibromatosis type 1, Down syndrome, radiation exposure, and other predisposing factors. Other than sickle cell disease, rare hemoglobinopathies, such as hemoglobin Fairfax and hemoglobin Alesha, have been reported to occur with moyamoya. We present a case of moyamoya syndrome associated with an unstable hemoglobinopathy, hemoglobin Southampton (Casper). This is the first reported case of moyamoya associated with this hemoglobinopathy.

Meningeal management for optimal revascularization from middle meningeal artery

Numerous surgical techniques have been developed and refined for the treatment of moyamoya disease. Among the indirect techniques of revascularization, encephaloduroarteriosynangiosis has been recognized as effective in promoting revascularization and reversing symptomatology. Neovascularization occurs between the donor artery, either the superficial temporal artery or the occipital artery, and the underlying ischemic cortex. Additionally, the middle meningeal artery and its dural branches have also been shown to contribute to collateral blood supply. In this report the authors describe an integrated management of the meninges for optimal revascularization. They emphasize the importance of recognizing the 3 major layers of the dura and describe a technique of dural splitting at the locus minoris resistentiae between the dura mater's vascular (middle) layer and internal median layer. Applying the dura's vascular layer to the surface of the brain after opening of the arachnoid is designed to optimize dural-pial synangiosis related to middle meningeal artery branches.

Collateral blood vessels in acute ischaemic stroke: a potential therapeutic target

Ischaemic stroke results from acute arterial occlusion leading to focal hypoperfusion. Thrombolysis is the only proven treatment. Advanced neuroimaging techniques allow a detailed assessment of the cerebral circulation in patients with acute stroke, and provide information about the status of collateral vessels and collateral blood flow, which could attenuate the effects of arterial occlusion. Imaging of the brain and vessels has shown that collateral flow can sustain brain tissue for hours after the occlusion of major arteries to the brain, and the augmentation or maintenance of collateral flow is therefore a potential therapeutic target. Several interventions that might augment collateral blood flow are being investigated.

Effect of mouth opening on bypass function after combined revascularization for Moyamoya disease

Moyamoya disease represents a rare steno-occlusive disease of the internal carotid artery (ICA) with a reactive and pathological basal network of collateral vessels. It may lead to ischemic stroke or intracerebral hemorrhage. Treatment options are either direct or indirect revascularization procedures or a combination thereof. Specialized centers report sufficient revascularization in most patients and low complication rates.Between 2005 and 2008, direct extra-intracranial bypass surgery in combination with encephalomyosynangiosis (EMS) was performed in 71 Moyamoya patients at the Mannheim University Medical Center.Following one case of reversible neurological deficits associated with mouth opening, we prospectively evaluated the effect of mouth opening on bypass function in this patient and four further consecutive patients by digital subtraction angiography.Three out of five patients showed alterations in bypass patency upon mouth opening. The obstruction was located at the junction of the bypass and the temporal muscle. Two temporary occlusions and one case of decreased flow were observed. One patient demonstrated reversible hemiparesis and aphasia.

Outcome of repeat revascularization surgery for moyamoya disease after an unsuccessful indirect revascularization

Object

Revascularization for moyamoya disease, either by direct anastomosis or indirect procedures, is an accepted and effective form of treatment for prevention of future ischemic events. Indirect procedures do not provide sufficient collateral vessels in a subset of patients, who then have persistent or new symptoms. Repeat revascularization procedures may be recommended for these patients.

Methods

Sixteen patients underwent repeat revascularization after undergoing an indirect procedure in the same hemisphere. These patients were included in the study, and a retrospective review of their clinical details, neuroimaging results, surgical details, and outcome was performed. Direct revascularization was the procedure of choice; however, in patients with no acceptable recipient vessel (> 0.6 mm) the authors added a second indirect procedure for further revascularization.

Results

Over the last 19 years, 16 patients (8 male and 8 female patients, age range 5–48 years, mean 16.7 years, 10 pediatric and 6 adult patients) underwent repeat revascularization for moyamoya disease. Initially all patients presented with ischemic symptoms (4 transient ischemic attacks [TIAs] and 12 strokes; 2 patients had bilateral symptoms). Angiography revealed that 13 patients had bilateral disease, and 3 had unilateral disease. Initial surgery was bilateral encephaloduroarteriosynangiosis (EDAS) in 9, unilateral EDAS alone in 3, unilateral EDAS with contralateral superficial temporal artery–middle cerebral artery (STA-MCA) bypass in 2, bilateral encephalomyosynangiosis (EMS) in 1, and unilateral EMS in 1. Thirteen of the 16 patients continued to have TIAs in the hemisphere ipsilateral to surgery, whereas 1 patient had seizures and cognitive deficit, 1 had asymptomatic infarct on MR imaging, and 1 had visual symptoms. Poor revascularization was seen on angiography studies in all patients. The median duration between the surgeries was 24 months (3 months–10 years).

Repeat revascularization was performed in 23 hemispheres (16 patients). Direct revascularization was performed in 14 hemispheres (60.9%): STA-MCA bypass in 10, external carotid artery–MCA vein bypass in 2, occipital artery (OA)–MCA in 1, and OA–posterior cerebral artery in 1 hemisphere. Indirect revascularization was performed for patients without an acceptable recipient vessel, and was done in 9 hemispheres. The procedures included EMS (4 hemispheres), repeat EDAS (2), and omental transposition (3). There was 1 postoperative death in a patient undergoing a high-flow vein graft implantation. None of the other patients experienced any neurological worsening after surgery.

Follow-up was available in all patients, ranging from 3 to 144 months (mean 34 months, median 12 months). Of the 15 patients who survived repeat revascularization surgery, 12 (80%) were free from any TIA, stroke, or any other neurological symptoms. Two patients had occasional TIAs, less frequent than before, whereas 1 patient had frequent TIAs and underwent revision of the revascularization. Angiographic studies were available in 11 patients, and showed improved flow in the hemispheres in 10 patients. Follow-up MR imaging performed at 6 months did not reveal a new infarct in any patient.

Conclusions

Repeat revascularization procedures are effective for patients who are clinically symptomatic and have inadequate collateral vessels following indirect procedures. Although direct procedures are preferred, the choice of procedure depends on the operative findings and the status of donor and recipient vessels.

Radiation-induced moyamoya disease after childhood astrocytoma

Adjunctive radiation treatment of childhood intracranial neoplasms of grade II or higher creates a risk of subsequent vasculopathy. A 28-year-old male presented with a Glasgow Coma Scale 12 after acute collapse and hemiparesis with an intraparenchymal haematoma. Emergent craniotomy, histopathology and subsequent imaging confirmed the cause as radiation-induced moyamoya disease, subsequent to treatment for a grade 2 astrocytoma 24 years previously. He had been lost to follow-up after normal serial imaging performed up to 10 years after his initial diagnosis. Long term surveillance imaging may be of benefit in identifying treatable vascular anomalies.

Non-aneurysmal subarachnoid hemorrhage as presentation of moyamoya disease in an adult

Background:

The presentation of moyamoya disease (MMD) as an aneurysmal subarachnoid hemorrhage (SAH) is relatively frequent and in the absence of aneurysms is extremely rare.

Case Description:

A 53-year-old male patient suddenly developed severe headache associated with dysarthria and an altered state of consciousness. At the time of admission, he was found drowsy with global aphasia, stiff neck, right hemiparesis and right Babinski's sign. A non-contrast brain computed tomography was performed and a small bleeding in the subarachnoid space over the left frontal and parietal cortex was observed. Four-vessel cerebral angiography showed bilateral stenosis of the internal carotid arteries, with multiple tortuous vessels branching from the anterior and middle cerebral arteries. These abnormal vessels were anastomosing with branches from the posterior cerebral and middle meningeal arteries. With this information, a diagnosis of MMD was made. A three-dimensional reconstruction from digital angiography ruled out aneurysms or vascular malformations. After 4 weeks, another angiography was performed and remained the same as previous one.

Conclusion:

Clinical and radiological characteristics of this case are consistent with previous reports, supporting the theory that non-aneurysmal SAH in MMD is caused by rupture of fragile moyamoya vessels.

Middle cerebral artery stenosis associated with moyamoya pattern collateralization

Background and Purpose: Moyamoya disease is a well described phenomenon. This pattern of collateralization associated with isolated middle cerebral artery stenosis and the natural history of this entity have not been well described. Methods: Cerebral angiograms and CT angiograms performed between August 2004 and August of 2006 demonstrating moyamoya collateralization were retrospectively reviewed. All cases of middle cerebral artery stenosis associated with a rete pattern of collateralization were included in this series. Demographic, clinical, and angiographic data were obtained. Results: There were three cases of middle cerebral artery stenosis associated with a moyamoya pattern of collateralization. The average age of the patients was 36-years old, 2 were male, and all were Caucasian. All patients presented with ischemic symptoms. The average degree of stenosis was 91%. No stenosis was seen in the supraclinoid internal carotid arteries or elsewhere in the intracranial vasculature. Conclusion: We describe an unusual pattern of anastomosis associated with isolated severe middle cerebral artery stenosis or occlusion in Caucasians.

Moyamoya disease in children

PURPOSE

Moyamoya disease, a rare cause of pediatric stroke, is a cerebrovascular occlusive disorder resulting from progressive stenosis of the distal intracranial carotid arteries and their proximal branches. In response to brain ischemia, there is the development of basal collateral vessels, which give rise to the characteristic angiographic appearance of moyamoya. If left untreated, the disease can result in overwhelming permanent neurological and cognitive deficits.

METHODS

Whereas moyamoya disease refers to the idiopathic form, moyamoya syndrome refers to the condition in which children with moyamoya also have a recognized clinical disorder. As opposed to adults who typically present in the setting of intracranial hemorrhage, the classic pediatric presentation is recurrent transient ischemic attacks and/or completed ischemic strokes.

RESULTS

Surgical revascularization, including direct and indirect techniques, remains the mainstay of treatment, and has been shown to improve long-term outcome in children with moyamoya.

CONCLUSION

The authors discuss the diagnosis and treatment of moyamoya disease in the pediatric population.

Relative contributions of the middle meningeal artery and superficial temporal artery in revascularization surgery for moyamoya syndrome in children: the results of superselective angiography

OBJECT

The authors used postoperative superselective angiography to assess the relative contributions of the middle meningeal artery (MMA) and the superficial temporal artery (STA) to revascularization following surgery for moyamoya syndrome in children.

METHODS

Using the neurosurgical database at the Hospital for Sick Children, the authors reviewed the clinical and pre- and postoperative angiographic records obtained in patients with moyamoya syndrome undergoing superselective angiography. Patients were 16 years of age or younger and were undergoing revascularization surgery for moyamoya syndrome during the study period. Lateral internal carotid artery, external carotid artery, STA, and MMA angiograms were analyzed in the late arterial phase to assess the relative contributions of the STA and MMA to overall revascularization as determined by the external carotid artery injection.

RESULTS

The total moyamoya surgical revascularization experience at the Hospital for Sick Children over a 12-year period (May 1996-December 2008) comprised 33 patients (20 girls and 13 boys) undergoing a total of 50 craniotomies. A decision was made in 2001 to perform superselective angiography postoperatively in patients with moyamoya syndrome. Superselective angiography was identified to have been performed postoperatively in 12 patients and 18 treated hemispheres, and it demonstrated that the MMA contributed more significantly than the STA in 11 (61%) of the 18 hemispheres. Seven patients were Asian, 3 patients had neurofibromatosis Type 1, 1 had Down syndrome, and 2 had no apparent risk factors (1 patient was Asian and had neurofibromatosis Type 1). Stroke had occurred in 58% of patients and transient ischemic attacks in 50% prior to surgery. Within the first 30 days of surgery, there were 2 episodes of stroke (11.7% per surgically treated hemisphere and 18.2% per patient). Seventy-eight percent of hemispheres surgically treated exhibited excellent revascularization (Matsushima Grade A) on follow-up angiography, and there were no strokes documented in any patients more than 1 month after surgery, in a long-term follow-up of mean 4.1 years.

CONCLUSIONS

The contributions of the MMA to revascularization after pial synangiosis for moyamoya syndrome are significant and may frequently exceed the contribution of the STA when surgery is performed with preservation of dural vasculature and dural inversion.

Intraventricular hemorrhage long after successful encephaloduroarterio synangiosis in moyamoya patient

Intraventricular hemorrhage long after successful encephaloduroarterio synangiosis (EDAS) is very rare. The effect of revascularization surgery for preventing hemorrhagic event of moyamoya disease remains controversial. We report a 17-year-old female with intracerebral hemorrhage and intraventricular hemorrahge 10 years after successful EDAS. Even though cerebral vessels angiography showed good collateral circulations without specific weak points, a cerebral hemorrhage could occur in patient with ischemic type of moyamoya disease long after successful indirect bypass operations. Good collateralization of cerebral angiography or magnetic resonance perfusion image after indirect bypass surgery would ensure against ischemic symptoms, not a hemorrhage. And, thus a life-time follow-up strategy might be necessary even if a good collateral circulation has been established.

Diagnosis and neurosurgical treatment of intracranial vascular occlusive syndromes

Intracranial atherosclerosis represents the most prevalent form of intracranial vascular occlusive disease in the adult population and is a major contributor to ischemic stroke. The most reliable method for diagnosing intracranial stenosis relies on conventional catheter angiography; MRI and CT imaging and transcranial Doppler currently are valuable screening tools, and ongoing advances in these modalities may render angiography nonessential for accurate diagnosis in the future. Given the potential for hemodynamic compromise from intracranial occlusive disease, a variety of imaging modalities may be used to assess the adequacy of cerebral perfusion, relying on direct measurements of oxygen extraction fraction or the response to vasodilatory stimuli to determine hemodynamic status. The modalities are well established for assessing the anterior circulation but have proven less useful for the posterior circulation, in which direct measurements of large vessel flow using quantitative magnetic resonance angiography may be more valuable. Surgical and endovascular interventions for treating intracranial stenosis are not, as of yet, proven therapies for routine management. Extracranial-intracranial bypass surgery and endovascular angioplasty and stenting are being investigated in randomized trials to evaluate their efficacy in treating intracranial vascular occlusive disease.

Surgical management of moyamoya disease

Moyamoya disease (MMD) is a progressive, occlusive disease of the distal internal carotid arteries associated with secondary stenosis of the circle of Willis. Symptoms include ischemic infarcts in children and hemorrhages in adults. Bypass of the stenotic vessel(s) is the primary surgical treatment modality for MMD. Superficial temporal artery-to-middle cerebral artery bypass is the most common direct bypass method. Indirect techniques rely on the approximation of vascularized tissue to the cerebral cortex to promote neoangiogenesis. This tissue may be in the form of muscle, pericranium, dura, or even omentum. This review highlights the surgical options available for the treatment of MMD.

Moyamoya disease in pediatric patients: outcomes of neurosurgical interventions

✓Neurosurgical interventions for moyamoya disease (MMD) in pediatric patients include direct, indirect, and combined revascularization procedures. Each technique has shown efficacy in the treatment of pediatric MMD; however, no single study has demonstrated the superiority of one technique over another. In this review, the authors explore the various studies focused on the use of these techniques for MMD in the pediatric population. They summarize the results of each study to clearly depict the clinical outcomes achieved at each institution that had utilized direct, indirect, or combined techniques. In certain studies, multiple techniques were used, and the clinical or radiological outcomes were compared accordingly.

Direct techniques have been shown to aid a reduction in perioperative strokes and provide immediate revascularization to ischemic areas; however, these procedures are technically challenging, and not all pediatric patients are appropriate candidates. Indirect techniques have also shown efficacy in the pediatric population but may require a longer period for revascularization to occur and perfusion deficits to be reversed. The authors concluded that the clinical efficacy of one technique over another is still unclear, as most studies have had small populations and the same outcome measures have not been applied. Authors who compared direct and indirect techniques noted approximately equal clinical outcomes with differences in radiological findings. Additional, larger studies are needed to determine the advantages and disadvantages of the different techniques for the pediatric age group.

Effect of transfusion on cerebral oxygenation, flow velocity in a patient with sickle cell anemia and Moyamoya disease: a case report

Vascular occlusive diseases affect brain blood flow, brain metabolism and are associated with arterial ischemic stroke. This study was designed to measure the brain blood flow velocity, brain oxygenation, hemoglobin concentrations, hematocrit, and cell free hemoglobin at pre- and post-exchange red cell transfusion in an 18 year old male patient with sickle cell disease and moyamoya syndrome (MMS). Exchange transfusion increased cerebral oxygen saturation 12%, total hemoglobin concentration 2%, hemoglobin AA 80%, and reduced sickle (SS) hemoglobin 12%, arterializations 33%, and cell free hemoglobin 33%. Brain blood flow velocity values were unaffected by transfusion. These observations suggest that exchange transfusion increases the hemoglobin carrying capacity and reduces sickle hemoglobin and shunting of blood, which may improve the peripheral and cerebral oxygenation. Transfusion did not affect the brain blood flow in this patient. Therefore the risk of transient ischemic attack and arterial ischemic stroke from mms still exist.

A novel heterozygous missense mutation 377T > C (V126A) ofTGIF gene in a family segregated with holoprosencephaly and moyamoya disease

OBJECTIVES

To identify whether any mutations of candidate genes including SHH, ZIC2, SIX3, and TGIF exist in a Taiwanese family segregated with holoprosencephaly (HPE) and moyamoya disease.

METHODS

Genotypes of the candidate genes SHH, ZIC2, SIX3, and TGIF were determined in the family members who were available for analysis by sequencing. In addition, genomic regions of another 50 unrelated Taiwanese (100 chromosomes) were studied to verify whether the nucleotide changes we found were mutations or polymorphisms.

RESULTS

A novel missense mutation 377T > C and two polymorphisms (420A > G and 487C > T) in the TGIF gene were identified. No mutations in SHH, ZIC2 and SIX3 were found. The mother of the three HPE fetuses was found to be afflicted with moyamoya disease. A brief review of the mutations as well as polymorphisms reported in the TGIF gene up to 2005 is given.

CONCLUSION

Molecular diagnosis can help genetic counseling in HPE, which is a heterogeneous disorder with its phenotypic and genotypic spectrum highly widened and variable. The possible association between TGIF mutation and moyamoya disease noted in our study also appeared to be novel.