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Kim JW, Hayashi T, Kim SK, Shirane R. Technical evolution of pediatric neurosurgery: moyamoya disease. Childs Nerv Syst 2023; 39:2819-2827. [PMID: 37395784 DOI: 10.1007/s00381-023-06017-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 07/04/2023]
Abstract
Moyamoya disease (MMD) is a rare steno-occlusive disease of the bilateral internal carotid arteries that predominantly occurs in East Asia. Since the first description of the MMD by Suzuki and Takaku in 1969, significant advances have been made in both basic and clinical understanding of the disease. The incidence and prevalence of pediatric MMD have increased, potentially due to improved detection rates. The advancement of neuroimaging techniques has enabled MRI-based diagnostics and detailed visualization of the vessel wall. Various methods of surgical treatments are successful in pediatric MMD patients, and recent studies emphasize the importance of reducing postoperative complications since the goal of MMD surgery is to prevent future cerebral infarction and hemorrhage. Long-term outcomes following appropriate surgical treatment in pediatric MMD patients have shown promising results, including favorable outcomes in very young patients. Further studies with a large patient cohort are needed to establish individualized risk group stratification for determining the optimal timing of surgical treatment and to conduct multidisciplinary outcome assessments.
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Affiliation(s)
- Joo Whan Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, 03080, 101 Daehak-Ro, Jongno-Gu, Seoul, Republic of Korea
| | - Toshiaki Hayashi
- Department of Pediatric Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Neurosurgery, Miyagi Children's Hospital, 4 Chome-3-17 Ochiai, Aoba Ward, Sendai, Miyagi, 989-3126, Japan
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, 03080, 101 Daehak-Ro, Jongno-Gu, Seoul, Republic of Korea.
| | - Reizo Shirane
- Department of Neurosurgery, Miyagi Children's Hospital, 4 Chome-3-17 Ochiai, Aoba Ward, Sendai, Miyagi, 989-3126, Japan.
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2
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Aldana PR, Hanel RA, Piatt J, Han SH, Bansal MM, Schultz C, Gauger C, Pederson JM, Iii JCW, Hulbert ML, Jordan LC, Qureshi A, Garrity K, Robert AP, Hatem A, Stein J, Beydler E, Adelson PD, Greene S, Grabb P, Johnston J, Lang SS, Leonard J, Magge SN, Scott A, Shah S, Smith ER, Smith J, Strahle J, Vadivelu S, Webb J, Wrubel D. Cerebral revascularization surgery reduces cerebrovascular events in children with sickle cell disease and moyamoya syndrome: Results of the stroke in sickle cell revascularization surgery retrospective study. Pediatr Blood Cancer 2023; 70:e30336. [PMID: 37057741 DOI: 10.1002/pbc.30336] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 03/01/2023] [Accepted: 03/04/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Recent studies suggest that cerebral revascularization surgery may be a safe and effective therapy to reduce stroke risk in patients with sickle cell disease and moyamoya syndrome (SCD-MMS). METHODS We performed a multicenter, retrospective study of children with SCD-MMS treated with conservative management alone (conservative group)-chronic blood transfusion and/or hydroxyurea-versus conservative management plus surgical revascularization (surgery group). We monitored cerebrovascular event (CVE) rates-a composite of strokes and transient ischemic attacks. Multivariable logistic regression was used to compare CVE occurrence and multivariable Poisson regression was used to compare incidence rates between groups. Covariates in multivariable models included age at treatment start, age at moyamoya diagnosis, antiplatelet use, CVE history, and the risk period length. RESULTS We identified 141 patients with SCD-MMS, 78 (55.3%) in the surgery group and 63 (44.7%) in the conservative group. Compared with the conservative group, preoperatively the surgery group had a younger age at moyamoya diagnosis, worse baseline modified Rankin scale scores, and increased prevalence of CVEs. Despite more severe pretreatment disease, the surgery group had reduced odds of new CVEs after surgery (odds ratio = 0.27, 95% confidence interval [CI] = 0.08-0.94, p = .040). Furthermore, comparing surgery group patients during presurgical versus postsurgical periods, CVEs odds were significantly reduced after surgery (odds ratio = 0.22, 95% CI = 0.08-0.58, p = .002). CONCLUSIONS When added to conservative management, cerebral revascularization surgery appears to reduce the risk of CVEs in patients with SCD-MMS. A prospective study will be needed to validate these findings.
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Affiliation(s)
- Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine - Jacksonville and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Joseph Piatt
- Division of Neurosurgery, Nemours Neuroscience Center, A.I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Sabrina H Han
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Manisha M Bansal
- Department of Pediatric Hematology/Oncology, Nemours Children's Health System and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - Corinna Schultz
- Department of Pediatrics, Nemours Center for Cancer and Blood Disorders, Nemours Children's Hospital, Wilmington, Delaware, USA
| | - Cynthia Gauger
- Department of Pediatric Hematology/Oncology, Nemours Children's Health System and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - John M Pederson
- Superior Medical Experts, St. Paul, Minnesota, USA
- Nested Knowledge, St. Paul, Minnesota, USA
| | - John C Wellons Iii
- Division of Pediatric Neurological Surgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Monica L Hulbert
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adnan Qureshi
- Department of Neurology, Zeenat Qureshi Stroke Institute, University of Missouri, Columbia, Missouri, USA
| | - Kelsey Garrity
- Department of Neurosurgery, University of Florida College of Medicine - Jacksonville and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - Adam P Robert
- Department of Neurosurgery, University of Florida College of Medicine - Jacksonville and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - Asmaa Hatem
- Department of Neurosurgery, University of Florida College of Medicine - Jacksonville and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - Jennifer Stein
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Emily Beydler
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - P David Adelson
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Stephanie Greene
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Paul Grabb
- Department of Neurosurgery, Children's Mercy Hospital, Kansas, Missouri, USA
| | - James Johnston
- Department of Neurosurgery, Children's Hospital of Alabama, Birmingham, Alabama, USA
| | - Shih-Shan Lang
- Department of Neurosurgery and Pediatric Neurosurgery, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey Leonard
- Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Suresh N Magge
- Department of Neurosurgery, CHOC Neuroscience Institute, Children's Health of Orange County, Orange, California, USA
| | - Alex Scott
- Department of Neurosurgery, Washington University School of Medicine, Washington University in Saint Louis, St Louis, Missouri, USA
| | - Sanjay Shah
- Department of Pediatric Hematology/Oncology, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Edward R Smith
- Department of Neurosurgery, Children's Hospital Boston, and Harvard Medical School, Boston, Massachusetts, USA
| | - Jodi Smith
- Department of Pediatric Neurosurgery, Goodman Campbell Brain and Spine, Peyton Manning Children's Hospital, Indianapolis, Indiana, USA
| | - Jennifer Strahle
- Department of Neurosurgery, Washington University School of Medicine, Washington University in Saint Louis, St Louis, Missouri, USA
| | - Sudhakar Vadivelu
- Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jennifer Webb
- Department of Hematology/Oncology, Children's National Hospital, Washington, District of Columbia, USA
| | - David Wrubel
- Department of Neurosurgery, Children's Healthcare of Atlanta, Egleston Hospital, Atlanta, Georgia, USA
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3
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Lee KS, Zhang JJY, Bhate S, Ganesan V, Thompson D, James G, Silva AHD. Surgical revascularizations for pediatric moyamoya: a systematic review, meta-analysis, and meta-regression analysis. Childs Nerv Syst 2023; 39:1225-1243. [PMID: 36752913 PMCID: PMC10167165 DOI: 10.1007/s00381-023-05868-6] [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: 11/16/2022] [Accepted: 01/28/2023] [Indexed: 02/09/2023]
Abstract
INTRODUCTION There is no clear consensus regarding the technique of surgical revascularization for moyamoya disease and syndrome (MMD/MMS) in the pediatric population. Previous meta-analyses have attempted to address this gap in literature but with methodological limitations that affect the reliability of their pooled estimates. This meta-analysis aimed to report an accurate and transparent comparison between studies of indirect (IB), direct (DB), and combined bypasses (CB) in pediatric patients with MMD/MMS. METHODS In accordance with PRISMA guidelines, systematic searches of Medline, Embase, and Cochrane Central were undertaken from database inception to 7 October 2022. Perioperative adverse events were the primary outcome measure. Secondary outcomes were rates of long-term revascularization, stroke recurrence, morbidity, and mortality. RESULTS Thirty-seven studies reporting 2460 patients and 4432 hemispheres were included in the meta-analysis. The overall pooled mean age was 8.6 years (95% CI: 7.7; 9.5), and 45.0% were male. Pooled proportions of perioperative adverse events were similar between the DB/CB and IB groups except for wound complication which was higher in the former group (RR = 2.54 (95% CI: 1.82; 3.55)). Proportions of post-surgical Matsushima Grade A/B revascularization favored DB/CB over IB (RR = 1.12 (95% CI 1.02; 1.24)). There was no significant difference in stroke recurrence, morbidity, and mortality. After meta-regression analysis, year of publication and age were significant predictors of outcomes. CONCLUSIONS IB, DB/CB are relatively effective and safe revascularization options for pediatric MMD/MMS. Low-quality GRADE evidence suggests that DB/CB was associated with better long-term angiographic revascularization outcomes when compared with IB, although this did not translate to long-term stroke and mortality benefits.
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Affiliation(s)
- Keng Siang Lee
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK.
- Great Ormond Street Institute of Child Health, University College London, London, UK.
- Department of Neurosurgery, King's College Hospital, London, UK.
- Department of Basic and Clinical Neurosciences, Maurice, Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
- Bristol Medical School, University of Bristol, Bristol, UK.
| | - John J Y Zhang
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Sanjay Bhate
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Vijeya Ganesan
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Dominic Thompson
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Greg James
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Adikarige Haritha Dulanka Silva
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
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Alakbarzade V, Maduakor C, Khan U, Khandanpour N, Rhodes E, Pereira AC. Cerebrovascular disease in sickle cell disease. Pract Neurol 2023; 23:131-138. [PMID: 36123118 DOI: 10.1136/pn-2022-003440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 11/04/2022]
Abstract
Sickle cell disease (SCD) is the most common type of hereditary anaemia and genetic disorder worldwide. Cerebrovascular disease is one of its most devastating complications, with consequent increased morbidity and mortality. Current guidelines suggest that children and adults with SCD who develop acute ischaemic stroke should be transfused without delay. Those with acute ischaemic stroke aged over 18 years who present within 4.5 hours of symptom onset should be considered for intravenous thrombolysis; older patients with conventional vascular risk factors are the most likely to benefit. Endovascular thrombectomy should be considered carefully in adults with SCD as there are few data to guide how the prevalence of cerebral vasculopathy may confound the expected benefits or risks of intervention. We present a practical approach to cerebrovascular disease in sickle cell patients based on the available evidence and our experience.
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Affiliation(s)
- Vafa Alakbarzade
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Chinedu Maduakor
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Usman Khan
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Nader Khandanpour
- Department of Neuroradiology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Elizabeth Rhodes
- Department of Haematology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Anthony C Pereira
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
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5
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Lehman LL, Kaseka ML, Stout J, See AP, Pabst L, Sun LR, Hassanein SA, Waak M, Vossough A, Smith ER, Dlamini N. Pediatric Moyamoya Biomarkers: Narrowing the Knowledge Gap. Semin Pediatr Neurol 2022; 43:101002. [PMID: 36344019 DOI: 10.1016/j.spen.2022.101002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 11/28/2022]
Abstract
Moyamoya is a progressive cerebrovascular disorder that leads to stenosis of the arteries in the distal internal carotid, proximal middle cerebral and proximal anterior cerebral arteries of the circle of Willis. Typically a network of collaterals form to bypass the stenosis and maintain cerebral blood flow. As moyamoya progresses it affects the anterior circulation more commonly than posterior circulation, and cerebral blood flow becomes increasingly reliant on external carotid supply. Children with moyamoya are at increased risk for ischemic symptoms including stroke and transient ischemic attacks (TIA). In addition, cognitive decline may occur over time, even in the absence of clinical stroke. Standard of care for stroke prevention in children with symptomatic moyamoya is revascularization surgery. Treatment of children with asymptomatic moyamoya with revascularization surgery however remains more controversial. Therefore, biomarkers are needed to assist with not only diagnosis but also with determining ischemic risk and identifying best surgical candidates. In this review we will discuss the current knowledge as well as gaps in research in relation to pediatric moyamoya biomarkers including neurologic presentation, cognitive, neuroimaging, genetic and biologic biomarkers of disease severity and ischemic risk.
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Affiliation(s)
- Laura L Lehman
- Department of Neurology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Matsanga Leyila Kaseka
- Department of Neurology, CHU Sainte-Justine, Montreal, Quebec, Canada; Université de Montréal, Montreal, Quebec, Canada
| | - Jeffery Stout
- Harvard Medical School, Boston, MA; Newborn Medicine, Boston Children's Hospital, Boston, MA
| | - Alfred P See
- Harvard Medical School, Boston, MA; Department of Neurosurgery, Boston Children's Hospital, Boston, MA; Department of Radiology, Boston Children's Hospital, Boston, MA
| | - Lisa Pabst
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Columbus, OH
| | - Lisa R Sun
- Division of Pediatric Neurology, Division of Cerebrovascular Neurology, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Sahar A Hassanein
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Michaela Waak
- Department of Paediatric Intensive Care, Queensland Children's Hospital; Centre for Child Health Research, The University of Queensland, Brisbane, Australia
| | - Arastoo Vossough
- Department of Radiology, Children's Hospital of Philadelphia, University of Philadelphia, Philadelphia, Pennsylvania
| | - Edward R Smith
- Harvard Medical School, Boston, MA; Department of Neurosurgery, Boston Children's Hospital, Boston, MA
| | - Nomazulu Dlamini
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada; Faculty of Medicine, University of Toronto, Canada
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6
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Newman S, McMahon JT, Boulter JH, Malcolm JG, Revuelta Barbero JM, Chern JJ, Barrow DL, Pradilla G. Revascularization Is Associated With a Reduced Stroke Risk in Patients With Sickle Cell-Associated Moyamoya Syndrome. Neurosurgery 2022; 90:441-446. [PMID: 35132969 DOI: 10.1227/neu.0000000000001847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 11/03/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Moyamoya syndrome refers to a progressive stenosis of the internal carotid arteries and can be associated with sickle cell disease. These codiagnoses result in severe risk for stroke, even in patients on optimal medical management. Surgical revascularization has been shown to be safe in small case series. OBJECTIVE To evaluate the efficacy of revascularization with direct comparison to a medically managed control group within a single institution. METHODS A retrospective cohort study of medically managed vs surgically revascularized patients with moyamoya syndrome and sickle cell disease was conducted. Demographic data and outcomes including the number of prediagnosis, postdiagnosis, and postrevascularization strokes were collected. Risk factors for stroke were identified using a binary logistic regression model, and stroke rates and mortality between groups were compared. RESULTS Of the 29 identified patients, 66% were medically managed and 34% underwent surgical revascularization (50% direct and 50% indirect). Calculated stroke rates were 1 per 5.37 (medical management), 1 per 3.43 (presurgical revascularization), and 1 per 23.14 patient-years (postsurgical revascularization). There was 1 surgical complication with no associated permanent deficits. No risk factors for stroke after time of diagnosis were found to be significant. CONCLUSION The results of this study demonstrate that revascularization is associated with a significant reduction in stroke risk, both relative to prerevascularization rates and compared with medical management. According to these findings, surgical revascularization offers a safe and durable preventative therapy for stroke and should be pursued aggressively in this patient population.
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Affiliation(s)
- Sarah Newman
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | | | - Jason H Boulter
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - James G Malcolm
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | | | - Joshua J Chern
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
- Department of Neurosurgery, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Daniel L Barrow
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
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Slingerland AL, Karsten MB, Smith ER, Sobota AE, See AP. Two Sides of a Coin: Case Report of Unilateral Synangiosis and Contralateral Stroke Highlighting Consequences of Disease Progression and Efficacy of Revascularization in Sickle Cell Disease Associated Moyamoya Syndrome. Acta Haematol 2021; 145:458-464. [PMID: 34879377 DOI: 10.1159/000521361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 11/15/2021] [Indexed: 11/19/2022]
Abstract
Moyamoya syndrome increases the risk of stroke in sickle cell disease, but revascularization surgery can modify this risk. Collaborative management between hematology and neurosurgery offers effective strategies to reduce stroke risk in these patients. We describe a challenging case where a patient with sickle cell disease undergoing standard of care management as prescribed by the Stroke Prevention Trial in Sickle Cell Anemia (STOP) and revascularization with pial synangiosis subsequently developed rapidly progressive disease in other cerebral vessels and suffered ischemic hemispheric stroke. This case demonstrates the success of management in accordance with American Heart Association (AHA) and American Stroke Association (ASA) guidelines, but also demonstrates critical areas where we lack understanding of disease progression.
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Affiliation(s)
- Anna L Slingerland
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Madeline B Karsten
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Amy E Sobota
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Alfred P See
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
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8
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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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9
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American Society of Hematology 2020 guidelines for sickle cell disease: prevention, diagnosis, and treatment of cerebrovascular disease in children and adults. Blood Adv 2021; 4:1554-1588. [PMID: 32298430 DOI: 10.1182/bloodadvances.2019001142] [Citation(s) in RCA: 194] [Impact Index Per Article: 64.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 02/03/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Central nervous system (CNS) complications are among the most common, devastating sequelae of sickle cell disease (SCD) occurring throughout the lifespan. OBJECTIVE These evidence-based guidelines of the American Society of Hematology are intended to support the SCD community in decisions about prevention, diagnosis, and treatment of the most common neurological morbidities in SCD. METHODS The Mayo Evidence-Based Practice Research Program supported the guideline development process, including updating or performing systematic evidence reviews. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE evidence-to-decision frameworks, to assess evidence and make recommendations. RESULTS The panel placed a higher value on maintaining cognitive function than on being alive with significantly less than baseline cognitive function. The panel developed 19 recommendations with evidence-based strategies to prevent, diagnose, and treat CNS complications of SCD in low-middle- and high-income settings. CONCLUSIONS Three of 19 recommendations immediately impact clinical care. These recommendations include: use of transcranial Doppler ultrasound screening and hydroxyurea for primary stroke prevention in children with hemoglobin SS (HbSS) and hemoglobin Sβ0 (HbSβ0) thalassemia living in low-middle-income settings; surveillance for developmental delay, cognitive impairments, and neurodevelopmental disorders in children; and use of magnetic resonance imaging of the brain without sedation to detect silent cerebral infarcts at least once in early-school-age children and once in adults with HbSS or HbSβ0 thalassemia. Individuals with SCD, their family members, and clinicians should become aware of and implement these recommendations to reduce the burden of CNS complications in children and adults with SCD.
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10
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Sesen J, Driscoll J, Moses-Gardner A, Orbach DB, Zurakowski D, Smith ER. Non-invasive Urinary Biomarkers in Moyamoya Disease. Front Neurol 2021; 12:661952. [PMID: 33868159 PMCID: PMC8047329 DOI: 10.3389/fneur.2021.661952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: A major difficulty in treating moyamoya disease is the lack of effective methods to detect novel or progressive disease prior to the onset of disabling stroke. More importantly, a tool to better stratify operative candidates and quantify response to therapy could substantively complement existing methods. Here, we present proof-of-principle data supporting the use of urinary biomarkers as diagnostic adjuncts in pediatric moyamoya patients. Methods: Urine and cerebrospinal fluid specimens were collected from pediatric patients with moyamoya disease and a cohort of age and sex-matched control patients. Clinical and radiographic data were paired with measurements of a previously validated panel of angiogenic proteins quantified by ELISA. Results were compared to age and sex-matched controls and subjected to statistical analyses. Results: Evaluation of a specific panel of urinary and cerebrospinal fluid biomarkers by ELISA demonstrated significant elevations of angiogenic proteins in samples from moyamoya patients compared to matched controls. ROC curves for individual urinary biomarkers, including MMP-2, MMP-9, MMP-9/NGAL, and VEGF, showed excellent discrimination. The optimal urinary biomarker was MMP-2, providing a sensitivity of 88%, specificity of 100%, and overall accuracy of 91%. Biomarker levels changed in response to therapy and correlated with radiographic evidence of revascularization. Conclusions: We report, for the first time, identification of a panel of urinary biomarkers that predicts the presence of moyamoya disease. These biomarkers correlate with presence of disease and can be tracked from the central nervous system to urine. These data support the hypothesis that urinary proteins are useful predictors of the presence of moyamoya disease and may provide a basis for a novel, non-invasive method to identify new disease and monitor known patients following treatment.
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Affiliation(s)
- Julie Sesen
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Jessica Driscoll
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Alexander Moses-Gardner
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Darren B Orbach
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - David Zurakowski
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.,Departments of Surgery and Anesthesiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Edward R Smith
- Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.,Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
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11
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Dorschel KB, Wanebo JE. Genetic and Proteomic Contributions to the Pathophysiology of Moyamoya Angiopathy and Related Vascular Diseases. APPLICATION OF CLINICAL GENETICS 2021; 14:145-171. [PMID: 33776470 PMCID: PMC7987310 DOI: 10.2147/tacg.s252736] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 12/26/2020] [Indexed: 12/13/2022]
Abstract
Rationale This literature review describes the pathophysiological mechanisms of the current classes of proteins, cells, genes, and signaling pathways relevant to moyamoya angiopathy (MA), along with future research directions and implementation of current knowledge in clinical practice. Objective This article is intended for physicians diagnosing, treating, and researching MA. Methods and Results References were identified using a PubMed/Medline systematic computerized search of the medical literature from January 1, 1957, through August 4, 2020, conducted by the authors, using the key words and various combinations of the key words “moyamoya disease,” “moyamoya syndrome,” “biomarker,” “proteome,” “genetics,” “stroke,” “angiogenesis,” “cerebral arteriopathy,” “pathophysiology,” and “etiology.” Relevant articles and supplemental basic science articles published in English were included. Intimal hyperplasia, medial thinning, irregular elastic lamina, and creation of moyamoya vessels are the end pathologies of many distinct molecular and genetic processes. Currently, 8 primary classes of proteins are implicated in the pathophysiology of MA: gene-mutation products, enzymes, growth factors, transcription factors, adhesion molecules, inflammatory/coagulation peptides, immune-related factors, and novel biomarker candidate proteins. We anticipate that this article will need to be updated in 5 years. Conclusion It is increasingly apparent that MA encompasses a variety of distinct pathophysiologic conditions. Continued research into biomarkers, genetics, and signaling pathways associated with MA will improve and refine our understanding of moyamoya’s complex pathophysiology. Future efforts will benefit from multicenter studies, family-based analyses, comparative trials, and close collaboration between the clinical setting and laboratory research.
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Affiliation(s)
- Kirsten B Dorschel
- Heidelberg University Medical School, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Germany
| | - John E Wanebo
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA.,Department of Neuroscience, HonorHealth Research Institute, Scottsdale, AZ, USA
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12
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Terrell D, Savardekar AR, Whipple SG, Dossani RH, Spetzler RF, Sun H. Cerebral Revascularization for Moyamoya Syndrome Associated with Sickle Cell Disease: A Systematic Review of the Literature on the Role of Extracranial-Intracranial Bypass in Treating Neurologic Manifestations of Pediatric Patients with Sickle Cell Disease. World Neurosurg 2020; 137:62-70. [PMID: 32014541 DOI: 10.1016/j.wneu.2020.01.182] [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: 12/11/2019] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 01/16/2023]
Abstract
Moyamoya syndrome (MMS) in patients with sickle cell disease (SCD) accentuates the risk of recurrent strokes. Chronic transfusion therapy (CTT) is an excellent option for preventing recurrent strokes in most patients with SCD. In SCD with MMS, CTT may fail as a long-term solution. Cerebral revascularization, in the form of extracranial-intracranial bypass, has been shown to prevent recurrent strokes in this cohort. We review the evolution of this paradigm shift in the management of SCD-associated MMS. A systematic review, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, was conducted. Our primary objectives were 1) to study the evolution of cerebral revascularization techniques in management of MMS in SCD and 2) to analyze the impact of neurosurgical intervention in this high-risk population. Four patients with SCD-associated MMS, who underwent indirect cerebral revascularization at our institute were retrospectively reviewed. A summary of 13 articles chronicling the advent and subsequent evolution of cerebral revascularization as a viable treatment strategy for stroke prevention in SCD-associated MMS is presented. The literature review suggests that early detection and surgical intervention (in addition to CTT) could significantly reduce stroke recurrence and improve neurocognitive outcome. Our short series of 4 patients also had a good outcome and no recurrence of strokes postoperatively. The literature emphasizes the use of a traditional standardized protocol for early identification (transcranial Dopplers, selective magnetic resonance angiography, and CTT). Early treatment and screening that involves early magnetic resonance angiography and referral to neurosurgery for revascularization may be considered for this high-risk population.
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Affiliation(s)
- Danielle Terrell
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Amey R Savardekar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Stephen Garrett Whipple
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Rimal H Dossani
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Hai Sun
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
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13
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Outcomes in Patients with Moyamoya Syndrome and Sickle Cell Disease: A Systematic Review. World Neurosurg 2019; 135:165-170. [PMID: 31790841 DOI: 10.1016/j.wneu.2019.11.137] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/22/2019] [Accepted: 11/23/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Moyamoya syndrome, a progressive, idiopathic stenosis of the internal carotid arteries, results in increased risk for both ischemic and hemorrhagic strokes. Revascularization procedures have been shown in small studies to be both safe and efficacious for these patients; however, randomized controlled trials are lacking. The goal of this systematic review is to organize the literature evaluating surgical intervention versus conservative medical management. METHODS A systematic review was performed including studies with 3 or more participants with moyamoya syndrome in the setting of sickle cell disease and a measured outcome after either medical or surgical intervention. Relevant studies were identified using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria and a set of predetermined key words. RESULTS Sixty-one articles were identified with 6 articles ultimately included in this review (N = 122). Of the patients, 73 (59.8%) were revascularized surgically (all indirect procedures), whereas 49 (40.2%) remained on chronic transfusion therapy. Of the patients that underwent indirect revascularization surgery, a total of 1 perioperative (1.4%) and 4 postoperative strokes (5.5%) were reported over 44 months (1 stroke per 53.3 patient-years). In comparison, an average of 46.5% of patients who were receiving chronic transfusions had major events (stroke or transient ischemic attack) while undergoing therapy (1 stroke per 13.65 patient-years, P = 0.00215). CONCLUSIONS We present a large systematic review of the literature regarding outcomes of surgical and medical management for patients with moyamoya syndrome and sickle cell disease. The findings redemonstrate the efficacy and safety of surgical revascularization, and advocate for earlier discussion around surgical intervention.
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14
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Fehnel KP, McClain CD, Smith ER. Indirect bypass for maternal symptomatic moyamoya in the first trimester of pregnancy: case report. J Neurosurg Pediatr 2019; 25:138-143. [PMID: 31756708 DOI: 10.3171/2019.9.peds19360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 09/10/2019] [Indexed: 11/06/2022]
Abstract
There are no practice guidelines for the treatment of moyamoya disease in pregnant women. The need for such guidelines, however, is evidenced by the numerous case reports, case series, and systematic reviews in the literature highlighting an at-risk period for female moyamoya patients of childbearing age. Here the authors review and interpret the existing literature as it applies to their index patient and expand the literature in support of treating select patients during pregnancy. The authors describe what is to their knowledge the first case reported in the literature of a patient successfully treated with indirect surgical revascularization during the first trimester, who went on to deliver a healthy term baby without complications.
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Affiliation(s)
- Katie P Fehnel
- 1Vascular Biology Program and
- Departments of2Neurosurgery and
| | - Craig D McClain
- 3Anesthesiology, Boston Children's Hospital, Boston, Massachusetts
| | - Edward R Smith
- 1Vascular Biology Program and
- Departments of2Neurosurgery and
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15
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Feghali J, Xu R, Yang W, Liew JA, Blakeley J, Ahn ES, Tamargo RJ, Huang J. Moyamoya disease versus moyamoya syndrome: comparison of presentation and outcome in 338 hemispheres. J Neurosurg 2019; 133:1441-1449. [PMID: 31585423 DOI: 10.3171/2019.6.jns191099] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Phenotypic differences between moyamoya disease (MMD) and moyamoya syndrome (MMS) remain unclear. The purpose of this study was to evaluate whether such differences exist when presentation, procedure-related, and outcome variables are compared quantitatively. METHODS The study cohort included 185 patients with moyamoya presenting to the Johns Hopkins Medical Institutions between 1994 and 2015. Baseline demographic, angiographic, and clinical characteristics were compared between patients with MMS and MMD, in addition to procedure-related complications and length of stay (LOS) after surgery. Stroke-free survival was compared between both disease variants after diagnosis. Kaplan-Meier analysis and Cox proportional hazards regression were used to compare stroke-free survival between surgically treated and conservatively managed hemispheres in both types of disease, while evaluating interaction between disease variant and management. RESULTS The cohort consisted of 137 patients with MMD (74%) with a bimodal age distribution and 48 patients with MMS (26%) who were mostly under 18 years of age (75%). Underlying diseases included sickle cell disease (48%), trisomy 21 (12%), neurofibromatosis (23%), and other disorders (17%). Patients with MMS were younger (p < 0.001) and less likely to be female (p = 0.034). Otherwise, baseline characteristics were statistically comparable. The rate of surgical complications was 33% in patients with MMD and 16% in patients with MMS (p = 0.097). Both groups of patients had a similar LOS after surgery (p = 0.823). Survival analysis (n = 330 hemispheres) showed similar stroke-free survival after diagnosis (p = 0.856) and lower stroke hazard in surgically managed patients in both MMD (hazard ratio [HR] 0.29, p = 0.028) and MMS (HR 0.62, p = 0.586). The disease variant (MMD vs MMS) did not affect the relationship between management approach (surgery vs conservative) and stroke hazard (p = 0.787). CONCLUSIONS MMD and MMS have largely comparable clinical and angiographic phenotypes with analogously favorable responses to surgical revascularization.
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Affiliation(s)
| | | | | | | | - Jaishri Blakeley
- 2Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Edward S Ahn
- 3Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
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16
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Ravindran K, Wellons JC, Dewan MC. Surgical outcomes for pediatric moyamoya: a systematic review and meta-analysis. J Neurosurg Pediatr 2019; 24:663-672. [PMID: 31518973 DOI: 10.3171/2019.6.peds19241] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/13/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The optimal revascularization for pediatric moyamoya for reducing the incidence of future stroke events remains to be determined. METHODS The authors conducted a search of PubMed, MEDLINE, Embase, and Web of Science electronic databases from inception until January 2019. The primary endpoint was the presence of a future ischemic stroke event. Secondary endpoints were angiographic outcomes as measured by postoperative Matsushima grade and clinical symptom persistence. Patients who underwent either direct or combined direct/indirect revascularization were classified into the direct cohort. Data from each study on presence of postoperative stroke events were used to generate standardized mean differences and 95% confidence intervals, which were combined using inverse variance-weighted averages of standardized mean differences in a random effects model. RESULTS Twenty-nine studies met the inclusion criteria for analysis, comprising 2258 patients (1011 males, mean age 8.3 ± 1.8 years) who were followed up clinically for an average of 71.4 ± 51.3 months. One hundred fifty-four patients underwent direct bypass alone, 680 patients underwent either direct or combined direct/indirect revascularization procedures, while 1424 patients underwent indirect bypass alone. The frequencies of future stroke events in patients undergoing direct bypass alone, combined bypass, or indirect bypass alone were 1 per 190.3 patient-years, 1 per 108.9 patient-years, and 1 per 61.1 patient-years, respectively, in each cohort. The estimated stroke rates were 9.0% with indirect revascularization, 4.5% with direct revascularization alone, and 6.0% with combined revascularization. A forest plot did not reveal any significant differences in the incidence of future stroke events or angiographic outcomes following direct-only, combined, or indirect-only revascularization. CONCLUSIONS Direct, indirect, and combined indirect/direct bypass techniques are all effective revascularization options for pediatric moyamoya disease. A relative paucity of granular studies-and inherent surgical selection bias-limits direct comparison between interventions. Suitably designed prospective cohort studies may be useful in identifying patients likely to receive benefit from specific procedures.
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Affiliation(s)
| | - John C Wellons
- 2Division of Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael C Dewan
- 2Division of Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2019; 50:e51-e96. [DOI: 10.1161/str.0000000000000183] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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19
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Abstract
Vascular injury is increasingly recognized as an important cause of mortality and morbidity in children (29 days to 18 years of age). Since vascular brain injury in children appears to be less common than in adults, the index of suspicion for vascular brain injury is usually lower. In this review article, we describe frequent and rare conditions underlying pediatric stroke including cardioembolic, viral, autoimmune, post-traumatic, and genetic etiologies. Furthermore, we provide a neuroimaging correlate for clinical mimics of pediatric stroke. This review highlights the role of multimodal noninvasive neuroimaging in the early diagnosis of pediatric stroke, providing a problem-solving approach to the differential diagnosis for the neuroradiologist, emergency room physician, and neurologist.
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20
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Jernigan S, Storey A, Hammer C, Riordan C, Orbach DB, Scott RM, Smith E. Moyamoya syndrome and PHACE syndrome: clinical and radiographic characterization of the intracranial arteriopathy and response to surgical revascularization. J Neurosurg Pediatr 2019; 23:493-497. [PMID: 30717056 DOI: 10.3171/2018.10.peds18582] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 10/29/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE PHACE syndrome (PHACES) has been linked to cervical and cerebral vascular anomalies, including persistent embryonic anastomoses and progressive steno-occlusive disease. However, no prior studies have documented the long-term response of PHACES patients with moyamoya disease to surgical revascularization with pial or myosynangiosis. The authors present their experience with 8 consecutive patients with PHACES and moyamoya disease. METHODS Retrospective review of patients who underwent pial synangiosis revascularization for moyamoya disease with concurrent diagnosis of PHACES. RESULTS A total of 8 patients out of 456 surgically treated moyamoya patients had a diagnosis of PHACES. All patients were female, and their average age at the time of surgical treatment was 9.3 years (range 1.8-25.8 years). Five patients had associated basilar artery anomalies or stenosis. All patients had symptomatic narrowing of the petrous segment of the internal carotid artery with tortuous collateralization. Three patients underwent unilateral pial or myo-synangiosis and 5 underwent bilateral procedures. The average hospital length of stay was 5.0 days (range 3-7 days). There were no postoperative complications. Follow-up ranged from 8 to 160 months (average 56 months). Seven of 8 patients have had follow-up angiograms and all had Matsushima grade A or B collateralization without progression of stenosis in other locations. All patients had reduced cortical FLAIR signal on 6-month follow-up MRI and no evidence of new radiographic or clinical strokes. CONCLUSIONS Patients with moyamoya disease and PHACES had an intracranial arteriopathy characterized by ectactic anterior vasculature with concomitant basilar artery stenosis, and were all female. The patients had both radiographic and clinical responses to pial synangiosis. The surgical treatment of these patients can be challenging given facial hemangiomas located near the surgical field. Patients with unilateral disease did not have evidence of progression in other cerebral circulation during the given follow-up period.
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Affiliation(s)
| | | | | | | | - Darren B Orbach
- Departments of1Neurosurgery and
- 2Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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21
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Aguilar-Salinas P, Hayward K, Santos R, Agarwal V, Sauvageau E, Hanel RA, Aldana PR. Surgical Revascularization for Pediatric Patients with Sickle Cell Disease and Moyamoya Disease in the Prevention of Ischemic Strokes: A Single-Center Case Series and a Systematic Review. World Neurosurg 2018; 123:435-442.e8. [PMID: 30496928 DOI: 10.1016/j.wneu.2018.11.157] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 11/15/2018] [Accepted: 11/17/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND This systematic review aims to identify and analyze the available evidence on the safety and efficacy of surgical revascularization for pediatric patients with sickle cell disease (SCD) and moyamoya disease (MMD). METHODS A systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The following databases were searched: PubMed, Ovid MEDLINE, and Scopus. Studies included in the review were original research articles in peer-reviewed journals in which individual participant data were available. The articles were thoroughly examined and compared on study design, outcomes, and results. The authors reviewed their institution's database to identify pediatric patients with SCD and MMD who underwent surgical revascularization and were included in the analysis. RESULTS A total of 53 patients were included and 82 hemispheres were intervened with direct or indirect surgical revascularization. Encephaloduroarteriosynangiosis (EDAS) was the most common procedure performed (42/82; 51.2%) followed by pial synangiosis (31/82; 37.8%). There was 1 intraprocedural complication. The median clinical follow-up was 37 months (interquartile range, 24.1-73.5 months) and during this period, 3 of 52 patients (5.8%) had ischemic strokes. All ischemic strokes occurred within the first 30 days after the surgery and the rate of ischemic stroke-free survival was 94.3% (95% confidence interval, 83.3-98.1). The estimated incidence rate of ischemic stroke was 1.42 events/100 patient-years (95% confidence interval, 0.46-4.4). CONCLUSIONS Our study suggests that surgical revascularization in pediatric patients with SCD and MMD is safe to perform and results in a low rate of future ischemic insults.
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Affiliation(s)
- Pedro Aguilar-Salinas
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA; Division of Neurosurgery, University of Arizona, Tucson, Arizona, USA
| | - Kelsey Hayward
- Division of Pediatric Neurosurgery, University of Florida Health Jacksonville, Jacksonville, Florida, USA
| | - Roberta Santos
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Vibhuti Agarwal
- Department of Pediatric Hematology-Oncology, Nemours Children's Specialty Care, Pensacola, Florida, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Philipp R Aldana
- Division of Pediatric Neurosurgery, University of Florida Health Jacksonville, Jacksonville, Florida, USA.
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The Genetic Landscape of Cerebral Steno-Occlusive Arteriopathy and Stroke in Sickle Cell Anemia. J Stroke Cerebrovasc Dis 2018; 27:2897-2904. [PMID: 30076115 DOI: 10.1016/j.jstrokecerebrovasdis.2018.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/28/2018] [Accepted: 06/02/2018] [Indexed: 11/24/2022] Open
Abstract
Sickle cell disease (SCD) is one of the most common autosomal recessive diseases in humans, occurring at a frequency of 1 in 365 African-American and 1 in 50 sub-Saharan African births. Despite progress in managing complications of SCD, these remain a major health burden worldwide. Stroke is a common and serious complication of SCD, most often associated with steno-occlusive cerebral arteriopathy, but little is known about its pathogenesis. Transcranial Doppler ultrasonography is currently the only predictive test for future development of stroke in patients with sickle cell anemia and is used to guide preventative treatment. However, transcranial Doppler ultrasonography does not identify all patients at increased risk for stroke, and progressive arteriopathy may occur despite preventative treatment. While sibling studies have shown a strong genetic contribution to the development of steno-occlusive arteriopathy (SOA) in SCD, the only genome-wide association study compared a relatively small cohort of 177 patients with stroke to 335 patients with no history of stroke. This single study detected variants in only 2 genes, ENPP1 and GOLGB1, and only one of these was confirmed in a subsequent independent study. Thus, the underlying genes and pathogenesis of SOA in SCD remain poorly understood, greatly limiting the ability to develop more effective preventive therapies. Dissecting the molecular causes of stroke in SCD will provide valuable information that can be used to better prevent stroke, stratify risk of SOA, and optimize personalized medicine approaches.
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When and why is surgical revascularization indicated for the treatment of moyamoya syndrome in patients with RASopathies? A systematic review of the literature and a single institute experience. Childs Nerv Syst 2018; 34:1311-1323. [PMID: 29797062 DOI: 10.1007/s00381-018-3833-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/13/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Moyamoya disease (MMD) is a cerebrovascular disorder characterized by the progressive occlusion of the supraclinoid internal carotid artery (ICA), resulting in the formation of an abnormal cerebral vascular network. When MMD occurs in association with an underlying medical condition, including some distinctive genetic disorders, it is named moyamoya syndrome (MMS). The discrimination between MMD and MMS has been validated by recent genetic researches and international reviews. Similarly to patients suffering from MMD, patients with MMS generally become symptomatic because of ischemic complications, which lead to hemiparesis, transient ischemic events, seizures, and sensory symptoms. RASopathies are a group of neurodevelopmental disorders that can be associated with MMS. RESULTS We retrospectively reviewed 18 RASopathy patients with MMS treated at our institution from 2000 to 2015 (16 neurofibromatosis type 1, 1 Costello syndrome, and 1 Schimmelpenning syndrome). Here, we report clinical data, performed surgical procedures, and clinic-radiological outcome of these patients. Most of them received both indirect revascularization and medical therapy. CONCLUSIONS At the moment, there are no univocal recommendations on which of these two treatment strategies is the treatment of choice in patients with RASopathies and MMS. We suggest that patients with a good overall prognosis (primarily depending on the distinctive underlying genetic disorder) and initial cerebrovascular disease could benefit from a prophylactic surgical revascularization, in order to prevent the cognitive impairment due to the progression of the vasculopathy.
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Corvest V, Blais S, Dahmani B, De Tersant M, Etienney AC, Maroni A, Ormières C, Roussel A, Pondarré C. [Cerebral vasculopathy in children with sickle cell disease: Key issues and the latest data]. Arch Pediatr 2017; 25:63-71. [PMID: 29254735 DOI: 10.1016/j.arcped.2017.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 09/07/2017] [Accepted: 11/04/2017] [Indexed: 10/18/2022]
Abstract
Cerebral vasculopathy is a common and severe complication of sickle cell disease in children. The pathophysiology consists of progressive damage to the basal intracranial arteries and cerebral microcirculation, while chronic anemia worsens exposure to cerebral hypoxia. It results in stroke and subclinical or poorly symptomatic ischemic lesions. Many clinical, biological, and radiological risk factors have been identified. The prevention strategy through systematic transcranial Doppler screening of large-vessel vasculopathy has revolutionized the management of this disease and has greatly decreased the risk of developing stroke. MRI-MRA is a complementary diagnostic tool for anatomical analysis of parenchymal and vascular lesions, which is used for chronic disease monitoring or in the context of an acute neurological event. New exploration opportunities are offered by submandibular Doppler sonography and indirect evaluation methods of cerebral oxygenation and perfusion. If chronic blood transfusion therapy is used to prevent the occurrence and recurrence of cerebral complications of sickle cell disease, only allogeneic hematopoietic stem cell transplantation can safely and definitively stop the transfusion program. It should therefore be proposed early, before irreversible cerebral or vascular lesions occur. Hydroxycarbamide treatment has recently emerged as a potential substitute for chronic transfusions for the maintenance of transcranial Doppler velocities, but only after an initial treatment by transfusions and provided there is close follow-up. In the long run, cerebral vascular damage can cause progressive cognitive impairment and disability, even in children without radiologically identified lesions, indicating the importance of systematic and repeated neuropsychological testing.
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Affiliation(s)
- V Corvest
- Assistance publique-Hôpitaux de Paris (AP-HP), 3, avenue Victoria, 75004 Paris, France
| | - S Blais
- Assistance publique-Hôpitaux de Paris (AP-HP), 3, avenue Victoria, 75004 Paris, France
| | - B Dahmani
- Assistance publique-Hôpitaux de Paris (AP-HP), 3, avenue Victoria, 75004 Paris, France
| | - M De Tersant
- Assistance publique-Hôpitaux de Paris (AP-HP), 3, avenue Victoria, 75004 Paris, France
| | - A-C Etienney
- Assistance publique-Hôpitaux de Paris (AP-HP), 3, avenue Victoria, 75004 Paris, France
| | - A Maroni
- Assistance publique-Hôpitaux de Paris (AP-HP), 3, avenue Victoria, 75004 Paris, France
| | - C Ormières
- Assistance publique-Hôpitaux de Paris (AP-HP), 3, avenue Victoria, 75004 Paris, France
| | - A Roussel
- Assistance publique-Hôpitaux de Paris (AP-HP), 3, avenue Victoria, 75004 Paris, France
| | - C Pondarré
- Université Paris-XII, centre hospitalier intercommunal de Créteil (CHIC), service de pédiatrie, 40, avenue de Verdun, 94000 Créteil, France.
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Yang W, Xu R, Porras JL, Takemoto CM, Khalid S, Garzon-Muvdi T, Caplan JM, Colby GP, Coon AL, Tamargo RJ, Huang J, Ahn ES. Effectiveness of surgical revascularization for stroke prevention in pediatric patients with sickle cell disease and moyamoya syndrome. J Neurosurg Pediatr 2017; 20:232-238. [PMID: 28686127 DOI: 10.3171/2017.1.peds16576] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sickle cell disease (SCD) in combination with moyamoya syndrome (MMS) represents a rare complication of SCD, with potentially devastating neurological outcomes. The effectiveness of surgical revascularization in this patient population is currently unclear. The authors' aim was to determine the effectiveness of surgical intervention in their series of SCD-MMS patients by comparing stroke recurrence in those undergoing revascularization and those undergoing conservative transfusion therapy. METHODS The authors performed a retrospective chart review of patients with MMS who were seen at the Johns Hopkins Medical Institution between 1990 and 2013. Pediatric patients (age < 18 years) with confirmed diagnoses of SCD and MMS were included. Intracranial stroke occurrence during the follow-up period was compared between surgically and conservatively managed patients. RESULTS A total of 15 pediatric SCD-MMS patients (28 affected hemispheres) were included in this study, and all were African American. Seven patients (12 hemispheres) were treated with indirect surgical revascularization. The average age at MMS diagnosis was 9.0 ± 4.0 years, and 9 patients (60.0%) were female. Fourteen patients (93.3%) had strokes before diagnosis of MMS, with an average age at first stroke of 6.6 ± 3.9 years. During an average follow-up period of 11.6 years, 4 patients in the conservative treatment group experienced strokes in 5 hemispheres, whereas no patient undergoing the revascularization procedure had any strokes at follow-up (p = 0.029). Three patients experienced immediate postoperative transient ischemic attacks, but all recovered without subsequent strokes. CONCLUSIONS Indirect revascularization is suggested as a safe and effective alternative to the best medical therapy alone in patients with SCD-MMS. High-risk patients managed on a regimen of chronic transfusion should be considered for indirect revascularization to maximize the effect of stroke prevention.
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Affiliation(s)
| | | | | | - Clifford M Takemoto
- Division of Pediatric Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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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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Titsworth WL, Scott RM, Smith ER. National Analysis of 2454 Pediatric Moyamoya Admissions and the Effect of Hospital Volume on Outcomes. Stroke 2016; 47:1303-11. [PMID: 27048697 DOI: 10.1161/strokeaha.115.012168] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 02/29/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Comprehensive multicenter data on treatment of pediatric moyamoya in the United States is lacking. We sought to identify national trends in the diagnosis and treatment of this disease. METHODS A total of 2454 moyamoya admissions from 1997 to 2012 were identified from the Kids Inpatient Database. Demographics, inpatient costs, interventions, and discharge status were analyzed. Admissions with and without surgical revascularization were reviewed separately. The effect of hospital moyamoya volume on outcomes was analyzed by multivariate regression analysis. RESULTS Care of moyamoya patients has been concentrating at high-volume centers during the past 12 years. Among moyamoya admission without surgical revascularization, high-volume hospitals show no difference in length of stay, cost, or complications compared with low-volume centers. However, low-volume hospitals have more nonroutine discharges (odds ratio, 2.32; P=0.0005) and inpatient deaths (odds ratio, 12.7; P=0.02) when no revascularization was performed. In contrast, among admissions with surgical revascularization, high-volume centers had decreased length of stay (4.7 versus 6.2 days; P=0.004), reduced cost ($88 000 versus $138 000; P<0.0001), and no increase in complications (P=0.29) compared with low-volume centers. Admissions with revascularization to low-volume hospitals also had increased likelihood of nonroutine discharge (odds ratio, 8.23; P=0.02) compared with high-volume centers. CONCLUSIONS This is the largest study of US pediatric moyamoya admissions to date. These data demonstrate that volume correlates with outcome, indicating high-volume centers provide significantly improved care and reduced mortality in pediatric moyamoya patients, with the most marked benefit observed in admissions for surgical revascularization.
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Affiliation(s)
- W Lee Titsworth
- From the Department of Neurosurgery, University of Florida, Gainesville (W.L.T.); Clinical Effectiveness, Harvard School of Public Health (W.L.T.) and Department of Surgery, Harvard Medical School (R.M.S., E.R.S.), Harvard University, Cambridge, MA; and Department of Neurosurgery, Children's Hospital Boston, MA (R.M.S., E.R.S.).
| | - R Michael Scott
- From the Department of Neurosurgery, University of Florida, Gainesville (W.L.T.); Clinical Effectiveness, Harvard School of Public Health (W.L.T.) and Department of Surgery, Harvard Medical School (R.M.S., E.R.S.), Harvard University, Cambridge, MA; and Department of Neurosurgery, Children's Hospital Boston, MA (R.M.S., E.R.S.)
| | - Edward R Smith
- From the Department of Neurosurgery, University of Florida, Gainesville (W.L.T.); Clinical Effectiveness, Harvard School of Public Health (W.L.T.) and Department of Surgery, Harvard Medical School (R.M.S., E.R.S.), Harvard University, Cambridge, MA; and Department of Neurosurgery, Children's Hospital Boston, MA (R.M.S., E.R.S.)
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Jack AS, Chow MM, Fiorillo L, Chibuk T, Yager JY, Mehta V. Bilateral pial synangiosis in a child with PHACE syndrome. J Neurosurg Pediatr 2016; 17:70-5. [PMID: 26405843 DOI: 10.3171/2015.5.peds1578] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The acronym PHACE has been used to denote a constellation of abnormalities: posterior fossa anomalies, facial hemangiomas, arterial anomalies, cardiac anomalies, and eye abnormalities. Approximately 30% of patients with large facial hemangiomas have PHACE syndrome, with the vast majority having intracranial arteriopathy. Few reports characterize neurological deterioration from this intracranial arteriopathy, and even fewer report successful treatment thereof. The authors report on a case of a child with PHACE syndrome who presented with an ischemic stroke from a progressive intracranial arteriopathy and describe her successful treatment with bilateral pial synangiosis. An 8-month old girl diagnosed with PHACE syndrome was found to have bilateral internal carotid artery stenosis. Although initially asymptomatic, a few months after diagnosis she suffered a right frontal and parietal stroke. MRI and cerebral angiography investigations demonstrated progressive intracranial arterial stenosis and occlusion. The patient then underwent indirect cerebral revascularization surgery. At 2-year follow-up, she exhibited clinical improvement with persistent speech and motor developmental delay. Follow-up MRI and cerebral angiography showed no new ischemic events and robust extensive vascular collateralization from surgery. PHACE syndrome is an uncommon disease, and affected patients often have cerebral arteriopathy. Although the underlying natural history of cerebral arteriopathy in PHACE remains unclear, cerebral revascularization may represent a potential therapy for symptomatic patients.
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Affiliation(s)
- Andrew S Jack
- Division of Neurosurgery, Department of Surgery, and
| | | | | | | | - Jerome Y Yager
- Pediatric Neurology, Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Vivek Mehta
- Division of Neurosurgery, Department of Surgery, and
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Affiliation(s)
- Vijeya Ganesan
- Neurosciences Unit, UCL Institute of Child Health, London, UK
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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See AP, Ropper AE, Underberg DL, Robertson RL, Scott RM, Smith ER. Down syndrome and moyamoya: clinical presentation and surgical management. J Neurosurg Pediatr 2015; 16:58-63. [PMID: 25837890 DOI: 10.3171/2014.12.peds14563] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Moyamoya can cause cerebral ischemia and stroke in Down syndrome (DS) patients. In this study, the authors defined a surgically treated population of patients with DS and moyamoya and compared their clinical presentation, response to surgical treatment, and long-term prognosis with those of the general population of patients with moyamoya but without DS. METHODS This study was a retrospective review of a consecutive operative series of moyamoya patients with DS treated at Boston Children's Hospital from 1985 through 2012. RESULTS Thirty-two patients, average age 9.7 years (range 1.8-29.3 years), underwent surgery for moyamoya in association with DS. The majority presented with ischemic symptoms (87% stroke, 42% transient ischemic attacks). Twenty-four patients (75%) had congenital heart disease. Nineteen patients (59%) had bilateral moyamoya on presentation, and 13 presented with unilateral disease, of which 2 progressed to surgery on the opposite side at a later date. Patients were followed for a median of 7.5 years (1-20.2 years) after surgery, with no patients lost to follow-up. Follow-up arteriography demonstrated Matsushima Grade A collaterals in 29 of 39 (74%) hemispheres, Grade B in 5 (13%), and Grade C in 5 (13%). Complications included postoperative strokes in 2 patients, which occurred within 48 hours of surgery in both; one of these patients had arm weakness and the other confusion (both had recovered completely at follow-up). Seizures occurred in 5 patients perioperatively, including one who had a new seizure disorder related to hypocalcemia. CONCLUSIONS Moyamoya disease is a cause of stroke in patients with DS. Both the incidence of preoperative stroke (87% vs 67%) and the average age at diagnosis for children under age 21 (8.4 vs 6.5 years) were greater in patients with DS and moyamoya than in the general moyamoya surgical population, suggesting a possible delay in reaching a correct diagnosis of the cause of cerebral ischemia in the DS patient population. Pial synangiosis provided long-term protection from stroke in all patients treated.
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Affiliation(s)
| | | | | | - Richard L Robertson
- Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Griessenauer CJ, Lebensburger JD, Chua MH, Fisher WS, Hilliard L, Bemrich-Stolz CJ, Howard TH, Johnston JM. Encephaloduroarteriosynangiosis and encephalomyoarteriosynangiosis for treatment of moyamoya syndrome in pediatric patients with sickle cell disease. J Neurosurg Pediatr 2015; 16:64-73. [PMID: 25837886 DOI: 10.3171/2014.12.peds14522] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Pediatric patients with sickle cell disease (SCD) and moyamoya syndrome (MMS) are at significant risk for cerebrovascular accidents despite chronic transfusion therapy. Encephaloduroarteriosynangiosis (EDAS) and encephalomyoarteriosynangiosis (EMAS) are additional therapeutic options for these patients. To date, the incidence of complications after and efficacy of EDAS and EMAS in stroke prevention in this population have been described in several institutional case series reports, but no randomized prospective trials have been reported. METHODS The authors retrospectively reviewed the cases of all pediatric patients at the University of Alabama at Birmingham with a history of homozygous hemoglobin S (HbS) and sickle cell/β-thalassemia (SB0 thalassemia) and on chronic transfusion therapy, including 14 patients with MMS who underwent EDAS or EMAS. RESULTS Sixty-two patients with SCD and on chronic transfusion therapy were identified. After exclusion of patients on chronic transfusion therapy for indications other than stroke prevention, 48 patients (77.4%) remained. Of those patients, 14 (29.1%) underwent EDAS or EMAS. Nine (18.8%) and 25 (52.1%) patients were on chronic transfusion therapy for primary or secondary stroke prevention, respectively, but did not undergo EDAS or EMAS. The 14 patients with SCD and radiological evidence of MMS and on chronic transfusion therapy for primary or secondary stroke prevention underwent 21 EDAS or EMAS procedures for progressive vascular disease (92.9% of patients), stroke (71.4%), and/or seizure (7.1%). The mean (± SD) time from initiation of chronic transfusion therapy to EDAS or EMAS was 76.8 ± 58.8 months. Complications included 1 perioperative stroke, 1 symptomatic subdural hygroma, 1 postoperative seizure, and 1 case of intraoperative cerebral edema that required subsequent cranioplasty. Before EDAS or EMAS, the stroke rate was calculated to be 1 stroke per 7.8 patient-years. One additional stroke occurred during the follow-up period (mean follow-up time 33.7 ± 19.6 months), resulting in a post-EDAS/EMAS stroke rate of 1 stroke per 39.3 patient-years, a 5-fold reduction compared with that in the pre-EDAS/EMAS period. The patients' mean pre-EDAS/EMAS HbS level of 29.5% ± 6.4% was comparable to the mean post-EDAS/EMAS HbS level of 25.5% ± 6.1% (p = 0.104). CONCLUSIONS The results of this retrospective case series in a large cohort of pediatric patients with SCD and MMS suggest that EDAS/EMAS provides a stroke-prevention benefit with an acceptably low morbidity rate. Given the combined experience with EDAS and EMAS for this indication at this and other institutions, a prospective clinical trial to assess their efficacy compared with that of chronic transfusion therapy alone is warranted.
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Affiliation(s)
| | | | | | | | - Lee Hilliard
- Pediatric Hematology Oncology, University of Alabama at Birmingham, Alabama; and
| | | | - Thomas H Howard
- Pediatric Hematology Oncology, University of Alabama at Birmingham, Alabama; and
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Smith ER. Moyamoya Biomarkers. J Korean Neurosurg Soc 2015; 57:415-21. [PMID: 26180608 PMCID: PMC4502237 DOI: 10.3340/jkns.2015.57.6.415] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 04/07/2015] [Accepted: 04/09/2015] [Indexed: 01/08/2023] Open
Abstract
Moyamoya disease (MMD) is an arteriopathy of the intracranial circulation predominantly affecting the branches of the internal carotid arteries. Heterogeneity in presentation, progression and response to therapy has prompted intense study to improve the diagnosis and prognosis of this disease. Recent progress in the development of moyamoya-related biomarkers has stimulated marked interest in this field. Biomarkers can be defined as biologically derived agents-such as specific molecules or unique patterns on imaging-that can identify the presence of disease or help to predict its course. This article reviews the current categories of biomarkers relevant to MMD-including proteins, cells and genes-along with potential limitations and applications for their use.
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Affiliation(s)
- Edward R Smith
- Department of Neurological Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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Factors Associated with the Presentation of Moyamoya in Childhood. J Stroke Cerebrovasc Dis 2015; 24:1204-10. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.01.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 01/05/2015] [Accepted: 01/09/2015] [Indexed: 11/21/2022] Open
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Baird LC, Smith ER, Ichord R, Piccoli DA, Bernard TJ, Spinner NB, Scott RM, Kamath BM. Moyamoya syndrome associated with Alagille syndrome: outcome after surgical revascularization. J Pediatr 2015; 166:470-3. [PMID: 25465847 DOI: 10.1016/j.jpeds.2014.10.067] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 09/22/2014] [Accepted: 10/27/2014] [Indexed: 10/24/2022]
Abstract
Vasculopathy is well-described in Alagille syndrome (ALGS); however, few data exist regarding neurosurgical interventions. We report 5 children with ALGS with moyamoya who underwent revascularization surgery. Postsurgical complications included 1 stroke and 1 death from thalamic hemorrhage. Global function improved in survivors. Revascularization is reasonably safe in patients with ALGS and may improve neurologic outcomes.
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Affiliation(s)
- Lissa C Baird
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR; Doernbecher Children's Hospital, Portland, OR
| | - Edward R Smith
- Department of Neurological Surgery, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Rebecca Ichord
- Departments of Neurology and Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - David A Piccoli
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA; Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Timothy J Bernard
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO
| | - Nancy B Spinner
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA; Division of Genomic Diagnostics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - R Michael Scott
- Department of Neurological Surgery, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada.
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Fasano RM, Meier ER, Hulbert ML. Cerebral vasculopathy in children with sickle cell anemia. Blood Cells Mol Dis 2015; 54:17-25. [DOI: 10.1016/j.bcmd.2014.08.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 08/28/2014] [Indexed: 01/14/2023]
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Ni J, Zhou LX, Wei YP, Li ML, Xu WH, Gao S, Cui LY. Moyamoya syndrome associated with Graves' disease: a case series study. ANNALS OF TRANSLATIONAL MEDICINE 2014; 2:77. [PMID: 25333052 DOI: 10.3978/j.issn.2305-5839.2014.08.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 07/28/2014] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The aim of this study was to describe the clinical and radiological findings of patients with moyamoya syndrome and Graves' disease. Possible mechanisms predisposing these individuals to ischemic stroke are discussed. METHODS We retrospectively analyzed 12 consecutive patients with both moyamoya syndrome and Graves' disease. Moyamoya vasculopathy was diagnosed by digital subtract angiography or magnetic resonance angiography (MRA). The clinical characteristics, laboratory data, vascular radiological characteristics and outcome were reported. RESULTS All patients were female and mean age was 33.33±12.65 years. Stenosis or occlusion of bilateral terminal internal carotid artery and/or proximal anterior/middle cerebral arteries was found in nine patients. Among them, three patients displayed asymmetrical stenosis. In addition, there were three patients with probable unilateral moamoya syndrome. Eleven patients presented with ischemic stroke and/or transient ischemic attack (TIA) and one with dizziness. Thyroid function tests demonstrated elevated thyroid hormone levels and suppressed thyroid stimulating hormone levels in all the patients with ischemic events. All patients received anti-thyroid therapy and two had recurrent ischemic attack after drug withdrawal. CONCLUSIONS Moyamoya syndrome associated Graves' disease often presented with asymmetric stenosis or occlusion. We hypothesize cerebrovascular hemodynamic changes due to thyrotoxicosis contribute to the ischemic events.
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Affiliation(s)
- Jun Ni
- 1 Department of Neurology, 2 Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China
| | - Li-Xin Zhou
- 1 Department of Neurology, 2 Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China
| | - Yan-Ping Wei
- 1 Department of Neurology, 2 Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China
| | - Ming-Li Li
- 1 Department of Neurology, 2 Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China
| | - Wei-Hai Xu
- 1 Department of Neurology, 2 Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China
| | - Shan Gao
- 1 Department of Neurology, 2 Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China
| | - Li-Ying Cui
- 1 Department of Neurology, 2 Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China
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Soares D, Bullock R, Ali S. Moyamoya syndrome in sickle cell anaemia: a cause of recurrent stroke. BMJ Case Rep 2014; 2014:bcr-2014-203727. [PMID: 25178886 DOI: 10.1136/bcr-2014-203727] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Summary We report a case with interesting imaging findings as well as an unfortunate but not unexpected clinical outcome. Our patient, an 8-year-old Jamaican boy of Afro-Caribbean descent with homozygous sickle cell disease, presented with left-sided upper limb weakness. He had a history of recurrent cerebrovascular accidents and transient ischaemic attacks beginning at 4 years of age. MRI revealed old bilateral infarctions and the ivy sign on fluid-attenuated inversion recovery sequences. MR angiography demonstrated numerous collaterals, most apparently arising from the left internal carotid, consistent with moyamoya syndrome. The patient had a full recovery and remained well for almost 2 years when he suffered another stroke.
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Affiliation(s)
- Deanne Soares
- Departments of Surgery, Radiology, Anaesthetics and Intensive Care, Radiology Section, University of the West Indies, Kingston, Jamaica
| | - Richard Bullock
- Departments of Surgery, Radiology, Anaesthetics and Intensive Care, Radiology Section, University of the West Indies, Kingston, Jamaica
| | - Susanna Ali
- Sickle Cell Unit, TMRI, University of the West Indies, Kingston, Jamaica
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Kennedy BC, McDowell MM, Yang PH, Wilson CM, Li S, Hankinson TC, Feldstein NA, Anderson RCE. Pial synangiosis for moyamoya syndrome in children with sickle cell anemia: a comprehensive review of reported cases. Neurosurg Focus 2014; 36:E12. [PMID: 24380478 DOI: 10.3171/2013.10.focus13405] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Pediatric patients with sickle cell anemia (SCA) carry a significant risk of developing moyamoya syndrome (MMS) and brain ischemia. The authors sought to review the safety and efficacy of pial synangiosis in the treatment of MMS in children with SCA by performing a comprehensive review of all previously reported cases in the literature. METHODS The authors retrospectively reviewed the clinical and radiographic records in 17 pediatric patients with SCA treated at the Morgan Stanley Children's Hospital of New York (MSCHONY) who developed radiological evidence of MMS and underwent pial synangiosis between 1996 and 2012. The authors then added any additional reported cases of pial synangiosis for this population in the literature for a combined analysis of clinical and radiographic outcomes. RESULTS The combined data consisted of 48 pial synangiosis procedures performed in 30 patients. Of these, 27 patients (90%) presented with seizure, stroke, or transient ischemic attack, whereas 3 (10%) were referred after transcranial Doppler screening. At the time of surgery, the median age was 12 years. Thirteen patients (43%) suffered an ischemic stroke while on chronic transfusion therapy. Long-term follow-up imaging (MR angiography or catheter angiography) at a mean of 25 months postoperatively was available in 39 (81%) treated hemispheres. In 34 (87%) of those hemispheres there were demonstrable collateral vessels on imaging. There were 4 neurological events in 1590 cumulative months of follow-up, or 1 event per 33 patient-years. In the patients in whom complete data were available (MSCHONY series, n = 17), the postoperative stroke rate was reduced more than 6-fold from the preoperative rate (p = 0.0003). CONCLUSIONS Pial synangiosis in patients with SCA, MMS, and brain ischemia appears to be a safe and effective treatment option. Transcranial Doppler and/or MRI screening in asymptomatic patients with SCA is recommended for the diagnosis of MMS.
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Affiliation(s)
- Benjamin C Kennedy
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York; and
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Abstract
BACKGROUND Indirect revascularization techniques for posterior circulation moyamoya are infrequently described in the literature given the relative rarity of the disease process, particularly in the best candidates for indirect approaches-children. METHODS We present a detailed, illustrated video demonstration of the occipital pial synangiosis procedure performed in a 5-year-old child. CONCLUSION The specific advantages of the pial synangiosis technique-suturing the donor vessel to the pia and a wide arachnoidal opening-can be successfully applied to posterior circulation indirect revascularization. KEY POINTS • Perioperative hydration and aspirin limit the risk of perioperative stroke. • Pain control and maintained normocapnea limit the risk of perioperative ischemic events. • The posterior auricular artery may be an alternative donor vessel. • The donor vessel is dissected from distal to proximal; forceps protect it during skin incision. • The donor vessel is dissected along a generous length to minimize tension. • Coagulation of the dura is limited as meningeal vessels may serve as synergistic collaterals. • A wide arachnoidal opening facilitates the ingrowth of collateral vessels. • Suturing the donor vessel to the pia ensures it remains well apposed to the brain surface. • The dura is left open to encourage ingrowth of collateral vessels and limit tension on the donor vessel. • EEG monitoring is a crucial adjunct.
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Kossorotoff M, Grevent D, de Montalembert M. Drépanocytose et atteinte vasculaire cérébrale chez l’enfant. Arch Pediatr 2014; 21:404-14. [DOI: 10.1016/j.arcped.2014.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 09/16/2013] [Accepted: 01/13/2014] [Indexed: 11/28/2022]
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Mukerji N, Steinberg GK. Burr Holes for Moyamoya. World Neurosurg 2014; 81:29-31. [DOI: 10.1016/j.wneu.2013.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Accepted: 10/01/2013] [Indexed: 10/26/2022]
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Venkataraman A, Adams RJ. Neurologic complications of sickle cell disease. HANDBOOK OF CLINICAL NEUROLOGY 2014; 120:1015-25. [PMID: 24365368 DOI: 10.1016/b978-0-7020-4087-0.00068-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Sickle cell disease (SCD) is a group of genetic blood disorders that vary in severity, but the most severe forms, primarily homozygous sickle cell anemia, are associated with neurologic complications. Over the last 90 years it has become established that some patients will develop severe arterial disease of the intracranial brain arteries and suffer brain infarction. Smaller infarctions and brain atrophy may also be seen and over time there appear to be negative cognitive effects in some patients, with or without abnormal brain imaging. Focal mononeuropathies and pneumococcal meningitis are also more common in these patients. Brain infarction in children can largely be prevented screening children beginning at age 2 years and instituting regular blood transfusion when the Doppler indicates high stroke risk (>200cm/sec). Iron overload and the uncertain duration of transfusion are disadvantages but overall this approach, tested in a randomized clinical trial, reduced first stroke by over 90%. Secondary stroke prevention has not been subjected to a randomized controlled trial except for one recently stopped comparison of regular transfusions compared to hydroxuyrea (results favored transfusion). The usual stroke prevention agents (such as aspirin or warfarin) have not been rigorously tested. Magnetic resonance imaging and positron emission tomography give evidence of subtle and sometimes overt brain injury due to stroke in many adults, but a preventive strategy for adults with SCD has not been developed. Bone marrow transplantation is the only cure, but some non-neurologic symptoms can be controlled in adults with hydroxuyrea.
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Affiliation(s)
- Akila Venkataraman
- Pediatric Neurology and Epilepsy Division, Lutheran Medical Center, Brooklyn, NY, USA
| | - Robert J Adams
- South Carolina Stroke Center of Economic Excellence and Medical University of South Carolina Stroke Center, Charleston, SC, USA.
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Houkin K, Ito M, Sugiyama T, Shichinohe H, Nakayama N, Kazumata K, Kuroda S. Review of past research and current concepts on the etiology of moyamoya disease. Neurol Med Chir (Tokyo) 2013; 52:267-77. [PMID: 22688062 DOI: 10.2176/nmc.52.267] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Research on moyamoya disease has progressed remarkably in the past several decades. Indeed, many new facts concerning the epidemiology of the disease have been revealed and surgical treatments have been drastically improved. However, despite extensive research, the mechanism of moyamoya disease is still unknown. Consequently, the cardinal treatment of this disease has not yet been developed. For further clarification of its etiology, innovative studies are therefore indispensable. The aim of this paper is to review research on the pathogenesis of moyamoya disease to identify milestones in the direction of its true solution. Many hypotheses of the pathogenesis of moyamoya disease have been proposed in the past half century, including infection (viral and bacterial), autoimmune disorders, proteins abnormality, and gene abnormality. Some of these are now considered to be historical achievements. Others, however, can be still subjected to contemporary research. Currently, several genetic abnormalities are considered to offer the most probable hypothesis. In addition, interesting papers have been presented on the role of the endothelial progenitor cell on the pathogenesis of moyamoya disease. Intuitively, however, it appears that a single theory cannot always explain the pathogenesis of this disease adequately. In other words, the complex mechanism of several factors may comprehensively explain the formation of moyamoya disease. The "double hit hypothesis" is probably the best explanation for the complicated pathology and epidemiology of this disease.
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Affiliation(s)
- Kiyohiro Houkin
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan.
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Lee JK, Williams M, Jennings JM, Jamrogowicz JL, Larson AC, Jordan LC, Heitmiller ES, Hogue CW, Ahn ES. Cerebrovascular autoregulation in pediatric moyamoya disease. Paediatr Anaesth 2013; 23:547-56. [PMID: 23506446 PMCID: PMC3648623 DOI: 10.1111/pan.12140] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Moyamoya syndrome carries a high risk of cerebral ischemia, and impaired cerebrovascular autoregulation may play a critical role. Autoregulation indices derived from near-infrared spectroscopy (NIRS) may clarify hemodynamic goals that conform to the limits of autoregulation. OBJECTIVES The aims of this pilot study were to determine whether the NIRS-derived indices could identify blood pressure ranges that optimize autoregulation and whether autoregulatory function differs between anatomic sides in patients with unilateral vasculopathy. METHODS Pediatric patients undergoing indirect surgical revascularization for moyamoya were enrolled sequentially. NIRS-derived autoregulation indices, the cerebral oximetry index (COx) and the hemoglobin volume index (HVx), were calculated intraoperatively and postoperatively to measure autoregulatory function. The 5-mmHg ranges of optimal mean arterial blood pressure (MAPOPT ) with best autoregulation and the lower limit of autoregulation (LLA) were identified. RESULTS Of seven enrolled patients (aged 2-16 years), six had intraoperative and postoperative autoregulation monitoring and one had only intraoperative monitoring. Intraoperative MAPOPT was identified in six (86%) of seven patients with median values of 60-80 mmHg. Intraoperative LLA was identified in three (43%) patients with median values of 55-65 mmHg. Postoperative MAPOPT was identified in six (100%) of six patients with median values of 70-90 mmHg. Patients with unilateral disease had higher intraoperative HVx (P = 0.012) on side vasculopathy. CONCLUSIONS NIRS-derived indices may identify hemodynamic goals that optimize autoregulation in pediatric moyamoya.
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Affiliation(s)
- Jennifer K. Lee
- Dept. of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesia, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Monica Williams
- Dept. of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesia, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jacky M. Jennings
- The Bloomberg School of Public Health, Baltimore, MD, and The Dept. of Pediatrics, The Johns Hopkins University School of Medicine, USA
| | - Jessica L. Jamrogowicz
- Dept. of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Abby C. Larson
- Dept. of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lori C. Jordan
- Dept. of Neurology, Vanderbilt University, Nashville, TN, USA
| | - Eugenie S. Heitmiller
- Dept. of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesia, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles W. Hogue
- Dept. of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Edward S. Ahn
- Dept. of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
Sickle cell disease (SCD) is caused by a mutation in both beta globin genes, resulting in chronic hemolysis and multiorgan disease that ultimately leads to premature death. Although hemoglobin S (HbS) polymerization and vaso-occlusion are central to the pathogenesis of SCD, overlapping pathways implicated in SCD-related endothelial dysfunction include hemolysis, defects in nitric oxide metabolism, ischemia-reperfusion injury, oxidative stress, increased cell-to-cell adhesion, and proinflammatory and coagulation mediators. Progression of organ-specific vasculopathy often precedes organ dysfunction and may provide targets for therapeutic intervention. SCD-related vasculopathies include, but are not limited to, moyamoya that often precedes cerebral infarcts or hemorrhage, proliferative retinopathy prior to loss of eyesight, pulmonary vasculopathy associated with pulmonary hypertension, and renal vasculopathy prior to the onset of chronic renal disease. This review evaluates evidence that SCD vasculopathy is a harbinger for organ dysfunction and reviews the potential for targeted antivasculopathy therapies.
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Affiliation(s)
- Adetola A Kassim
- Department of Medicine, Hematology/Stem Cell Transplant, Vanderbilt and Meharry Center for Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.
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Sturiale CL, Puca A, Sebastiani P, Gatto I, Albanese A, Di Rocco C, Maira G, Pola R. Single nucleotide polymorphisms associated with sporadic brain arteriovenous malformations: where do we stand? Brain 2012; 136:665-81. [DOI: 10.1093/brain/aws180] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Lin N, Baird L, Koss M, Kopecky KE, Gone E, Ullrich NJ, Scott RM, Smith ER. Discovery of asymptomatic moyamoya arteriopathy in pediatric syndromic populations: radiographic and clinical progression. Neurosurg Focus 2012; 31:E6. [PMID: 22133171 DOI: 10.3171/2011.10.focus11228] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Limited data exist to guide management of incidentally discovered pediatric moyamoya. Best exemplified in the setting of unilateral moyamoya, in which the unaffected side is monitored, this phenomenon also occurs in populations undergoing routine surveillance of the cerebral vasculature for other conditions, such as sickle cell disease (SCD) or neurofibromatosis Type 1 (NF1). The authors present their experience with specific syndromic moyamoya populations to better characterize the natural history of radiographic and clinical progression in patients with asymptomatic moyamoya. METHODS The authors performed a retrospective review of the clinical database of the neurosurgery department at Children's Hospital Boston, including both nonoperative referrals and a consecutive series of 418 patients who underwent surgical revascularization for moyamoya disease between 1988 and 2010. RESULTS Within the period of time studied, 83 patients were asymptomatic at the time of radiographic diagnosis of moyamoya, while also having either unilateral moyamoya or moyamoya in association with either SCD or NF1. The mean age at presentation was 9.1 years (range 1-21 years), and there were 49 female (59%) and 34 male (41%) patients. The mean follow-up duration was 5.4 ± 3.8 years (mean ± SD), with 45 patients (54%) demonstrating radiographic progression and 37 (45%) becoming symptomatic within this period. Patients with SCD had the highest incidence of both radiographic (15 patients [75%]) and clinical (13 patients [65%]) progression, followed by NF1 (20 patients [59%] with radiographic progression and 15 patients [44%] with clinical progression) and patients with unilateral moyamoya (10 patients [35%] with radiographic progression and 9 patients [31%] with clinical progression). CONCLUSIONS Radiographic progression occurred in the majority of asymptomatic patients and generally heralded subsequent clinical symptoms. These data demonstrate that moyamoya is a progressive disorder, even in asymptomatic populations, and support the rationale of early surgical intervention to minimize morbidity from stroke.
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Affiliation(s)
- Ning Lin
- Department of Neurosurgery, Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Abstract
PURPOSE Children with moyamoya disease/syndrome (MM) have a high rate of recurrent arterial ischaemic stroke (AIS) and associated neurological morbidity; surgical revascularisation (SR) has the potential to prevent this. Here we describe our experience of SR for childhood mm. METHODS This study is a retrospective review of case notes and radiology of children with moyamoya who underwent SR at our centre. RESULTS Seventy-three children with MM and who had SR were identified, with median age at presentation of 4.75 years (range 0.6-14.5). Children with >1 AIS or transient ischaemic attack (TIA) and who had not infarcted the whole territory of the diseased carotid artery were offered SR, with the primary aim of preventing further AIS. One hundred and thirty-four SR procedures were undertaken: 82 indirect (62.4 %) and 49 (37.6 %) direct procedures with 3 second SR procedures following initial SR. Median age at surgery was 7.3 (1-18.2) years. There was no perioperative mortality. One anticoagulated child developed an intracranial haemorrhage on the fifth post-operative day. Median duration of follow-up was 34 (5-166) months. Three children (4.1 %) had recurrent AIS (one silent) after SR; two with sickle cell disease had intracranial haemorrhage 1.5 and 11 months post-SR. TIAs improved in 42 out of 53 (79.2 %). CONCLUSION Our experience of SR for paediatric MM is comparable to other large series. SR is safe, and the rate of recurrent AIS after SR is lower than would be anticipated, on the basis of known natural history of MM. There was no observed difference in outcome of recurrent AIS for direct versus indirect procedures in this series.
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Smith ER, Scott RM. Spontaneous occlusion of the circle of Willis in children: pediatric moyamoya summary with proposed evidence-based practice guidelines. A review. J Neurosurg Pediatr 2012; 9:353-60. [PMID: 22462697 DOI: 10.3171/2011.12.peds1172] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Moyamoya is a progressive arteriopathy of unknown origin affecting the branches of the internal carotid artery (ICA). The arteriopathy can present as an isolated medical condition, affecting both sides of the brain ("moyamoya disease") or can be unilateral or found in association with systemic disorders ("moyamoya syndrome"). The ischemia resulting from luminal narrowing predisposes children to transient ischemic attacks and stroke-the primary presentations of affected patients. Although it is rare-affecting 1 in 1 million children in the US-moyamoya is implicated in 6% of all childhood strokes. Diagnosis is defined by characteristic findings on arteriograms, including stenosis of the branches of the ICA and a pathognomonic spray of small collateral vessels in this region, descriptively likened to a "puff of smoke" ("moyamoya" in Japanese). Treatment is predicated on restoration of cerebral blood flow by surgical revascularization. The rarity of this disorder has limited research and the development of evidence-based clinical management. While acknowledging these limitations, in this article the authors aim to summarize current studies of pediatric moyamoya, with the objective of providing a framework for construction of evidence-based guidelines for treatment. The compilation of current data in these guidelines should serve as a resource to aid pediatric neurosurgeons in their role as advocates for providing appropriate care to affected children.
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Affiliation(s)
- Edward R Smith
- Department of Neurosurgery, Children's Hospital Boston, Harvard Medical Center, Boston, MA 02115, USA.
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