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Viteva E, Vasilev P, Vasilev G, Chompalov K. Clinical Case of a 23-Year-Old Patient with Moyamoya Disease and Epilepsy in Bulgaria. Neurol Int 2024; 16:869-879. [PMID: 39195567 DOI: 10.3390/neurolint16040065] [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: 07/01/2024] [Revised: 08/10/2024] [Accepted: 08/14/2024] [Indexed: 08/29/2024] Open
Abstract
Moyamoya disease is a cerebrovascular pathology characterized by progressive stenosis of the internal carotid arteries and their branches, leading to ischemic and/or hemorrhagic disorders of the cerebral circulation, primarily affecting children and young adults. We present a case of a 23-year-old woman with a history of recurrent cerebrovascular accidents since childhood. Despite experiencing focal motor seizures and transient ischemic attacks, her condition remained undiagnosed until 2006, when, at the age of 7, a digital subtraction angiography revealed characteristic bilateral internal carotid artery occlusions. Subsequent diagnostic challenges and treatments preceded a worsening of symptoms in adulthood, including generalized tonic-clonic seizures. Upon presentation to our clinic, the patient exhibited upper motor neuron syndrome and occipital lobe syndrome, consistent with the disease's pathophysiology, neuroimaging, and clinical manifestations. Imaging studies confirmed multiple ischemic lesions throughout the cerebral vasculature. Treatment adjustments were made due to the increased incidence of seizures, and the dose of her anti-seizure medication-divalproex sodium-was increased. This case underscores the diagnostic complexities and challenges in managing moyamoya disease, emphasizing the importance of early recognition and prompt intervention.
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Affiliation(s)
- Ekaterina Viteva
- Department of Neurology, Faculty of Medicine, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria
- Clinic of Neurology, UMHAT "Sv. Georgi", 4000 Plovdiv, Bulgaria
| | - Petar Vasilev
- Department of Neurology, Faculty of Medicine, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria
- Clinic of Neurology, UMHAT "Sv. Georgi", 4000 Plovdiv, Bulgaria
| | - Georgi Vasilev
- Clinic of Neurology, UMHAT "Sv. Georgi", 4000 Plovdiv, Bulgaria
- Medical Faculty, Sofia University St. Kliment Ohridski, 1 Kozyak Str., 1407 Sofia, Bulgaria
| | - Kostadin Chompalov
- Department of Neurology, Faculty of Medicine, Medical University of Plovdiv, 4000 Plovdiv, Bulgaria
- Clinic of Neurology, UMHAT "Sv. Georgi", 4000 Plovdiv, Bulgaria
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Kim SU, Huh J, Kim DS, Huh CW, Sung JH, Lee DH. Analysis of Factors Affecting Good Neovascularization After Indirect Bypass Surgery: A Two-center Retrospective Study. World Neurosurg 2023; 180:e99-e107. [PMID: 37648205 DOI: 10.1016/j.wneu.2023.08.094] [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: 06/28/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE The purpose of this study was to analyze factors affecting good neovascularization after indirect bypass surgery. METHODS From August 2000 to July 2020, postoperative image results and medical records of 132 patients (159 hemispheres) who underwent EDAS of indirect bypass surgery at two institutions were reviewed retrospectively. Based on DSA results, angiogenesis after indirect bypass was divided into "good" or "poor" according to the Matsushima criteria. STA flap length affecting GPN were analyzed in the entire group (n = 159) and a MMD group (n = 134). RESULTS In the entire group, GPN after EDAS was observed in 94 (59.1%) hemispheres. Age, MMD, hypertension, and bone flap size were identified as significant factors in univariate analysis. Also, in the MMD group, 86 (64.2%) hemispheres showed GPN. Hypertension and bone flap size were significant factors in both univariate and multivariate analyses. Cutoff values of bone flap size and GPN were 47.91 cm2 in the entire group and the MMD group. CONCLUSIONS In all patients who received EDAS, good postoperative neovascularization was significant in those with a young age, MMD, without hypertension, and large bone flap size. No hypertension and large bone flap size were meaningful factors in the MMD group. AUROC showed that an appropriate bone flap size was 47.91 cm2. However, a further controlled prospective study is needed.
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Affiliation(s)
- Sang-Uk Kim
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, Seoul, South Korea
| | - Joon Huh
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, Seoul, South Korea
| | - Dal-Soo Kim
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, Seoul, South Korea
| | - Choon-Woong Huh
- Department of Neurosurgery, Myong-Ji St. Mary's Hospital, Seoul, South Korea
| | - Jae Hoon Sung
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Hoon Lee
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Rennert RC, Brandel MG, Budohoski KP, Twitchell S, Fredrickson VL, Grandhi R, Couldwell WT. Influence of Patient and Technical Variables on Combined Direct and Indirect Cerebral Revascularization: Case Series. Oper Neurosurg (Hagerstown) 2023; 24:610-618. [PMID: 36786755 DOI: 10.1227/ons.0000000000000618] [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: 09/07/2022] [Accepted: 11/05/2022] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Cerebral bypass for flow augmentation is an important technique for selected neurosurgical patients, with multiple techniques used (direct, indirect, or combined). OBJECTIVE To assess the impact of patient and technical variables on direct and indirect bypass flow after combined revascularization. METHODS This was a retrospective, single-institution review of patients undergoing direct superficial temporal artery-to-middle cerebral artery bypass with indirect encephaloduro-myosynangiosis for moyamoya disease and steno-occlusive cerebrovascular disease over a 2-year period. We evaluated the effect of baseline patient characteristics, preoperative imaging characteristics, and operative variables on direct and indirect patency grades. RESULTS Twenty-six hemispheres (8 moyamoya disease and 18 steno-occlusive cerebrovascular disease) in 23 patients were treated with combined revascularization. The mean patient age was 53.4 ± 19.1 years. Direct bypass patency was 96%. Over a mean follow-up of 8.3 ± 5.4 months, there were 3 strokes in the treated hemispheres (11.5%). The mean modified Rankin Scale score improved from 1.3 ± 1.1 preoperatively to 0.7 ± 0.8 postoperatively. Preservation of the nondonor superficial temporal artery branch was associated with a lower direct bypass grade ( P < .01), whereas greater mean time to maximum perfusion (Tmax)> 4 and >6 seconds and mismatch volumes were associated with higher direct bypass grades ( P < .05). Tmax >4-second volume inversely predicted indirect bypass patency. CONCLUSION Patient and technical variables may influence the relative contributions of the direct and indirect components of combined revascularizations.
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Affiliation(s)
- Robert C Rennert
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Michael G Brandel
- Department of Neurological Surgery, University of California San Diego, San Diego, California, USA
| | - Karol P Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Spencer Twitchell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Vance L Fredrickson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
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Cheung AHK, Lam AKC, Ho WSW, Tsang CP, Tsang ACO, Lee R, Lui WM, Leung GKK. Surgical Outcome for Moyamoya Disease: Clinical and Perfusion Computed Tomography Correlation. World Neurosurg 2016; 98:81-88. [PMID: 27810451 DOI: 10.1016/j.wneu.2016.10.117] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/23/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To compare surgical outcome both radiologically and clinically after interventions for patients with Moyamoya disease. METHODS This retrospective observational study included 25 patients who were treated surgically for Moyamoya disease in the past 14 years. Clinical outcomes were analyzed by subgroups stratified by age, disease presentation, and surgical intervention. Serial postoperative brain computed tomography perfusion records were analyzed with respect to the cerebral blood flow and cerebrovascular reserve capacity (CVRC) of the middle cerebral artery territory. Changes in both the intervention (n = 23) and nonintervtion (n = 9) cerebral hemispheres were compared. RESULTS All children treated by synangiosis (n = 9), all adults receiving synangiosis (n = 5), and 88.9% of adults undergoing bypass (n = 9) had no neurologic deterioration, with a duration of at least 50.6 months, 85.7 months, and 27.7 months, respectively. Radiologically, CVRC improved more markedly after bypass surgery than synangiosis, particularly 12-24 months postoperatively (51.1% vs. -2.86%). The hemispheres that did not undergo intervention showed similar improvement in cerebral blood flow over time compared with the hemispheres that did undergo intervention, after surgery was performed. CONCLUSIONS Bypass surgery improved CVRC greater than synangiosis, which may correlate with decreased future stroke risks. The decision for bypass is to be balanced with a greater risk of postoperative neurologic deterioration in adults after this procedure. The hemisphere that did not undergo intervention also appeared to benefit from surgery performed on the contralateral brain.
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Affiliation(s)
- Alvin Ho-Kwan Cheung
- Divsion of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong
| | | | - Wai-Shing Wilson Ho
- Divsion of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong
| | - Chun-Pong Tsang
- Divsion of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong
| | - Anderson Chun-On Tsang
- Divsion of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong
| | - Raymond Lee
- Department of Radiology, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Wai-Man Lui
- Divsion of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong
| | - Gilberto Ka-Kit Leung
- Divsion of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong.
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Treatment of moyamoya syndrome associated with systemic lupus erythematosus and hypothyroidism in an adult by encephaloduroarteriosynangiosis: a case report. Case Rep Med 2012; 2012:120867. [PMID: 22966233 PMCID: PMC3432552 DOI: 10.1155/2012/120867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 07/23/2012] [Indexed: 11/17/2022] Open
Abstract
A 54-year-old woman presented to our hospital with progressive motor weakness of the right arm. She had a medical history of systemic lupus erythematosus (SLE) and hypothyroidism. Magnetic resonance imaging indicated a watershed infarction of the left hemisphere. Cervical echogram indicated severe stenosis of the internal carotid artery (ICA) without wall thickening. Cerebral angiography indicated left ICA occlusion, development of unilateral moyamoya vessels, and leptomeningeal anastomosis. Encephaloduroarteriosynangiosis (EDAS) was performed after cerebral (99) (m)Technetium-ethyl-cysteinate-dimer single-photon emission computed tomography indicated a decreased cerebral blood flow, diminished cerebrovascular perfusion reserve. Motor weakness finally disappeared 6 months after surgery. Moyamoya syndrome is a rare complication of both SLE and hypothyroidism, and the surgical indication remains controversial. By evaluating the decreased cerebral perfusion reserve capacity and the existence of leptomeningeal anastomosis, EDAS could be an efficient method for the treatment of moyamoya syndrome associated with SLE and hypothyroidism.
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Dusick JR, Gonzalez NR, Martin NA. Clinical and angiographic outcomes from indirect revascularization surgery for Moyamoya disease in adults and children: a review of 63 procedures. Neurosurgery 2011; 68:34-43; discussion 43. [PMID: 21150753 DOI: 10.1227/neu.0b013e3181fc5ec2] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Several forms of indirect cerebral revascularization have been proposed to promote neovascularity to the ischemic brain. OBJECTIVE To present clinical and angiographic outcomes of indirect revascularization by encephaloduroarteriosynangiosis and burr holes for the treatment of Moyamoya disease in adults and children. METHODS Data from 63 hemispheres treated in 42 patients (average age, 30 years; 33 adults; 30 female patients; median follow-up, 14 months) were reviewed. In hemispheres with preoperative and postoperative (6- to 12-month) angiograms available, superficial temporal artery (STA) and middle meningeal artery (MMA) diameters were measured. Preoperative and postoperative corrected arterial sizes were compared. RESULTS Seven patients (17%) had transient ischemic attacks that resolved within 1 month of surgery. No patients suffered moyamoya-related hemorrhage after treatment. Two patients developed additional symptoms many years after surgery. In 18 hemispheres with preoperative and postoperative angiograms, there was an average postoperative increase in STA and MMA diameters of 51% (P = .003) and 49% (P = .002), respectively. Both children and adults displayed revascularization. Two patients did not demonstrate increased vessel size. STA blush and new branches and MMA blush and new branches were identified in 12, 14, 14, and 16 hemispheres, respectively. Angiographic blush was identified in 59% of frontal and 19% of parietal burr holes (P = .03). Surgical complications included 2 subdural hemorrhages requiring evacuation and 2 new ischemic deficits (1 transient). CONCLUSION Indirect revascularization by encephaloduroarteriosynangiosis and burr holes for moyamoya results in long-term resolution of ischemic and hemorrhagic manifestations in 95% of adults and children. The MMA appears to contribute significantly to the revascularization on follow-up angiograms with increased size and neovascularity comparable to that of the STA. Angiographically, parietal burr holes do not contribute as significantly as frontal burr holes.
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Affiliation(s)
- Joshua R Dusick
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California 90095-7436, USA
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Ishii K, Morishige M, Anan M, Sugita K, Abe E, Kubo T, Fujiki M, Kobayashi H. Superficial temporal artery-to-middle cerebral artery anastomosis with encephalo-duro-myo-synangiosis as a modified operative procedure for moyamoya disease. ACTA NEUROCHIRURGICA. SUPPLEMENT 2010; 107:95-99. [PMID: 19953378 DOI: 10.1007/978-3-211-99373-6_15] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Various types of revascularization surgery have been performed for moyamoya disease. Although the efficacies of these operations are well recognized, the optimal operative procedure remains undecided. In this report, we describe our modified surgical revascularization procedure for moyamoya disease and retrospectively analyze the results of such surgeries on six sides in six adult patients. METHODS Our operative procedure, combining direct and indirect bypasses, is a superficial temporal artery to middle cerebral artery anastomosis with encephalo-duro-myo-synangiosis. The encephalo-duro-myo-synangiosis is an indirect bypass combining the encephalo-duro- and encephalo-myo-synangioses. This operative procedure has been used routinely in adult patients since 2002. RESULTS Perioperative complications were noted in one of the six operations. This complication was transient and no attributive lesions were detected on CT or MRI. Revascularization was seen in cerebral blood flow studies in all patients, and the clinical outcomes were excellent or good. Effective neovascularization through the grafts was observed in all patients in follow-up angiographies. CONCLUSIONS This operative procedure provides needed revascularization and prevents ischemic deficits. This modified procedure is useful for responding to subsequent additional ischemia in the area of the anterior cerebral artery and should be considered one of the optimal procedures for treating moyamoya disease.
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Affiliation(s)
- Keisuke Ishii
- Department of Neurosurgery, Oita University School of Medicine, 1-1 Idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan.
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Affiliation(s)
- R Michael Scott
- Department of Neurosurgery, Children's Hospital Boston, and Harvard Medical School, Boston 02115, USA
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Iguchi Y, Kimura K, Tateishi Y, Shibazaki K, Iwanaga T, Inoue T. Microembolic signals are associated with progression of arterial lesion in Moyamoya disease: A case report. J Neurol Sci 2007; 260:253-5. [PMID: 17475282 DOI: 10.1016/j.jns.2007.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2007] [Revised: 03/30/2007] [Accepted: 04/02/2007] [Indexed: 11/30/2022]
Abstract
Transcranial Doppler ultrasonography (TCD) and magnetic resonance angiography (MRA) confirmed a rapid progression of arterial lesion in Moyamoya disease after the patient gave birth. TCD could initially detect a large number of microembolic signals (MES) at the distal portion of stenotic lesions. After MRA showed the development of stenotic lesions 10 days after first TCD monitoring, MES were absent. MES may be related to the clinical activity of Moyamoya disease.
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Affiliation(s)
- Yasuyuki Iguchi
- Department of Stroke Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki-city, Okayama, 701-0192, Japan.
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Russell SM, Post N, Jafar JJ. Revascularizing the upper basilar circulation with saphenous vein grafts: operative technique and lessons learned. ACTA ACUST UNITED AC 2006; 66:285-97. [PMID: 16935638 DOI: 10.1016/j.surneu.2006.03.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2005] [Accepted: 03/21/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND The purpose of this study was to report our operative technique and lessons learned using saphenous vein conduits to revascularize the rostral basilar circulation (ie, bypass to the posterior cerebral or superior cerebellar arteries). We also review the evolution of this technique for the treatment of vertebrobasilar insufficiency (VBI) and complex posterior fossa aneurysms. METHODS Data were collected retrospectively for 8 consecutive patients undergoing rostral basilar circulation saphenous vein bypass grafts at our institution between 1989 and 2004 for the treatment of VBI or in conjunction with Hunterian ligation of complex posterior circulation aneurysms. The indications for treatment, pre- and postoperative neurologic status, angiographic results, operative complications, and long-term clinical outcomes were analyzed for each patient. RESULTS With clinical and angiographic follow-up ranging from 3 months to 15 years, 7 of 8 bypasses remained patent, 3 of 3 aneurysms remained obliterated, and 4 of 5 patients with VBI experienced resolution of their preoperative symptoms. There were no surgery-related deaths, but 2 patients did experience major neurologic morbidity. The outcomes for the 217 total patients reported in the literature were as follows: 135 excellent (62%), 26 good (12%), 30 poor (14%), and 26 dead (12%). CONCLUSIONS Despite the risk of serious neurologic complications with this procedure, when one considers the natural history of untreated patients, saphenous vein revascularization of the rostral basilar circulation remains an acceptable option. Although surgical technique has varied, patient selection criteria, graft patency, and patient outcomes have been relatively constant over the past 25 years.
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Affiliation(s)
- Stephen M Russell
- Department of Neurosurgery, New York University School of Medicine, New York, NY 10016, USA.
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