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Numoto S, Takasu S, Nakamura T, Takagi M, Kurahashi H, Azuma Y, Okumura A. Acute Magnetic Resonance Imaging Findings in Young Children With Moyamoya Disease. Pediatr Neurol 2024; 156:106-112. [PMID: 38749382 DOI: 10.1016/j.pediatrneurol.2024.03.025] [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: 08/29/2023] [Revised: 03/01/2024] [Accepted: 03/27/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND To describe the diffusion-weighted imaging (DWI) findings in young children with moyamoya disease (MMD) during the acute period of the condition. METHODS Clinical data were collected from 12 children with MMD aged less than six years, in whom abnormalities were observed on DWI scans obtained within one week after the appearance of symptoms related to MMD. The DWI abnormalities were classified into gyral, atypical territorial, honeycomb, classical territorial, multiple-dot, border zone, and deep lacunar patterns. The severity of arterial stenosis was graded by angiographic stages that have been previously described. RESULTS In all but one child, the DWI abnormalities were restricted to the cerebral cortex. The lesions were gyral in nature in seven children and atypical territorial in five; all differed from those of typical arterial strokes. Internal carotid artery stenosis was observed in all 12 children, although the stenosis was mild in 11. The severity of arterial stenosis did not match the regions of ischemic lesions in some children. There was no statistically significant difference in the severity of arterial stenosis according to the presence or absence of ischemic lesions or the pattern of the lesions. CONCLUSIONS Lesions located mainly in the cerebral cortex, i.e., not in arterial territories, are characteristic of young children with MMD.
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Affiliation(s)
- Shingo Numoto
- Department of Pediatrics, Aichi Medical University, Nagakute, Aichi, Japan; Department of Child Neurology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan.
| | - Syuntaro Takasu
- Department of Neurosurgery, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Aichi, Japan; Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Aichi, Japan
| | - Tomomi Nakamura
- Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Mizuki Takagi
- Department of Pediatrics, Aichi Medical University, Nagakute, Aichi, Japan
| | - Hirokazu Kurahashi
- Department of Pediatrics, Aichi Medical University, Nagakute, Aichi, Japan
| | - Yoshiteru Azuma
- Department of Pediatrics, Aichi Medical University, Nagakute, Aichi, Japan
| | - Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, Nagakute, Aichi, Japan
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Sun LR, Jordan LC, Smith ER, Aldana PR, Kirschen MP, Guilliams K, Gupta N, Steinberg GK, Fox C, Harrar DB, Lee S, Chung MG, Dirks P, Dlamini N, Maher CO, Lehman LL, Hong SJ, Strahle JM, Pineda JA, Beslow LA, Rasmussen L, Mailo J, Piatt J, Lang SS, Adelson PD, Dewan MC, Mineyko A, McClugage S, Vadivelu S, Dowling MM, Hersh DS. Pediatric Moyamoya Revascularization Perioperative Care: A Modified Delphi Study. Neurocrit Care 2024; 40:587-602. [PMID: 37470933 PMCID: PMC11023720 DOI: 10.1007/s12028-023-01788-0] [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: 05/13/2023] [Accepted: 06/20/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Surgical revascularization decreases the long-term risk of stroke in children with moyamoya arteriopathy but can be associated with an increased risk of stroke during the perioperative period. Evidence-based approaches to optimize perioperative management are limited and practice varies widely. Using a modified Delphi process, we sought to establish expert consensus on key components of the perioperative care of children with moyamoya undergoing indirect revascularization surgery and identify areas of equipoise to define future research priorities. METHODS Thirty neurologists, neurosurgeons, and intensivists practicing in North America with expertise in the management of pediatric moyamoya were invited to participate in a three-round, modified Delphi process consisting of a 138-item practice patterns survey, anonymous electronic evaluation of 88 consensus statements on a 5-point Likert scale, and a virtual group meeting during which statements were discussed, revised, and reassessed. Consensus was defined as ≥ 80% agreement or disagreement. RESULTS Thirty-nine statements regarding perioperative pediatric moyamoya care for indirect revascularization surgery reached consensus. Salient areas of consensus included the following: (1) children at a high risk for stroke and those with sickle cell disease should be preadmitted prior to indirect revascularization; (2) intravenous isotonic fluids should be administered in all patients for at least 4 h before and 24 h after surgery; (3) aspirin should not be discontinued in the immediate preoperative and postoperative periods; (4) arterial lines for blood pressure monitoring should be continued for at least 24 h after surgery and until active interventions to achieve blood pressure goals are not needed; (5) postoperative care should include hourly vital signs for at least 24 h, hourly neurologic assessments for at least 12 h, adequate pain control, maintaining normoxia and normothermia, and avoiding hypotension; and (6) intravenous fluid bolus administration should be considered the first-line intervention for new focal neurologic deficits following indirect revascularization surgery. CONCLUSIONS In the absence of data supporting specific care practices before and after indirect revascularization surgery in children with moyamoya, this Delphi process defined areas of consensus among neurosurgeons, neurologists, and intensivists with moyamoya expertise. Research priorities identified include determining the role of continuous electroencephalography in postoperative moyamoya care, optimal perioperative blood pressure and hemoglobin targets, and the role of supplemental oxygen for treatment of suspected postoperative ischemia.
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Affiliation(s)
- Lisa R Sun
- Division of Cerebrovascular Neurology, Division of Pediatric Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Lori C Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Boston, MA, USA
| | - Philipp R Aldana
- Division of Pediatric Neurosurgery, University of Florida College of Medicine, Section of Neurosurgery, Wolfson Children's Hospital, Jacksonville, FL, USA
| | - Matthew P Kirschen
- Departments of Anesthesiology and Critical Care Medicine, Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kristin Guilliams
- Departments of Neurology, Pediatrics, and Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Nalin Gupta
- Departments of Neurological Surgery and Pediatrics, University of California, San Francisco, CA, USA
| | - Gary K Steinberg
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Christine Fox
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Dana B Harrar
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Melissa G Chung
- Department of Pediatrics, Divisions of Pediatric Neurology and Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Peter Dirks
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Canada
| | - Nomazulu Dlamini
- Division of Neurology, The Hospital for Sick Children, Toronto, Canada
| | - Cormac O Maher
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Laura L Lehman
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Sue J Hong
- Department of Pediatrics, Divisions of Critical Care and Child Neurology, Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jennifer M Strahle
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jose A Pineda
- Department of Critical Care, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lindsey Rasmussen
- Department of Critical Care, Stanford University School of Medicine, Stanford, CA, USA
| | - Janette Mailo
- Division of Pediatric Neurology, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Joseph Piatt
- Division of Neurosurgery, Nemours Children's Hospital Delaware, Wilmington, DE, USA
| | - Shih-Shan Lang
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - P David Adelson
- Department of Neurosurgery, WVU Medicine and WVU Medicine Children's Hospital, Morgantown, WV, USA
| | - Michael C Dewan
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aleksandra Mineyko
- Department of Pediatrics, Section on Neurology, University of Calgary, Calgary, AB, Canada
| | - Samuel McClugage
- Department of Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Sudhakar Vadivelu
- Division of Pediatric Neurosurgery and Interventional Neuroradiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michael M Dowling
- Departments of Pediatrics and Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David S Hersh
- Division of Neurosurgery, Connecticut Children's, Hartford, CT, USA
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Schwartzmann Y, Spektor S, Moscovici S, Jubran H, Metanis I, Jouaba T, Cohen JE, Gomori JM, Leker RR. Comparison between moyamoya disease and moyamoya syndrome in Israel. J Stroke Cerebrovasc Dis 2024; 33:107635. [PMID: 38342272 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107635] [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: 06/26/2023] [Revised: 01/23/2024] [Accepted: 02/09/2024] [Indexed: 02/13/2024] Open
Abstract
BACKGROUND AND AIMS Moyamoya is a chronic brain vasculopathy involving the distal intracranial internal carotid artery (ICA) or proximal middle cerebral artery (MCA). Moyamoya patients can be divided into those with primary moyamoya disease (MMD) and those with moyamoya secondary to other known causes such as intracranial atherosclerosis (moymoya syndrome [MMS]). Our aim was to compare the characteristics of MMD patients to those of MMS patients in a sample of Israeli patients seen over the course of 20 years at a tertiary referral center. METHODS Included patients were diagnosed with either MMD or MMS based on typical imaging findings and the presence or absence of known concomitant vascular risk factors or associated disorders and vascular disease. Patients with MMS were compared to those with MMD. Demographics, symptoms, signs, and radiological data were compared between the groups. Treatment options and long-term rates of recurrent stroke and functional outcome were also studied. RESULTS Overall, 64 patients were included (25 MMD, 39 MMS). Patients with MMD were significantly younger (median IQR 20 (7-32) vs. 40 (19-52); p=0.035). Patients with MMS more often had vascular risk factors but there were no significant differences in clinical presentations or long-term disability rates between the groups and a similar proportion of patients underwent surgical interventions to restore hemispheric perfusion in both groups (48% vs. 44% MMS vs. MMD; p=0.7). Almost one in four patient had a recurrent stroke after the initial diagnosis in both groups. Most recurrences occurred in the pre-surgery period in the MMS group and in the post-surgery period in the MMD group. CONCLUSIONS There were no statistically significant differences in clinical or radiological presentations between the MMS and MMD patients. The course is not benign with recurrent stroke occurring in as many as 25%. More data is needed in order to identify those at high risk for stroke occurrence and recurrence.
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Affiliation(s)
- Y Schwartzmann
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - S Spektor
- Departments of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - S Moscovici
- Departments of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - H Jubran
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - I Metanis
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - T Jouaba
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J E Cohen
- Departments of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J M Gomori
- Departments of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - R R Leker
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Sun LR, Gatti JR, Ahmad SA, Burton N, Ziai W, Gottesman RF, Jordan LC. Transcranial Doppler in Childhood Moyamoya: An Underutilized Tool? Pediatr Neurol 2024; 151:111-114. [PMID: 38154237 PMCID: PMC10872573 DOI: 10.1016/j.pediatrneurol.2023.12.002] [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: 10/24/2023] [Revised: 11/21/2023] [Accepted: 12/04/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Children with moyamoya are at high risk for incident and recurrent stroke. Transcranial Doppler (TCD) ultrasound is an attractive option to screen high-risk populations for moyamoya and to provide stroke risk stratification information due to its safety and cost-effectiveness. We used TCD to evaluate cerebral blood flow velocities in children with presurgical moyamoya and to determine if velocities differ between children with stable and unstable disease. METHODS Fourteen participants aged ≤21 years with a radiographic diagnosis of moyamoya or moyamoya-like arteriopathy underwent a research TCD at a median age of 7.2 years. TCDs were performed outside of the setting of acute stroke and before surgical revascularization. Arteriopathy was classified as unstable if the participant had a stroke or transient ischemic attack within three months preceding the TCD. RESULTS Middle cerebral artery and internal carotid artery (ICA) blood flow velocities were elevated. The median M1 velocity was 138 cm/s (interquartile range [IQR] 106 to 168). Individual M1 flow velocities were a median of 5.0 S.D.s above age-based normative values. The median distal ICA velocity was 146 cm/s (IQR 124 to 163). Individual ICA flow velocities were a median of 5.9 S.D.s above normative values. Participants with unstable arteriopathy had higher M1 velocities compared with those with stable arteriopathy (170 vs 119 cm/s, P = 0.0003). We did not identify velocity differences based on comorbid conditions or age. CONCLUSIONS These preliminary data suggest that TCD is a promising tool for screening for cerebral arteriopathies in high-risk pediatric populations and assessment for unstable disease.
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Affiliation(s)
- Lisa R Sun
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland.
| | - John R Gatti
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Noah Burton
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Wendy Ziai
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rebecca F Gottesman
- National Institute of Neurological Disease and Stroke Intramural Research Program, Bethesda, Maryland
| | - Lori C Jordan
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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Hill NM, Malone LA, Sun LR. Stroke in the Developing Brain: Neurophysiologic Implications of Stroke Timing, Location, and Comorbid Factors. Pediatr Neurol 2023; 148:37-43. [PMID: 37651976 DOI: 10.1016/j.pediatrneurol.2023.08.008] [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: 02/10/2023] [Revised: 08/02/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Pediatric stroke, which is unique in that it represents a static insult to a developing brain, often leads to long-term neurological disability. Neuroplasticity in infants and children influences neurophysiologic recovery patterns after stroke; therefore outcomes depend on several factors including the timing and location of stroke and the presence of comorbid conditions. METHODS In this review, we discuss the unique implications of stroke occurring in the fetal, perinatal, and childhood/adolescent time periods. First, we highlight the impact of the developmental stage of the brain at the time of insult on the motor, sensory, cognitive, speech, and behavioral domains. Next, we consider the influence of location of stroke on the presence and severity of motor and nonmotor outcomes. Finally, we discuss the impact of associated conditions on long-term outcomes and risk for stroke recurrence. RESULTS Hemiparesis is common after stroke at any age, although the severity of impairment differs by age group. Risk of epilepsy is elevated in all age groups compared with those without stroke. Outcomes in other domains vary by age, although several studies suggest worse cognitive outcomes when stroke occurs in early childhood compared with fetal and later childhood epochs. Conditions such as congenital heart disease, sickle cell disease, and moyamoya increase the risk of stroke and leave patients differentially vulnerable to neurodevelopmental delay, stroke recurrence, silent infarcts, and cognitive impairment. CONCLUSIONS A comprehensive understanding of the interplay of various factors is essential in guiding the clinical care of patients with pediatric stroke.
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Affiliation(s)
- Nayo M Hill
- Center for Movement Studies, Kennedy Krieger Institute, Baltimore, Maryland; Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura A Malone
- Center for Movement Studies, Kennedy Krieger Institute, Baltimore, Maryland; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lisa R Sun
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Kaseka ML, Dlamini N. Investigation and management of pediatric moyamoya arteriopathy in the era of genotype-phenotype correlation studies. Eur J Hum Genet 2023; 31:735-737. [PMID: 37188827 PMCID: PMC10326028 DOI: 10.1038/s41431-023-01369-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023] Open
Affiliation(s)
- M L Kaseka
- Division of Neurology, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada.
| | - N Dlamini
- Division of Neurology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
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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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Gatti JR, Penn R, Ahmad SA, Sun LR. Seizures in Pediatric Moyamoya: Risk Factors and Functional Outcomes. Pediatr Neurol 2023; 145:36-40. [PMID: 37271055 DOI: 10.1016/j.pediatrneurol.2023.04.025] [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: 03/16/2023] [Revised: 04/23/2023] [Accepted: 04/29/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Children with moyamoya arteriopathy are at high risk for stroke and seizures. Risk factors for seizures and the impact of seizures on neurological outcomes in children with moyamoya are unknown. METHODS This is a single-center retrospective cohort study of children with moyamoya evaluated between 2003 and 2021. Functional outcome was assessed using the Pediatric Stroke Outcome Measure (PSOM). Associations between clinical variables and seizure occurrence were assessed using univariate and multivariable logistic regression. Associations between clinical variables and final PSOM score were assessed using ordinal logistic regression. RESULTS Eighty-four patients met inclusion criteria, and 34 (40%) children experienced seizure. Factors associated with seizures included moyamoya disease (vs syndrome; odds ratio [OR] 3.43, P = 0.008) and the presence of infarcts on baseline neuroimaging (OR 5.80, P = 0.002). Factors associated with decreased likelihood of experiencing seizures included older age at initial presentation (OR 0.82, P = 0.002) and asymptomatic (radiographic) presentation (OR 0.05, P = 0.006). Both older age at presentation (adjusted OR [AOR] 0.80, P = 0.004) and incidental radiographic presentation (AOR 0.06, P = 0.022) remained significant after adjusting for potential confounders. Seizures were associated with worse functional outcomes as assessed by the PSOM (regression coefficient 2.03, P < 0.001). This association remained significant after adjusting for potential confounders (adjusted regression coefficient 1.54, P = 0.025). CONCLUSIONS Younger age and symptomatic presentation are associated with increased likelihood of seizures among children with moyamoya. Seizures are associated with worse functional outcomes. Prospective studies should clarify how seizures impact outcomes and how effective seizure treatment modifies this relationship.
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Affiliation(s)
- John R Gatti
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rachel Penn
- Division of Epilepsy, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Lisa R Sun
- Divisions of Cerebrovascular Neurology and Pediatric Neurology, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland.
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Gatti JR, Peterson RK, Cannon A, Yedavalli V, Malone LA, Sun LR. Characterization of Neuropsychological Outcomes in a Cohort of Pediatric Patients with Moyamoya Arteriopathy. Neuropediatrics 2023; 54:134-138. [PMID: 36473489 PMCID: PMC10893819 DOI: 10.1055/a-1993-3860] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Moyamoya arteriopathy is a severe, progressive cerebral arteriopathy that places affected children at high risk for stroke. Moyamoya has been associated with a range of neuropsychological deficits in adults, but data on many cognitive domains remain limited in the pediatric population and little is known about the neuropsychological profile of children with syndromic moyamoya. METHODS This is a single-center, retrospective cohort study of children with moyamoya arteriopathy followed at our center who underwent neuropsychological testing between 2003 and 2021. Test scores were extracted from neuropsychological reports. Medical records were reviewed with attention to individual neuropsychological test results, medical comorbidities, presence of infarct(s) on neuroimaging, and history of clinical ischemic stroke. RESULTS Of the 83 children with moyamoya followed at our center between 2003 and 2021, 13 had completed neuropsychological testing across multiple cognitive domains. Compared to age-based normative data, children in this sample had lower scores in overall intelligence (p = 0.003), global executive functioning (p = 0.005), and overall adaptive functioning (p = 0.015). There was no significant difference in overall intelligence between children with (n = 6) versus without (n = 7) a history of clinical stroke (p = 0.368), though children with any radiographic infarct scored lower in this domain (p = 0.032). CONCLUSION In our cohort, children with moyamoya demonstrated impaired intelligence and executive functioning, even in the absence of clinical stroke. Neuropsychological evaluation should be considered standard of care for all children with moyamoya, even those without a history of clinical stroke.
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Affiliation(s)
- John R Gatti
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Rachel K Peterson
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland, United States
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Alicia Cannon
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland, United States
| | - Vivek Yedavalli
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Laura A Malone
- Center for Movement Studies, Kennedy Krieger Institute, Baltimore, Maryland, United States
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Lisa R Sun
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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Sun LR, Lynch JK. Advances in the Diagnosis and Treatment of Pediatric Arterial Ischemic Stroke. Neurotherapeutics 2023; 20:633-654. [PMID: 37072548 PMCID: PMC10112833 DOI: 10.1007/s13311-023-01373-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/20/2023] Open
Abstract
Though rare, stroke in infants and children is an important cause of mortality and chronic morbidity in the pediatric population. Neuroimaging advances and implementation of pediatric stroke care protocols have led to the ability to rapidly diagnose stroke and in many cases determine the stroke etiology. Though data on efficacy of hyperacute therapies, such as intravenous thrombolysis and mechanical thrombectomy, in pediatric stroke are limited, feasibility and safety data are mounting and support careful consideration of these treatments for childhood stroke. Recent therapeutic advances allow for targeted stroke prevention efforts in high-risk conditions, such as moyamoya, sickle cell disease, cardiac disease, and genetic disorders. Despite these exciting advances, important knowledge gaps persist, including optimal dosing and type of thrombolytic agents, inclusion criteria for mechanical thrombectomy, the role of immunomodulatory therapies for focal cerebral arteriopathy, optimal long-term antithrombotic strategies, the role of patent foramen ovale closure in pediatric stroke, and optimal rehabilitation strategies after stroke of the developing brain.
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Affiliation(s)
- Lisa R Sun
- Divisions of Pediatric Neurology and Cerebrovascular Neurology, Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Ste 2158, Baltimore, MD, 21287, USA.
| | - John K Lynch
- Acute Stroke Research Section, Stroke Branch (SB), National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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11
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Hausman-Kedem M, Herring R, Torres MD, Santoro JD, Kaseka ML, Vargas C, Amico G, Bertamino M, Nagesh D, Tilley J, Schenk A, Ben-Shachar S, Musolino PL. The Genetic Landscape of Ischemic Stroke in Children - Current Knowledge and Future Perspectives. Semin Pediatr Neurol 2022; 44:100999. [PMID: 36456039 DOI: 10.1016/j.spen.2022.100999] [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: 06/12/2022] [Revised: 09/12/2022] [Accepted: 09/12/2022] [Indexed: 11/18/2022]
Abstract
Stroke in childhood has multiple etiologies, which are mostly distinct from those in adults. Genetic discoveries over the last decade pointed to monogenic disorders as a rare but significant cause of ischemic stroke in children and young adults, including small vessel and arterial ischemic stroke. These discoveries contributed to the understanding that stroke in children may be a sign of an underlying genetic disease. The identification of these diseases requires a detailed medical and family history collection, a careful clinical evaluation for the detection of systemic symptoms and signs, and neuroimaging assessment. Establishing an accurate etiological diagnosis and understanding the genetic risk factors for stroke are essential steps to decipher the underlying mechanisms, optimize the design of tailored prevention strategies, and facilitate the identification of novel therapeutic targets in some cases. Despite the increasing recognition of monogenic causes of stroke, genetic disorders remain understudied and therefore under-recognized in children with stroke. Increased awareness among healthcare providers is essential to facilitate accurate diagnosis in a timely manner. In this review, we provide a summary of the main single-gene disorders which may present as ischemic stroke in childhood and describe their clinical manifestations. We provide a set of practical suggestions for the diagnostic work up of these uncommon causes of stroke, based upon the stroke subtype and imaging characteristics that may suggest a monogenic diagnosis of ischemic stroke in children. Current hurdles in the genetic analyses of children with ischemic stroke as well as future prospectives are discussed.
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Affiliation(s)
- Moran Hausman-Kedem
- Pediatric Neurology Institute, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, Israel; The Sacker Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Rachelle Herring
- Neurology Department, Cook Children's Medical Center, Fort Worth, TX, USA
| | - Marcela D Torres
- Hematology Department, Cook Children's Medical Center, Fort Worth, TX, USA
| | - Jonathan D Santoro
- Division of Neurology, Children's Hospital Los Angeles, Department of Neurology, Keck School of Medicine at the University of Southern California, Los Angeles, CA USA
| | | | - Carolina Vargas
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Giulia Amico
- Laboratory of Human Genetics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Marta Bertamino
- Physical Medicine and Rehabilitation Unit, IRCCS Instituto Giannina Gaslini, Genoa, Italy
| | - Deepti Nagesh
- Division of Neurology, Children's Hospital Los Angeles, Department of Neurology, Keck School of Medicine at the University of Southern California, Los Angeles, CA USA
| | - Jo Tilley
- Departments of Hematology and Neurology, Cook Children's Medical Center, Fort Worth, TX, USA
| | - Allyson Schenk
- Research Data Science and Analytics Department-Stroke and Thrombosis Program, Cook Children's Medical Center, Fort Worth, TX, USA
| | - Shay Ben-Shachar
- Research Data Science and Analytics Department-Stroke and Thrombosis Program, Cook Children's Medical Center, Fort Worth, TX, USA; Clalit Research Institute, Innovation Division, Clalit Health Services, Ramat Gan, Israel
| | - Patricia L Musolino
- Center for Genomic Medicine, Center for Rare Neurological Disorders, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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12
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Penn R, Harrar D, Sun LR. Seizures, Epilepsy, and Electroencephalography Findings in Pediatric Moyamoya Arteriopathy: A Scoping Review. Pediatr Neurol 2022; 142:95-103.e2. [PMID: 36577597 DOI: 10.1016/j.pediatrneurol.2022.11.016] [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: 07/02/2022] [Revised: 10/27/2022] [Accepted: 11/26/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Although seizures are known to occur in children with moyamoya arteriopathy, data regarding characteristics, prevalence, and predictive factors for their development are less established. This study aimed to systematically review literature addressing seizures, epilepsy, and electroencephalography findings in the pediatric moyamoya population. METHODS A scoping review was performed by searching PubMed and Ovid:Embase databases for articles that described seizures, epilepsy, and electroencephalography findings in patients aged 0 to 21 years with moyamoya arteriopathy. RESULTS The search yielded 43 total articles that addressed the following topics in childhood moyamoya: seizures as the presenting symptom, epilepsy characteristics and management, characteristic electroencephalography findings including rebuildup with discussion of proposed mechanisms, and potential predictive clinical factors for the development of seizures preoperatively and the persistence of epilepsy postoperatively. In the reviewed literature, 9% to 19% of children with moyamoya had epilepsy, with over half of the cases lacking radiographic evidence of ischemia. Young age was the most consistent clinical factor associated with both seizures as the presenting symptom and with moyamoya-related epilepsy. Multiple studies report that seizures, electroencephalographic background abnormalities, and the rebuildup phenomenon improve after successful revascularization surgery. CONCLUSIONS This scoping review provides a thorough investigation of the literature available to date on the clinical features of seizures in the pediatric moyamoya population. Literature on this topic is scarce and further studies assessing predictive factors for the development of epilepsy, prognosis as a result of having seizures, and seizure management in this population will help to fill existing knowledge gaps.
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Affiliation(s)
- Rachel Penn
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dana Harrar
- Children's National Hospital, Washington, District of Columbia
| | - Lisa R Sun
- Johns Hopkins University School of Medicine, Baltimore, Maryland.
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13
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Lehman LL, Kaseka ML, Stout J, See AP, Pabst L, Sun LR, Hassanein SA, Waak M, Vossough A, Smith ER, Dlamini N. Pediatric Moyamoya Biomarkers: Narrowing the Knowledge Gap. Semin Pediatr Neurol 2022; 43:101002. [PMID: 36344019 DOI: 10.1016/j.spen.2022.101002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 11/28/2022]
Abstract
Moyamoya is a progressive cerebrovascular disorder that leads to stenosis of the arteries in the distal internal carotid, proximal middle cerebral and proximal anterior cerebral arteries of the circle of Willis. Typically a network of collaterals form to bypass the stenosis and maintain cerebral blood flow. As moyamoya progresses it affects the anterior circulation more commonly than posterior circulation, and cerebral blood flow becomes increasingly reliant on external carotid supply. Children with moyamoya are at increased risk for ischemic symptoms including stroke and transient ischemic attacks (TIA). In addition, cognitive decline may occur over time, even in the absence of clinical stroke. Standard of care for stroke prevention in children with symptomatic moyamoya is revascularization surgery. Treatment of children with asymptomatic moyamoya with revascularization surgery however remains more controversial. Therefore, biomarkers are needed to assist with not only diagnosis but also with determining ischemic risk and identifying best surgical candidates. In this review we will discuss the current knowledge as well as gaps in research in relation to pediatric moyamoya biomarkers including neurologic presentation, cognitive, neuroimaging, genetic and biologic biomarkers of disease severity and ischemic risk.
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Affiliation(s)
- Laura L Lehman
- Department of Neurology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Matsanga Leyila Kaseka
- Department of Neurology, CHU Sainte-Justine, Montreal, Quebec, Canada; Université de Montréal, Montreal, Quebec, Canada
| | - Jeffery Stout
- Harvard Medical School, Boston, MA; Newborn Medicine, Boston Children's Hospital, Boston, MA
| | - Alfred P See
- Harvard Medical School, Boston, MA; Department of Neurosurgery, Boston Children's Hospital, Boston, MA; Department of Radiology, Boston Children's Hospital, Boston, MA
| | - Lisa Pabst
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Columbus, OH
| | - Lisa R Sun
- Division of Pediatric Neurology, Division of Cerebrovascular Neurology, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Sahar A Hassanein
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Michaela Waak
- Department of Paediatric Intensive Care, Queensland Children's Hospital; Centre for Child Health Research, The University of Queensland, Brisbane, Australia
| | - Arastoo Vossough
- Department of Radiology, Children's Hospital of Philadelphia, University of Philadelphia, Philadelphia, Pennsylvania
| | - Edward R Smith
- Harvard Medical School, Boston, MA; Department of Neurosurgery, Boston Children's Hospital, Boston, MA
| | - Nomazulu Dlamini
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada; Faculty of Medicine, University of Toronto, Canada
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14
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Brosius SN, Vossough A, Fisher MJ, Lang SS, Beslow LA, George BJ, Ichord R. Characteristics of Moyamoya Syndrome in Pediatric Patients With Neurofibromatosis Type 1. Pediatr Neurol 2022; 134:85-92. [PMID: 35849956 DOI: 10.1016/j.pediatrneurol.2022.05.013] [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: 02/03/2022] [Revised: 05/09/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Moyamoya syndrome (MMS) is a progressive cerebral arteriopathy with increased incidence in children with neurofibromatosis type 1 (NF1). Despite the potential for significant neurological morbidity including stroke, little is known about the natural history, and no guidelines exist for screening and management of NF1-associated MMS. METHODS We identified 152 literature cases of children aged ≤18 years with NF1-associated MMS. A meta-analysis was performed evaluating clinical and neuroimaging findings and patient outcomes. Data from 19 patients with NF1-associated MMS from our center treated from January 1995 to July 2020 were abstracted via chart review and similarly analyzed for clinical and neuroimaging features. RESULTS Meta-analysis of literature cases showed a median age of MMS diagnosis of 6 years (interquartile range 3 to 10.8 years). Optic pathway gliomas were more common in patients with MMS (42%) compared with historical prevalence. Stroke or transient ischemic attack (TIA) was present at diagnosis in 46%. TIA and stroke were more common in patients with bilateral versus unilateral MMS (62% vs 34%, P = 0.001) and in children aged <4 years versus those aged ≥4 years (61% vs 40%, P = 0.02). Compared with the literature cases, our cohort was more frequently asymptomatic (42% vs 25%) and less likely to present with TIA or stroke (32% vs 46%) at diagnosis. CONCLUSIONS These data suggest there is an aggressive form of MMS in children with NF1 <4 years of age. Therefore, early screening should be considered to facilitate early detection and treatment of cerebral arteriopathy.
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Affiliation(s)
- Stephanie N Brosius
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Arastoo Vossough
- Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Neuroradiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael J Fisher
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Shih-Shan Lang
- Department of Neurosurgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lauren A Beslow
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Neurology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brandon J George
- Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania; Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Rebecca Ichord
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Neurology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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15
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Gatti JR, Sun LR. Nonischemic Presentations of Pediatric Moyamoya Arteriopathy: A Natural History Study. Stroke 2022; 53:e219-e220. [PMID: 35502663 DOI: 10.1161/strokeaha.122.038771] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- John R Gatti
- Johns Hopkins School of Medicine, Baltimore, MD (J.R.G.)
| | - Lisa R Sun
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD (L.R.S.)
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16
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Montaser AS, Lalgudi Srinivasan H, Staffa SJ, Zurakowski D, Slingerland AL, Orbach DB, Hausman-Kedem M, Roth J, Smith ER. Ivy sign: a diagnostic and prognostic biomarker for pediatric moyamoya. J Neurosurg Pediatr 2022; 29:458-466. [PMID: 34972077 DOI: 10.3171/2021.11.peds21384] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 11/04/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ivy sign is a radiographic finding on FLAIR MRI sequences and is associated with slow cortical blood flow in moyamoya. Limited data exist on the utility of the ivy sign as a diagnostic and prognostic tool in pediatric patients, particularly outside of Asian populations. The authors aimed to investigate a modified grading scale with which to characterize the prevalence and extent of the ivy sign in children with moyamoya and evaluate its efficacy as a biomarker in predicting postoperative outcomes, including stroke risk. METHODS Pre- and postoperative clinical and radiographic data of all pediatric patients (21 years of age or younger) who underwent surgery for moyamoya disease or moyamoya syndrome at two major tertiary referral centers in the US and Israel, between July 2009 and August 2019, were retrospectively reviewed. Ivy sign scores were correlated to Suzuki stage, Matsushima grade, and postoperative stroke rate to quantify the diagnostic and prognostic utility of ivy sign. RESULTS A total of 171 hemispheres in 107 patients were included. The median age at the time of surgery was 9 years (range 3 months-21 years). The ivy sign was most frequently encountered in association with Suzuki stage III or IV disease in all vascular territories, including the anterior cerebral artery (53.7%), middle cerebral artery (56.3%), and posterior cerebral artery (47.5%) territories. Following surgical revascularization, 85% of hemispheres with Matsushima grade A demonstrated a concomitant, statistically significant reduction in ivy sign scores (OR 5.3, 95% CI 1.4-20.0; p = 0.013). Postoperatively, revascularized hemispheres that exhibited ivy sign score decreases had significantly lower rates of postoperative stroke (3.4%) compared with hemispheres that demonstrated no reversal of the ivy sign (16.1%) (OR 5.5, 95% CI 1.5-21.0; p = 0.008). CONCLUSIONS This is the largest study to date that focuses on the role of the ivy sign in pediatric moyamoya. These data demonstrate that the ivy sign was present in approximately half the pediatric patients with moyamoya with Suzuki stage III or IV disease, when blood flow was most unstable. The authors found that reversal of the ivy sign provided both radiographic and clinical utility as a prognostic biomarker postoperatively, given the statistically significant association with both better Matsushima grades and a fivefold reduction in postoperative stroke rates. These findings can help inform clinical decision-making, and they have particular value in the pediatric population, as the ability to minimize additional radiographic evaluations and tailor radiographic surveillance is requisite.
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Affiliation(s)
- Alaa S Montaser
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,2Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida
| | | | - Steven J Staffa
- 4Departments of Anesthesiology and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Zurakowski
- 4Departments of Anesthesiology and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anna L Slingerland
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Darren B Orbach
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,5Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Moran Hausman-Kedem
- 6Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; and.,7Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Roth
- 3Department of Neurosurgery, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,7Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Edward R Smith
- 1Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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17
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Wilson JL, Dowling M, Fullerton HJ. Stroke in Children. Stroke 2021; 52:3388-3390. [PMID: 34470487 DOI: 10.1161/strokeaha.121.033967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jenny L Wilson
- Pediatric Neurology, Oregon Health & Science University, Portland (J.L.W.)
| | - Michael Dowling
- Departments of Pediatrics and Neurology, University of Texas Southwestern Medical Center, Dallas (M.D.)
| | - Heather J Fullerton
- Departments of Neurology and Pediatrics, University of California, San Francisco (H.J.F.)
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