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Lin CY, Chen HC, Wu YH. Using High-Resolution Vessel Wall Magnetic Resonance Images in a Patient of Intracranial Artery Dissection Related Acute Infarction. Diagnostics (Basel) 2024; 14:1463. [PMID: 39061600 PMCID: PMC11276065 DOI: 10.3390/diagnostics14141463] [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: 04/13/2024] [Revised: 05/15/2024] [Accepted: 05/29/2024] [Indexed: 07/28/2024] Open
Abstract
Acute ischemic stroke in young adults typically carries significant implications for morbidity, mortality, and long-term disability. In this study, we describe the case of a 34-year-old male with no prior medical history who presented with symptoms of right-sided weakness and slurred speech, suggesting an acute ischemic stroke. Initial CT angiography revealed an occlusion in the left M2 segment middle cerebral artery (MCA). The occlusion was successfully recanalized through emergent endovascular thrombectomy, which also identified a dissection as the cause of the stroke. Follow-up assessments at 3 days and three months, which included advanced vessel wall MRI, highlighted the critical role of intracranial artery dissection in strokes among young adults and provided essential images for ongoing evaluation.
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Affiliation(s)
- Chia-Yu Lin
- Division of Neuroradiology, Department of Radiology, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Hung-Chieh Chen
- Division of Neuroradiology, Department of Radiology, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- School of Medicine, National Yang-Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Yu-Hsuan Wu
- Division of Neurology, Neurological Institute, Taichung Veterans General Hospital, Taichung 40705, Taiwan
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Muengtaweepongsa S, Panpattanakul V. Is medical management useful in Moyamoya disease? World J Clin Cases 2024; 12:466-473. [PMID: 38322475 PMCID: PMC10841962 DOI: 10.12998/wjcc.v12.i3.466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/24/2023] [Accepted: 01/05/2024] [Indexed: 01/18/2024] Open
Abstract
Moyamoya disease (MMD), characterized by progressive internal carotid artery stenosis and collateral vessel formation, prompts cerebral perfusion complications and is stratified into idiopathic and Moyamoya syndrome subtypes. A multifaceted approach toward MMD management addresses cerebral infarctions through revascularization surgery and adjunctive medical therapy, while also navigating risks such as intracranial hemorrhage and cerebral infarction resulting from arterial stenosis and fragile collateral vessels. Addressing antithrombotic management reveals a potential role for treatments like antiplatelet agents and anticoagulants, despite the ambiguous contribution of thrombosis to MMD-related infarctions and the critical balance between preventing ischemic events and averting hemorrhagic complications. Transcranial doppler has proven useful in thromboembolic detection, despite persisting challenges concerning the efficacy and safety of antithrombotic treatments. Furthermore, antihypertensive interventions aim to manage blood pressure meticulously, especially during intracerebral hemorrhage, with recommendations and protocols varying based on the patient's hypertension status. Additionally, lipid-lowering therapeutic strategies, particularly employing statins, are appraised for their possible beneficial role in MMD management, even as comprehensive data from disease-specific clinical trials remains elusive. Comprehensive guidelines and protocols to navigate the multifaceted therapeutic avenues for MMD, while maintaining a delicate balance between efficacy and safety, warrant further meticulous research and development. This protocol manuscript seeks to elucidate the various aspects and challenges imbued in managing and navigating through the complex landscape of MMD treatment.
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Affiliation(s)
- Sombat Muengtaweepongsa
- Center of Excellence in Stroke, Division of Neurology, Department of Medicine, Faculty of Medicine, Thammasat University, Rangsit Campus, Klonglaung 12120, Pathum Thani, Thailand
| | - Vatcharasorn Panpattanakul
- Division of Neurology, Department of Internal Medicine, School of Medicine, University of Phayao, Phayao 56000, Thailand
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Ballout AA, Oh SY, Libman RB, Choi Y, Black K, Sideras P, Ayoub MS, Arora R, Langer DJ, Dehdashti AR, Katz JM. Stroke mechanisms in adult moyamoya disease: The association between infarction patterns and quantitative magnetic resonance angiography flow state. J Stroke Cerebrovasc Dis 2023; 32:107447. [PMID: 38745444 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107447] [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: 05/10/2023] [Revised: 10/02/2023] [Accepted: 10/24/2023] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Flow augmentation is the mainstay treatment for moyamoya disease as hemodynamic failure is believed to be the dominant mechanism. We aimed to investigate the mechanisms of stroke in moyamoya disease by assessing the relationship between infarction patterns and quantitative magnetic resonance angiography flow state. METHODS A retrospective study of adult patients with suspected MMD who presented with MRI confirmed acute ischemic stroke predating or following QMRA by a maximum of six months between 2009 and 2021 was conducted. Of the 177 consecutive patients with MMD who received QMRA, 35 patients, consisting of 41 hemispheres, met inclusion criteria. Flow-status was dichotomized into low-flow and normal-flow state based on previously established criteria. RESULTS Mixed infarction pattern was the most frequent finding (70.7 %), followed by embolic (17.1 %), perforator (7.3 %), and internal borderzone (IBZ) (4.9 %). Infarction patterns were further dichotomized into IBZ+ (internal borderzone alone or mixed) and IBZ- (no internal borderzone constituent). Low-flow states were not significantly more frequent in the IBZ+ compared to IBZ- population (48.4 % vs. 20.0 %, p = 0.14). Ipsilateral posterior cerebral artery fractional flow was significantly higher with IBZ+ compared to IBZ- (345.0 % vs. 214.7 %, p = 0.04). CONCLUSION Mixed infarction pattern was the most common pattern of infarction in patients with moyamoya disease, implying hypoperfusion and thromboembolism are codominant stroke mechanisms. An association between ICA flow status and infarction pattern was not found, although QMRA evidence of more robust posterior cerebral artery leptomeningeal collaterals was found in patients with a hypoperfusion contribution to their stroke mechanism.
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Affiliation(s)
- Ahmad A Ballout
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra University, Hempstead, NY 11549, USA.
| | - Seok Yoon Oh
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra University, Hempstead, NY 11549, USA
| | - Richard B Libman
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra University, Hempstead, NY 11549, USA
| | - Yuna Choi
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra University, Hempstead, NY 11549, USA
| | - Karen Black
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Panagiotis Sideras
- Department of Radiology, Columbia University Irving Medical Center at New York-Presbyterian Hospital, New York, NY, USA
| | - Marc S Ayoub
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Rohan Arora
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra University, Hempstead, NY 11549, USA
| | - David J Langer
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jeffrey M Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra University, Hempstead, NY 11549, USA; Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Liu T, Qin M, Xiong X, Li T, Feng L, Lai X, Gao Y. Benefits and risks of antiplatelet therapy for moyamoya disease: a systematic review and meta-analysis. Front Neurol 2023; 14:1132339. [PMID: 37409015 PMCID: PMC10318533 DOI: 10.3389/fneur.2023.1132339] [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: 12/27/2022] [Accepted: 05/30/2023] [Indexed: 07/07/2023] Open
Abstract
Background Moyamoya disease (MMD) is a leading cause of stroke in children and young adults, whereas no specific drugs are available. Antiplatelet therapy (APT) has been considered a promising treatment option, but its effectiveness remains controversial. Therefore, we aimed to comprehensively evaluate the benefits and risks of APT for MMD. Methods We systematically searched PubMed, Embase, and Cochrane Library electronic databases from their inception to 30 June 2022 and conducted a systematic review. All-cause mortality was taken as the primary outcome. Results Nine studies that enrolled 16,186 patients with MMD were included. The results from a single study showed that APT was associated with lower mortality [hazard ratio (HR) = 0.60; 95% confidence interval (CI) (0.50-0.71); p < 0.01] and improved bypass patency after surgical revascularization [HR = 1.57; 95% CI (1.106-2.235); p < 0.05]. The results of the meta-analysis showed that APT reduced the risk of hemorrhagic stroke [HR = 0.47; 95% CI (0.24-0.94); p < 0.05] but neither reduced the risk of ischemic stroke [HR = 0.80; 95% CI (0.33-1.94); p = 0.63] nor increased the proportion of independent patients [RR = 1.02; 95% CI (0.97-1.06); p = 0.47]. Conclusion Current evidence showed that APT was associated with a reduced risk of hemorrhagic stroke in MMD patients but did not reduce the risk of ischemic stroke or increase the proportion of independent patients. There was insufficient evidence about the benefit of APT on survival and postoperative bypass patency after surgical revascularization. However, the results should be interpreted cautiously because of the limited number of studies. Systematic review registration https://www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Tingting Liu
- Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, China
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Mingzhen Qin
- Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, China
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Xuejiao Xiong
- Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, China
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Tingting Li
- Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, China
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Luda Feng
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Xinxing Lai
- Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, China
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Ying Gao
- Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, China
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Chinese Medicine Key Research Room of Brain Disorders Syndrome and Treatment of the National Administration of Traditional Chinese Medicine, Beijing, China
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Luo Y, Cao Z, Ye H, Wu S, Sun X. Antiplatelet therapy may improve the prognosis of patients with moyamoya disease: a 12-year retrospective study. J Neurol 2023:10.1007/s00415-023-11702-5. [PMID: 37106259 DOI: 10.1007/s00415-023-11702-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/22/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVES The clinical value of antiplatelet therapy (APT) for moyamoya disease (MMD) remains controversial. Our study attempts to clarify the value of APT in this disease. METHODS We collected basic information, treatment strategies, and prognostic information on patients with MMD from 2010 to 2022 at our center. The data were divided into two groups, depending on whether APT was used or not, and compared by Pearson Chi-Square, Fisher's exact test, or Wilcoxon rank-sum test. We used propensity scores or inverse probability of treatment weighting to balance the covariates. Following this, we performed a meta-analysis of APT use in MMD. RESULTS 177 patients were enrolled, with a median follow-up of 41.1 months. APT did not affect the prognosis of patients with perioperative MMD, ischemic MMD, or asymptomatic MMD (P > 0.05), without increasing cerebral hemorrhagic risk. In contrast, APT was found to reduce mortality among patients with hemorrhagic MMD (P = 0.019), without affecting functional status, increasing stroke risk, or causing intracerebral hemorrhage (P > 0.05). But the small group cannot show the effect of APT. Our meta-analysis included nine articles involving 28,925 patients with MMD. It showed that APT could reduce stroke risk (odds ratio, OR = 0.57, 95% CI 0.49 to 0.65) and the Modified Rankin Scale (mRS) (weighted mean difference, WMD = - 0.07, 95% CI 0.14-0.00) during follow-up. The cohort study has limited weight (1.97% and 19.29%) in the meta-analysis. CONCLUSION Although the limited number of included documents, APT could be beneficial to the prognosis of MMD.
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Affiliation(s)
- Yuting Luo
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, No.58 Zhongshan Road 2, Guangzhou, 510080, China
| | - Zhixin Cao
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, No.58 Zhongshan Road 2, Guangzhou, 510080, China
| | - Heng Ye
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, No.58 Zhongshan Road 2, Guangzhou, 510080, China
| | - Shaoqing Wu
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
| | - Xunsha Sun
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University; Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases; National Key Clinical Department and Key Discipline of Neurology, No.58 Zhongshan Road 2, Guangzhou, 510080, China.
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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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Yamashita K, Tateishi Y, Kanamoto T, Ueda M, Nakamura Y, Tsujino A. [Two cases of ischemic stroke due to low protein C caused by severe hyperthyroidism]. Rinsho Shinkeigaku 2022; 62:839-843. [PMID: 36288963 DOI: 10.5692/clinicalneurol.cn-001754] [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: 06/16/2023]
Abstract
We reported two patients with acute ischemic stroke who had presented with symptoms of thyroid storm. Case1: A 43-year-old man abruptly developed left hemiparesis caused by the right middle cerebral artery occlusion. Cardiac evaluations revealed atrial fibrillation and left atrial enlargement. He had successful recanalization after reperfusion therapies. Case 2: A 66-year-old woman with severe bilateral middle cerebral artery stenosis presented with right hemiparesis and dysarthria. MRI revealed the acute infarction in the left frontal and parietal lobe. In both cases, protein C activity was decreased which could be related to severe hyperthyroidism. They concomitantly had arterial lesions where blood stasis could occur. Severe hyperthyroidism which could evoke the decreasing of protein C activity could be responsible to develop acute ischemic stroke.
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Affiliation(s)
- Kairi Yamashita
- Department of Neurology and Strokology, Nagasaki University Hospital
| | - Yohei Tateishi
- Department of Neurology and Strokology, Nagasaki University Hospital
| | - Tadashi Kanamoto
- Department of Neurology and Strokology, Nagasaki University Hospital
| | - Mayu Ueda
- Department of Endocrinology and Metabolism, Nagasaki University Hospital
| | - Yuta Nakamura
- Department of Endocrinology and Metabolism, Nagasaki University Hospital
| | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital
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Pompsch M, Veltkamp R, Diehl RR, Kraemer M. Microembolic signals and antiplatelet therapy in Moyamoya angiopathy. J Neurol 2022; 269:6605-6612. [PMID: 36002693 DOI: 10.1007/s00415-022-11323-4] [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: 07/17/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Embolism as a cause of stroke is widely neglected in Moyamoya angiopathy (MMA), and recommendations for use of antiplatelet therapy (APT) vary. We examined the presence of microembolic signals (MES) during transcranial Doppler (TCD) monitoring and assessed the effects of APT on the occurrence of MES in MMA. PATIENTS AND METHODS We retrospectively analysed patients with MMA treated at our centre between 2011 and 2021. TCD was performed at first presentation and at most visits, while number of visits varied between individual patients. TCD was performed for 30 min bilaterally. Patient demographics, vascular risk factors, and antiplatelet treatment were collected from each clinic visit and ischemic and haemorrhagic episodes were captured as recorded during follow-up visits. RESULTS 209 patients were included in the analysis (mean age 38.7 ± 15.3, 28% male). 21 patients with 27 MES-positive TCD examinations were identified (10%). Patient characteristics were similar in MES-positive and MES-negative groups. However, recent ischemic events were detected at a significantly higher rate in MES-positive patients (42.9% vs 4.8%, p < 0.001). After MES detection, change of antiplatelet drug regime was performed, leading to loss of MES in all cases. Dual APT was preferably used in the MES-positive group (p < 0.001) but no significant difference of haemorrhage during follow-up-visits was observed. Reduction of APT before bypass-surgery triggered MES in four patients. CONCLUSION APT is required in patients with MMA. MES monitoring may help to identify risk patients in need of intensified APT.
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Affiliation(s)
- Mosche Pompsch
- Department of Neurology, Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45130, Essen, Germany
| | - Roland Veltkamp
- Department of Neurology, Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45130, Essen, Germany.,Department of Brain Sciences, Imperial College London, London, UK
| | - Rolf R Diehl
- Department of Neurology, Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45130, Essen, Germany.,University of Duisburg-Essen, Essen, Germany
| | - Markus Kraemer
- Department of Neurology, Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45130, Essen, Germany. .,Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
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Chen Y, Tang M, Li H, Liu H, Wang J, Huang J. TGFβ1 as a Predictive Biomarker for Collateral Formation Within Ischemic Moyamoya Disease. Front Neurol 2022; 13:899470. [PMID: 35873760 PMCID: PMC9301205 DOI: 10.3389/fneur.2022.899470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Moyamoya disease (MMD) is a unique cerebrovascular occlusive disease characterized by progressive steno-occlusion within the terminal segment of the internal carotid artery. However, good collaterals from an external carotid artery are essential to compensate for the ischemia in moyamoya disease. This study aimed to investigate the transforming growth factor-beta 1 (TGFβ1) in plasma as a potential biomarker for predicting collateral formation in ischemic MMD. Methods The transcriptome profile downloaded from Gene Expression Omnibus (GEO) was used to analyze the differential expression of genes between the ischemic MMD and the control groups. We prospectively recruited 23 consecutive patients with ischemic MMD that was diagnosed via digital subtraction angiography (DSA). Nine patients with intracranial aneurysms and four healthy people served as controls. The collaterals from the external carotid artery were examined using DSA. We evaluated whether the collateral formation was associated with TGFβ1 in patients with ischemic MMD. Western blot, RT-qPCR, ELISA, and tube formation assay were used to explore the relationship between TGFβ1 and angiogenesis, as well as the potential mechanisms. Results The mRNA levels of TGFβ1 were upregulated in the patients with ischemic MMD. The plasma TGFβ1 levels were higher in the patients with ischemic MMD than in the aneurysm and healthy patients (p < 0.05). The collateral formation group has higher levels of serum TGFβ1 than the non-collateral formation group (p < 0.05). The levels of vascular endothelial growth factor (VEGF) are positively correlated with TGFβ1 levels in the plasma (R2 = 0.6115; p < 0.0001). TGFβ1 regulates VEGF expression via the activation of the TGFβ pathway within HUVEC cells, as well as TGFβ1 stimulating HUVEC cells to secrete VEGF into the cell culture media. An in vitro assay revealed that TGFβ1 promotes angiogenesis within the endothelial cells. Conclusion Our findings suggest that TGFβ1 plays a vital role in promoting collateral formation by upregulating VEGF expression in ischemic MMD.
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Affiliation(s)
- Yuanbing Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Miao Tang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Hui Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Hongwei Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Junyu Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Jun Huang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Jun Huang
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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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Horn JD, Johnson MJ, Starosolski Z, Meoded A, Milewicz DM, Annapragada A, Hossain SS. Patient-Specific Modeling Could Predict Occurrence of Pediatric Stroke. Front Physiol 2022; 13:846404. [PMID: 35295566 PMCID: PMC8920501 DOI: 10.3389/fphys.2022.846404] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/02/2022] [Indexed: 11/23/2022] Open
Abstract
Moyamoya disease (MMD) is a progressive steno-occlusive cerebrovascular disease leading to recurrent stroke. There is a lack of reliable biomarkers to identify unilateral stroke MMD patients who are likely to progress to bilateral disease and experience subsequent contralateral stroke(s). We hypothesized that local hemodynamics are predictive of future stroke and set out to noninvasively assess this stroke risk in pediatric MMD patients. MR and X-ray angiography imaging were utilized to reconstruct patient-specific models of the circle of Willis of six pediatric MMD patients who had previous strokes, along with a control subject. Blood flow simulations were performed by using a Navier-Stokes solver within an isogeometric analysis framework. Vascular regions with a wall shear rate (WSR) above the coagulation limit (>5,000 s-1) were identified to have a higher probability of thrombus formation, potentially leading to ischemic stroke(s). Two metrics, namely, "critical WSR coverage" and "WSR score," were derived to assess contralateral stroke risk and compared with clinical follow-up data. In two patients that suffered a contralateral stroke within 2 months of the primary stroke, critical WSR coverages exceeding 50% of vessel surface and WSR scores greater than 6× the control were present in multiple contralateral vessels. These metrics were not as clearly indicative of stroke in two additional patients with 3-5 year gaps between primary and contralateral strokes. However, a longitudinal study of one of these two cases, where a subsequent timepoint was analyzed, suggested disease stabilization on the primary stroke side and an elevated contralateral stroke risk, which was confirmed by patient outcome data. This indicates that post-stroke follow-up at regular intervals might be warranted for secondary stroke prevention. The findings of this study suggest that WSR-based metrics could be predictive of future stroke risk after an initial stroke in pediatric MMD patients. In addition, better predictions may be possible by performing patient-specific hemodynamic analysis at multiple timepoints during patient follow-up to monitor changes in the WSR-based metrics.
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Affiliation(s)
- John D. Horn
- Molecular Cardiology Research Laboratory, Texas Heart Institute, Houston, TX, United States
| | - Michael J. Johnson
- Oden Institute for Computational Engineering and Sciences, University of Texas at Austin, Austin, TX, United States
| | - Zbigniew Starosolski
- Translational Imaging Group, Texas Children’s Hospital, Houston, TX, United States
- Department of Radiology, Baylor College of Medicine, Houston, TX, United States
| | - Avner Meoded
- Translational Imaging Group, Texas Children’s Hospital, Houston, TX, United States
- Department of Radiology, Baylor College of Medicine, Houston, TX, United States
| | - Dianna M. Milewicz
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, TX, United States
| | - Ananth Annapragada
- Translational Imaging Group, Texas Children’s Hospital, Houston, TX, United States
- Department of Radiology, Baylor College of Medicine, Houston, TX, United States
| | - Shaolie S. Hossain
- Molecular Cardiology Research Laboratory, Texas Heart Institute, Houston, TX, United States
- Oden Institute for Computational Engineering and Sciences, University of Texas at Austin, Austin, TX, United States
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12
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Jeong W, Seong GM, Oh JH, Choi JC, Kim JG. A case report of critical ischemic stroke in moyamoya-like vasculopathy accompanied by systemic lupus erythematosus. ENCEPHALITIS 2022; 2:24-27. [PMID: 37469610 PMCID: PMC10295907 DOI: 10.47936/encephalitis.2021.00150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/24/2021] [Accepted: 11/01/2021] [Indexed: 07/21/2023] Open
Abstract
Moyamoya-like vasculopathy (MMV) is a rare, chronic, progressive cerebrovascular disorder characterized by stenosis or occlusion of the terminal portion of the bilateral internal carotid arteries and development of abnormal collateral vessels at the base of the brain. This disorder develops in association with various systemic diseases and conditions, including neurofibromatosis type 1, Down syndrome, thyroid disease, radiation therapy, and autoimmune disease. We report a case of a 51-year-old female patient with low-activity systemic lupus erythematosus (SLE) who had a sudden onset of global aphasia and right hemiplegia. Three months previous, she had been on antiplatelet medication due to a single transient ischemic attack. Brain magnetic resonance imaging demonstrated a massive infarct of the left middle cerebral artery territory. Conventional angiography showed complete occlusion of the left middle cerebral artery with poor development of basal collateral vessels. This case demonstrates that a patient with underlying autoimmune disease such as SLE accompanied by MMV should be considered vulnerable to ischemic stroke.
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Affiliation(s)
- Wooseong Jeong
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Gil Myeong Seong
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Jung-Hwan Oh
- Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Joong-Goo Kim
- Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
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13
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Kim JY, Kim HJ, Choi EH, Pan KH, Chung JW, Seo WK, Kim GM, Jee TK, Yeon JY, Kim JS, Hong SC, Seong MJ, Cha J, Kim KH, Jeon P, Bang OY. Vessel Wall Changes on Serial High-Resolution MRI and the Use of Cilostazol in Patients With Adult-Onset Moyamoya Disease. J Clin Neurol 2022; 18:610-618. [DOI: 10.3988/jcn.2022.18.6.610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Jae Youn Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyung Jun Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun-Hyeok Choi
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Hyun Pan
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Won Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo-Keun Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Keun Jee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Soo Kim
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Chyul Hong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min-Jung Seong
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jihoon Cha
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keon Ha Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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14
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Clinical Management of Moyamoya Patients. J Clin Med 2021; 10:jcm10163628. [PMID: 34441923 PMCID: PMC8397113 DOI: 10.3390/jcm10163628] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 01/01/2023] Open
Abstract
Moyamoya angiopathy (MMA) is a peculiar cerebrovascular condition characterized by progressive steno-occlusion of the terminal part of the internal carotid arteries (ICAs) and their proximal branches, associated with the development of a network of fragile collateral vessels at the base of the brain. The diagnosis is essentially made by radiological angiographic techniques. MMA is often idiopathic (moyamoya disease-MMD); conversely, it can be associated with acquired or hereditary conditions (moyamoya Syndrome-MMS); however, the pathophysiology underlying either MMD or MMS has not been fully elucidated to date, and this poor knowledge reflects uncertainties and heterogeneity in patient management. MMD and MMS also have similar clinical expressions, including, above all, ischemic and hemorrhagic strokes, then headaches, seizures, cognitive impairment, and movement disorders. The available treatment strategies are currently shared between idiopathic MMD and MMS, including pharmacological and surgical stroke prevention treatments and symptomatic drugs. No pharmacological treatment able to reverse the progressive disappearance of the ICAs has been found to date in both idiopathic and syndromic cases. Antithrombotic agents are usually prescribed in ischemic MMA, although the coexisting hemorrhagic risk should be considered. Surgical revascularization techniques, which are currently the best available treatment in symptomatic MMA, are associated with good long-term outcomes and reduced ischemic and hemorrhagic risks. Given the lack of dedicated randomized clinical trials, current treatment is mainly based on observational studies and physicians’ and surgeons’ expertise.
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15
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Han Q, Yao F, Zhang Z, Huang Y. Evaluation of Revascularization in Different Suzuki Stages of Ischemic Moyamoya Disease by Whole-Brain CT Perfusion. Front Neurol 2021; 12:683224. [PMID: 34367049 PMCID: PMC8343098 DOI: 10.3389/fneur.2021.683224] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 06/28/2021] [Indexed: 12/12/2022] Open
Abstract
Objective: This study compared the clinical features and hemodynamic characteristics of patients in different Suzuki stages of ischemic moyamoya disease (iMMD) before and after treatment with extracranial-intracranial (EC-IC) bypass surgery combined with encephalo-duro-myo-synangiosis and whole-brain computed tomography perfusion (WB-CTP). Methods: A total of 126 patients in different Suzuki stages (II, III, IV, and V) of iMMD who underwent bypass surgery from April 2013 to August 2020 were included in this retrospective study. MIStar automatic analysis of Whole brain CT perfusion imaging software (WB-CTP, Apollo Medical Imaging Technology, Melbourne, Australia) was used. The patients also underwent WB-CTP 1 day before and 1 week and 3 months after the surgery. The relationships between hemodynamic parameters in WB-CTP including delay time (DT) > 3 s, relative cerebral blood flow (rCBF) < 30%, mismatch and mismatch ratio, and clinical outcomes were evaluated for different Suzuki stages, with comparisons between early (II and III) and late (IV and V) stages. Results: Combined bypass surgery was performed in 161 hemispheres of 126 patients with iMMD. Brain volume with DT > 3 s was decreased 1 week (51.5 ± 11.8 ml, P < 0.05) and 3 months (41.5 ± 10.7 ml, P < 0.05) after bypass compared to 1 day before bypass (104.7 ± 15.1 ml) in early-stage patients. In late-stage patients, the volume was increased 1 week after bypass compared to the preoperative value (154.3 ± 14.7 vs. 118.3 ± 19.1 ml, P < 0.05). Preoperative brain volume with rCBF < 30% was lower (9.8 ± 3.9 vs. 33.5 ± 11.0 ml) whereas preoperative mismatch ratio was higher (11.2 ± 2.8 vs. 3.6 ± 1.6) in early-stage as compared to late-stage patients (both P < 0.05). A higher modified Rankin scale score (0–1) was achieved by early-stage patients than by those in the late stage (93.8 vs. 80.4%, P < 0.05) at the 3-month follow-up. Conclusions: WB-CTP is useful for assessing the effectiveness of combined bypass/revascularization in different Suzuki stages of iMMD. Patients in the early stage of disease with higher preoperative brain volume with DT > 3 s and mismatch ratio show greater improvements in hemodynamic parameters and fewer postoperative complications associated with hemodynamic disturbance following bypass than patients in the late stage. Preoperative mismatch ratio can serve as a marker for assessing the status of collateral circulation in different Suzuki stages of iMMD.
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Affiliation(s)
- Qingdong Han
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Feirong Yao
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhengyu Zhang
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yabo Huang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
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16
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1198] [Impact Index Per Article: 399.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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17
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Blood Pressure and Transient Postoperative Neurologic Deterioration, Following Superficial Temporal-to-Middle Cerebral Artery Anastomosis in Adult Patients with Moyamoya Disease: A Retrospective Cohort Study. J Clin Med 2021; 10:jcm10122567. [PMID: 34200622 PMCID: PMC8227225 DOI: 10.3390/jcm10122567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/28/2021] [Accepted: 06/07/2021] [Indexed: 11/17/2022] Open
Abstract
We investigated whether intraoperative systolic blood pressure (ISBP) is associated with the risk of transient neurologic deficits (TND) following superficial temporal-to-middle cerebral artery (STA-MCA) anastomosis in adult patients with moyamoya disease (MMD). In this retrospective observational study, data from adult patients with MMD who had undergone STA-MCA anastomosis at a single tertiary academic hospital during May 2003–April 2014 were examined. Data on patient characteristics were obtained from electronic medical records, including the details of comorbidities and laboratory findings. TND was the primary outcome of interest. Out of 192 patients (228 hemispheres), 66 (29%) hemispheres had TND after surgery. There were significant differences in ISBP between patients with and without TND. The lowest ISBP quartile was independently associated with TND (odds ratio: 5.50; 95% confidence interval: 1.96–15.46). Low ISBP might lead to TND after STA-MCA anastomosis in adult patients with MMD. In patients with poor perfusion status, low ISBP was associated with an increased risk of TND. Our findings suggest that strict ISBP control might be required to prevent TND after anastomosis in patients with MMD, in particular, in patients with poor perfusion status. Given limitations due to the retrospective design, further studies are needed to clarify these findings.
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18
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Chen Z, Wu X, Zhou D, Shang S, Ding Y, Ji X, Meng R. Characteristics of cerebral ischemic stroke based on moyamoya disease and atherosclerosis-associated intracranial arterial stenosis. Neurol Sci 2021; 43:1087-1096. [PMID: 34106367 DOI: 10.1007/s10072-021-05359-z] [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: 03/14/2021] [Accepted: 05/28/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE To analyze the characteristics of acute ischemic stroke (AIS) resulting from moyamoya disease (MMD) and intracranial large artery atherosclerotic stenosis (LAS). METHOD This real-world case control study enrolled imaging-confirmed AIS patients owing to MMD or LAS hospitalized from January 2015 through September 2020 consecutively. The features of risk factors, peripheral blood, and imaging presentations were compared between the two cohorts. RESULTS A total of 191 eligible patients entered into final analysis, including 70 cases with MMD stroke and 121 with LAS stroke. LAS stroke vs. MMD stroke, the ratios of hyperlipidemia, hypertension, diabetes, and hyperhomocysteinemia were higher in the former (65.3 vs.12.9%, 65.3% vs. 4.3%, 39.7% vs. 2.9%, and 43.8% vs.12.9%; all p < 0.01) as well as baseline plasma arachidonic acid (AA) and adenosine diphosphate (ADP)-stimulated maximum platelet aggregation rates (75.3% vs. 60.8% and 73.1% vs.64.9%, respectively, all p < 0.01), which were positively correlated with triglycerides and cholesterol levels, blood glucose, age, and platelet counts (all p < 0.01). Classical watershed infarction (WSI) accounted for 87.14% in MMD stroke and 40.49% in LAS stroke, respectively (p < 0.01). Almost all of the patients with LAS showed plaques in arterial walls on CTA maps and non-homogeneous thickening with irregular luminal narrowing on HRMRI, while plaques were seldom found in MMD besides homogeneous thickening with regular luminal narrowing. CONCLUSIONS Differing from LAS stroke, MMD stroke mainly presents with WSI and does not feature with platelet hyper-aggregation and fragmentation of ulcer plaque. Whereby, focusing on perfusion improvement rather than antiplatelets and statins may be the predominant step in MMD-stroke correction.
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Affiliation(s)
- Zhiying Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Xiaoqin Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Da Zhou
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Shuling Shang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Department of Neurology, Xiehe Hospital, Tangshan, Hebei, 063000, China
| | - Yuchuan Ding
- Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Xunming Ji
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China.,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Ran Meng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China. .,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053, China. .,Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.
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19
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Seo WK, Kim JY, Choi EH, Kim YS, Chung JW, Saver JL, Bang OY, Kim GM. Association of Antiplatelet Therapy, Including Cilostazol, With Improved Survival in Patients With Moyamoya Disease in a Nationwide Study. J Am Heart Assoc 2021; 10:e017701. [PMID: 33615836 PMCID: PMC8174237 DOI: 10.1161/jaha.120.017701] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Although antiplatelet agents are frequently prescribed in moyamoya disease in routine clinical practice, there are no large‐scale epidemiologic trials or randomized trial evidence to support their use in patients with moyamoya disease. Methods and Results Using the Korean National Health Insurance Service database, patients diagnosed with moyamoya disease between 2002 and 2016 were followed up for up to 14 years to assess, using time‐dependent Cox regression in all patients and in a propensity score–matched cohort, the association of antiplatelet therapy and individual antiplatelet agents with survival. Among 25 978 patients with newly diagnosed moyamoya disease, mean age was 37.6±19.9 years, 61.6% were women, and total follow‐up was 163 347 person‐years. Among 9154 patients who were prescribed antiplatelet agents at least once during the follow‐up period, the proportion prescribed cilostazol gradually increased from 5.5% in 2002 to 56.0% in 2016. Any antiplatelet use was associated with reduced risk of death (hazard ratio, 0.77; 95% CI, 0.70–0.84) in a multivariate model. Among individual antiplatelet agents, cilostazol was associated with greater reduction in mortality than the 5 other antiplatelet regimens. Subgroup analysis, according to the age group and history of ischemic stroke, and sensitivity analysis, using propensity score–matched analysis, revealed consistent results. Conclusions Antiplatelet therapy is associated with substantial improvement in survival in patients with moyamoya disease, and cilostazol is associated with greater survival benefit compared with other antiplatelet regimens. These results provisionally support the use of antiplatelet therapy in patients with moyamoya disease and the conduct of confirmatory randomized controlled trials.
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Affiliation(s)
- Woo-Keun Seo
- Department of Neurology and Stroke Center Samsung Medical Center Seoul Korea.,Department of Digital Health Samsung Advanced Institute for Health Sciences & TechnologySungkyunkwan University Seoul Korea
| | - Jae-Young Kim
- Department of Neurology and Stroke Center Samsung Medical Center Seoul Korea.,Department of Digital Health Samsung Advanced Institute for Health Sciences & TechnologySungkyunkwan University Seoul Korea
| | - Eun-Hyeok Choi
- Department of Neurology and Stroke Center Samsung Medical Center Seoul Korea
| | - Ye-Sel Kim
- Department of Neurology and Stroke Center Samsung Medical Center Seoul Korea
| | - Jong-Won Chung
- Department of Neurology and Stroke Center Samsung Medical Center Seoul Korea
| | - Jeffrey L Saver
- Department of Digital Health Samsung Advanced Institute for Health Sciences & TechnologySungkyunkwan University Seoul Korea.,Department of Neurology University of California Los Angeles CA
| | - Oh Young Bang
- Department of Neurology and Stroke Center Samsung Medical Center Seoul Korea
| | - Gyeong-Moon Kim
- Department of Neurology and Stroke Center Samsung Medical Center Seoul Korea
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20
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Time to peak and full width at half maximum in MR perfusion: valuable indicators for monitoring moyamoya patients after revascularization. Sci Rep 2021; 11:479. [PMID: 33436788 PMCID: PMC7804964 DOI: 10.1038/s41598-020-80036-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/15/2020] [Indexed: 12/18/2022] Open
Abstract
Moyamoya disease (MMD) is a chronic, steno-occlusive cerebrovascular disorder of unknown etiology. Surgical treatment is the only known effective method to restore blood flow to affected areas of the brain. However, there are lack of generally accepted noninvasive tools for therapeutic outcome monitoring. As dynamic susceptibility contrast (DSC) magnetic resonance imaging (MRI) is the standard MR perfusion imaging technique in the clinical setting, we investigated a dataset of nineteen pediatric MMD patients with one preoperational and multiple periodic DSC MRI examinations for four to thirty-eight months after indirect revascularization. A rigid gamma variate model was used to derive two nondeconvolution-based perfusion parameters: time to peak (TTP) and full width at half maximum (FWHM) for monitoring transitional bolus delay and dispersion changes respectively. TTP and FWHM values were normalized to the cerebellum. Here, we report that 74% (14/19) of patients improve in both TTP and FWHM measurements, and whereof 57% (8/14) improve more noticeably on FWHM. TTP is in good agreement with Tmax in estimating bolus delay. Our study data also suggest bolus dispersion estimated by FWHM is an additional, informative indicator in pediatric MMD monitoring.
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21
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Intraoperative local hemodynamic quantitative analysis of direct revascularization in patients with moyamoya disease. Neurosurg Rev 2020; 44:2659-2666. [PMID: 33242129 DOI: 10.1007/s10143-020-01442-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/19/2020] [Accepted: 11/13/2020] [Indexed: 10/22/2022]
Abstract
Direct bypass surgery improves blood flow in patients with moyamoya disease (MMD) as well as causes local flow relocation and disturbance. This study aimed to describe the characteristics and changes of quantitative blood flow in MMD patients. Sixty-four consecutive MMD patients (67 hemispheres) who underwent STA-MCA anastomosis between August 2013 and September 2017 were included in this study. Intraoperative blood flow of superficial temporal artery and middle cerebral artery was measured with a noninvasive, ultrasound flowprobe, before and after the bypass. All data were collected prospectively. Before the bypass, 67 hemispheres were measured and 45 hemispheres acquired post-bypass measurements. Thirty-three (49.3%) had anterograde flow and 34 (50.7%) had retrograde. Retrograde blood flow was significantly higher than anterograde blood flow in MCA-M4 section (3.71 ± 2.78 ml/min vs 2.39 ± 1.71 ml/min, P = 0.023). Thirty-eight (56.7%) patients had local cerebrovascular reactivity, whereas 29 (43.3%) lost it. After bypass, blood flow was changed into three patterns: anterograde flow (1, 2.2%), retrograde flow (3, 6.7%), and bi-direction flow (41, 91.1%). Flow of M4 was significantly improved in both proximal (13.64 ± 9.16 vs 3.28 ± 2.57, P < 0.001) and distal (7.17 ± 7.21 vs 3.28 ± 2.57, P = 0.002) sides to the bypass. Postoperative infarctions occurred in 4 (8.9%) patients. All postoperative infarctions (n = 4) happened in those patients who did not have change of flow direction in M4 section distal to the bypass (P = 0.040). Direct bypass surgery improves local blood flow after bypass surgery in both sides of the anastomosis. Flow direction was usually changed after the surgery into a bi-direction pattern: anterograde flow in M4 distal to the bypass, and retrograde flow in M4 proximal to the bypass. Proximal side acquired around 5.4 times of flow than the distal side. Patients with change of flow direction in distal M4 were related with lower risks of postoperative infarctions.
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22
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Moussouttas M, Rybinnik I. A critical appraisal of bypass surgery in moyamoya disease. Ther Adv Neurol Disord 2020; 13:1756286420921092. [PMID: 32547641 PMCID: PMC7273549 DOI: 10.1177/1756286420921092] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/30/2020] [Indexed: 01/25/2023] Open
Abstract
Moyamoya disease (MMD) is a complex cerebrovascular disorder about which little
is known. Conventionally, revascularization surgery is recommended for patients,
despite an absence of conclusive data from adequate clinical trials.
Underscoring the uncertainty that exists in treating MMD patients, investigators
continue to present data comparing revascularization with conservative or
medical management, most of which originates from East Asia where MMD is most
prevalent. The purpose of this manuscript is to review contemporary large case
series, randomized trials, and recent meta-analyses that compare surgical and
medical treatments in adult patients with MMD, and to critically analyze the
modern literature in the context of current practice standards. Data from the
available literature is limited, but revascularization seems superior to
conservative therapy in adult patients presenting with hemorrhage, and in
preventing future hemorrhages. Conversely, evidence that surgery is superior to
medical therapy is not convincing in adult patients presenting with cerebral
ischemia, or for the prevention of future ischemic events. In contrast to East
Asian populations, MMD in Europe and in the Americas is predominantly an
ischemic disease that presents in adulthood. Adequate multinational trials are
warranted.
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Affiliation(s)
- Michael Moussouttas
- Department of Neurology, Cerebrovascular Division, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite 6200, New Brunswick, NJ 08901, USA
| | - Igor Rybinnik
- Department of Neurology, Cerebrovascular Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Zhang M, Tang J, Liu N, Xue Y, Ren X, Fu J. Postoperative Functional Outcomes and Prognostic Factors in Two Types of Adult Moyamoya Diseases. J Stroke Cerebrovasc Dis 2020; 29:104846. [PMID: 32439351 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104846] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/24/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND To determine the functional outcomes in each period for adult ischemic and hemorrhagic Moyamoya disease (MMD) patients and identify prognostic factors. METHODS The current retrospective study reviewed consecutive adult MMD patients surgically treated from January 2012 to June 2017. Perioperative clinical data were collected and follow-up was conducted via telephone interviews. Functional outcomes and prognostic factors were analyzed. RESULTS A total of 219 ischemic MMD patients (268 hemispheres) and 157 hemorrhagic patients (193 hemispheres) were included. The median follow-up time was 18 months (3-69 months). MMD type had no significant effect on the modified Rankin Scale(mRS) score at discharge. Perioperative complications (P = 0.004) and the mRS score at baseline (P < 0.001) were risk factors correlated with the short-term functional outcomes in both groups, while diabetes mellitus (DM, P = 0.022) also played a role in the ischemic group. During the follow-up period, functional outcomes obviously improved in both groups, but two groups showed nonproportional cumulative curves for favorable functional outcomes (log-rank test, P = 0.483). Stroke recurrence (P < 0.001) and mRS at discharge (P < 0.001) were common factors related with long-term functional outcomes in two types of MMD patients. Particularly, female patients with ischemic MMD were more likely to have higher mRS scores (P = 0.028) and Suzuki stage was positively associated with long-term functional outcomes in hemorrhagic group (P = 0.044). CONCLUSIONS MMD type had no significant effect on prognosis while both types of MMD patients showed overall significant improvements in functional outcomes after surgery. Different types of MMD patients have distinct prognostic factors for short-term and long-term functional outcomes.
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Affiliation(s)
- Miaoyi Zhang
- Department of Neurology, North Huashan hospital, Fudan University, No.108 Lu Xiang Road, Shanghai 201900, China
| | - Jie Tang
- Department of Neurology, Huashan Hospital, Fudan University, No.12 Wulumuqi Zhong Road, Jing an District, Shanghai 200040, China
| | - Na Liu
- Department of Neurology, Huashan Hospital, Fudan University, No.12 Wulumuqi Zhong Road, Jing an District, Shanghai 200040, China
| | - Yang Xue
- Department of Neurology, Huashan Hospital, Fudan University, No.12 Wulumuqi Zhong Road, Jing an District, Shanghai 200040, China
| | - Xue Ren
- Department of Neurology, Huashan Hospital, Fudan University, No.12 Wulumuqi Zhong Road, Jing an District, Shanghai 200040, China
| | - Jianhui Fu
- Department of Neurology, North Huashan hospital, Fudan University, No.108 Lu Xiang Road, Shanghai 201900, China; Department of Neurology, Huashan Hospital, Fudan University, No.12 Wulumuqi Zhong Road, Jing an District, Shanghai 200040, China.
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24
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Jeon C, Yeon JY, Jo KI, Hong SC, Kim JS. Clinical Role of Microembolic Signals in Adult Moyamoya Disease With Ischemic Stroke. Stroke 2020; 50:1130-1135. [PMID: 30935317 DOI: 10.1161/strokeaha.118.022490] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Hemodynamic compromise has been implicated in moyamoya disease (MMD) with transient ischemic attacks or ischemic stroke. However, increasing evidence supports the notion that artery-to-artery embolism may also contribute to ischemic events based on microembolic signal (MES) monitoring. Methods- A total of 48 patients aged between 20 and 60 years with newly diagnosed MMD were enrolled and angiographically classified according to the Suzuki staging system. For detection of MESs, transcranial Doppler was performed at the middle cerebral artery bilaterally for a 30-minute period. Mean flow velocities in the middle cerebral artery were also evaluated and categorized into low (<40 cm/s), normal (40-80 cm/s), and high (>80 cm/s). Clinical characteristics, cerebral angiography findings, recent ischemic events within 3 months, and antiplatelet medication were correlated with transcranial Doppler findings. Results- MESs were detected in 11 of the 48 patients (23%), with a frequency of 11 of 89 (12%) examined hemispheres. The mean number of MESs was 2 (range, 1-6). Six of the 11 hemispheres (55%) presented with ischemic strokes or transient ischemic attacks, and 2 (18%) presented with hemorrhagic strokes. The presence of MESs was associated with recent ischemic events ( P=0.024) and high mean flow velocities ( P=0.016), which was usually observed in Suzuki stage I and II (early-stage MMD). After controlling for age, sex, and antiplatelet medication, both recent ischemic events (odds ratio, 6.294; 95% CI, 1.345-29.457; P=0.019) and high mean flow velocities (odds ratio, 6.172; 95% CI, 1.235-31.25; P=0.027) were found to be independent predictors of MESs. Conclusions- MESs were observed in patients with high mean flow velocities, particularly early-stage MMD, and clinically associated with recent ischemic events. A randomized controlled study is necessary to determine the efficacy of antiplatelet agents in the treatment of MES-positive MMD.
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Affiliation(s)
- Chiman Jeon
- From the Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (C.J., J.Y.Y., S.-C.H., J.-S.K.)
| | - Je Young Yeon
- From the Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (C.J., J.Y.Y., S.-C.H., J.-S.K.)
| | - Kyung Il Jo
- Department of Neurosurgery, Hana General Hospital, Cheongju, Korea (K.I.J.)
| | - Seung-Chyul Hong
- From the Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (C.J., J.Y.Y., S.-C.H., J.-S.K.)
| | - Jong-Soo Kim
- From the Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (C.J., J.Y.Y., S.-C.H., J.-S.K.)
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25
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Moyamoya Disease and Spectrums of RNF213 Vasculopathy. Transl Stroke Res 2019; 11:580-589. [DOI: 10.1007/s12975-019-00743-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 10/25/2022]
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26
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Wang JZ, He W, Zhang D, Yu LB, Zhao YH, Cai JX. Changing Ischemic Lesion Patterns and Hemodynamics of the Posterior Cerebral Artery in Moyamoya Disease. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:2621-2630. [PMID: 30702756 DOI: 10.1002/jum.14959] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/28/2018] [Accepted: 01/04/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The aim of this study was to determine how hemodynamics of the posterior cerebral artery (PCA) are associated with cerebral ischemic lesions in moyamoya disease (MMD). METHODS Thirty-six patients with ischemic MMD (Suzuki grade IV-V) were retrospectively analyzed. Hemodynamic parameters of the PCA were measured by transcranial color-coded sonography. We classified the range of ischemic lesions into 3 grades and perfusion levels into 3 grades according to computed tomography (CT) results. PCA steno-occlusion and leptomeningeal collaterals were confirmed by digital subtraction angiography. Ultrasonographic parameters in the PCA were compared with these radiographic findings. RESULTS The velocity in the involved PCA (mean flow velocity [MFV] median, 42.00 [range, 34.50-58.00] cm/s) was significantly lower than that in the normal PCA (MFV median, 95.00 [range, 76.50-119.50] cm/s) (P < .001). The velocity in the PCA increased significantly as the leptomeningeal collateral stage advanced (MFV stage 1: median, 38.50 [range, 29.75-63.50] cm/s; stage 2: median, 55.00 [range, 44.00-96.00] cm/s; stage 3: median, 94.00 [range, 54.00-118.25] cm/s; stage 4: median, 85.50 [range, 70.50-117.75] cm/s, respectively) (P < .05). Decreased PCA velocities were associated with a larger ischemic area on CT (P ≤ .001). PCA velocity had no correlation with CT perfusion level of the temporal and frontal lobes. PCA velocity had significant correlations with perfusion level in the occipital (P < .001) and parietal lobes (P < .05). CONCLUSIONS Our results suggest ischemic lesion patterns (as demonstrated on CT imaging) are associated with PCA velocity measurements in the advanced stage of MMD. Thus, monitoring PCA velocity in patients with advanced MMD may provide additional information to assist in managing these patients.
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Affiliation(s)
- Jing-Zhe Wang
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wen He
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Le-Bao Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ya-Hui Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jin-Xiu Cai
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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27
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Rudilosso S, Laredo C, Mancosu M, Moya-Planas N, Zhao Y, Chirife O, Chamorro Á, Urra X. Cerebral perfusion and compensatory blood supply in patients with recent small subcortical infarcts. J Cereb Blood Flow Metab 2019; 39:1326-1335. [PMID: 29436885 PMCID: PMC6668517 DOI: 10.1177/0271678x18758548] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 12/05/2017] [Accepted: 01/09/2018] [Indexed: 12/15/2022]
Abstract
Hypoperfusion is the typical perfusion pattern associated with recent small subcortical infarcts of the brain, but other perfusion patterns may be present in patients with these infarcts. Using CT perfusion, we studied 67 consecutive patients who had a small subcortical infarct at a follow-up MRI study to investigate the correlation between the perfusion pattern and the clinical and radiological course. On CT perfusion map analysis, 51 patients (76%) had focal hypoperfusion, 4 patients (6%) had hyperperfusion and the remaining 12 patients (18%) showed no abnormalities. On dynamic sequential imaging analysis obtained from the source perfusion images, 32 patients (48%) had a sustained hypoperfusion pattern, 11 patients (16%) had a reperfusion pattern, and 18 patients (27%) had a delayed compensation pattern. Systolic blood pressure was higher in patients with sustained hypoperfusion although the perfusion pattern was independent of the final volume of infarction. These results reinforce the notion that mechanisms other than hypoperfusion are at play in patients with small subcortical infarcts including the intervention of compensatory sources of blood flow. The ultimate clinical significance of these perfusion patterns remains to be determined in larger series of patients assessed longitudinally.
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Affiliation(s)
- Salvatore Rudilosso
- Functional Unit of Cerebrovascular
Diseases,
Hospital
Clínic, Barcelona, Spain
| | - Carlos Laredo
- Functional Unit of Cerebrovascular
Diseases,
Hospital
Clínic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques
August Pi i Sunyer, Barcelona, Spain
| | - Marco Mancosu
- Department of Neurology, AOU Policlinico
Universitario, Monserrato (Cagliari), Italy
| | - Nuria Moya-Planas
- Institut d'Investigacions Biomèdiques
August Pi i Sunyer, Barcelona, Spain
| | - Yashu Zhao
- Functional Unit of Cerebrovascular
Diseases,
Hospital
Clínic, Barcelona, Spain
| | - Oscar Chirife
- Department of Radiology,
Hospital
Clínic, Barcelona, Spain
| | - Ángel Chamorro
- Functional Unit of Cerebrovascular
Diseases,
Hospital
Clínic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques
August Pi i Sunyer, Barcelona, Spain
| | - Xabier Urra
- Functional Unit of Cerebrovascular
Diseases,
Hospital
Clínic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques
August Pi i Sunyer, Barcelona, Spain
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28
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Xue J, Peng Y, Zhang Y, Chen W, Pan Y, Qi Y, Hao L, Gu W, Wang N, Gao P. Preliminary application of CT perfusion source images for evaluating regional collateral circulation in unilateral Moyamoya disease. Quant Imaging Med Surg 2019; 9:615-624. [PMID: 31143652 DOI: 10.21037/qims.2019.04.05] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background Collateral flow is associated with clinical outcomes for patients with Moyamoya disease and served as a parameter for patient selection of therapeutic strategies. Therefore, we explored whether a noninvasive imaging modality, computed tomography perfusion (CTP) source images (CTP-Sis), could be used to identify the presence and intensity of collateral flow using digital subtraction angiography (DSA) as a gold standard for collateral flow. Methods CTP-Sis and DSA were performed for 24 patients with unilateral Moyamoya disease. A collateral grading system was developed based on arterial and venous phase CTP-Sis, imitating the DSA score system. Two neuroradiologists scored the DSA images using a collateral grading scale for the regions of interest corresponding to the Alberta Stroke Program Early computed tomography Score (ASPECTS) methodology. Another two neuroradiologists scored CTP-Sis in a similar manner. Agreement between the CTP-Sis and DSA consensus scores was determined, including kappa statistics. Results The agreement between the CTP-Sis and DSA consensus readings was moderate to strong, with a weighted kappa value of 0.768 [95% confidence interval (CI), 0.703-0.832], but there was a better agreement for readers of CTP-Sis, as compared with those of DSA. The sensitivity and specificity for identifying collaterals with CTP-Sis were 0.714 (95% CI, 0.578-0.851) and 0.995 (95% CI, 0.985-1.000), respectively. Conclusions CTP-Sis could help identify in a noninvasive manner the presence and intensity of collateral flow in patients with unilateral Moyamoya disease using DSA as a gold standard. Further study with a large number of cases is warranted. Further application of this method to other cerebrovascular diseases including acute ischemic stroke can also be warranted.
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Affiliation(s)
- Jing Xue
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.,Beijing Neurosurgical Institute, Beijing 100070, China
| | - Yujing Peng
- Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Yanan Zhang
- Department of Radiology, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing 100010, China
| | - Weiqi Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Yu Qi
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Lina Hao
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Weibin Gu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Ning Wang
- Department of Neurology and Institute of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350005, China
| | - Peiyi Gao
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.,Beijing Neurosurgical Institute, Beijing 100070, China
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29
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Posterior circulation involvement and collateral flow pattern in moyamoya disease with the RNF213 polymorphism. Childs Nerv Syst 2019; 35:309-314. [PMID: 30283986 DOI: 10.1007/s00381-018-3985-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 09/28/2018] [Indexed: 01/31/2023]
Abstract
PURPOSE Moyamoya disease is a chronic cerebrovascular disorder characterized by progressive stenosis of the circle of Willis with a compensatory collateral vessel network. Recent studies have identified the ring finger protein 213 gene (RNF213) as the unique susceptibility gene for moyamoya disease. The purpose of this study was to compare clinical features of moyamoya disease, especially angiographic findings, between patients with and without the RNF213 mutation. METHODS Blood samples from 35 patients with moyamoya disease were obtained between May 2016 and May 2017. Information on age at the time of diagnosis, sex, and initial symptom were obtained via retrospective chart review. Angiographic records were evaluated. RESULTS RNF213 variants were detected in the 28 of 35 patients (80%), including all pediatric patients (100%) and 18 of 25 adult patients (72%) in our cohort. Leptomeningeal collateral flow from posterior to anterior circulation was more frequent in the RNF213-negative group than in the RNF213-positive group (100% versus 38.9%; p = 0.020). Posterior cerebral arterial territorial involvement was more frequently observed in RNF213-positive patients than in RNF213-negative patients (50% versus 0%; p = 0.027). CONCLUSIONS RNF213 may play a significant role in the development of collateral anastomoses.
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30
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Agarwal S, Bivard A, Warburton E, Parsons M, Levi C. Collateral response modulates the time–penumbra relationship in proximal arterial occlusions. Neurology 2017; 90:e316-e322. [DOI: 10.1212/wnl.0000000000004858] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 10/10/2017] [Indexed: 11/15/2022] Open
Abstract
ObjectiveWhile clinical benefit from thrombolysis decreases with increase in time from stroke onset, the relationship of acute physiologic tissue compartments and collateral response to stroke onset time remains unclear.MethodsWe studied consecutive patients with proximal arterial occlusions (n = 355) with whole-brain perfusion CT with CT angiography within 6 hours of stroke onset. Penumbra and core were defined using voxel-based thresholds. Tissue mismatch was defined as the ratio of penumbra to core. Collateral scores were assessed using a previously validated visual score.ResultsMean (SD) age was 72.1 (12.4) years, median (interquartile range) NIH Stroke Scale score 16 (4), mean (SD) time to imaging 152.5 (69.7) minutes. Penumbra volume (Spearman ρ = 0.119,p= 0.026) and mismatch increased (Spearman ρ = 0.115,p= 0.030) with time from onset. Core volume decreased (Spearman ρ = −0.112,p= 0.035) while collateral scores increased with time (Spearman ρ = 0.117,p= 0.028). On multivariable regression, good collateral scores predicted longer time since onset (β = 0.101,p= 0.039) while mismatch was not a predictor (β = 0.001,p= 0.351). Good collateral score was the strongest independent predictor of final infarct volume and improvement in clinical deficit.ConclusionsIn our large patient cohort study of proximal arterial occlusions, we found an incremental collateral response and preserved penumbral volume with time. Thus, tissue viability can be maintained in this time window (0–6 hours) after stroke if leptomeningeal collaterals are able to sustain the penumbra. Our findings suggest that a longer therapeutic window may exist for intra-arterial intervention and that multimodal imaging may have a role in strokes of unknown onset time.
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31
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Zhao Y, Zhang Q, Zhang D, Zhao Y. Effect of Aspirin in Postoperative Management of Adult Ischemic Moyamoya Disease. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.057] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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