Familial moyamoya disease in Caucasians

Specific learning disorder in mathematics and moyamoya disease: A case report

Moyamoya disease (MMD) is a rare neurological condition that causes impaired blood flow to the brain, transient ischemic attacks or strokes, and accompanying cognitive impairments, especially in executive functioning. There is little data on the impact of this rare condition on academic outcomes in late childhood and adolescence. Here, we present the case of Ms. X, a 17-year-old white female diagnosed with MMD, who presented with evidence of a specific learning disorder (SLD) in mathematics. Ms. X was diagnosed with MMD at 6 years old and underwent revascularization surgery. Though she recovered well and progressed adequately in home schooling, she and her mother noticed a decline in memory and academic performance around 16 years old, prompting a neuropsychological evaluation. Cognitive testing revealed low average overall cognitive abilities with impaired planning and organizational skills. While her reading and spelling skills were consistent with her 10th grade academic level, she scored in the 1st percentile on the WRAT-5 Math Computation section, and her mathematical skills were estimated to be at a 2nd grade level. This case adds to the literature by documenting a specific area of academic deficit in an adolescent with MMD. The case highlights that individuals with MMD, especially those with similar executive deficits, may experience selective learning challenges in mathematics. Children with MMD may benefit from specialized academic services and interventions in specific areas of difficulty.

Familial Risk for Moyamoya Disease Among First-Degree Relatives, Based on a Population-Based Aggregation Study in Korea

BACKGROUND AND PURPOSE

Genetic factors have been known to play a role in the etiology of moyamoya disease (MMD); however, population-level studies quantifying familial risk estimates are unavailable. We aimed to quantify familial incidence and risk for MMD in first-degree relatives (FDR) in the general population of Korea.

METHODS

By using the Korean National Health Insurance database which has complete population coverage and confirmed FDR information, we constructed a cohort of 21 940 795 study subjects constituting 12 million families with blood-related FDR and followed them for a familial occurrence of MMD from 2002 to 2017. Incidence risk ratios were calculated as MMD incidence in individuals with affected FDR compared with those without affected FDR, according to age, sex, and family relationships.

RESULTS

Among total study subjects, there were 22 459 individuals with affected FDR, of whom 712 familial cases developed MMD with an incidence of 21.8/10⁴ person-years. Overall, the familial risk for MMD was 132-fold higher in individuals with versus without affected FDR. Familial risk (incidence risk ratio; incidence/10⁴ person-years) increased with the degree of genetic relatedness, being highest in individuals with an affected twin (1254.1; 230.0), followed by a sibling (212.4; 35.6), then mother (87.7; 14.4) and father (62.5; 10.4). Remarkably, there was no disease concordance between spouses. The risks were age-dependent and were particularly high in younger age groups. Familial risks were similar in males and females, and the risk of disease transmission was higher in same-sex parent-offspring and sibling pairs.

CONCLUSIONS

Our study indicates that genetic predisposition is the predominant driver in MMD pathogenesis, with minimal contribution of environmental factors. These results could be utilized to direct future genetic studies and clinical risk counseling.

Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.

Caucasian familial moyamoya syndrome with rare multisystemic malformations

Moyamoya disease is an idiopathic progressive steno-occlusive disorder of the intracranial arteries located at the base of the brain. It is associated with the development of compensatory extensive network of fine collaterals. Moyamoya disease is considered syndromic when certain genetic or acquired disorders such as polycystic kidney disease, neurofibromatosis, or meningitis are also present. Although the genetic contribution in moyamoya is indisputable, its cause and pathogenesis remain under discussion. Herein, we report a rare occurrence of moyamoya syndrome in two European Caucasian siblings in association with unusual multisystemic malformations (polycystic kidney disease in one, and intestinal duplication cyst in the other). The karyotype was normal. No mutation in the RFN213 gene was found, and none of the HLA types linked to moyamoya disease or described in similar familial cases were identified. By describing these multisystemic associations, polycystic kidney disease for the second time, and intestinal malformation for the first time in the literature, our report expands the phenotypic variability of moyamoya syndrome. The coexistence of disparate malformations among close relatives suggests an underlying common genetic background predisposing to structural or physiological abnormalities in different tissues and organs.

Clinical features, prothrombotic risk factors, and long-term follow-up of eight pediatric Moyamoya patients

Background and Purpose

The aim of this study was to elucidate the clinical features, prothrombotic risk factors, and outcome of pediatric Moyamoya patients.

Methods

Patients diagnosed with Moyamoya disease at a tertiary center between January 2000 and December 2006 were enrolled in this study. The clinical presentations, underlying diseases, prothrombotic risk factors, family history of thrombosis, radiological findings, treatment, and outcome of the patients were reviewed retrospectively.

Results

Eight patients with angiographically proven Moyamoya disease were identified, one of whom had neurofibromatosis type I and one had Down syndrome. The age at diagnosis varied between 19 months and 11 years (73.4±41.8 months, mean±SD). The follow-up period after diagnosis was 52.5±14.8 months. In six patients, the initial clinical presentation was hemiparesis. None of the patients had any identifiable prothrombotic factors. Despite medical and surgical treatment, three patients had recurrences and one died. Only two patients recovered without sequelae.

Conclusions

The value of prothrombotic risk factor evaluation appears to be limited in Moyamoya patients; the outcome for pediatric patients remains dismal.

Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

This guideline provides an overview of the evidence on established and emerging risk factors for stroke to provide evidence-based recommendations for the reduction of risk of a first stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council Scientific Statement Oversight Committee and the AHA Manuscript Oversight Committee. The writing group used systematic literature reviews (covering the time since the last review was published in 2006 up to April 2009), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations using standard AHA criteria (Tables 1 and 2). All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive peer review by the Stroke Council leadership and the AHA scientific statements oversight committees before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Schemes for assessing a person's risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic predisposition. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, excessive alcohol consumption, drug abuse, use of oral contraceptives, sleep-disordered breathing, migraine, hyperhomocysteinemia, elevated lipoprotein(a), hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed.

CONCLUSIONS

Extensive evidence identifies a variety of specific factors that increase the risk of a first stroke and that provide strategies for reducing that risk.

Moyamoya disease in which pentazocine treatment caused cerebral infarction

A 37-year-old man was admitted to hospital for treatment of perineum damage and haematoma in the scrotum. His consciousness deteriorated after two intramuscular injections of pentazocine 15 mg. Faint low signals in the left putamin to frontal island and frontal lobe and obnubilation of the corticomedullary junction were apparent on head CT, which led to suspicion of cerebral infarction. MR angiography showed bilateral obstruction of the middle cerebral artery and moyamoya disease was diagnosed. Treatment with edaravone, argatroban and heparin was ineffective for opening the middle cerebral artery and serious after effects occurred. This case suggests that cerebrovascular accident should be suspected in a young patient with disturbance of consciousness but stable breathing and circulation, particularly if previous drug treatment has affected brain circulation. Moyamoya disease should be suspected based on medical or family history. In such a case, MR angiography is required for early diagnosis to facilitate treatment by re-establishment of blood circulation.

"Swimming worms in a bare cistern": a sign for moyamoya disease. A case report

Moyamoya disease is a rare cerebrovascular occlusive disorder most often found among the Japanese. It is angiographically defined as a progressive steno-occlusion of the bilateral internal carotid arteries with characteristic abnormal vascular networks, so-called Moyamoya vessels, at the base of the brain. MRI is the initial investigation of choice and we describe an MRI sign to diagnose Moyamoya disease warranting digital subtraction angiography.

Familial Moyamoya disease in two European children

We present familial Moyamoya disease in two European children and emphasize the importance of familial factors in the pathogenesis of this disease and its appearance not only in Asians but in the Western population as well. The first patient, a Greek female infant, also has coagulation disorders. Her mother, also suffering from Moyamoya and other family members, have similar coagulation disorders (Factor V Leiden, Methylene-tetrahydrofolic reductase and Factor II 20210A mutations). The second patient, a Scottish boy, is unique in that familial Moyamoya affects five members of three consecutive generations of his maternal family. Genetic analysis in the Greek family demonstrated no abnormality on chromosome 3p26, as in other cases. However, the mitochondrial DNA and Y chromosomal genotype showed that affected members had the same sequence of the Mitochondrial 3 portion of D-loop with Japanese patients. These findings suggest that the pathogenesis of Moyamoya may vary across races and ethnic groups.

Caution in Treating Transsphenoidal Encephalocele with Concomitant Moyamoya Disease

A basal encephalocele is a rare congenital malformation involving a cranial bone defect and cystic-like herniation through the defect. Moyamoya is a rare cerebrovascular disease of unclear etiology involving occlusion of the distal internal carotids and formation of collateral vascular networks. Both diseases have been correlated with optic disc anomalies, hypopituitarism, and midfacial defects. We present a case of a 2-year-old boy with a midline facial cleft who underwent surgical correction of a basal encephalocele. His moyamoya disease may have contributed to a vascular complication. There is growing evidence indicating an overlap in disease profiles for these two rare diseases. In addition, molecular evidence indicates elevated levels of fibroblast growth factor and transforming growth factor in both diseases, suggesting common molecular pathways.

Familial occurrence of moyamoya disease: a clinical study

BACKGROUND

We reviewed a consecutive series of moyamoya disease (MMD) in children and studied their familial pedigrees to determine whether they showed specific clinical features or patterns of inheritance, and to investigate any correlation between familial MMD and common Asian diseases.

METHODS

Cases of familial MMD (N=10) were reviewed in the aspect of clinical presentation, such as, symptoms and signs, age of onset, imaging studies including magnetic resonance imaging (MRI), cerebral angiography, and single photon emission computed tomography (SPECT), and operative results including complications, to identify differences between these patients and those with sporadic MMD (N=194). The male to female ratio in those with familial MMD was 4:6 and mean age was 8 years (3-17). All were ischemic cases and five showed cerebral infarction on MRI. As a preliminary genetic study, familial pedigrees were examined. In addition, their familial histories concerning common Asian diseases, such as, hepatic disease, cancers, stroke, coronary heart disease, amyloidosis, and systemic lupus erythematosus, were investigated by telephone survey.

RESULTS AND CONCLUSIONS

The familial MMD cases did not reveal any differences from the other MMD children in terms of clinical findings, imaging data, or surgical results. In our series, five cases (50%) showed MMD between siblings. Familial MMD relations were also observed with cousins, a mother, and an aunt. No specific pattern of genetic inheritance was observed, and no relation was found between the familial occurrence of MMD and common Asian diseases.

Primary Prevention of Ischemic Stroke

Background and Purpose— This guideline provides an overview of the evidence on various established and potential stroke risk factors and provides recommendations for the reduction of stroke risk.

Methods— Writing group members were nominated by the committee chair on the basis of each writer’s previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee. The writers used systematic literature reviews (covering the time period since the last review published in 2001 up to January 2005), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations based on standard American Heart Association criteria. All members of the writing group had numerous opportunities to comment in writing on the recommendations and approved the final version of this document. The guideline underwent extensive peer review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

Results— Schemes for assessing a person’s risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to their potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic factors. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, alcohol abuse, drug abuse, oral contraceptive use, sleep-disordered breathing, migraine headache, hyperhomocysteinemia, elevated lipoprotein(a), elevated lipoprotein-associated phospholipase, hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed.

Conclusion— Extensive evidence is available identifying a variety of specific factors that increase the risk of a first stroke and providing strategies for reducing that risk.

Familial moyamoya disease in a Greek family

Moyamoya disease (M-M) is characterized by progressive obstruction of the supraclinoid portion of internal carotid arteries and the proximal middle, anterior and posterior cerebral arteries, associated with the formation of a characteristic net of collateral vessels in the basal ganglia region. Clinical manifestations in childhood include transient ischaemic attacks, seizures and multiple infarcts. Approximately 7% of M-M cases are familial. We report two affected Greek siblings with typical clinical and neuroradiological findings of M-M. Linkage analysis of the whole family was consistent with linkage to the region 3p24-26, as previously reported in other familial Japanese M-M cases.