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Mehmood Qadri H, Bashir RA, Amir A, Chaudhry MJ, Alam MF, Younas UA, Bashir A. Post-infectious Moyamoya Syndrome: A Review of Existing Scientific Literature From 2000 to 2023. Cureus 2024; 16:e63643. [PMID: 39092349 PMCID: PMC11292458 DOI: 10.7759/cureus.63643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2024] [Indexed: 08/04/2024] Open
Abstract
Moyamoya disease (MMD) is considered a primary disorder of an unknown etiology. In contrast, Moyamoya syndrome (MMS) refers to MMD associated with other underlying diseases, such as meningitis in childhood, neurofibromatosis type II, Down syndrome, cranial irradiation, and different types of anemias, particularly hemoglobinopathies. We aimed to provide a comprehensive clinicopathological overview of MMS. All case reports and case series published from 2000 to 2023 pertaining to MMD were included in the study. Case studies, original articles, editorials, letters to editors, and clinical images were excluded. The search was conducted using the Boolean operators ("AND" and "OR") on PubMed and Google Scholar. A total of 13 case reports and one case series study were included. The study suggests infection might be a trigger in susceptible individuals. The autoimmune antibody findings (anti-double stranded DNA IgG) suggest a potential autoimmune component in some cases. There were diverse presentations and outcomes of post-infectious MMS, with a striking predominance of pediatric cases (66.66%) and a possible female predominance. Both computerized tomography (CT) and magnetic resonance imaging (MRI) showed evidence of restricted blood flow. CT showed that stenosis, occlusion, and collateral formation were frequent vascular findings, but often unspecified in severity. Infarction, hypodensities, and hematoma were the most common parenchymal findings (22.22% each). The findings on MRI were stenosis (50%) and collateral formation (44.44%). Infarction was the most common finding (66.66%) in parenchyma. Hydrocephalus, encephalomalacia, and atrophy were less frequent. Lesions were most frequent in the internal carotid artery (66.66%), middle cerebral artery (66.66%), and anterior cerebral artery (50%). Lesions were less frequent in the posterior cerebral, vertebral, and basilar arteries. The frontal lobe (38.89%) and basal ganglia (33.33%) were commonly affected parenchymal regions. The most common risk factor was human immunodeficiency virus (HIV) infection (50%), followed by trisomy 21, cryptococcal, and other types of meningitides. Aspirin (50%) and antiretroviral therapy (38.89%) were the cornerstones of treatment for MMS. This review accentuates the noteworthy obstacles presented by post-infectious MMS, especially its catastrophic effect on children and its correlation with HIV/AIDS. According to our elaborate literature search using PubMed and Google Scholar, this is the first narrative review in the existing scientific literature summarizing the literature on post-infectious MMS.
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Affiliation(s)
| | - Raahim A Bashir
- Neurological Surgery, Punjab Institute of Neurosciences, Lahore, PAK
| | - Arham Amir
- General Surgery and Surgical Oncology, Shaikh Zayed Medical Complex, Lahore, PAK
| | | | | | | | - Asif Bashir
- Neurological Surgery, Punjab Institute of Neurosciences, Lahore, PAK
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Gökten DB, Gökten M, Deniz Ç, Mercan R. Rare combo: moyamoya and lupus in men. Clin Rheumatol 2024; 43:2139-2143. [PMID: 38625644 DOI: 10.1007/s10067-024-06960-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/30/2024] [Accepted: 04/02/2024] [Indexed: 04/17/2024]
Abstract
Moyamoya syndrome (MMS) is a rare, chronic, progressive cerebrovascular disorder characterized by stenosis at the apices of the intracranial internal carotid arteries, including the proximal anterior cerebral arteries and middle cerebral arteries. Cerebral angiography images are used for detection through measurement. Systemic lupus erythematosus (SLE) is an autoimmune disease that can cause multisystemic involvement. The coexistence of SLE and MMS has been rarely reported in the literature. A 46-year-old male patient with malar rash, Raynaud phenomenon presented to the hospital with a complaint of weakness in the left lower extremity, which began 3 days before the date of the visit. In the diffusion magnetic resonance imaging, multiple diffusion restrictions were observed in the right frontal region. The patient underwent MR angiography, revealing stenosis in the terminal and supraclinoid segments of the right internal carotid artery, which made us consider moyamoya disease. This patient, with a malar rash and Raynaud's, a positive antibody profile, was diagnosed as a male with SLE accompanied by MMS.
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Affiliation(s)
- Dilara Bulut Gökten
- Department of Rheumatology, Tekirdag Namik Kemal University, Tekirdag, Turkey.
| | - Murat Gökten
- Department of Neurosurgery, Tekirdag City Hospital, Tekirdag, Turkey
| | - Çiğdem Deniz
- Department of Neurology, Tekirdag Namik Kemal University, Tekirdag, Turkey
| | - Rıdvan Mercan
- Department of Rheumatology, Tekirdag Namik Kemal University, Tekirdag, Turkey
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Gupta N, Miller E, Bhatia A, Richer J, Aviv RI, Wilson N. Imaging Review of Pediatric Monogenic CNS Vasculopathy with Genetic Correlation. Radiographics 2024; 44:e230087. [PMID: 38573816 DOI: 10.1148/rg.230087] [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: 04/06/2024]
Abstract
Monogenic cerebral vasculopathy is a rare but progressively recognizable cause of pediatric cerebral vasculopathy manifesting as early as fetal life. These monogenic cerebral vasculopathies can be silent or manifest variably as fetal or neonatal distress, neurologic deficit, developmental delay, cerebral palsy, seizures, or stroke. The radiologic findings can be nonspecific, but the presence of disease-specific cerebral and extracerebral imaging features can point to a diagnosis and guide genetic testing, allowing targeted treatment. The authors review the existing literature describing the frequently encountered and rare monogenic cerebral vascular disorders affecting young patients and describe the relevant pathogenesis, with an attempt to categorize them based on the defective step in vascular homeostasis and/or signaling pathways and characteristic cerebrovascular imaging findings. The authors also highlight the role of imaging and a dedicated imaging protocol in identification of distinct cerebral and extracerebral findings crucial in the diagnostic algorithm and selection of genetic testing. Early and precise recognition of these entities allows timely intervention, preventing or delaying complications and thereby improving quality of life. It is also imperative to identify the specific pathogenic variant and pattern of inheritance for satisfactory genetic counseling and care of at-risk family members. Last, the authors present an image-based approach to these young-onset monogenic cerebral vasculopathies that is guided by the size and predominant radiologic characteristics of the affected vessel with reasonable overlap. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Affiliation(s)
- Neetika Gupta
- From the Department of Diagnostic and Interventional Radiology, Divisions of ER (N.G.) and Neuroradiology (E.M.), The Hospital for Sick Children, University of Toronto, 170 Elizabeth St, Toronto, ON, Canada M5G 1E8; Departments of Medical Imaging (N.G., N.W.) and Genetics (J.R.), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada; Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa (A.B.); and Department of Radiology, Radiation Oncology, and Medical Physics, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Canada (R.I.A.)
| | - Elka Miller
- From the Department of Diagnostic and Interventional Radiology, Divisions of ER (N.G.) and Neuroradiology (E.M.), The Hospital for Sick Children, University of Toronto, 170 Elizabeth St, Toronto, ON, Canada M5G 1E8; Departments of Medical Imaging (N.G., N.W.) and Genetics (J.R.), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada; Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa (A.B.); and Department of Radiology, Radiation Oncology, and Medical Physics, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Canada (R.I.A.)
| | - Aashim Bhatia
- From the Department of Diagnostic and Interventional Radiology, Divisions of ER (N.G.) and Neuroradiology (E.M.), The Hospital for Sick Children, University of Toronto, 170 Elizabeth St, Toronto, ON, Canada M5G 1E8; Departments of Medical Imaging (N.G., N.W.) and Genetics (J.R.), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada; Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa (A.B.); and Department of Radiology, Radiation Oncology, and Medical Physics, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Canada (R.I.A.)
| | - Julie Richer
- From the Department of Diagnostic and Interventional Radiology, Divisions of ER (N.G.) and Neuroradiology (E.M.), The Hospital for Sick Children, University of Toronto, 170 Elizabeth St, Toronto, ON, Canada M5G 1E8; Departments of Medical Imaging (N.G., N.W.) and Genetics (J.R.), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada; Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa (A.B.); and Department of Radiology, Radiation Oncology, and Medical Physics, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Canada (R.I.A.)
| | - Richard I Aviv
- From the Department of Diagnostic and Interventional Radiology, Divisions of ER (N.G.) and Neuroradiology (E.M.), The Hospital for Sick Children, University of Toronto, 170 Elizabeth St, Toronto, ON, Canada M5G 1E8; Departments of Medical Imaging (N.G., N.W.) and Genetics (J.R.), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada; Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa (A.B.); and Department of Radiology, Radiation Oncology, and Medical Physics, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Canada (R.I.A.)
| | - Nagwa Wilson
- From the Department of Diagnostic and Interventional Radiology, Divisions of ER (N.G.) and Neuroradiology (E.M.), The Hospital for Sick Children, University of Toronto, 170 Elizabeth St, Toronto, ON, Canada M5G 1E8; Departments of Medical Imaging (N.G., N.W.) and Genetics (J.R.), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada; Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa (A.B.); and Department of Radiology, Radiation Oncology, and Medical Physics, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Canada (R.I.A.)
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Das S, Chakraborty AP, Dubey S, Ray BK. Cortical Blindness and Moyamoya Angiopathy in the Context of an Acute COVID-19 Infection. J Neuroophthalmol 2024; 44:e172-e173. [PMID: 36166773 DOI: 10.1097/wno.0000000000001633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Shambaditya Das
- Department of Neurology (SD), Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India; Department of Neurology (AC), Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India; Department of Neurology (SD), Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India; and Department of Neurology (BKR), Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
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Sunil A, Sivarajakumar B, Kumari V. Beta-Thalassemia Presenting as Moyamoya Syndrome With a Review of Skeletal Manifestations. Cureus 2023; 15:e38372. [PMID: 37265898 PMCID: PMC10230447 DOI: 10.7759/cureus.38372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2023] [Indexed: 06/03/2023] Open
Abstract
Moyamoya angiopathy (MMA) is a progressive vasculopathy characterized by slowly progressive stenosis involving the proximal portions of the major intracranial arteries, resulting in strokes and intracranial hemorrhages. If it occurs secondary to a known cause, it is called Moyamoya syndrome (MMS). Here, we describe the case of a five-year-old male child who presented to us with symptoms of stroke and, upon evaluation, revealed Moyamoya angiopathy. He was further evaluated, and it was found that MMA occurred as a complication of undetected beta-thalassemia. Thalassemia is an autosomal recessive blood disorder where there is a defect in hemoglobin production. It affects 100 to 150 thousand children in the Indian subcontinent. It is classified into two main types: alpha thalassemia and beta thalassemia, depending on which globin chain is affected. It primarily presents with symptoms of anemia such as easy fatiguability, dizziness, jaundice, or breathlessness. The occurrence of Moyamoya syndrome in beta-thalassemia is extremely rare, and it is extremely important to identify MMS at the earliest as it can cause long-term disabilities. We describe the imaging findings in MMS and the various classical skeletal radiographic findings in thalassemia that were seen in our patient.
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Affiliation(s)
- Aswathy Sunil
- Department of Radiology, Osmania Medical College, Hyderabad, IND
| | | | - Vijaya Kumari
- Department of Radiology, Osmania Medical College, Hyderabad, IND
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Giraldo Tapias LM, Arango Guerra P, Lopez Brokate L. Moyamoya syndrome resulting in stroke as a manifestation of paroxysmal nocturnal hemoglobinuria. Neurologia 2023; 38:303-305. [PMID: 37169471 DOI: 10.1016/j.nrleng.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/24/2022] [Indexed: 05/13/2023] Open
Affiliation(s)
| | | | - L Lopez Brokate
- CES University-Instituto Neurológico de Colombia, Medellín, Colombia
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Das S, Mossa-Basha M, Dey M, Hazra A, Pandit A, Das G, Dubey S, Ray BK. High-resolution vessel wall magnetic resonance imaging in intracranial vasculopathies: an experience from eastern India. Br J Radiol 2023; 96:20230114. [PMID: 37066831 PMCID: PMC10161925 DOI: 10.1259/bjr.20230114] [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: 02/06/2023] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 04/18/2023] Open
Abstract
OBJECTIVE To evaluate the role of high-resolution intracranial vessel wall imaging (HR-IVWI) in differentiation of various intracranial vasculopathies in addition to luminal and clinical imaging in the largest cohort of Indian stroke patients. METHODS A single-center, cross-sectional study was undertaken recruiting consecutive stroke or TIA patients presenting within a month of onset, with luminal irregularity/narrowing upstream from the stroke territory. The patients were initially classified into TOAST and Chinese ischemic stroke sub-classification (CISS) on the basis of clinical and luminal characteristics and reclassified again following incorporation of HR-IVWI findings. RESULTS In our cohort of 150 patients, additional use of HR-IVWI led to a 10.7 and 14% change in initial TOAST and CISS classification respectively (p < 0.001). In TOAST classification, 12 "undetermined aetiology" were reclassified into intracranial atherosclerotic disease (ICAD), 1 "undetermined aetiology" into CNS angiitis and 1 "undetermined aetiology" into arterial dissection. Similarly, in CISS 19 "undetermined aetiology" was reclassified into 16 large artery atherosclerosis (LAA) and 3 "other aetiology" consisting of one CNS angiitis, Moyamoya disease (MMD) and arterial dissection each. Two initial classification of MMD by CISS and TOAST were changed into ICAD. The observed change in diagnosis following incorporation of HR-IVWI was proportionately highest in ICAD (LAA) subgroup (TOAST-9.3%, CISS-12%). CONCLUSION Adjunctive use of HR-IVWI, to clinical and luminal assessment, can significantly improve diagnostic accuracy during evaluation of intracranial vasculopathies, with its greatest utility in diagnosing in ICAD, CNS angiitis and dissection. ADVANCES IN KNOWLEDGE HR-IVWI allows clearer etiological distinction of intracranial vasculopathies having therapeutic and prognostic implications.
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Affiliation(s)
- Shambaditya Das
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, United States
| | - Mousam Dey
- Department of Radiology, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Avijit Hazra
- Department of Pharmacology, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Alak Pandit
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Gautam Das
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Souvik Dubey
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Biman Kanti Ray
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education & Research, Kolkata, India
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Temporal lobe epilepsy with nocturnal wandering leading to discovery of Moyamoya Angiopathy. Acta Neurol Belg 2023; 123:279-281. [PMID: 34704169 DOI: 10.1007/s13760-021-01830-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 10/21/2021] [Indexed: 10/20/2022]
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Profile of precipitating factors and its implication in 160 Indian patients with Moyamoya angiopathy. J Neurol 2023; 270:1654-1661. [PMID: 36477636 PMCID: PMC9734856 DOI: 10.1007/s00415-022-11499-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Moyamoya angiopathy (MMA) has been known to manifest with myriad of neurological manifestations, often in association with various precipitating factors. This is the first study to systematically analyze the precipitating triggers to neurological symptoms done on the largest cohort of MMA in India. METHODS A single-centered, cross-sectional observational study, recruiting 160 patients with consecutive angiographically proven MMA over a period of 5 years (2016-2021), was undertaken to evaluate the profile of immediate precipitating factors in temporal association to the neurological symptoms, along with their clinical and radiological characteristics. SPSS 25 was used for statistical analysis. RESULTS Among the 160 patients (Adult-85, children-75), precipitating factors were seen in 41.3%, significantly higher in children (52%) than adults (31.8%) (p value: 0.011). The commonest triggers included fever (18.8%), emotional stress (8.1%), heavy exercise and diarrhea (6.3% each). Cold bath triggered MMA symptoms in 1.3%. Fever (p value: 0.008) and persistent crying (p value: 0.010) triggered neurological symptoms more commonly in children than in adults. Amongst MMA patients with precipitating factors, the commonest MMA presentation included cerebral infarction type (37.9%) and TIA (31.8%). The majority of precipitating factors that preceded an ischemic event were BP-lowing ones (54.7%). CONCLUSION Neurological symptoms of MMA are commonly associated with several precipitating factors, including the lesser known triggers like cold bath. The frequency and profile precipitating factors varies with the age of presentation and type of MMA. It can serve as an early clue to the diagnosis of MMA and its careful avoidance can be largely beneficial in limiting the distressing transient neurological symptoms.
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Tan MA, Layug EJV, Singh BP, Parakh M. Diagnosis of Pediatric Stroke in Resource Limited Settings. Semin Pediatr Neurol 2022; 44:100997. [PMID: 36456040 DOI: 10.1016/j.spen.2022.100997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 09/01/2022] [Accepted: 09/07/2022] [Indexed: 10/14/2022]
Abstract
Global awareness of stroke as a significant cause of neurologic sequelae and death in children has increased over the years as more data in this field becomes available. However, most published literature on pediatric stroke have limited geographic representation. Data on childhood stroke from developing countries remains limited. Thus, this paper reviewed geographic/ethnic differences in pediatric stroke risk factors highlighting those reported in low- and middle-income countries, and proposes a childhood arterial ischemic stroke diagnostic algorithm for resource limited settings. Stroke risk factors include cardiac disorders, infectious diseases, cerebral arteriopathies, hematologic disorders, inflammatory diseases, thrombophilia and genetic conditions. Infection of the central nervous system particularly tuberculous meningitis, is a leading cause of pediatric arterial ischemic stroke in developing countries. Stroke should be considered in children with acute focal neurologic deficit especially in the presence of aforementioned risk factors. Cranial magnetic resonance imaging with angiography is the neuroimaging modality of choice but if unavailable, cranial computed tomography with angiography may be performed as an alternative. If both are not available, transcranial doppler together with neurologic exam may be used to screen children for arterial ischemic stroke. Etiological diagnosis follows with the aid of appropriate laboratory tests that are available in each level of care. International collaborative research on stroke risk factors that are prevalent in low and middle income countries will provide information for drafting of stroke care guidelines that are universal yet inclusive taking into consideration regional differences in available resources with the goal of reducing global stroke burden.
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Affiliation(s)
- Marilyn A Tan
- Division of Pediatric Neurology, Departments of Pediatrics and Neurosciences, University of the Philippines - Philippine General Hospital, Manila, Philippines.
| | - Elbert John V Layug
- Division of Pediatric Neurology, Departments of Pediatrics and Neurosciences, University of the Philippines - Philippine General Hospital, Manila, Philippines
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Pompsch M, Veltkamp R, Diehl RR, Kraemer M. Microembolic signals and antiplatelet therapy in Moyamoya angiopathy. J Neurol 2022; 269:6605-6612. [PMID: 36002693 DOI: 10.1007/s00415-022-11323-4] [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: 07/17/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Embolism as a cause of stroke is widely neglected in Moyamoya angiopathy (MMA), and recommendations for use of antiplatelet therapy (APT) vary. We examined the presence of microembolic signals (MES) during transcranial Doppler (TCD) monitoring and assessed the effects of APT on the occurrence of MES in MMA. PATIENTS AND METHODS We retrospectively analysed patients with MMA treated at our centre between 2011 and 2021. TCD was performed at first presentation and at most visits, while number of visits varied between individual patients. TCD was performed for 30 min bilaterally. Patient demographics, vascular risk factors, and antiplatelet treatment were collected from each clinic visit and ischemic and haemorrhagic episodes were captured as recorded during follow-up visits. RESULTS 209 patients were included in the analysis (mean age 38.7 ± 15.3, 28% male). 21 patients with 27 MES-positive TCD examinations were identified (10%). Patient characteristics were similar in MES-positive and MES-negative groups. However, recent ischemic events were detected at a significantly higher rate in MES-positive patients (42.9% vs 4.8%, p < 0.001). After MES detection, change of antiplatelet drug regime was performed, leading to loss of MES in all cases. Dual APT was preferably used in the MES-positive group (p < 0.001) but no significant difference of haemorrhage during follow-up-visits was observed. Reduction of APT before bypass-surgery triggered MES in four patients. CONCLUSION APT is required in patients with MMA. MES monitoring may help to identify risk patients in need of intensified APT.
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Affiliation(s)
- Mosche Pompsch
- Department of Neurology, Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45130, Essen, Germany
| | - Roland Veltkamp
- Department of Neurology, Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45130, Essen, Germany.,Department of Brain Sciences, Imperial College London, London, UK
| | - Rolf R Diehl
- Department of Neurology, Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45130, Essen, Germany.,University of Duisburg-Essen, Essen, Germany
| | - Markus Kraemer
- Department of Neurology, Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45130, Essen, Germany. .,Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
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Zhu J, Zhang M, Sun Y, Zhang X. Moyamoya syndrome with ruptured aneurysm in α‑thalassemia: A case report. Exp Ther Med 2022; 24:556. [PMID: 35978939 PMCID: PMC9366260 DOI: 10.3892/etm.2022.11494] [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: 05/10/2022] [Accepted: 06/22/2022] [Indexed: 12/03/2022] Open
Abstract
Moyamoya syndrome (MMS) refers to the moyamoya vascular disease associated with various systemic diseases and conditions, including sickle cell anemia, Fanconi anemia and iron deficiency anemia. However, the association between MMS and other hemoglobinopathies is less frequently observed. MMS, like moyamoya disease, is a cerebrovascular condition that is characterized by chronic progressive stenosis or occlusion at the ends of the bilateral internal carotid arteries, anterior cerebral arteries and the beginning of the middle cerebral arteries, and is secondary to the formation of an abnormal vascular network at the base of the skull. Patients with MMS are prone to thrombosis, aneurysm and bleeding. The present study reports the case of a 43-year-old man with α-thalassemia who presented with moyamoya vessels with a ruptured aneurysm bleeding into the ventricle. α-thalassemia is considered as an extremely rare but potential cause of MMS. Since MMS is a progressive disease, early diagnosis and treatment is vital to prevent the disease from worsening.
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Affiliation(s)
- Jiabin Zhu
- Department of Neurosurgery, Affiliated Xiaolan Hospital, Southern Medical University, Xiaolan People's Hospital of Zhongshan, Zhongshan, Guangdong 528415, P.R. China
| | - Mingwen Zhang
- Department of Neurosurgery, Affiliated Xiaolan Hospital, Southern Medical University, Xiaolan People's Hospital of Zhongshan, Zhongshan, Guangdong 528415, P.R. China
| | - Yichun Sun
- Department of Neurosurgery, Affiliated Xiaolan Hospital, Southern Medical University, Xiaolan People's Hospital of Zhongshan, Zhongshan, Guangdong 528415, P.R. China
| | - Xiaofeng Zhang
- Department of Neurosurgery, Affiliated Xiaolan Hospital, Southern Medical University, Xiaolan People's Hospital of Zhongshan, Zhongshan, Guangdong 528415, P.R. China
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Das S, Ray BK, Pandit A, Kumar S, Dubey S. Multiple sclerosis and Moyamoya angiopathy: Mimic and misdiagnosis. Mult Scler Relat Disord 2022; 66:104036. [PMID: 35858500 DOI: 10.1016/j.msard.2022.104036] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 06/24/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022]
Abstract
Moyamoya Angiopathy (MMA) is frequently not considered in differential diagnosis of Multiple Sclerosis (MS). This is the first study to prospectively analyze rate of misdiagnosis of MMA as MS and its clinical implications. Of the 160 angiographically proven MMA, 5 patients had an initial misdiagnosis of MS (3.13%). These 5 cases had female-predominance (80%).Out of the 5 cases, 4 cases (80%) presented with hemiparesis; 3 cases (60%) had an immediate precipitating factor. Radiologically, presence of both periventricular and juxtacortical white-matter-lesions was seen in 4 out of 5 cases (80%);none had infratentorial/spinal lesion, while all 5 cases had presence of "Ivy" sign and abnormal flow voids. Differentiation relies on careful evaluation of clinico-radiological features. MMA should be considered as a rare but important differential to MS.
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Affiliation(s)
- Shambaditya Das
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Biman Kanti Ray
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Alak Pandit
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Swati Kumar
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Souvik Dubey
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India.
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“Asymptomatic” Moyamoya Angiopathy: Is it Truly Asymptomatic? J Stroke Cerebrovasc Dis 2022; 31:106432. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106432] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/14/2022] [Accepted: 02/20/2022] [Indexed: 11/22/2022] Open
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Ghosh R, Das S, Roy D, Ray A, Benito-León J. Moyamoya angiopathy in a case of Klinefelter syndrome. Childs Nerv Syst 2022; 38:1195-1199. [PMID: 34628529 DOI: 10.1007/s00381-021-05371-w] [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: 04/26/2021] [Accepted: 09/20/2021] [Indexed: 11/29/2022]
Abstract
Moyamoya angiopathy, a rare cerebrovascular condition, can be primary (moyamoya disease) or secondary (moyamoya syndrome). Genetic factors, such as the ring finger protein 213 (RNF213), have been associated with moyamoya disease. However, X-linked moyamoya angiopathy/moyamoya syndrome and hypergonadotropic hypogonadism associated with moyamoya syndrome are rare. We report a case of a 14-year-old boy who presented with transient bilateral hemiparesis, recurrent seizures and cognitive decline. He previously had surgery for left-sided cryptorchidism and had been diagnosed with "epileptic attacks" or "functional movement disorders" in previous hospital admissions. Magnetic resonance angiography of the brain showed narrowing of supraclinoid portion of internal carotid arteries, as well as of middle and anterior cerebral arteries, and the presence of multiple collaterals. These findings were suggestive of moyamoya angiopathy. Laboratory investigations and karyotyping revealed a diagnosis of Klinefelter syndrome. This case presents a unique association of moyamoya angiopathy and Klinefelter syndrome in a boy from a poor socio-economic background, where the diagnosis and adequate treatment were delayed due to a lack of awareness and expertise.
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Affiliation(s)
- Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College & Hospital, Burdwan, West Bengal, India
| | - Shambaditya Das
- Department of Neuromedicine, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Dipayan Roy
- Department of Biochemistry, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
- Indian Institute of Technology (IIT), Madras, Tamil Nadu, India
| | - Adrija Ray
- R G Kar Medical College & Hospital, Kolkata, West Bengal, India
| | - Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain.
- Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain.
- Department of Medicine, Complutense University, Madrid, Spain.
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16
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Giraldo Tapias L, Arango Guerra P, Lopez Brokate L. Moyamoya syndrome resulting in stroke as a manifestation of paroxysmal nocturnal hemoglobinuria. Neurologia 2022. [DOI: 10.1016/j.nrl.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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17
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Das S, Dubey S, Das S, Hazra A, Pandit A, Ghosh R, Ray BK. Epidemiology of Moyamoya Angiopathy in Eastern India. Front Neurol 2022; 13:837704. [PMID: 35309562 PMCID: PMC8931392 DOI: 10.3389/fneur.2022.837704] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/31/2022] [Indexed: 01/15/2023] Open
Abstract
Introduction Moyamoya angiopathy (MMA) is a chronic, progressive intracranial vasculopathy with variation in prevalence and clinical manifestations across different populations. This study was aimed to estimate the frequency of MMA as an etiology of stroke and its epidemiological features in the largest cohort of MMA patients in India. Method A single-centered cross-sectional observational study over a period of 5 years (2016–2021) was undertaken among consecutive stroke and transient ischemic attack (TIA) patients to look for the presence of MMA angiographically. Each patient with angiographically proven MMA was further evaluated for demographic, clinical, and radiological characteristics. Results Among 10,250 consecutive stroke and TIA patients (ischemic = 78%, hemorrhagic = 22%), frequency of MMA was 1.56% (n = 160); 15.3% among children. Female preponderance (Male:Female = 1:1.4) was noted among 160 MMA patients, with bimodal age distribution, first peak at 3–8 years, and a shorter second peak at 41–47 years. Childhood-onset MMA was seen in 75 (46.9%) with commonest initial neurological symptom of fixed-motor-weakness (44.0%), followed by TIA (26.7%); while 85 (53.1%) had adult-onset MMA with fixed-motor-weakness (50.6%) followed by headache (24.7%) as the predominant initial neurological symptom; seizure significantly higher in children (p < 0.001) and headache in adults (p = 0.012). Transient and fixed neurological manifestations constituted 87.5 and 69.4% respectively, of symptoms throughout the disease course. Cerebral infarction (45.0%) and TIA (21.9%) were the commonest types of MMA. On brain imaging, infarction was noted in 80.6%, hemorrhage in 11.3%, significantly higher among adults (p < 0.001). Cortical infarct and Gyral pattern were commoner in children (p = 0.004), subcortical infarcts in adults (p = 0.018). Frequent Suzuki staging observed was stage 4 (31.3%), followed by stage 3 (30.0%). Involvement of posterior circulation was detected in 55.6%, brain atrophy at the time of diagnosis was seen in 65.0%. Conclusion MMA is an important etiological consideration in patients with stroke, especially in children. It can present with a myriad of transient neurological symptoms, frequently overlooked, leading to delayed diagnosis, and contributing to socio-economic burden. Indian MMA showed aberrations in its gender predisposition, age distribution, frequency of familial cases, disease manifestation, and type of stroke, in comparison to its Japanese and Caucasian counterparts pointing to the inter- and intra-continent differences of MMA phenotype. Future development of the Indian MMA national registry is of essence.
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Affiliation(s)
- Shambaditya Das
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Souvik Dubey
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Suman Das
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Avijit Hazra
- Department of Pharmacology, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Alak Pandit
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, India
| | - Biman Kanti Ray
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
- *Correspondence: Biman Kanti Ray
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Zahra A, Al‐Abboh H, Habeeb Y, Adekile A. Moyamoya syndrome in a child with HbEβ-thalassemia. Clin Case Rep 2022; 10:e05536. [PMID: 35280101 PMCID: PMC8905131 DOI: 10.1002/ccr3.5536] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 02/11/2022] [Accepted: 02/20/2022] [Indexed: 12/03/2022] Open
Abstract
Moyamoya is a progressive cerebrovascular disease associated with stenosis or occlusion of the arteries of the Circle of Willis. It is uncommon in thalassemia. We present a 9-year-old girl with HbEβ-thalassemia who presented with headache, vomiting, and episodes of transient hemiparesis with complete occlusion internal carotid arteries.
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Affiliation(s)
- Akmal Zahra
- Hematology UnitDepartment of PediatricsMubarak Al‐Kabeer HospitalJabriyaKuwait
| | - Hanan Al‐Abboh
- Hematology UnitDepartment of PediatricsMubarak Al‐Kabeer HospitalJabriyaKuwait
| | - Yousif Habeeb
- Neurology UnitDepartment of PediatricsMubarak Al‐Kabeer HospitalJabriyaKuwait
| | - Adekunle Adekile
- Hematology UnitDepartment of PediatricsMubarak Al‐Kabeer HospitalJabriyaKuwait
- Department of PediatricsFaculty of MedicineKuwait UniversityKuwait CityKuwait
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19
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Bhatt V, Koneru K, Diggikar P, Gopal P. A case of acute confusional state in a patient of chronic hemolytic anemia with secondary Moya–Moya disease. MEDICAL JOURNAL OF DR. D.Y. PATIL VIDYAPEETH 2022. [DOI: 10.4103/mjdrdypu.mjdrdypu_849_21] [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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20
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Covid-19 vaccine (covishield) heralding Moyamoya angiopathy. NEUROIMMUNOLOGY REPORTS 2022. [PMCID: PMC9061582 DOI: 10.1016/j.nerep.2022.100100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Indroduction Thrombotic complications leading to cerebrovascular events occuring in conjunction with Covid-19 vaccination though rare, is well-documented. Moyamoya Angiopathy is a progressive intracranial vasculopathy leading to recurrent strokes. Case presentation We present two index cases of young patient presenting with stroke and TIA following Covid-19 vaccination (COVISHIELD) leading to unmasking of Moyamoya Angiopathy. Conclusion Arterial stroke following Covid-19 vaccination is documented, but uncommon. However, in the background of a vasculopathy, it may not be so rare. Moyamoya Angiopathy has been closely studied in the model of inflammatory pathophysiology in genetically predisposed patients leading to progressive vaso-occlusive disease. Few reports of Covid-19 infection potentiating Moyamoya Angiopathy symptoms are also documented. Thus, as an extrapolation of the inflammatory etiopathogenesis of Moyamoya Angiopathy, Covid-19 vaccination can similarly affect the Moyamoya symptomatology. These two index cases open new lines of enquiry regarding the interplay of Covid-19 vaccination and neurological destabilization in patients with underlying vasculopathy of inflammatory pathophysiology.
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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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22
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Das S, Ray BK, Ghosh R, Sengupta S, Pandit A, Dubey S. Impact of COVID-19 pandemic in natural course of Moyamoya Angiopathy: an experience from tertiary-care-center in India. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021; 57:166. [PMID: 34924748 PMCID: PMC8665313 DOI: 10.1186/s41983-021-00412-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/03/2021] [Indexed: 12/23/2022] Open
Abstract
Background COVID-19 mediated immune dysregulation and cytokine storm can precipitate and aggravate Moyamoya angiopathy (MMA), influencing its disease course. This index study was undertaken to prospectively evaluate the status of neurological symptoms of MMA in relation to COVID-19 affection. Methodology and results Follow-up MMA patients of institute’s Stroke-clinic were telephonically interview from 24th March to 30th September, 2020. The first call familiarized them with COVID-19 symptoms and neurological manifestations of MMA, followed by monthly-calls with predesigned questionnaire. Patients with suggestion of COVID-19 underwent nasopharyngeal-swab-testing for COVID-19 Reverse transcription-polymerase chain reaction (RT-PCR) positive cases were subjected to antibody levels for COVID-19 Enzyme-linked immunoassay (ELISA) 8–12 weeks after recovery. During symptomatic phase till 14 days of asymptomatic, they were contacted daily/alternate day. Any new onset/worsening of neurological symptoms were noted. The baseline clinico-radiological details were obtained from stroke-clinic registery. Subsequently, all data were analyzed and compared using descriptive statistics. Seventy four of 104 MMA patients could be contacted and enrolled. The mean age, time since last follow-up and compliance to previously prescribed medication were 23.5 ± 16.1 years, 9.2 ± 1.7 months and 90.5% (n = 67), respectively. Aggravation/new onset neurological symptom were seen in 64.3% (n = 9) of COVID-19 positive MMA (n = 14), of which 8 were seen among the 11 pediatric COVID-19 positive MMA [(Transient ischemic attacks) TIA-4, TIA with headache-1, seizure-2, stroke causing mortality-1]. Conclusion COVID-19 infection can potentiate MMA causing significant morbidity and mortality, especially in children. Providing optimal care for severe diseases (such as MMA) in developing countries during pandemic remains a challenge.
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Affiliation(s)
- Shambaditya Das
- Department of Neurology, Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, 52 1/A Sambhu Nath Pandit Road, Bhowanipore, Kolkata, West Bengal 700020 India
| | - Biman Kanti Ray
- Department of Neurology, Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, 52 1/A Sambhu Nath Pandit Road, Bhowanipore, Kolkata, West Bengal 700020 India
| | - Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal India
| | - Samya Sengupta
- Department of General Medicine, Apollo Gleneagles Hospital, Kolkata, West Bengal India
| | - Alak Pandit
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal India
| | - Souvik Dubey
- Department of Neurology, Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, 52 1/A Sambhu Nath Pandit Road, Bhowanipore, Kolkata, West Bengal 700020 India
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23
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Chakraborty AP, Dubey S, Sarkar P, Das S, Ray BK, Pandit A. A Case of Moyamoya Syndrome with Isolated Protein S Deficiency Unmasked by Pregnancy. Ann Indian Acad Neurol 2021; 24:628-630. [PMID: 34728978 PMCID: PMC8513990 DOI: 10.4103/aian.aian_833_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/30/2020] [Accepted: 11/18/2020] [Indexed: 12/02/2022] Open
Affiliation(s)
- Arka P Chakraborty
- Department of Neurology, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Souvik Dubey
- Department of Neurology, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Peyalee Sarkar
- Department of Neurology, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Shambaditya Das
- Department of Neurology, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Biman K Ray
- Department of Neurology, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Alak Pandit
- Department of Neurology, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
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Abstract
PURPOSE OF THE REVIEW Anemia has been called the fifth cardiovascular risk factor. It is one of the most prevalent pathologies worldwide. In this article, we aimed to perform a narrative review of the main cerebrovascular complications of anemia and its influence on stroke prognosis. RECENT FINDINGS Both hypoproliferative anemia (thalassemia, iron deficiency anemia, etc.) and hyperproliferative anemia (sickle cell disease, paroxysmal nocturnal hemoglobinuria, hereditary spherocytosis, etc.) are associated to cerebrovascular disease ranging from transient ischemic attack to ischemic stroke and hemorrhagic stroke with both intraparenchymal hemorrhage and subarachnoid hemorrhage or cerebral venous thrombosis. Anemia is associated to a worse prognosis in patients with cerebrovascular disease In some cases, like sickle cell disease, pathophysiological mechanisms and therapeutic guidelines are well established, while in others, due to their rarity, there are still lack of robust data. More studies are needed to clarify how the prognosis of stroke patients with anemia could be improved.
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Pilgram-Pastor S, Chapot R, Kraemer M. The angiographic presentation of European Moyamoya angiopathy. J Neurol 2021; 269:997-1006. [PMID: 34240321 PMCID: PMC8782787 DOI: 10.1007/s00415-021-10684-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/21/2021] [Accepted: 06/22/2021] [Indexed: 11/26/2022]
Abstract
Background and purpose Little is known about the angiographic presentation of Moyamoya angiopathy (MMA) in non-Asian patients. Methods Conventional cerebral angiograms from 155 Caucasian patients diagnosed as MMA were analyzed with respect to extracranial champagne bottle neck sign, Suzuki stages, collateral status, as well as presence of aneurysms and posterior cerebral artery stenosis. Results In 84 of 155 angiograms, the extracranial carotid artery was visualized, in 65 of them (77.4%), a champagne bottle neck sign was noted. Of the 278 analyzable hemispheres, 13.7%,11.2%, 37.8%, 27.3%, 8.6%, and 1.4% were classified as Suzuki stage I, stage II, stage III, stage IV, stage V, and stage VI, respectively. Among 280 hemispheres, in 53 hemispheres (18.9%) isolated basal collaterals (pathway I) and in 104 hemispheres (37.1%) choroidal and pericallosal collaterals (including basal collaterals, pathway II) were found. In 74 hemispheres (26.4%) ethmoidal collaterals (pathways III), and in 17 hemispheres (6.1%) vault collaterals were visualized. Patients with higher Suzuki stages IV–VI (p = 0.008) and ethmoidal collaterals (p < 0.001) suffered more often from cerebral hemorrhage. Transient ischemic attacks occurred more frequently in patients with Suzuki stage I to III (p < 0.001). In 10 of 155 patients (6.5%), the angiogram revealed a cerebral aneurysm. In 13 patients (8.4%), a stenotic P1 segment of the posterior cerebral artery was found. Conclusions This is so far the largest observational study about angiography in Caucasian European MMA patients. A comparison with Asian data indicates similarity of disease in Caucasian and Asian patients.
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Affiliation(s)
- Sara Pilgram-Pastor
- Department of Neuroradiology, Alfried Krupp Hospital, Essen, Germany
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - René Chapot
- Department of Neuroradiology, Alfried Krupp Hospital, Essen, Germany
| | - Markus Kraemer
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany.
- Department of Neurology, Alfried Krupp Von Bohlen Und Halbach Hospital, Alfried-Krupp-Str. 21, 45117, Essen, Germany.
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26
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Das S, Ghosh R, Dubey S, Pandit A, Ray BK, Kraemer M. Limb-shaking TIA in Moyamoya angiopathy. Clin Neurol Neurosurg 2021; 207:106783. [PMID: 34225004 DOI: 10.1016/j.clineuro.2021.106783] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/06/2021] [Accepted: 06/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Limb shaking TIA(LS-TIA) is an rare manifestation seen in high grade steno-occlusive carotid disease. LS-TIA is rarely recognized as a presenting manifestation of MMA and has never been previously studied prospectively in MMA cohort. METHODS Of 104 cases of MMA collected in our Indian center in last 4 years, 5 new patients had LS-TIA. MMA was diagnosed by MR angiography and LS-TIA was confirmed by three different neurologist by detailed scrutiny of history, neurological examination and EEG-recording (to rule out seizure). Seven previously reported cases of LS-TIA in MMA were retrieved by literature search in PubMed using keywords "Moyamoya" AND "Limb shaking TIA", "Moyamoya" AND "Limb shaking". Subsequently all data were analyzed and compared using descriptive statistics. RESULTS Analysis of our 5 cases and those 7 found in the literature showed mean age at the time of diagnosis of MMA was 12.2 ± 8.9(Mean ± S.D.) years in our cases and 32.7 ± 13.6 years in previous cases. The commonest precipitating factors included prolonged crying and hyperventilation(3 of 5 our cases each) and exercise (3 of 7 previous cases). CT-perfusion demonstrated frontal white matter hypoperfusion in 2 of our 5 cases, corroborative with fronto-parietal hypoperfusion in previous cases. Medical management showed decreased symptoms in 4 of our 5 cases in a follow-up of 15.8 ± 11.6 months, while all previous patients had underwent revascularization surgery with resolution of symptoms. CONCLUSION LS-TIA in MMA may not be so uncommon, especially in children. Early recognition is imperative to avoid future catastrophe. Steno-occlusive posterior circulation lesions might be an independent predictor of development of LS-TIA in MMA. In a resource-limited setting, careful avoidance of triggers and anti-platelet therapy can lead to decreased symptomatology of LS-TIA in MMA.
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Affiliation(s)
- Shambaditya Das
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India.
| | - Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, India.
| | - Souvik Dubey
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India.
| | - Alak Pandit
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India.
| | - Biman Kanti Ray
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India.
| | - Markus Kraemer
- Department of Neurology, Alfried Krupp Von Bohlen Und Halbach, Hospital, Alfried-Krupp-Str. 21, 45117 Essen, Germany; Heinrich Heine University of Duesseldorf, Medical Faculity, Duesseldorf, Germany.
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Das S, Karmakar K, Mukherjee R, Panda S, Dubey S, Sarkar N, Ray BK. Acute stroke in young adult secondary to moyamoya angiopathy unveiling HbE-β thalassemia. Ann Hematol 2021; 101:449-451. [PMID: 33864135 DOI: 10.1007/s00277-021-04519-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Shambaditya Das
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, 52/1A Shambu Nath Pandit Street, Kolkata, India
| | - Kousik Karmakar
- Department of General Medicine, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Reetam Mukherjee
- Department of General Medicine, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Sourav Panda
- Department of General Medicine, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Souvik Dubey
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, 52/1A Shambu Nath Pandit Street, Kolkata, India.
| | - Niladri Sarkar
- Department of General Medicine, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Biman Kanti Ray
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, 52/1A Shambu Nath Pandit Street, Kolkata, India
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Njue L, Medri C, Keller P, Diepold M, Taleghani BM, Rovó A. The rare hemoglobin variant Hb Mizuho: report of a Swiss family and literature review. Ann Hematol 2021; 100:1677-1683. [PMID: 33590291 PMCID: PMC8195896 DOI: 10.1007/s00277-021-04458-3] [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: 08/30/2020] [Accepted: 02/07/2021] [Indexed: 11/29/2022]
Abstract
Hb Mizuho is a very rare unstable hemoglobin; here, we describe the clinical history of three Swiss family members with Hb Mizuho together with a systematic review of the previously six published cases. The clinical history of the adult woman we report here is unique since this is the first Hb Mizuho presenting with Moyamoya complications and the first case reported with long-term erythrocyte exchange. The literature review showed that Hb Mizuho was mainly reported as a de novo mutation, with the exception of children descended from known cases. All published patients with this unstable hemoglobin showed severe hemolytic anemia with the exception of one; all were regularly transfused. Patients with higher HbF levels might require fewer transfusions. All patients underwent splenectomy at a median age of 4 years and had variable clinical improvement; some achieved complete resolution of transfusion dependency after splenectomy. Iron overload in Hb Mizuho patients seems to be mainly attributed to transfusions and has less to do with ineffective erythropoiesis. Diagnosis might be challenging; a normal hemoglobin electrophoresis should not rule out the diagnosis of unstable hemoglobin in patients with otherwise unexplained hemolytic anemia. This series shows the enormous utility of using molecular techniques for diagnosis.
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Affiliation(s)
- Linet Njue
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Cesare Medri
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Peter Keller
- Hematology, Spital Langenthal SRO AG, 4900, Langenthal, Switzerland
| | - Miriam Diepold
- Hematology and Oncology, Children's Hospital, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Behrouz Mansouri Taleghani
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Alicia Rovó
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
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Das S, Dubey S, Pandit A, Ray BK. Moyamoya angiopathy unmasking systemic lupus erythematosus. BMJ Case Rep 2021; 14:14/1/e239307. [PMID: 33504534 PMCID: PMC7843324 DOI: 10.1136/bcr-2020-239307] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
A 47-year-old woman with history of seizure disorder (semiology of seizure unknown), not well controlled with antiepileptic drugs since last 30 years presented with 1-year history of intermittent throbbing headache. On the day prior to admission, she experienced worst headache, followed by loss of consciousness. On regaining consciousness, she had neck pain without any focal neurological deficit, but examination was marked by positive meningeal signs. She had history of oral ulceration, photosensitivity and small joints pain for which no medical consultancy was sought until. Following relevant investigations, this case came out to be moyamoya angiopathy secondary to underlying systemic lupus erythematosus. She was put on immunosuppressive and immunomodulator as per recommendations. Among neurological symptoms, headache improved dramatically without any further seizure recurrence till the 6 months of follow-up.
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Affiliation(s)
- Shambaditya Das
- Department of Neurology, Institute of Postgraduate Medical Education and Research, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Souvik Dubey
- Department of Neurology, Institute of Postgraduate Medical Education and Research, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Alak Pandit
- Department of Neurology, Institute of Postgraduate Medical Education and Research, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Biman Kanti Ray
- Department of Neurology, Institute of Postgraduate Medical Education and Research, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
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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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Tartaglione I, Caiazza M, Di Concilio R, Ciancio A, De Michele E, Maietta C, Valentino MS, Russo C, Roberti D, Casale M, Elefante A, Femina G, Esposito F, Ponticorvo S, Russo AG, Canna A, Ermani M, Cirillo M, Perrotta S, Manara R. Headache in beta-thalassemia: An Italian multicenter clinical, conventional MRI and MR-angiography case-control study. Blood Cells Mol Dis 2019; 81:102403. [PMID: 31918383 DOI: 10.1016/j.bcmd.2019.102403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 12/30/2019] [Accepted: 12/30/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVES A strikingly increased headache prevalence was recently noted in Sri Lankan beta-thalassemia patients, raising several concerns regarding long-term neurological involvement in this condition. METHODS We interviewed on headache occurrence and characteristics 102 Italian beta-thalassemia patients and 129 healthy controls. 3T-MRI, MR-angiography, MR-venography, cognitive and psychiatric findings were considered. RESULTS Headache was diagnosed in 39/102 (38.2%) beta-thalassemia patients without significant phenotype-related differences and in 51/129 (39.5%) controls. Patients and controls did not differ significantly regarding episode number (5.9 ± 6.2 vs 5.4 ± 4.4 days/month), subjective severity-score (6.8 ± 1.4 vs 7.1 ± 1.3), age-at-onset (24.3 ± 13.0 vs 19.5 ± 9.6 years) and headache-subtype rate. No main demographic, clinical or laboratory data was associated with headache but female gender. Headache was not associated with white matter lesions (number or maximal diameter), intracranial aneurysms, intracranial artery stenoses or venous sinus thrombosis. Cognitive and psychiatric evaluations were worse in beta-thalassemia, however, headache did not correlate with full-scale Intelligence Quotient (75.4 ± 18.0 vs 76.7 ± 15.3, with and without headache, respectively) or Brief Psychiatric Rating Scale scores (29.1 ± 2.7 vs 28.5 ± 3.4). CONCLUSIONS Among Italian beta-thalassemia patients, headache does not seem to be more common or severe than in the general population. In addition, patients with headache do not seem to present increased conventional MRI, MR-angiography and cognitive/psychiatric changes.
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Affiliation(s)
- Immacolata Tartaglione
- Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Università degli studi della Campania "Luigi Vanvitelli", Napoli, Italy.
| | - Martina Caiazza
- Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Università degli studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | | | - Angela Ciancio
- Unità Operativa Ematologia - Day Hospital di Talassemia, Ospedale "Madonna delle Grazie", Matera, Italy
| | - Elisa De Michele
- Medicina Trasfusionale AUO "San Giovanni di Dio e Ruggi D'Aragona", Salerno, Italy
| | - Caterina Maietta
- Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Università degli studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Maria Sole Valentino
- Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Università degli studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Camilla Russo
- Neuroradiologia, Università degli Studi di Napoli "Federico II", Napoli, Italy
| | - Domenico Roberti
- Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Università degli studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Maddalena Casale
- Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Università degli studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Andrea Elefante
- Neuroradiologia, Università degli Studi di Napoli "Federico II", Napoli, Italy
| | - Gianluca Femina
- Dipartimento di Medicina e Chirurgia, Scuola Medica Salernitana, Sezione di Neuroscienze, Università di Salerno, Salerno, Italy
| | - Fabrizio Esposito
- Dipartimento di Medicina e Chirurgia, Scuola Medica Salernitana, Sezione di Neuroscienze, Università di Salerno, Salerno, Italy
| | - Sara Ponticorvo
- Dipartimento di Medicina e Chirurgia, Scuola Medica Salernitana, Sezione di Neuroscienze, Università di Salerno, Salerno, Italy
| | - Andrea G Russo
- Dipartimento di Medicina e Chirurgia, Scuola Medica Salernitana, Sezione di Neuroscienze, Università di Salerno, Salerno, Italy
| | - Antonietta Canna
- Dipartimento di Medicina e Chirurgia, Scuola Medica Salernitana, Sezione di Neuroscienze, Università di Salerno, Salerno, Italy
| | - Mario Ermani
- Dipartimento di Neuroscienze (DNS), Unità di Statistica e di Informatica, Scuola di Medicina, Università of Padova, Padova, Italy
| | - Mario Cirillo
- Dipartimento di Scienze Mediche, Chirurgiche, Neurologiche, Metaboliche e dell'Invecchiamento, Università della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Silverio Perrotta
- Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Università degli studi della Campania "Luigi Vanvitelli", Napoli, Italy
| | - Renzo Manara
- Dipartimento di Medicina e Chirurgia, Scuola Medica Salernitana, Sezione di Neuroscienze, Università di Salerno, Salerno, Italy
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