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Cicutti SE, Gromadzyn GP, Buompadre MC, Rugilo C, Requejo F, Gonzalez Dutra ML, Gonzalez Ramos JD, Jaimovich SG. Experience of an interdisciplinary management for pediatric Moyamoya disease: application of a novel Hemispheric Surgical Score. Childs Nerv Syst 2024:10.1007/s00381-024-06602-6. [PMID: 39259297 DOI: 10.1007/s00381-024-06602-6] [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: 07/20/2024] [Accepted: 08/28/2024] [Indexed: 09/13/2024]
Abstract
PURPOSE The primary purpose of this study was to develop and implement a novel Hemispheric Surgical Score to guide the treatment of pediatric patients with Moyamoya disease (MMD). Additionally, we aimed to describe a comprehensive flowchart for the evaluation, treatment, and follow-up of these patients and to share our experience with the interdisciplinary management of a large pediatric cohort at a referral pediatric hospital. METHODS We conducted a retrospective observational study using medical records of patients diagnosed with MMD at the Pediatric Hospital "Prof. Dr. Juan P. Garrahan" in Buenos Aires, Argentina, from July 2013 to July 2023. From July 2016 onward, data were analyzed prospectively following the implementation of the Hemispheric Surgical Score and the flowchart. Evaluations included clinical, MRI, and angiographic criteria, and patients were managed by an interdisciplinary team. Demographic, clinical, and neuroimaging data were collected and analyzed. RESULTS Eighty hemispheres from 40 patients were analyzed, with cerebral revascularization performed on 72 hemispheres from 37 patients. The Hemispheric Surgical Score and flowchart standardized treatment decisions, and reduced the need for invasive studies like angiographies for follow-up. The majority of patients (79.1%) had favorable outcomes, with complete disease progression arrest and no worsening of imaging nor clinical scores during a median follow-up of 35.8 months. CONCLUSION The Hemispheric Surgical Score and the comprehensive flowchart have improved the management of MMD in pediatric patients by standardizing treatment and reducing unnecessary invasive procedures. This interdisciplinary approach has led to better patient outcomes, highlighting the need for further validation in larger studies and comparisons of different revascularization techniques through randomized clinical trials.
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Affiliation(s)
- Santiago Ezequiel Cicutti
- Department of Pediatric Neurosurgery, Pediatric Hospital "Prof. Dr. Juan P. Garrahan", Pichincha 1890, C1245, Buenos Aires, Argentina.
| | - Guido Patricio Gromadzyn
- Department of Pediatric Neurosurgery, Pediatric Hospital "Prof. Dr. Juan P. Garrahan", Pichincha 1890, C1245, Buenos Aires, Argentina
| | - María Celeste Buompadre
- Department of Pediatric Neurology, Pediatric Hospital "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina
| | - Carlos Rugilo
- Department of Magnetic Resonance, Pediatric Hospital "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina
| | - Flavio Requejo
- Department of Neuroradiology, Pediatric Hospital "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina
| | | | - Javier Danilo Gonzalez Ramos
- Department of Pediatric Neurosurgery, Pediatric Hospital "Prof. Dr. Juan P. Garrahan", Pichincha 1890, C1245, Buenos Aires, Argentina
| | - Sebastián Gastón Jaimovich
- Department of Pediatric Neurosurgery, Pediatric Hospital "Prof. Dr. Juan P. Garrahan", Pichincha 1890, C1245, Buenos Aires, Argentina
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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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Lim YC, Lee E, Song J. Outcomes of Bypass Surgery in Adult Moyamoya Disease by Onset Type. JAMA Netw Open 2024; 7:e2415102. [PMID: 38842810 PMCID: PMC11157360 DOI: 10.1001/jamanetworkopen.2024.15102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/04/2024] [Indexed: 06/07/2024] Open
Abstract
Importance Moyamoya disease (MMD) is a rare chronic cerebrovascular disease, and the outcomes of bypass management in adult patients remain controversial. Objective To categorize adult MMD based on asymptomatic, ischemic, and hemorrhagic onset and compare the outcomes (death, hemorrhagic stroke [HS], and ischemic stroke [IS]) of bypass surgery (direct or indirect) with those of conservative management. Design, Setting, and Participants This retrospective, nationwide, population-based longitudinal cohort study used Korean National Health Insurance Research data to identify adults (aged ≥15 years) with MMD who were diagnosed between January 1, 2008, and December 31, 2020, and followed up until December 31, 2021 (median follow-up, 5.74 [IQR, 2.95-9.42] years). A total of 19 700 participants (3194 with hemorrhagic, 517 with ischemic, and 15 989 with asymptomatic MMD) were included. Data were analyzed from January 2 to April 1, 2023. Exposures Bypass surgery and conservative management. Main Outcomes and Measures Death constituted the primary outcome; secondary outcomes consisted of HS or IS. Kaplan-Meier survival curve and Cox proportional hazards regression analysis were applied. The propensity score-matching and stratified analyses were performed to control covariate effects. Results A total of 19 700 patients (mean [SD] age, 45.43 [14.98] years; 12 766 [64.8%] female) were included. Compared with conservative management, bypass was associated with a reduced risk of death (adjusted hazard ratio [AHR], 0.50 [95% CI, 0.41-0.61]; P < .001) and HS (AHR, 0.36 [0.30-0.40]; P < .001) in hemorrhagic MMD; reduced risk of IS (AHR, 0.55 [95% CI, 0.37-0.81]; P = .002) in ischemic MMD; and reduced risk of death (AHR, 0.74 [95% CI, 0.66-0.84]; P < .001) in asymptomatic MMD. However, bypass was associated with an increased risk of HS (AHR, 1.76 [95% CI, 1.56-2.00]; P < .001) in asymptomatic MMD. Both direct and indirect bypass demonstrated similar effects in hemorrhagic and asymptomatic MMD, except only direct bypass was associated with a reduced risk of IS (AHR, 0.52 [95% CI, 0.33- 0.83]; P = .01) in ischemic MMD. After stratification, bypass was associated with a reduced risk of death in patients younger than 55 years with ischemic (AHR, 0.34 [95% CI, 0.13- 0.88]; P = .03) and asymptomatic (AHR, 0.69 [95% CI, 0.60-0.79]; P < .001) MMD, but an increased risk of HS in patients 55 years or older with ischemic MMD (AHR, 2.13 [95% CI, 1.1-4.16]; P = .03). Conclusions and Relevance The findings of this cohort study of bypass outcomes for patients with MMD emphasize the importance of tailoring management strategies in adult patients based on onset types.
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Affiliation(s)
- Yong Cheol Lim
- Department of Neurosurgery, Ajou University School of Medicine, Ajou University Hospital, Suwon, Republic of Korea
| | - Eunyoung Lee
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Jihye Song
- Department of Neurosurgery, Ajou University School of Medicine, Ajou University Hospital, Suwon, Republic of Korea
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Zedde M, Grisendi I, Assenza F, Napoli M, Moratti C, Pavone C, Bonacini L, Di Cecco G, D’Aniello S, Stoenoiu MS, Persu A, Valzania F, Pascarella R. RNF213 Polymorphisms in Intracranial Artery Dissection. Genes (Basel) 2024; 15:725. [PMID: 38927660 PMCID: PMC11203323 DOI: 10.3390/genes15060725] [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: 04/26/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
The ring finger protein 213 gene (RNF213) is involved in several vascular diseases, both intracranial and systemic ones. Some variants are common in the Asian population and are reported as a risk factor for moyamoya disease, intracranial stenosis and intracranial aneurysms. Among intracranial vascular diseases, both moyamoya disease and intracranial artery dissection are more prevalent in the Asian population. We performed a systematic review of the literature, aiming to assess the rate of RNF213 variants in patients with spontaneous intracranial dissections. Four papers were identified, providing data on 53 patients with intracranial artery dissection. The rate of RNF213 variants is 10/53 (18.9%) and it increases to 10/29 (34.5%), excluding patients with vertebral artery dissection. All patients had the RNF213 p.Arg4810Lys variant. RNF213 variants seems to be involved in intracranial dissections in Asian cohorts. The small number of patients, the inclusion of only patients of Asian descent and the small but non-negligible coexistence with moyamoya disease familiarity might be limiting factors, requiring further studies to confirm these preliminary findings and the embryological interpretation.
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Affiliation(s)
- Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (I.G.); (F.A.); (F.V.)
| | - Ilaria Grisendi
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (I.G.); (F.A.); (F.V.)
| | - Federica Assenza
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (I.G.); (F.A.); (F.V.)
| | - Manuela Napoli
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (C.M.); (C.P.); (L.B.); (G.D.C.); (S.D.); (R.P.)
| | - Claudio Moratti
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (C.M.); (C.P.); (L.B.); (G.D.C.); (S.D.); (R.P.)
| | - Claudio Pavone
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (C.M.); (C.P.); (L.B.); (G.D.C.); (S.D.); (R.P.)
| | - Lara Bonacini
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (C.M.); (C.P.); (L.B.); (G.D.C.); (S.D.); (R.P.)
| | - Giovanna Di Cecco
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (C.M.); (C.P.); (L.B.); (G.D.C.); (S.D.); (R.P.)
| | - Serena D’Aniello
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (C.M.); (C.P.); (L.B.); (G.D.C.); (S.D.); (R.P.)
| | - Maria Simona Stoenoiu
- Department of Internal Medicine, Rheumatology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 1200 Brussels, Belgium;
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 1200 Brussels, Belgium;
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Franco Valzania
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (I.G.); (F.A.); (F.V.)
| | - Rosario Pascarella
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy; (M.N.); (C.M.); (C.P.); (L.B.); (G.D.C.); (S.D.); (R.P.)
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Joshi SB, Sharma R, Manjunath N, Dhanakshirur RR, Ganesh VL, Jain S, Raheja A, Devrajan LJ, Nehra A, Suri A. Functional and Neuropsychological Outcome After Surgical Treatment of Moyamoya Disease. World Neurosurg 2024; 185:e397-e406. [PMID: 38364899 DOI: 10.1016/j.wneu.2024.02.038] [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: 12/29/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Moyamoya disease (MMD) is a rare cerebrovascular disease characterized by progressive stenosis of the supraclinoid internal carotid artery. As a result of chronically decreased brain perfusion, eloquent areas of the brain become hypoperfused, leading to cognitive changes in patients. Repeated infarcts and bleeds produce clinically apparent neurologic deficits. OBJECTIVES 1) To study the functional and neuropsychological outcome in MMD after revascularization surgery. 2) To find postrevascularization correlation between functional and neuropsychological improvement and radiologic improvement. METHODS A single-center prospective and analytic study was carried out including 21 patients with MMD during the study period from March 2021 to December 2022. Patients were evaluated and compared before and after revascularization for functional, neuropsychological, and radiologic status. RESULTS Postoperative functional outcome in terms of modified Rankin Scale score showed improvement in 33.33% of cases (P = 0.0769). An overall improving trend was observed in different neuropsychological domains in both adult and pediatric age groups. However, the trend of neuropsychological improvement was better in adults compared with pediatric patients. Radiologic outcome in the form of the Angiographic Outcome Score (AOS) significantly improved after revascularization (P = 0.0001). There was a trend toward improvement in magnetic resonance imaging (MRI) perfusion in the middle cerebral artery and anterior cerebral artery territories, 4.7% (P = 0.075) and 9.33% (P = 0.058) respectively, compared with preoperative MRI perfusion. CONCLUSIONS After revascularization, significant improvement occurred in functional and neuropsychological status. This result was also shown radiologically as evidenced by improvement in MRI perfusion and cerebral angiography.
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Affiliation(s)
- Siddharth B Joshi
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Rajeev Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Niveditha Manjunath
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Rohan Raju Dhanakshirur
- Amarnath and Shashi Khosla School of Information Technology, Indian Institute of Technology, New Delhi, India
| | - V L Ganesh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Savyasachi Jain
- Department of Neuroimaging and Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Amol Raheja
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Leve Joseph Devrajan
- Department of Neuroimaging and Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ashima Nehra
- Department of Neuropsychology, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
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Tigchelaar SS, Wang AR, Vaca SD, Li Y, Steinberg GK. Incidence and Outcomes of Posterior Circulation Involvement in Moyamoya Disease. Stroke 2024; 55:1254-1260. [PMID: 38567531 DOI: 10.1161/strokeaha.123.044693] [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: 08/31/2023] [Accepted: 02/29/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Moyamoya disease (MMD) is a progressive, occlusive disease of the internal carotid arteries and their proximal branches, with the subsequent development of an abnormal vascular network that is rupture-prone. Steno-occlusive changes in the posterior cerebral arteries (PCAs) may contribute to worsened outcomes in patients with MMD; however, there is little information on the incidence and natural history of posterior circulation MMD (PCMMD). We describe clinical PCMMD characteristics in a large cohort of patients with MMD. METHODS We retrospectively reviewed patients with MMD treated between 1991 and 2019 at a large academic medical center. Demographics, perioperative outcomes, and radiological phenotypes were recorded for 770 patients. PCA disease was graded as either 0 (no disease), 1 (mild), 2 (moderate), or 3 (severe or occluded) based on cerebral angiography. Patients with angiographically confirmed MMD diagnosis with at least 6 months follow-up and completion of revascularization surgery were included; patients with intracranial atherosclerosis, intracranial dissection, vasculitis, and undefined inflammatory processes were excluded. The presence of stenosis/occlusion was graded radiographically to assess for disease progression and the prevalence of risk factors related to reduced progression-free survival. RESULTS In all, 686 patients met the inclusion criteria, with PCA disease identified in 282 (41.1%) patients. Of those 282 patients with PCMMD, disease severity ranged from 99 (35.1%) with mild, 72 (25.5%) with moderate, and 111 (39.4%) with severe. The total number of postoperative complications was significantly associated with PCMMD severity (P=0.0067). Additionally, PCMMD severity correlated with worse postoperative modified Rankin Scale scores (P<0.0001). At a mean follow-up of 6.0±3.9 (range, 0.1-25.0) years, a total of 60 (12.6%) patients showed new/worsening PCMMD. The overall postoperative, progression-free survival in patients with PCMMD was 95.4% at 1 year, 82.4% at 3 years, 68.8% at 5 years, and 28.3% at 10 years, with prognostic factors for progression including preoperative PCMMD status, history of tobacco use, and hypertension (P<0.0001, P<0.001, and P<0.0001, respectively). CONCLUSIONS PCA disease involvement in MMD is associated with higher rates of ischemic perioperative complications and worsened functional outcomes, likely due to reduced collateral flow. Ten-year progression of PCA disease is highly likely and should be monitored throughout follow-up; future studies will assess the impact of PCA disease progression on long-term outcomes.
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Affiliation(s)
- Seth S Tigchelaar
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Allan R Wang
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Silvia D Vaca
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Yiping Li
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Gary K Steinberg
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
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Shih-Yüng Wang S, Hauser TK, Haas P, Tellermann J, Hurth H, Ernemann U, Tatagiba M, Bender B, Khan N, Roder C. Intensity Score of Vessel Wall Contrast Enhancement in MRI Allows Prediction of Disease Progression in Moyamoya Angiopathy. Neurosurgery 2024:00006123-990000000-01151. [PMID: 38687044 DOI: 10.1227/neu.0000000000002965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 03/07/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The underlying pathophysiological cause of moyamoya angiopathy (MMA) is still unclear. High-resolution vessel wall imaging has become a useful tool. The aim was to study vessel wall contrast-enhancement (VW-CE) as an imaging marker to predict disease progression in MMA. METHODS Patients with MMA, who had undergone serial contrast-enhanced high-resolution MRI with concomitant and follow-up digital subtraction angiography, were analyzed retrospectively. VW-CE was semiquantified by measurement of the signal intensity of the vessel wall in in contrast-enhanced high-resolution MRI. A comparative quotient with the contrast-intensity of the pituitary stalk was calculated and graded accordingly from grade 1 to 5. VW-CE status was correlated with disease status, stroke, cerebrovascular reactivity in CO2-triggered blood-oxygen level-dependent MRI, angiographic disease progression, revascularization surgery, and follow-up imaging. RESULTS Forty eight patients met the inclusion criteria. N = 56 MRI and digital subtraction angiography time-intervals were evaluated for 12 vessel sections per hemisphere each (N = 1344). N = 38 (79%) patients showed VW-CE and N = 10 (21%) did not. VW-CE was only observed in the terminal internal carotid artery and the proximal circle of Willis (N = 96/1344). Notably, patients with VW-CE significantly more often presented with acute infarction in the concomitant MRI. The incidence of angiographically proven disease progression was significantly associated with the incidence of VW-CE, and time to disease progression was earlier in higher grades of VW-CE compared with lower grades. CONCLUSION VW-CE is a semiquantifiable marker for disease activity in patients with MMA and associated with disease progression and increased risk of stroke. VW-CE analysis can be routinely performed in patients with MMA to estimate the risk for disease progression and stroke.
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Affiliation(s)
- Sophie Shih-Yüng Wang
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
- Center for Moyamoya and Cerebral Revascularization, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Till-Karsten Hauser
- Department of Neuroradiology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Patrick Haas
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
- Center for Moyamoya and Cerebral Revascularization, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Jonas Tellermann
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
- Center for Moyamoya and Cerebral Revascularization, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Helene Hurth
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
- Center for Moyamoya and Cerebral Revascularization, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Ulrike Ernemann
- Department of Neuroradiology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
- Center for Moyamoya and Cerebral Revascularization, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Benjamin Bender
- Department of Neuroradiology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Nadia Khan
- Center for Moyamoya and Cerebral Revascularization, Eberhard Karls University of Tübingen, Tübingen, Germany
- Moyamoya Center, University Children's Hospital and University of Zurich, Zurich, Switzerland
| | - Constantin Roder
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
- Center for Moyamoya and Cerebral Revascularization, Eberhard Karls University of Tübingen, Tübingen, Germany
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8
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Kang YS, Cho WS, Nam SM, Chung Y, Lee SH, Kim K, Kang HS, Kim JE. Natural course of hemodynamically stable hemispheres contralateral to operated hemispheres in adult patients with ischemic moyamoya diseases. Sci Rep 2024; 14:8358. [PMID: 38600292 PMCID: PMC11006865 DOI: 10.1038/s41598-024-59141-0] [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: 12/26/2023] [Accepted: 04/08/2024] [Indexed: 04/12/2024] Open
Abstract
The necessity of bilateral bypass in adult moyamoya disease (MMD) remains unclear despite its recommendation for pediatric and hemorrhagic cases. We aimed to investigate the natural course of hemodynamically stable unoperated hemispheres after bypass surgery for symptomatic and hemodynamically unstable hemispheres in adult patients with ischemic MMD. Among 288 patients, the mean age at the first operation of the unstable hemispheres was 40.8 ± 12.2 years. The mean follow-up period was 62.9 ± 46.5 months. 45 patients (15.6%) experienced stroke events in the unoperated hemisphere, consisting of hemorrhagic stroke in 8 (2.8%) and ischemic stroke in 37 (12.8%), including progressive transient ischemic attack in 25 (8.7%) and infarction in 12 (4.2%). Among them, 39 patients (13.5%) underwent bypass surgery. The annual risk of total stroke is 3.0%/patient-year, with 2.5% for ischemic stroke and 0.5% for hemorrhagic stroke. The 5- and 10-year cumulative risks of ischemic stroke were 13.4% and 18.3%, respectively, and those of hemorrhagic stroke were each 3.2%. The natural course of hemodynamically stable hemispheres contralateral to the operated ones appeared fairly good. Additional bypass surgery on the unoperated hemispheres should be considered for symptomatic and hemodynamically unstable hemispheres in adult patients with ischemic MMD during the follow-up.
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Affiliation(s)
- Young Sill Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - Sun Mo Nam
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Yuwhan Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Sung Ho Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Kangmin Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
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Birkeland P, Hansen V, Tharmabalan V, Lauritsen J, Nielsen T, Truelsen T, Rosenbaum S, von Weitzel-Mudersbach P. Long-term stroke risk in Moyamoya disease. Int J Stroke 2024; 19:452-459. [PMID: 37950387 DOI: 10.1177/17474930231216037] [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] [Indexed: 11/12/2023]
Abstract
BACKGROUND Moyamoya disease (MMD) is considered a progressive disease with an ongoing risk of recurrent stroke. However, there is a lack of long-term observational data to quantify the extent of the stroke risk. METHODS This study aimed to provide insight into the long-term stroke risk in MMD and explore possible risk factors for stroke. Records from all patients diagnosed with MMD in 13 clinical departments from 6 different Danish hospitals between 1994 and 2017 were retrospectively reviewed until 2021. RESULTS The cohort comprised 50 patients (33 females and 17 males). Patients were followed up for a median of 9.4 years, with more than 10 years of follow-up for 24 patients. Ten patients had 11 new stroke events-6 ischemic strokes and 5 brain hemorrhages. Events occurred at a median of 7 years and up to 25 years after diagnosis. The overall Kaplan-Meier 5-year stroke risk was 10%. Patients with bypass performed had significantly fewer events than conservatively treated patients (HR 0.25, 95% confidence interval (CI) 0.07-0.91, p < 0.05). All but one event occurred in females, a difference that reached statistical significance. CONCLUSIONS The study provides data on the extent of the risk of recurrent stroke in MMD. Bypass surgery patients had fewer stroke events than those treated conservatively. There was a trend toward a higher stroke risk in females. DATA ACCESS STATEMENT The data supporting this study's findings are available from the corresponding author upon reasonable request.
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Affiliation(s)
- Peter Birkeland
- Department of Neurosurgery, Copenhagen University Hospital, København Ø, Denmark
| | - Victoria Hansen
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | - Vinosha Tharmabalan
- Department of Neurosurgery, Copenhagen University Hospital, København Ø, Denmark
| | - Jens Lauritsen
- Department of Orthopaedic Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Denmark
| | - Troels Nielsen
- Department of Neurosurgery, Odense University Hospital, Odense C, Denmark
| | - Thomas Truelsen
- Department of Neurology, Copenhagen University Hospital, København Ø, Denmark
| | - Sverre Rosenbaum
- Department of Neurology, Bispebjerg Hospital, København, Denmark
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10
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Hong J, Yoon S, Shim KW, Park YR. Screening of Moyamoya Disease From Retinal Photographs: Development and Validation of Deep Learning Algorithms. Stroke 2024; 55:715-724. [PMID: 38258570 PMCID: PMC10896198 DOI: 10.1161/strokeaha.123.044026] [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: 06/04/2023] [Accepted: 12/13/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Moyamoya disease (MMD) is a rare and complex pathological condition characterized by an abnormal collateral circulation network in the basal brain. The diagnosis of MMD and its progression is unpredictable and influenced by many factors. MMD can affect the blood vessels supplying the eyes, resulting in a range of ocular symptoms. In this study, we developed a deep learning model using real-world data to assist a diagnosis and determine the stage of the disease using retinal photographs. METHODS This retrospective observational study conducted from August 2006 to March 2022 included 498 retinal photographs from 78 patients with MMD and 3835 photographs from 1649 healthy participants. Photographs were preprocessed, and an ResNeXt50 model was developed. Model performance was measured using receiver operating curves and their area under the receiver operating characteristic curve, accuracy, sensitivity, and F1-score. Heatmaps and progressive erasing plus progressive restoration were performed to validate the faithfulness. RESULTS Overall, 322 retinal photographs from 67 patients with MMD and 3752 retinal photographs from 1616 healthy participants were used to develop a screening and stage prediction model for MMD. The average age of the patients with MMD was 44.1 years, and the average follow-up time was 115 months. Stage 3 photographs were the most prevalent, followed by stages 4, 5, 2, 1, and 6 and healthy. The MMD screening model had an average area under the receiver operating characteristic curve of 94.6%, with 89.8% sensitivity and 90.4% specificity at the best cutoff point. MMD stage prediction models had an area under the receiver operating characteristic curve of 78% or higher, with stage 3 performing the best at 93.6%. Heatmap identified the vascular region of the fundus as important for prediction, and progressive erasing plus progressive restoration result shows an area under the receiver operating characteristic curve of 70% only with 50% of the important regions. CONCLUSIONS This study demonstrated that retinal photographs could be used as potential biomarkers for screening and staging of MMD and the disease stage could be classified by a deep learning algorithm.
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Affiliation(s)
- JaeSeong Hong
- Department of Biomedical Systems Informatics (J.H., Y.R.P.), Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sangchul Yoon
- Department of Medical Humanities and Social Sciences (S.Y.), Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyu Won Shim
- Department of Neurosurgery (K.W.S.), Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yu Rang Park
- Department of Biomedical Systems Informatics (J.H., Y.R.P.), Yonsei University College of Medicine, Seoul, Republic of Korea
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11
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Alotaibi AB, Alrashedi HB, Elsafi TS. Moyamoya Disease in a Patient With Sickle Cell Disease: A Case Report and Review of the Literature. Cureus 2024; 16:e55592. [PMID: 38576669 PMCID: PMC10994675 DOI: 10.7759/cureus.55592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 04/06/2024] Open
Abstract
Moyamoya disease (MMD) is a relatively rare, progressively worsening steno-occlusive condition primarily characterized by a progressive narrowing of the intracranial arteries, causing hypoperfusion and consequent cerebral ischemia and infarction. This case report discusses the rare presentation of a patient who was known to have sickle cell disease and MMD. Various investigations have revealed a typical presentation of such a disease through radiological findings. Our report highlights this rare disease and its possible association with other comorbidities, as well as the medical treatment options that patients may undergo with the option of surgical treatment.
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Affiliation(s)
| | - Hind B Alrashedi
- Department of Internal Medicine, Prince Sultan Medical Military City, Riyadh, SAU
| | - Tayseer S Elsafi
- Department of Internal Medicine, Prince Sultan Medical Military City, Riyadh, SAU
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12
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Wang XP, Zou ZX, Bao XY, Wang QN, Ren B, Yu D, Zhang Q, Liu JQ, Hao FB, Gao G, Guo QB, Fu HG, Li JJ, Wang MJ, Liu SM, Duan L. Clinical and genetic factors associated with contralateral progression in unilateral moyamoya disease: Longitudinal and Cross-Sectional Study. Heliyon 2024; 10:e26108. [PMID: 38404780 PMCID: PMC10884840 DOI: 10.1016/j.heliyon.2024.e26108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 01/12/2024] [Accepted: 02/07/2024] [Indexed: 02/27/2024] Open
Abstract
Objective This study aimed to explore the long-term outcome of unilateral moyamoya disease and predict the clinical and genetic factors associated with contralateral progression in unilateral moyamoya disease. Methods We retrospectively recruited unilateral moyamoya disease patients with available genetic data who underwent encephaloduroarteriosynangiosis (EDAS) surgery at our institution from January 2009 to November 2017. Long-term follow-up data, including clinical outcomes, angiographic features, and genetic information, were analyzed. Results A total of 83 unilateral moyamoya disease patients with available genetic data were enrolled in our study. The mean duration of clinical follow-up was 7.9 ± 2.0 years. Among all patients, 19 patients demonstrated contralateral progression to bilateral disease. Heterozygous Ring Finger Protein 213 p.R4810K mutations occurred significantly more frequently in unilateral moyamoya disease patients with contralateral progression. Furthermore, patients with contralateral progression typically demonstrated an earlier age of onset than those with non-progressing unilateral moyamoya disease. In the contralateral progression group, posterior circulation involvement was observed in 11 (11/19, 57.9%) patients compared to 12 (12/64, 18.8%) in the non-contralateral progression group (P = 0.001). The time to peak of cerebral perfusion and neurological status showed significant postoperative improvement. Conclusion Long-term follow-up revealed that the EDAS procedure might provide benefits for unilateral moyamoya disease patients. Ring Finger Protein 213 p.R4810K mutations, younger age, and posterior circulation involvement might predict the contralateral progression of unilateral moyamoya disease.
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Affiliation(s)
- Xiao-Peng Wang
- Medical School of Chinese PLA, Beijing, 100039, China
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Zheng-Xing Zou
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Xiang-Yang Bao
- Medical School of Chinese PLA, Beijing, 100039, China
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Qian-Nan Wang
- Department of Neurosurgery, the Eighth Medical Center of Chinese PLA General Hospital, Beijing, 100000, China
| | - Bin Ren
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Dan Yu
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100071, China
| | - Qian Zhang
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100071, China
| | - Jia-Qi Liu
- Department of Neurology, the First Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Fang-Bin Hao
- Medical School of Chinese PLA, Beijing, 100039, China
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Gan Gao
- Medical School of Chinese PLA, Beijing, 100039, China
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Qing-Bao Guo
- Medical School of Chinese PLA, Beijing, 100039, China
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - He-Guan Fu
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100071, China
| | - Jing-Jie Li
- Medical School of Chinese PLA, Beijing, 100039, China
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Min-Jie Wang
- Medical School of Chinese PLA, Beijing, 100039, China
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Si-Meng Liu
- Medical School of Chinese PLA, Beijing, 100039, China
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Lian Duan
- Medical School of Chinese PLA, Beijing, 100039, China
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
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13
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Kim JH, Jeon H, Kim M, Byun J, Chung Y, Lee SU, Park W, Park JC, Ahn JS, Lee S. Chemical and perfusion markers as predictors of moyamoya disease progression and complication types. Sci Rep 2024; 14:56. [PMID: 38167529 PMCID: PMC10762200 DOI: 10.1038/s41598-023-47984-y] [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: 05/18/2023] [Accepted: 11/21/2023] [Indexed: 01/05/2024] Open
Abstract
To investigate the association between chemical markers (triglyceride, C-reactive protein (CRP), and inflammation markers) and perfusion markers (relative cerebral vascular reserve (rCVR)) with moyamoya disease progression and complication types. A total of 314 patients diagnosed with moyamoya disease were included. Triglyceride and CRP levels were assessed and categorized based on Korean guidelines for dyslipidemia and CDC/AHA guidelines, respectively. Perfusion markers were evaluated using Diamox SPECT. Cox proportional hazard analysis was performed to examine the relationship between these markers and disease progression, as well as complication types (ischemic stroke, hemorrhagic stroke, and rCVR deterioration). Elevated triglyceride levels (≥ 200) were significantly associated with higher likelihood of end-point events (HR: 2.292, CI 1.00-4.979, P = 0.03). Severe decreased rCVR findings on Diamox SPECT were also significantly associated with end-point events (HR: 3.431, CI 1.254-9.389, P = 0.02). Increased CRP levels and white blood cell (WBC) count were significantly associated with moyamoya disease progression. For hemorrhagic stroke, higher triglyceride levels were significantly associated with end-point events (HR: 5.180, CI 1.355-19.801, P = 0.02). For ischemic stroke, severe decreased rCVR findings on Diamox SPECT (HR: 5.939, CI 1.616-21.829, P < 0.01) and increased CRP levels (HR: 1.465, CI 1.009-2.127, P = 0.05) were significantly associated with end-point events. Elevated triglyceride, CRP, and inflammation markers, as well as decreased rCVR, are potential predictors of moyamoya disease progression and complication types. Further research is warranted to understand their role in disease pathophysiology and treatment strategies.
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Affiliation(s)
- Jae Hyun Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hanwool Jeon
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
- Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Translational Biomedical Research Group, Asan Institute for Life Science, Asan Medical Center, Seoul, 05505, Republic of Korea
- Bio-Medical Institute of Technology, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Moinay Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Joonho Byun
- Department of Neurosurgery, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Yeongu Chung
- Department of Neurosurgery, Kangbuk Samsung Medical Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Wonhyoung Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Seungjoo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
- Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
- Translational Biomedical Research Group, Asan Institute for Life Science, Asan Medical Center, Seoul, 05505, Republic of Korea.
- Bio-Medical Institute of Technology, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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14
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Park MG, Roh J, Ahn SH, Cho JW, Park KP, Baik SK. Dilated perivascular spaces and steno-occlusive changes in children and adults with moyamoya disease. BMC Neurol 2024; 24:14. [PMID: 38166838 PMCID: PMC10759593 DOI: 10.1186/s12883-023-03520-z] [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: 10/12/2023] [Accepted: 12/22/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Dilated perivascular spaces (DPVS), known as one of imaging markers in cerebral small vessel disease, may be found in patients with moyamoya disease (MMD). However, little is known about DPVS in MMD. The purpose of this study was to investigate the distribution pattern of dPVS in children and adults with MMD and determine whether it is related to steno-occlusive changes of MMD. METHODS DPVS was scored in basal ganglia (BG) and white matter (WM) on T2-weighted imaging, using a validated 4-point semi-quantitative score. The degree of dPVS was classified as high (score > 2) or low (score ≤ 2) grade. The steno-occlusive changes on MR angiography (MRA) was scored using a validated MRA grading. Asymmetry of DPVS and MRA grading was defined as a difference of 1 grade or higher between hemispheres. RESULTS Fifty-one patients with MMD (mean age 24.9 ± 21.1 years) were included. Forty-five (88.2%) patients had high WM-DPVS grade (degree 3 or 4). BG-DPVS was found in 72.5% of all patients and all were low grade (degree 1 or 2). The distribution patterns of DPVS degree in BG (P = 1.000) and WM (P = 0.767) were not different between child and adult groups. The asymmetry of WM-DPVS (26%) and MRA grade (42%) were significantly correlated to each other (Kendall's tau-b = 0.604, P < 0.001). CONCLUSIONS DPVS of high grade in MMD is predominantly found in WM, which was not different between children and adults. The correlation between asymmetry of WM-DPVS degree and MRA grade suggests that weak cerebral artery pulsation due to steno-occlusive changes may affect WM-DPVS in MMD.
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Affiliation(s)
- Min-Gyu Park
- Department of Neurology, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University School of Medicine, 20 Geumo-ro, Yangsan, 50612, Republic of Korea.
| | - Jieun Roh
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Sung-Ho Ahn
- Department of Neurology, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University School of Medicine, 20 Geumo-ro, Yangsan, 50612, Republic of Korea
| | - Jae Wook Cho
- Department of Neurology, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University School of Medicine, 20 Geumo-ro, Yangsan, 50612, Republic of Korea
| | - Kyung-Pil Park
- Department of Neurology, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University School of Medicine, 20 Geumo-ro, Yangsan, 50612, Republic of Korea
| | - Seung Kug Baik
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
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15
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Bouchaala W, Laroussi S, Mzid Y, Maaloul I, Jallouli O, Zouari S, Ben Nsir S, Mnif Z, Kammoun F, Triki C. Moyamoya Angiopathy: An Underdiagnosed Cause of Ischemic Stroke in a Tunisian Pediatric Cohort. Pediatr Neurol 2024; 150:3-9. [PMID: 37925769 DOI: 10.1016/j.pediatrneurol.2023.09.017] [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: 02/11/2023] [Revised: 09/17/2023] [Accepted: 09/22/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Moyamoya angiopathy is a rare cerebral vasculopathy and an underdiagnosed cause of arterial ischemic stroke in children. We aim to report the clinical and radiological presentations in a Tunisian pediatric cohort. METHODS We identified moyamoya angiopathy in pediatric patients managed at the Child Neurology Department of Hedi Chaker Sfax University Hospital between 2008 and 2020 and reviewed their clinical and radiological data as well as their evolutionary profile. RESULTS We collected 14 patients with median age 40.6 months and a female predominance (sex ratio of 0.75). An arterial ischemic stroke (AIS) revealed the disease in all patients, with the major symptom being a motor deficit. Symptoms related to a transient ischemic attack before the diagnostic consultation were reported in four patients. Carotid territory was, clinically and radiologically, the most frequently involved. Brain magnetic resonance imaging with angiography was performed in 12 patients confirming the diagnosis by revealing the development of collateral vessels. All the investigations concluded to moyamoya disease in 57.2% and moyamoya syndrome in 42.8%. The latter was related to Down syndrome in five patients and neurofibromatosis type 1 in one patient. With a mean follow-up of 2.35 years, two patients had at least two more AISs during the first two years following diagnosis and 42.8% of patients were diagnosed with vascular or poststroke epilepsy. Full recovery was noted in 14.3% of cases. CONCLUSIONS Moyamoya angiopathy in children is a serious condition that needs to be recognized due to the high risk of recurrent ischemic strokes.
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Affiliation(s)
- Wafa Bouchaala
- Child Neurology Department, Hedi Chaker Sfax University Hospital, Sfax, Tunisia; Search Laboratory "Neuropediatrie" LR19ES15 Sfax University, Sfax, Tunisia
| | - Sirine Laroussi
- Child Neurology Department, Hedi Chaker Sfax University Hospital, Sfax, Tunisia.
| | - Yosra Mzid
- Search Laboratory "Neuropediatrie" LR19ES15 Sfax University, Sfax, Tunisia
| | - Imen Maaloul
- Search Laboratory "Neuropediatrie" LR19ES15 Sfax University, Sfax, Tunisia; Radiology Department, Hedi Chaker Sfax University Hospital, Sfax, Tunisia
| | - Olfa Jallouli
- Child Neurology Department, Hedi Chaker Sfax University Hospital, Sfax, Tunisia; Search Laboratory "Neuropediatrie" LR19ES15 Sfax University, Sfax, Tunisia
| | - Salma Zouari
- Child Neurology Department, Hedi Chaker Sfax University Hospital, Sfax, Tunisia; Search Laboratory "Neuropediatrie" LR19ES15 Sfax University, Sfax, Tunisia
| | - Sihem Ben Nsir
- Child Neurology Department, Hedi Chaker Sfax University Hospital, Sfax, Tunisia; Search Laboratory "Neuropediatrie" LR19ES15 Sfax University, Sfax, Tunisia
| | - Zeineb Mnif
- Search Laboratory "Neuropediatrie" LR19ES15 Sfax University, Sfax, Tunisia; Radiology Department, Hedi Chaker Sfax University Hospital, Sfax, Tunisia
| | - Fatma Kammoun
- Child Neurology Department, Hedi Chaker Sfax University Hospital, Sfax, Tunisia; Search Laboratory "Neuropediatrie" LR19ES15 Sfax University, Sfax, Tunisia
| | - Chahnez Triki
- Child Neurology Department, Hedi Chaker Sfax University Hospital, Sfax, Tunisia; Search Laboratory "Neuropediatrie" LR19ES15 Sfax University, Sfax, Tunisia
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16
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Guo Q, Wang Q, Li J, Liu S, Wang X, Yu D, Zou Z, Gao G, Zhang Q, Hao F, Feng J, Yang R, Wang M, Fu H, Bao X, Duan L. Proteomic and metabolomic characterizations of moyamoya disease patient sera. Brain Behav 2023; 13:e3328. [PMID: 37962021 PMCID: PMC10726768 DOI: 10.1002/brb3.3328] [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: 06/04/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND The pathogenesis of moyamoya disease (MMD) is unclear. Inflammation and immune imbalance have been identified as potential factors contributing to the occurrence and progression of MMD. However, the specific proteins and metabolites responsible for triggering this process are yet to be established. The purpose of this study is to identify differentially expressed proteins and metabolites in patients with MMD and perform Kyoto Encyclopedia of Genes and Genomes pathway integration analysis to pinpoint crucial proteins and metabolites involved in the disease. METHODS We performed untargeted metabolomic and data-independent acquisition proteomic analyses on the serum samples of individuals with MMD and healthy controls (HC). RESULTS In patients with MMD versus HC, 24 proteins and 60 metabolites, including 21 anionic metabolites and 39 cationic metabolites, which were significantly different, were identified. In patients with MMD, several proteins involved in inflammation and immune metabolism, such as tubulin beta-6 and complement C4, were found to have significantly altered levels. Similarly, many metabolites involved in inflammation and immune metabolisms, such as dimethyl 4-hydroxyisophthalate, beta-nicotinamide mononucleotide, 2-(3-(4-pyridyl)-1H-1,2,4-triazol-5-yl)pyridine, and PC (17:1/18:2), were significantly altered. Intriguingly, these proteins and metabolites are involved in the progression of atherosclerosis through immune and inflammatory pathways, although some have never been reported in MMD. Moreover, integrated proteomics and metabolomics studies were conducted to determine shared pathways involving cholesterol metabolism, vitamin digestion, fat digestion, and absorption pathways of proteins and metabolites, which warrant further investigation. CONCLUSIONS Significant increases in pro-inflammatory and immunosuppressive abilities have been observed in patients with MMD, accompanied by significant reductions in anti-inflammatory and immune regulation. Various metabolites and proteins implicated in these processes have been identified for the first time. These findings hold immense significance for comprehending the pathogenesis of MMD and for the development of future drug therapies.
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Affiliation(s)
- Qingbao Guo
- Medical School of Chinese PLABeijingChina
- Department of Neurosurgery, The First Medical CentreChinese PLA General HospitalBeijingChina
- Department of Neurosurgery, The Fifth Medical CentreChinese PLA General HospitalBeijingChina
| | - Qian‐Nan Wang
- Department of Neurosurgery, The Eighth Medical CentreChinese PLA General HospitalBeijingChina
| | - Jingjie Li
- Medical School of Chinese PLABeijingChina
- Department of Neurosurgery, The First Medical CentreChinese PLA General HospitalBeijingChina
- Department of Neurosurgery, The Fifth Medical CentreChinese PLA General HospitalBeijingChina
| | - Simeng Liu
- Medical School of Chinese PLABeijingChina
- Department of Neurosurgery, The First Medical CentreChinese PLA General HospitalBeijingChina
- Department of Neurosurgery, The Fifth Medical CentreChinese PLA General HospitalBeijingChina
| | - Xiaopeng Wang
- Medical School of Chinese PLABeijingChina
- Department of Neurosurgery, The First Medical CentreChinese PLA General HospitalBeijingChina
- Department of Neurosurgery, The Fifth Medical CentreChinese PLA General HospitalBeijingChina
| | - Dan Yu
- Department of Neurosurgery, The Fifth Medical CentreChinese PLA General HospitalBeijingChina
| | - Zheng‐Xing Zou
- Department of Neurosurgery, The Fifth Medical CentreChinese PLA General HospitalBeijingChina
| | - Gan Gao
- Medical School of Chinese PLABeijingChina
- Department of Neurosurgery, The First Medical CentreChinese PLA General HospitalBeijingChina
- Department of Neurosurgery, The Fifth Medical CentreChinese PLA General HospitalBeijingChina
| | - Qian Zhang
- Department of Neurosurgery, The Fifth Medical CentreChinese PLA General HospitalBeijingChina
| | - Fang‐Bin Hao
- Medical School of Chinese PLABeijingChina
- Department of Neurosurgery, The First Medical CentreChinese PLA General HospitalBeijingChina
- Department of Neurosurgery, The Fifth Medical CentreChinese PLA General HospitalBeijingChina
| | - Jie Feng
- Department of Neurosurgery, The Fifth Medical CentreChinese PLA General HospitalBeijingChina
| | - Ri‐Miao Yang
- Department of Neurosurgery, The Fifth Medical CentreChinese PLA General HospitalBeijingChina
| | - Minjie Wang
- Medical School of Chinese PLABeijingChina
- Department of Neurosurgery, The First Medical CentreChinese PLA General HospitalBeijingChina
- Department of Neurosurgery, The Fifth Medical CentreChinese PLA General HospitalBeijingChina
| | - Heguan Fu
- Department of Neurosurgery, The Fifth Medical CentreChinese PLA General HospitalBeijingChina
| | - Xiangyang Bao
- Department of Neurosurgery, The Fifth Medical CentreChinese PLA General HospitalBeijingChina
| | - Lian Duan
- Department of Neurosurgery, The First Medical CentreChinese PLA General HospitalBeijingChina
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17
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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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Mailankody P, Pruthi N, Kulanthaivelu K, Mahale R, Padmanabha H, Mathuranath PS, Dubbal R. Adult-Onset Ischemic Moyamoya Disease: Reasoning and Decision-Making. Neurol India 2023; 71:1065-1067. [PMID: 37929473 DOI: 10.4103/0028-3886.388102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Pooja Mailankody
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Nupur Pruthi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Karthik Kulanthaivelu
- Department of Neuroimaging and Interventional Radiology (NIIR), National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Rohan Mahale
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Hansashree Padmanabha
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - P S Mathuranath
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Rohin Dubbal
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
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Lu M, Zhang H, Liu D, Hao F, Zhang L, Peng P, Yuan F, Liu S, Sheng F, Liu Y, Zhao X, He Y, Han C, Cai J. Vessel wall enhancement as a predictor of arterial stenosis progression and poor outcomes in moyamoya disease. Eur Radiol 2023; 33:2489-2499. [PMID: 36334103 DOI: 10.1007/s00330-022-09223-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/03/2022] [Accepted: 10/05/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVES This study aimed to determine the association between vessel wall enhancement and progression of arterial stenosis and clinical outcomes in patients with moyamoya (MMD) using high-resolution magnetic resonance (HRMR) vessel wall imaging. METHODS Consecutive participants diagnosed with MMD were prospectively recruited and underwent HRMR at baseline and during follow-up, which had an interval period of ≥ 6 months and were clinically followed up for ≤ 24 months to record the occurrence of ischemic stroke. The relationship between vessel wall enhancement and arterial stenosis progression and stroke occurrence was evaluated. RESULTS HRMR vessel wall imaging was used to identify 309 stenotic lesions at the internal carotid artery (ICA) in 170 participants (mean age: 37.7 ± 11.3 years old, male: 44.1%). The baseline presence (adjusted odds ratio [aOR] = 3.57, 95% CI = 1.97-6.44, p < 0.001) and progression (aOR = 2.96, 95% CI = 1.29-6.80, p = 0.010) of vessel wall enhancement and middle cerebral artery (MCA) involvement (aOR = 4.98, 95% CI = 1.50-16.52, p = 0.009) were significantly associated with rapid progression of arterial stenosis. Furthermore, vessel wall enhancement (adjusted HR = 3.59, 95% CI = 1.33-9.70, p = 0.011) and rapid progression of arterial stenosis (adjusted HR = 4.52, 95% CI = 1.48-13.81, p = 0.008) were correlated with future stroke occurrence. CONCLUSION The baseline presence of vessel wall enhancement was associated with rapid progression of arterial stenosis and increased risk for stroke in MMD patients. Our findings suggest that vessel wall enhancement may serve as a predictor of disease progression and poor outcomes in MMD. KEY POINTS • The baseline presence of vessel wall enhancement was significantly associated with the rapid progression of arterial stenosis. • The baseline presence of vessel wall enhancement and rapid progression of arterial stenosis were both correlated with increased risk for future occurrence of stroke. • Our findings suggest that vessel wall enhancement may serve as a predictor of rapid progression of arterial stenosis and poor outcomes in MMD patients.
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Affiliation(s)
- Mingming Lu
- Institute of Geriatrics, State Key Laboratory of Kidney Disease, Beijing Key Laboratory of Aging and Geriatrics, the Second Medical Center of Chinese PLA General Hospital, Beijing, 100853, China.,Department of Radiology, Pingjin Hospital, Characteristic Medical Center of Chinese People's Armed Police Force, Tianjin, China
| | - Hongtao Zhang
- Department of Radiology, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Dongqing Liu
- Department of Radiology, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Fangbin Hao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Lichen Zhang
- Department of Radiology, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Peng Peng
- Department of Radiology, Pingjin Hospital, Characteristic Medical Center of Chinese People's Armed Police Force, Tianjin, China
| | - Fei Yuan
- Department of Radiology, Pingjin Hospital, Characteristic Medical Center of Chinese People's Armed Police Force, Tianjin, China
| | - Shitong Liu
- Department of Radiology, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Fugeng Sheng
- Department of Radiology, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Yuan Liu
- Department of Radiology, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Xihai Zhao
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China
| | - Yao He
- Institute of Geriatrics, State Key Laboratory of Kidney Disease, Beijing Key Laboratory of Aging and Geriatrics, the Second Medical Center of Chinese PLA General Hospital, Beijing, 100853, China.
| | - Cong Han
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Jianming Cai
- Department of Radiology, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100853, China.
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Gao P, Chen D, Yuan S, Kong T, Zhang D, Zhu X, Li X, Zhen Y, Yan D. Follow-up outcomes of different bypass surgical modalities for adults with ischaemic-type moyamoya disease. Br J Neurosurg 2023; 37:148-157. [PMID: 34553657 DOI: 10.1080/02688697.2021.1981239] [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: 10/20/2022]
Abstract
PURPOSE The preferred surgical method for treating adults with moyamoya disease (MMD) remains controversial. The purpose of this study was to compare the efficacy of different surgical methods in the treatment of adults with ischaemic-type MMD. METHODS We retrospectively analyzed the data of patients with ischaemic-type MMD who underwent indirect bypass (IB), direct bypass (DB), or combined bypass (CB) at the First Affiliated Hospital of Zhengzhou University from January 2013 to December 2019. Postoperative complications, improvements in neurological function, haemodynamics, recurrent stroke and neovascularization were compared. RESULTS A total of 310 adults (371 hemispheres) with ischaemic-type MMD were included in our study. Ninety, 127, and 154 hemispheres underwent IB, DB and CB, respectively. A total of 24 (6.5%) ischaemic events and 8 (2.8%) symptomatic hyperperfusion events occurred after the operations. There was no significant difference in postoperative complications among the three types of surgery (p = 0.300). During the follow-up period, there were 21 cases (5.7%) of recurrent ischaemia and 12 cases (3.2%) of recurrent haemorrhage. Kaplan-Meier survival analysis showed that the ischaemia-free survival of the CB group was significantly longer than that of the IB group (p = 0.047), but there was no significant difference in haemorrhage-free survival among the three groups (p = 0.660). Six months after the operation, DB and CB were superior to IB in improving cerebral blood flow and neovascularization (p = 0.002), but there was no significant difference in the improvement of neurological function among the three groups at the last follow-up (p = 0.784). CONCLUSION The three surgical methods achieved satisfactory results in the treatment of ischaemic-type MMD. DB and CB can significantly improve haemodynamics and reduce recurrent stroke. In terms of improving neurological function, the curative effect of the three surgical methods remains to be further explored.
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Affiliation(s)
- Peng Gao
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Di Chen
- Department of Neurosurgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shanpeng Yuan
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Tengxiao Kong
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Dongtao Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Xuqiang Zhu
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Xueyuan Li
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yingwei Zhen
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Dongming Yan
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
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Abou-El-Hassan H, Azhand H, Kantono M, Bhagat A, Karp D, Baranski T, Salahuddin T, Farmand F. Incidental Moyamoya Disease in an Elderly Patient Presenting With Acute Ischemic Pontine Stroke. Cureus 2023; 15:e36198. [PMID: 37065418 PMCID: PMC10104681 DOI: 10.7759/cureus.36198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
Moyamoya disease (MMD) is a rare occlusive cerebrovascular disease that is characterized by progressive stenosis of the terminal portion of the internal carotid artery and its main branches with compensatory development of dilated and fragile collateral vasculature at the base of the brain. MMD has a bimodal age distribution commonly affecting children and adults, whereas onset in the elderly population is a rare occurrence. Here, we present a case of a 78-year-old patient of Indonesian descent who was incidentally found to have moyamoya arteriopathy after presenting with acute ischemic stroke in the left pons. The patient underwent diagnostic cerebral angiogram that showed right middle cerebral artery stenosis with pathognomonic collateral moyamoya vessels. The patient was discharged on antiplatelet therapy. We report a rare case of an elderly patient with MMD. The role of medical or surgical management in asymptomatic MMD in elderly patients remains largely unknown.
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Si L, Tu J, Lei H, Ji L, Zhang Z, Liu Z. A case of limb shaking transient ischaemic attack due to internal carotid artery dissection: an unusual presentation of fibromuscular dysplasia. BMC Neurol 2023; 23:91. [PMID: 36859180 PMCID: PMC9976537 DOI: 10.1186/s12883-023-03130-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 02/17/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Fibromuscular dysplasia (FMD) has a high prevalence of associated nontraumatic carotid artery dissection, which could further result in transient ischaemic attack (TIA) or stroke. Limb shaking TIA is an unusual form of TIA that is commonly discribed in elderly patients with atherosclerotic backgrounds, while there are limited data about it in patients with FMD. Furthermore, discussions of limb shaking TIA in nonelderly patients are scarce. CASE PRESENTATION An Asian 47-year-old female presented with intermittent involuntary movement of the left upper limb accompanied by neck torsion. The episode stopped soon after changing to the supine position. On native source images of time-of-flight magnetic resonance angiography (TOF-MRA), the right internal carotid artery showed a "dual lumen sign" with an intimal flap. On contrast-enhanced magnetic resonance angiography and sagittal black-blood T1WI, an intravascular haematoma with irregular lumen stenosis was observed, which overall indicated right internal carotid artery dissection. Digital subtraction angiography showed the characteristic "string-of-beads" appearance in the left internal carotid artery, and the presence of this sign pointed to the diagnosis of FMD. The patient was finally diagnosed with limb shaking TIA due to internal carotid dissection with fibromuscular dysplasia. The patient was prescribed dual anti-platelet therapy. The limb shaking vanished soon after admission with no reoccurrence in the three-month follow-up. CONCLUSIONS This case demonstrates that limb shaking TIA can present in patients with FMD. Limb shaking TIA in nonelderly patients can be caused by multiple diseases, and more detailed patient guidance is required in clinical practice.
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Affiliation(s)
- Lei Si
- grid.16821.3c0000 0004 0368 8293Department of Neurology, Xi’an Central Hospital, Xi’an, Jiaotong University School of Medicine, Xi’an 710003, Shaanxi, China
| | - Jing Tu
- grid.508540.c0000 0004 4914 235XXi’an Medical University, Xi’an 710021, Shaanxi, China
| | - Hui Lei
- grid.16821.3c0000 0004 0368 8293Department of Neurology, Xi’an Central Hospital, Xi’an, Jiaotong University School of Medicine, Xi’an 710003, Shaanxi, China
| | - Liya Ji
- grid.16821.3c0000 0004 0368 8293Department of Neurology, Xi’an Central Hospital, Xi’an, Jiaotong University School of Medicine, Xi’an 710003, Shaanxi, China
| | - Zhiyong Zhang
- Department of Neurology, Beijing Geriatric Hospital, Beijing, 100095, China.
| | - Zhiqin Liu
- Department of Neurology, Xi'an Central Hospital, Xi'an, Jiaotong University School of Medicine, Xi'an 710003, Shaanxi, China.
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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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Cao J, Xing Z, Dai L, Wang T, Zhang Y, Feng Y, Chen Y. Potential predictors for progression of moyamoya disease: A systematic review and meta-analysis. Front Neurol 2023; 14:1128338. [PMID: 36937514 PMCID: PMC10018164 DOI: 10.3389/fneur.2023.1128338] [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: 12/20/2022] [Accepted: 02/13/2023] [Indexed: 03/06/2023] Open
Abstract
Background The progress of Moyamoya disease (MMD) is often accompanied by the occurrence of new ischemia or hemorrhagic events, which was difficult to predict. This systematic review and meta-analysis aimed to identify predictors for progression in MMD patients. Methods We searched PubMed, Web of Science, Cochrane Library, and Embase databases up to December 10th, 2022 for randomized controlled trials, case-control studies, or cohort studies reporting predictors of disease progression in MMD patients. The results of each predictor were pooled by meta-analysis and further analyzed by subgroup analysis for predictors of unilateral to bilateral progression of MMD. Results A total of 842 patients from 12 studies were included. The estimated pooled means indicated lower age (standard mean difference [SMD]: -0.29, 95% confidence interval [CI]: -0.55 to -0.03; P = 0.03), family history (odds ratio [OR] 3.97, 95% CI: 1.96 to 8.03; P < 0.001) and contralateral abnormality (OR 3.95, 95% CI: 1.10 to 14.20; P = 0.04) were associated with progression in MMD patients. Subgroup analyses indicated that the same three factors were associated with the progression of unilateral to bilateral MMD. Conclusions This meta-analysis revealed that lower age, family history and contralateral abnormality were associated with progression in MMD patients. The same three factors are associated with the progression of unilateral to bilateral MMD. Further studies are needed to validate our results.
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Affiliation(s)
- Jun Cao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, The Affiliated Rizhao People's Hospital, Jining Medical University, Rizhao, China
| | - Zixuan Xing
- Health Science Center, Xi'an Jiaotong University, Xi'an, China
| | - Ling Dai
- Department of Neurosurgery, Jinshan Hospital, Fudan University, Shanghai, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuhai Zhang
- Department of Neurosurgery, The Affiliated Rizhao People's Hospital, Jining Medical University, Rizhao, China
| | - Yao Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yanfei Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- *Correspondence: Yanfei Chen
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Khan NR, Elarjani T, Jamshidi AM, Lu VM, Silva MA, Richardson A, Harrington T, Valdes T, Campo N, Krementz N, Asdaghi N, Sur N, Londono EM, Malik AM, Koch S, Romano J, Morcos JJ. Direct Bypass Surgery for Moyamoya and Steno-occlusive Vasculopathy: Clinical Outcomes, Intraoperative Blood Flow Analysis, Long-term Follow-up, and Long-term Bypass Patency in a Single Surgeon Case Series of 162 Procedures. World Neurosurg 2022; 168:e500-e517. [DOI: 10.1016/j.wneu.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
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Kuroda S, Fujimura M, Takahashi J, Kataoka H, Ogasawara K, Iwama T, Tominaga T, Miyamoto S. Diagnostic Criteria for Moyamoya Disease - 2021 Revised Version. Neurol Med Chir (Tokyo) 2022; 62:307-312. [PMID: 35613882 PMCID: PMC9357455 DOI: 10.2176/jns-nmc.2022-0072] [Citation(s) in RCA: 85] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
In this report, we, the Research Committee on Moyamoya Disease (Spontaneous Occlusion of the circle of Willis), describe in detail the changes in the new “Diagnostic Criteria 2021” for moyamoya disease and its scientific basis to make it widely known to the world. The revised criteria cover all aspects of the disease, including a definition of the disease concept, diagnostic imaging, and the concept of quasi-moyamoya disease (moyamoya syndrome).
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Affiliation(s)
- Satoshi Kuroda
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Jun Takahashi
- Department of Neurosurgery, Kindai University Faculty of Medicine
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center
| | | | - Toru Iwama
- Department of Neurosurgery, Gifu University School of Medicine
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
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Kumar M, Larson A, Jabal MS, Rinaldo L, Savastano L, Lanzino G, Meyer F, Lehman V, Klaas J. Comparison of Stroke Risk Factors Between Symptomatic and Asymptomatic Patients in a North American Moyamoya Disease Cohort. Cerebrovasc Dis Extra 2022; 12:72-75. [PMID: 35588715 PMCID: PMC9247436 DOI: 10.1159/000525098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/06/2022] [Indexed: 11/19/2022] Open
Abstract
Background Risk factors for stroke in symptomatic and asymptomatic moyamoya disease (MMD) patients have recently been reported in a Japanese cohort. Such information in a North American population is lacking. Objective We sought to elucidate the prevalence of stroke risk factors among North American patients with ischemic, hemorrhagic, and asymptomatic MMD. Methods We retrospectively reviewed our institution's database between 1990 and 2021. We excluded cases of moyamoya syndrome. We divided 119 patients into 3 groups based on the onset pattern; ischemic, hemorrhagic, and asymptomatic. We compared the prevalence of well-known stroke risk factors (diabetes, hypertension, etc.) between these three groups of patients. In the asymptomatic group, we analyzed the prevalence of cerebrovascular events on follow-up from the time of diagnosis. Results Overall, 119 patients with MMD were available with predominately White ethnicity (80.7%). The mean age was 39 years, and 73.9% were female. Patients presented with ischemic stroke (82%) and hemorrhagic stroke (11%); 7% of patients were asymptomatic. The prevalence of stroke risk factors did not differ among ischemic, hemorrhagic, or asymptomatic MMD patients. In 8 asymptomatic patients, there was 81.8 months (SD ±51.0) of follow-up, and none of them developed any cerebrovascular events. Conclusions No significant differences in the prevalence of stroke risk factors between MMD cohorts were found, corroborating evidence provided in a recent Japanese-based study. There were no apparent associations between stroke risk factors and interval cerebrovascular events in an asymptomatic group of MMD patients.
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Affiliation(s)
- Mukaish Kumar
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Anthony Larson
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
- *Anthony Larson,
| | | | - Lorenzo Rinaldo
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Luis Savastano
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fredric Meyer
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Vance Lehman
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - James Klaas
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
- *Anthony Larson,
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Lai PMR, Gomez-Paz S, Patel NJ, Frerichs KU, Thomas AJ, Aziz-Sultan MA, Patel AB, Ogilvy CS, Du R. Asymptomatic Moyamoya Disease in a North American Adult Cohort. World Neurosurg 2022; 161:e146-e153. [PMID: 35092810 DOI: 10.1016/j.wneu.2022.01.076] [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: 09/23/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The natural history of asymptomatic adult moyamoya disease (MMD) is unclear, and the benefit of treatment remains controversial. This study aimed to investigate the natural history of asymptomatic MMD in a North American cohort and to evaluate risk factors associated with and the effects of treatment on disease progression. METHODS Medical records from 3 institutions of consecutive adult patients with MMD diagnosed between 1984 and 2018 were retrospectively reviewed. Patients with unilateral or bilateral asymptomatic MMD were evaluated for subsequent development of infarction or hemorrhage. Multivariate Cox proportional hazards regression assessed risk factors associated with infarction or hemorrhage, adjusting for age, sex, race, initial Suzuki grade, hypertension, hyperlipidemia, diabetes, obesity, presence of aneurysms, smoking status, aspirin, and statin use at diagnosis. RESULTS We identified 106 hemispheres with asymptomatic MMD in 97 patients with mean 5.1 years (interquartile range, 1.0-7.9 years) of follow-up. Of 106 hemispheres, 59 were treated medically, and 47 were treated with revascularization with direct or indirect bypasses. The medical and surgical cohorts had a 1.9% and 1.3% annual rate of radiographic infarction or hemorrhage per hemisphere, respectively. Cox regression for radiographic events, including early postoperative events, showed no significant difference between the treatment groups (adjusted hazard ratio 0.34 [95% confidence interval 0.05-2.5]). CONCLUSIONS We found an overall 1.7% annual rate of radiographic infarction or hemorrhage in asymptomatic MMD hemispheres. Although we did not find a benefit to surgical treatment within the study period, asymptomatic patients with expected long-term survival may benefit from surgery given the sustained long-term benefits after surgery despite an initial postoperative risk.
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Affiliation(s)
- Pui Man Rosalind Lai
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Santiago Gomez-Paz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nirav J Patel
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kai U Frerichs
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - M Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Mineharu Y, Takagi Y, Koizumi A, Morimoto T, Funaki T, Hishikawa T, Araki Y, Hasegawa H, Takahashi JC, Kuroda S, Houkin K, Miyamoto S. Genetic and nongenetic factors for contralateral progression of unilateral moyamoya disease: the first report from the SUPRA Japan Study Group. J Neurosurg 2022; 136:1005-1014. [PMID: 34507293 DOI: 10.3171/2021.3.jns203913] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/05/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although many studies have analyzed risk factors for contralateral progression in unilateral moyamoya disease, they have not been fully elucidated. The aim of this study was to examine whether genetic factors as well as nongenetic factors are involved in the contralateral progression. METHODS The authors performed a multicenter cohort study in which 93 cases with unilateral moyamoya disease were retrospectively reviewed. The demographic features, RNF213 R4810K mutation, lifestyle factors such as smoking and drinking, past medical history, and angiographic findings were analyzed. A Cox proportional hazards model was used to find risk factors for contralateral progression. RESULTS Contralateral progression was observed in 24.7% of cases during a mean follow-up period of 72.2 months. Clinical characteristics were not significantly different between 67 patients with the R4810K mutation and those without it. Cox regression analysis showed that the R4810K mutation (hazard ratio [HR] 4.64, p = 0.044), childhood onset (HR 7.21, p < 0.001), male sex (HR 2.85, p = 0.023), and daily alcohol drinking (HR 4.25, p = 0.034) were independent risk factors for contralateral progression. CONCLUSIONS These results indicate that both genetic and nongenetic factors are associated with contralateral progression of unilateral moyamoya disease. The findings would serve to help us better understand the pathophysiology of moyamoya disease and to manage patients more appropriately.
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Affiliation(s)
- Yohei Mineharu
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto
| | - Yasushi Takagi
- 2Department of Neurosurgery, Tokushima University Graduate School of Medicine, Tokushima
| | - Akio Koizumi
- 3Social Health Welfare Medicine Laboratory, Kyoto
| | - Takaaki Morimoto
- 4Department of Neurosurgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki
| | - Takeshi Funaki
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto
| | | | - Yoshio Araki
- 6Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya
| | - Hitoshi Hasegawa
- 7Department of Neurosurgery, Brain Research Institute, Niigata University, Niigata
| | - Jun C Takahashi
- 8Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita
| | - Satoshi Kuroda
- 9Department of Neurosurgery, Toyama University Graduate School of Medicine, Toyama; and
| | - Kiyohiro Houkin
- 10Department of Neurological Cell Therapy, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Susumu Miyamoto
- 1Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto
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Infarction Patterns and Recurrent Adverse Cerebrovascular Events in Moyamoya Disease. DISEASE MARKERS 2022; 2022:8255018. [PMID: 35392499 PMCID: PMC8983186 DOI: 10.1155/2022/8255018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/17/2022] [Indexed: 11/17/2022]
Abstract
For moyamoya disease (MMD) patients who suffered an acute ischemic attack, the infarction patterns on DWI and its association with recurrent adverse cerebrovascular events (ACEs) after bypass surgery remain unknown. 327 patients who suffered an acute ischemic attack and received following revascularization surgery were retrospectively reviewed and were divided into three patterns according to the lesion number and distribution on DWI that obtained within 7 days of onset: no acute infarction (NAI), single acute infarction (SAI), and multiple acute infarctions (MAIs). We used Cox proportional hazard models to estimate hazard ratios (HR) for associations of infarction patterns and the risk of recurrent ACEs and strokes. Over a median follow-up of 41 months (IQR 26-60), there were 61 ACEs and 27 strokes. Compared to the NAI cohort, patients with SAI (HR, 2.92; 95% CI, 1.41-6.05; p = 0.004) and MAIs (HR, 4.44; 95% CI, 2.10-9.41; p < 0.001) were associated with higher risk of ACEs recurrences. In analysis adjusted for age and surgery modalities, the corresponding HR was 2.90 (95% CI: 1.41-5.98) for SAI and 4.10 (95% CI: 1.95-8.63) for MAIs, and this effect remained persistent on further adjustment for several potential confounders. Similar but less precise association was found in separate analysis that only takes into account stroke recurrences. Thus, different infarction patterns on DWI imply different risks of recurrent ACEs, and more attention should be paid to prevent ACEs in MMD patients with MAIs.
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Tian X, Hu M, Zhang J. The contralateral progression in a cohort of Chinese adult patients with unilateral moyamoya disease after revascularization: a single-center long-term retrospective study. Acta Neurochir (Wien) 2022; 164:1837-1844. [PMID: 35347450 PMCID: PMC9233650 DOI: 10.1007/s00701-022-05153-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/09/2022] [Indexed: 11/29/2022]
Abstract
Background Moyamoya disease (MMD) is a chronic progressive cerebrovascular disease mainly existing in the Asian population, which can be divided into unilateral and bilateral types. Contralateral progression has been reported in pediatric patients with unilateral MMD, while large series about contralateral progression in Chinese adult patients were rare. The goal of this study is to elucidate the clinical features and incidence of contralateral progression in Chinese MMD adult patients. Methods One hundred one Chinese adult patients with unilateral MMD who received surgery treatments between January 2015 and January 2017 in our hospital were enrolled in this study. This study contained 89 patients. Digital subtraction angiography was performed in all patients for initial diagnosis, and magnetic resonance angiography was repeated 6 months from the initial operation and then annually. Clinical characteristics, contralateral progression, and risk factors were studied. Previous related studies were also reviewed and meta-analyzed. Results Of these 89 patients, contralateral progression was identified in 8 patients (9.0%) within a median follow-up period of 63 months, which was lower than that in previous studies (25.9%). Single-factor analysis and multivariate analysis did not reveal significant risk factors related to the contralateral progression. Conclusion The progress rate in this cohort of Chinese adult patients with unilateral MMD after revascularization was 9.0%, which indicates that some of the unilateral MMD were an early form of bilateral MMD rather than a separate condition. Trial registration. This work was approved by the Medical Ethics Committee of Zhongnan Hospital of Wuhan University (approval number: Kelun-2017005). Supplementary Information The online version contains supplementary material available at 10.1007/s00701-022-05153-6.
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Kuribara T, Akiyama Y, Mikami T, Komatsu K, Kimura Y, Takahashi Y, Sakashita K, Chiba R, Mikuni N. Macrohistory of Moyamoya Disease Analyzed Using Artificial Intelligence. Cerebrovasc Dis 2022; 51:413-426. [PMID: 35104814 DOI: 10.1159/000520099] [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: 05/30/2021] [Accepted: 10/06/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Moyamoya disease is characterized by progressive stenotic changes in the terminal segment of the internal carotid artery and the development of abnormal vascular networks called moyamoya vessels. The objective of this review was to provide a holistic view of the epidemiology, etiology, clinical findings, treatment, and pathogenesis of moyamoya disease. A literature search was performed in PubMed using the term "moyamoya disease," for articles published until 2021. RESULTS Artificial intelligence (AI) clustering was used to classify the articles into 5 clusters: (1) pathophysiology (23.5%); (2) clinical background (37.3%); (3) imaging (13.2%); (4) treatment (17.3%); and (5) genetics (8.7%). Many articles in the "clinical background" cluster were published from the 1970s. However, in the "treatment" and "genetics" clusters, the articles were published from the 2010s through 2021. In 2011, it was confirmed that a gene called Ringin protein 213 (RNF213) is a susceptibility gene for moyamoya disease. Since then, tremendous progress in genomic, transcriptomic, and epigenetic profiling (e.g., methylation profiling) has resulted in new concepts for classifying moyamoya disease. Our literature survey revealed that the pathogenesis involves aberrations of multiple signaling pathways through genetic mutations and altered gene expression. CONCLUSION We analyzed the content vectors in abstracts using AI, and reviewed the pathophysiology, clinical background, radiological features, treatments, and genetic peculiarity of moyamoya disease.
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Affiliation(s)
| | - Yukinori Akiyama
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Takeshi Mikami
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Katsuya Komatsu
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Yusuke Kimura
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | | | - Kyoya Sakashita
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Ryohei Chiba
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
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Arteriovenous Malformations and Other Vascular Anomalies. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00030-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Connolly F, Alsolivany J, Czabanka M, Vajkoczy P, Valdueza JM, Röhl JE, Siebert E, Danyel LA. Blood volume flow in the superficial temporal artery assessed by duplex sonography: predicting extracranial-intracranial bypass patency in moyamoya disease. J Neurosurg 2021; 135:1666-1673. [PMID: 33836503 DOI: 10.3171/2020.9.jns202709] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery is an important therapy for symptomatic moyamoya disease. Its success depends on bypass function, which may be impaired by primary or secondary bypass insufficiency. Catheter angiography is the current gold standard to assess bypass function, whereas the diagnostic value of ultrasonography (US) has not been systematically analyzed so far. METHODS The authors analyzed 50 STA-MCA bypasses in 39 patients (age 45 ± 14 years [mean ± SD]; 26 female, 13 male). Bypass patency was evaluated by catheter angiography, which was performed within 24 hours after US. The collateral circulation through the bypass was classified into 4 types as follows: the bypass supplies more than two-thirds (type A); between one-third and two-thirds (type B); or less than one-third (type C) of the MCA territory; or there is bypass occlusion (type D). The authors assessed the mean blood flow velocity (BFV), the blood volume flow (BVF), and the pulsatility index (PI) in the external carotid artery and STA by duplex sonography. Additionally, they analyzed the flow direction of the MCA by transcranial color-coded sonography. US findings were compared between bypasses with higher (types A and B) and lower (types C and D) capacity. RESULTS Catheter angiography revealed high STA-MCA bypass capacity in 35 cases (type A: n = 22, type B: n = 13), whereas low bypass capacity was noted in the remaining 15 cases (type C: n = 12, type D: n = 3). The BVF values in the STA were 60 ± 28 ml/min (range 4-121 ml/min) in the former and 12 ± 4 ml/min (range 6-18 ml/min) in the latter group (p < 0.0001). Corresponding values of mean BFV and PI were 57 ± 21 cm/sec (range 16-100 cm/sec) versus 22 ± 8 cm/sec (range 10-38 cm/sec) (p < 0.0001) and 0.8 ± 0.2 (range 0.4-1.3) versus 1.4 ± 0.5 (range 0.5-2.4) (p < 0.0001), respectively. Differences in the external carotid artery were less distinct: BVF 217 ± 71 ml/min (range 110-425 ml/min) versus 151 ± 41 ml/min (range 87-229 ml/min) (p = 0.001); mean BFV 47 ± 17 cm/sec (range 24-108 cm/sec) versus 40 ± 7 cm/sec (range 26-50 cm/sec) (p = 0.15); PI 1.5 ± 0.4 (range 1.0-2.5) versus 1.9 ± 0.4 (range 1.2-2.6) (p = 0.009). A retrograde blood flow in the MCA was found in 14 cases (9 in the M1 and M2 segment; 5 in the M2 segment alone), and all of them showed a good bypass function (type A, n = 10; type B, n = 4). The best parameter (cutoff value) to distinguish bypasses with higher capacity from bypasses with lower capacity was a BVF in the STA ≥ 21 ml/min (sensitivity 100%, negative predictive value 100%, specificity 91%, positive predictive value 83%). CONCLUSIONS Duplex sonography is a suitable diagnostic tool to assess STA-MCA bypass function in moyamoya disease. Hemodynamic monitoring of the STA by US provides an excellent predictor of bypass patency.
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Affiliation(s)
| | | | | | | | - Jose M Valdueza
- 3Neurological Center, Segeberger Kliniken, Schleswig-Holstein, Bad Segeberg; and
| | | | - Eberhard Siebert
- 4Institute of Neuroradiology, University Hospital Charité, Berlin, Germany
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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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Sun H, Li W, Xia C, Ren Y, Ma L, Xiao A, You C, Liu Y, Tian R. Angiographic and Hemodynamic Features in Asymptomatic Hemispheres of Patients With Moyamoya Disease. Stroke 2021; 53:210-217. [PMID: 34547926 DOI: 10.1161/strokeaha.121.035296] [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] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE There is also a risk of stroke in the asymptomatic hemispheres of moyamoya disease (MMD), but it does not draw enough attention. The study investigated the differences between the three types of asymptomatic hemispheres in MMD and their associations with the two types of symptomatic hemispheres, respectively. METHODS Retrospectively reviewed clinical and imaging characteristics of asymptomatic and symptomatic hemispheres in consecutive cases of single-center MMD patients, with an emphasis on imaging characterization regarding vascular morphology and cerebral perfusion. MMD hemispheres were categorized into 5 types: hemorrhagic hemispheres, ischemic hemispheres, asymptomatic hemispheres in unilateral hemorrhagic MMD, asymptomatic hemispheres in unilateral ischemic MMD, and bilateral asymptomatic hemispheres in MMD. Angiographic feature was assessed by Suzuki's angiographic stage, while hemodynamic feature was assessed by preinfarction period stage. RESULTS One hundred ninety-four MMD patients with 388 hemispheres were enrolled. Asymptomatic hemispheres in unilateral hemorrhagic MMD were largely similar to hemorrhagic hemispheres, both had more advanced Suzuki's angiographic stage and lower degree of hemodynamic failure compared with bilateral asymptomatic hemispheres in MMD and asymptomatic hemispheres in unilateral ischemic MMD. Asymptomatic hemispheres in unilateral ischemic MMD were similar to ischemic hemispheres, both had less advanced Suzuki's angiographic stage and higher degree of hemodynamic failure compared with bilateral asymptomatic hemispheres in MMD and asymptomatic hemispheres in unilateral hemorrhagic MMD. Bilateral asymptomatic hemispheres in MMD were different from the other hemispheres and had less advanced Suzuki's angiographic stage and lower degree of hemodynamic failure. CONCLUSIONS The three types of asymptomatic hemispheres in MMD are defined and have unique angiographic and hemodynamic features. Different combinations of the two features can reflect the tendency of pathological evolution in these different asymptomatic hemispheres.
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Affiliation(s)
- Haogeng Sun
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China. (H.S., C.X., Y.R., L.M., A.X., C.Y., Y.L., R.T.)
| | - Wanjiang Li
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China. (W.L.)
| | - Chao Xia
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China. (H.S., C.X., Y.R., L.M., A.X., C.Y., Y.L., R.T.).,George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (C.X.)
| | - Yutao Ren
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China. (H.S., C.X., Y.R., L.M., A.X., C.Y., Y.L., R.T.)
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China. (H.S., C.X., Y.R., L.M., A.X., C.Y., Y.L., R.T.).,West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu (L.M., A.X., C.Y., Y.L., R.T.)
| | - Anqi Xiao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China. (H.S., C.X., Y.R., L.M., A.X., C.Y., Y.L., R.T.).,West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu (L.M., A.X., C.Y., Y.L., R.T.)
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China. (H.S., C.X., Y.R., L.M., A.X., C.Y., Y.L., R.T.).,West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu (L.M., A.X., C.Y., Y.L., R.T.)
| | - Yi Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China. (H.S., C.X., Y.R., L.M., A.X., C.Y., Y.L., R.T.).,West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu (L.M., A.X., C.Y., Y.L., R.T.)
| | - Rui Tian
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China. (H.S., C.X., Y.R., L.M., A.X., C.Y., Y.L., R.T.).,West China Brain Research Centre, West China Hospital, Sichuan University, Chengdu (L.M., A.X., C.Y., Y.L., R.T.)
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Fox BM, Dorschel KB, Lawton MT, Wanebo JE. Pathophysiology of Vascular Stenosis and Remodeling in Moyamoya Disease. Front Neurol 2021; 12:661578. [PMID: 34539540 PMCID: PMC8446194 DOI: 10.3389/fneur.2021.661578] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 08/09/2021] [Indexed: 12/04/2022] Open
Abstract
Moyamoya disease (MMD) and moyamoya syndrome (MMS) are progressive vascular pathologies unique to the cerebrovasculature that are important causes of stroke in both children and adults. The natural history of MMD is characterized by primary progressive stenosis of the supraclinoid internal carotid artery, followed by the formation of fragile collateral vascular networks. In MMS, stenosis and collateralization occur in patients with an associated disease or condition. The pathological features of the stenosis associated with MMD include neointimal hyperplasia, disruption of the internal elastic lamina, and medial attenuation, which ultimately lead to progressive decreases in both luminal and external arterial diameter. Several molecular pathways have been implicated in the pathophysiology of stenosis in MMD with functions in cellular proliferation and migration, extracellular matrix remodeling, apoptosis, and vascular inflammation. Importantly, several of these molecular pathways overlap with those known to contribute to diseases of systemic arterial stenosis, such as atherosclerosis and fibromuscular dysplasia (FMD). Despite these possible shared mechanisms of stenosis, the contrast of MMD with other stenotic pathologies highlights the central questions underlying its pathogenesis. These questions include why the stenosis that is associated with MMD occurs in such a specific and limited anatomic location and what process initiates this stenosis. Further investigation of these questions is critical to developing an understanding of MMD that may lead to disease-modifying medical therapies. This review may be of interest to scientists, neurosurgeons, and neurologists involved in both moyamoya research and treatment and provides a review of pathophysiologic processes relevant to diseases of arterial stenosis on a broader scale.
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Affiliation(s)
- Brandon M Fox
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Kirsten B Dorschel
- Medical Faculty, Heidelberg University Medical School, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Germany
| | - Michael T Lawton
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - John E Wanebo
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
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MURAOKA S, TAOKA T, KAWAI H, OKAMOTO S, UDA K, NAGANAWA S, ARAKI Y. Changes in Vessel Wall Enhancement Related to the Recent Neurological Symptoms in Patients with Moyamoya Disease. Neurol Med Chir (Tokyo) 2021; 61:515-520. [PMID: 34078772 PMCID: PMC8443970 DOI: 10.2176/nmc.oa.2021-0058] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/22/2021] [Indexed: 11/20/2022] Open
Abstract
Moyamoya disease (MMD) causes intracranial arterial stenosis progression. The progression of intracranial arterial stenosis will increase the risk of ischemic cerebrovascular events. This study aims to investigate the relationship between intracranial arterial stenosis progression, vessel wall enhancement (VWE), and the recent neurological symptoms. A total of 39 MMD patients (12 male; 37.6 ± 18.0 years old) were registered in this study analysis between April 2016 and July 2018. All patients received MRI at registration and 6, 12, and 24 months post-registration. The incidence of ischemic cerebrovascular events (transit ischemic attacks or cerebral infarction) was checked until December 2018. We evaluated the relationship between the intensity of VWE, intracranial arterial stenosis, and the recent neurological symptoms. During the mean follow-up period of 13.8 ± 5.5 months, the changes in VWE were observed in 33 hemispheres (42.3%), stenosis progression was observed in 21 hemispheres (26.9%), and recent neurological symptoms occurred in 10 hemispheres (12.8%). Stenosis progression was observed in 11 hemispheres (33.3%) in the VWE(+) group and ten hemispheres (22.2%) in the VWE(-) group (p = 0.310). The recent neurological symptoms were observed in eight hemispheres (21.2%) in the VWE(+) group and two hemispheres (4.44%) in the VWE(-) group (odds ratio 6.88, 95% confidence interval 1.35-34.98, p = 0.015). The intensity of VWE sometimes changes. The changes in VWE were significantly associated with the recent neurological symptoms but not with stenosis progression.
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Affiliation(s)
- Shinsuke MURAOKA
- Department of Neurosurgery, Tosei General Hospital, Seto, Aichi, Japan
| | - Toshiaki TAOKA
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Hisashi KAWAI
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Sho OKAMOTO
- Department of Neurosurgery, Aichi Rehabilitation Hospital, Nishio, Aichi, Japan
| | - Kenji UDA
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Shinji NAGANAWA
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yoshio ARAKI
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Kitakami K, Kubo Y, Yabuki M, Oomori D, Takahashi T, Igarashi S, Fujiwara S, Yoshida K, Kobayashi M, Terasaki K, Ogasawara K. Five-Year Outcomes of Medical Management Alone for Adult Patients with Ischemic Moyamoya Disease without Cerebral Misery Perfusion. Cerebrovasc Dis 2021; 51:158-164. [PMID: 34518462 DOI: 10.1159/000518725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 07/23/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION No clear guidelines for treating adult patients with ischemic moyamoya disease (MMD) without cerebral hemodynamic compromise such as misery perfusion have been established. Our previous prospective cohort study of adult patients with MMD without misery perfusion who were treated with medical management alone, including an antiplatelet drug, showed a recurrent ischemic event rate of 3% per 2 years. The present prospective study aimed to elucidate the 5-year clinical, cerebral perfusion, and cognitive outcomes of medical management alone for Japanese adult patients with ischemic MMD without cerebral misery perfusion by following the same patients for another 3 years. METHODS In total, 68 patients without recurrent events at a 2-year follow-up were prospectively followed up for another 3 years. Cerebral blood flow (CBF) in the symptomatic cerebral hemisphere was measured using brain perfusion single-photon emission computed tomography at inclusion and at the end of the subsequent 3-year follow-up. Neuropsychological testing was performed at inclusion and at the end of the initial 2- and subsequent 3-year follow-ups. RESULTS During the subsequent 3-year follow-up, 2 patients (3%) developed further ischemic events. In patients without further ischemic events, CBF was significantly greater at the end of the subsequent 3-year follow-up than at inclusion (p = 0.0037), and all neuropsychological test scores improved or remained unchanged at the end of initial 2- and subsequent 3-year follow-ups compared with that at inclusion. CONCLUSION In adult patients receiving medical management alone for ischemic MMD without cerebral misery perfusion, the incidence of further ischemic events was 6% per 5 years and did not change between the initial 2 years after the last is-chemic event and the subsequent 3 years. In patients without further ischemic events, CBF and cognitive function had not deteriorated at 5 years after the last ischemic event.
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Affiliation(s)
- Kei Kitakami
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Yoshitaka Kubo
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Masahiro Yabuki
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Daisuke Oomori
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Tatsuhiko Takahashi
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Suguru Igarashi
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Shunrou Fujiwara
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Kenji Yoshida
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Masakazu Kobayashi
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Kazunori Terasaki
- Institute for Biomedical Sciences, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University School of Medicine, Yahaba, Japan
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Grüter BE, Tosic L, Voglis S, Vasella F, Mutschler V, Bichsel O, Scherrer N, Regli L, Esposito G. Trends in Literature on Cerebral Bypass Surgery: A Systematic Review. Cerebrovasc Dis 2021; 51:102-113. [PMID: 34289475 DOI: 10.1159/000517415] [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: 02/12/2021] [Accepted: 05/14/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Ever since the beginning of cerebral bypass surgery, the role of the bypass has been debated and indications have changed over the last 5 decades. This systematic literature research analysed all clinical studies on cerebral bypass that have been published from January 1959 to January 2020 for their year of publication, country of origin, citation index, role of and indication for bypass, bypass technique, revascularized territory, flow capacity, and title (for word cloud analysis per decade). METHODS A systematic literature research was conducted using PubMed, Web of Science, EMBASE, and SCOPUS databases. All studies that have been published until January 1, 2020, were included. RESULTS Of 6,013 identified studies, 2,585 were included in the analysis. Of these, n = 1,734 (67%) studies addressed flow-augmentation bypass and n = 701 (27%) addressed flow-preservation bypass. The most common indication reported for flow augmentation is moyamoya (n = 877, 51%), followed by atherosclerotic steno-occlusive disease (n = 753, 43%). For flow preservation, the most common indication is studies reporting on cerebral aneurysm surgery (n = 659, 94%). The increasing popularity of reporting on these bypass operations almost came to an end with the FDA approval of flow diverters for aneurysm treatment in 2011. Japan is the country with the most bypass studies (cumulatively published 933 articles), followed by the USA (630 articles) and China (232 articles). DISCUSSION/CONCLUSION Clinical studies on cerebral bypass surgery have become increasingly popular in the past decades. Since the introduction of moyamoya as a distinct pathologic entity, Asian countries in particular have a very active community regarding this disease, with an increasing number of articles published every year. Studies on bypass for chronic steno-occlusive disease peaked in the 1980s but have remained the main focus of bypass research, particularly in many European departments. The number of reports published on these bypass operations significantly decreased after the FDA approval of flow diverters for aneurysm treatment in 2011.
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Affiliation(s)
- Basil E Grüter
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Lazar Tosic
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Stefanos Voglis
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Flavio Vasella
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Valentino Mutschler
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Oliver Bichsel
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Natalie Scherrer
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.,Neurointensive Care Unit, University Hospital Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Giuseppe Esposito
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.,Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
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Hirano Y, Miyawaki S, Imai H, Hongo H, Teranishi Y, Dofuku S, Ishigami D, Ohara K, Koizumi S, Ono H, Nakatomi H, Saito N. Differences in Clinical Features among Different Onset Patterns in Moyamoya Disease. J Clin Med 2021; 10:jcm10132815. [PMID: 34202349 PMCID: PMC8267932 DOI: 10.3390/jcm10132815] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 12/02/2022] Open
Abstract
Moyamoya disease is characterized by severe stenosis at the ends of the bilateral internal carotid arteries and the development of collateral circulation. The disease is very diverse in terms of age at onset, onset patterns, radiological findings, and genetic phenotypes. The pattern of onset is mainly divided into ischemic and hemorrhagic onsets. Recently, the opportunity to identify asymptomatic moyamoya disease, which sometimes manifests as nonspecific symptoms such as headache and dizziness, through screening with magnetic resonance imaging has been increasing. Various recent reports have investigated the associations between the clinical features of different onset patterns of moyamoya disease and the corresponding imaging characteristics. In this article, we have reviewed the natural history, clinical features, and imaging features of each onset pattern of moyamoya disease.
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Affiliation(s)
- Yudai Hirano
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
- Department of Neurosurgery, Fuji Brain Institute and Hospital Fujinomiya, Shizuoka 418-0021, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
- Correspondence: ; Tel.: +81-35-800-8853
| | - Hideaki Imai
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
- Department of Neurosurgery, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Shinjuku-ku, Tokyo 162-8543, Japan
| | - Hiroki Hongo
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
| | - Yu Teranishi
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
| | - Shogo Dofuku
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
| | - Daiichiro Ishigami
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
| | - Kenta Ohara
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
| | - Satoshi Koizumi
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
| | - Hideaki Ono
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
- Department of Neurosurgery, Fuji Brain Institute and Hospital Fujinomiya, Shizuoka 418-0021, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
- Department of Neurosurgery, Kyorin University Hospital, Mitaka, Tokyo 181-8611, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
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Clinical and Genetic Risk Factors of Long-Term Outcomes after Encephaloduroarteriosynangiosis in Moyamoya Disease in China. J Stroke Cerebrovasc Dis 2021; 30:105847. [PMID: 33992965 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES This retrospective study was conducted to analyze the associations between ring finger protein 213 p.R4810K variant, clinical features and long-term outcomes in patients with moyamoya disease (MMD) after encephaloduroarteriosynangiosis treatment. MATERIALS AND METHODS A total of 2,545 patients with MMD in China were included in this study (median of follow-up duration: 32.00 months). Multiple Cox regression models were used to assess the associations between p.R4810K variant, clinical features and long-term outcomes. RESULTS For all patients, in multivariate Cox analysis, no association was observed between p.R4810K and long-term outcomes. Pediatric onset (HR, 0.38; 95%CI, 0.25-0.59) and headache (HR, 0.26; 95%CI, 0.08-0.83) were inversely and hypertension (HR, 1.43 95%CI, 1.06-1.94), diabetes (HR, 1.55; 95%CI, 1.00-2.40), bilateral lesions (HR, 2.73; 95%CI, 1.12-6.65) and posterior cerebral artery involvement (HR, 1.44; 95%CI, 1.08-1.90) were positively associated with follow-up stroke (all P < 0.05). Pediatric onset (HR, 0.46; 95%CI, 0.26-0.82) was inversely and hyperlipidemia (HR, 1.83; 95%CI, 1.23-2.73), smoking (HR, 1.86; 95%CI, 1.13-3.07), high Suzuki angiographic stage (HR, 1.71, 95%CI, 1.09-2.70), poor admission neurologic status (HR, 8.93; 95%CI, 6.49-12.29) and follow-up stroke (HR, 8.31; 95%CI, 6.01-11.49) were positively associated with poor neurologic outcome at the last follow-up visit (all P < 0.05). The factors were not consistent in the different groups of age at onset. CONCLUSIONS In our study, p.R4810K may play no role in long-term outcomes in Chinese MMD. Clinical features including age at onset, initial symptoms, risk factors of stroke, imaging, poor admission neurologic status were associated with poor outcomes in MMD after EDAS.
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Alkhaibary A, Almutairi OT, Elarjani T, Alnefaie N, Alhussinan MA, Bafaquh M, Alturki AY. The Top-100 most cited articles on Moyamoya disease: A bibliometric analysis. J Cerebrovasc Endovasc Neurosurg 2021; 23:85-98. [PMID: 33975427 PMCID: PMC8256026 DOI: 10.7461/jcen.2021.e2020.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 12/17/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Moyamoya disease (MMD) is a progressive steno-occlusive cerebrovascular phenomenon with unknown pathogenesis. Considering the abundance of articles addressing Moyamoya disease, a detailed analysis concerning the publication trends is of paramount importance. The aim of the study is to report the current knowledge of the top-100 most cited articles on Moyamoya disease in the literature. METHODS A non-time restricted keyword-based search was performed in June 2020 using the Scopus database. The search keywords included the following: "Moyamoya", "Moyamoya disease", and "Moyamoya syndrome". The search result was used to rank the articles based on their citation count. The top-100 most-cited articles were obtained and classified into seven categories. RESULTS A total of 3,543 articles on Moyamoya disease were published between 1955 and 2020. The Top-100 articles were published between 1977 and 2016 with a total of 16,119 citations, per year, and 7.23% rate of self-citation. The 1990s was the most productive decade (N=42). The most contributing country to the list was Japan (N=60). Stroke was the most active journal (N=23). Houkin, K., a Japanese neurosurgeon, was the most prolific author (N=15). CONCLUSIONS Moyamoya disease has been extensively investigated in the literature throughout the years. The majority of articles published in the literature were addressing the surgical management and clinical outcome. Authors from neurosurgical backgrounds were the most active contributors to the field of Moyamoya disease.
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Affiliation(s)
- Ali Alkhaibary
- Division of Neurosurgery, Department of Surgery, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Othman T Almutairi
- Department of Adult Neurosurgery, National Neurosciences Institute, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Turki Elarjani
- Department of Neurological Surgery, University of Miami, Miami, FL, USA
| | - Nada Alnefaie
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Mohammed Bafaquh
- Neurocritical Care Division, Critical Care Administration, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Abdulrahman Y Alturki
- Department of Adult Neurosurgery, National Neurosciences Institute, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia.,Neurocritical Care Division, Critical Care Administration, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
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Nakamura A, Kawashima A, Andrade-Barazarte H, Funatsu T, Hernesniemi J, Kawamata T. Occipital artery to middle cerebral artery bypass in pediatric moyamoya disease: rescue therapy after failed revascularization. J Neurosurg Pediatr 2021; 27:429-436. [PMID: 33450732 DOI: 10.3171/2020.8.peds20424] [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: 05/19/2020] [Accepted: 08/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients with pediatric moyamoya disease (PMMD) showing recurrent symptoms or decreased cerebral blood flow after initial revascularization therapy may require additional revascularization to improve their clinical condition. The authors evaluated the clinical and hemodynamic benefits of an occipital artery (OA)-middle cerebral artery (MCA) bypass for patients with PMMD who have undergone an initial revascularization procedure. METHODS The authors retrospectively identified 9 patients with PMMD who had undergone OA-MCA bypass between March 2013 and December 2017, and who had received a previous superficial temporal artery-MCA bypass. The following clinical data were collected: initial revascularization procedure, symptoms (presence or recurrence), pre- and postoperative cerebral blood flow and cerebrovascular reactivity (CVR) changes, posterior cerebral artery (PCA) stenosis, PCA-related and nonrelated symptoms, and latest follow-up. RESULTS Preoperatively, all patients (n = 9) suffered non-PCA-related recurrent symptoms, and 4 had PCA-related symptoms. At 1-year follow-up, all patients with PCA-related symptoms showed complete recovery. Additionally, 8 (89%) patients with non-PCA symptoms experienced improvement. Only 1 (11%) patient showed no improvement after the surgical procedure. The mean pre- and postoperative CVR values of the MCA territory were 14.8% and 31.3%, respectively, whereas the respective mean CVR values of the PCA territory were 22.8% and 40.0%. CONCLUSIONS The OA-MCA bypass is an effective rescue therapy to improve the clinical condition and hemodynamic changes caused by PMMD in patients who experience recurrent symptoms after initial revascularization.
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Affiliation(s)
- Akikazu Nakamura
- 1Department of Neurosurgery, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba, Japan
| | - Akitsugu Kawashima
- 1Department of Neurosurgery, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba, Japan
| | - Hugo Andrade-Barazarte
- 2Department of Neurosurgery, Juha Hernesniemi International Center for Neurosurgery, Henan People's Provincial Hospital, University of Zhengzhou, China; and
| | - Takayuki Funatsu
- 3Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Juha Hernesniemi
- 2Department of Neurosurgery, Juha Hernesniemi International Center for Neurosurgery, Henan People's Provincial Hospital, University of Zhengzhou, China; and
| | - Takakazu Kawamata
- 3Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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Kuroda S, Nakayama N, Yamamoto S, Kashiwazaki D, Uchino H, Saito H, Hori E, Akioka N, Kuwayama N, Houkin K. Late (5-20 years) outcomes after STA-MCA anastomosis and encephalo-duro-myo-arterio-pericranial synangiosis in patients with moyamoya disease. J Neurosurg 2021; 134:909-916. [PMID: 32168480 DOI: 10.3171/2019.12.jns192938] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/17/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical revascularization is known to reduce the incidence of further ischemic and hemorrhagic events in patients with moyamoya disease, but the majority of previous studies report only short-term (< 5 years) outcomes. Therefore, in this study the authors aimed to evaluate late (5-20 years) outcomes of moyamoya patients after superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis and indirect bypass (encephalo-duro-myo-arterio-pericranial synangiosis [EDMAPS]). METHODS Cumulative incidences of late morbidity/mortality and disease progression were evaluated among 93 patients who underwent STA-MCA anastomosis and EDMAPS. All of the patients were prospectively followed up for longer than 5 years postsurgery (10.5 ± 4.4 years). There were 35 pediatric and 58 adult patients. Initial presentation included transient ischemic attack/ischemic stroke in 80 patients and hemorrhagic stroke in 10 patients, and 3 patients were asymptomatic. Surgery was performed in a total of 141 hemispheres. Follow-up MRI/MRA was performed within a 6- or 12-month interval during the follow-up periods. RESULTS During the follow-up periods, 92/93 patients were free from any stroke or death, but 1 patient had a recurrence of hemorrhagic stroke (0.10% per patient-year). Disease progression occurred in the territory of the contralateral carotid or posterior cerebral artery (PCA) in 19 hemispheres of 15 patients (1.5% per patient-year). The interval between initial surgery and disease progression varied widely, from 0.5 to 15 years. Repeat bypass surgery for the anterior and posterior circulation resolved ischemic attacks in all 10 patients. CONCLUSIONS The study results indicate that STA-MCA anastomosis and EDMAPS would be the best choice to prevent further ischemic and hemorrhagic stroke for longer than 10 years on the basis of the demonstrated widespread improvement in cerebral hemodynamics in both the MCA and ACA territories in the study patients. However, after 10 years postsurgery regular follow-up is essential to detect disease progression in the territory of the contralateral carotid artery and PCA and prevent late cerebrovascular events.
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Affiliation(s)
- Satoshi Kuroda
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
- 2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Naoki Nakayama
- 2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Shusuke Yamamoto
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
| | - Daina Kashiwazaki
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
| | - Haruto Uchino
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
- 2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hisayasu Saito
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
- 2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Emiko Hori
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
| | - Naoki Akioka
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
| | - Naoya Kuwayama
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
| | - Kiyohiro Houkin
- 2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Kazumata K, Tokairin K, Ito M, Uchino H, Sugiyama T, Kawabori M, Osanai T, Tha KK, Houkin K. Combined structural and diffusion tensor imaging detection of ischemic injury in moyamoya disease: relation to disease advancement and cerebral hypoperfusion. J Neurosurg 2021; 134:1155-1164. [PMID: 32244209 DOI: 10.3171/2020.1.jns193260] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The microstructural integrity of gray and white matter is decreased in adult moyamoya disease, suggesting covert ischemic injury as a mechanism of cognitive dysfunction. Establishing a microstructural brain imaging marker is critical for monitoring cognitive outcomes following surgical interventions. The authors of the present study determined the pathophysiological basis of altered microstructural brain injury in relation to advanced arterial occlusion, cerebral hypoperfusion, and cognitive function. METHODS The authors examined 58 patients without apparent brain lesions and 30 healthy controls by using structural MRI, as well as diffusion tensor imaging (DTI). Arterial occlusion in each hemisphere was classified as early or advanced stage based on MRA and posterior cerebral artery (PCA) involvement. Regional cerebral blood flow (rCBF) was measured with N-isopropyl-p-[123I]-iodoamphetamine SPECT. Furthermore, cognitive performance was examined using the Wechsler Adult Intelligence Scale, Third Edition and the Trail Making Test (TMT). Both voxel- and region of interest-based analyses were performed for groupwise comparisons, as well as correlation analysis, using parameters such as cognitive test scores; gray matter volume; fractional anisotropy (FA) of association fiber tracts, including the inferior frontooccipital fasciculus (IFOF) and superior longitudinal fasciculus (SLF); PCA involvement; and rCBF. RESULTS Compared to the early stages, advanced stages of arterial occlusion in the left hemisphere were associated with a lower Performance IQ (p = 0.031), decreased anterior cingulate volumes (p = 0.0001, uncorrected), and lower FA in the IFOF, cingulum, and forceps major (all p < 0.01, all uncorrected). There was no significant difference in rCBF between the early and the advanced stage. In patients with an advanced stage, PCA involvement was correlated with a significantly lower Full Scale IQ (p = 0.036), cingulate volume (p < 0.01, uncorrected), and FA of the left SLF (p = 0.0002, uncorrected) compared to those with an intact PCA. The rCBF was positively correlated with FA of the SLF, IFOF, and forceps major (r > 0.34, p < 0.05). Global gray matter volumes were moderately correlated with TMT part A (r = 0.40, p = 0.003). FA values in the left SLF were moderately associated with processing speed (r = 0.40, p = 0.002). CONCLUSIONS Although hemodynamic compensation may mask cerebral ischemia in advanced stages of adult moyamoya disease, the disease progression is detrimental to gray and white matter microstructure as well as cognition. In particular, additional PCA involvement in advanced disease stages may impair key neural substrates such as the cingulum and SLF. Thus, combined structural MRI and DTI are potentially useful for tracking the neural integrity of key neural substrates associated with cognitive function and detecting subtle anatomical changes associated with persistent ischemia, as well as disease progression.
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Affiliation(s)
- Ken Kazumata
- 1Department of Neurosurgery, Hokkaido University Graduate School of Medicine; and
| | - Kikutaro Tokairin
- 1Department of Neurosurgery, Hokkaido University Graduate School of Medicine; and
| | - Masaki Ito
- 1Department of Neurosurgery, Hokkaido University Graduate School of Medicine; and
| | - Haruto Uchino
- 1Department of Neurosurgery, Hokkaido University Graduate School of Medicine; and
| | - Taku Sugiyama
- 1Department of Neurosurgery, Hokkaido University Graduate School of Medicine; and
| | - Masahito Kawabori
- 1Department of Neurosurgery, Hokkaido University Graduate School of Medicine; and
| | - Toshiya Osanai
- 1Department of Neurosurgery, Hokkaido University Graduate School of Medicine; and
| | - Khin Khin Tha
- 2Clinical Research and Medical Innovation Center, Hokkaido University Hospital, Sapporo, Japan
| | - Kiyohiro Houkin
- 1Department of Neurosurgery, Hokkaido University Graduate School of Medicine; and
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47
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Goren O, Hendrix P, Peled A, Kimchi G, Zauberman J, Griessenauer C, Feldman Z. Encephaloduroarteriosynangiosis with Dural Inversion for Moyamoya Disease in a Pediatric and Adult Population-a Single-Center 20-Year Experience. World Neurosurg 2021; 149:e16-e21. [PMID: 33647488 DOI: 10.1016/j.wneu.2021.02.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/20/2021] [Accepted: 02/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Moyamoya disease refers to a progressive vasostenotic or vaso-occlusive disease that puts patients at risk for ischemic and/or hemorrhagic events. Surgical revascularization procedures aim to restore cerebral blood flow to mitigate stroke risk and functional decline. Direct and indirect bypass procedures have been proposed. Encephaloduroarteriosynangiosis (EDAS) with dural inversion is a well-accepted indirect procedure. METHODS Patients with moyamoya disease undergoing EDAS with dural inversion between 2000 and 2019 were retrospectively reviewed. Clinical data including short-term and long-term outcome were measured using the modified Rankin Scale. Patient satisfaction was assessed in patients with a minimum of 3 years of clinical follow-up. RESULTS Over a 20-year period, 54 patients underwent 88 EDAS with dural inversion procedures. Most patients underwent bilateral surgery (34/54 patients, 63.0%). Median age at surgery was 19 years (range, 1-63 years) with a median follow-up of 6 years (range, 1-20 years). Periprocedural complications occurred in 4 of 54 patients (7.4%). Periprocedural infarction occurred in 3 of 88 operations (3.4%). Functional outcome at 90 days was favorable (modified Rankin Scale score 0-2) in 92.6% of cases. On long-term follow-up, 3 patients experienced ischemic infarction (5.6%), and 1 patient (1.9%) experienced hemorrhagic infarction. Patients' overall satisfaction with the surgical procedure at last follow-up was determined in 36 of 45 patients with at least 3 years of follow-up (response rate 80.0%). Median satisfaction was very good (score 5; range, 3-5). CONCLUSIONS EDAS with dural inversion is a safe and effective indirect revascularization procedure for pediatric and adult moyamoya disease that is associated with favorable long-term outcomes and high patient satisfaction.
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Affiliation(s)
- Oded Goren
- Department of Neurosurgery, Sheba Medical Center Hospital-Tel Hashomer, Ramat Gan, Israel; Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania, USA.
| | - Philipp Hendrix
- Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania, USA
| | - Anton Peled
- Department of Neurosurgery, Sheba Medical Center Hospital-Tel Hashomer, Ramat Gan, Israel
| | - Gil Kimchi
- Department of Neurosurgery, Sheba Medical Center Hospital-Tel Hashomer, Ramat Gan, Israel
| | - Jacob Zauberman
- Department of Neurosurgery, Sheba Medical Center Hospital-Tel Hashomer, Ramat Gan, Israel
| | - Christoph Griessenauer
- Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania, USA; Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Zeev Feldman
- Department of Neurosurgery, Sheba Medical Center Hospital-Tel Hashomer, Ramat Gan, Israel
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48
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Scott RM, Smith ER. Transition to Adulthood for Pediatric Moyamoya Patients. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0040-1715500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractMoyamoya is a progressive arteriopathy of the intracranial vasculature, predominantly affecting the terminal branches of the internal carotid artery. Treatment is predicated on surgical revascularization to reduce the risk of stroke. For patients diagnosed and treated as children, it is important to recognize the long-term implications of the disease, for example, that moyamoya is treatable, but not curable. Pediatric moyamoya patients face unique challenges as they transition to adulthood as a consequence of the chronic nature of this disorder. Successful long-term care requires a strategy that incorporates ongoing longitudinal disease monitoring, coordination of care between physician teams, and anticipation of socioeconomic factors that change over time. This article provides an approach to transition care to adult caregivers for pediatric moyamoya patients with a specific focus on the three key stakeholders in the process: the neurosurgeon, the primary care physician, and the individual patient.
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Affiliation(s)
- R Michael Scott
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Edward R. Smith
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, United States
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49
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Song JW, Fan Z. Emerging multi-modal diagnostic approaches for moyamoya disease. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1208. [PMID: 33178740 PMCID: PMC7607114 DOI: 10.21037/atm-20-4215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Jae W Song
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Zhaoyang Fan
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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50
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Takahashi S, Matsui Y, Kubo H, Toda M. A case of moyamoya disease symptomatized early after nivolumab initiation - Possible association between immune checkpoint inhibitors and moyamoya disease. Clin Neurol Neurosurg 2020; 200:106355. [PMID: 33162258 DOI: 10.1016/j.clineuro.2020.106355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Satoshi Takahashi
- Department of Neurosurgery, Keio University, School of Medicine, 35 Shinanomachi Shinjuku, Tokyo, 160-8582, Japan.
| | - Yusuke Matsui
- Department of Neurosurgery, Keio University, School of Medicine, 35 Shinanomachi Shinjuku, Tokyo, 160-8582, Japan
| | - Hajime Kubo
- Department of Neurosurgery, Keio University, School of Medicine, 35 Shinanomachi Shinjuku, Tokyo, 160-8582, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University, School of Medicine, 35 Shinanomachi Shinjuku, Tokyo, 160-8582, Japan
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