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Hayashi T, Hara S, Inaji M, Arai Y, Kiyokawa J, Tanaka Y, Nariai T, Maehara T. Long-term prognosis of 452 moyamoya disease patients with and without revascularization under perfusion-based indications. J Stroke Cerebrovasc Dis 2023; 32:107389. [PMID: 37778161 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107389] [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: 07/06/2023] [Revised: 09/15/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVES To evaluate the long-term outcomes of patients treated under our perfusion-based strategy and assess whether conservative treatment without surgical treatment under our strategy is acceptable. MATERIALS AND METHODS A total of 315 adult and 137 pediatric MMD patients (follow-up period ≥ 3 years from 2001 to 2020) were included. Follow-up events in each patient group (pediatric or adult, surgically treated or conservatively treated) were evaluated and compared to each other using a log-rank test. Risk factors for stroke and nonstroke events were also investigated using a multivariate Cox proportional hazard model. RESULTS In adult-onset patients, the stroke event rates (person-year %) were not different between surgically treated patients and conservatively treated patients (2.00 % vs. 1.59 %, p = 0.558); however, conservative patients showed a higher stroke rate than surgically treated hemispheres (0.34 %; p = 0.025) and hemorrhagic stroke was the major type (18/26, 69.2 %). Hemorrhagic onset was associated with increased risk of stroke in adults (hazard ratio (95 % confidence interval) = 2.43 (1.10-5.36)). In pediatric-onset patients, no conservatively treated patients experienced stroke; however, nonstroke events occurred more frequently than in surgically treated hemispheres (4.86 % vs. 1.71 %, p = 0.020 for transient ischemic attack; and 7.91 % vs. 1.31 %, p < 0.001 for asymptomatic progression on magnetic resonance angiography). CONCLUSIONS In adult patients, conservatively treated patients experienced stroke more frequently, especially hemorrhagic stroke. An additive strategy to prevent stroke in hemorrhagic-onset patients without hemodynamic disturbance seems to be needed. Pediatric patients with mild hemodynamic disturbance can be safely observed without initial surgical intervention, but close follow-up for disease progression is necessary.
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Affiliation(s)
- Toshihiko Hayashi
- Department of Neurosurgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Shoko Hara
- Department of Neurosurgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan.
| | - Motoki Inaji
- Department of Neurosurgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Yukika Arai
- Department of Neurosurgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Juri Kiyokawa
- Department of Neurosurgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Yoji Tanaka
- Department of Neurosurgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Tadashi Nariai
- Department of Neurosurgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Taketoshi Maehara
- Department of Neurosurgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
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Ogasawara K, Akamatsu Y, Chida K, Kobayashi M, Yoshida K, Fujiwara S, Terasaki K, Koji T, Kubo Y. Influence of atherosclerotic burden on adult patients with ischemic moyamoya disease: combined analysis of two prospective cohorts. Neurol Res 2023; 45:1011-1018. [PMID: 37634169 DOI: 10.1080/01616412.2023.2252285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023]
Abstract
OBJECTIVE This study aimed to determine the influence of atherosclerotic risk factors on initial and further cerebrovascular events in adult patients with moyamoya disease (MMD) by combined analysis of two prospective cohorts in which patients received pharmacotherapy alone and were prospectively followed-up for 5 years. METHODS In 71 patients, smoking status, home blood pressure, hemoglobin (Hb)A1c and low-density lipoprotein cholesterol (LDL-chol) were checked at inclusion and at further cerebrovascular event or at the end of 5-year follow-up. When a patient had daily smoking, increased HbA1c, increased LDL-chol, increased systolic blood pressure, or increased diastolic blood pressure, the patient was categorized as showing atherosclerotic burden. Angiographic disease progression was determined using changes on magnetic resonance angiography. RESULTS Eleven patients showed angiographic disease progression and seven of these 11 patients experienced further cerebrovascular events during the follow-up period. The remaining 60 patients did not exhibit either condition. At inclusion, the incidence of atherosclerotic burden was significantly greater in patients without angiographic disease progression (80%) than in those with such progression (45%; p = 0.0249). For patients without angiographic disease progression, values or incidence of almost all variables showed significant interval decreases at the end of 5-year follow-up (p < 0.05). CONCLUSIONS Adult patients with ischemic MMD who do not exhibit angiographic disease progression appear more strongly affected by atherosclerotic burden at the initial onset of cerebrovascular events than those exhibiting angiographic disease progression. A reduction in atherosclerotic burden by medical treatments for the former patients prevents further cerebrovascular events.
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Affiliation(s)
- Kuniaki Ogasawara
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Yosuke Akamatsu
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kohei Chida
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Masakazu Kobayashi
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kenji Yoshida
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Shunrou Fujiwara
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kazunori Terasaki
- Institute for Biomedical Sciences, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Takahiro Koji
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Yoshitaka Kubo
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
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Gonzalez NR, Amin-Hanjani S, Bang OY, Coffey C, Du R, Fierstra J, Fraser JF, Kuroda S, Tietjen GE, Yaghi S. Adult Moyamoya Disease and Syndrome: Current Perspectives and Future Directions: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2023; 54:e465-e479. [PMID: 37609846 DOI: 10.1161/str.0000000000000443] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Adult moyamoya disease and syndrome are rare disorders with significant morbidity and mortality. A writing group of experts was selected to conduct a literature search, summarize the current knowledge on the topic, and provide a road map for future investigation. The document presents an update in the definitions of moyamoya disease and syndrome, modern methods for diagnosis, and updated information on pathophysiology, epidemiology, and both medical and surgical treatment. Despite recent advancements, there are still many unresolved questions about moyamoya disease and syndrome, including lack of unified diagnostic criteria, reliable biomarkers, better understanding of the underlying pathophysiology, and stronger evidence for treatment guidelines. To advance progress in this area, it is crucial to acknowledge the limitations and weaknesses of current studies and explore new approaches, which are outlined in this scientific statement for future research strategies.
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Osteraas ND, Dafer RM. Advances in Management of the Stroke Etiology One-Percenters. Curr Neurol Neurosci Rep 2023; 23:301-325. [PMID: 37247169 PMCID: PMC10225785 DOI: 10.1007/s11910-023-01269-z] [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] [Accepted: 04/13/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE OF REVIEW Uncommon causes of stroke merit specific attention; when clinicians have less common etiologies of stoke in mind, the diagnosis may come more easily. This is key, as optimal management will in many cases differs significantly from "standard" care. RECENT FINDINGS Randomized controlled trials (RCT) on the best medical therapy in the treatment of cervical artery dissection (CeAD) have demonstrated low rates of ischemia with both antiplatelet and vitamin K antagonism. RCT evidence supports the use of anticoagulation with vitamin K antagonism in "high-risk" patients with antiphospholipid antibody syndrome (APLAS), and there is new evidence supporting the utilization of direct oral anticoagulation in malignancy-associated thrombosis. Migraine with aura has been more conclusively linked not only with increased risk of ischemic and hemorrhagic stroke, but also with cardiovascular mortality. Recent literature has surprisingly not provided support the utilization of L-arginine in the treatment of patients with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS); however, there is evidence at this time that support use of enzyme replacement in patients with Fabry disease. Additional triggers for reversible cerebral vasoconstriction syndrome (RCVS) have been identified, such as capsaicin. Imaging of cerebral blood vessel walls utilizing contrast-enhanced MRA is an emerging modality that may ultimately prove to be very useful in the evaluation of patients with uncommon causes of stroke. A plethora of associations between cerebrovascular disease and COVID-19 have been described. Where pertinent, authors provide additional tips and guidance. Less commonly encountered conditions with updates in diagnosis, and management along with clinical tips are reviewed.
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Affiliation(s)
| | - Rima M Dafer
- Rush University Medical Center, Chicago, IL, USA.
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison St., Suite 1118, Chicago, IL, 60612, USA.
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Luo Y, Cao Z, Ye H, Wu S, Sun X. Antiplatelet therapy may improve the prognosis of patients with moyamoya disease: a 12-year retrospective study. J Neurol 2023:10.1007/s00415-023-11702-5. [PMID: 37106259 DOI: 10.1007/s00415-023-11702-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/22/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVES The clinical value of antiplatelet therapy (APT) for moyamoya disease (MMD) remains controversial. Our study attempts to clarify the value of APT in this disease. METHODS We collected basic information, treatment strategies, and prognostic information on patients with MMD from 2010 to 2022 at our center. The data were divided into two groups, depending on whether APT was used or not, and compared by Pearson Chi-Square, Fisher's exact test, or Wilcoxon rank-sum test. We used propensity scores or inverse probability of treatment weighting to balance the covariates. Following this, we performed a meta-analysis of APT use in MMD. RESULTS 177 patients were enrolled, with a median follow-up of 41.1 months. APT did not affect the prognosis of patients with perioperative MMD, ischemic MMD, or asymptomatic MMD (P > 0.05), without increasing cerebral hemorrhagic risk. In contrast, APT was found to reduce mortality among patients with hemorrhagic MMD (P = 0.019), without affecting functional status, increasing stroke risk, or causing intracerebral hemorrhage (P > 0.05). But the small group cannot show the effect of APT. Our meta-analysis included nine articles involving 28,925 patients with MMD. It showed that APT could reduce stroke risk (odds ratio, OR = 0.57, 95% CI 0.49 to 0.65) and the Modified Rankin Scale (mRS) (weighted mean difference, WMD = - 0.07, 95% CI 0.14-0.00) during follow-up. The cohort study has limited weight (1.97% and 19.29%) in the meta-analysis. CONCLUSION Although the limited number of included documents, APT could be beneficial to the prognosis of MMD.
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Affiliation(s)
- Yuting Luo
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, No.58 Zhongshan Road 2, Guangzhou, 510080, China
| | - Zhixin Cao
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, No.58 Zhongshan Road 2, Guangzhou, 510080, China
| | - Heng Ye
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, No.58 Zhongshan Road 2, Guangzhou, 510080, China
| | - Shaoqing Wu
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
| | - Xunsha Sun
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, No.58 Zhongshan Road 2, Guangzhou, 510080, China.
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Ogasawara K, Takahashi T, Igarashi S, Yabuki M, Omori D, Akamatsu Y, Chida K, Kobayashi M, Fujiwara S, Terasaki K. Effect of the addition of 123I-iomazenil single-photon emission computed tomography to brain perfusion single-photon emission computed tomography on the detection accuracy of misery perfusion in adult patients with ischemic moyamoya disease. Ann Nucl Med 2023; 37:280-288. [PMID: 36805493 DOI: 10.1007/s12149-023-01825-0] [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: 12/05/2022] [Accepted: 02/06/2023] [Indexed: 02/21/2023]
Abstract
OBJECTIVE The present prospective study aimed to determine whether the addition of 123I-iomazenil (IMZ) single-photon emission computed tomography (SPECT) to brain perfusion SPECT could improve the detection accuracy of misery perfusion on positron emission tomography (PET) in adult patients with ischemic moyamoya disease (MMD). METHODS Oxygen extraction fraction (OEF) and brain perfusion were assessed using 15O gas PET and N-isopropyl-p-[123I]-iodoamphetamine (IMP) SPECT, respectively, in 137 patients. IMZ SPECT was also performed. Regions of interest (ROIs) were automatically placed in the five middle cerebral artery (MCA) territories ipsilateral to the symptomatic cerebral hemisphere and in the contralateral posterior cerebral artery territory using a three-dimensional stereotaxic ROI template. The radioactive count of the MCA ROI to the contralateral posterior cerebral artery ROI was calculated on IMP SPECT (relative SPECT-IMP uptake) and IMZ SPECT (relative SPECT-IMZ uptake). The relative SPECT-IMZ uptake to the relative SPECT-IMP uptake was also calculated (relative SPECT-IMZ/IMP uptake). Of the five MCA ROIs in the symptomatic cerebral hemisphere in each patient, the ROI with the highest PET-OEF value (one ROI per patient) was selected for analysis. RESULTS Significant correlations were observed between the PET-OEF and relative SPECT-IMP uptake (correlation coefficient, - 0.683) and relative SPECT-IMZ/IMP uptake (correlation coefficient, 0.875). The area under the receiver operating characteristic curve for detecting misery perfusion (PET-OEF > 51.3%) was significantly greater for the relative SPECT-IMZ/IMP uptake than for the relative SPECT-IMP uptake (difference between areas, 0.080; p = 0.0004). The sensitivity, specificity, and positive- and negative-predictive values for the relative SPECT-IMZ/IMP uptake for detecting misery perfusion were 100%, 92%, 81%, and 100%, respectively. The specificity and positive-predictive value were significantly greater for the relative SPECT-IMZ/IMP uptake than for the relative SPECT-IMP uptake. CONCLUSIONS The addition of IMZ SPECT to brain perfusion SPECT improves the detection accuracy of misery perfusion on PET in adult patients with ischemic MMD.
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Affiliation(s)
- Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Iwate, Japan. .,Institute for Biomedical Sciences, Iwate Medical University, Iwate, Japan.
| | - Tatsuhiko Takahashi
- Department of Neurosurgery, Iwate Medical University, Iwate, Japan.,Institute for Biomedical Sciences, Iwate Medical University, Iwate, Japan
| | - Suguru Igarashi
- Department of Neurosurgery, Iwate Medical University, Iwate, Japan.,Institute for Biomedical Sciences, Iwate Medical University, Iwate, Japan
| | - Masahiro Yabuki
- Department of Neurosurgery, Iwate Medical University, Iwate, Japan.,Institute for Biomedical Sciences, Iwate Medical University, Iwate, Japan
| | - Daisuke Omori
- Department of Neurosurgery, Iwate Medical University, Iwate, Japan.,Institute for Biomedical Sciences, Iwate Medical University, Iwate, Japan
| | - Yosuke Akamatsu
- Department of Neurosurgery, Iwate Medical University, Iwate, Japan
| | - Kohei Chida
- Department of Neurosurgery, Iwate Medical University, Iwate, Japan.,Institute for Biomedical Sciences, Iwate Medical University, Iwate, Japan
| | - Masakazu Kobayashi
- Department of Neurosurgery, Iwate Medical University, Iwate, Japan.,Institute for Biomedical Sciences, Iwate Medical University, Iwate, Japan
| | - Shunrou Fujiwara
- Department of Neurosurgery, Iwate Medical University, Iwate, Japan
| | - Kazunori Terasaki
- Institute for Biomedical Sciences, Iwate Medical University, Iwate, Japan
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Bersano A, Khan N, Fuentes B, Acerbi F, Canavero I, Tournier-Lasserve E, Vajcoczy P, Zedde ML, Hussain S, Lémeret S, Kraemer M, Herve D. European Stroke Organisation (ESO) Guidelines on Moyamoya angiopathy: Endorsed by Vascular European Reference Network (VASCERN). Eur Stroke J 2023; 8:55-84. [PMID: 37021176 PMCID: PMC10069176 DOI: 10.1177/23969873221144089] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/16/2022] [Indexed: 02/05/2023] Open
Abstract
The European Stroke Organisation (ESO) guidelines on Moyamoya Angiopathy (MMA), developed according to ESO standard operating procedure and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, were compiled to assist clinicians in managing patients with MMA in their decision making. A working group involving neurologists, neurosurgeons, a geneticist and methodologists identified nine relevant clinical questions, performed systematic literature reviews and, whenever possible, meta-analyses. Quality assessment of the available evidence was made with specific recommendations. In the absence of sufficient evidence to provide recommendations, Expert Consensus Statements were formulated. Based on low quality evidence from one RCT, we recommend direct bypass surgery in adult patients with haemorrhagic presentation. For ischaemic adult patients and children, we suggest revascularization surgery using direct or combined technique rather than indirect, in the presence of haemodynamic impairment and with an interval of 6–12 weeks between the last cerebrovascular event and surgery. In the absence of robust trial, an Expert Consensus was reached recommending long-term antiplatelet therapy in non-haemorrhagic MMA, as it may reduce risk of embolic stroke. We also agreed on the utility of performing pre- and post- operative haemodynamic and posterior cerebral artery assessment. There were insufficient data to recommend systematic variant screening of RNF213 p.R4810K. Additionally, we suggest that long-term MMA neuroimaging follow up may guide therapeutic decision making by assessing the disease progression. We believe that this guideline, which is the first comprehensive European guideline on MMA management using GRADE methods will assist clinicians to choose the most effective management strategy for MMA.
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Affiliation(s)
- Anna Bersano
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Nadia Khan
- Moyamoya Center, University Children’s Hospital Zurich, Switzerland
- Moyamoya Center for adults, Department of Neurosurgery, University Tubingen, Germany
| | - Blanca Fuentes
- Department of Neurology and Stroke Center, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | - Francesco Acerbi
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Isabella Canavero
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Peter Vajcoczy
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Germany
| | - Maria Luisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale – IRCCS di Reggio Emilia, Italy
| | | | | | - Markus Kraemer
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Dominique Herve
- CNVT-CERVCO et département de Neurologie, Hôpital Lariboisière, APHP Nord, Paris, France
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Yabuki M, Kubo Y, Kitakami K, Oomori D, Fujiwara S, Yoshida K, Kobayashi M, Ogasawara K. Development of cerebral microbleeds and its impact on cognitive function in adult patients receiving medical management alone for ischemic moyamoya disease: supplementary analysis of a 5-year prospective cohort. Neurol Res 2022; 44:1104-1112. [PMID: 35975947 DOI: 10.1080/01616412.2022.2112375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE De novo cerebral microbleeds (CMBs) on T2*-weighted magnetic resonance imaging (MRI) develop over time in adult moyamoya disease (MMD) and are generally associated with a decline in global cognitive function. The present supplementary analysis of a 5-year prospective cohort aimed to elucidate the incidence of an interval increase in CMBs in adult patients receiving medical management alone for ischemic MMD and its impact on cognitive function. METHODS Sixty-four patients without misery perfusion in the symptomatic cerebral hemispheres at inclusion who did not experience any further ischemic symptoms or new hemorrhagic events during a 5-year follow-up period underwent T2*-weighted MRI and five kinds of neuropsychologic tests at inclusion and the end of the 5-year follow-up. RESULTS When T2*-weighted MRI was compared between inclusion and the end of the 5-year follow-up, 10 patients (15%) had an interval increase in CMBs in the symptomatic cerebral hemisphere at inclusion. The scores from two kinds of neuropsychologic tests significantly deteriorated at the end of the 5-year follow-up compared with those at inclusion in patients with an interval increase in CMBs, whereas the scores of four kinds of neuropsychologic tests significantly improved at the end of the 5-year follow-up compared with those at inclusion in patients without interval increases in CMBs, asymptomatic ischemic lesions, or angiographic disease progression. CONCLUSIONS The incidence of an interval increase in CMBs was 15% per 5 years in adult patients receiving medical management alone for ischemic MMD, and this increase was associated with a decline in cognitive decline.
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Affiliation(s)
- Masahiro Yabuki
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Yoshitaka Kubo
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kei Kitakami
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Daisuke Oomori
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Shunrou Fujiwara
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kenji Yoshida
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Masakazu Kobayashi
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
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Ogasawara K, Uchida S, Akamatsu Y, Chida K, Kobayashi M, Yoshida K, Fujiwara S, Terasaki K, Kubo Y. Outcomes of medical management alone for adult patients with cerebral misery perfusion due to ischemic moyamoya disease. J Stroke Cerebrovasc Dis 2022; 31:106588. [PMID: 35671656 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/18/2022] [Accepted: 05/29/2022] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES Although revascularization surgery is recommended for adult patients with moyamoya disease (MMD) who present with ischemic symptoms due to hemodynamic compromise, the clinical course of such patients who are treated with medical management alone remains unclear. Here, we report outcomes of adult patients with cerebral misery perfusion due to ischemic MMD who received medical management alone. MATERIALS AND METHODS We prospectively followed up patients who showed misery perfusion in the symptomatic cerebral hemisphere on 15O gas positron emission tomography (PET) and received strict medical management alone after refusing revascularization surgery. RESULTS Of 57 patients who showed symptomatic misery perfusion on 15O gas PET, three (5%) were included into the present study. Two of these patients suffered further ischemic events at 7 and 8 months after inclusion, after which, their modified Rankin disability scale scores deteriorated. In the remaining patient, fatal intracerebral hemorrhage developed at 10 months after inclusion. CONCLUSIONS These findings suggest that receiving medical management alone is associated with considerably poor outcomes for adult patients with cerebral misery perfusion due to ischemic MMD.
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Affiliation(s)
| | - Shun Uchida
- Department of Neurosurgery, Iwate Medical University, Japan.
| | - Yosuke Akamatsu
- Department of Neurosurgery, Iwate Medical University, Japan.
| | - Kohei Chida
- Department of Neurosurgery, Iwate Medical University, Japan.
| | | | - Kenji Yoshida
- Department of Neurosurgery, Iwate Medical University, Japan.
| | | | | | - Yoshitaka Kubo
- Department of Neurosurgery, Iwate Medical University, Japan.
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Ihara M, Yamamoto Y, Hattori Y, Liu W, Kobayashi H, Ishiyama H, Yoshimoto T, Miyawaki S, Clausen T, Bang OY, Steinberg GK, Tournier-Lasserve E, Koizumi A. Moyamoya disease: diagnosis and interventions. Lancet Neurol 2022; 21:747-758. [DOI: 10.1016/s1474-4422(22)00165-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 03/28/2022] [Accepted: 04/01/2022] [Indexed: 12/14/2022]
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Oomori D, Kubo Y, Yabuki M, Kitakami K, Fujiwara S, Yoshida K, Kobayashi M, Terasaki K, Ogasawara K. Angiographic disease progression in medically treated adult patients with ischemic moyamoya disease without cerebral misery perfusion: supplementary analysis of a 5-year prospective cohort. Neurosurg Rev 2021; 45:1553-1561. [PMID: 34689243 DOI: 10.1007/s10143-021-01677-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/02/2021] [Accepted: 10/20/2021] [Indexed: 10/20/2022]
Abstract
Angiographic disease progression reportedly develops in adult moyamoya disease (MMD). However, more than half of patients analyzed underwent revascularization surgery. The present supplementary analysis of a 5-year prospective cohort with follow-up using magnetic resonance angiography (MRA) and cerebral blood flow (CBF) measurements was to elucidate the incidence and clinical features of angiographic disease progression in adult patients receiving medical management alone for ischemic MMD. Sixty-eight patients without misery perfusion in the symptomatic cerebral hemispheres underwent MRA and CBF measurement using brain perfusion single-photon emission computed tomography at inclusion and at the end of the 5-year follow-up. When neurological symptoms recurred or newly developed during the 5-year follow-up period, additional MRA and CBF measurements were also performed at that time. All four patients with further ischemic events during the 5-year follow-up period exhibited angiographic disease progression on MRA at such events. Of the remaining 64 patients without further events during the 5-year follow-up period, four exhibited angiographic disease progression on MRA at the end of the 5-year follow-up. CBF was significantly lower at the time of further ischemic events or at the end of the 5-year follow-up than at inclusion in eight patients with angiographic disease progression (p = 0.0117). The incidence of angiographic disease progression was 12% for 5 years in medically treated adult patients with ischemic MMD without cerebral misery perfusion. Patients with further ischemic events always exhibited angiographic disease progression. Cerebral perfusion was reduced in patients with angiographic disease progression even when further ischemic events did not occur.
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Affiliation(s)
- Daisuke Oomori
- Department of Neurosurgery, Iwate Medical University, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3695, Japan
| | - Yoshitaka Kubo
- Department of Neurosurgery, Iwate Medical University, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3695, Japan
| | - Masahiro Yabuki
- Department of Neurosurgery, Iwate Medical University, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3695, Japan
| | - Kei Kitakami
- Department of Neurosurgery, Iwate Medical University, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3695, Japan
| | - Shunrou Fujiwara
- Department of Neurosurgery, Iwate Medical University, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3695, Japan
| | - Kenji Yoshida
- Department of Neurosurgery, Iwate Medical University, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3695, Japan
| | - Masakazu Kobayashi
- Department of Neurosurgery, Iwate Medical University, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3695, Japan.,Institute for Biomedical Sciences, School of Medicine, Iwate Medical University, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3695, Japan
| | - Kazunori Terasaki
- Institute for Biomedical Sciences, School of Medicine, Iwate Medical University, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3695, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3695, Japan. .,Institute for Biomedical Sciences, School of Medicine, Iwate Medical University, 2-1-1 Idai-dori, Yahaba, Iwate, 028-3695, Japan.
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