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Lehman LL, Wu C, Kaseka ML, Muthusami P, Armstrong D, Dirks P, Shroff M, Moharir M, Macgregor D, deVeber G, Dlamini N. Magnetic Resonance Angiography Alone Is Insufficient for Diagnosis and Surgical Planning in Children With Moyamoya. Pediatr Neurol 2024; 159:1-3. [PMID: 39089182 DOI: 10.1016/j.pediatrneurol.2024.06.008] [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: 02/09/2024] [Revised: 06/07/2024] [Accepted: 06/16/2024] [Indexed: 08/03/2024]
Abstract
BACKGROUND The gold standard for evaluation of the severity of moyamoya vasculopathy is the Suzuki grade determined with cerebral catheter angiography (CA). With greater use of magnetic resonance angiography (MRA) it is important to understand if MRA is truly comparable to CA. METHODS Children with moyamoya were evaluated using the Suzuki score for CA and the modified MRA six-stage Suzuki score to describe the angiographic findings in moyamoya from initial narrowing of the distal internal carotid artery to the "puff of smoke" appearance of the lenticulostriate collaterals and finally to the disappearance of this network of collaterals. Using Cohen kappa we compared Suzuki grade based on CA with MRA in the same patients. RESULTS A total of 27 children with moyamoya were reviewed. We calculated a weighted Cohen kappa of 0.49 (P < 0.0001), which is a moderate correlation. CONCLUSIONS We suggest caution in the reliance on MRA for the diagnosis and evaluation of severity of moyamoya in children.
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Affiliation(s)
- Laura L Lehman
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts.
| | - Clara Wu
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Prakash Muthusami
- Department of Diagnostic Imaging, Hospital for Sick Kids, Toronto, Ontario
| | - Derek Armstrong
- Department of Diagnostic Imaging, Hospital for Sick Kids, Toronto, Ontario
| | - Peter Dirks
- Department of Neurosurgery, Hospital for Sick Kids, Toronto, Ontario
| | - Manohar Shroff
- Department of Diagnostic Imaging, Hospital for Sick Kids, Toronto, Ontario
| | | | - Daune Macgregor
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario
| | | | - Nomazulu Dlamini
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario
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Suh L, Puri AS, Singh J, Kuhn AL. I saw the 'puff of smoke' sign before it vanished into thin air. Clin Imaging 2024; 111:110190. [PMID: 38759602 DOI: 10.1016/j.clinimag.2024.110190] [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: 02/14/2024] [Revised: 05/07/2024] [Accepted: 05/09/2024] [Indexed: 05/19/2024]
Abstract
Moyamoya is characterized as a non-atherosclerotic and non-inflammatory vasculopathy that leads to progressive stenosis of the intracranial internal carotid arteries as well as the Circle of Willis. While it can be idiopathic (Moyamoya disease) or associated with another condition (Moyamoya syndrome), there is a characteristic 'puff of smoke' sign that can be appreciated on cerebral angiography.
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Affiliation(s)
- Lyle Suh
- University of Massachusetts Chan Medical School, Worcester, MA, USA.
| | - Ajit S Puri
- Department of Radiology, Division of Neurointerventional Radiology, University of Massachusetts Medical Center, Worcester, MA, USA.
| | - Jasmeet Singh
- Department of Radiology, Division of Neurointerventional Radiology, University of Massachusetts Medical Center, Worcester, MA, USA.
| | - Anna Luisa Kuhn
- Department of Radiology, Division of Neurointerventional Radiology, University of Massachusetts Medical Center, Worcester, MA, USA.
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Morello A, Scala M, Schiavetti I, Diana MC, Severino M, Tortora D, Piatelli G, Pavanello M. Surgical revascularization as a procedure to prevent neurological complications in children with moyamoya syndrome associated with neurofibromatosis I: a single institution case series. Childs Nerv Syst 2024; 40:1731-1741. [PMID: 38316674 PMCID: PMC11111570 DOI: 10.1007/s00381-024-06304-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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 01/24/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND The optimal timing and surgical approach for surgical revascularization in patients with moyamoya syndrome (MMS) associated with neurofibromatosis type I (NF1) remain so far elusive. We aimed to compare the long-term clinical, radiological, and cognitive effects of different revascularization procedures in a pediatric cohort of NF1-associated MMS. METHODS We reviewed the clinical, radiological, and surgical data of 26 patients with NF1-associated MMS diagnosed at our institution between 2012 and 2022, at the clinical onset and last follow-up. RESULTS Indirect bypasses were performed in 12/26 patients (57.1%), while combined direct and indirect procedures in 9/26 subjects (42.9%); 5 patients did not undergo surgery. Through logistic regression analysis, pathological Wechsler Intelligence Scale for Children (WISC) at onset was found to be associated with symptom improvement at 1-year follow up (p = 0.006). No significant differences were found in long-term neurocognitive outcome and stroke rate in patients receiving combined or indirect bypass (p > 0.05). CONCLUSIONS Currently, whether combined or indirect bypass should be considered the treatment of choice in pediatric patients with NF1-associated MMS remains unclear, as well as the optimal time approach. In our series, no significant differences were found in long-term neurocognitive outcome and stroke rate between patients treated with either of these two approaches. Clinical evidence supports the crucial role of early diagnosis and surgical revascularization in subjects with MMS-associated NF1, even in case of mildly symptomatic vasculopathy. This allows to achieve a good long-term outcome with improved intellectual function and prevention of stroke and seizure in these patients.
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Affiliation(s)
- Alberto Morello
- Department of Neurosurgery, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
- Department of Neuroscience, Neurosurgery Unit, Rita Levi Montalcini", "Città Della Salute e della Scienza" University Hospital, University of Turin, Turin, Italy.
| | - Marcello Scala
- Department of Neurosciences, Genetics, Maternal and Child Health, University of Genoa, Rehabilitation, Genoa, Ophthalmology, Italy
- Medical Genetics Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Irene Schiavetti
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Maria Cristina Diana
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Domenico Tortora
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Gianluca Piatelli
- Department of Neurosurgery, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Marco Pavanello
- Department of Neurosurgery, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Shieh A, Schoenheit TR, Mallon ST, Mathias EJ. Acute Weakness in a Toddler with Sickle Cell Disease. Pediatr Rev 2024; 45:296-300. [PMID: 38689111 DOI: 10.1542/pir.2022-005746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Affiliation(s)
| | | | - Shane T Mallon
- Division of Emergency Radiology, University of Michigan, Ann Arbor, MI
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5
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El Naamani K, Chen CJ, Jabre R, Saad H, Grossberg JA, Dmytriw AA, Patel AB, Khorasanizadeh M, Ogilvy CS, Thomas A, Monteiro A, Siddiqui A, Cortez GM, Hanel RA, Porto G, Spiotta AM, Piscopo AJ, Hasan DM, Ghorbani M, Weinberg J, Nimjee SM, Bekelis K, Salem MM, Burkhardt JK, Zetchi A, Matouk C, Howard BM, Lai R, Du R, Abbas R, Sioutas GS, Amllay A, Munoz A, Atallah E, Herial NA, Tjoumakaris SI, Gooch MR, Rosenwasser RH, Jabbour P. Direct Versus Indirect Revascularization for Moyamoya: a Large Multicenter Study. J Neurol Neurosurg Psychiatry 2024; 95:256-263. [PMID: 37673641 DOI: 10.1136/jnnp-2022-329176] [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: 03/02/2022] [Accepted: 08/22/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Moyamoya is a chronic occlusive cerebrovascular disease of unknown etiology causing neovascularization of the lenticulostriate collaterals at the base of the brain. Although revascularization surgery is the most effective treatment for moyamoya, there is still no consensus on the best surgical treatment modality as different studies provide different outcomes. OBJECTIVE In this large case series, we compare the outcomes of direct (DR) and indirect revascularisation (IR) and compare our results to the literature in order to reflect on the best revascularization modality for moyamoya. METHODS We conducted a multicenter retrospective study in accordance with the Strengthening the Reporting of Observational studies in Epidemiology guidelines of moyamoya affected hemispheres treated with DR and IR surgeries across 13 academic institutions predominantly in North America. All patients who underwent surgical revascularization of their moyamoya-affected hemispheres were included in the study. The primary outcome of the study was the rate of symptomatic strokes. RESULTS The rates of symptomatic strokes across 515 disease-affected hemispheres were comparable between the two cohorts (11.6% in the DR cohort vs 9.6% in the IR cohort, OR 1.238 (95% CI 0.651 to 2.354), p=0.514). The rate of total perioperative strokes was slightly higher in the DR cohort (6.1% for DR vs 2.0% for IR, OR 3.129 (95% CI 0.991 to 9.875), p=0.052). The rate of total follow-up strokes was slightly higher in the IR cohort (8.1% vs 6.6%, OR 0.799 (95% CI 0.374 to 1.709) p=0.563). CONCLUSION Since both modalities showed comparable rates of overall total strokes, both modalities of revascularization can be performed depending on the patient's risk assessment.
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Affiliation(s)
- Kareem El Naamani
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Roland Jabre
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hassan Saad
- Neurosurgery, Emory University, Atlanta, Georgia, USA
| | | | - Adam A Dmytriw
- Neuroradiology and Neurointervention Service, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medical Imaging, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Aman B Patel
- Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | - Ajith Thomas
- Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Andre Monteiro
- Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Adnan Siddiqui
- Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Gustavo M Cortez
- Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Guilherme Porto
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Anthony J Piscopo
- Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - David M Hasan
- Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Mohammad Ghorbani
- Neurosurgery, Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Joshua Weinberg
- Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Shahid M Nimjee
- Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kimon Bekelis
- Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Mohamed M Salem
- Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Akli Zetchi
- Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Charles Matouk
- Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Brian M Howard
- Neurological Surgery, Emory University, Atlanta, Georgia, USA
| | - Rosalind Lai
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rawad Abbas
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Georgios S Sioutas
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abdelaziz Amllay
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alfredo Munoz
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Elias Atallah
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Michael Reid Gooch
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Transient ischemic attack after indirect revascularization surgery for pediatric patients with moyamoya disease: A retrospective study of intraoperative blood pressure. Anaesth Crit Care Pain Med 2023; 42:101168. [PMID: 36309164 DOI: 10.1016/j.accpm.2022.101168] [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: 11/04/2021] [Revised: 09/29/2022] [Accepted: 10/18/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study aimed to investigate the association between intraoperative blood pressure and postoperative transient ischemic attacks (TIAs) in pediatric patients with moyamoya disease after indirect revascularization surgery. METHODS We retrospectively reviewed the medical records of patients with moyamoya disease younger than 15 years who underwent indirect revascularizations under general anesthesia from 2013 to 2019. Perioperative clinical factors and intraoperative blood pressure data were collected and analyzed. Univariate and multivariable mixed-effect logistic regressions were used to identify predictors of postoperative TIA and symptom progression. RESULTS Among 444 hemispheres in 296 pediatric patients, 70 cases (16%) experienced postoperative TIAs within 2 weeks after surgery, and 34 cases (7.7%) developed postoperative symptom progression. Baseline mean blood pressure (MBP) (adjusted odds ratio, 1.261; 95% confidence interval, 1.037-1.528; P < 0.001), Average mean arterial pressure (MAP) (adjusted odds ratio, 1.137; 95% confidence interval, 1.052-1.228; P = 0.006), and Ipsilateral magnetic resonance angiography (MRA) score (adjusted odds ratio, 1.464; 95% confidence interval, 0.886-2.419; P = 0.012) were statistically significant risk factors for postoperative TIA. Average real variability of MAP (ARV-MAP), which were measures of intraoperative MAP variability (adjusted odds ratio, 4.731; 95% confidence interval, 1.419-15.257; P = 0.003) and maximum MAP declination (MaxD-MAP) (adjusted odds ratio, 1.271; 95% confidence interval, 1.013-1.520; P = 0.010) were statistically significant risk factors for postoperative symptom progression. CONCLUSION Higher pre-induction baseline blood pressure and ipsilateral MRA score were independent risk factors predicting postoperative TIA in pediatric patients with moyamoya disease after indirect revascularization. The high variability and drastic decline in intraoperative MAP showed predictive value in postoperative symptom progression.
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Han MJ, Kim SJ. Clinical significance of asymmetric venous vasculature on minimum-intensity projection in patients with moyamoya disease. Medicine (Baltimore) 2022; 101:e31067. [PMID: 36254048 PMCID: PMC9575748 DOI: 10.1097/md.0000000000031067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study analyzed the clinical significance and characteristics of asymmetric venous blood flow in patients with Moyamoya disease (MMD) using minimum intensity projection (minIP) susceptibility-weighted imaging. The minIP views of 30 patients diagnosed with MMD were retrospectively analyzed using clinical features, brain magnetic resonance angiography, electroencephalography, and brain single-photon emission computed tomography (SPECT). Simultaneously, differences between patients with acute cerebral infarction and non-MMD causes were analyzed. Twelve (40.0%) of the 30 patients had asymmetrical venous flow, which is usually seen in patients with acute cerebral infarction (P = .146). They also had significantly higher Suzuki stages than symmetric patients (P = .014), with five (41.7%) and three (25.0%) of them in stages 4 and 5, respectively. When the Suzuki stages of both hemispheres were different, more veins were found in the stenotic hemisphere (88.9%). Brain SPECT showed more severe hypoperfusion on the side with prominent vascularity in the minIP view (100.0%). Additionally, asymmetric blood flow was observed in 66.7% of the patients with cerebral infarction caused by MMD, whereas only 11.1% of the children with cerebral infarction caused by non-MMD had asymmetry (P = .005). Patients with MMD showed asymmetric hypointensity of the cortical veins with a minIP appearance. The venous structure showed greater signal loss on SWI and was more prominent in the hemisphere where stenosis was advanced or infarction occurred in other examinations. Cerebral infarction in patients with MMD tended to occur with asymmetrically prominent venous patterns with damaged areas in minIP images, which had distinct characteristics from those of patients without MMD.
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Affiliation(s)
- Min Jeong Han
- Department of Pediatrics, Jeonbuk National University Medical School, Jeonbuk, Korea
- Research Institute of Clinical Medicine of Jeonbuk National University, Jeonbuk National University Medical School, Jeonbuk, Korea
- Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonbuk, Korea
| | - Sun Jun Kim
- Department of Pediatrics, Jeonbuk National University Medical School, Jeonbuk, Korea
- Research Institute of Clinical Medicine of Jeonbuk National University, Jeonbuk National University Medical School, Jeonbuk, Korea
- Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonbuk, Korea
- *Correspondence: Sun Jun Kim, Department of Pediatrics, Jeonbuk National University Medical School, 20 Geonjiro, Deokjingu, Jeonju, Jeonbuk, 54907, South Korea (e-mail: )
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Abstract
ABSTRACT Cerebral perfusion imaging provides useful information about the hemodynamic state of the brain that is relevant to a number of neurologic conditions, including stroke, epilepsy, and brain tumors. Multiple imaging modalities have been developed to evaluate brain perfusion, primarily by the use of different tracers to measure cerebral blood volume and cerebral blood flow. Here, we provide an overview of magnetic resonance imaging perfusion techniques; summarize the role of perfusion imaging in adult stroke; describe changes in cerebral blood flow over childhood; and discuss the relevance and future directions of perfusion imaging in pediatric cerebrovascular disorders and stroke.
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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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10
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Srinivasan HL, Hausman-Kedem M, Smith ER, Constantini S, Roth J. Current trends in pediatric moyamoya: a survey of international practitioners. Childs Nerv Syst 2021; 37:2011-2023. [PMID: 33694129 DOI: 10.1007/s00381-021-05074-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/04/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Moyamoya angiopathy (MM) is a chronic, progressive steno-occlusive arteriopathy of the distal internal carotid artery and its proximal branches. MM is recognized as a shared end-pathway common to a broad range of inciting pathologies, suggesting that tailored management is important. Pediatric MM differs from MM in adults. Currently, there are many uncertainties and controversies regarding the diagnosis and management of children with MM. Hence, we conducted an international survey to identify the contemporary management trends followed worldwide. METHODS A survey relating to lifestyle modifications, medical management, diagnosis, surgical management, and follow-up for pediatric MM was circulated across web-based platforms, through various international pediatric neurological and neurosurgical societies. Data collected included geographic region of practice, experience, responses to questions, and comments. RESULTS One hundred twenty-seven responses were evaluated (104 neurosurgeons and 23 neurologists, from 32 countries, across 6 continents). We found wide variations in the recommendations for management and lifestyle modification, with significant differences between regions of practice. Eighty percent recommend restrictions on physical activity, particularly for symptomatic and non-operated patients. Eighty-four percent prescribe aspirin. Sixty-five percent perform indirect revascularization. Seventy-eight percent recommend performing a staged surgery for bilateral MM. Only 26% perform acetazolamide challenge SPECT to evaluate brain perfusion. Only 15% of responders were from highly experienced centers. CONCLUSION This survey reflects the contemporary trends in management of pediatric MM, while highlighting the heterogeneity in the management approach of these patients. There is a need for multicenter, international studies to evaluate the safety, efficacy, and long-term outcome of various aspects of treatment of these patients.
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Affiliation(s)
- Harishchandra Lalgudi Srinivasan
- Pediatric Neurosurgery Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Moran Hausman-Kedem
- Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Edward R Smith
- Pediatric Cerebrovascular Surgery, Pediatric Neurosurgery, Children's Hospital Boston/Harvard Medical School, Boston, MA, USA
| | - Shlomi Constantini
- Pediatric Neurosurgery Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Roth
- Pediatric Neurosurgery Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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11
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A rare triad of morning glory disc anomaly, moyamoya vasculopathy, and transsphenoidal cephalocele: pathophysiological considerations and surgical management. Neurol Sci 2021; 42:5433-5439. [PMID: 33825116 PMCID: PMC8642253 DOI: 10.1007/s10072-021-05221-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/23/2021] [Indexed: 11/04/2022]
Abstract
Morning glory disc anomaly is a congenital abnormality of the optic disc and peripapillary retina reported as an isolated condition or associated with various anomalies, including basal encephaloceles and moyamoya vasculopathy. However, the co-occurrence of these three entities is extremely rare and the pathogenesis is still poorly understood. Moreover, data on the surgical management and long-term follow-up of the intracranial anomalies are scarce. Here, we describe the case of a 11-year-old boy with morning glory disc anomaly, transsphenoidal cephalocele, and moyamoya vasculopathy, who underwent bilateral indirect revascularization with encephalo-duro-myo-arterio-pericranio-synangiosis at the age of 2 years, and endoscopic repair of the transsphenoidal cephalocele at the age of 6 years. A rare missense variant (c.1081T>C,p.Tyr361His) was found in OFD1, a gene responsible for a X-linked ciliopathy, the oral-facial-digital syndrome type 1 (OFD1; OMIM 311200). This case expands the complex phenotype of OFD1 syndrome and suggests a possible involvement of OFD1 gene and Shh pathway in the pathogenesis of these anomalies.
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12
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Ong JA, Low SY, Seow WT, Goh CP, Yeo TT, Chou N, Low DC, Nga V. Revascularisation surgery for paediatric moyamoya disease: The Singapore experience. J Clin Neurosci 2020; 82:207-213. [PMID: 33246909 DOI: 10.1016/j.jocn.2020.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/20/2020] [Accepted: 11/01/2020] [Indexed: 11/26/2022]
Abstract
Moyamoya disease (MMD) is characterized by the spontaneous occlusion of the distal internal carotid arteries and resultant neo-angiogenesis of fragile collateral blood vessels. Direct and indirect revascularization surgeries have shown to effectively reduce stroke risks in paediatric MMD, whereby the latter is a more utilised technique in children. This study was undertaken to determine the outcomes of revascularization in Singapore's multi-ethnic, Southeast Asian paediatric population. This is an ethics-approved study conducted in Singapore's 2 tertiary children hospital units: KK Women's and Children's Hospital and National University Hospital. Sixteen patients with a diagnosis of ischaemic-type MMD are recruited between 01 January 2002 to 31 January 2019; and a total of 24 surgeries are undertaken (24 cerebral hemispheres). There are 2 cases of stroke within 30 days post-surgery. However, no stroke recurrence is observed beyond 30 days after surgery in all patients. Four patients reported recurrent transient ischaemic attack symptoms in the follow-up period ranging from 3 months to 12 years. Data analyses show a statistically significant improvement in modified Rankin's Scale (mMRS) in post-operative patients from baseline to discharge, and at 3 months after surgery. Our study also observes that predictors of recurrent ischaemic events include higher pre-operative MRS, Suzuki stage and perioperative infarction. To the authors' knowledge, this is the first study to date reporting the outcomes of revascularisation in a paediatric Southeast Asian cohort.
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Affiliation(s)
- Jamie Ah Ong
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road Level 11, 119228, Singapore
| | - Sharon Yy Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, 11 Jalan Tan Tock Seng, 308433, Singapore.
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, 11 Jalan Tan Tock Seng, 308433, Singapore
| | - Chun Peng Goh
- Division of Neurosurgery, Department of Surgery, National University Hospital, 5 Lower Kent Ridge Rd, 119074, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Hospital, 5 Lower Kent Ridge Rd, 119074, Singapore
| | - Ning Chou
- Division of Neurosurgery, Department of Surgery, National University Hospital, 5 Lower Kent Ridge Rd, 119074, Singapore
| | - David Cy Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, 11 Jalan Tan Tock Seng, 308433, Singapore
| | - Vincent Nga
- Division of Neurosurgery, Department of Surgery, National University Hospital, 5 Lower Kent Ridge Rd, 119074, Singapore
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Successful Surgical Management of Traumatic Intracranial Hemorrhaging After Revascularization Surgery for Moyamoya Vasculopathy: A Case Report and Review of Literature. World Neurosurg 2020; 137:24-28. [PMID: 32014547 DOI: 10.1016/j.wneu.2020.01.184] [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: 10/10/2019] [Accepted: 01/22/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Traumatic intracranial hemorrhaging associated with revascularization surgery for moyamoya vasculopathy is a potentially devastating problem that requires meticulous management, including surgery. However, only a few studies on this subject have been reported, and the clinical characteristics are poorly understood. We report a case of successful surgical management for a patient with traumatic intracranial hematoma managed with encephalo-duro-arterio-myo-synangiosis (EDAMS). The purpose of this article is to clarify the specific features of clinical scenarios, hemorrhagic sites, and operative techniques by reviewing all published cases. CASE DESCRIPTION A 10-year-old Japanese girl with a history of EDAMS for quasi-moyamoya disease was referred to our institution after minor head trauma. Cranial computed tomography scans revealed a right intracranial hematoma overlying the temporal muscle flap. After admission, hematoma developed, and emergency hematoma evacuation was performed. Venous hemorrhaging from the fascia of the temporal muscle flap was confirmed. Collaterals from indirect bypass were preserved in the surgery. Postoperative diffusion-weighted imaging revealed no ischemic complications. She immediately recovered and returned to her preinjury baseline. CONCLUSION In moyamoya vasculopathy, intrinsic collaterals or de novo anastomoses from revascularization surgery are easily injured, even with mild head trauma. Furthermore, the administration of antiplatelets agents increases the risk of hematoma development. Sacrifice of collaterals can lead to acute cerebral infarction. During emergency surgery for traumatic intracranial hematoma, a careful surgical strategy is needed to preserve the collateral supply.
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Bose R, Banerjee AD. Paediatric Moyamoya Disease and Tourette's Syndrome: An Unusual Association Responding Favourably to Direct and Indirect Cerebral Revascularisation Surgery. Pediatr Neurosurg 2019; 54:436-440. [PMID: 31590166 DOI: 10.1159/000503114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 09/03/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Moyamoya disease, an uncommon chronic intra-cerebral arteriopathy asymmetrically affecting the proximal vasculature, is rarely associated with clinical features pertaining to movement disorders. CASE DESCRIPTION A 5-year-and-9-month-old boy developed repetitive episodic involuntary winking of the right eye along with ipsilateral shoulder shrugging movements in an absolutely conscious state, associated with paroxysmal shouts and loud laughs and punctuated with abusive verbal expressions (coprolalia). These episodic features, over the course of the next 1.5 years, got progressively accentuated by situations which evoked stress. In addition, there was progressive regression of verbal and cognitive milestones, emotional lability and aspects of attention deficit hyperkinetic disorder. The child was evaluated by a neurologist with magnetic resonance imaging of the brain, which showed characteristic ischaemic areas involving the basal ganglia and fronto-parietal cortical areas along the middle cerebral artery territory, predominantly on the left side. Subsequent cerebral angiography revealed extensive stenosis of bilateral (predominantly left-sided) internal cerebral arteries and middle cerebral arteries with evidence of diffuse leptomeningeal collaterals. The electroencephalography was reported to be normal. He was eventually diagnosed to be suffering from Moyamoya disease with associated Tourette's syndrome. Subsequently, the child underwent left-sided superficial temporal artery to middle cerebral artery anastomosis along with encephalo-duro-arterio-myo-synangiosis. Significant clinico-radiological improvement was noted after 3 months. The clinical deficiencies had dramatically resolved. There was evidence of excellent development of both direct and indirect surgical collaterals along the left middle cerebral artery territory. He could go back to school. CONCLUSION Ours is probably the first case reporting an association of paediatric Moyamoya disease with Tourette's syndrome, which significantly resolved after cerebral revascularisation surgery.
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Affiliation(s)
- Ratnadip Bose
- Department of Neurosurgery, Institute of Neurosciences, Medanta - The Medicity, Gurgaon, India
| | - Anirban Deep Banerjee
- Department of Neurosurgery, Institute of Neurosciences, Medanta - The Medicity, Gurgaon, India,
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Houba A, Laaribi N, Meziane M, Jaafari A, Abouelalaa K, Bensghir M. Moyamoya disease in a Moroccan baby: a case report. J Med Case Rep 2018; 12:165. [PMID: 29895322 PMCID: PMC5998455 DOI: 10.1186/s13256-018-1642-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 03/06/2018] [Indexed: 11/16/2022] Open
Abstract
Background A stroke in a baby is uncommon, recent studies suggested that their incidence is rising. Moyamoya disease is one of the leading causes of stroke in babies. This condition is mostly described in Japan. In Morocco, moyamoya disease has rarely been reported and a few cases were published. We report a rare Moroccan case of a 23-month-old baby boy who presented with left-sided hemiparesis and was diagnosed as having moyamoya disease. Case presentation A 23-month-old full-term Moroccan baby boy born to a non-consanguineous couple was referred to our hospital with the complaint of sudden onset left-sided hemiparesis. On neurological examination, there were no signs of meningeal irritation, his gait was hemiplegic, tone was decreased over left side, power was 2/5 over left upper and lower limb, and deep tendon reflexes were exaggerated. Preliminary neuroimaging suggested an arterial ischemic process. Clinical and laboratory evaluation excluded hematologic, metabolic, and vasculitic causes. Cerebral angiography confirmed the diagnosis of moyamoya disease. Our patient was treated with acetylsalicylic acid 5 mg/kg per day and referred to follow-up with pediatric neurosurgeon. Cerebral revascularization surgery using encephaloduroarteriosynangiosis was performed. At 8-month follow-up, his hemiparesis had improved and no further ischemic events had occurred. Conclusion This case highlights the importance of considering moyamoya disease to be one of the classic etiologies of acute ischemic strokes in children from North Africa. It also emphasizes the rare presentation among the African population and the use of neurovascular imaging techniques to facilitate diagnosis of moyamoya disease.
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Affiliation(s)
- Abdelhafid Houba
- Department of Anesthesiology, Military Hospital Mohammed V Rabat, Faculty of Medicine and Pharmacy, University of Mohammed V, Souissi, district Riyadh, BP: 1000, Rabat, Morocco.
| | - Nisrine Laaribi
- Department of Pediatric, Children's Hospital Rabat, Faculty of Medicine and Pharmacy, University of Mohammed V, Souissi, Rabat, Morocco
| | - Mohammed Meziane
- Department of Anesthesiology, Military Hospital Mohammed V Rabat, Faculty of Medicine and Pharmacy, University of Mohammed V, Souissi, district Riyadh, BP: 1000, Rabat, Morocco
| | - Abdelhamid Jaafari
- Department of Anesthesiology, Military Hospital Mohammed V Rabat, Faculty of Medicine and Pharmacy, University of Mohammed V, Souissi, district Riyadh, BP: 1000, Rabat, Morocco
| | - Khalil Abouelalaa
- Department of Anesthesiology, Military Hospital Mohammed V Rabat, Faculty of Medicine and Pharmacy, University of Mohammed V, Souissi, district Riyadh, BP: 1000, Rabat, Morocco
| | - Mustapha Bensghir
- Department of Anesthesiology, Military Hospital Mohammed V Rabat, Faculty of Medicine and Pharmacy, University of Mohammed V, Souissi, district Riyadh, BP: 1000, Rabat, Morocco
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Kim W, Lee EY, Park SE, Park EK, Kim JS, Kim DS, Shim KW. Neuropsychological impacts of indirect revascularization for pediatric moyamoya disease. Childs Nerv Syst 2018; 34:1199-1206. [PMID: 29679197 DOI: 10.1007/s00381-018-3804-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 04/11/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Moyamoya disease (MMD) commonly leads to neurocognitive impairment. This study was carried out to show that temporal encephaloduroarteriosynangiosis (EDAS) has a positive neuropsychological impact on pediatric MMD patients. METHODS Fifty-five participants diagnosed with MMD from 2008 to 2014 were included in this retrospective study. The mean age at the preoperative evaluation was 9.5 years and the mean age at postoperative evaluation was 10.4. The average interval of initial and follow-up test was 10 months. K-WISC-III, Rey-Kim memory test, Children's Color Trails test (CCTT), Wisconsin Card Sorting Test (WCST), and Advanced Test of Attention (ATA) were used to evaluate patient's neurocognitive profile. RESULTS In this study, preoperative and postoperative neuropsychological fields were compared. Prior operation, pediatric MMD patients showed 54.2% deficit of inattention but only around 2.5% deficit in verbal memory recall function. There was a significant increase of performance IQ and PO score component of PIQ improved almost 10 scores after surgery. For memorial function, there was an improvement of approximately 10 scores in MQ after the surgery. This study also showed parietal activation following surgical treatment which enhanced the ability to interpret visual materials, to register and to retrieve visual information. Interestingly, despite the parietal cover surgery, there was a significant improvement of performance on WCST and CCTT measuring the prefrontal executive function. Concerning failure to maintain set, no significant postoperative improvements were made. However, simple and selective visual attention on ATA was significantly improved postoperatively. CONCLUSIONS The results from neuropsychological field comparison testifies the effectiveness of temporal EDAS in pediatric MMD patients. The surgery not only enhances the blood flow in operative regions, but it also improves the broad cerebral function including frontoparietal domains. Such alteration leads to overall advancement in cognitive function which are impaired due to MMD.
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Affiliation(s)
- WooHyun Kim
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Yonsei University College of Medicine, 50 Yonseiro, Seodaemungu, Seoul, South Korea
| | - Eun-Young Lee
- Happience Psychology Clinic attached to Korea Jeail Psychiatric Clinic, Seoul, South Korea
| | - Seong-Eun Park
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Yonsei University College of Medicine, 50 Yonseiro, Seodaemungu, Seoul, South Korea
| | - Eun-Kyung Park
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Yonsei University College of Medicine, 50 Yonseiro, Seodaemungu, Seoul, South Korea
| | - Ju-Seong Kim
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Yonsei University College of Medicine, 50 Yonseiro, Seodaemungu, Seoul, South Korea
| | - Dong-Seok Kim
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Yonsei University College of Medicine, 50 Yonseiro, Seodaemungu, Seoul, South Korea
| | - Kyu-Won Shim
- Department of Pediatric Neurosurgery, Severance Children's Hospital, Yonsei University College of Medicine, 50 Yonseiro, Seodaemungu, Seoul, South Korea.
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Murchison J, Wilson JM, Ray C, Ginsberg J, Nagy L. Moyamoya Disease in an 18-Month-Old Female Caucasian Complicated by Cerebral Hyperperfusion Syndrome Following Indirect Revascularization. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:1077-1080. [PMID: 28989169 PMCID: PMC5644817 DOI: 10.12659/ajcr.905325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cerebral hyperperfusion syndrome is a rare complication of indirect revascularization due to moyamoya disease, but has not been reported previously in the pediatric population. We present a case of an 18-month-old girl with moyamoya disease that was treated with bilateral pial synangiosis and had complications consistent with cerebral hyperperfusion syndrome. This case report discusses the pathophysiological mechanisms involved in cerebral hyperperfusion in moyamoya syndrome. CASE REPORT An 18-month-old female Caucasian presented with seizures and weakness of the left side. Angiography confirmed bilateral cerebral moyamoya disease that was worse on the right side. Indirect revascularization with pial synangiosis was first performed on the right side to allow for healing. Five months later, pial synangiosis was then performed on the left side. Postoperatively, the patient experienced increased intracranial pressure (ICP), suggesting cerebral hyperperfusion syndrome. She was treated with a repeat lumbar puncture, a lumbar drain, and a lumbar shunt. CONCLUSIONS This report demonstrates a case of cerebral hyperperfusion syndrome as a complication of moyamoya disease in a pediatric patient. Although the patient progressed well after placement of a lumbar shunt, this case demonstrates the occurrence of cerebral hyperperfusion syndrome as a complication of revascularization in pediatric patients and highlights the need for further research in this area.
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Affiliation(s)
| | - John M Wilson
- Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX, USA
| | - Coby Ray
- Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX, USA
| | - Jessica Ginsberg
- Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX, USA
| | - Laszlo Nagy
- Department of Pediatrics, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX, USA
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Gunawan P, Suryaningtyas W, Saharso D, Prasetyo R. Combination of Encephalo-Myo-Pial-Synangiosis and Encephalo-Arterio-Pial-Synangiosis Procedure in Pediatric Moya-Moya Disease. Ethiop J Health Sci 2017; 27:193-196. [PMID: 28579715 PMCID: PMC5440834 DOI: 10.4314/ejhs.v27i2.12] [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] [Indexed: 11/28/2022] Open
Abstract
Background Moya-moya disease in children is a cerebrovascular disorder that may cause cerebral ischemic or hemorrhage. Case Details We report an 8-year-old boy that was admitted with the chief complaint of repeated sudden half left body paralyze. MRA showed acute thrombotic infarction in the right hemisphere and internal carotid artery stenosis in the form of puffs of smokes. Indirect revascularization surgical procedure with combination of Encephalo-myo-pial-synangiosis (EMS) and Encephalo-arterio-pial-synangiosis (EAS) was performed. It resulted in a good response. Conclusion Moya-moya disease can lead to permanent neurological disability if untreated. Satisfactory outcome was noted following combination surgery management with EMS and EAS.
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Affiliation(s)
- Prastiya Gunawan
- Department Of Child Health, Airlangga University, College of Medicine, Dr Soetomo Hospital, Surabaya, Indonesia
| | - Wihasto Suryaningtyas
- Department Of Child Health, Airlangga University, College of Medicine, Dr Soetomo Hospital, Surabaya, Indonesia
| | - Darto Saharso
- Department Of Child Health, Airlangga University, College of Medicine, Dr Soetomo Hospital, Surabaya, Indonesia
| | - Risky Prasetyo
- Department Of Child Health, Airlangga University, College of Medicine, Dr Soetomo Hospital, Surabaya, Indonesia
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Hall EM, Leonard J, Smith JL, Guilliams KP, Binkley M, Fallon RJ, Hulbert ML. Reduction in Overt and Silent Stroke Recurrence Rate Following Cerebral Revascularization Surgery in Children with Sickle Cell Disease and Severe Cerebral Vasculopathy. Pediatr Blood Cancer 2016; 63:1431-7. [PMID: 27106860 PMCID: PMC5443666 DOI: 10.1002/pbc.26022] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 03/21/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Children with sickle cell disease (SCD) and moyamoya may benefit from indirect cerebral revascularization surgery in addition to chronic blood transfusion therapy for infarct prevention. We sought to compare overt and silent infarct recurrence rates in children with SCD undergoing revascularization. METHODS This was a retrospective cohort study of all children with SCD and moyamoya treated at two children's hospitals. Clinical events and imaging studies were reviewed. RESULTS Twenty-seven children with SCD and confirmed moyamoya receiving chronic transfusion therapy were identified, of whom 12 underwent indirect cerebral revascularization. Two subjects had postoperative transient ischemic attacks and another had a subarachnoid blood collection, none of which caused permanent consequences. Two subjects had surgical wound infections. Among these 12 children, the rate of overt and silent infarct recurrence decreased from 13.4 infarcts/100 patient-years before revascularization to 0 infarcts/100 patient-years after revascularization (P = 0.0057); the postrevascularization infarct recurrence rate was also significantly lower than the overall infarct recurrence of 8.87 infarcts/100 patient-years in 15 children without cerebral revascularization (P = 0.025). CONCLUSIONS The rate of overt and silent infarct recurrence was significantly lower following indirect cerebral revascularization. A prospective study of cerebral revascularization in children with SCD is needed.
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Affiliation(s)
- Erin M. Hall
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Jeffrey Leonard
- Department of Neurosurgery, The Ohio State University School of Medicine and Nationwide Children’s Hospital, Columbus, OH
| | - Jodi L. Smith
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, IN
| | - Kristin P. Guilliams
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Michael Binkley
- Department of Biostatistics, Washington University School of Medicine, St. Louis, MO
| | - Robert J. Fallon
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Monica L. Hulbert
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
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Decompressive hemicraniectomy in the management of acute stroke in children with Moyamoya disease: the difficult balance between the spontaneous postoperative revascularization process and the need for cranial reconstruction. Childs Nerv Syst 2015. [PMID: 26201551 DOI: 10.1007/s00381-015-2802-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND IMPORTANCE The decompressive hemicraniectomy (DCH) after malignant middle cerebral artery infarction in children is a rare procedure, and the indication is discussed as being controversial. Etiological Moyamoya disease has some additional challenges concerning the therapeutic strategy that have not mentioned in the recent literature, as it is dependent on special pathophysiology. CLINICAL PRESENTATION We report a case of a four-year-old patient with a decompressive hemicraniectomy after malignant middle cerebral artery infarction on the right hemisphere based on a Moyamoya syndrome with proximal MCA occlusions on both sides. After the decompression there was a good restitution of the hemiparesis, aphasia, and consciousness loss on admission. The bone flap replacement is usually done after three month in our department to ensure brain swelling has subsided. In this patient the cranioplasty was not arranged because of the development of collateral vessels to the right motor region through the craniotomy defect, to protect the supply of the eloquent cortex. CONCLUSION We conclude that the indication of DCH and postoperative treatment should be discussed individually, especially when neovascularisation developments can occur like in Moyamoya disease. An important point is the right timing for bone flap replacement, which should be directly after cerebral edema has subsided prior to the evolution of collaterals through the craniotomy defect. Additionally, leaving the opportunity for neovascularization through smaller defects has to be taken into account.
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Network-based gene expression analysis of vascular wall of juvenile Moyamoya disease. Childs Nerv Syst 2015; 31:399-404. [PMID: 25503250 DOI: 10.1007/s00381-014-2605-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 11/26/2014] [Indexed: 10/24/2022]
Abstract
SUBJECTS Little is known about the pathology and pathogenesis of the Moyamoya disease (MMD). To better understand the molecular processes involved in MMD gene expression analysis of Moyamoya artery tissue to a control artery, this study was conducted. METHODS Tissue samples of two MMD and two non-MMD were profiled using oligonucleotide microarrays. Gene ontology classification of the differentially expressed genes was analyzed, and regulatory functional networks and pathways were identified with a network-based computational pathway analysis tool. Analysis of MMD and control tissue revealed 104 differentially expressed genes. RESULTS The two major significantly associated gene ontology terms was cellular development and cellular movement. Further network-based analysis showed significant interaction between RNF213 downstream gene networks and the top 3 score gene networks of MMD. Three major nodes of this network were evident in the merged network and were showing interactions with downstream network of RNF213. CONCLUSIONS Our results demonstrate that cellular development and cellular movement in MMD are the key role of mechanisms.
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Surgical management of Moyamoya disease and syndrome: Current concepts and personal experience. Rev Neurol (Paris) 2015; 171:31-44. [DOI: 10.1016/j.neurol.2014.08.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 06/05/2014] [Accepted: 08/29/2014] [Indexed: 11/18/2022]
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Blanc C, Janoura S, Pallot C, Mettey L, Bardin F, Ricolfi F, Chavent A, Osseby GV, Giroud M, Béjot Y. Maladie de Moyamoya : aspects diagnostiques, cliniques, évolutifs et thérapeutiques chez 10 patients. Rev Neurol (Paris) 2015; 171:58-64. [DOI: 10.1016/j.neurol.2014.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 09/26/2014] [Accepted: 10/08/2014] [Indexed: 10/24/2022]
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Baek HJ, Chung SY, Park MS, Kim SM, Park KS, Son HU. Preliminary study of neurocognitive dysfunction in adult moyamoya disease and improvement after superficial temporal artery-middle cerebral artery bypass. J Korean Neurosurg Soc 2014; 56:188-93. [PMID: 25368759 PMCID: PMC4217053 DOI: 10.3340/jkns.2014.56.3.188] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 07/24/2014] [Accepted: 09/06/2014] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Moyamoya disease (MMD) is a chronic cerebrovascular occlusive disease of unknown etiology. In addition, the neurocognitive impairment of adults with MMD is infrequently reported and, to date, has not been well described. We attempted to determine both the neurocognitive profile of adult moyamoya disease and whether a superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis can improve the neurocognitive impairment in exhibiting hemodynamic disturbance without stroke. METHODS From September 2010 through November 2012, 12 patients with angiographically diagnosed MMD underwent STA-MCA anastomosis for hemodynamic impairment. Patients with hypoperfusion and impaired cerebrovascular reserve (CVR) capacity but without evidence of ischemic stroke underwent a cognitive function test, the Seoul Neuropsychological Screening Battery (SNSB). Five patients agreed to undergo a follow-up SNSB test. Data from preoperative and postoperative neurocognitive function tests were compared and analyzed. RESULTS Five of 12 patients were enrolled. The median age was 45 years (range, 24-55 years). A comparison of preoperative to postoperative status of SNSB, memory domain, especially delayed recall showed significant improvement. Although most of the domains showed improvement after surgery, the results were not statistically significant. CONCLUSION In our preliminary study, large proportions of adult patients with MMD demonstrate disruption of cognitive function. This suggests the possibility of chronic hypoperfusion as a primary cause of the neurocognitive impairment. When preoperative and postoperative status of cognitive function was compared, memory domain showed remarkable improvement. Although further study is needed, neurocognitive impairment may be an indication for earlier intervention with reperfusion procedures that can improve cognitive function.
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Affiliation(s)
- Hyun Joo Baek
- Department of Neurosurgery, Eulji University Hospital, College of Medicine, Eulji University, Daejeon, Korea
| | - Seung Young Chung
- Department of Neurosurgery, Eulji University Hospital, College of Medicine, Eulji University, Daejeon, Korea
| | - Moon Sun Park
- Department of Neurosurgery, Eulji University Hospital, College of Medicine, Eulji University, Daejeon, Korea
| | - Seong Min Kim
- Department of Neurosurgery, Eulji University Hospital, College of Medicine, Eulji University, Daejeon, Korea
| | - Ki Suk Park
- Department of Neurosurgery, Eulji University Hospital, College of Medicine, Eulji University, Daejeon, Korea
| | - Hee Un Son
- Department of Neurosurgery, Eulji University Hospital, College of Medicine, Eulji University, Daejeon, Korea
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The maya behind moyamoya--the two extremes of the disease. Indian J Pediatr 2013; 80:601-3. [PMID: 22733293 DOI: 10.1007/s12098-012-0813-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 05/25/2012] [Indexed: 10/28/2022]
Abstract
Two children with moyamoya disease at the extremes of the disease- one with minimal clinical involvement and the other one with profound clinical features are reported with an interesting finding of the collaterals being the reason (maya) behind such varied presentations. To the best of authors' knowledge this is the first Indian report describing the reason behind the varied presentations of moyamoya disease.
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Rosenberg RE, Egan M, Rodgers S, Harter D, Burnside RD, Milla S, Pappas J. Complex chromosome rearrangement of 6p25.3->p23 and 12q24.32->qter in a child with moyamoya. Pediatrics 2013; 131:e1996-2001. [PMID: 23713105 DOI: 10.1542/peds.2012-0749] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A 7-year-old white girl presented with left hemiparesis and ischemic stroke secondary to moyamoya syndrome, a progressive cerebrovascular occlusive disorder of uncertain but likely multifactorial etiology. Past medical history revealed hearing loss and developmental delay/intellectual disability. Routine karyotype demonstrated extra chromosomal material on 6p. Single nucleotide polymorphism microarray revealed a previously unreported complex de novo genetic rearrangement involving subtelomeric segments on chromosomes 6p and 12q. The duplicated/deleted regions included several known OMIM-annotated genes. This novel phenotype and genotype provides information about a possible association of genomic copy number variation and moyamoya syndrome. Dosage-sensitive genes in the deleted and duplicated segments may be involved in aberrant vascular proliferation. Our case also emphasizes the importance of comprehensive evaluation of both developmental delay and congenital anomalies such as moyamoya.
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Affiliation(s)
- Rebecca E Rosenberg
- Department of Pediatrics, New York University School of Medicine, New York, NY, USA.
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Nagiub M, Allarakhia I. Pediatric Moyamoya disease. AMERICAN JOURNAL OF CASE REPORTS 2013; 14:134-8. [PMID: 23826451 PMCID: PMC3700478 DOI: 10.12659/ajcr.889170] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Accepted: 04/12/2013] [Indexed: 11/10/2022]
Abstract
Background: Moyamoya disease (MMD) is a progressive cerebrovascular occlusive disease of the bilateral internal carotid arteries that leads to a compensatory abnormal vascular network at the base of the brain. Its average annual incidence 0.54 per 100,000 population but it is the most common pediatric cerebrovascular disease in East Asia. The reported incidence in USA is approximately 0.086 per 100,000 patients. Case Report: We present a case of Moyamoya disease that was to detected in a 7-year-old female who presented with transient altered mental status. Conclusions: Moyamoya disease can be diagnosed if history, physical exam and brain imaging is highly suspicious. Conventional angiography remains the gold standard for diagnosis and aids in surgical planning for patients with suspected Moyamoya disease.
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Affiliation(s)
- Mohamed Nagiub
- Department of Pediatrics, St. John Providence Children's Hospital, Detroit, Michigan, U.S.A
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Sim YW, Lee MS, Kim YG, Kim DH. Unpredictable postoperative global cerebral infarction in the patient of williams syndrome accompanying moyamoya disease. J Korean Neurosurg Soc 2011; 50:256-9. [PMID: 22102960 DOI: 10.3340/jkns.2011.50.3.256] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 05/19/2011] [Accepted: 08/30/2011] [Indexed: 11/27/2022] Open
Abstract
We report a rare case of Williams syndrome accompanying moyamoya disease in whom postoperative global cerebral infarction occurred unpredictably. Williams syndrome is an uncommon hereditary disorder associated with the connective tissue abnormalities and cardiovascular disease. To our knowledge, our case report is the second case of Williams syndrome accompanying moyamoya disease. A 9-year-old boy was presented with right hemiparesis after second operation for coarctation of aorta. He was diagnosed as having Williams syndrome at the age of 1 year. Brain MRI showed left cerebral cortical infarction, and angiography showed severe stenosis of bilateral internal carotid arteries and moyamoya vessels. To reduce the risk of furthermore cerebral infarction, we performed indirect anastomosis successfully. Postoperatively, the patient recovered well, but at postoperative third day, without any unusual predictive abnormal findings the patient's pupils were suddenly dilated. Brain CT showed the global cerebral infarction. Despite of vigorous treatment, the patient was not recovered and fell in brain death one week later. We suggest that in this kind of labile patient with Williams syndrome accompanying moyamoya disease, postoperative sedation should be done with more thorough strict patient monitoring than usual moyamoya patients. Also, we should decide the revascularization surgery more cautiously than usual moyamoya disease. The possibility of unpredictable postoperative ischemic complication should be kept in mind.
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Affiliation(s)
- Yang-Won Sim
- Department of Neurosurgery, Chungbuk National University College of Medicine, Chungbuk, Korea
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Moyamoya syndrome associated with systemic lupus erythematosus: A case report and literature review. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.ejrex.2011.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Currie S, Raghavan A, Batty R, Connolly DJA, Griffiths PD. Childhood moyamoya disease and moyamoya syndrome: a pictorial review. Pediatr Neurol 2011; 44:401-13. [PMID: 21555050 DOI: 10.1016/j.pediatrneurol.2011.02.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 11/24/2010] [Accepted: 02/10/2011] [Indexed: 10/18/2022]
Abstract
Moyamoya disease is an uncommon chronic cerebrovasculopathy, characterized by progressive stenosis of the terminal portion of the internal carotid artery and its main branches, in association with the development of compensatory collateral vessels at the base of the brain. The etiology is unknown, and was originally considered exclusive to East Asia, with particular prevalence in Japan. Moyamoya disease is increasingly diagnosed throughout the world, and represents an important cause of childhood stroke in Western countries. In some cases, similar angiographic features are evident in children with other medical conditions, such as sickle cell disease and Down syndrome. In these instances, the term "moyamoya syndrome" is used. Diagnosing the vasculopathy, excluding possible associated conditions, and planning treatment and follow-up imaging comprise important aspects of clinical management. We review the key imaging features of childhood moyamoya disease and syndrome, present examples of its associations, and discuss new neuroradiologic methods that may be useful in management.
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Affiliation(s)
- Stuart Currie
- Leeds and West Yorkshire Radiology Academy, Leeds General Infirmary, Leeds University Teaching Hospitals, National Health Service Trust, Leeds, United Kingdom.
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Patel NN, Mangano FT, Klimo P. Indirect revascularization techniques for treating moyamoya disease. Neurosurg Clin N Am 2011; 21:553-63. [PMID: 20561503 DOI: 10.1016/j.nec.2010.03.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
There have been many indirect revascularization techniques described by surgeons for the treatment of moyamoya disease. These surgical procedures are typically used more commonly in pediatric, than in adults', cases. Some of the techniques include: cervical sympathectomy, omental transplantation, multiple burr holes, encephalo-myo-synangiosis (EMS), encephalo-arterio-synangiosis (EAS), encephalo-duro-synangiosis (EDS), encephalo-myo-arterio-synangiosis (EMAS), encephalo-duro-arterio-synangiosis (EDAS), encephalo-duro-arterio-myo-synangiosis (EDAMS), encephalo-duro-galeo (periosteal)-synangiosis (EDGS), and combinations of all the above. This chapter will detail the technical aspects of many of these procedures and some of the reported clinical outcomes.
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Affiliation(s)
- Neil N Patel
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2019, Cincinnati, OH 45229, USA.
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Moyamoya disease associated with hereditary spherocytosis. Pediatr Neurol 2011; 44:69-71. [PMID: 21147392 DOI: 10.1016/j.pediatrneurol.2010.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 05/19/2010] [Accepted: 08/05/2010] [Indexed: 11/23/2022]
Abstract
A 5-year-old girl with hereditary spherocytosis presented with two episodes of transient ischemic attacks within a month. Cranial magnetic resonance imaging angiography revealed a left internal carotid artery and middle cerebral artery stenosis, with an extensive vascular mesh in the thalamic area indicative of moyamoya disease. Treatment consisted of supporting cerebral perfusion with blood transfusions, and splenectomy to prevent recurrence. Moyamoya disease is a very unusual cerebrovascular disorder in childhood and its association with hereditary spherocytosis is rarely reported.
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Abstract
PURPOSE Moyamoya disease, a rare cause of pediatric stroke, is a cerebrovascular occlusive disorder resulting from progressive stenosis of the distal intracranial carotid arteries and their proximal branches. In response to brain ischemia, there is the development of basal collateral vessels, which give rise to the characteristic angiographic appearance of moyamoya. If left untreated, the disease can result in overwhelming permanent neurological and cognitive deficits. METHODS Whereas moyamoya disease refers to the idiopathic form, moyamoya syndrome refers to the condition in which children with moyamoya also have a recognized clinical disorder. As opposed to adults who typically present in the setting of intracranial hemorrhage, the classic pediatric presentation is recurrent transient ischemic attacks and/or completed ischemic strokes. RESULTS Surgical revascularization, including direct and indirect techniques, remains the mainstay of treatment, and has been shown to improve long-term outcome in children with moyamoya. CONCLUSION The authors discuss the diagnosis and treatment of moyamoya disease in the pediatric population.
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