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Shieh A, Schoenheit TR, Mallon ST, Mathias EJ. Acute Weakness in a Toddler with Sickle Cell Disease. Pediatr Rev 2024; 45:296-300. [PMID: 38689111 DOI: 10.1542/pir.2022-005746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Affiliation(s)
| | | | - Shane T Mallon
- Division of Emergency Radiology, University of Michigan, Ann Arbor, MI
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Kang YS, Cho WS, Nam SM, Chung Y, Lee SH, Kim K, Kang HS, Kim JE. Natural course of hemodynamically stable hemispheres contralateral to operated hemispheres in adult patients with ischemic moyamoya diseases. Sci Rep 2024; 14:8358. [PMID: 38600292 PMCID: PMC11006865 DOI: 10.1038/s41598-024-59141-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 04/08/2024] [Indexed: 04/12/2024] Open
Abstract
The necessity of bilateral bypass in adult moyamoya disease (MMD) remains unclear despite its recommendation for pediatric and hemorrhagic cases. We aimed to investigate the natural course of hemodynamically stable unoperated hemispheres after bypass surgery for symptomatic and hemodynamically unstable hemispheres in adult patients with ischemic MMD. Among 288 patients, the mean age at the first operation of the unstable hemispheres was 40.8 ± 12.2 years. The mean follow-up period was 62.9 ± 46.5 months. 45 patients (15.6%) experienced stroke events in the unoperated hemisphere, consisting of hemorrhagic stroke in 8 (2.8%) and ischemic stroke in 37 (12.8%), including progressive transient ischemic attack in 25 (8.7%) and infarction in 12 (4.2%). Among them, 39 patients (13.5%) underwent bypass surgery. The annual risk of total stroke is 3.0%/patient-year, with 2.5% for ischemic stroke and 0.5% for hemorrhagic stroke. The 5- and 10-year cumulative risks of ischemic stroke were 13.4% and 18.3%, respectively, and those of hemorrhagic stroke were each 3.2%. The natural course of hemodynamically stable hemispheres contralateral to the operated ones appeared fairly good. Additional bypass surgery on the unoperated hemispheres should be considered for symptomatic and hemodynamically unstable hemispheres in adult patients with ischemic MMD during the follow-up.
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Affiliation(s)
- Young Sill Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - Sun Mo Nam
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Yuwhan Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Sung Ho Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Kangmin Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
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Montaser A, Kappel AD, Driscoll J, Day E, Karsten M, See AP, Orbach DB, Smith ER. Posterior cerebral territory ischemia in pediatric moyamoya: Surgical techniques and long-term clinical and radiographic outcomes. Childs Nerv Syst 2024; 40:791-800. [PMID: 37955716 DOI: 10.1007/s00381-023-06219-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE To describe a surgical technique for posterior cerebral revascularization in pediatric patients with moyamoya arteriopathy. Here, we describe the clinical characteristics, surgical indications, operative techniques, and clinical and radiographic outcomes in a series of pediatric patients with moyamoya disease affecting the posterior cerebral artery (PCA) territory. METHODS A retrospective single-center series of all pediatric patients with moyamoya disease who presented to our institute between July 2009 through August 2019 were reviewed. The clinical characteristics, surgical indications, operative techniques, and long-term clinical and radiographic outcomes of pediatric moyamoya patients with PCA territory ischemia were collected and analyzed. RESULTS A total of 10 PCA revascularization procedures were performed in 9 patients, 5 female, ages 1 to 11.1 years (average 5.2 years). Complications included 1 stroke, with no infections, hemorrhages, seizures, or deaths. One patient had less than 1 year of radiographic and clinical follow-up. In 8 of 9 patients with at least 1 year of radiographic follow-up, there was engraftment of surgical vessels present in all cases. No new strokes were identified on long-term follow-up despite the radiographic progression of the disease. In the 8 cases available for analysis, the average follow-up was 50.8 months with a range of 12 to 117 months. CONCLUSIONS PCA territory ischemia in patients with progressive moyamoya disease can be surgically treated with indirect revascularization. Here, we describe our experience with PCA revascularization procedures for moyamoya disease, including pial pericranial dural (PiPeD) revascularization and pial synangiosis utilizing the occipital artery. These surgical options may be useful for decreasing the risk of stroke in pediatric moyamoya patients with severe posterior circulation disease.
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Affiliation(s)
- Alaa Montaser
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
| | - Ari D Kappel
- Vascular Biology Program, Department of Neurosurgery Boston Children's Hospital, Hunnewell 2nd floor, 300 Longwood Ave, Harvard Medical School, Boston, MA, 02115, USA
- Department of Interventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jessica Driscoll
- Vascular Biology Program, Department of Neurosurgery Boston Children's Hospital, Hunnewell 2nd floor, 300 Longwood Ave, Harvard Medical School, Boston, MA, 02115, USA
| | - Emily Day
- Vascular Biology Program, Department of Neurosurgery Boston Children's Hospital, Hunnewell 2nd floor, 300 Longwood Ave, Harvard Medical School, Boston, MA, 02115, USA
| | - Madeline Karsten
- Vascular Biology Program, Department of Neurosurgery Boston Children's Hospital, Hunnewell 2nd floor, 300 Longwood Ave, Harvard Medical School, Boston, MA, 02115, USA
| | - Alfred P See
- Vascular Biology Program, Department of Neurosurgery Boston Children's Hospital, Hunnewell 2nd floor, 300 Longwood Ave, Harvard Medical School, Boston, MA, 02115, USA
- Department of Interventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Darren B Orbach
- Department of Interventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward R Smith
- Vascular Biology Program, Department of Neurosurgery Boston Children's Hospital, Hunnewell 2nd floor, 300 Longwood Ave, Harvard Medical School, Boston, MA, 02115, USA.
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Scrimshaw L, Gorman K, Mansour S, Ganesan V, Sabir A. Moyamoya disease/cerebral vasculopathy in osteopathia striata with cranial sclerosis: a rare but important complication. Clin Dysmorphol 2024; 33:31-37. [PMID: 38037992 DOI: 10.1097/mcd.0000000000000479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Osteopathia striata with cranial sclerosis (OSCS) is a rare X-linked dominant sclerosing osteodysplasia, due to AMER1 pathogenic variants. Characteristic features include craniofacial sclerosis and long-bone metaphyseal striations. Moyamoya disease (a type of progressive cerebral vasculopathy) and other types of cerebral vascular disease are not currently clearly associated with OSCS (except for two separate case reports), and can often first present with stroke. Through informal networks with UK-based bone experts and the UK skeletal dysplasia group, three cases from the UK and Ireland were identified. Medical literature was also reviewed to identify the known cases of OSCS with the described complications. We report four females, in whom OSCS and cerebral vasculopathy co-exist, with varying clinical outcomes. There appears to be an emerging association between OSCS and cerebral vasculopathy, which pre-disposes patients to stroke. Given this, screening OSCS patients for cerebral vasculopathy may be of value, especially pre-surgery. Further research regarding optimal screening and management is needed. The mechanism of cerebral vasculopathy and its progression remain unclear.
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Affiliation(s)
- Lucy Scrimshaw
- Birmingham Children's Hospital, Birmingham Women and Children's NHS Foundation Trust, Birmingham, UK
| | - Kathleen Gorman
- Department of Neurology and Clinical Neurophysiology, Children's Health Ireland at Temple Street
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Sahar Mansour
- Molecular and Clinical Sciences Research Institute, St. George's University of London
- South West Thames Centre for Genomics, St. George's University Hospitals NHS Foundation Trust
| | - Vijeya Ganesan
- Neurology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Ataf Sabir
- Birmingham Children's Hospital, Birmingham Women and Children's NHS Foundation Trust, Birmingham, UK
- West Midlands Regional Clinical Genetics Unit, Birmingham Women's and Children's NHS FT
- Institute of Cancer and Genomics, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Chen P, Wang Y, Li S, Tang D, Yang S, Zeng F, Yu L, Zhang D, Ding W, Wu S, Chen F, Huang Z. Development and External Validation of Nomogram for Cerebral Infarction in Moyamoya Diseases. Transl Stroke Res 2023; 14:890-898. [PMID: 36656462 DOI: 10.1007/s12975-023-01127-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 12/31/2022] [Accepted: 01/04/2023] [Indexed: 01/20/2023]
Abstract
More than 60% of moyamoya disease (MMD) patients suffers cerebral ischemia and preoperative cerebral infarction (CI) increases the risk of postoperative stroke and unfavorable outcome. We established a nomogram system for risk stratification of CI to help tailoring individualized management. We enrolled 380 patients including 680 hemispheres for the training cohort from our hospital and 183 patients including 348 hemispheres for the validation cohort from multicenter. A nomogram for CI was formulated based on the multivariable logistic regression analysis. The predictive accuracy and discriminative ability of nomogram were determined with concordance index (C-index) and calibration curve. For the training cohort, 246 hemispheres (36.2%) were found with CI. In multivariable logistic regression used generalized estimating equations approach, anterior choroidal artery (AchA) grade (grade 1, OR 0.214, 95%CI 0.124-0.372, P < 0.001; grade 2, OR 0.132, 95%CI 0.066-0.265, P < 0.001), cerebral perfusion (OR 4.796, 95%CI 2.922-7.872; P < 0.001), white matter hyperintensity (OR 3.652, 95%CI 1.933-6.902; P < 0.001), brush sign (OR 3.555, 95%CI 2.282-5.538; P < 0.001), and ivy sign (equivocal, OR 4.752, 95%CI 2.788-8.099, P < 0.001; present, OR 8.940, 95%CI 4.942-16.173, P < 0.001) were significant factors for CI. The C-index of the nomogram for predicting cerebral infarction was 0.890 (95%CI 0.866-0.915) in the training cohort and 0.847 (95%CI 0.805-0.889) in the validation cohort. The nomogram composed of AchA grade, cerebral perfusion, white matter hyperintensity, brush sign, and ivy sign could provide risk stratification of CI before surgery in patients with MMD. Active treatment might be recommended before CI, which could reduce the risk of stroke after surgery.
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Affiliation(s)
- Pan Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Ying Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Shifu Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Dong Tang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Shuai Yang
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Feiyue Zeng
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Lebao Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Wei Ding
- Department of Neurosurgery, Hunan Children's Hospital, Changsha, 410007, China
| | - Shuihua Wu
- Department of Neurosurgery, Hunan Children's Hospital, Changsha, 410007, China
| | - Fenghua Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Zheng Huang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China.
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Choi SA, Moon YJ, Koh EJ, Phi JH, Lee JY, Kim KH, Kim SK. Cyclin-Dependent Kinase Inhibitor 2A is a Key Regulator of Cell Cycle Arrest and Senescence in Endothelial Colony-Forming Cells in Moyamoya Disease. J Korean Neurosurg Soc 2023; 66:642-651. [PMID: 37138505 PMCID: PMC10641413 DOI: 10.3340/jkns.2023.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/17/2023] [Accepted: 04/22/2023] [Indexed: 05/05/2023] Open
Abstract
OBJECTIVE Endothelial colony-forming cells (ECFCs) have been reported to play an important role in the pathogenesis of moyamoya disease (MMD). We have previously observed stagnant growth in MMD ECFCs with functional impairment of tubule formation. We aimed to verify the key regulators and related signaling pathways involved in the functional defects of MMD ECFCs. METHODS ECFCs were cultured from peripheral blood mononuclear cells of healthy volunteers (normal) and MMD patients. Low-density lipoproteins uptake, flow cytometry, high content screening, senescence-associated β-galactosidase, immunofluorescence, cell cycle, tubule formation, microarray, real-time quantitative polymerase chain reaction, small interfering RNA transfection, and western blot analyses were performed. RESULTS The acquisition of cells that can be cultured for a long time with the characteristics of late ECFCs was significantly lower in the MMD patients than the normal. Importantly, the MMD ECFCs showed decreased cellular proliferation with G1 cell cycle arrest and cellular senescence compared to the normal ECFCs. A pathway enrichment analysis demonstrated that the cell cycle pathway was the major enriched pathway, which is consistent with the results of the functional analysis of ECFCs. Among the genes associated with the cell cycle, cyclin-dependent kinase inhibitor 2A (CDKN2A) showed the highest expression in MMD ECFCs. Knockdown of CDKN2A in MMD ECFCs enhanced proliferation by reducing G1 cell cycle arrest and inhibiting senescence through the regulation of CDK4 and phospho retinoblastoma protein. CONCLUSION Our study suggests that CDKN2A plays an important role in the growth retardation of MMD ECFCs by inducing cell cycle arrest and senescence.
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Affiliation(s)
- Seung Ah Choi
- Division of Pediatric Neurosurgery, Pediatric Clinical Neuroscience Center, Seoul National University Children’s Hospital, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Youn Joo Moon
- Division of Pediatric Neurosurgery, Pediatric Clinical Neuroscience Center, Seoul National University Children’s Hospital, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Jung Koh
- Division of Pediatric Neurosurgery, Pediatric Clinical Neuroscience Center, Seoul National University Children’s Hospital, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Hoon Phi
- Division of Pediatric Neurosurgery, Pediatric Clinical Neuroscience Center, Seoul National University Children’s Hospital, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Neuroscience Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Yeoun Lee
- Division of Pediatric Neurosurgery, Pediatric Clinical Neuroscience Center, Seoul National University Children’s Hospital, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Department of Anatomy, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Hyun Kim
- Division of Pediatric Neurosurgery, Pediatric Clinical Neuroscience Center, Seoul National University Children’s Hospital, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Pediatric Clinical Neuroscience Center, Seoul National University Children’s Hospital, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Neuroscience Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Kim JW, Hayashi T, Kim SK, Shirane R. Technical evolution of pediatric neurosurgery: moyamoya disease. Childs Nerv Syst 2023; 39:2819-2827. [PMID: 37395784 DOI: 10.1007/s00381-023-06017-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 07/04/2023]
Abstract
Moyamoya disease (MMD) is a rare steno-occlusive disease of the bilateral internal carotid arteries that predominantly occurs in East Asia. Since the first description of the MMD by Suzuki and Takaku in 1969, significant advances have been made in both basic and clinical understanding of the disease. The incidence and prevalence of pediatric MMD have increased, potentially due to improved detection rates. The advancement of neuroimaging techniques has enabled MRI-based diagnostics and detailed visualization of the vessel wall. Various methods of surgical treatments are successful in pediatric MMD patients, and recent studies emphasize the importance of reducing postoperative complications since the goal of MMD surgery is to prevent future cerebral infarction and hemorrhage. Long-term outcomes following appropriate surgical treatment in pediatric MMD patients have shown promising results, including favorable outcomes in very young patients. Further studies with a large patient cohort are needed to establish individualized risk group stratification for determining the optimal timing of surgical treatment and to conduct multidisciplinary outcome assessments.
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Affiliation(s)
- Joo Whan Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, 03080, 101 Daehak-Ro, Jongno-Gu, Seoul, Republic of Korea
| | - Toshiaki Hayashi
- Department of Pediatric Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Neurosurgery, Miyagi Children's Hospital, 4 Chome-3-17 Ochiai, Aoba Ward, Sendai, Miyagi, 989-3126, Japan
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, 03080, 101 Daehak-Ro, Jongno-Gu, Seoul, Republic of Korea.
| | - Reizo Shirane
- Department of Neurosurgery, Miyagi Children's Hospital, 4 Chome-3-17 Ochiai, Aoba Ward, Sendai, Miyagi, 989-3126, Japan.
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Ha EJ, Phi JH, Lee JY, Koh EJ, Kim KH, Wang KC, Cho BK, Kim SK. Long-Term Surgical Outcome of Indirect Bypass Surgery in Young Children With Moyamoya Disease. Neurosurgery 2023; 93:901-909. [PMID: 37561505 DOI: 10.1227/neu.0000000000002489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/13/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND The prognosis of moyamoya disease (MMD) in young children (younger than 4 years) is worse than that of older adults. The effectiveness of surgery is still inconclusive. OBJECTIVE To evaluate long-term outcomes after indirect bypass in young children with MMD. METHODS A total of 1417 MMD children underwent indirect bypass from August 1988 to October 2020. This study included 135 patients who were younger than 4 years at the time of surgery. The clinical features and surgical outcomes of these patients were assessed. We analyzed the long-term outcome of 102 children who were followed up for more than 5 years (mean: 18.8 years, range: 5-27.3 years). Cross-sectional analysis was performed to evaluate overall outcomes based on the Lansky Play Performance Scale (LPS). The annual risk of symptomatic stroke after surgery was calculated with a person-year method, and the event-free survival rate was evaluated using the Kaplan-Meier method. RESULTS The overall clinical outcome was favorable (LPS ≥ 80) in 88% of the patients. The overall postoperative adverse event rate was 15%, including 1 death. At the last follow-up, 86% of patients who had seizures at diagnosis were seizure-free. During the follow-up, there were 3 symptomatic infarctions on the operated hemisphere (postoperative 3, 3, and 10 months each). There was no hemorrhagic event. The annual infarction rate was 0.16% per person-year. The 20-year event-free survival rates for symptomatic infarction were 97%. CONCLUSION Indirect bypass could provide a satisfactory long-term outcome and prevent recurrent stroke in young children with MMD.
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Affiliation(s)
- Eun Jin Ha
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul , Republic of Korea
| | - Ji Hoon Phi
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
| | - Ji Yeoun Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
- Department of Anatomy and Cell Biology, Seoul National University College of Medicine, Seoul , Republic of Korea
| | - Eun Jung Koh
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
| | - Kyung Hyun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
| | - Kyu-Chang Wang
- Center for Rare Cancers, National Cancer Center, Goyang , Gyeonggi-do , Republic of Korea
| | - Byung-Kyu Cho
- Department of Neurosurgery, Armed Forces Capital Hospital, Seongnam , Gyeonggi-do , Republic of Korea
| | - Seung-Ki Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
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Kim JW, Phi JH, Lee JY, Koh EJ, Kim KH, Kim HS, Kim SK. Comparison of Bifrontal Craniotomy and Multiple Burr Hole Encephalogaleoperiosteal-Synangiosis for Pediatric Moyamoya Disease: An Experience of 346 Patients. Neurosurgery 2023; 93:824-834. [PMID: 37057917 DOI: 10.1227/neu.0000000000002499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/23/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Moyamoya disease (MMD) is a steno-occlusive disease treated with revascularization surgery. Craniotomy and multiple burr hole encephalogaleoperiosteal-synangiosis (EGPS) are used for revascularization of the anterior cerebral artery territory. The aim of this study was to compare the clinical outcome between the 2 surgical methods in pediatric patients with MMD. METHODS A retrospective review of patients with MMD who underwent bifrontal indirect bypass surgery was performed. Clinical features, perioperative data, and angiographic, perfusion, and functional outcomes were compared between the 2 groups. Propensity score matching was performed to compare the perioperative characteristics and clinical outcomes. RESULTS A total of 346 patients were included in this study, 111 patients underwent bifrontal craniotomy EGPS, and 235 patients had bifrontal multiple burr hole EGPS. An insignificant higher rate of postoperative infarction (11.7% vs 5.5%, P = .072) and more postoperative hemorrhage occurred in the craniotomy EGPS group (3.6% vs 0%, P = .004). Of the 83 patients selected with propensity score matching for each group, the duration of operation was shorter ( P < .001) and the amount of intraoperative bleeding was significantly less in the multiple burr hole EGPS group ( P = .008). There was no difference in clinical outcomes between the 2 groups. CONCLUSION Bifrontal multiple burr hole EGPS has benefits over craniotomy with shorter surgical time, less intraoperative bleeding, fewer postoperative complications, and comparable perfusion and functional outcomes. Multiple burr hole EGPS is a safe and effective method that might be considered for revascularization of the anterior cerebral artery territory in pediatric patients with MMD.
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Affiliation(s)
- Joo Whan Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
| | - Ji Hoon Phi
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul , Republic of Korea
| | - Ji Yeoun Lee
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Neural Development and Anomaly Laboratory, Department of Anatomy and Cell Biology, Seoul National University College of Medicine, Seoul , Republic of Korea
| | - Eun Jung Koh
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
| | - Kyung Hyun Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
| | - Hee-Soo Kim
- Division of Pediatric Anesthesiology and Pain Medicine, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul , Republic of Korea
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Gao G, Liu SM, Hao FB, Wang QN, Wang XP, Wang MJ, Bao XY, Han C, Duan L. Factors Influencing Collateral Circulation Formation After Indirect Revascularization for Moyamoya Disease: a Narrative Review. Transl Stroke Res 2023:10.1007/s12975-023-01185-x. [PMID: 37592190 DOI: 10.1007/s12975-023-01185-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/19/2023]
Abstract
Indirect revascularization is one of the main techniques for the treatment of Moyamoya disease. The formation of good collateral circulation is a key measure to improve cerebral blood perfusion and reduce the risk of secondary stroke, and is the main method for evaluating the effect of indirect revascularization. Therefore, how to predict and promote the formation of collateral circulation before and after surgery is important for improving the success rate of indirect revascularization in Moyamoya disease. Previous studies have shown that vascular endothelial growth factor, endothelial progenitor cells, Caveolin-1, and other factors observed in patients with Moyamoya disease may play a key role in the generation of collateral vessels after indirect revascularization through endothelial hyperplasia and smooth muscle migration. In addition, mutations in the genetic factor RNF213 have also been associated with this process. This study summarizes the factors and mechanisms influencing collateral circulation formation after indirect revascularization in Moyamoya disease.
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Affiliation(s)
- Gan Gao
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China
| | - Si-Meng Liu
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China
| | - Fang-Bin Hao
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China
| | - Qian-Nan Wang
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China
| | - Xiao-Peng Wang
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China
| | - Min-Jie Wang
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China
| | - Xiang-Yang Bao
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China
| | - Cong Han
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China
| | - Lian Duan
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China.
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11
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Zanoni P, Steindl K, Sticht H, Oneda B, Joset P, Ivanovski I, Horn AHC, Cabello EM, Laube J, Zweier M, Baumer A, Rauch A, Khan N. The genetic landscape and clinical implication of pediatric Moyamoya angiopathy in an international cohort. Eur J Hum Genet 2023; 31:784-792. [PMID: 37012328 PMCID: PMC10325976 DOI: 10.1038/s41431-023-01320-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 12/16/2022] [Accepted: 02/13/2023] [Indexed: 04/05/2023] Open
Abstract
Pediatric Moyamoya Angiopathy (MMA) is a progressive intracranial occlusive arteriopathy that represents a leading cause of transient ischemic attacks and strokes in childhood. Despite this, up to now no large, exclusively pediatric MMA cohort has been subjected to systematic genetic investigation. In this study, we performed molecular karyotyping, exome sequencing and automated structural assessment of missense variants on a series of 88 pediatric MMA patients and correlated genetic, angiographic and clinical (stroke burden) findings. The two largest subgroups in our cohort consisted of RNF213 and neurofibromatosis type 1 (NF1) patients. While deleterious RNF213 variants were associated with a severe MMA clinical course with early symptom onset, frequent posterior cerebral artery involvement and higher stroke rates in multiple territories, NF1 patients had a similar infarct burden compared to non-NF1 individuals and were often diagnosed incidentally during routine MRIs. Additionally, we found that MMA-associated RNF213 variants have lower predicted functional impact compared to those associated with aortic disease. We also raise the question of MMA as a feature of recurrent as well as rare chromosomal imbalances and further support the possible association of MMA with STAT3 deficiency. In conclusion, we provide a comprehensive characterization at the genetic and clinical level of a large exclusively pediatric MMA population. Due to the clinical differences found across genetic subgroups, we propose genetic testing for risk stratification as part of the routine assessment of pediatric MMA patients.
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Affiliation(s)
- Paolo Zanoni
- Institute of Medical Genetics, University of Zürich, Schlieren-Zurich, 8952, Switzerland.
| | - Katharina Steindl
- Institute of Medical Genetics, University of Zürich, Schlieren-Zurich, 8952, Switzerland
| | - Heinrich Sticht
- Institute of Biochemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, 91054, Germany
| | - Beatrice Oneda
- Institute of Medical Genetics, University of Zürich, Schlieren-Zurich, 8952, Switzerland
| | - Pascal Joset
- Institute of Medical Genetics, University of Zürich, Schlieren-Zurich, 8952, Switzerland
| | - Ivan Ivanovski
- Institute of Medical Genetics, University of Zürich, Schlieren-Zurich, 8952, Switzerland
| | - Anselm H C Horn
- Institute of Medical Genetics, University of Zürich, Schlieren-Zurich, 8952, Switzerland
- Institute of Biochemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, 91054, Germany
| | - Elena M Cabello
- Institute of Medical Genetics, University of Zürich, Schlieren-Zurich, 8952, Switzerland
| | - Julia Laube
- Institute of Medical Genetics, University of Zürich, Schlieren-Zurich, 8952, Switzerland
| | - Markus Zweier
- Institute of Medical Genetics, University of Zürich, Schlieren-Zurich, 8952, Switzerland
| | - Alessandra Baumer
- Institute of Medical Genetics, University of Zürich, Schlieren-Zurich, 8952, Switzerland
| | - Anita Rauch
- Institute of Medical Genetics, University of Zürich, Schlieren-Zurich, 8952, Switzerland.
- Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, 8000, Switzerland.
- Neuroscience Center Zurich, University of Zurich and ETH Zurich, Zurich, 8000, Switzerland.
- Moyamoya Center, University Children's Hospital, University of Zurich, Zurich, 8032, Switzerland.
| | - Nadia Khan
- Moyamoya Center, University Children's Hospital, University of Zurich, Zurich, 8032, Switzerland.
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12
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Guo Q, Pei S, Wang QN, Li J, Han C, Liu S, Wang X, Yu D, Hao F, Gao G, Zhang Q, Zou Z, Feng J, Yang R, Wang M, Fu H, Du F, Bao X, Duan L. Risk Factors for Preoperative Cerebral Infarction in Infants with Moyamoya Disease. Transl Stroke Res 2023:10.1007/s12975-023-01167-z. [PMID: 37314678 DOI: 10.1007/s12975-023-01167-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 06/15/2023]
Abstract
There have been few reports on the risk factors for preoperative cerebral infarction in childhood moyamoya disease (MMD) in infants under 4 years. The aim of this retrospective study is to identify clinical and radiological risk factors for preoperative cerebral infarction in infants under 4 years old with MMD, and the optimal timing for EDAS was also considered. We retrospectively analyzed the risk factors for preoperative cerebral infarction, confirmed by magnetic resonance angiography (MRA), in pediatric patients aged ˂4 years who underwent encephaloduroarteriosynangiosis between April 2005 and July 2022. The clinical and radiological outcomes were determined by two independent reviewers. In addition, potential risk factors for preoperative cerebral infarction, including infarctions at diagnosis and while awaiting surgery, were analyzed using a univariate model and multivariate logistic regression to identify independent predictors of preoperative cerebral infarction. A total of 160 hemispheres from 83 patients aged <4 years with MMD were included in this study. The mean age of all surgical hemispheres at diagnosis was 2.17±0.831 years (range 0.380-3.81 years). In the multivariate logistic regression model, we included all variables with P<0.1 in the univariate analysis. The multivariate logistic regression analysis indicated that preoperative MRA grade (odds ratio [OR], 2.05 [95% confidence interval [CI], 1.3-3.25], P=0. 002), and age at diagnosis (OR, 0.61 [95% CI, 0.4-0.92], P=0. 018) were predictive factors of infarction at diagnosis. The analysis further indicated that the onset of infarction (OR, 0.01 [95% CI, 0-0.08], P<0.001), preoperative MRA grade (OR, 1.7 [95% CI, 1.03-2.8], P=0.037), and duration from diagnosis to surgery (Diag-Op) (OR, 1.25 [95% CI, 1.11-1.41], P<0.001) were predictive factors for infarction while awaiting surgery. Moreover, the regression analysis indicated that family history (OR, 8.88 [95% CI, 0.91-86.83], P=0.06), preoperative MRA grade (OR, 8.72 [95% CI, 3.44-22.07], P<0.001), age at diagnosis (OR, 0.36 [95% CI, 0.14-0.91], P=0.031), and Diag-Op (OR, 1.38 [95% CI, 1.14-1.67], P=0.001) were predictive factors for total infarction. Therefore, during the entire treatment process, careful observation, adequate risk factor management, and optimal operation time are required to prevent preoperative cerebral infarction, particularly in pediatric patients with a family history, higher preoperative MRA grade, duration from diagnosis to operation longer than 3.53 months, and aged ˂3 years at diagnosis.
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Affiliation(s)
- Qingbao Guo
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Songtao Pei
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Qian-Nan Wang
- Department of Neurosurgery, the Eighth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jingjie Li
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Cong Han
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Simeng Liu
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Xiaopeng Wang
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Dan Yu
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Fangbin Hao
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Gan Gao
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Qian Zhang
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Zhengxing Zou
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jie Feng
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Rimiao Yang
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Minjie Wang
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Heguan Fu
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Feiyan Du
- Beijing Garrison Haidian 13th Retired Cadre Rest House, Beijing, China
| | - Xiangyang Bao
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China.
| | - Lian Duan
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China.
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13
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Jiang X, Liu L, Ai S, Xie X, Deng J, Jiang Z, Teng B, Liu C, Huang H. Meta-analysis of the association between RNF213 polymorphisms and clinical features of moyamoya disease in Asian population. Clin Neurol Neurosurg 2023; 231:107801. [PMID: 37267801 DOI: 10.1016/j.clineuro.2023.107801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/13/2023] [Accepted: 05/22/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND We performed this study to explore the relationship between ring finger protein 213 (RNF213) gene polymorphisms and clinical features in moyamoya disease (MMD). METHODS Electronic databases (PubMed, Google Scholar, Embase, Scopus, Cochrane Library) were conducted from inception to May 15th, 2022. Odds ratios (ORs) with 95 % confidence intervals (CIs) were generated as effect size for binary variants. Subgroup analyses were performed by the RNF213 polymorphisms. Sensitivity was used to examine the robustness of associations. RESULTS A total of 16 articles and 3061 MMD patients were included and the association of five RNF213 polymorphisms on 9 clinical features of MMD were identified. Patients under 18 years of age at onset, familial MMD, cerebral ischemic stroke and posterior cerebral artery involvement (PCi) were significantly more common in mutant type compared with wild type of RNF213. Compared with each wild type, subgroup analysis showed that rs11273543 and rs9916351 remarkably increased risk of MMD on early onset, but rs371441113 evidently delayed the onset of MMD. Rs112735431 in mutant type was significantly higher than wild type in patients with PCi. Subgroup analysis in mutant type showed that rs112735431 conspicuously decreased intracerebral/ intraventricular hemorrhage (ICH/IVH) risk and yet rs148731719 obviously increased the risk in ICH/IVH. CONCLUSION More attention should be paid to patients on whom the ischemic MMD occurs younger than 18 years old. RNF213 polymorphism screening and cerebrovascular imaging examination should be performed to evaluate intracranial vascular involvement, to achieve early detection and early treatment and avoid more serious cerebrovascular events.
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Affiliation(s)
- Xiaolong Jiang
- Department of Neurosurgery, The First Hospital of Nanchang, Nanchang, Jiangxi, China
| | - Li Liu
- Central department of venous allocation, The First Hospital of Nanchang, Nanchang, Jiangxi, China
| | - Sijin Ai
- Department of Neurosurgery, The First Hospital of Nanchang, Nanchang, Jiangxi, China
| | - Xinrui Xie
- Department of Neurosurgery, The First Hospital of Nanchang, Nanchang, Jiangxi, China
| | - Jiajun Deng
- Department of Neurosurgery, The First Hospital of Nanchang, Nanchang, Jiangxi, China
| | - Zeshen Jiang
- Department of Neurosurgery, The First Hospital of Nanchang, Nanchang, Jiangxi, China
| | - Bin Teng
- Department of Neurosurgery, The First Hospital of Nanchang, Nanchang, Jiangxi, China
| | - Chengjiang Liu
- Department of General Medicine, Affiliated Anqing First People's Hospital of Anhui Medical University, 246000, China.
| | - Haiying Huang
- Department of Neurosurgery, The First Hospital of Nanchang, Nanchang, Jiangxi, China.
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14
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Lee KS, Zhang JJY, Bhate S, Ganesan V, Thompson D, James G, Silva AHD. Surgical revascularizations for pediatric moyamoya: a systematic review, meta-analysis, and meta-regression analysis. Childs Nerv Syst 2023; 39:1225-1243. [PMID: 36752913 PMCID: PMC10167165 DOI: 10.1007/s00381-023-05868-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/28/2023] [Indexed: 02/09/2023]
Abstract
INTRODUCTION There is no clear consensus regarding the technique of surgical revascularization for moyamoya disease and syndrome (MMD/MMS) in the pediatric population. Previous meta-analyses have attempted to address this gap in literature but with methodological limitations that affect the reliability of their pooled estimates. This meta-analysis aimed to report an accurate and transparent comparison between studies of indirect (IB), direct (DB), and combined bypasses (CB) in pediatric patients with MMD/MMS. METHODS In accordance with PRISMA guidelines, systematic searches of Medline, Embase, and Cochrane Central were undertaken from database inception to 7 October 2022. Perioperative adverse events were the primary outcome measure. Secondary outcomes were rates of long-term revascularization, stroke recurrence, morbidity, and mortality. RESULTS Thirty-seven studies reporting 2460 patients and 4432 hemispheres were included in the meta-analysis. The overall pooled mean age was 8.6 years (95% CI: 7.7; 9.5), and 45.0% were male. Pooled proportions of perioperative adverse events were similar between the DB/CB and IB groups except for wound complication which was higher in the former group (RR = 2.54 (95% CI: 1.82; 3.55)). Proportions of post-surgical Matsushima Grade A/B revascularization favored DB/CB over IB (RR = 1.12 (95% CI 1.02; 1.24)). There was no significant difference in stroke recurrence, morbidity, and mortality. After meta-regression analysis, year of publication and age were significant predictors of outcomes. CONCLUSIONS IB, DB/CB are relatively effective and safe revascularization options for pediatric MMD/MMS. Low-quality GRADE evidence suggests that DB/CB was associated with better long-term angiographic revascularization outcomes when compared with IB, although this did not translate to long-term stroke and mortality benefits.
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Affiliation(s)
- Keng Siang Lee
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK.
- Great Ormond Street Institute of Child Health, University College London, London, UK.
- Department of Neurosurgery, King's College Hospital, London, UK.
- Department of Basic and Clinical Neurosciences, Maurice, Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
- Bristol Medical School, University of Bristol, Bristol, UK.
| | - John J Y Zhang
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Sanjay Bhate
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Vijeya Ganesan
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Dominic Thompson
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Greg James
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Adikarige Haritha Dulanka Silva
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
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15
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Bao XY, Duan L. Chinese expert consensus on the treatment of MMD. Chin Neurosurg J 2023; 9:5. [PMID: 36823677 PMCID: PMC9948401 DOI: 10.1186/s41016-023-00318-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/16/2023] [Indexed: 02/25/2023] Open
Abstract
Moyamoya disease (MMD), also known as spontaneous occlusion of the circle of Willis, is defined by progressive stenosis or occlusion of the internal carotid arteries, and it can progress to the anterior, middle, and posterior cerebral arteries. As these arteries are gradually stenosed, a collateral network of capillaries develops at the base of the brain, producing the characteristic reticulate appearance ("puff of smoke") on angiography. Therefore, it was named by Suzuki and Takaku in 1969 after the Japanese term "moyamoya" (Suzuki and Takaku, Arch Neurol 20:288-299, 1969). MMD is most common in East Asian countries such as Japan and Korea, and it shows a slight female predominance. MMD is mainly characterized by ischemia and hemorrhage. Hemorrhagic MMD is very rare in children, and most cases occur in adults due to the rupture of the compensatory blood vessels, which often leads to hemorrhagic symptoms (Scott and Smith, N Engl J Med 360:1226-1237, 2009). In recent years, the diagnosis rate has increased with the popularization of imaging techniques. However, the pathogenesis of MMD is still not completely understood, and there is currently no evidence to suggest that drug treatment can delay or even reverse the progression of MMD. The current drug treatment for in MMD only targets its clinical symptoms, including ischemia and hemorrhage. The main choice of treatment for MMD is surgical revascularization. As an increasing number of hospitals have developed surgical treatment for MMD, our compiling group has jointly discussed the formulation of a consensus among Chinese experts on the treatment of MMD.
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Affiliation(s)
- Xiang-Yang Bao
- grid.414252.40000 0004 1761 8894Department of Neurosurgery, the First Medical Centre, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, Beijing, 100071 China
| | - Lian Duan
- Department of Neurosurgery, the First Medical Centre, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, Beijing, 100071, China.
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16
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Dawkins D, Aagaard-Kienitz B, Capel K, Eisenmenger L, Samsonov A, Li Y, Sandoval-Garcia C, Iskandar B. Wide Arterial Sparing Encephalo-Duro-Synangiosis for Moyamoya: Surgical Technique and Outcomes. Oper Neurosurg (Hagerstown) 2022; 23:489-498. [PMID: 36113163 PMCID: PMC10593263 DOI: 10.1227/ons.0000000000000376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 06/05/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Moyamoya is managed by surgical revascularization, but no standardized method has yet been universally adopted. OBJECTIVE To describe a new indirect bypass technique for pediatric moyamoya, wide arterial sparing encephalo-duro-synangiosis (WASEDS), which provides a much wider area of revascularization with minimal compromise to the middle meningeal arterial tree compared with traditional procedures. Initially used as a salvage technique after failed encephalo-duro-arterio-synangiosis, its success later motivated its use as a first-line procedure. METHODS Clinical and radiographic records of patients who underwent WASEDS for moyamoya from 2009 to 2020 were reviewed. Brain perfusion relative cerebral blood volume on the side of the WASEDS procedure was calculated. Two-tailed paired t tests were performed to identify the statistically significant differences ( P ≤ .05). RESULTS WASEDS was successfully performed on 8 patients for a total of 14 cerebral hemispheres. Age ranged from 2 to 25 years. There were no mortalities. The average clinical and radiographic follow-up was 49.79 months (range 2-126 months), demonstrating improvement in neurological condition and no postoperative stroke and significant diminution or cessation of transient ischemic attacks in all patients. Relative cerebral blood volume increased 9.24% after the WASEDS procedure ( P = .012). There were no neurological complications. There were 2 pseudomeningoceles related to the extensive dural openings. CONCLUSION WASEDS is a safe and effective indirect revascularization technique for both primary and salvage techniques. It provides an extensive area of cortical revascularization with no compromise of the middle meningeal vasculature and subjective reports of early improvement in cognition and behavior. The main disadvantage is elevated risk of pseudomeningocele secondary to the large craniotomy.
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Affiliation(s)
- Demi Dawkins
- Department of Neurosurgery, University of Tennessee Health Sciences/Semmes-Murphey Clinic, Memphis, Tennessee, USA
| | - Beverly Aagaard-Kienitz
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Department of Neurosurgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kelly Capel
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Laura Eisenmenger
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Alexey Samsonov
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Yiping Li
- Department of Neurosurgery, Inland Neurosurgery, Spokane, Washington, USA
| | | | - Bermans Iskandar
- Department of Neurosurgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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17
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Park KW, Choi N, Oh E, Lyoo CH, Baek MS, Kim HJ, Yoo D, Lee JY, Choi JH, Lee JH, Koh SB, Sung YH, Cho JW, Yang HJ, Park J, Shin HW, Ahn TB, Ryu HS, You S, Choi SM, Kim BJ, Lee SH, Chung SJ. Movement Disorders Associated With Cerebral Artery Stenosis: A Nationwide Study. Front Neurol 2022; 13:939823. [PMID: 35911886 PMCID: PMC9330487 DOI: 10.3389/fneur.2022.939823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/20/2022] [Indexed: 11/26/2022] Open
Abstract
Background Studies of secondary movement disorder (MD) caused by cerebrovascular diseases have primarily focused on post-stroke MD. However, MD can also result from cerebral artery stenosis (CAS) without clinical manifestations of stroke. In this study, we aimed to investigate the clinical characteristics of MD associated with CAS. Materials and Methods A nationwide multicenter retrospective analysis was performed based on the data from patients with CAS-associated MDs from 16 MD specialized clinics in South Korea, available between January 1999 and September 2019. CAS was defined as the >50% luminal stenosis of the major cerebral arteries. The association between MD and CAS was determined by MD specialists using pre-defined clinical criteria. The collected clinical information included baseline demographics, features of MD, characteristics of CAS, treatment, and MD outcomes. Statistical analyses were performed to identify factors associated with the MD outcomes. Results The data from a total of 81 patients with CAS-associated MD were analyzed. The mean age of MD onset was 60.5 ± 19.7 years. Chorea was the most common MD (57%), followed by tremor/limb-shaking, myoclonus, and dystonia. Atherosclerosis was the most common etiology of CAS (78%), with the remaining cases attributed to moyamoya disease (MMD). Relative to patients with atherosclerosis, those with MMD developed MD at a younger age (p < 0.001) and had a more chronic mode of onset (p = 0.001) and less acute ischemic lesion (p = 0.021). Eight patients who underwent surgical treatment for CAS showed positive outcomes. Patients with acute MD onset had a better outcome than those with subacute-to-chronic MD onset (p = 0.008). Conclusions This study highlights the spectrum of CAS-associated with MD across the country. A progressive, age-dependent functional neuronal modulation in the basal ganglia due to CAS may underlie this condition.
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Affiliation(s)
- Kye Won Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, South Korea
| | - Nari Choi
- Department of Neurology, Heavenly Hospital, Goyang, South Korea
| | - Eungseok Oh
- Department of Neurology, Chungnam National University College of Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Chul Hyoung Lyoo
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Seok Baek
- Department of Neurology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Han-Joon Kim
- Department of Neurology, Movement Disorder Center, College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Dalla Yoo
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Jee-Young Lee
- Department of Neurology, Seoul National University-Seoul Metropolitan Government Boramae Medical Center and Seoul National University Medical College, Seoul, South Korea
| | - Ji-Hyun Choi
- Department of Neurology, Seoul National University-Seoul Metropolitan Government Boramae Medical Center and Seoul National University Medical College, Seoul, South Korea
| | - Jae Hyeok Lee
- Department of Neurology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, South Korea
| | - Seong-Beom Koh
- Department of Neurology, Korea University College of Medicine, Guro Hospital, Seoul, South Korea
| | - Young Hee Sung
- Department of Neurology, Gachon University Gil Medical Center, Incheon, South Korea
| | - Jin Whan Cho
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hui-Jun Yang
- Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Jinse Park
- Department of Neurology, Haeundae Paik Hospital, Inje University, Busan, South Korea
| | - Hae-Won Shin
- Department of Neurology, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Tae-Beom Ahn
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Ho-Sung Ryu
- Department of Neurology, Kyungpook National University Hospital, Daegu, South Korea
| | - Sooyeoun You
- Department of Neurology, Dongsan Medical Center, Keimyung University, Daegu, South Korea
| | - Seong-Min Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seung Hyun Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sun Ju Chung
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
- *Correspondence: Sun Ju Chung
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18
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Zhang K, Ren W, Sun YX, Wang XJ, Li CY, Wang ZL, Li TX, Gao BL. Angiographic Characteristics of Cerebral Perfusion and Hemodynamics of the Bridging Artery After Surgical Treatment of Unilateral Moyamoya Disease. Front Neurosci 2022; 16:922482. [PMID: 35774553 PMCID: PMC9239480 DOI: 10.3389/fnins.2022.922482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/16/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose To investigate the characteristics of cerebral perfusion and hemodynamics of bypass grafting in the treatment of moyamoya disease (MMD) using the iFlow color-coded flow map in comparison with magnetic resonance imaging–perfusion-weighted imaging (MRI–PWI) and computational fluid dynamic (CFD) analysis. Materials and Methods Patients with MMD treated with bypass grafting who had undergone MRI PWI and digital subtraction angiography for iFlow color-coded map was retrospectively enrolled and CFD was performed for calculating the hemodynamic stresses around the bypass grafting. Results Forty-five patients with unilateral MMD treated with bypass surgery were enrolled. The bypass surgery was successful in all patients, with no severe neurological complications during the periprocedural period. Followed up for 4–12 months (median 5.5), the neurological function was good in all patients. The cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time to peak (TTP) were significantly (p < 0.05) improved in the middle cerebral artery distribution area on the surgical side before and after vascular bypass, and the difference of TTP (s) measured from the proximal bifurcation of common carotid artery to the confluence of sinus was also significant (p < 0.05). A significant (p < 0.05) positive correlation existed in the perfusion parameters between the iFlow blood perfusion and the MRI–PWI perfusion, with r-value for TTP of 0.765 (p < 0.01). The iFlow color-coded blood flow map showed warm color changes on the diseased side, similar to those on the contralateral side. In CFD analysis, the hemodynamic stresses were all improved, in and around the bypass grafting and distal vessels, which were beneficial to blood flow entering distal arterial branches. Conclusion The iFlow color-coded flow map can be used to analyze cerebral perfusion after bypass grafting for MMD, similar to MRI–PWI, and CFD can be used to analyze the hemodynamics after bypass grafting, revealing improved hemodynamics to promote blood flow entering distal arteries.
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Affiliation(s)
- Kun Zhang
- The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Wei Ren
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Yu-Xue Sun
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Xin-Jun Wang
- The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Xin-Jun Wang,
| | - Chao-Yue Li
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Zi-Liang Wang
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- Zi-Liang Wang,
| | - Tian-Xiao Li
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Bu-Lang Gao
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
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19
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Bao XY, Fan YN, Wang QN, Wang XP, Yang RM, Zou ZX, Zhang Q, Li DS, Duan L, Yu XG. The Potential Mechanism Behind Native and Therapeutic Collaterals in Moyamoya. Front Neurol 2022; 13:861184. [PMID: 35557620 PMCID: PMC9086844 DOI: 10.3389/fneur.2022.861184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose To explore the genetic basis and molecular mechanism of native arteriogenesis and therapeutic synangiosis in moyamoya disease (MMD). Methods An angiography-based study using patients from a prospective trial of encephaloduroarteriosynangiosis (EDAS) surgery was performed. The spontaneous collaterals grades were evaluated according to the system described by a new grading system. Blood samples were collected from all the recruited patients before EDAS and during the second hospitalization 3 months post-EDAS. We performed Boolean analysis using a combination of specific cell surface markers of CD34briCD133+CD45dimKDR+. Genotyping of p.R4810K was also performed. The correlation of age, sex, initial symptoms at diagnosis, collateral grade, Suzuki stages, the RNF213 genotype, time to peak (TTP), and endothelial progenitor cell (EPC) count with good collateral circulation was evaluated. Results Eighty-five patients with MMD were included in this study. The mutation rate of RNF213 p.R4810K in our study was 25.9% (22/85). The heterozygous mutations were occurred significantly more frequently in the cases that were presented with infarction, worse neurological status, severe posterior cerebral artery (PCA) stenosis, and longer TTP delay. Further, the heterozygous mutations occurred significantly more frequently in the poor collateral stage group. Lower grades were significantly correlated with severe ischemia symptoms, worse neurological status, and a longer TTP delay. The post-operative angiographic findings showed that a good Matsushima grade was correlated with heterozygous mutations, a lower collateral stage, and a longer TTP delay. The CD34briCD133+CD45dimKDR+ cell count in patients 3 months post-EDAS was significantly higher as compared to the count before EDAS in the good Matsushima grade group. However, this change was not observed in the poor Matsushima grade group. Conclusions These data imply that mutations of RNF213 p.R4810K affect the establishment of spontaneous collateral circulation, and EPCs are involved in the process of formation of new EDAS collaterals.
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Affiliation(s)
- Xiang-Yang Bao
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
- Chinese PLA Medical School, Beijing, China
| | - Yan-Na Fan
- Department of Radiation Oncology, The Fifth Medical Center of Chinese PLA General Hospital (Former 307th Hospital of the PLA), Beijing, China
| | - Qian-Nan Wang
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - Xiao-Peng Wang
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - Ri-Miao Yang
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - Zheng-Xing Zou
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - Qian Zhang
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - De-Sheng Li
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - Lian Duan
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
- *Correspondence: Lian Duan
| | - Xin-Guang Yu
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
- Chinese PLA Medical School, Beijing, China
- Xin-Guang Yu
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20
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Araki Y, Uda K, Yokoyama K, Kanamori F, Kurimoto M, Shiba Y, Mamiya T, Nishihori M, Takeuchi K, Tanahashi K, Nagata Y, Nishimura Y, Okamoto S, Sumitomo M, Izumi T, Saito R. Risk Factors for Cerebral Infarction Early After Revascularization in Children Younger than 5 Years with Moyamoya Disease. World Neurosurg 2022; 160:e220-e226. [PMID: 34995829 DOI: 10.1016/j.wneu.2021.12.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Cerebral revascularization is necessary for pediatric patients younger than 5 years with moyamoya disease (MMD). However, they have a high risk of developing cerebral infarction early after surgery. This study aimed to analyze the risk factors for developing cerebral infarction among these patients. METHODS The charts of 21 consecutive patients with MMD (39 surgeries) younger than 5 years who had undergone revascularization at our hospital were retrospectively analyzed. Because cerebral infarction occurring within 1 month after surgery was the primary end point, other clinical information was evaluated, including each surgical procedure. Multivariate analysis of the risk factors for postoperative cerebral infarction was performed. RESULTS Cerebral infarction occurred after 7 of 39 surgeries (17.9%). Of the 39 surgeries, 23 (59%) included direct and indirect combined revascularization. The incidence of cerebral infarction did not differ significantly between the combined (21.7%) and indirect (12.5%) groups (P = 0.46). Logistic regression showed no association between the revascularization procedure and the occurrence of cerebral infarction after surgery (P = 0.3). However, younger age at surgery was correlated with a higher risk of developing cerebral infarction in the early postoperative period (P = 0.05). CONCLUSIONS No differences were found in the risk of developing cerebral infarction early after surgery as a result of surgical procedures. However, younger patients had higher postoperative risk. Further multicenter research should examine this issue for young pediatric patients with moyamoya at high risk of developing cerebral infarction.
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Affiliation(s)
- Yoshio Araki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan.
| | - Kenji Uda
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Kinya Yokoyama
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Fumiaki Kanamori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Michihiro Kurimoto
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Yoshiki Shiba
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Takashi Mamiya
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Masahiro Nishihori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Kazuhito Takeuchi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Kuniaki Tanahashi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Yuichi Nagata
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Yusuke Nishimura
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Sho Okamoto
- Aichi Rehabilitation Hospital, Ehara, Nishio, Aichi, Japan
| | - Masaki Sumitomo
- Department of Neurosurgery, Toyota Kosei Hospital, Josui-cho, Toyota, Aichi, Japan
| | - Takashi Izumi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Aichi, Japan
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21
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Fujimura M, Tominaga T, Kuroda S, Takahashi JC, Endo H, Ogasawara K, Miyamoto S. 2021 Japanese Guidelines for the Management of Moyamoya Disease: Guidelines from the Research Committee on Moyamoya Disease and Japan Stroke Society. Neurol Med Chir (Tokyo) 2022; 62:165-170. [PMID: 35197402 PMCID: PMC9093674 DOI: 10.2176/jns-nmc.2021-0382] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine
| | - Satoshi Kuroda
- Department of Neurosurgery, University of Toyama School of Medicine
| | - Jun C Takahashi
- Department of Neurosurgery, Kindai University Faculty of Medicine
| | | | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University School of Medicine
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
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22
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Kuribara T, Akiyama Y, Mikami T, Komatsu K, Kimura Y, Takahashi Y, Sakashita K, Chiba R, Mikuni N. Macrohistory of Moyamoya Disease Analyzed Using Artificial Intelligence. Cerebrovasc Dis 2022; 51:413-426. [PMID: 35104814 DOI: 10.1159/000520099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 10/06/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Moyamoya disease is characterized by progressive stenotic changes in the terminal segment of the internal carotid artery and the development of abnormal vascular networks called moyamoya vessels. The objective of this review was to provide a holistic view of the epidemiology, etiology, clinical findings, treatment, and pathogenesis of moyamoya disease. A literature search was performed in PubMed using the term "moyamoya disease," for articles published until 2021. RESULTS Artificial intelligence (AI) clustering was used to classify the articles into 5 clusters: (1) pathophysiology (23.5%); (2) clinical background (37.3%); (3) imaging (13.2%); (4) treatment (17.3%); and (5) genetics (8.7%). Many articles in the "clinical background" cluster were published from the 1970s. However, in the "treatment" and "genetics" clusters, the articles were published from the 2010s through 2021. In 2011, it was confirmed that a gene called Ringin protein 213 (RNF213) is a susceptibility gene for moyamoya disease. Since then, tremendous progress in genomic, transcriptomic, and epigenetic profiling (e.g., methylation profiling) has resulted in new concepts for classifying moyamoya disease. Our literature survey revealed that the pathogenesis involves aberrations of multiple signaling pathways through genetic mutations and altered gene expression. CONCLUSION We analyzed the content vectors in abstracts using AI, and reviewed the pathophysiology, clinical background, radiological features, treatments, and genetic peculiarity of moyamoya disease.
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Affiliation(s)
| | - Yukinori Akiyama
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Takeshi Mikami
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Katsuya Komatsu
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Yusuke Kimura
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | | | - Kyoya Sakashita
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Ryohei Chiba
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
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23
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Po' C, Nosadini M, Zedde M, Pascarella R, Mirone G, Cicala D, Rosati A, Cosi A, Toldo I, Colombatti R, Martelli P, Iodice A, Accorsi P, Giordano L, Savasta S, Foiadelli T, Sanfilippo G, Lafe E, Thyrion FZ, Polonara G, Campa S, Raviglione F, Scelsa B, Bova SM, Greco F, Cordelli DM, Cirillo L, Toni F, Baro V, Causin F, Frigo AC, Suppiej A, Sainati L, Azzolina D, Agostini M, Cesaroni E, De Carlo L, Di Rosa G, Esposito G, Grazian L, Morini G, Nicita F, Operto FF, Pruna D, Ragazzi P, Rollo M, Spalice A, Striano P, Skabar A, Lanterna LA, Carai A, Marras CE, Manara R, Sartori S. Pediatric Moyamoya Disease and Syndrome in Italy: A Multicenter Cohort. Front Pediatr 2022; 10:892445. [PMID: 35601411 PMCID: PMC9120837 DOI: 10.3389/fped.2022.892445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/05/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Moyamoya is a rare progressive cerebral arteriopathy, occurring as an isolated phenomenon (moyamoya disease, MMD) or associated with other conditions (moyamoya syndrome, MMS), responsible for 6-10% of all childhood strokes and transient ischemic attacks (TIAs). METHODS We conducted a retrospective multicenter study on pediatric-onset MMD/MMS in Italy in order to characterize disease presentation, course, management, neuroradiology, and outcome in a European country. RESULTS A total of 65 patients (34/65 women) with MMD (27/65) or MMS (38/65) were included. About 18% (12/65) of patients were asymptomatic and diagnosed incidentally during investigations performed for an underlying condition (incMMS), whereas 82% (53/65) of patients with MMD or MMS were diagnosed due to the presence of neurological symptoms (symptMMD/MMS). Of these latter, before diagnosis, 66% (43/65) of patients suffered from cerebrovascular events with or without other manifestations (ischemic stroke 42%, 27/65; TIA 32%, 21/65; and no hemorrhagic strokes), 18% (12/65) of them reported headache (in 4/12 headache was not associated with any other manifestation), and 26% (17/65) of them experienced multiple phenotypes (≥2 among: stroke/TIA/seizures/headache/others). Neuroradiology disclosed ≥1 ischemic lesion in 67% (39/58) of patients and posterior circulation involvement in 51% (30/58) of them. About 73% (47/64) of patients underwent surgery, and 69% (45/65) of them received aspirin, but after diagnosis, further stroke events occurred in 20% (12/61) of them, including operated patients (11%, 5/47). Between symptom onset and last follow-up, the overall patient/year incidence of stroke was 10.26% (IC 95% 7.58-13.88%). At last follow-up (median 4 years after diagnosis, range 0.5-15), 43% (26/61) of patients had motor deficits, 31% (19/61) of them had intellectual disability, 13% (8/61) of them had epilepsy, 11% (7/61) of them had behavioral problems, and 25% (13/52) of them had mRS > 2. The proportion of final mRS > 2 was significantly higher in patients with symptMMD/MMS than in patients with incMMS (p = 0.021). Onset age <4 years and stroke before diagnosis were significantly associated with increased risk of intellectual disability (p = 0.0010 and p = 0.0071, respectively) and mRS > 2 at follow-up (p = 0.0106 and p = 0.0009, respectively). CONCLUSIONS Moyamoya is a severe condition that may affect young children and frequently cause cerebrovascular events throughout the disease course, but may also manifest with multiple and non-cerebrovascular clinical phenotypes including headache (isolated or associated with other manifestations), seizures, and movement disorder. Younger onset age and stroke before diagnosis may associate with increased risk of worse outcome (final mRS > 2).
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Affiliation(s)
- Chiara Po'
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy.,Department of Women's and Children's Health, University of Padova, Padova, Italy.,Unit of Pediatrics, AULSS 2 Marca Trevigiana, Ca' Foncello Hospital, Treviso, Italy
| | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy.,Neuroimmunology Group, Paediatric Research Institute "Città della Speranza", Padova, Italy
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Rosario Pascarella
- Neuroradiology Unit, Arcispedale S. Maria Nuova AUSL Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Giuseppe Mirone
- Pediatric Neurosurgery Unit, Department of Neuroscience, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Domenico Cicala
- Pediatric Neuroradiology, Department of Neuroscience, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Anna Rosati
- Department of Neuroscience, Children's Hospital Anna Meyer, University of Firenze, Firenze, Italy
| | - Alessandra Cosi
- Department of Neuroscience, Children's Hospital Anna Meyer, University of Firenze, Firenze, Italy
| | - Irene Toldo
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Raffaella Colombatti
- Clinic of Pediatric Hematology Oncology, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Paola Martelli
- Child Neurology and Psychiatry Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Alessandro Iodice
- Child Neurology and Psychiatry Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Patrizia Accorsi
- Child Neurology and Psychiatry Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Lucio Giordano
- Child Neurology and Psychiatry Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Salvatore Savasta
- Pediatric Clinic, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Thomas Foiadelli
- Pediatric Clinic, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Giuseppina Sanfilippo
- Department of Diagnostic and Interventional Radiology and Neuroradiology, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Elvis Lafe
- Department of Diagnostic and Interventional Radiology and Neuroradiology, IRCSS Policlinico San Matteo, Pavia, Italy
| | - Federico Zappoli Thyrion
- Department of Diagnostic and Interventional Radiology and Neuroradiology, IRCSS Policlinico San Matteo, Pavia, Italy
| | - Gabriele Polonara
- Neuroradiology - Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Serena Campa
- Neuroradiology Unit, University Hospital "Ospedali Riuniti di Ancona, " Università Politecnica delle Marche, Ancona, Italy
| | | | - Barbara Scelsa
- Department of Pediatric Neurology, Vittore Buzzi Children's Hospital, Milan, Italy
| | - Stefania Maria Bova
- Department of Pediatric Neurology, Vittore Buzzi Children's Hospital, Milan, Italy
| | - Filippo Greco
- Pediatric Clinic, Department of Clinical and Experimental Medicine, University Hospital A.U.O. "Policlinico-San Marco" of Catania, Catania, Italy
| | - Duccio Maria Cordelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell'età Pediatrica, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Luigi Cirillo
- Neuroradiology Unit, IRCSS "Istituto delle Scienze Neurologiche di Bologna, " Ospedale Bellaria, Bologna, Italy
| | - Francesco Toni
- Neuroradiology Unit, IRCSS "Istituto delle Scienze Neurologiche di Bologna, " Ospedale Bellaria, Bologna, Italy
| | - Valentina Baro
- Academic Neurosurgery, Department of Neurosciences, University of Padova, Padova, Italy
| | - Francesco Causin
- Neuroradiology, Department of Neurological Sciences, University of Padova, Padova, Italy
| | - Anna Chiara Frigo
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Agnese Suppiej
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy.,Pediatric Section, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Laura Sainati
- Clinic of Pediatric Hematology Oncology, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Danila Azzolina
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Manuela Agostini
- Department of Pediatrics, Regina Margherita Children's Hospital, Torino, Italy
| | - Elisabetta Cesaroni
- Department of Child Neuropsychiatry, University Hospital Ospedali Riuniti, Ancona, Italy
| | - Luigi De Carlo
- Pediatric Section, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Gabriella Di Rosa
- Unit of Child Neurology and Psychiatry, Department of Human Pathology of the Adult and Developmental Age, Messina, Italy
| | - Giacomo Esposito
- Pediatric Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, Roma, Italy
| | - Luisa Grazian
- Unit of Pediatrics, AULSS 2 Marca Trevigiana, Ca' Foncello Hospital, Treviso, Italy
| | - Giovanna Morini
- Department of Pediatrics, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Francesco Nicita
- Unit of Neuromuscular and Neurodegenerative Disorders, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,Child Neurology Division, Department of Pediatrics, Sapienza University, Rome, Italy
| | - Francesca Felicia Operto
- Child and Adolescent Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Dario Pruna
- Neurology and Epileptology Unit, Department of Pediatric, ARNAS Brotzu, Cagliari, Italy
| | - Paola Ragazzi
- Department of Neurosurgery, "Regina Margherita" Children's Hospital, Torino, Italy
| | - Massimo Rollo
- Interventional Radiology Unit, Department of Imaging, Bambino Gesù Children's Hospital (IRCCS), Rome, Italy
| | - Alberto Spalice
- Department of Maternal Sciences, Sapienza University, Rome, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS "Istituto Giannina Gaslini", Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Aldo Skabar
- Department of Pediatrics, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | | | - Andrea Carai
- Pediatric Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, Roma, Italy
| | - Carlo Efisio Marras
- Pediatric Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, Roma, Italy
| | - Renzo Manara
- Neuroradiology Unit, Department of Neurological Sciences, University of Padova, Padova, Italy
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy.,Department of Women's and Children's Health, University of Padova, Padova, Italy.,Department of Neuroscience, University of Padova, Padova, Italy.,Neuroimmunology Group, Paediatric Research Institute "Città della Speranza", Padova, Italy
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Chatterjee S, Ghosh R, Dubey S, Ray B. Moyamoya angiopathy masquerading as febrile seizures. MEDICAL JOURNAL OF DR. D.Y. PATIL VIDYAPEETH 2022. [DOI: 10.4103/mjdrdypu.mjdrdypu_19_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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25
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Ijner P, Tompkins G, Shiohama T, Takahashi E, Levman J. Structural Abnormalities in Pediatric Moyamoya Disease Revealed by Clinical Magnetic Resonance Imaging, Regionally Distributed Relative Signal Intensities and Volumes. Int J Dev Neurosci 2021; 82:146-158. [PMID: 34969179 DOI: 10.1002/jdn.10167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/15/2021] [Accepted: 12/22/2021] [Indexed: 11/05/2022] Open
Abstract
Moyamoya disease (MMD) is a rare, progressive cerebrovascular disorder, with an unknown etiology and pathogenesis. It is characterized by steno-occlusive changes at the terminal portion of the internal carotid artery (ICA), which is accompanied by variable development of the basal collaterals called moyamoya vessels. In this study, we investigate the potential for structural T1 magnetic resonance imaging (MRI) to help characterize MMD clinically, with the help of regionally distributed relative signal intensities (RRSIs) and volumes (RRVs). These RRSIs and RRVs provide the ability to characterize aspects of regional brain development and represent an extension to existing automated biomarker extraction technologies. This study included 269 MRI examinations from MMD patients and 993 MRI examinations from neurotypical controls, with regional biomarkers compared between groups with the area under the receiver operating characteristic curve (AUC). Results demonstrate abnormal presentation of RRSIs and RRVs in the insula (15-20 year old cohort, left AUC: 0.74, right AUC: 0.71), and the lateral orbitofrontal region (5-10 year old cohort, left AUC: 0.67; 15-20 year cohort, left AUC: 0.62, right AUC: 0.65). Results indicate that RRSIs and RRVs may help in characterizing brain development, assist in the assessment of the presentation of the brains of children with MMD, and may help overcome standardization challenges in multi-protocol clinical MRI. Further investigation of the potential for RRSIs and RRVs in clinical imaging is warranted and supported through the release of open source software.
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Affiliation(s)
- Prahar Ijner
- Department of Computer Science, St. Francis Xavier University, Antigonish, NS, Canada
| | - Grace Tompkins
- Department of Mathematics and Statistics, St. Francis Xavier University, Antigonish, NS, Canada
| | - Tadashi Shiohama
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Japan
| | - Emi Takahashi
- Division of Newborn Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Jacob Levman
- Department of Computer Science, St. Francis Xavier University, Antigonish, NS, Canada
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McCreary D, McArdle J, Minks D, Horridge K. Something hazy drifting in the air…. Arch Dis Child Educ Pract Ed 2021; 106:341-343. [PMID: 31862781 DOI: 10.1136/archdischild-2019-317535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 11/13/2019] [Indexed: 11/04/2022]
Abstract
-A 7-year-old boy with a background of autism presented to the paediatric emergency department with his left arm 'feeling strange' then became difficult to rouse. On examination, he was found to have left arm weakness and a left-sided facial droop without forehead muscle involvement. Three hours later, his symptoms had completely resolved and he was suspected to have had a first seizure. He was admitted for observation and an electroencephalography which showed slower rhythms in the right posterior quadrant, which was reported as within normal appearances for his age. He was discharged home the following day. Three days later he became lethargic and vomited. His parents reported dysphasia with use of single-word phrases only, he also appeared confused. He re-presented to the paediatric emergency department, where he was found to have increased tone in the left arm, ankle clonus and an upgoing plantar reflex on the left hand side.
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Affiliation(s)
| | - Jane McArdle
- Paediatrics, Sunderland Royal Hospital, Sunderland, UK
| | - David Minks
- Radiology department, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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Chiang CC, Shahid AH, Harriott AM, Tietjen GE, Savastano LE, Klaas JP, Lanzino G. Evaluation and treatment of headache associated with moyamoya disease - a narrative review. Cephalalgia 2021; 42:542-552. [PMID: 34786968 DOI: 10.1177/03331024211056250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Headache in patients with moyamoya disease is an under-addressed topic in the medical literature. Delay in the diagnosis of moyamoya disease or inappropriate treatment of headache could lead to devastating cerebrovascular outcome. With the evolving understanding of moyamoya disease, migraine pathophysiology, and various migraine-specific medications that have become available, it is crucial to provide an updated overview on this topic. METHODS We searched PubMed for keywords including moyamoya disease, moyamoya syndrome, headache in moyamoya, surgical revascularization, surgical bypass, migraine and moyamoya, and calcitonin gene-related peptide (CGRP). We summarized the literature and provide a comprehensive review of the headache presentation, possible mechanisms, the impact of various surgical revascularizations on headache in patients with moyamoya disease, and the medical management of headache incorporating novel migraine-specific treatments.Results and conclusion: The most common headache phenotype is migraine; tension-type headache, hemiplegic migraine, and cluster headache have also been reported. Most patients experience improvement of headache after surgical revascularization, though some patients report worsening, or new-onset headache after surgery. Given the complexity of moyamoya disease, careful consideration of different types of medical therapy for headache is necessary to improve the quality of life while not increasing the risk of adverse cerebrovascular events. More prospective studies are warranted to better understand and manage headache in patients with moyamoya disease.
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Affiliation(s)
- Chia-Chun Chiang
- Department of Neurology, 6915Mayo Clinic, Mayo Clinic, Rochester, MN
| | | | | | | | | | - James P Klaas
- Department of Neurology, 6915Mayo Clinic, Mayo Clinic, Rochester, MN
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Fox BM, Dorschel KB, Lawton MT, Wanebo JE. Pathophysiology of Vascular Stenosis and Remodeling in Moyamoya Disease. Front Neurol 2021; 12:661578. [PMID: 34539540 PMCID: PMC8446194 DOI: 10.3389/fneur.2021.661578] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 08/09/2021] [Indexed: 12/04/2022] Open
Abstract
Moyamoya disease (MMD) and moyamoya syndrome (MMS) are progressive vascular pathologies unique to the cerebrovasculature that are important causes of stroke in both children and adults. The natural history of MMD is characterized by primary progressive stenosis of the supraclinoid internal carotid artery, followed by the formation of fragile collateral vascular networks. In MMS, stenosis and collateralization occur in patients with an associated disease or condition. The pathological features of the stenosis associated with MMD include neointimal hyperplasia, disruption of the internal elastic lamina, and medial attenuation, which ultimately lead to progressive decreases in both luminal and external arterial diameter. Several molecular pathways have been implicated in the pathophysiology of stenosis in MMD with functions in cellular proliferation and migration, extracellular matrix remodeling, apoptosis, and vascular inflammation. Importantly, several of these molecular pathways overlap with those known to contribute to diseases of systemic arterial stenosis, such as atherosclerosis and fibromuscular dysplasia (FMD). Despite these possible shared mechanisms of stenosis, the contrast of MMD with other stenotic pathologies highlights the central questions underlying its pathogenesis. These questions include why the stenosis that is associated with MMD occurs in such a specific and limited anatomic location and what process initiates this stenosis. Further investigation of these questions is critical to developing an understanding of MMD that may lead to disease-modifying medical therapies. This review may be of interest to scientists, neurosurgeons, and neurologists involved in both moyamoya research and treatment and provides a review of pathophysiologic processes relevant to diseases of arterial stenosis on a broader scale.
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Affiliation(s)
- Brandon M Fox
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Kirsten B Dorschel
- Medical Faculty, Heidelberg University Medical School, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Germany
| | - Michael T Lawton
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - John E Wanebo
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
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Validation and Extension Study Exploring the Role of RNF213 p.R4810K in 2,877 Chinese Moyamoya Disease Patients. J Stroke Cerebrovasc Dis 2021; 30:106071. [PMID: 34482123 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/12/2021] [Accepted: 08/14/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To validate, update, and extend the role of RNF213 p.R4810K (G>A) for predicting the phenotype of moyamoya disease (MMD) patients and explore the different effects on pediatric and adult groups. METHODS A total of 2,877 patients conducted from 2004 to 2018 were included. Review Manage 5.3 and SPSS 20.0 were applied to complete all statistical analyses. Information on age at onset, sex, initial symptom, family history and complications were obtained via retrospective chart review. Angiographic records were evaluated. RESULTS In China, geographic proximity to Korea or Japan may affect the carrying rate of RNF213 p.R4810K. The proportion of patients with the following characteristics was significantly higher (P <0.017) in the GA than in the GG group: female, age at onset < 18 years, infarct after transient ischemic attack, family history of MMD, and posterior cerebral artery involvement. For pediatric patients, GA showed more cerebral hemorrhage (CH) (odds ratios (ORs) [95% confidence intervals (CIs)] = 3.99 (1.61-9.88), P = 0.003), more patients were in the Suzuki early and intermediate stage (P = 0.001; P = 0.001, respectively), while for the adult group, GA indicated more female (OR [95% CIs] = 1.43 [1.15-1.79], P = 0.001), fewer patients with diabetes (0.58 [0.38-0.86], P = 0.007) and intermediate Suzuki stage (P = 3.70 × 10-4). CONCLUSIONS The incidence and carrying rates of RNF213 p.R4810K in various regions for Chinese MMD patients were obviously different. RNF213 p.R4810K has different predictive effects on phenotypes of pediatric and adult patients.
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Wang QN, Bao XY, Zou ZX, Wang XP, Zhang Q, Li DS, Zhao YQ, Duan L. The role of atorvastatin in collateral circulation formation induced by encephaloduroarteriosynangiosis: a prospective trial. Neurosurg Focus 2021; 51:E9. [PMID: 34469867 DOI: 10.3171/2021.6.focus21112] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/21/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This prospective study was designed to confirm the role of atorvastatin in collateral circulation formation induced by encephaloduroarteriosynangiosis (EDAS) in patients with moyamoya disease (MMD). METHODS Patients who were diagnosed with MMD at the Department of Neurosurgery in the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China, between June 2017 and May 2018 were included. Blood samples were obtained from an antecubital vein and were analyzed using flow cytometry. Endothelial progenitor cells (EPCs) were defined as CD34brCD133+CD45dimKDR+. All patients included in the study underwent EDAS. Patients voluntarily chose whether to undergo atorvastatin treatment after EDAS. The correlation between atorvastatin and good postoperative collateral circulation was evaluated. RESULTS A total of 106 patients with MMD were included in this study. Fifty-three patients (50%) received atorvastatin treatment. The baseline characteristics did not display statistically significant differences between the atorvastatin-treated and non-atorvastatin groups. Seventy-eight (42.9%) of the 182 hemispheres investigated postoperatively were classified as grade A collateral circulation, 47 (25.8%) as grade B, and 57 (31.3%) as grade C. Multivariate analysis revealed that only atorvastatin was significantly correlated with good collateral circulation after EDAS (p = 0.041). CONCLUSIONS The results of this prospective clinical trial have indicated that atorvastatin administered at 20 mg daily is safe and effective for the formation of postoperative collateral induced by EDAS.
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Affiliation(s)
- Qian-Nan Wang
- 1Department of Neurosurgery, Chinese PLA General Hospital (former Department of Neurosurgery, the Eighth Medical Center of Chinese PLA General Hospital); and
| | - Xiang-Yang Bao
- 2Department of Neurosurgery, Chinese PLA General Hospital (former Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
| | - Zheng-Xing Zou
- 2Department of Neurosurgery, Chinese PLA General Hospital (former Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
| | - Xiao-Peng Wang
- 2Department of Neurosurgery, Chinese PLA General Hospital (former Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
| | - Qian Zhang
- 2Department of Neurosurgery, Chinese PLA General Hospital (former Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
| | - De-Sheng Li
- 2Department of Neurosurgery, Chinese PLA General Hospital (former Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
| | - Ya-Qun Zhao
- 1Department of Neurosurgery, Chinese PLA General Hospital (former Department of Neurosurgery, the Eighth Medical Center of Chinese PLA General Hospital); and
| | - Lian Duan
- 2Department of Neurosurgery, Chinese PLA General Hospital (former Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
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Tompkins G, Levman J, Ijner P, Shiohama T, Takahashi E. Cortical thickness in clinical moyamoya disease: A magnetic resonance imaging study. Int J Dev Neurosci 2021; 81:698-705. [PMID: 34370351 DOI: 10.1002/jdn.10146] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 06/03/2021] [Accepted: 08/04/2021] [Indexed: 11/10/2022] Open
Abstract
Moyamoya disease (MMD) is a progressive cerebrovascular disorder, with an unknown pathogenesis and aetiology. MMD is characterized by steno-occlusive changes at the terminal portion of the internal carotid artery (ICA), which is accompanied by variable development of the basal collaterals, also known as moyamoya vessels. Patients with MMD show variable patterns of brain damage and may experience recurrent multiple transient ischaemic attacks, intracranial bleeding and cerebral infarction. In this study, we investigate the potential for structural T1 magnetic resonance imaging (MRI) to help characterize abnormal cortical development in MMD clinically, with an analysis of both average and variability of regional cortical thicknesses. This study also included a machine learning analysis to assess the predictive capacity of the cortical thickness abnormalities observed in this research. This study included 993 MRI examinations from neurotypical controls and 269 MRI examinations from MMD patients. Results demonstrate abnormal cortical presentation of the insula, caudate, postcentral, precuneus and cingulate regions, in agreement with previous literature cortical thickness findings as well as alternative methods such as functional MRI (fMRI) and digital angiography. To the best of our knowledge, this is the first manuscript to report cortical thickness abnormalities in the middle temporal visual area in MMD and the first study to report on cortical thickness variability abnormalities in MMD.
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Affiliation(s)
- Grace Tompkins
- Department of Mathematics and Statistics, St. Francis Xavier University, Antigonish, Nova Scotia, Canada
| | - Jacob Levman
- Department of Computer Science, St. Francis Xavier University, Antigonish, Nova Scotia, Canada
| | - Prahar Ijner
- Department of Computer Science, St. Francis Xavier University, Antigonish, Nova Scotia, Canada
| | - Tadashi Shiohama
- Department of Pediatrics, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Emi Takahashi
- Division of Newborn Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Gupta SK, Narayanan R, Aggarwal A, Mohanty M, Ahuja C, Verma N, Praneeth K, Agarwal V. Outcome Following Surgical Revascularization in Patients of Moyamoya Disease with Focus on Graft Patency and Angiographic Changes. Neurol India 2021; 69:620-627. [PMID: 34169855 DOI: 10.4103/0028-3886.319228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Surgical revascularization is the mainstay of treatment in symptomatic patients of moyamoya disease (MMD). Objective The present study analyzed the postoperative angio-architecture in pediatric and adult patients of moyamoya disease. Material and Methods Patients with MMD, both ischemic and hemorrhagic, were subjected to surgery. A superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis was attempted in all. It was augmented by an encephalo-duro-myo-synangiosis), this was labelled as the combined surgical group. In patients where a direct bypass was not possible encephalo-duro-arterio-myo-synangiosis (EDAMS) was performed and these patients were put in the indirect surgery group. In the postoperative period, MRA was performed in all patients to look for (a) graft patency, (b) regression of moyamoya vessels, and (c) degree of surgical neovascularization (as quantified on adapted Matsushima and Inaba grading system). Results Eighty-two patients underwent 131 surgical revascularization procedures. A combined surgery (STA-MCA bypass and EDAMS) was performed in 100 hemispheres and indirect surgery (EDAMS) on 31 sides. In children less than 5 years of age, STA-MCA anastomosis was possible in more than 50% of patients. Clinical improvement was seen in 85.4% of patients. Postoperative MRA demonstrated a patent bypass graft in 97% of cases. Regression of moyamoya vessels was seen in half of the cases and good surgical revascularization (type A and B) was seen in more than 80% of hemispheres in the combined surgery and indirect surgery group. Conclusions Revascularization procedures led to a regression of moyamoya collaterals, appearance of surgical neo angiogenesis, and a graft patency rate of 97%. Surgical group with combined revascularization had a trend towards better collateral development.
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Affiliation(s)
- Sunil K Gupta
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajashekhar Narayanan
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Aggarwal
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manju Mohanty
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Chirag Ahuja
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Verma
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kokkula Praneeth
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivek Agarwal
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Deng X, Ge P, Wang R, Zhang D, Zhao J, Zhang Y. Risk factors for postoperative ischemic complications in pediatric moyamoya disease. BMC Neurol 2021; 21:229. [PMID: 34157993 PMCID: PMC8218458 DOI: 10.1186/s12883-021-02283-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 06/10/2021] [Indexed: 11/30/2022] Open
Abstract
Background Ischemic events are the most common postoperative complication in bypass surgery for moyamoya disease (MMD), but the risk factors for pediatric MMD remain unclear. The goal of the study was to investigate the risk factors for postoperative ischemic complications in pediatric MMD patients. Methods We retrospectively reviewed a consecutive series of pediatric MMD cases at Beijing Tiantan Hospital, Capital Medical University from June 2010 through June 2019. Preoperative clinical variables and radiographic findings were recorded, and logistic regression analysis was carried out to identify the risk factors for postoperative ischemic events. Results A total of 533 operations in 336 patients were included in this study. Postoperative complications occurred after 51 operations (9.6%), including 40/447 indirect bypass procedures, 9/70 direct bypass procedures, and 2/16 combined bypass procedures. Postoperative ischemic events were the most common complication and occurred in 30 patients after 31 procedures (8.9% per patient; 5.8% per operation), including 26/447 indirect bypass procedures, 4/70 direct bypass procedures, and 1/16 combined bypass procedures, and the incidence of these events did not differ significantly between indirect and non-indirect bypass (5.8% vs 5.8%; p = 0.999). Multivariate logistic regression analyses revealed that older age at operation (OR 1.129, 95% CI 1.011–1.260, p = 0.032) and posterior cerebral artery involvement (OR 2.587, 95% CI 1.030–6.496, p = 0.043) were significantly associated with postoperative ischemic events. Conclusion We speculate that older age at operation and posterior cerebral artery involvement are risk factors for postoperative ischemic events in pediatric MMD patients.
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Affiliation(s)
- Xiaofeng Deng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Peicong Ge
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Rong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, China
| | - Yan Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, China. .,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China. .,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
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Deckers PT, van Hoek W, Kronenburg A, Yaqub M, Siero JCW, Bhogal AA, van Berckel BNM, van der Zwan A, Braun KPJ. Contralateral improvement of cerebrovascular reactivity and TIA frequency after unilateral revascularization surgery in moyamoya vasculopathy. NEUROIMAGE-CLINICAL 2021; 30:102684. [PMID: 34215154 PMCID: PMC8102652 DOI: 10.1016/j.nicl.2021.102684] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/24/2021] [Accepted: 04/18/2021] [Indexed: 11/17/2022]
Abstract
Contralateral cerebrovascular reactivity may improve after unilateral surgery in moyamoya. TIA frequency from the contralateral hemisphere can decrease after unilateral moyamoya surgery. These findings support staged rather than direct bilateral surgery in moyamoya.
Objective Moyamoya vasculopathy is a rare, often bilateral disease characterized by progressive stenosis and occlusion of the distal internal carotid artery, leading to a progressive deterioration of cerebrovascular reactivity (CVR) and increased risk of transient ischemic attacks (TIAs), infarction and hemorrhage. Surgical revascularization is a widely accepted symptomatic treatment, often performed bilaterally in one or two stages. To possibly further optimize treatment strategy, we investigated the effect of unilateral revascularization surgery on the CVR of, and TIA frequency originating from, the contralateral hemisphere. Methods From our database of 143 moyamoya vasculopathy patients we selected those with bilateral disease, who underwent hemodynamic imaging ([15O]H2O positron emission tomography (PET)-CT with acetazolamide challenge) before and 14 months (median) after unilateral revascularization. We evaluated CVR in three regions per hemisphere, and averaged these per hemisphere for statistical comparison. Conservatively treated patients were showed as a comparison group. To examine TIA frequency, we selected patients who presented with TIAs that (also) originated from the contralateral – not to be operated – hemisphere. We scored changes in CVR and TIA frequency of the ipsilateral and contralateral hemisphere over time. Results Seven surgical and seven conservative patients were included for CVR comparison. Of the 20 scored contralateral regions in the surgical group, 15 showed improved CVR after unilateral revascularization, while 5 remained stable. The averaged scores improved significantly for both hemispheres. In conservatively treated patients, however, only 3 of the 20 scored regions improved in the least-affected (contralateral) hemispheres, and 9 deteriorated. From the 6 patients with contralateral TIAs at presentation, 4 had a decreased TIA frequency originating from the contralateral hemisphere after unilateral surgery, while 2 patients remained stable. Conclusion Both CVR and TIA frequency in the contralateral hemisphere can improve after unilateral revascularization surgery in bilateral MMV.
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Affiliation(s)
- Pieter T Deckers
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht, the Netherlands.
| | - Wytse van Hoek
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht, the Netherlands
| | - Annick Kronenburg
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht, the Netherlands
| | - Maqsood Yaqub
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Jeroen C W Siero
- Imaging Division, Department of Radiology, Utrecht Center for Image Sciences, University Medical Center Utrecht, Utrecht the Netherlands; Spinoza Centre for Neuroimaging, Amsterdam, the Netherlands
| | - Alex A Bhogal
- Imaging Division, Department of Radiology, Utrecht Center for Image Sciences, University Medical Center Utrecht, Utrecht the Netherlands
| | - Bart N M van Berckel
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Albert van der Zwan
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht, the Netherlands
| | - Kees P J Braun
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht, the Netherlands
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Finkenstaedt S, Guida L, Regli L, Esposito G. Surgical revascularization of frontal areas in pediatric Moyamoya vasculopathy: a systematic review. J Neurosurg Sci 2021; 65:287-304. [PMID: 33870665 DOI: 10.23736/s0390-5616.20.05172-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The aim of this study is to systematically review the literature on surgical revascularization techniques for flow-augmentation of the frontal areas and/or anterior cerebral artery (ACA) territory in children with Moyamoya vasculopathy (MMV), to elucidate the current surgical practice and describe the outcome associated to the different techniques. EVIDENCE ACQUISITION The systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. MEDLINE, Web of Science and EMBASE were searched up to April 2020. Published techniques were systematically analyzed according to level of evidence, revascularization technique, opening of the interhemispheric fissure (IF), uni- or bilateral revascularization, clinical, neurocognitive, angiographic, perfusion and hemodynamic outcome. EVIDENCE SYNTHESIS Twenty-five studies were enrolled, including 829 patients: among these, 13 patients underwent direct revascularization of ACA territories, 570 indirect revascularization and 246 patients combined revascularization. One study reached a level of evidence II (grade of recommendation B), 8 studies were level III (grade B) and 16 studies were level IV (grade C). The surgical techniques proposed in the enrolled papers were systematically described. CONCLUSIONS Combined techniques (grade of recommendation B) and indirect techniques (grade of recommendation C) are considered effective for revascularizing the frontal areas and/or anterior cerebral artery (ACA) territory in children with MMV. While performing the revascularization, surgical risks can be reduced by avoiding the exposure of the superior sagittal sinus and opening of IF (recommendation grade C). There is not sufficient evidence to define which type of surgical technique should be preferred. Future studies are needed for a longitudinal assessment of comparable outcomes and to determine which revascularization technique for the frontal areas and/or ACA territory is optimal for this highly specific pediatric population.
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Affiliation(s)
- Sina Finkenstaedt
- Department of Neurosurgery, University Hospital of Zurich, Clinical Neuroscience Center, Zurich, Switzerland.,Department of Neurosurgery, Inselspital University Hospital of Bern, Bern, Switzerland
| | - Lelio Guida
- Department of Neurosurgery, University Hospital of Zurich, Clinical Neuroscience Center, Zurich, Switzerland.,Department of Neurosurgery, University of Milan, Milan, Italy
| | - Luca Regli
- Department of Neurosurgery, University Hospital of Zurich, Clinical Neuroscience Center, Zurich, Switzerland
| | - Giuseppe Esposito
- Department of Neurosurgery, University Hospital of Zurich, Clinical Neuroscience Center, Zurich, Switzerland -
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Chen D, Zhang G, Wang J, Chen S, Wang J, Nie H, Tang Z. Mapping Trends in Moyamoya Angiopathy Research: A 10-Year Bibliometric and Visualization-Based Analyses of the Web of Science Core Collection (WoSCC). Front Neurol 2021; 12:637310. [PMID: 33737903 PMCID: PMC7960774 DOI: 10.3389/fneur.2021.637310] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/08/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Moyamoya angiopathy (MMA), which includes moyamoya disease (MMD) and moyamoya syndrome (MMS), is an uncommon cerebrovascular condition characterized by recurrent stroke. We carried out a bibliometric analysis to examine the development of and research trends in MMA research. Methods: Studies published between 2010 and 2019 on MMA were retrieved from the Web of Science Core Collection (WoSCC) on August 14, 2020, and bibliometric and visualization-based analyses were performed by using three different scientometric tools: HistCite, VOSviewer, and CiteSpace. Results: A total of 1,896 publications published in 384 journals by 6,744 authors, 1,641 institutions and 56 countries/regions were included in the analyses. Annual publication outputs increased from 2010 to 2019. The USA, Japan and China were three key contributors to this study field. Capital Medical University, Seoul National University, and Stanford University were three major institutions with larger numbers of publications. Zhang D, World Neurosurgery, Kuroda S, and STROKE were the most prolific author, prolific journal, top co-cited author and top co-cited journal, respectively. The top five keywords during this period were moyamoya disease, revascularization, stroke, children and surgery, while revascularization surgery and RNF213 were the most common frontier topics. Conclusions: In this study, the research trends of global scientific research on MMA over the past decade were systematically analyzed. The study can provide guidance for scholars who want to understand current trends in research in this area and new research frontiers.
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Affiliation(s)
- Danyang Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan Hubei, China
| | - Ge Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan Hubei, China
| | - Jiahui Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan Hubei, China
| | - Shiling Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan Hubei, China
| | - Jingxuan Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan Hubei, China
| | - Hao Nie
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan Hubei, China
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Zhang A, Brown N, Cheaney B, Campos JK, Chase Ransom R, Hsu FP. Updates in the management of moyamoya disease. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.100976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Aono T, Ono H, Inoue T, Tanishima T, Tamura A, Saito I. Impact of Extracranial-Intracranial Bypass on Cognitive Function in a Patient with Chronic Cerebral Ischemia. Asian J Neurosurg 2021; 16:212-216. [PMID: 34211898 PMCID: PMC8202360 DOI: 10.4103/ajns.ajns_485_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/25/2020] [Accepted: 01/04/2021] [Indexed: 11/05/2022] Open
Abstract
Extracranial–intracranial (EC-IC) arterial bypass surgery was developed to prevent subsequent stroke by improving hemodynamics distal to the occluded intracranial artery, but its utilization has been decreasing due to the development in medical treatment. However, EC-IC bypass surgery may be effective for arresting or reversing cognitive decline in patients with cerebral ischemia. A 69-year-old man with the left internal carotid artery occlusion that manifested as scattered cerebral infarction of the left hemisphere presented with dysarthria and transient right hemiparesis. Hemodynamic condition was impaired in the left side, and therefore, EC-IC bypass surgery was performed to prevent recurrence of cerebral infarction. Neuropsychological examination at 6 months after the surgery showed marked improvement as compared to the preoperative examination and there was no recurrence of stroke in the patient. EC-IC bypass may contribute to the improvement of cognitive function as well as the prevention of recurrence of cerebral infarction in patients with hemodynamic insufficiency, but there might be a threshold of hemodynamic impairment with respect to the reversibility of cognitive performance. Investigation of the target and timing can identify cases in which the cognitive function is improved by surgery.
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Affiliation(s)
- Toshiya Aono
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
| | - Hideaki Ono
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
| | - Takeo Tanishima
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
| | - Akira Tamura
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
| | - Isamu Saito
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
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Inoue K, Shimokawa S, Yoshioka F, Ogata A, Masuoka J, Abe T. A case of pediatric moyamoya disease with severe cerebral vasospasm and delayed cerebral infarction following an intraventricular hemorrhage. Childs Nerv Syst 2021; 37:695-698. [PMID: 32666155 DOI: 10.1007/s00381-020-04769-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 06/23/2020] [Indexed: 11/29/2022]
Abstract
Reports on patients with moyamoya disease presenting cerebral ischemic complications after the onset of intraventricular hemorrhage (IVH) and/or intracerebral hemorrhage (ICH) are limited. Herein, we report a case of a 7-year-old girl with moyamoya disease with severe cerebral vasospasm and delayed cerebral infarction following an IVH. Although the case is rare, the potential for vasospasm-induced cerebral infarction should be carefully considered and thus, intensive treatment should be immediately initiated.
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Affiliation(s)
- Kohei Inoue
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan.
| | | | - Fumitaka Yoshioka
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Atsushi Ogata
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Jun Masuoka
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Tatsuya Abe
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
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Postoperative stroke and neurological outcomes in the early phase after revascularization surgeries for moyamoya disease: an age-stratified comparative analysis. Neurosurg Rev 2021; 44:2785-2795. [PMID: 33415521 DOI: 10.1007/s10143-020-01459-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 11/16/2020] [Accepted: 12/09/2020] [Indexed: 01/09/2023]
Abstract
Stroke and neurological outcomes in the early phase following revascularization for moyamoya disease (MMD) may depend on the patient's age. In this study, an age-stratified comparative analysis was performed to clarify this issue. We reviewed 105 MMD patients who underwent 179 revascularization surgeries. The demographic characteristics were collected in four age groups (≤ 5 and 6-17 years for pediatric patients and 18-49 and ≥ 50 years for adults). Additionally, we assessed the incidence of subsequent stroke and deterioration of modified Rankin Scale (mRS) score. Then, we evaluated predictors of postoperative stroke and mRS deterioration using logistic regression. The mean patient age was 26.2 ± 18.5 years. No significant difference in the incidence of postoperative stroke was observed between age groups; however, the incidence tended to be increased among patients aged ≤ 5 years (17.9%) and patients aged ≥ 50 years (16.7%). Deterioration of mRS scores was significantly associated with ages ≤ 5 years (17.9%) and ≥ 50 years (11.1%). Logistic regression showed that posterior cerebral artery involvement (odds ratio [OR], 4.6) and postoperative transient neurological events (TNEs) (OR, 5.93) were risk factors for postoperative stroke. Age ≤ 5 years (OR, 9.73), postoperative TNEs (OR, 7.38), and postoperative stroke (OR, 49) were identified as predictors of unfavorable neurological outcomes. The novel feature of this comparative analysis by age group is that membership in the early-childhood MMD patient group (under 5 years old) was an independent risk factor for unfavorable short-term neurological outcomes and was mainly associated with the incidence of postoperative severe cerebral infarction.
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Wang Y, Yang L, Wang X, Zeng F, Zhang K, Zhang Q, Liu M, Liu S, Shang M, Li Q, Yang Y, Liang M, Liu W. Meta-analysis of genotype and phenotype studies to confirm the predictive role of the RNF213 p.R4810K variant for moyamoya disease. Eur J Neurol 2020; 28:823-836. [PMID: 33175469 DOI: 10.1111/ene.14635] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/29/2020] [Accepted: 11/04/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this meta-analysis study was to assess the predictive effects of RNF213 p.R4810K on phenotype in moyamoya disease (MMD). METHODS Electronic databases (e.g., Pubmed and EMBASE) were searched, and relevant articles published up to August 2020 were retrieved. Review Manager 5.3 and Stata 12.0 were used for all statistical analyses. Pooled odds ratios, with 95% confidence intervals, and three comparison models were evaluated to analyze the association between RNF213 pR4810K variant and clinical characteristics of MMD patients using a fixed-effects model. RESULTS A total of 2798 patients with MMD were selected and the effects of the heterozygous or homozygous RNF213 p.R4810K variant on 18 clinical features were identified. There were more patients aged <15 years in the GA and AA groups (AA vs GA: p = 0.009; AA vs GG: p = 0.003; GA vs GG: p = 0.001). Among homozygous patients, the majority experienced MMD onset before the age of 4 years (AA vs. GA: p < 0.00001; AA vs GG: p < 0.00001). The frequency of infarctions and transient ischemic attack was significantly higher in homozygotes and heterozygotes,respectively. However, the frequency of intracerebral/intraventricular hemorrhage was lower in patients with the GA than the GG genotype. More MMD patients with AA and GA genotypes had a family history of the disease (p = 0.003, p < 0.00001, respectively). Posterior cerebral artery involvement was more common in patients with the GA genotype (p < 0.00001). CONCLUSION The homozygous or heterozygous RNF213 variant may be an efficient biomarker with which to classify different clinical phenotypes of MMD.
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Affiliation(s)
- Yue Wang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Luping Yang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Xiaotong Wang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Fanxin Zeng
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Kaili Zhang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Qian Zhang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Mengwei Liu
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Shan Liu
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Mengke Shang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Qian Li
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Yuetian Yang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Man Liang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Wanyang Liu
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
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Ong JA, Low SY, Seow WT, Goh CP, Yeo TT, Chou N, Low DC, Nga V. Revascularisation surgery for paediatric moyamoya disease: The Singapore experience. J Clin Neurosci 2020; 82:207-213. [PMID: 33246909 DOI: 10.1016/j.jocn.2020.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/20/2020] [Accepted: 11/01/2020] [Indexed: 11/26/2022]
Abstract
Moyamoya disease (MMD) is characterized by the spontaneous occlusion of the distal internal carotid arteries and resultant neo-angiogenesis of fragile collateral blood vessels. Direct and indirect revascularization surgeries have shown to effectively reduce stroke risks in paediatric MMD, whereby the latter is a more utilised technique in children. This study was undertaken to determine the outcomes of revascularization in Singapore's multi-ethnic, Southeast Asian paediatric population. This is an ethics-approved study conducted in Singapore's 2 tertiary children hospital units: KK Women's and Children's Hospital and National University Hospital. Sixteen patients with a diagnosis of ischaemic-type MMD are recruited between 01 January 2002 to 31 January 2019; and a total of 24 surgeries are undertaken (24 cerebral hemispheres). There are 2 cases of stroke within 30 days post-surgery. However, no stroke recurrence is observed beyond 30 days after surgery in all patients. Four patients reported recurrent transient ischaemic attack symptoms in the follow-up period ranging from 3 months to 12 years. Data analyses show a statistically significant improvement in modified Rankin's Scale (mMRS) in post-operative patients from baseline to discharge, and at 3 months after surgery. Our study also observes that predictors of recurrent ischaemic events include higher pre-operative MRS, Suzuki stage and perioperative infarction. To the authors' knowledge, this is the first study to date reporting the outcomes of revascularisation in a paediatric Southeast Asian cohort.
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Affiliation(s)
- Jamie Ah Ong
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road Level 11, 119228, Singapore
| | - Sharon Yy Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, 11 Jalan Tan Tock Seng, 308433, Singapore.
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, 11 Jalan Tan Tock Seng, 308433, Singapore
| | - Chun Peng Goh
- Division of Neurosurgery, Department of Surgery, National University Hospital, 5 Lower Kent Ridge Rd, 119074, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Hospital, 5 Lower Kent Ridge Rd, 119074, Singapore
| | - Ning Chou
- Division of Neurosurgery, Department of Surgery, National University Hospital, 5 Lower Kent Ridge Rd, 119074, Singapore
| | - David Cy Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, 11 Jalan Tan Tock Seng, 308433, Singapore
| | - Vincent Nga
- Division of Neurosurgery, Department of Surgery, National University Hospital, 5 Lower Kent Ridge Rd, 119074, Singapore
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Couldwell MW, Cheshier S, Taussky P, Mortimer V, Couldwell WT. Right frontotemporal craniotomy for ECA-to-MCA direct and indirect bypass and occipital artery indirect bypass to the posterior circulation: case report. J Neurosurg Pediatr 2020; 27:180-184. [PMID: 33254140 DOI: 10.3171/2020.7.peds20181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 07/06/2020] [Indexed: 11/06/2022]
Abstract
Moyamoya is an uncommon disease that presents with stenoocclusion of the major vasculature at the base of the brain and associated collateral vessel formation. Many pediatric patients with moyamoya present with transient ischemic attacks or complete occlusions. The authors report the case of a 9-year-old girl who presented with posterior fossa hemorrhage and was treated with an emergency suboccipital craniotomy for evacuation. After emergency surgery, an angiogram was performed, and the patient was diagnosed with moyamoya disease. Six months later, the patient was treated for moyamoya using direct and indirect revascularization; after surgery there was excellent vascularization in both regions of the bypass and no further progression of moyamoya changes. This case illustrates a rare example of intracerebral hemorrhage associated with moyamoya changes in the posterior vascularization in a pediatric patient and subsequent use of direct and indirect revascularization to reduce the risk of future hemorrhage and moyamoya progression.
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Affiliation(s)
- Mitchell W. Couldwell
- Department of Neurological Surgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Samuel Cheshier
- Department of Neurological Surgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Philipp Taussky
- Department of Neurological Surgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Vance Mortimer
- Department of Neurological Surgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - William T. Couldwell
- Department of Neurological Surgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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Teo M, Furtado S, Kaneko OF, Azad TD, Madhugiri V, Do HM, Steinberg GK. Validation and Application for the Berlin Grading System of Moyamoya Disease in Adult Patients. Neurosurgery 2020; 86:203-212. [PMID: 30864668 DOI: 10.1093/neuros/nyz025] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 01/29/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Traditional moyamoya disease (MMD) classification relies on morphological digital subtraction angiography (DSA) assessment, which do not reflect hemodynamic status, clinical symptoms, or surgical treatment outcome. OBJECTIVE To (1) validate the new Berlin MMD preoperative symptomatology grading system and (2) determine the clinical application of the grading system in predicting radiological and clinical outcomes after surgical revascularization. METHODS Ninety-six MMD patients (192 hemispheres) with all 3 investigations (DSA, magnetic resonance imaging [MRI], Xenon-CT) performed preoperatively at our institution (2007-2013) were included. Two clinicians independently graded the imaging findings according to the proposed criteria. Patients' modified Rankin Score (mRS) scores (preoperative, postoperative, last follow-up), postoperative infarct (radiological, clinical) were collected and statistical correlations performed. RESULTS One hundred fifty-seven direct superficial temporal artery-middle cerebral artery bypasses were performed on 96 patients (66 female, mean age 41 yr, mean follow-up 4.3 yr). DSA, MRI, and cerebrovascular reserve capacity were independent factors associated hemispheric symptomatology (when analyzed individually or in the combined grading system). Mild (grade I), moderate (grade II), severe (grade III) were graded in 45, 71, and 76 hemispheres respectively; of which, clinical symptoms were found in 33% of grade I, 92% of grade II, 100% of grade III hemispheres (P < .0001). Two percent of grade I, 11% of grade II, 20% of grade III hemispheres showed postoperative radiological diffusion weighted image-positive ischemic changes or hemorrhage on MRI (P = .018). Clinical postoperative stroke was observed in 1.4% of grade II, 6.6% of grade III hemispheres (P = .077). The grading system also correlated well to dichotomized mRS postoperative outcome. CONCLUSION The Berlin MMD grading system is able to stratify preoperative hemispheric symptomatology. Furthermore, it correlated with postoperative new ischemic changes on MRI, and showed a strong trend in predicting clinical postoperative stroke.
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Affiliation(s)
- Mario Teo
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine and Stanford Health Care, Stanford, California.,Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, United Kingdom
| | - Sunil Furtado
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine and Stanford Health Care, Stanford, California
| | - Osamu F Kaneko
- Department of Radiology, Stanford University School of Medicine and Stanford Health Care, Stanford, California
| | - Tej D Azad
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine and Stanford Health Care, Stanford, California
| | - Venkatesh Madhugiri
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine and Stanford Health Care, Stanford, California
| | - Huy M Do
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine and Stanford Health Care, Stanford, California.,Department of Radiology, Stanford University School of Medicine and Stanford Health Care, Stanford, California
| | - Gary K Steinberg
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine and Stanford Health Care, Stanford, California
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D'Amico A, Ugga L, Cocozza S, Giorgio SMDA, Cicala D, Santoro C, Melis D, Cinalli G, Brunetti A, Pappatà S. Multimodal evaluation of the cerebrovascular reserve in Neurofibromatosis type 1 patients with Moyamoya syndrome. Neurol Sci 2020; 42:655-663. [PMID: 32651859 PMCID: PMC7843564 DOI: 10.1007/s10072-020-04574-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/02/2020] [Indexed: 11/25/2022]
Abstract
Purpose Moyamoya syndrome (MMS) is a rare intracranial arterial vasculopathy which can occur in neurofibromatosis type 1 (NF1) disease, representing a cause of cerebrovascular reserve (CVR) impairment, possibly leading to ischemic stroke. Here, we evaluated noninvasive imaging techniques used to assess CVR in MMS patients, describing clinical and imaging findings in patients affected by MMS-NF1. Methods Following strict inclusion and exclusion criteria, in this retrospective observational study, we evaluated imaging data of nine consecutive MMS-NF1 patients (M/F = 5/4, mean age: 12.6 ± 4.0). Subjects underwent a multimodal evaluation of cerebral vascular status, including intracranial arterial MR Angiography (MRA), MRI perfusion with dynamic susceptibility contrast (DSC) technique, and 99mTc-hexamethylpropyleneamine oxime (HMPAO) SPECT. Results In 8 out 9 patients (88.8%, 6/8 symptomatic), time-to-peak maps were correlated with the involved cerebral hemisphere, while in 6 out 9 patients (66.6%, 5/6 symptomatic), mean transit time (MTT) maps showed correspondence with the affected cerebrovascular territories. Cerebral blood flow (CBF) calculated using DSC perfusion failed to detect the hypoperfused regions instead identified by SPECT-CBF in all patients, while MTT maps overlapped with SPECT-CBF data in all cases and time-to-peak maps in 60.0%. Conclusions Although SPECT imaging still represents the gold standard for CBF assessment, our results suggest that data obtained using DSC perfusion technique, and in particular MTT maps, might be a very useful and noninvasive tool for evaluating hemodynamic status in MMS-NF1 patients. Electronic supplementary material The online version of this article (10.1007/s10072-020-04574-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alessandra D'Amico
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via Pansini, 5, 80131, Naples, Italy
| | - Lorenzo Ugga
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via Pansini, 5, 80131, Naples, Italy
| | - Sirio Cocozza
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via Pansini, 5, 80131, Naples, Italy.
| | | | - Domenico Cicala
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Claudia Santoro
- Referral Centre of Neurofibromatosis, Department of Woman and Child, Specialistic and General Surgery, University "Luigi Vanvitelli", Naples, Italy
| | - Daniela Melis
- Department of Translational Medical Sciences, Section of Pediatrics, University of Naples "Federico II", Naples, Italy
| | - Giuseppe Cinalli
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Arturo Brunetti
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via Pansini, 5, 80131, Naples, Italy
| | - Sabina Pappatà
- Institute of Biostructure and Bioimaging, National Research Council, Naples, Italy
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Das S, Dubey S, Acharya M, Ghosh R, Chatterjee S, Hazra A, Lahiri D, Segupta S, Chatterjee S, Das G, Sarkar N, Ray BK, Kraemer M. The disease presentation of Moyamoya angiopathy in Eastern India. J Stroke Cerebrovasc Dis 2020; 29:104957. [PMID: 32689603 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104957] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/18/2020] [Accepted: 05/12/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Clinical spectrum of Moyamoya angiopathy (MMA) differs across populations with different ethnicity. This study, the largest one done among Indian population was undertaken to assess clinico-radiological profile of MMA patients in eastern India. METHODS A single centre cross-sectional study was undertaken among 76 MMA cases. Each patient was evaluated for epidemiological, clinical and radiological characteristics. SPSS 25 was used for statistical analysis. P < 0.05 was taken as statistically significant. RESULTS 36 (47.4%) were children without gender preponderance. There were female predominance among adults (male:female = 1:2.33). Mean age at onset of first neurological symptoms for children was 4.2 ± 2.0years, followed by 34.9 ± 58.2months of latency with final diagnosis at the mean age of 7.4 ± 3.5years. For adults, mean age of onset of first neurological symptoms was 31.5 ± 12.3years, followed by 14.7 ± 41.7months time gap and diagnosed at the mean age of 33.5 ± 12.5years. There was a statistically significant difference between child and adult regarding the diagnostic latency (p = 0.035). Fixed motor weakness (FMW) was the predominant symptom across the whole disease course. Among children predominant first neurological symptom was fixed motor weakness (FMW) (52.8%), followed by seizures (22.2%). FMW was predominant (55%) first neurological complaint, followed by headache (22.5%) among adults. Seizure was more prevalent among children both as first (p = 0.002) and presenting symptom at the time of diagnosis (p = 0.048). Over the course of the disease seizure was more common among children (p = 0.001), while headache was more common among adults (p = 0.017). Recurrence of symptoms was more common among children (p = 0.059). Infarcts were more common among children (91.7%) than adults (72.5%), while hemorrhage was seen only among adults (25%) (p = 0.004). Isolated cerebral cortex was involved more commonly among children (59.4%) than adults (36.1%), while isolated subcortical involvement was seen only among adults (19.4%) (p = 0.016). Majority of the MMA cases were of Suzuki stage 4 (39.5%) and 5 (27.6%). Brain atrophy was associated with diagnostic latency (p = 0.009). CONCLUSION Indian Moyamoya presents similar to disease presentation in Caucasian and Japanese patients. It is a frequently overlooked cause of stroke in young, often with various non-motor presentations, failure to recognize which leads to delay in diagnosis. Radiological burden disproportionate to number of acute vascular events, with subtle neurological manifestations like headache or seizure, often with cognitive decline, should raise suspicion of MMA.
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Affiliation(s)
- Shambaditya Das
- Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research& SSKM Hospital, Kolkata, West Bengal, India
| | - Souvik Dubey
- Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research& SSKM Hospital, Kolkata, West Bengal, India
| | - Mrinal Acharya
- Department of Neurology, Malda Medical College and Hospital, Malda, West Bengal, India
| | - Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Subhankar Chatterjee
- Department of General Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Avijit Hazra
- Department of Pharmacology, Institute of Post Graduate Medical Education and Research & SSKM Hospital, Kolkata, West Bengal, India
| | - Durjoy Lahiri
- Department of Neuromedicine, R.G. Kar Medical College & Hospital, Kolkata, West Bengal, India
| | - Samya Segupta
- Department of Medicine, Apollo Gleneagles Hospital, Kolkata, West Bengal, India
| | - Subham Chatterjee
- Institute of Psychiatry, Institute of Post Graduate Medical Education and Research & SSKM Hospital, Kolkata, West Bengal, India
| | - Goutam Das
- Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research& SSKM Hospital, Kolkata, West Bengal, India
| | - Niladri Sarkar
- Department of General Medicine, Institute of Post Graduate Medical Education and Research & SSKM Hospital, Kolkata, West Bengal, India
| | - Biman Kanti Ray
- Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research& SSKM Hospital, Kolkata, West Bengal, India.
| | - Markus Kraemer
- Department of Neurology, Alfried Krupp Von Bohlen Und Halbach Hospital, Alfried-Krupp-Str. 21, 45117, Essen, Germany and Heinrich Heine University of Duesseldorf, Medical Faculity, Duesseldorf, Germany
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47
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Miyoshi K, Chida K, Kobayashi M, Kubo Y, Yoshida K, Terasaki K, Ogasawara K. Two-Year Clinical, Cerebral Hemodynamic, and Cognitive Outcomes of Adult Patients Undergoing Medication Alone for Symptomatically Ischemic Moyamoya Disease Without Cerebral Misery Perfusion: A Prospective Cohort Study. Neurosurgery 2020; 84:1233-1241. [PMID: 29850833 DOI: 10.1093/neuros/nyy234] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/03/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In nonsurgical adult moyamoya disease (MMD) patients with ischemic onset and stable hemodynamics, the cerebral hemodynamic and cognitive course remains unclear. OBJECTIVE To clarify, through a prospective cohort study, 2-yr clinical, cerebral hemodynamic, and cognitive outcomes of adult patients receiving medication alone for symptomatically ischemic MMD without cerebral misery perfusion. METHODS Seventy patients without cerebral misery perfusion on the first 15O gas positron emission tomography (PET) were clinically followed up for 2 yr. The second PET was performed at the end of the 2-yr follow-up. Neuropsychological tests were also performed at the study entry and the end of the 2-yr follow-up. RESULTS During the 2-yr follow-up period, 2 patients (3%) developed further cerebral ischemic symptoms and showed new cerebral misery perfusion on PET performed at recurrence. None of the 68 patients without further ischemic symptoms showed cerebral misery perfusion on second PET. All 66 patients who underwent the first and second neuropsychological tests displayed unchanged interval cognition at the 2-yr follow-up. CONCLUSION Among adult patients receiving medication alone for symptomatically ischemic MMD without cerebral misery perfusion, the incidence of recurrent ischemic events was 3% per 2 yr. In patients without recurrent ischemic events, cerebral hemodynamics and cognitive function had not deteriorated by 2 yr after the last event.
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Affiliation(s)
- Kenya Miyoshi
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kohei Chida
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Masakazu Kobayashi
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Yoshitaka Kubo
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kenji Yoshida
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kazunori Terasaki
- Cyclotron Research Center, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
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48
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Lee WJ, Jeong SK, Han KS, Lee SH, Ryu YJ, Sohn CH, Jung KH. Impact of Endothelial Shear Stress on the Bilateral Progression of Unilateral Moyamoya Disease. Stroke 2020; 51:775-783. [DOI: 10.1161/strokeaha.119.028117] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
In unilateral moyamoya disease, altered endothelial shear stress on the intact-side terminal internal carotid artery might trigger the progression to bilateral disease. We analyzed the endothelial shear stress parameters of the normally appearing terminal internal carotid artery in unilateral moyamoya disease and its association with the progression to bilateral disease.
Methods—
This retrospective cohort study included patients diagnosed with unilateral moyamoya disease by cerebral angiography and followed-up with regular magnetic resonance imaging/magnetic resonance angiography evaluations for >1 year. Endothelial shear stress parameters acquired were mean and maximum signal intensity gradients (SIG) and SIG SD at the vessel boundary in time-of-flight sequences in initial brain magnetic resonance imaging/magnetic resonance angiography. Contralateral disease progression defined as the detection of newly developed vessel steno-occlusion with an magnetic resonance angiography steno-occlusive stage of ≥2, in the previously intact side of the brain on follow-up magnetic resonance imaging/magnetic resonance angiography evaluation.
Results—
Among 146 patients (66 males [45.2%] and 80 females [54.8%]; 76 pediatric [52.1%]), contralateral disease progression was detected in 43 patients (29.5%) after a mean follow-up of 4.3±2.4 years. Multivariate analysis showed that SIG SD was significantly associated with this progression (odds ratio, 13.001 [95% CI, 1.764−95.794],
P
=0.012). In receiver operating characteristic curve analysis, SIG SD predicted the contralateral progression with area under the curve values of 0.803 (95% CI, 0.726−0.880,
P
<0.001). The regression model was reproduced in the external cohort of 31 patients.
Conclusions—
Increased spatial variability of the endothelial shear stress around the normally appearing terminal internal carotid artery, as measured by SIG SD in time-of-flight sequences, may predict the contralateral progression of unilateral moyamoya disease.
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Affiliation(s)
- Woo-Jin Lee
- From the Department of Neurology (W.-J.L., K.-H.J.), Seoul National University Hospital, South Korea
| | - Seul-Ki Jeong
- Jeong Seul-Ki Neurology Clinic, Medi Image, Inc, Seoul, South Korea (S.-K.J.)
| | - Kap-Soo Han
- Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Jeonbuk, Republic of Korea (K.-S.H.)
| | - Sang Hyuk Lee
- Nuclear Equipment Qualification & Safety Research Group, Korea Institute of Machinery & Materials, Daejeon, South Korea (S.H.L.)
| | - Young Jin Ryu
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea (Y.J.R.)
| | - Chul-Ho Sohn
- Department of Radiology (C.-H.S.), Seoul National University Hospital, South Korea
| | - Keun-Hwa Jung
- From the Department of Neurology (W.-J.L., K.-H.J.), Seoul National University Hospital, South Korea
- Program in Neuroscience, Neuroscience Research Institute of SNUMRC, College of Medicine, Seoul National University, South Korea (K.-H.J.)
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49
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Wong TH, Shagera QA, Ryoo HG, Ha S, Lee DS. Basal and Acetazolamide Brain Perfusion SPECT in Internal Carotid Artery Stenosis. Nucl Med Mol Imaging 2020; 54:9-27. [PMID: 32206127 PMCID: PMC7062956 DOI: 10.1007/s13139-019-00633-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/19/2019] [Accepted: 12/26/2019] [Indexed: 10/25/2022] Open
Abstract
Internal carotid artery (ICA) stenosis including Moyamoya disease needs revascularization when hemodynamic insufficiency is validated. Vascular reserve impairment was the key to find the indication for endarterectomy/bypass surgery in the atherosclerotic ICA stenosis and to determine the indication, treatment effect, and prognosis in Moyamoya diseases. Vascular reserve was quantitatively assessed by 1-day split-dose I-123 IMP basal/acetazolamide SPECT in Japan or by Tc-99m HMPAO SPECT in other countries using qualitative or semi-quantitative method. We summarized the development of 1-day basal/ acetazolamide brain perfusion SPECT for ICA stenosis, both quantitative and qualitative methods, and their methodological issues regarding (1) acquisition protocol; (2) qualitative assessment, either visual or deep learning-based; (3) clinical use for atherosclerotic ICA steno-occlusive diseases and mostly Moyamoya diseases; and (4) their impact on the choice of treatment options. Trials to use CT perfusion or perfusion MRI using contrast materials or arterial spin labeling were briefly discussed in their endeavor to use basal studies alone to replace acetazolamide-challenge SPECT. Theoretical and practical issues imply that basal perfusion evaluation, no matter how much sophisticated, will not disclose vascular reserve. Acetazolamide rarely causes serious adverse reactions but included fatality, and now, we need to monitor patients closely in acetazolamide-challenge studies.
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Affiliation(s)
- Teck Huat Wong
- Department of Nuclear Medicine, Seoul National University College of Medicine, 28 Yongon-Dong, Jongno-Gu, Seoul, 110-744 South Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Seoul National University, Seoul, South Korea
| | - Qaid Ahmed Shagera
- Department of Nuclear Medicine, Seoul National University College of Medicine, 28 Yongon-Dong, Jongno-Gu, Seoul, 110-744 South Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Seoul National University, Seoul, South Korea
| | - Hyun Gee Ryoo
- Department of Nuclear Medicine, Seoul National University College of Medicine, 28 Yongon-Dong, Jongno-Gu, Seoul, 110-744 South Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Seoul National University, Seoul, South Korea
| | - Seunggyun Ha
- Division of Nuclear Medicine Department of Radiology, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Dong Soo Lee
- Department of Nuclear Medicine, Seoul National University College of Medicine, 28 Yongon-Dong, Jongno-Gu, Seoul, 110-744 South Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Seoul National University, Seoul, South Korea
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50
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Marushima A, Nieminen M, Kremenetskaia I, Gianni-Barrera R, Woitzik J, von Degenfeld G, Banfi A, Vajkoczy P, Hecht N. Balanced single-vector co-delivery of VEGF/PDGF-BB improves functional collateralization in chronic cerebral ischemia. J Cereb Blood Flow Metab 2020; 40:404-419. [PMID: 30621518 PMCID: PMC7370608 DOI: 10.1177/0271678x18818298] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The myoblast-mediated delivery of angiogenic genes represents a cell-based approach for targeted induction of therapeutic collateralization. Here, we tested the superiority of myoblast-mediated co-delivery of vascular endothelial growth factor-A (VEGF) together with platelet-derived growth factor-BB (PDGF-BB) on transpial collateralization of an indirect encephalomyosynangiosis (EMS) in a model of chronic cerebral ischemia. Mouse myoblasts expressing a reporter gene alone (empty vector), VEGF, PDGF-BB or VEGF and PDGF-BB through a single bi-cistronic vector (VIP) were implanted into the temporalis muscle of an EMS following permanent ipsilateral internal carotid artery occlusion in adult, male C57BL/6N mice. Over 84 days, myoblast engraftment and gene product expression, hemodynamic impairment, transpial collateralization, angiogenesis, pericyte recruitment and post-ischemic neuroprotection were assessed. By day 42, animals that received PDGF-BB in combination with VEGF (VIP) showed superior hemodynamic recovery, EMS collateralization and ischemic protection with improved pericyte recruitment around the parenchymal vessels and EMS collaterals. Also, supplementation of PDGF-BB resulted in a striking astrocytic activation with intrinsic VEGF mobilization in the cortex below the EMS. Our findings suggest that EMS surgery together with myoblast-mediated co-delivery of VEGF/PDGF-BB may have the potential to serve as a novel treatment strategy for augmentation of collateral flow in the chronically hypoperfused brain.
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Affiliation(s)
- Aiki Marushima
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Melina Nieminen
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Irina Kremenetskaia
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Roberto Gianni-Barrera
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Johannes Woitzik
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Andrea Banfi
- Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Peter Vajkoczy
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery and Center for Stroke research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
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