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Sun T, Zeng Q, Huang L, Sun J, Wu Z, Zhang B, Ling C, Chen C, Wang H. Exploration of the risk factor for infarction after revascularization in moyamoya disease. Ann Med 2024; 56:2362872. [PMID: 38913594 PMCID: PMC11198149 DOI: 10.1080/07853890.2024.2362872] [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: 11/06/2023] [Accepted: 05/02/2024] [Indexed: 06/26/2024] Open
Abstract
RESULTS Eventually, 108 consecutive patients received 174 surgeries were enrolled, experienced new or expanded infarction occured in 13 (7.47%) surgeries, which showed higher Suzuki stage on the non-operative side, more posterior cerebral artery (PCA) involvement, and more intraoperative hypotension compared to those without infarction(p < .05). The Suzuki stage on the non-operative side had the highest area under the curve (AUC) of 0.737, with a sensitivity of 0.692 and specificity of 0.783. Combination of the three factors showed better efficiency, with an AUC of 0.762, a sensitivity of 0.692, and a specificity of 0.907. CONCLUSIONS Revascularization was a safe option for patients with MMD, higher Suzuki stage on the non-operative side, PCA involvement, and intraoperative hypotension might be the risk factors for new or expanded infarction after revascularization in patients with MMD.
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Affiliation(s)
- Tao Sun
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Qiuhua Zeng
- Department of Radiology, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Lixin Huang
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jun Sun
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Zhimin Wu
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Baoyu Zhang
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Cong Ling
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Chuan Chen
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Hui Wang
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
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Tsunoda S, Inoue T, Ohwaki K, Takeuchi N, Shinkai T, Fukuda A, Segawa M, Kawashima M, Akabane A, Miyawaki S, Saito N. Influence of an improvement in frontal lobe hemodynamics on neurocognitive function in adult patients with moyamoya disease. Neurosurg Rev 2024; 47:395. [PMID: 39093494 DOI: 10.1007/s10143-024-02639-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/31/2024] [Accepted: 07/29/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND In adults, moyamoya disease (MMD) often presents with slight neurocognitive impairment, which may result from frontal lobe hemodynamic insufficiency. METHODS In this study, we performed revascularization surgery by superficial temporal artery-anterior cerebral artery (ACA) direct bypass in 20 adults with MMD with poor anterograde ACA flow (Group M). The pre- and postoperative neurocognitive test results of these patients were retrospectively analyzed. The comparative group (Group C) included 23 patients with unruptured aneurysms or brain tumors who underwent craniotomy, as well as the same neurocognitive tests as Group M. We calculated the compositive frontal lobe function index (CFFI) based on the results of seven neurocognitive tests for each patient, and the difference between the pre- and postoperative CFFI values (CFFI Post - Pre) was compared between the two groups. RESULTS Frontal perfusion improved postoperatively in all patients in Group M. The CFFI Post - Pre was significantly higher in Group M than in Group C (0.23 ± 0.44 vs. - 0.20 ± 0.32; p < 0.001). After adjusting for postoperative age, sex, preoperative non-verbal intelligence quotient, and preoperative period of stress, Group M had a significantly higher CFFI Post - Pre than Group C in the multiple regression analysis (t value = 4.01; p < 0.001). CONCLUSION Improving frontal lobe hemodynamics might be the key for improving neurocognitive dysfunction in adults with MMD. The surgical indication and method should be considered from the perspective of both stroke prevention and neurocognitive improvement or protection.
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Affiliation(s)
- Sho Tsunoda
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-Ku, Tokyo, 141-0022, Japan.
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-Ku, Tokyo, 141-0022, Japan
| | - Kazuhiro Ohwaki
- Teikyo University Graduate School of Public Health, Kaga, Itabashi-Ku, Tokyo, Japan
| | - Naoko Takeuchi
- Department of Rehabilitation, NTT Medical Center Tokyo, Higashigotanda, Shinagawa-Ku, Tokyo, Japan
| | - Takako Shinkai
- Department of Rehabilitation, NTT Medical Center Tokyo, Higashigotanda, Shinagawa-Ku, Tokyo, Japan
| | - Akira Fukuda
- Department of Rehabilitation, NTT Medical Center Tokyo, Higashigotanda, Shinagawa-Ku, Tokyo, Japan
| | - Masafumi Segawa
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-Ku, Tokyo, 141-0022, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-Ku, Tokyo, 141-0022, Japan
| | - Atsuya Akabane
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-Ku, Tokyo, 141-0022, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, The University of Tokyo Hospital, Hongo, Bunkyo-Ku, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Hongo, Bunkyo-Ku, Tokyo, Japan
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Uchino H, Osanai T, Ito M, Kurisu K, Sugiyama T, Fujimura M. Effective Smartphone Application Use for Postoperative Management of Moyamoya Disease. Neurol Med Chir (Tokyo) 2024; 64:272-277. [PMID: 38839292 PMCID: PMC11304447 DOI: 10.2176/jns-nmc.2024-0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/22/2024] [Indexed: 06/07/2024] Open
Abstract
Continuous and careful management is necessary after revascularization surgery for moyamoya disease (MMD). The postoperative information has been shared in person or by telephone and emails among doctors; however, this is not always efficient. We aimed to describe the feasibility of remote diagnosis and text chats using a smartphone application on postoperative MMD management. Twenty consecutive patients who underwent combined direct and indirect revascularization for MMD were prospectively investigated in this study. In ten patients, the operator viewed postoperative images uploaded on a smartphone screen using the Join application (Allm Inc., Tokyo, Japan). The doctors shared the radiological findings and treatment plans using the group text chat function and performed postoperative management. We evaluated the intermodality agreements of radiological findings between the smartphone screen and conventional viewer. Postoperative courses were compared between the two patient groups that used or did not use the application. All postoperative images were uploaded to the cloud server and the operator viewed them remotely on the smartphone screen without restriction of location. Detected abnormal findings were cerebral hyperperfusion (CHP), CHP-related watershed shift phenomenon, fluid-attenuated inversion recovery cortical hyperintensity, high signal intensity on diffusion-weighted imaging, CHP-related crossed cerebellar diaschisis, and hypoperfusion. Radiological agreement between the modalities was good in all cases, and additional findings were not obtained on the conventional viewer. The postoperative courses of the Join group were as good as those of the control group. Remote radiological diagnosis and text chat using a smartphone application were feasible and useful for efficient and safe postoperative MMD management.
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Affiliation(s)
- Haruto Uchino
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
- Research Department of Information and Communication Technology for Cerebrovascular Diseases, Hokkaido University Hospital
| | - Toshiya Osanai
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
- Research Department of Information and Communication Technology for Cerebrovascular Diseases, Hokkaido University Hospital
| | - Masaki Ito
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Kota Kurisu
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Taku Sugiyama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
- Research Department of Information and Communication Technology for Cerebrovascular Diseases, Hokkaido University Hospital
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Kühnl T, Januschek E, Offenbach SK. Moyamoya syndrome in a patient with D-2-hydroxyglutaric aciduria type II: a rare association. Childs Nerv Syst 2024; 40:2241-2244. [PMID: 38668906 DOI: 10.1007/s00381-024-06340-9] [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: 08/12/2023] [Accepted: 02/26/2024] [Indexed: 06/16/2024]
Abstract
PURPOSE Several underlying conditions of moyamoya syndrome (MMS) are well established, but so far, D-2-hydroxyglutaric aciduria (D-2-HGA) has not been mentioned. We are the first to describe a case of a patient suffering from D-2-HGA developing MMS. METHODS The co-occurrence of D-2-HGA and MMS in a patient is reported. Furthermore, we describe the neurosurgical revascularization procedure performed and report on the follow-up. RESULTS A 7-year-old girl suffering from D-2-HGA developed two transient ischemic attacks (TIAs). Using MRI/MRA and invasive angiography MMS was diagnosed. We performed an encephalo-duro-arterio-myo-synangiosis (EDAMS) as an indirect revascularization procedure first on the right and 2 months later on the left hemisphere. We have followed her up until the age of 10. Since the second surgery, she has not suffered further TIAs and is in a better general medical condition. CONCLUSION Even though children with D-2-HGA often suffer epileptic attacks, every new (transient) neurological deficit should be followed up by an MRI/MRA so as not to oversee a possible underlying MMS. After diagnosis, EDAMS in combination with acetylsalicylic acid (ASA) is recommended to prevent further ischemic events.
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Affiliation(s)
- Tobias Kühnl
- Department of Neurosurgery, Offenbach, Hessen, Germany.
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Lim YC, Lee E, Song J. Outcomes of Bypass Surgery in Adult Moyamoya Disease by Onset Type. JAMA Netw Open 2024; 7:e2415102. [PMID: 38842810 PMCID: PMC11157360 DOI: 10.1001/jamanetworkopen.2024.15102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/04/2024] [Indexed: 06/07/2024] Open
Abstract
Importance Moyamoya disease (MMD) is a rare chronic cerebrovascular disease, and the outcomes of bypass management in adult patients remain controversial. Objective To categorize adult MMD based on asymptomatic, ischemic, and hemorrhagic onset and compare the outcomes (death, hemorrhagic stroke [HS], and ischemic stroke [IS]) of bypass surgery (direct or indirect) with those of conservative management. Design, Setting, and Participants This retrospective, nationwide, population-based longitudinal cohort study used Korean National Health Insurance Research data to identify adults (aged ≥15 years) with MMD who were diagnosed between January 1, 2008, and December 31, 2020, and followed up until December 31, 2021 (median follow-up, 5.74 [IQR, 2.95-9.42] years). A total of 19 700 participants (3194 with hemorrhagic, 517 with ischemic, and 15 989 with asymptomatic MMD) were included. Data were analyzed from January 2 to April 1, 2023. Exposures Bypass surgery and conservative management. Main Outcomes and Measures Death constituted the primary outcome; secondary outcomes consisted of HS or IS. Kaplan-Meier survival curve and Cox proportional hazards regression analysis were applied. The propensity score-matching and stratified analyses were performed to control covariate effects. Results A total of 19 700 patients (mean [SD] age, 45.43 [14.98] years; 12 766 [64.8%] female) were included. Compared with conservative management, bypass was associated with a reduced risk of death (adjusted hazard ratio [AHR], 0.50 [95% CI, 0.41-0.61]; P < .001) and HS (AHR, 0.36 [0.30-0.40]; P < .001) in hemorrhagic MMD; reduced risk of IS (AHR, 0.55 [95% CI, 0.37-0.81]; P = .002) in ischemic MMD; and reduced risk of death (AHR, 0.74 [95% CI, 0.66-0.84]; P < .001) in asymptomatic MMD. However, bypass was associated with an increased risk of HS (AHR, 1.76 [95% CI, 1.56-2.00]; P < .001) in asymptomatic MMD. Both direct and indirect bypass demonstrated similar effects in hemorrhagic and asymptomatic MMD, except only direct bypass was associated with a reduced risk of IS (AHR, 0.52 [95% CI, 0.33- 0.83]; P = .01) in ischemic MMD. After stratification, bypass was associated with a reduced risk of death in patients younger than 55 years with ischemic (AHR, 0.34 [95% CI, 0.13- 0.88]; P = .03) and asymptomatic (AHR, 0.69 [95% CI, 0.60-0.79]; P < .001) MMD, but an increased risk of HS in patients 55 years or older with ischemic MMD (AHR, 2.13 [95% CI, 1.1-4.16]; P = .03). Conclusions and Relevance The findings of this cohort study of bypass outcomes for patients with MMD emphasize the importance of tailoring management strategies in adult patients based on onset types.
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Affiliation(s)
- Yong Cheol Lim
- Department of Neurosurgery, Ajou University School of Medicine, Ajou University Hospital, Suwon, Republic of Korea
| | - Eunyoung Lee
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Jihye Song
- Department of Neurosurgery, Ajou University School of Medicine, Ajou University Hospital, Suwon, Republic of Korea
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Uchino H, Ito M, Fujima N, Tokairin K, Tatezawa R, Sugiyama T, Fujimura M. Predictive value of the hemispheric magnetic resonance angiography score on the development of indirect pial synangiosis after combined revascularization surgery for adult moyamoya disease. Acta Neurochir (Wien) 2024; 166:181. [PMID: 38630203 DOI: 10.1007/s00701-024-06079-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/10/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE It is difficult to precisely predict indirect bypass development in the context of combined bypass procedures in moyamoya disease (MMD). We aimed to investigate the predictive value of magnetic resonance angiography (MRA) signal intensity in the peripheral portion of the major cerebral arteries for indirect bypass development in adult patients with MMD. METHODS We studied 93 hemispheres from 62 adult patients who underwent combined direct and indirect revascularization between 2005 and 2019 and genetic analysis for RNF213 p.R4810K. The signal intensity of the peripheral portion of the major intracranial arteries during preoperative MRA was graded as a hemispheric MRA score (0-3 in the middle cerebral artery and 0-2 in the anterior cerebral and posterior cerebral arteries, with a high score representing low visibility) according to each vessel's visibility. Postoperative bypass development was qualitatively evaluated using MRA, and we evaluated the correlation between preoperative factors, including the hemispheric MRA score and bypass development, using univariate and multivariate analyses. RESULTS A good indirect bypass was observed in 70% of the hemispheres. Hemispheric MRA scores were significantly higher in hemispheres with good indirect bypass development than in those with poor indirect bypass development (median: 3 vs. 1; p < 0.0001). Multiple logistic regression analysis revealed hemispheric MRA score as an independent predictor of good indirect bypass development (odds ratio, 2.1; 95% confidence interval, 1.3-3.6; p < 0.01). The low hemispheric MRA score (< 2) and wild-type RNF213 predicted poor indirect bypass development with a specificity of 0.92. CONCLUSION Hemispheric MRA score was a predictive factor for indirect bypass development in adult patients who underwent a combined bypass procedure for MMD. Predicting poor indirect bypass development may lead to future tailored bypass surgeries for MMD.
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Affiliation(s)
- Haruto Uchino
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-Ku, Sapporo, 060-8638, Japan.
| | - Masaki Ito
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Noriyuki Fujima
- Department of Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kikutaro Tokairin
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Ryota Tatezawa
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Taku Sugiyama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-Ku, Sapporo, 060-8638, Japan
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Zhang H, Lu M, Liu S, Liu D, Liu X, Shen X, Han C, Sheng F, Cai J. Predictors of Stroke Outcomes in Conservatively Treated Patients With Moyamoya Disease: A Follow-up MRI Study. J Magn Reson Imaging 2024; 59:1456-1463. [PMID: 37357525 DOI: 10.1002/jmri.28880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 06/11/2023] [Accepted: 06/13/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND Little is known about the association between stroke and imaging and clinical features in conservatively treated patients with moyamoya disease (MMD). PURPOSE To investigate independent risk factors for stroke in conservatively treated patients with MMD during a long-term follow-up. STUDY TYPE Prospective study. SUBJECTS One hundred sixty conservatively managed patients with MMD (median age 46 years, 89 male). FIELD STRENGTH/SEQUENCE Time of flight, turbo inversion recovery magnitude T1WI, turbo spin echo (TSE) T2WI, echo-planar imaging DWI, T2-fluid attenuated inversion recovery, dynamic susceptibility contrast-magnetic resonance imaging, and pre- and post-contrast 3D TSE T1WI sequences at 3.0 Tesla. ASSESSMENT Patients were assessed at baseline and followed yearly. Ischemic and hemorrhagic stroke incidence rates were determined. Multiple demographic, clinical (modified Rankin score [mRS]), and cerebral imaging (cerebral blood volume [CBV] and concentric enhancement of arterial wall) factors at baseline were considered as potential predictors of stroke during the follow-up period. STATISTICAL TESTS Univariable and multivariable Cox proportional hazards models to calculate the hazard ratios (HRs) and corresponding 95% confidence interval (CI) for stroke. Cumulative risk of stroke was estimated by the Kaplan-Meier product-limit method. A P value <0.05 was considered statistically significant. RESULTS The median follow-up duration was 47 months. During the follow-up period, 18 (11.25%) patients experienced stroke events (13 [8.13%] ischemic, 5 [3.12%] hemorrhagic). Univariable analysis showed that 11 factors were significantly associated with stroke. After adjustment for clinical characteristics, multivariable analysis showed that mRS score ≥3 (HR, 1.99; 95% CI, 1.26-3.14), decreased CBV (HR, 5.31; 95% CI, 2.32-12.13), and concentric enhancement of the arterial wall (HR, 4.16; 95% CI, 1.55-11.15) were significantly associated with stroke. DATA CONCLUSION Decreased CBV, mRS score ≥ 3, and concentric enhancement of the arterial wall were significantly associated with increased incidence of stroke in conservatively treated MMD. EVIDENCE LEVEL 2 TECHNICAL EFFICACY: Stage 4.
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Affiliation(s)
- Hongtao Zhang
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Mingming Lu
- Department of Radiology, Pingjin Hospital, Characteristic Medical Center of Chinese People's Armed Police Force, Tianjin, China
| | - Shitong Liu
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Dongqing Liu
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xu Liu
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xuxuan Shen
- Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Cong Han
- Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Fugeng Sheng
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jianming Cai
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
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Onodera K, Ooigawa H, Tabata S, Kimura T, Lepic M, Suzuki K, Kurita H. Effect of revascularization surgery on cerebral hemodynamics in adult moyamoya disease. Clin Neurol Neurosurg 2024; 239:108180. [PMID: 38452713 DOI: 10.1016/j.clineuro.2024.108180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/31/2024] [Accepted: 02/14/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVE Few studies have reported local hemodynamic changes after revascularization surgery. This study aimed to identify regional hemodynamic changes after combined revascularization surgery for moyamoya disease using single-photon emission computed tomography with N-isopropyl-p-123I-iodoamphetamine. METHODS A total of 46 adults with moyamoya disease who underwent combined revascularization surgery from August 2009 to July 2021 at our facility were enrolled. The combined bypass procedure comprised a single direct bypass to the motor area and encephalo-duro-arterio-myo-synangiosis. The preoperative and postoperative cerebral blood flow (CBF) and cerebral vascular reserve (CVR) in the genu; precentral, central, parietal, angular, temporal, and posterior regions; splenium; hippocampus; and cerebellum were measured. To modify the examination variability, the cerebral-to-cerebellar activity ratio (CCR) was calculated by dividing the counts in the region by those in the cerebellum (CBF-CCR and CVR-CCR). RESULTS Postoperatively, asymptomatic cerebral infarction occurred in three (6.5%) patients. The CBF-CCR and CVR-CCR improved in the precentral, parietal, and temporal regions and in the overall middle cerebral artery (MCA) territory. Sub-analysis of anterior cerebral artery (ACA) and posterior cerebral artery (PCA) territory hemodynamics revealed that patients with normal preoperative hemodynamics showed no changes in the CBF-CCR and CVR-CCR postoperatively, whereas patients with preoperative perfusion impairment exhibited improved CVR-CCR in the ACA territory (0.13-0.3, p=0.019) and CBF-CCR in the PCA territory (0.93-0.96, p=0.0039). CONCLUSION Combined revascularization surgery with single bypass to the motor area improved hemodynamics in the primary targeted MCA territory and in the ACA and PCA territories among patients with preoperative hemodynamic impairment.
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Affiliation(s)
- Koki Onodera
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Japan.
| | - Hidetoshi Ooigawa
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Shinya Tabata
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Tatsuki Kimura
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Milan Lepic
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Japan; Clinic for Neurosurgery, Faculty of Medicine of the Military Medical Academy, University of Defense, Belgrade, Serbia
| | - Kaima Suzuki
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Japan
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Jiang B, Wang X, Ma J, Fayyaz A, Wang L, Qin P, Ding Y, Ji X, Li S. Remote ischemic conditioning after stroke: Research progress in clinical study. CNS Neurosci Ther 2024; 30:e14507. [PMID: 37927203 PMCID: PMC11017418 DOI: 10.1111/cns.14507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/14/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND AND PURPOSE Stroke is a leading cause of global morbidity and mortality, indicating the necessity and urgency of effective prevention and treatment. Remote ischemic conditioning (RIC) is a convenient, simple, non-intrusive, and effective method that can be easily added to the treatment regime of stroke patients. Animal experiments and clinical trials have proved the neuroprotective effects of RIC on brain injury including (examples of neuroprotective effects). This neuroprotection is achieved by raising brain tolerance to ischemia, increasing local cerebral blood perfusion, promoting collateral circulations, neural regeneration, and reducing the incidence of hematomas in brain tissue. This current paper will summarize the studies within the last 2 years for the comprehensive understanding of the use of RIC in the treatment of stroke. METHODS This paper summarizes the clinical research progress of RIC on stroke (ischemic stroke and hemorrhagic stroke (HS)). This paper is a systematic review of research published on registered clinical trials using RIC in stroke from inception through November 2022. Four major databases (PUBMED, WEB OF SCIENCE, EMBASE, and ClinicalTrials.gov) were searched. RESULTS Forty-eight studies were identified meeting our criteria. Of these studies, 14 were in patients with acute ischemic stroke with onset times ranging from 6 h to 14 days, seven were in patients with intravenous thrombolysis or endovascular thrombectomy, 10 were in patients with intracranial atherosclerotic stenosis, six on patients with vascular cognitive impairment, three on patients with moyamoya disease, and eight on patients with HS. Of the 48 studies, 42 were completed and six are ongoing. CONCLUSIONS RIC is safe, feasible, and effective in the treatment of stroke. Large-scale research is still required to explore the optimal treatment options and mechanisms of RIC in the future to develop a breakthrough in stroke prevention and treatment.
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Affiliation(s)
- Bin Jiang
- Department of NeurologyShenzhen Qianhai Shekou Free Trade Zone HospitalShenzhenChina
| | - Xiaojie Wang
- Department of NeurologyShenzhen Qianhai Shekou Free Trade Zone HospitalShenzhenChina
| | - Jianping Ma
- Department of NeurologyShenzhen Qianhai Shekou Free Trade Zone HospitalShenzhenChina
| | - Aminah Fayyaz
- Department of NeurosurgeryWayne State University School of MedicineDetroitMichiganUSA
| | - Li Wang
- Department of NeurologyShenzhen Qianhai Shekou Free Trade Zone HospitalShenzhenChina
| | - Pei Qin
- Department of NeurologyShenzhen Qianhai Shekou Free Trade Zone HospitalShenzhenChina
| | - Yuchuan Ding
- Department of NeurosurgeryWayne State University School of MedicineDetroitMichiganUSA
| | - Xunming Ji
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
- Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain DisordersCapital Medical UniversityBeijingChina
| | - Sijie Li
- Department of Emergency, Xuanwu HospitalCapital Medical UniversityBeijingChina
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu HospitalCapital Medical UniversityBeijingChina
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Elder TA, White TG, Woo HH, Siddiqui AH, Nunna R, Siddiq F, Esposito G, Chang D, Gonzalez NR, Amin-Hanjani S. Future of Endovascular and Surgical Treatments of Atherosclerotic Intracranial Stenosis. Stroke 2024; 55:344-354. [PMID: 38252761 DOI: 10.1161/strokeaha.123.043634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Intracranial atherosclerotic disease and resultant intracranial stenosis is a global leading cause of stroke, and poses an ongoing treatment challenge. Among patients with intracranial stenosis, those with hemodynamic compromise are at high risk for recurrent stroke despite medical therapy and risk factor modification. Revascularization of the hypoperfused territory is the most plausible treatment strategy for these high-risk patients, yet surgical and endovascular therapies have not yet shown to be sufficiently safe and effective in randomized controlled trials. Advances in diagnostic and therapeutic technologies have led to a resurgence of interest in surgical and endovascular treatment strategies, with a growing body of evidence to support their further evaluation in the treatment of select patient populations. This review outlines the current and emerging endovascular and surgical treatments and highlights promising future management strategies.
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Affiliation(s)
- Theresa A Elder
- University Hospitals Cleveland Medical Center/Case Western Reserve University School of Medicine, OH (T.A.E., S.A.-H.)
| | - Timothy G White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY (T.G.W., H.H.W.)
| | - Henry H Woo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY (T.G.W., H.H.W.)
| | - Adnan H Siddiqui
- Departments of Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, NY (A.H.S.)
| | - Ravi Nunna
- Department of Neurological Surgery, University of Missouri School of Medicine, Columbia (R.N., F.S.)
| | - Farhan Siddiq
- Department of Neurological Surgery, University of Missouri School of Medicine, Columbia (R.N., F.S.)
| | - Giuseppe Esposito
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Switzerland (G.E.)
| | - Daniel Chang
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (D.C., N.R.G.)
| | - Nestor R Gonzalez
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (D.C., N.R.G.)
| | - Sepideh Amin-Hanjani
- University Hospitals Cleveland Medical Center/Case Western Reserve University School of Medicine, OH (T.A.E., S.A.-H.)
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11
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Teo CKA, Zheng Y, Lin JB, Teoh HL, Chan BPL, Sharma VK, Teo K, Nga VDW, Yeo TT. Outcomes after surgical revascularization for adult Moyamoya disease: A Southeast Asian tertiary centre experience. J Clin Neurosci 2024; 119:116-121. [PMID: 38006812 DOI: 10.1016/j.jocn.2023.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 11/01/2023] [Accepted: 11/20/2023] [Indexed: 11/27/2023]
Abstract
There are numerous studies on the natural history and outcomes of adult Moyamoya disease (MMD) in the literature, but limited data from Southeast Asian cohorts. Hence, we aimed to retrospectively review the clinical characteristics and outcomes after surgical revascularization for adult MMD in our Southeast Asian cohort. Patients were included if they were above 18 years old at the first surgical revascularization for MMD, and underwent surgery between 2012 and 2022 at the National University Hospital, Singapore. The outcomes were transient ischemic attack (TIA), ischemic stroke, intracerebral hemorrhage, and all-cause mortality during the postoperative follow-up period. In total, 26 patients who underwent 27 revascularization procedures were included. Most patients were of Chinese ethnicity, and the mean (SD) age at the time of surgery was 47.7 (12.6) years. The commonest clinical presentation was intracerebral hemorrhage, followed by TIA and ischemic stroke. Direct revascularization with superficial temporal artery-middle cerebral artery (STA-MCA) bypass was the most common procedure (24/27 surgeries, 88.9 %). The mean (SD) follow-up duration was 4.2 (2.5) years, during which the overall incidence of postoperative TIA/stroke was 25.9 % (7/27 surgeries), with most cases occurring within 7 days postoperatively. There were no mortalities during the postoperative follow-up period. Risk factors for 30-day postoperative TIA/stroke included a higher number of TIAs/strokes preoperatively (p = 0.044) and indirect revascularization (p = 0.028). Diabetes mellitus demonstrated a trend towards an increased risk of 30-day postoperative TIA/stroke, but this was not statistically significant (p = 0.056). These high-risk patients may benefit from more aggressive perioperative antithrombotic and hydration regimens.
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Affiliation(s)
- Colin Kok Ann Teo
- Division of Neurosurgery, National University Health System, Singapore.
| | - Yilong Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jeremy Bingyuan Lin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Hock Luen Teoh
- Division of Neurology, National University Health System, Singapore
| | | | - Vijay Kumar Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, National University Health System, Singapore
| | - Kejia Teo
- Division of Neurosurgery, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Vincent Diong Weng Nga
- Division of Neurosurgery, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, National University Health System, Singapore
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12
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Krylov VV, Senko IV, Amiralieva MS, Staroverov MS, Grigoryev IV, Kordonskaya OO, Glotova NA. [Moyamoya disease in adults: treatment methods in modern era]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:75-82. [PMID: 38512098 DOI: 10.17116/jnevro202412403275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
Moyamoya angiopathy is a chronic progressive cerebrovascular disease characterized by stenosis and occlusion of the distal segments of the internal carotid arteries and/or proximal segments of the middle and anterior cerebral arteries, with a gradual compensatory restructuring of the cerebral circulation to the system of the external carotid arteries. Today, the main treatment method for Moyamoya angiopathy is surgical revascularization of the brain. A search and analysis of publications on the treatment of adult patients with Moyamoya angiopathy was carried out in the PubMed and Medscape databases over the past 10 years. We present a case of an adult female patient with a hemorrhagic form of Moyamoya angiopathy stage IV according to J. Suzuki, who underwent staged combined revascularization of both cerebral hemispheres. Surgical revascularization included the creation of a low-flow extra-intracranial shunt combined with a combination of indirect synangiosis. The combination of direct and indirect methods of surgical revascularization enables to achieve the development of an extensive network of collaterals and fully compensate for cerebral circulatory disorders both in the early and late postoperative periods, which is confirmed by instrumental diagnostic data. Combined revascularization is the most effective modern method of treating patients with Moyamoya angiopathy due to the complementary influence of direct and indirect components of revascularization.
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Affiliation(s)
- V V Krylov
- Federal Center of Brain Research and Neurotechnology, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
- Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - I V Senko
- Federal Center of Brain Research and Neurotechnology, Moscow, Russia
| | - M Sh Amiralieva
- Federal Center of Brain Research and Neurotechnology, Moscow, Russia
| | - M S Staroverov
- Federal Center of Brain Research and Neurotechnology, Moscow, Russia
- Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
- Clinical City Hospital No. 4, Perm, Russia
| | - I V Grigoryev
- Federal Center of Brain Research and Neurotechnology, Moscow, Russia
| | - O O Kordonskaya
- Federal Center of Brain Research and Neurotechnology, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - N A Glotova
- Federal Center of Brain Research and Neurotechnology, Moscow, Russia
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13
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Chen P, Wang Y, Li S, Tang D, Yang S, Zeng F, Yu L, Zhang D, Ding W, Wu S, Chen F, Huang Z. Development and External Validation of Nomogram for Cerebral Infarction in Moyamoya Diseases. Transl Stroke Res 2023; 14:890-898. [PMID: 36656462 DOI: 10.1007/s12975-023-01127-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 12/31/2022] [Accepted: 01/04/2023] [Indexed: 01/20/2023]
Abstract
More than 60% of moyamoya disease (MMD) patients suffers cerebral ischemia and preoperative cerebral infarction (CI) increases the risk of postoperative stroke and unfavorable outcome. We established a nomogram system for risk stratification of CI to help tailoring individualized management. We enrolled 380 patients including 680 hemispheres for the training cohort from our hospital and 183 patients including 348 hemispheres for the validation cohort from multicenter. A nomogram for CI was formulated based on the multivariable logistic regression analysis. The predictive accuracy and discriminative ability of nomogram were determined with concordance index (C-index) and calibration curve. For the training cohort, 246 hemispheres (36.2%) were found with CI. In multivariable logistic regression used generalized estimating equations approach, anterior choroidal artery (AchA) grade (grade 1, OR 0.214, 95%CI 0.124-0.372, P < 0.001; grade 2, OR 0.132, 95%CI 0.066-0.265, P < 0.001), cerebral perfusion (OR 4.796, 95%CI 2.922-7.872; P < 0.001), white matter hyperintensity (OR 3.652, 95%CI 1.933-6.902; P < 0.001), brush sign (OR 3.555, 95%CI 2.282-5.538; P < 0.001), and ivy sign (equivocal, OR 4.752, 95%CI 2.788-8.099, P < 0.001; present, OR 8.940, 95%CI 4.942-16.173, P < 0.001) were significant factors for CI. The C-index of the nomogram for predicting cerebral infarction was 0.890 (95%CI 0.866-0.915) in the training cohort and 0.847 (95%CI 0.805-0.889) in the validation cohort. The nomogram composed of AchA grade, cerebral perfusion, white matter hyperintensity, brush sign, and ivy sign could provide risk stratification of CI before surgery in patients with MMD. Active treatment might be recommended before CI, which could reduce the risk of stroke after surgery.
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Affiliation(s)
- Pan Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Ying Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Shifu Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Dong Tang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Shuai Yang
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Feiyue Zeng
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Lebao Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Wei Ding
- Department of Neurosurgery, Hunan Children's Hospital, Changsha, 410007, China
| | - Shuihua Wu
- Department of Neurosurgery, Hunan Children's Hospital, Changsha, 410007, China
| | - Fenghua Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Zheng Huang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China.
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14
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Park H, Han M, Jang D, Kim D, Huh P, Park H, Park IS, Han Y, Sung JH, Lee K, Lee H, Kim YW. Association of Bypass Surgery and Mortality in Moyamoya Disease. J Am Heart Assoc 2023; 12:e030834. [PMID: 37947101 PMCID: PMC10727291 DOI: 10.1161/jaha.123.030834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/11/2023] [Indexed: 11/12/2023]
Abstract
Background Patients with moyamoya disease (MMD) have a high risk of stroke or death. We investigated whether extracranial to intracranial bypass surgery can reduce mortality by preventing strokes in patients with MMD. Methods and Results This nationwide retrospective cohort study encompassed patients with MMD registered under the Rare Intractable Diseases program via the Relieved Co-Payment Policy between 2006 and 2019, using the Korean National Health Insurance Service database. Following a 4-year washout period, landmark analyses were employed to assess mortality and stroke occurrence between the bypass surgery group and the nonsurgical control group at specific time points postindex date (1 month and 3, 6, 12, and 36 months). The study included 18 480 patients with MMD (mean age, 40.7 years; male to female ratio, 1:1.86) with a median follow-up of 5.6 years (interquartile range, 2.5-9.3; mean, 6.1 years [SD, 4.0 years]). During 111 775 person-years of follow-up, 265 patients in the bypass surgery group and 1144 patients in the nonsurgical control group died (incidence mortality rate of 618.1 events versus 1660.3 events, respectively, per 105 person-years). The overall adjusted hazard ratio (HR) revealed significantly lower all-cause mortality in the bypass surgery group from the 36-month landmark time point, for any stroke mortality from 3- and 6-month landmark time points, and for hemorrhagic stroke mortality from the 6-month landmark time point. Furthermore, the overall adjusted HRs for hemorrhagic stroke occurrence were beneficially maintained from all 5 landmark time points in the bypass surgery group. Conclusions Bypass surgery in patients with MMD was associated with a lower risk of all-cause and hemorrhagic stroke mortality and hemorrhagic stroke occurrence compared with nonsurgical control.
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Affiliation(s)
- Hyunjun Park
- Department of Neurosurgery, Incheon St. Mary’s Hospital, College of MedicineThe Catholic University of KoreaIncheonRepublic of Korea
| | - Minkyung Han
- Biostatistics Collaboration Unit, Department of Biomedical Systems InformaticsYonsei University College of MedicineSeoulRepublic of Korea
| | - Dong‐Kyu Jang
- Department of Neurosurgery, Incheon St. Mary’s Hospital, College of MedicineThe Catholic University of KoreaIncheonRepublic of Korea
| | - Dal‐Soo Kim
- Department of NeurosurgeryMyong‐Ji St. Mary’s HospitalSeoulRepublic of Korea
| | - Pil‐Woo Huh
- Department of Neurosurgery, Uijeongbu St. Mary’s Hospital. College of MedicineThe Catholic University of KoreaGyeonggi‐doRepublic of Korea
| | - Hae‐Kwan Park
- Department of Neurosurgery, Eunpyeong St. Mary’s Hospital, College of MedicineThe Catholic University of KoreaSeoulRepublic of Korea
| | - Ik Seong Park
- Department of Neurosurgery, Bucheon St. Mary’s Hospital, College of MedicineThe Catholic University of KoreaGyeonggi‐doRepublic of Korea
| | - Young‐Min Han
- Department of NeurosurgeryNaeun HospitalIncheonRepublic of Korea
| | - Jae Hoon Sung
- Department of Neurosurgery, St. Vincent’s Hospital, College of MedicineThe Catholic University of KoreaGyeonggi‐doRepublic of Korea
| | - Kwan‐Sung Lee
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of MedicineThe Catholic University of KoreaSeoulRepublic of Korea
| | - Hyung‐Jin Lee
- Department of Neurosurgery, Daejeon St. Mary’s Hospital, College of MedicineThe Catholic University of KoreaDaejeonRepublic of Korea
| | - Young Woo Kim
- Department of Neurosurgery, Uijeongbu St. Mary’s Hospital. College of MedicineThe Catholic University of KoreaGyeonggi‐doRepublic of Korea
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15
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Yuan X, Yu H, Sun Z, Wu J, Gao L, Chong Z, Jin F, Chen Y, Liu D. Evaluation of surgical revascularization procedure outcomes for adult Moyamoya disease: a computed tomography perfusion-based study. Insights Imaging 2023; 14:184. [PMID: 37924434 PMCID: PMC10625502 DOI: 10.1186/s13244-023-01519-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 09/03/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND The effectiveness of surgical interventions, whether direct or indirect, for Moyamoya disease (MMD) remains controversial. This study aims to investigate CT perfusion (CTP) as an objective method to evaluate the outcomes of different surgical modalities for adult MMD. METHODS The clinical and imaging data of 41 patients who underwent superficial temporal artery-middle cerebral artery (STA-MCA) bypass and 43 who received encephaloduroarteriosynangiosis (EDAS) were retrospectively analyzed. Intra- and intergroup differences in the Modified Rankin Scale (mRS) score, the change in clinical symptoms, collateral grade, and CTP parameters pre- and postoperatively were compared. RESULTS The overall level of the change in clinical symptoms in the STA-MCA group was higher than in the EDAS group (p < 0.05). In the operative area, the relative cerebral blood flow (rCBF) was significantly higher whereas the relative time to peak (rTTP) and the relative mean transit time (rMTT) were significantly lower in the STA-MCA and EDAS groups postoperatively than preoperatively (all p < 0.05). In the ipsilateral frontal lobe and basal ganglia, the postoperative rCBF was significantly higher, and the rTTP was significantly lower than the preoperative in the STA-MCA group (all p < 0.05). The postoperative rCBF improvement was higher in each brain area for STA-MCA than in the EDAS group (all p < 0.05). CONCLUSION Highlighting the utility of CTP, this study demonstrates its effectiveness in assessing postoperative cerebral hemodynamic changes in adult MMD patients. STA-MCA yielded a larger postoperative perfusion area and greater improvement compared to EDAS, suggesting CTP's potential to elucidate symptom variation between two surgical revascularization procedures. CRITICAL RELEVANCE STATEMENT We analyzed computed tomography perfusion parameters in pre- and postoperative adult Moyamoya disease patients undergoing superficial temporal artery-middle cerebral artery bypass and encephaloduroarteriosynangiosis. Our findings suggest computed tomography perfusion's potential in objectively elucidating symptom variations between these surgical revascularization approaches for MMD. KEY POINTS • Postoperative perfusion improvement is only confined to the operative area after EDAS. • Besides the operative area, postoperative perfusion in the ipsilateral frontal lobe and basal ganglia was also improved after STA-MCA. • The degree of perfusion improvement in each brain area in the STA-MCA group was generally greater than that in the EDAS group.
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Affiliation(s)
- Xuexia Yuan
- Department of Radiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Hao Yu
- Department of Radiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Zhanguo Sun
- Department of Radiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Jiaxing Wu
- Siemens Healthineers, No. 399, West Haiyang Road, Shanghai, China
| | - Lingyun Gao
- Department of Radiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Zhen Chong
- Department of Radiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Feng Jin
- Department of Neurosurgery, Affiliated Hospital of Jining Medical University, Jining, China
| | - Yueqin Chen
- Department of Radiology, Affiliated Hospital of Jining Medical University, Jining, China.
| | - Deguo Liu
- Department of Radiology, Affiliated Hospital of Jining Medical University, Jining, China.
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16
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Gonzalez NR, Amin-Hanjani S, Bang OY, Coffey C, Du R, Fierstra J, Fraser JF, Kuroda S, Tietjen GE, Yaghi S. Adult Moyamoya Disease and Syndrome: Current Perspectives and Future Directions: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2023; 54:e465-e479. [PMID: 37609846 DOI: 10.1161/str.0000000000000443] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Adult moyamoya disease and syndrome are rare disorders with significant morbidity and mortality. A writing group of experts was selected to conduct a literature search, summarize the current knowledge on the topic, and provide a road map for future investigation. The document presents an update in the definitions of moyamoya disease and syndrome, modern methods for diagnosis, and updated information on pathophysiology, epidemiology, and both medical and surgical treatment. Despite recent advancements, there are still many unresolved questions about moyamoya disease and syndrome, including lack of unified diagnostic criteria, reliable biomarkers, better understanding of the underlying pathophysiology, and stronger evidence for treatment guidelines. To advance progress in this area, it is crucial to acknowledge the limitations and weaknesses of current studies and explore new approaches, which are outlined in this scientific statement for future research strategies.
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17
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Mizushima M, Ito M, Fujima N, Uchino H, Sugiyama T, Fujimura M. Chronological Volume Changes of the Temporal Muscle Pedicle Used for Encephalo-myo-synangiosis in Combined Revascularization for Moyamoya Disease: A Prospective Observational Study. Neurol Med Chir (Tokyo) 2023; 63:304-312. [PMID: 37081648 PMCID: PMC10406459 DOI: 10.2176/jns-nmc.2023-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/20/2023] [Indexed: 04/22/2023] Open
Abstract
Although postoperative neurological events due to brain compression by the swollen temporal muscle are a rare complication, the chronological volume changes of the temporal muscle pedicle and their clinical impact have not yet been documented. This prospective observational study aimed to investigate the chronological volume changes in the temporal muscle pedicle in Moyamoya disease (MMD). Eighteen consecutive combined revascularization procedures using the temporal muscle were performed for symptomatic MMD in 2021. The postoperative pedicle volume was quantified using repeated computed tomography images on postoperative days (PODs) 0, 1, 7, 14, and 30. Postoperative neurological events with radiological evaluations and collateral development evaluated using magnetic resonance angiography obtained 6 months after surgery were studied. On average, the postoperative temporal muscle pedicle volume was most significantly increased by as much as 112% ± 9.6% on POD 7 (P < 0.001) and decreased by as little as 52% ± 21% on POD 30 (P < 0.0001) relative to POD 0. One exceptional patient (overall incidence, 5.6%) demonstrated postoperative transient neurological events due to brain compression by the swollen temporal muscle with decreased focal cerebral blood flow in the adjacent cortical area. The postoperative collateral development via direct and indirect revascularizations was confirmed in 16 (89%) and 12 (67%) hemispheres, respectively. All patients, except for one rebleeding case, showed independent outcomes at the mean latest follow-up period on 290 ± 96 days after surgery. Our observations confirmed the temporal profile of muscle pedicle volume changes after combined revascularization. Through routine attempts to avoid the unfavorable effects of temporal muscle swelling, combined revascularization can provide favorable outcomes in symptomatic MMD.
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Affiliation(s)
- Makoto Mizushima
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Masaki Ito
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Noriyuki Fujima
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital
| | - Haruto Uchino
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Taku Sugiyama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
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18
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Lucia K, Acker G, Rubarth K, Beyaztas D, Vajkoczy P. The Development and Effect of Systemic Hypertension on Clinical and Radiological Outcome in Adult Moyamoya Angiopathy Following Revascularization Surgery: Experience of a Single European Institution. J Clin Med 2023; 12:4219. [PMID: 37445259 DOI: 10.3390/jcm12134219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/10/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Patients with Moyamoya Angiopathy (MMA) display structurally altered vessels with decreased cerebral autoregulatory capacity, so aggressive lowering of systemic hypertension may aggravate ischemic symptoms, whereas uncontrolled hypertension may promote hemorrhage. This study provides an in-depth analysis of the role of hypertension in adult MMA patients including long-term analysis of clinical and radiological development. In this single-center retrospective analysis of 137 adult MMA patients with 206 surgically treated hemispheres angiographic images, clinical/operative data were reviewed and scored. Univariate Cox-regression analysis was performed to evaluate hypertension as a predictor for negative angiographic and clinical outcomes following revascularization surgery. A total of 50% of patients were being treated for hypertension prior to the first surgery. Patients with and without hypertension did not differ in terms of age, gender, diagnosis, symptom onset or disease severity (Berlin and Suzuki Grades). Although hypertension did not statistically significantly affect postoperative collaterals, moyamoya vessels or STA-MCA bypass patency, patients with hypertension showed higher rates of bypass patency and better bypass filling compared to those without hypertension. No significant differences in adverse events were found in patients with and without systemic hypertension and the presence of systemic hypertension was not found to predict negative clinical or radiological outcomes. In conclusion, the rate of systemic hypertension in MMA patients appears to be higher than the general population; however, this is not associated with an increased risk of postoperative complications or negative angiographic development following revascularization procedures. Systemic hypertension may also positively influence the rate of bypass patency and filling following revascularization procedures.
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Affiliation(s)
- Kristin Lucia
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neurosurgery, Goethe University Hospital Frankfurt Am Main, Schleusenweg 2-16, 60528 Frankfurt Am Main, Germany
| | - Güliz Acker
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Kerstin Rubarth
- Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Institute of Biometrics and Clinical Epidemiology Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Institute of Medical Informatics Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Defne Beyaztas
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
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19
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Osteraas ND, Dafer RM. Advances in Management of the Stroke Etiology One-Percenters. Curr Neurol Neurosci Rep 2023; 23:301-325. [PMID: 37247169 PMCID: PMC10225785 DOI: 10.1007/s11910-023-01269-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2023] [Indexed: 05/30/2023]
Abstract
PURPOSE OF REVIEW Uncommon causes of stroke merit specific attention; when clinicians have less common etiologies of stoke in mind, the diagnosis may come more easily. This is key, as optimal management will in many cases differs significantly from "standard" care. RECENT FINDINGS Randomized controlled trials (RCT) on the best medical therapy in the treatment of cervical artery dissection (CeAD) have demonstrated low rates of ischemia with both antiplatelet and vitamin K antagonism. RCT evidence supports the use of anticoagulation with vitamin K antagonism in "high-risk" patients with antiphospholipid antibody syndrome (APLAS), and there is new evidence supporting the utilization of direct oral anticoagulation in malignancy-associated thrombosis. Migraine with aura has been more conclusively linked not only with increased risk of ischemic and hemorrhagic stroke, but also with cardiovascular mortality. Recent literature has surprisingly not provided support the utilization of L-arginine in the treatment of patients with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS); however, there is evidence at this time that support use of enzyme replacement in patients with Fabry disease. Additional triggers for reversible cerebral vasoconstriction syndrome (RCVS) have been identified, such as capsaicin. Imaging of cerebral blood vessel walls utilizing contrast-enhanced MRA is an emerging modality that may ultimately prove to be very useful in the evaluation of patients with uncommon causes of stroke. A plethora of associations between cerebrovascular disease and COVID-19 have been described. Where pertinent, authors provide additional tips and guidance. Less commonly encountered conditions with updates in diagnosis, and management along with clinical tips are reviewed.
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Affiliation(s)
| | - Rima M Dafer
- Rush University Medical Center, Chicago, IL, USA.
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison St., Suite 1118, Chicago, IL, 60612, USA.
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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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21
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Gao P, Chen D, Yuan S, Kong T, Zhang D, Zhu X, Li X, Zhen Y, Yan D. Follow-up outcomes of different bypass surgical modalities for adults with ischaemic-type moyamoya disease. Br J Neurosurg 2023; 37:148-157. [PMID: 34553657 DOI: 10.1080/02688697.2021.1981239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE The preferred surgical method for treating adults with moyamoya disease (MMD) remains controversial. The purpose of this study was to compare the efficacy of different surgical methods in the treatment of adults with ischaemic-type MMD. METHODS We retrospectively analyzed the data of patients with ischaemic-type MMD who underwent indirect bypass (IB), direct bypass (DB), or combined bypass (CB) at the First Affiliated Hospital of Zhengzhou University from January 2013 to December 2019. Postoperative complications, improvements in neurological function, haemodynamics, recurrent stroke and neovascularization were compared. RESULTS A total of 310 adults (371 hemispheres) with ischaemic-type MMD were included in our study. Ninety, 127, and 154 hemispheres underwent IB, DB and CB, respectively. A total of 24 (6.5%) ischaemic events and 8 (2.8%) symptomatic hyperperfusion events occurred after the operations. There was no significant difference in postoperative complications among the three types of surgery (p = 0.300). During the follow-up period, there were 21 cases (5.7%) of recurrent ischaemia and 12 cases (3.2%) of recurrent haemorrhage. Kaplan-Meier survival analysis showed that the ischaemia-free survival of the CB group was significantly longer than that of the IB group (p = 0.047), but there was no significant difference in haemorrhage-free survival among the three groups (p = 0.660). Six months after the operation, DB and CB were superior to IB in improving cerebral blood flow and neovascularization (p = 0.002), but there was no significant difference in the improvement of neurological function among the three groups at the last follow-up (p = 0.784). CONCLUSION The three surgical methods achieved satisfactory results in the treatment of ischaemic-type MMD. DB and CB can significantly improve haemodynamics and reduce recurrent stroke. In terms of improving neurological function, the curative effect of the three surgical methods remains to be further explored.
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Affiliation(s)
- Peng Gao
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Di Chen
- Department of Neurosurgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shanpeng Yuan
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Tengxiao Kong
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Dongtao Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Xuqiang Zhu
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Xueyuan Li
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yingwei Zhen
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Dongming Yan
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
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22
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Luo M, Yu J, Xin C, Hu M, Tao T, Wan G, Chen J, Zhang J. Expression of hypoxia-inducing factor-1α and matrix metalloproteinase-9 in the recipient parasylvian cortical arteries with different hemodynamic sources in adult moyamoya disease. Front Surg 2023; 10:1080395. [PMID: 36998597 PMCID: PMC10043197 DOI: 10.3389/fsurg.2023.1080395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/09/2023] [Indexed: 03/16/2023] Open
Abstract
ObjectiveIn our latest research, we have demonstrated that the recipient parasylvian cortical arteries (PSCAs) with hemodynamic sources from the middle cerebral artery (M-PSCAs) has a higher risk of postoperative cerebral hyperperfusion (CHP) syndrome than those from non-M-PSCAs in adult moyamoya disease (MMD) patient. However, whether there are differences between M-PSCAs and non-M-PSCAs in vascular specimens characteristics has not been studied. In this study, we further investigate the vascular specimen of recipient PSCAs by histological and immunohistochemical methods.Methods50 vascular specimens of recipient PSCAs were obtained from 50 adult MMD patients during the combined bypass surgeries in our departments of Zhongnan hospital. 4 recipient PSCAs samples were also obtained in the same way from the middle cerebral artery occlusion patients. The samples were received the pathological sectioning, hematoxylin and eosin staining, and immunohistochemistry, then the vascular wall thickness, matrix metalloproteinase-9 (MMP-9) and hypoxia-inducing factor-1α (HIF-1α) were analyzed.ResultsM-PSCAs adult MMD patients had a thinner intima than non-M-PSCAs in the recipient PSCAs specimens. In recipient non-M-PSCAs vascular specimens, the immunoreactivity indicating HIF-1α and matrix metalloproteinase-9 (MMP-9) was significantly higher than M-PSCAs groups. The logistic regression analyses showed that the M-PSCAs was an independent risk factor of postoperative cerebral hyperperfusion (CHP) syndrome (OR 6.235, 95% CI1.018-38.170, P = 0.048) in MMD.ConclusionOur results indicate that M-PSCAs adult MMD patients had thinner intima than non-MCAs adult MMD patients in the PSCAs. More importantly, HIF-1α and MMP-9 were overexpressed in non-M-PSCAs vascular specimens.
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Sun H, Li Y, Xiao A, Li W, Xia C, You C, Ma L, Liu Y, Xia C. Nomogram to Predict Good Collateral Formation After the STA-MCA Bypass Surgery in Adult Patients With Moyamoya Disease. Stroke 2023; 54:751-758. [PMID: 36748463 DOI: 10.1161/strokeaha.122.039975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Collateral formation from the extracranial carotid artery to ischemic brain tissue determines the clinical success of superficial temporal artery (STA) to middle cerebral artery (MCA) bypass surgery in adult patients with moyamoya disease, but postoperative collateral formation (PCF) after STA-MCA bypass surgery is unpredictable. Accurate preoperative prediction of acceptable PCF could improve patient selection. This study aims to develop a prediction nomogram model for PCF in this patient population. METHODS Adult patients with moyamoya disease undergoing the STA-MCA bypass surgery between January 2013 and December 2020 at a single institution were retrospectively or prospectively enrolled in this observational study. Data including potential clinical and radiological predictors were obtained from hospital records. A nomogram was generated based on a multivariate logistic regression analysis, to identify potential predictors associated with good PCF. The performance of the nomogram was evaluated for discrimination, calibration, and clinical utility. RESULTS Data from 243 patients with moyamoya disease who underwent the STA-MCA bypass surgery were analyzed to build the nomogram. After 1-year follow-up, 162 (66.7%) hemispheres had good PCF and 81 (33.3%) had poor PCF. Good PCF is associated with 3 preoperative factors: age at operation, a diameter of donor branch of STA, and the preinfarction period stage. Incorporating these 3 factors, the model achieved a concordance index of 0.88 (95% CI, 0.84-0.92) and had a well-fitted calibration curve and good clinical application value. A cutoff value of 100 was determined to predict good PCF via this nomogram. CONCLUSIONS The nomogram exhibits high accuracy in predicting good PCF after the STA-MCA bypass surgery in adult patients with moyamoya disease and may allow surgeons to better evaluate preoperatively candidacy for successful bypass surgery.
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Affiliation(s)
- Haogeng Sun
- Department of Neurosurgery (H.S., Y. Li, A.X., C.Y., L.M., Y. Liu.), West China Hospital, Sichuan University, Chengdu, China
| | - Yue Li
- Department of Neurosurgery (H.S., Y. Li, A.X., C.Y., L.M., Y. Liu.), West China Hospital, Sichuan University, Chengdu, China
| | - Anqi Xiao
- Department of Neurosurgery (H.S., Y. Li, A.X., C.Y., L.M., Y. Liu.), West China Hospital, Sichuan University, Chengdu, China
| | - Wanjiang Li
- Department of Radiology (W.L., Chao Xia, Chunchao Xia), West China Hospital, Sichuan University, Chengdu, China
| | - Chao Xia
- Department of Radiology (W.L., Chao Xia, Chunchao Xia), West China Hospital, Sichuan University, Chengdu, China
| | - Chao You
- Department of Neurosurgery (H.S., Y. Li, A.X., C.Y., L.M., Y. Liu.), West China Hospital, Sichuan University, Chengdu, China
| | - Lu Ma
- Department of Neurosurgery (H.S., Y. Li, A.X., C.Y., L.M., Y. Liu.), West China Hospital, Sichuan University, Chengdu, China
| | - Yi Liu
- Department of Neurosurgery (H.S., Y. Li, A.X., C.Y., L.M., Y. Liu.), West China Hospital, Sichuan University, Chengdu, China
| | - Chunchao Xia
- Department of Radiology (W.L., Chao Xia, Chunchao Xia), West China Hospital, Sichuan University, Chengdu, China
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Bersano A, Khan N, Fuentes B, Acerbi F, Canavero I, Tournier-Lasserve E, Vajcoczy P, Zedde ML, Hussain S, Lémeret S, Kraemer M, Herve D. European Stroke Organisation (ESO) Guidelines on Moyamoya angiopathy: Endorsed by Vascular European Reference Network (VASCERN). Eur Stroke J 2023; 8:55-84. [PMID: 37021176 PMCID: PMC10069176 DOI: 10.1177/23969873221144089] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/16/2022] [Indexed: 02/05/2023] Open
Abstract
The European Stroke Organisation (ESO) guidelines on Moyamoya Angiopathy (MMA), developed according to ESO standard operating procedure and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, were compiled to assist clinicians in managing patients with MMA in their decision making. A working group involving neurologists, neurosurgeons, a geneticist and methodologists identified nine relevant clinical questions, performed systematic literature reviews and, whenever possible, meta-analyses. Quality assessment of the available evidence was made with specific recommendations. In the absence of sufficient evidence to provide recommendations, Expert Consensus Statements were formulated. Based on low quality evidence from one RCT, we recommend direct bypass surgery in adult patients with haemorrhagic presentation. For ischaemic adult patients and children, we suggest revascularization surgery using direct or combined technique rather than indirect, in the presence of haemodynamic impairment and with an interval of 6–12 weeks between the last cerebrovascular event and surgery. In the absence of robust trial, an Expert Consensus was reached recommending long-term antiplatelet therapy in non-haemorrhagic MMA, as it may reduce risk of embolic stroke. We also agreed on the utility of performing pre- and post- operative haemodynamic and posterior cerebral artery assessment. There were insufficient data to recommend systematic variant screening of RNF213 p.R4810K. Additionally, we suggest that long-term MMA neuroimaging follow up may guide therapeutic decision making by assessing the disease progression. We believe that this guideline, which is the first comprehensive European guideline on MMA management using GRADE methods will assist clinicians to choose the most effective management strategy for MMA.
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Affiliation(s)
- Anna Bersano
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Nadia Khan
- Moyamoya Center, University Children’s Hospital Zurich, Switzerland
- Moyamoya Center for adults, Department of Neurosurgery, University Tubingen, Germany
| | - Blanca Fuentes
- Department of Neurology and Stroke Center, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | - Francesco Acerbi
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Isabella Canavero
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Peter Vajcoczy
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Germany
| | - Maria Luisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale – IRCCS di Reggio Emilia, Italy
| | | | | | - Markus Kraemer
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Dominique Herve
- CNVT-CERVCO et département de Neurologie, Hôpital Lariboisière, APHP Nord, Paris, France
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25
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Lucia K, Acker G, Mrosk F, Beyaztas D, Vajkoczy P. Longitudinal angiographic characterization of the efficacy of combined cerebral revascularization using minimally invasive encephalodurosynangiosis in patients with moyamoya angiopathy. Neurosurg Rev 2022; 45:3689-3698. [PMID: 36163319 DOI: 10.1007/s10143-022-01862-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/23/2022] [Accepted: 09/11/2022] [Indexed: 11/30/2022]
Abstract
Moyamoya angiopathy (MMA) can be treated using direct, indirect, or combined revascularization procedures. We perform combined revascularization using the STA-MCA bypass and minimally invasive encephalodurosynangiosis (MIS-EDS). Due to lack of systematic analyses to date it remains unclear whether and to which extent this limited EDS serves as a growth source for extracerebral blood vessels into the brain. The objective of the current study is to characterize the extent of angiographic filling of MIS-EDS and STA-MCA bypass development over time and to determine possible predictors of EDS development in adult MMA patients. Single-center retrospective analysis of 81 MMA patients (139 hemispheres) treated with a MIS-EDS and STA-MCA bypass was performed. Angiographic images and clinical/operative data were reviewed and scored. Uni-/ and multivariate Cox regression analyses identified preoperative predictors of good EDS vascularization. At 3-6 months after surgery EDS showed moderate and high angiographic filling in 40% and 5% of hemispheres, respectively. After 12 months moderate and high filling was found in 57% and 4% of hemispheres, respectively. STA-MCA bypass filling was moderate in 47% and high in 7% of hemispheres at 3-6 months and 45% moderate and 9% high after 12 months. High STA-MCA bypass filling on angiography was a negative predictor of EDS development. MIS-EDS is a simple technique and serves as a source of vessel growth into the brain. EDS development lags behind that of STA-MCA bypass and can be recommended as an additive revascularization source when combined with a direct bypass.
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Affiliation(s)
- K Lucia
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - G Acker
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Clinician Scientist Program, Charitéplatz 1, 10117, Berlin, Germany
| | - F Mrosk
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - D Beyaztas
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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Funaki T, Miyakoshi A, Kataoka H, Takahashi JC, Takagi Y, Yoshida K, Kikuchi T, Mineharu Y, Okawa M, Yamao Y, Fushimi Y, Miyamoto S. Larger Posterior Revascularization Associated with Reduction of Choroidal Anastomosis in Moyamoya Disease: A Quantitative Angiographic Analysis. AJNR Am J Neuroradiol 2022; 43:1279-1285. [PMID: 36007950 PMCID: PMC9451642 DOI: 10.3174/ajnr.a7609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/28/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Choroidal anastomosis, a hemorrhage-prone periventricular collateral manifestation in Moyamoya disease, outflows to the cortex posterior to the central sulcus. The objective of the present study was to test whether the angiographic extent of revascularization posterior to the central sulcus contributes to the postoperative reduction of choroidal anastomosis. MATERIALS AND METHODS This retrospective cohort study included choroidal anastomosis-positive hemispheres before direct bypass surgery. The postoperative reduction of choroidal anastomosis was determined by a consensus of 2 raters according to the previous research. An imaging software automatically traced the angiographic revascularization area, which was subsequently divided into anterior and posterior parts by an anatomic line corresponding to the central sulcus. Each area was quantitatively measured as a percentage relative to the whole supratentorial area. RESULTS Postoperative reduction of choroidal anastomosis was achieved in 68 (85.0%) of the 80 included hemispheres. The revascularization area posterior to the central sulcus was significantly larger in the hemispheres with reduction than in those with no reduction (mean, 15.2% [SD, 7.1%] versus 4.2% [SD, 3.4%], P < .001), whereas no significant difference was observed in the revascularization area anterior to the central sulcus. Multivariate analysis revealed that the revascularization area posterior to the central sulcus was the only significant factor associated with reduction (OR, 1.57; 95% CI, 1.21-2.03, for every 1% increase). CONCLUSIONS The results suggest that a larger revascularization posterior to the central sulcus is associated with postoperative reduction of choroidal anastomosis regardless of the extent of anterior revascularization. It might facilitate optimal selection of the revascularization site for preventing hemorrhage.
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Affiliation(s)
- T Funaki
- From the Departments of Neurosurgery (T.F., A.M., K.Y., T.K., Y.M., M.O., Y.Y., S.M.)
| | - A Miyakoshi
- From the Departments of Neurosurgery (T.F., A.M., K.Y., T.K., Y.M., M.O., Y.Y., S.M.)
| | - H Kataoka
- Department of Neurosurgery (H.K.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - J C Takahashi
- Department of Neurosurgery (J.C.T.), Kindai University Faculty of Medicine, Osaka, Japan
| | - Y Takagi
- Department of Neurosurgery (Y.T.), Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - K Yoshida
- From the Departments of Neurosurgery (T.F., A.M., K.Y., T.K., Y.M., M.O., Y.Y., S.M.)
| | - T Kikuchi
- From the Departments of Neurosurgery (T.F., A.M., K.Y., T.K., Y.M., M.O., Y.Y., S.M.)
| | - Y Mineharu
- From the Departments of Neurosurgery (T.F., A.M., K.Y., T.K., Y.M., M.O., Y.Y., S.M.)
| | - M Okawa
- From the Departments of Neurosurgery (T.F., A.M., K.Y., T.K., Y.M., M.O., Y.Y., S.M.)
| | - Y Yamao
- From the Departments of Neurosurgery (T.F., A.M., K.Y., T.K., Y.M., M.O., Y.Y., S.M.)
| | - Y Fushimi
- Diagnostic Imaging and Nuclear Medicine (Y.F.), Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - S Miyamoto
- From the Departments of Neurosurgery (T.F., A.M., K.Y., T.K., Y.M., M.O., Y.Y., S.M.)
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Sreenivasan SA, Suri A, Raheja A, Phuyal S, Singh M, Mishra S, Tandon V, Devarajan LJ, Kalaivani M, Poodipedi SC, Kale SS. Effect of Age, Stage, and Type of Surgical Revascularization on Clinical and Angiographic Outcome in Moyamoya Disease - Experience from a Case Series of 175 Revascularization Procedures. Neurol India 2022; 70:2072-2081. [PMID: 36352611 DOI: 10.4103/0028-3886.359200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND There is dearth of literature on impact of age - pediatric versus adult, Suzuki staging - early versus late, and revascularization type - indirect versus direct on clinical and angiographic outcome in moyamoya disease (MMD). Hence, we intend to comprehensively evaluate factors influencing outcome in MMD following surgical revascularization. METHODS MMD patients operated at our institute from January 2011 to August 2018 were followed for an average 24 months. Primary outcomes were modified Rankin score (mRS) and stroke risk reduction. Secondary outcome was angiographic outcome score (AOS). RESULTS A total of 133 patients including 37.6% adults (>18 years; n = 50) underwent 175 revascularizations - 89 direct (DR) and 86 indirect (IR) subgroups. Mean mRS scores improved in pediatric DR (P < 0.001), IR (P < 0.001), adult IR (P = 0.10), and DR (P = 0.25) subgroups. Recurrent stroke rate was similar in pediatric-DR (2.7%) and IR (7.6%, P = 0.61), and adult-DR (0%) and IR (4.1%) subgroups (P = 1.00). AOS scores improved in pediatric DR (P = 0.002) and IR (P = 0.01), and adult-DR (P = 0.02) and IR (P = 0.06) subgroups. Late-stage MMD (Suzuki IV-VI) showed better improvement in mRS scores than early-stage-Suzuki (I-III; P < 0.001). Recurrent stroke rates were similar (P = 0.26) and AOS scores improved significantly in early- and late-stage MMD (P < 0.001). CONCLUSIONS In pediatrics, clinical and angiographic outcome significantly improved after revascularization procedure, and in adults, angiographic improvement was more evident than clinical recovery. Late-stage Suzuki MMD patients demonstrated significantly better clinical improvement than early stage. The angiographic improvement was equivalent to early stage, irrespective of age and type of revascularization.
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Affiliation(s)
- Sanjeev A Sreenivasan
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Suri
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Amol Raheja
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Subhash Phuyal
- Department of Neuroradiology and Neurointervention Imaging, All India Institute of Medical Sciences, New Delhi, India
| | - Manmohan Singh
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Shashwat Mishra
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Vivek Tandon
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Leve J Devarajan
- Department of Neuroradiology and Neurointervention Imaging, All India Institute of Medical Sciences, New Delhi, India
| | - M Kalaivani
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Sarat C Poodipedi
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Shashank S Kale
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
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Influence of Autologous Bone Marrow Stem Cell Therapy on the Levels of Inflammatory Factors and Conexin43 of Patients with Moyamoya Disease. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2022; 2022:7620287. [PMID: 36052043 PMCID: PMC9427228 DOI: 10.1155/2022/7620287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/13/2022] [Accepted: 07/28/2022] [Indexed: 11/18/2022]
Abstract
Moyamoya disease is a medical condition that shows the typical characteristics like continuous and chronic thickening of the walls and the contraction of the internal carotid artery; as a result, the internal diameter of the artery gets narrowed. There are six phases of the disease ranging from I to VI (moyamoya vessels completely disappear, followed by the complete blockage of the arteries). Surgery is a commonly recommended treatment for the moyamoya disease. Our research study identifies the effect of autologous bone marrow stem cell therapy (ABMSCT) on the levels of inflammatory factors and Conexin43 (Cx43) protein in patients suffering from moyamoya. In our study, we have selected 52 moyamoya patients admitted to our hospital from 30 July 2019 to 10 February 2020. The control group (CG) was treated with superficial temporal artery to a middle cerebral artery (STA-MCA) bypass + encephalo-duro-myosinangiosis (EDMS). The experimental group (Exp. Grp) was treated with ABMSC. The cerebral vascular tissue of the patients was treated with hematoxylin-eosin (HE) staining. Immunohistochemical staining was used to identify the levels of Cx43 protein. The concentrations of vascular endothelial growth factor (VEGF), inflammatory factor interleukin-6 (IL6), interleukin-1β (IL1β), tumor necrosis factor (TNFα), and anti-inflammatory factor interleukin-1β (IL1β) were determined by enzyme-linked immunosorbent assay (ELISA). We have found that after treatment of the expression of Cx43 protein, the proportions of grade IV (7.7%), grade III (311.5%), and grade II (3.8%) patients in the Exp. Grp were lower than those in the CG. The proportion of grade I patients in the Exp. Grp (77%) was higher than that in the CG (38.5%). After treatment, the inflammatory factors IL6 (0.97 ± 0.82 pg/mL), IL1β (8.33 ± 1.21 pg/mL), and TNFα (1.73 ± 0.71 pg/mL) in the Exp. Grp were lower than those in the CG. The anti-inflammatory factor IL1β (15.09 ± 4.72 pg/mL) increased in the Exp. Grp compared with the CG (11.25 ± 3.48 pg/mL) post treatment. Intracranial infection, hydrocephalus, hemiplegia, and transient neurological dysfunction in the Exp. Grp were lower than those in the CG, with statistical differences (P < 0.05). Our study suggests that the treatment of autologous bone marrow stem cells (ABMSC) was beneficial to balance the inflammatory response of disorders, reduce the damage of vascular tissue in the brain, and regulate tissue repair by co-acting with various inflammatory factors as compared to traditional surgery. We conclude that the involvement of Cx43 in the occurrence and development of moyamoya. We also have found that the risk factors of intracranial infection after ABMSCT were less as compared to those after conventional surgery.
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Intravenous thrombolysis and endovascular thrombectomy for acute ischaemic stroke in patients with Moyamoya disease - a systematic review and meta-summary of case reports. J Thromb Thrombolysis 2022; 54:339-349. [PMID: 35699873 DOI: 10.1007/s11239-022-02670-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND AIMS Patients with Moyamoya disease (MMD) can present with ischaemic or haemorrhagic stroke. There is no good evidence for treatment strategies in MMD-associated acute ischaemic stroke (AIS), particularly for treatments like intravenous thrombolysis (IVT) and endovascular thrombectomy (ET). As the intracranial vessels are friable in MMD, and the risk of bleeding is high, the use of IVT and ET is controversial. To clarify the safety and efficacy of IVT/ET in the treatment of MMD-associated AIS, we performed a systematic review and meta-summary to examine this issue. METHODS A systematic search was performed from four electronic databases: PubMed (MEDLINE), Cochrane Library, EMBASE and Scopus, profiling data from inception till 21 November 2021, as well as, manually on Google Scholar. RESULTS Ten case reports detailing 10 MMD patients presenting with AIS and undergoing IVT or ET, or both, were included in the analysis. The median National Institute of Health Stroke Scale score at presentation was 10 (Interquartile Range [IQR] = 6.0-16.5). IVT alone was instituted in 6 patients, primary ET was attempted in 2, and 2 had received bridging IVT with ET. Of the 4 patients who underwent ET, 2 patients achieved successful reperfusion (modified Thrombolysis In Cerebral Infarction scale [mTICI] ≥ 2b). In terms of functional outcomes, One patient achieved complete recovery (modified Rankin Scale 0), 4 patients attained improvement in neurological status, and 4 had no improvement, whilst functional outcome was unreported in 1 patient. No patient experienced symptomatic intracranial haemorrhage. CONCLUSIONS In this systematic review and meta-summary, the utility of IVT and ET in MMD-associated AIS appears feasible in selected cases. Further larger cohort studies are required to evaluate these treatment approaches. HIGHLIGHTS · AIS in MMD was typically managed with bypass surgery but not via thrombolysis or thrombectomy. · In this meta-summary, all patients treated with thrombolysis and/or thrombectomy survived and some experienced symptomatic and/or functional improvement. · Further larger cohort studies are necessary for investigating the role of thrombolysis and/or thrombectomy as treatment of AIS in MMD.
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Zhang K, Ren W, Sun YX, Wang XJ, Li CY, Wang ZL, Li TX, Gao BL. Angiographic Characteristics of Cerebral Perfusion and Hemodynamics of the Bridging Artery After Surgical Treatment of Unilateral Moyamoya Disease. Front Neurosci 2022; 16:922482. [PMID: 35774553 PMCID: PMC9239480 DOI: 10.3389/fnins.2022.922482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/16/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose To investigate the characteristics of cerebral perfusion and hemodynamics of bypass grafting in the treatment of moyamoya disease (MMD) using the iFlow color-coded flow map in comparison with magnetic resonance imaging–perfusion-weighted imaging (MRI–PWI) and computational fluid dynamic (CFD) analysis. Materials and Methods Patients with MMD treated with bypass grafting who had undergone MRI PWI and digital subtraction angiography for iFlow color-coded map was retrospectively enrolled and CFD was performed for calculating the hemodynamic stresses around the bypass grafting. Results Forty-five patients with unilateral MMD treated with bypass surgery were enrolled. The bypass surgery was successful in all patients, with no severe neurological complications during the periprocedural period. Followed up for 4–12 months (median 5.5), the neurological function was good in all patients. The cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time to peak (TTP) were significantly (p < 0.05) improved in the middle cerebral artery distribution area on the surgical side before and after vascular bypass, and the difference of TTP (s) measured from the proximal bifurcation of common carotid artery to the confluence of sinus was also significant (p < 0.05). A significant (p < 0.05) positive correlation existed in the perfusion parameters between the iFlow blood perfusion and the MRI–PWI perfusion, with r-value for TTP of 0.765 (p < 0.01). The iFlow color-coded blood flow map showed warm color changes on the diseased side, similar to those on the contralateral side. In CFD analysis, the hemodynamic stresses were all improved, in and around the bypass grafting and distal vessels, which were beneficial to blood flow entering distal arterial branches. Conclusion The iFlow color-coded flow map can be used to analyze cerebral perfusion after bypass grafting for MMD, similar to MRI–PWI, and CFD can be used to analyze the hemodynamics after bypass grafting, revealing improved hemodynamics to promote blood flow entering distal arteries.
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Affiliation(s)
- Kun Zhang
- The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Wei Ren
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Yu-Xue Sun
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Xin-Jun Wang
- The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Xin-Jun Wang,
| | - Chao-Yue Li
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Zi-Liang Wang
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
- Zi-Liang Wang,
| | - Tian-Xiao Li
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Bu-Lang Gao
- Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, China
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Sutton CXY, Carrazana E, Mitchell C, Viereck J, Liow KK, Ghaffari-Rafi A. Identification of associations and distinguishing moyamoya disease from ischemic strokes of other etiologies: A retrospective case-control study. Ann Med Surg (Lond) 2022; 78:103771. [PMID: 35734698 PMCID: PMC9206914 DOI: 10.1016/j.amsu.2022.103771] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/07/2022] [Accepted: 05/08/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Better characterizing moyamoya disease (MMD) from ischemic strokes of other etiologies may facilitate earlier diagnosis by raising suspicion for a diagnostic work-up. Methods To identify associated variables, MMD cases (n = 12) were compared against three sets of controls: age-, sex-, and race-matched controls of patients with general neurological disorders (n = 48), unmatched general controls (n = 48), and unmatched non-MMD ischemic stroke controls (n = 48). Results MMD patients were 32 years (p < 0.0001) younger than ischemic stroke controls. Relative to non-MMD ischemic strokes, MMD patients had greater odds of presenting with visual field defects (OR: 9.13, p = 0.09) or dizziness (OR: 9.13, p = 0.09), as well as being female (OR: 8.04, p = 0.008), Asian (OR: 3.68, p = 0.087), employed (OR: 6.96, p = 0.02), having migraines (OR: 21.61, p = 0.005), epilepsy (OR: 6.69, p = 0.01), insomnia (OR: 8.90, p = 0.099), and a lower Charlson Comorbidity Index (CCI; p = 0.002). Patients with MMD, compared to non-MMD ischemic strokes, also had a 4.67 kg/ m2 greater body mass index (BMI) and larger odds (OR relative to normal BMI: 21.00, p = 0.03) of being from obesity class III (>40 kg/ m2), yet reduced odds of coronary artery disease (OR: 0.13, p = 0.02). Relative to general controls, MMD patients had greater odds of diabetes mellitus type 2 (OR: 10.07, p = 0.006) and hypertension (OR: 7.28, p = 0.004). Conclusion MMD not only has a unique clinical presentation from other ischemic strokes, but also unique comorbidities, which may facilitate earlier work-up and treatment. Moyamoya patients are 32 years younger than ischemic strokes of other etiologies. Moyamoya patients are 4.67 kg/ m2 heavier than those with ischemic strokes. Moyamoya patients are at greater odds of type 2 diabetes mellitus and hypertension. Moyamoya patients are at reduced odds of coronary artery disease. Moyamoya patients present more often with visual field deficits or dizziness.
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Bao Y, Yu F, Wei L, Zhu W, Wang L, Ding H, Yang J, Huang D. Association between Cognitive Decline and Altered Cerebral Perfusion in Adults with Moyamoya Disease after Revascularization. Cerebrovasc Dis 2022; 51:764-773. [PMID: 35477140 DOI: 10.1159/000524240] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/09/2022] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Certain studies have observed that patients with moyamoya disease (MMD) have cognitive decline after revascularization. Thus, this study analyzed the relationship between cognitive decline and altered cerebral perfusion after revascularization. METHODS Here, 313 adult patients with MMD underwent single unilateral revascularization. First, cognitive function was scored using a Mini-Mental Scale (MMSE) and Montreal cognitive function scale (MoCA) before and 3 months after the operation (superficial temporal artery-middle cerebral artery anastomosis with encephalo-myo-synangiosis). Then, computed tomography perfusion was performed before and 1 week after the operation to assess the cerebral perfusion. RESULTS Our data showed that cognitive function decreased in 55 cases (17.6%) after revascularization. Furthermore, the incidence of cerebral hyperperfusion (CHP) was significantly higher in the cognitive decline group (49/55) than in the cognitive nondecline group (89.1% vs. 5.4%, p < 0.001). Results also showed that although all 55 patients had postoperative cognitive decline, 47 experienced relative cerebral blood flow (CBF) decrease at a relatively distant area of the anastomosis compared with that before the operation, which was significantly higher than in patients without cognitive decline (85.5% vs. 1.94%, p < 0.001). In addition, 41 patients had a simultaneous occurrence of local CHP and paradoxical CBF decrease at a relatively distant anastomosis area, which indicated the incident of watershed shift (WS). As observed, WS occurred in 74.5% of patients with cognitive decline, significantly higher than in patients without cognitive decline (74.5% vs. 0%, p < 0.0001). Through multiple logistic regression analysis, WS was also observed to be a strong independent risk factor for predicting postoperative cognitive decline 3 months after revascularization (odds ratio 17.780, 95% confidence interval 1.668-18.564; p = 0.017). CONCLUSION Therefore, cognitive decline in patients with MMD after revascularization is related to WS, leading to an uneven distribution of CBF.
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Affiliation(s)
- Yiwen Bao
- Department of Neurology, Tongji University, School Med, East Hospital, Shanghai, China,
| | - Fei Yu
- Department of Neurology, Tongji University, School Med, East Hospital, Shanghai, China
| | - Liang Wei
- Department of Neurosurgery, Tongji University, School Med, East Hospital, Shanghai, China
| | - Wenxia Zhu
- Department of Neurology, Tongji University, School Med, East Hospital, Shanghai, China
| | - Lufeng Wang
- Department of Neurology, Tongji University, School Med, East Hospital, Shanghai, China
| | - Hao Ding
- Department of Neurology, Tongji University, School Med, East Hospital, Shanghai, China
| | - Jie Yang
- Department of Neurology, Tongji University, School Med, East Hospital, Shanghai, China
| | - Dongya Huang
- Department of Neurology, Tongji University, School Med, East Hospital, Shanghai, China
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Infarction Patterns and Recurrent Adverse Cerebrovascular Events in Moyamoya Disease. DISEASE MARKERS 2022; 2022:8255018. [PMID: 35392499 PMCID: PMC8983186 DOI: 10.1155/2022/8255018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/17/2022] [Indexed: 11/17/2022]
Abstract
For moyamoya disease (MMD) patients who suffered an acute ischemic attack, the infarction patterns on DWI and its association with recurrent adverse cerebrovascular events (ACEs) after bypass surgery remain unknown. 327 patients who suffered an acute ischemic attack and received following revascularization surgery were retrospectively reviewed and were divided into three patterns according to the lesion number and distribution on DWI that obtained within 7 days of onset: no acute infarction (NAI), single acute infarction (SAI), and multiple acute infarctions (MAIs). We used Cox proportional hazard models to estimate hazard ratios (HR) for associations of infarction patterns and the risk of recurrent ACEs and strokes. Over a median follow-up of 41 months (IQR 26-60), there were 61 ACEs and 27 strokes. Compared to the NAI cohort, patients with SAI (HR, 2.92; 95% CI, 1.41-6.05; p = 0.004) and MAIs (HR, 4.44; 95% CI, 2.10-9.41; p < 0.001) were associated with higher risk of ACEs recurrences. In analysis adjusted for age and surgery modalities, the corresponding HR was 2.90 (95% CI: 1.41-5.98) for SAI and 4.10 (95% CI: 1.95-8.63) for MAIs, and this effect remained persistent on further adjustment for several potential confounders. Similar but less precise association was found in separate analysis that only takes into account stroke recurrences. Thus, different infarction patterns on DWI imply different risks of recurrent ACEs, and more attention should be paid to prevent ACEs in MMD patients with MAIs.
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Tsunoda S, Inoue T, Segawa M, Kawashima M, Akabane A, Saito N. Superficial temporal artery lengthening technique to prevent postoperative wound complications in direct revascularization to the anterior cerebral artery for Moyamoya disease. Acta Neurochir (Wien) 2022; 164:1845-1854. [PMID: 35304649 DOI: 10.1007/s00701-022-05180-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/02/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Neurocognitive dysfunctions or psychomotor symptoms of Moyamoya disease may improve after direct revascularization to the anterior cerebral artery (ACA). However, long-distance harvest of the frontal branch of the superficial temporal artery (STA) is needed to reach the cortical ACA, frequently resulting in postoperative wound complications. To solve this problem, we devised a novel method (STA lengthening technique). In this study, we compared the STA lengthening technique and the conventional method regarding postoperative wound complications. METHODS Twenty-five patients who underwent STA-ACA direct bypass from December 2016 to October 2021 were retrospectively reviewed, and postoperative wound complications were recorded. Magnetic resonance angiography was performed to evaluate the patency of the bypass to the ACA and postoperative development of collaterals to the skin flap. RESULTS Thirty-eight hemispheres (new method [n = 12] vs. conventional method [n = 26]) were treated. Wound complications occurred in 12 surgeries (46%) of the conventional method, and none (0%) of the new method. The anastomosis with the cortical ACA was patent in all surgeries. Postoperative development of collaterals to the skin flap was confirmed after all surgeries (100%) in the new method, whereas after only five surgeries (20%) in the conventional method. CONCLUSION The STA lengthening technique can enable to preserve the collateral circulation to the skin flap postoperatively, resulting in good wound healing.
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Affiliation(s)
- Sho Tsunoda
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-ku, Tokyo, 141-0022, Japan.
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-ku, Tokyo, 141-0022, Japan
| | - Masafumi Segawa
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-ku, Tokyo, 141-0022, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-ku, Tokyo, 141-0022, Japan
| | - Atsuya Akabane
- Department of Neurosurgery, NTT Medical Center Tokyo, 5-9-22, Higashigotanda, Shinagawa-ku, Tokyo, 141-0022, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Rose DK, Chamberlain L, Ashton J, Yaghi S, Hauck EF, Mac Grory B. Moyamoya syndrome in a young person with Down syndrome: diagnostic and therapeutic considerations. BMJ Case Rep 2022; 15:e246168. [PMID: 35246432 PMCID: PMC8900050 DOI: 10.1136/bcr-2021-246168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2022] [Indexed: 11/04/2022] Open
Abstract
An 18-year-old woman with a history of Down syndrome (DS) presented with left upper extremity weakness. Neurological examination revealed moderate hypotonia throughout, with mild spasticity of the left ankle. She had 2/5 left upper and lower extremity strength, mild pronation with drift in the left arm and 3+ deep tendon reflexes in the left biceps, brachioradialis, patellar and Achilles. Strength was 5/5 in the right upper and lower extremities. A CT angiography of the head and neck with contrast demonstrated severe narrowing of the bilateral supraclinoid internal carotid arteries (ICAs), suggestive of moyamoya pattern. A diagnostic angiography confirmed stenosis in the right and left supraclinoid ICAs. The patient was started on aspirin therapy and underwent an indirect bypass procedure via encephaloduroarteriosynangiosis 6 weeks after initial presentation. DS is associated with a high risk of congenital heart disease, which in turn increases risk of stroke, namely cardioembolic events, including moyamoya disease. Intellectual disability is nearly ubiquitous in DS, thus adding to the challenges of making a diagnosis of moyamoya in this population.
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Affiliation(s)
- Deborah Kathleen Rose
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lauren Chamberlain
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jeffrey Ashton
- Department of Radiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Erik F Hauck
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
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Fujimura M, Tominaga T, Kuroda S, Takahashi JC, Endo H, Ogasawara K, Miyamoto S. 2021 Japanese Guidelines for the Management of Moyamoya Disease: Guidelines from the Research Committee on Moyamoya Disease and Japan Stroke Society. Neurol Med Chir (Tokyo) 2022; 62:165-170. [PMID: 35197402 PMCID: PMC9093674 DOI: 10.2176/jns-nmc.2021-0382] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine
| | - Satoshi Kuroda
- Department of Neurosurgery, University of Toyama School of Medicine
| | - Jun C Takahashi
- Department of Neurosurgery, Kindai University Faculty of Medicine
| | | | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University School of Medicine
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
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Fujimura M. Moyamoya Disease-Standards and Advances in Revascularization Procedure and Peri-operative Management. Adv Tech Stand Neurosurg 2022; 44:175-186. [PMID: 35107679 DOI: 10.1007/978-3-030-87649-4_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Moyamoya disease (MMD) is a chronic, occlusive cerebrovascular disease with unknown etiology characterized by progressive stenosis at the terminal portion of the internal carotid artery and the abnormal vascular network formation at the base of the brain. Superficial temporal artery-middle cerebral artery (STA-MCA) bypass is a preferred surgical procedure for ischemic-onset MMD patients by improving cerebral blood flow. Recent evidence further indicates that flow-augmentation bypass has a potential role for preventing re-bleeding in hemorrhagic-onset MMD patients. Based on such cumulative evidence, there is a worldwide increase in the number of MMD patients undergoing bypass surgery, thus thorough understanding of the basic pathology of MMD including peri-operative hemodynamics is critical for avoiding surgical complications. The author sought to demonstrate the standard surgical procedure of STA-MCA bypass with indirect pial synangiosis for adult MMD patients and its pitfall in the early postoperative period, introducing the characteristic peri-operative hemodynamic condition of adult MMD after surgery, such as local cerebral hyperperfusion and intrinsic hemodynamic ischemia caused by watershed shift phenomenon.
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Affiliation(s)
- Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan.
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Xu J, Zhang Q, Rajah GB, Zhao W, Wu F, Ding Y, Zhang B, Guo W, Yang Q, Xing X, Li S, Ji X. Daily Remote Ischemic Conditioning Can Improve Cerebral Perfusion and Slow Arterial Progression of Adult Moyamoya Disease—A Randomized Controlled Study. Front Neurol 2022; 12:811854. [PMID: 35185755 PMCID: PMC8850829 DOI: 10.3389/fneur.2021.811854] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
Background and PurposeMoyamoya disease (MMD) is a complicated cerebrovascular disease with recurrent ischemic or hemorrhagic events. This study aimed to prove the safety and efficacy of remote ischemic conditioning (RIC) on MMD.MethodsIn total, 34 patients with MMD participated in this pilot, prospective randomized controlled study for 1 year. 18 patients were allocated into the RIC group, and 16 patients accepted routine medical treatment only. RIC-related adverse events were recorded. The primary outcome was the improvement ratio of mean cerebral blood flow (mCBF) in middle cerebral artery territory measured by multidelay pseudocontinuous arterial spin labeling, and the secondary outcomes were the cumulative incidence of major adverse cerebrovascular events (MACEs), the prevalence of stenotic-occlusive progression, and periventricular anastomosis at 1-year follow-up.ResultsIn total, 30 of the 34 patients with MMD completed the final follow-up (17 in the RIC group and 13 in the control group). No adverse events of RIC were observed. The mCBF improvement ratio of the RIC group was distinctively higher compared with the control group (mCBF−whole-brain: 0.16 ± 0.15 vs. −0.03 ± 0.13, p = 0.001). Stenotic-occlusive progression occurred in 11.8% hemispheres in the RIC group and 38.5% in the control group (p = 0.021). The incidence of MACE was 5.9% in the RIC group and 30.8% in the control group (hazard ratio with RIC, 0.174; 95% CI, 0.019–1.557; p = 0.118). No statistical difference was documented in the periventricular anastomosis between the two groups after treatment.ConclusionsRemote ischemic conditioning has the potential to be a safe and effective adjunctive therapy for patients with MMD largely due to improving cerebral blood flow and slowing the arterial progression of the stenotic-occlusive lesions. These findings warrant future studies in larger trials.
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Affiliation(s)
- Jiali Xu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Laboratory of Brain Disorders, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Qian Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Gary B. Rajah
- Department of Neurosurgery, Wayne State University, Detroit, MI, United States
- Department of Neurosurgery, Munson Medical Center, Traverse City, MI, United States
| | - Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Laboratory of Brain Disorders, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Fang Wu
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University, Detroit, MI, United States
| | - Bowei Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenting Guo
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qi Yang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiurong Xing
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Sijie Li
- Laboratory of Brain Disorders, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
- *Correspondence: Sijie Li
| | - Xunming Ji
- Laboratory of Brain Disorders, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
- Xunming Ji
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Kuribara T, Akiyama Y, Mikami T, Komatsu K, Kimura Y, Takahashi Y, Sakashita K, Chiba R, Mikuni N. Macrohistory of Moyamoya Disease Analyzed Using Artificial Intelligence. Cerebrovasc Dis 2022; 51:413-426. [PMID: 35104814 DOI: 10.1159/000520099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 10/06/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Moyamoya disease is characterized by progressive stenotic changes in the terminal segment of the internal carotid artery and the development of abnormal vascular networks called moyamoya vessels. The objective of this review was to provide a holistic view of the epidemiology, etiology, clinical findings, treatment, and pathogenesis of moyamoya disease. A literature search was performed in PubMed using the term "moyamoya disease," for articles published until 2021. RESULTS Artificial intelligence (AI) clustering was used to classify the articles into 5 clusters: (1) pathophysiology (23.5%); (2) clinical background (37.3%); (3) imaging (13.2%); (4) treatment (17.3%); and (5) genetics (8.7%). Many articles in the "clinical background" cluster were published from the 1970s. However, in the "treatment" and "genetics" clusters, the articles were published from the 2010s through 2021. In 2011, it was confirmed that a gene called Ringin protein 213 (RNF213) is a susceptibility gene for moyamoya disease. Since then, tremendous progress in genomic, transcriptomic, and epigenetic profiling (e.g., methylation profiling) has resulted in new concepts for classifying moyamoya disease. Our literature survey revealed that the pathogenesis involves aberrations of multiple signaling pathways through genetic mutations and altered gene expression. CONCLUSION We analyzed the content vectors in abstracts using AI, and reviewed the pathophysiology, clinical background, radiological features, treatments, and genetic peculiarity of moyamoya disease.
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Affiliation(s)
| | - Yukinori Akiyama
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Takeshi Mikami
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Katsuya Komatsu
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Yusuke Kimura
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | | | - Kyoya Sakashita
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Ryohei Chiba
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
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Extracranial–Intracranial Bypass for Cerebral Ischemia. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00077-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Tashiro R, Fujimura M, Katsuki M, Nishizawa T, Tomata Y, Niizuma K, Tominaga T. Prolonged/delayed cerebral hyperperfusion in adult patients with moyamoya disease with RNF213 gene polymorphism c.14576G>A (rs112735431) after superficial temporal artery-middle cerebral artery anastomosis. J Neurosurg 2021; 135:417-424. [PMID: 33096527 DOI: 10.3171/2020.6.jns201037] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/08/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is the standard surgical management for moyamoya disease (MMD), whereas cerebral hyperperfusion (CHP) is one of the potential complications of this procedure that can result in delayed intracerebral hemorrhage and/or neurological deterioration. Recent advances in perioperative management in the early postoperative period have significantly reduced the risk of CHP syndrome, but delayed intracerebral hemorrhage and prolonged/delayed CHP are still major clinical issues. The clinical implication of RNF213 gene polymorphism c.14576G>A (rs112735431), a susceptibility variant for MMD, includes early disease onset and a more severe form of MMD, but its significance in perioperative pathology is unknown. Thus, the authors investigated the role of RNF213 polymorphism in perioperative hemodynamics after STA-MCA anastomosis for MMD. METHODS Among 96 consecutive adult patients with MMD comprising 105 hemispheres who underwent serial quantitative cerebral blood flow (CBF) analysis by N-isopropyl-p-[123I]iodoamphetamine SPECT after STA-MCA anastomosis, 66 patients consented to genetic analysis of RNF213. Patients were routinely maintained under strict blood pressure control during and after surgery. The local CBF values were quantified at the vascular territory supplied by the bypass on postoperative days (PODs) 1 and 7. The authors defined the radiological CHP phenomenon as a local CBF increase of more than 150% compared with the preoperative values, and then they investigated the correlation between RNF213 polymorphism and the development of CHP. RESULTS CHP at POD 1 was observed in 23 hemispheres (23/73 hemispheres [31.5%]), and its incidence was not statistically different between groups (15/41 [36.6%] in RNF213-mutant group vs 8/32 [25.0%] in RNF213-wild type (WT) group; p = 0.321). CHP on POD 7, which is a relatively late period of the CHP phenomenon in MMD, was evident in 9 patients (9/73 hemispheres [12.3%]) after STA-MCA anastomosis. This prolonged/delayed CHP was exclusively observed in the RNF213-mutant group (9/41 [22.0%] in the RNF213-mutant group vs 0/32 [0.0%] in the RNF213-WT group; p = 0.004). Multivariate analysis revealed that RNF213 polymorphism was significantly associated with CBF increase on POD 7 (OR 5.47, 95% CI 1.06-28.35; p = 0.043). CONCLUSIONS Prolonged/delayed CHP after revascularization surgery was exclusively found in the RNF213-mutant group. Although the exact mechanism underlying the contribution of RNF213 polymorphism to the prolonged/delayed CBF increase in patients with MMD is unclear, the current study suggests that genetic analysis of RNF213 is useful for predicting the perioperative pathology of patients with MMD.
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Affiliation(s)
- Ryosuke Tashiro
- 1Department of Neurosurgery, Kohnan Hospital, Sendai
- 2Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai; and
| | - Miki Fujimura
- 1Department of Neurosurgery, Kohnan Hospital, Sendai
| | - Masahito Katsuki
- 1Department of Neurosurgery, Kohnan Hospital, Sendai
- 2Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai; and
| | | | - Yasutake Tomata
- 3Division of Epidemiology, Department of Health Informatics and Public Health, Tohoku University School of Public Health, Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Kuniyasu Niizuma
- 2Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai; and
| | - Teiji Tominaga
- 2Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai; and
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Zhang X, Xiao W, Zhang Q, Xia D, Gao P, Su J, Yang H, Gao X, Ni W, Lei Y, Gu Y. Progression in Moyamoya Disease: Clinical Feature, Neuroimaging Evaluation and Treatment. Curr Neuropharmacol 2021; 20:292-308. [PMID: 34279201 PMCID: PMC9413783 DOI: 10.2174/1570159x19666210716114016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/08/2021] [Accepted: 07/09/2021] [Indexed: 11/22/2022] Open
Abstract
Moyamoya disease (MMD) is a chronic cerebrovascular disease characterized by progressive stenosis of the arteries of the circle of Willis, with the formation of collateral vascular network at the base of the brain. Its clinical manifestations are complicated. Numerous studies have attempted to clarify the clinical features of MMD, including its epidemiology, genetic characteristics, and pathophysiology. With the development of neuroimaging techniques, various neuroimaging modalities with different advantages have deepened the understanding of MMD in terms of structural, functional, spatial, and temporal dimensions. At present, the main treatment for MMD focuses on neurological protection, cerebral blood flow reconstruction, and neurological rehabilitation, such as pharmacological treatment, surgical revascularization, and cognitive rehabilitation. In this review, we discuss recent progress in understanding the clinical features, in the neuroimaging evaluation and treatment of MMD.
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Affiliation(s)
- Xin Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Weiping Xiao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Qing Zhang
- Department of Nursing, Huashan Hospital North, Fudan University, China
| | - Ding Xia
- Department of Radiology, Huashan Hospital North, Fudan University, China
| | - Peng Gao
- Department of Radiology, Huashan Hospital North, Fudan University, China
| | - Jiabin Su
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Heng Yang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Xinjie Gao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Wei Ni
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Yu Lei
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Yuxiang Gu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
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Pilgram-Pastor S, Chapot R, Kraemer M. The angiographic presentation of European Moyamoya angiopathy. J Neurol 2021; 269:997-1006. [PMID: 34240321 PMCID: PMC8782787 DOI: 10.1007/s00415-021-10684-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/21/2021] [Accepted: 06/22/2021] [Indexed: 11/26/2022]
Abstract
Background and purpose Little is known about the angiographic presentation of Moyamoya angiopathy (MMA) in non-Asian patients. Methods Conventional cerebral angiograms from 155 Caucasian patients diagnosed as MMA were analyzed with respect to extracranial champagne bottle neck sign, Suzuki stages, collateral status, as well as presence of aneurysms and posterior cerebral artery stenosis. Results In 84 of 155 angiograms, the extracranial carotid artery was visualized, in 65 of them (77.4%), a champagne bottle neck sign was noted. Of the 278 analyzable hemispheres, 13.7%,11.2%, 37.8%, 27.3%, 8.6%, and 1.4% were classified as Suzuki stage I, stage II, stage III, stage IV, stage V, and stage VI, respectively. Among 280 hemispheres, in 53 hemispheres (18.9%) isolated basal collaterals (pathway I) and in 104 hemispheres (37.1%) choroidal and pericallosal collaterals (including basal collaterals, pathway II) were found. In 74 hemispheres (26.4%) ethmoidal collaterals (pathways III), and in 17 hemispheres (6.1%) vault collaterals were visualized. Patients with higher Suzuki stages IV–VI (p = 0.008) and ethmoidal collaterals (p < 0.001) suffered more often from cerebral hemorrhage. Transient ischemic attacks occurred more frequently in patients with Suzuki stage I to III (p < 0.001). In 10 of 155 patients (6.5%), the angiogram revealed a cerebral aneurysm. In 13 patients (8.4%), a stenotic P1 segment of the posterior cerebral artery was found. Conclusions This is so far the largest observational study about angiography in Caucasian European MMA patients. A comparison with Asian data indicates similarity of disease in Caucasian and Asian patients.
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Affiliation(s)
- Sara Pilgram-Pastor
- Department of Neuroradiology, Alfried Krupp Hospital, Essen, Germany
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - René Chapot
- Department of Neuroradiology, Alfried Krupp Hospital, Essen, Germany
| | - Markus Kraemer
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany.
- Department of Neurology, Alfried Krupp Von Bohlen Und Halbach Hospital, Alfried-Krupp-Str. 21, 45117, Essen, Germany.
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1134] [Impact Index Per Article: 378.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Lucia K, Acker G, Schlinkmann N, Georgiev S, Vajkoczy P. Surgical Management of Failed Revascularization in Moyamoya Vasculopathy. Front Neurol 2021; 12:652967. [PMID: 34267719 PMCID: PMC8275848 DOI: 10.3389/fneur.2021.652967] [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: 01/13/2021] [Accepted: 04/27/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Moyamoya vasculopathy (MMV) is a rare stenoocclusive cerebrovascular disease associated with increased risk of ischemic and hemorrhagic stroke, which can be treated using surgical revascularization techniques. Despite well-established neurosurgical procedures performed in experienced centers, bypass failure associated with neurological symptoms can occur. The current study therefore aims at characterizing the cases of bypass failure and repeat revascularization at a single center. Methods: A single-center retrospective analysis of all patients treated with revascularization surgery for MMV between January 2007 and December 2019 was performed. Angiographic data, cerebral blood flow analysis [H2O PET or single-photon emission CT (SPECT)], MRI, and clinical/operative data including follow-up assessments were reviewed. Results: We identified 308 MMV patients with 405 surgically treated hemispheres. Of the 405 hemispheres treated, 15 patients (3.7%) underwent repeat revascularization (median age 38, time to repeat revascularization in 60% of patients was within 1 year of first surgery). The most common cause of repeat revascularization was a symptomatic bypass occlusion (80%). New ischemic lesions were found in 13% of patients prior to repeat revascularization. Persistence of reduced or progressive worsening of cerebrovascular reserve capacity (CVRC) compared with preoperative status was observed in 85% of repeat revascularization cases. Intermediate-flow bypass using a radial artery graft was most commonly used for repeat revascularization (60%) followed by re-superficial temporal artery to middle cerebral artery (re-STA-MCA) bypass (26%). High-flow bypass using a saphenous vein graft and using an occipital artery to MCA bypass was each used once. Following repeat revascularization, no new ischemic events were recorded. Conclusion: Overall, repeat revascularization is needed only in a small percentage of the cases in MMV. A rescue surgery should be considered in those with neurological symptoms and decreased CVRC. Intermediate-flow bypass using a radial artery graft is a reliable technique for patients requiring repeat revascularization. Based on our institutional experience, we propose an algorithm for guiding the decision process in cases of bypass failure.
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Affiliation(s)
- Kristin Lucia
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Güliz Acker
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Nicolas Schlinkmann
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Stefan Georgiev
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin (Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin, Germany
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Larson AS, Lehman VT, Savastano LE, Lanzino G, Campeau NG, Welker KM, Klaas JP. Implementation and Rationale for a Unified Clinical and Imaging Protocol for Evaluation and Treatment of Moyamoya Angiopathy: A Single Institutional Experience. Front Neurol 2021; 12:662393. [PMID: 34079514 PMCID: PMC8165224 DOI: 10.3389/fneur.2021.662393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/21/2021] [Indexed: 11/13/2022] Open
Abstract
Moyamoya disease (MMD) is a complex and incompletely-understood cerebrovascular pathological entity that requires thorough clinical and imaging evaluation. Moyamoya is rare, thereby making the establishment of an effective, thorough and interdisciplinary patient evaluation protocol challenging, even within specialized referral centers. Nevertheless, implementation of such a protocol is crucial in order to provide the best possible evaluation and treatment for MMD patients. Here, we describe our institution's implementation of, rationale for, and experience with a comprehensive multidisciplinary collaboration and evaluation strategy for adult patients with moyamoya. This evaluation course consists of, first of all, a thorough clinical and laboratory evaluation with a vascular neurologist. This is followed by a comprehensive imaging assessment which evaluates angiographic and parenchymal features, in addition to cerebrovascular functionality. Finally, appropriate referrals are made to consulting services as indicated, which includes vascular neurosurgery. These steps are described in detail herein.
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Affiliation(s)
- Anthony S Larson
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Luis E Savastano
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Giuseppe Lanzino
- Department of Radiology, Mayo Clinic, Rochester, MN, United States.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | | | - Kirk M Welker
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - James P Klaas
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
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Encephaloduroarteriosynangiosis (EDAS) treatment of moyamoya syndrome: evaluation by computed tomography perfusion imaging. Eur Radiol 2021; 31:8364-8373. [PMID: 33956177 DOI: 10.1007/s00330-021-07960-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 03/17/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To explore the value of computed tomography perfusion (CTP) imaging for evaluating the efficacy of encephaloduroarteriosynangiosis (EDAS) treatment of moyamoya syndrome (MMS). METHODS Forty-three patients with MMS (48 hemispheres) who received EDAS treatment were examined using CTP and DSA before and after surgery. CTP of the ipsilateral cortex, contralateral mirror area, and pons region were measured, and the relative cerebral blood flow (rCBF) and volume (rCBV), mean transit time (rMTT), and time-to-peak (rTTP) were calculated. Based on postoperative DSA, 48 hemispheres were apportioned to two groups based on rich (grades 2, 3) or poor (grades 0, 1) collateral vessel formation, and the pre- and post-operative differences in perfusion changes were compared. The association between clinical outcome, CTP, and the degree of DSA collateral vessels was explored. RESULTS rCBF and rMTT significantly improved in both the poor and rich collateral vessel formation groups (n = 21 and 27, respectively), while rTTP significantly improved only in the latter. Postoperative CTP improved in the rich and the grade 1 collateral vessel groups (p < 0.01). The clinical improvement was consistent with the improvement of CTP (p = 0.07), but less consistent with the degree of collateral angiogenesis (p = 0.003). CONCLUSION CTP can quantitatively evaluate the improvement of brain tissue perfusion in the operated area after EDAS. Brain tissue perfusion in operated areas improved regardless of postoperative rich or poor collateral vessel formation observed via DSA. A significant improvement in rTTP in the operated area may indicate the formation of abundant collateral vessels. KEY POINTS • CTP showed that brain tissue perfusion in the operated area after EDAS improved regardless of rich or poor collateral vessel formation observed via DSA. • Significant improvement of rTTP in the operated area may indicate the formation of abundant collateral vessels.
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Nielsen TH, Abhinav K, Sussman ES, Han SS, Weng Y, Bell-Stephens T, Heit JJ, Steinberg GK. Direct versus indirect bypass procedure for the treatment of ischemic moyamoya disease: results of an individualized selection strategy. J Neurosurg 2021; 134:1578-1589. [PMID: 32534489 DOI: 10.3171/2020.3.jns192847] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The only effective treatment for ischemic moyamoya disease (iMMD) is cerebral revascularization by an extracranial to intracranial bypass. The preferred revascularization method remains controversial: direct versus indirect bypass. The purpose of this study was to test the hypothesis that method choice should be personalized based on angiographic, hemodynamic, and clinical characteristics to balance the risk of perioperative major stroke against treatment efficacy. METHODS Patients with iMMD were identified retrospectively from a prospectively maintained database. Those with mild to moderate internal carotid artery or M1 segment stenosis, preserved cerebrovascular reserve, intraoperative M4 segment anterograde flow ≥ 8 ml/min, or the absence of frequent and severe transient ischemic attacks (TIAs) or stroke had been assigned to indirect bypass. The criteria for direct bypass were severe ICA or M1 segment stenosis or occlusion, impaired cerebrovascular reserve or steal phenomenon, intraoperative M4 segment retrograde flow or anterograde flow < 8 ml/min, and the presence of frequent and severe TIAs or clinical strokes. The primary study endpoint was MRI-confirmed symptomatic stroke ≤ 7 days postoperatively resulting in a decline in the modified Rankin Scale (mRS) score from preoperatively to 6 months postoperatively. As a secondary endpoint, the authors assessed 6-month postoperative DSA-demonstrated revascularization, which was classified as < 1/3, 1/3-2/3, or > 2/3 of the middle cerebral artery territory. RESULTS One hundred thirty-eight patients with iMMD affecting 195 hemispheres revascularized in the period from March 2016 to June 2018 were included in this analysis. One hundred thirty-three hemispheres were revascularized with direct bypass and 62 with indirect bypass. The perioperative stroke rate was 4.7% and 6.8% in the direct and indirect groups, respectively (p = 0.36). Degree of revascularization was higher in the direct bypass group (p = 0.03). The proportion of patients improving to an mRS score 0-1 (from preoperatively to 6 months postoperatively) tended to be higher in the direct bypass group, although the difference between the two bypass groups was not statistically significant (p = 0.27). CONCLUSIONS The selective use of an indirect bypass procedure for iMMD did not decrease the perioperative stroke rate. Direct bypass provided a significantly higher degree of revascularization. The authors conclude that direct bypass is the treatment of choice for iMMD.
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Affiliation(s)
- Troels H Nielsen
- 1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine
| | - Kumar Abhinav
- 1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine
| | - Eric S Sussman
- 1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine
| | - Summer S Han
- 1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine
- 2Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine; and
| | - Yingjie Weng
- 2Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine; and
| | | | - Jeremy J Heit
- 3Department of Radiology, NeuroInterventional Radiology Section, and Stanford Stroke Center, Stanford University School of Medicine, Stanford, California
| | - Gary K Steinberg
- 1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine
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Araki Y, Yokoyama K, Uda K, Kanamori F, Mamiya T, Nishihori M, Sumitomo M, Okamoto S, Izumi T. Ipsilateral late stroke after revascularization surgery for patients with Moyamoya disease. Acta Neurochir (Wien) 2021; 163:1493-1502. [PMID: 33624115 DOI: 10.1007/s00701-021-04773-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/16/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Ipsilateral late stroke events occurring after cerebral revascularization for Moyamoya disease (MMD) and their risk factors have not been fully investigated. METHODS We retrospectively analyzed 123 patients with MMD who underwent 212 revascularizations. We investigated preoperative demographic data, surgical procedures, and ipsilateral stroke events occurring more than 1 month after surgery. The effect of revascularization and the residual Moyamoya vessel (MMV) score were examined using magnetic resonance angiography (MRA). Then, predictive factors for postoperative late stroke occurrence were evaluated by logistic regression. RESULTS The mean age was 26 ± 18.4 years (range 1 to 66 years). Ipsilateral late stroke events were present in 11 of 123 (9%) patients. Stroke occurred in 11 out of 212 surgeries (5.2%) on a hemispheric basis. During the 1300.1 hemisphere-years of follow-up more than 1 month after surgery, the annual stroke rate was 0.84%. The postoperative MRA time-of-flight image showed a mean revascularization score of 1.82 ± 0.6 and a mean residual MMV score of 1.91 ± 0.83. Postoperative strokes occurring within 1 month after cerebral revascularization (36.4%, p = 0.0026) and lower revascularization scores (1.82 ± 0.6 vs 2.51 ± 0.59, p = 0.0006) were significant factors related to the presence of ipsilateral late stroke. Logistic regression showed that stroke events within 1 month after revascularization (odds ratio [OR], 9.79; 95% confidence interval [CI], 0.02-0.57; p = 0.0103), low revascularization score (OR, 0.15; 95% CI, 0.001-0.37; p = 0.0069), and high residual MMV score (OR, 16.2; 95% CI, 1.88-187.4; p = 0.0107) were risk factors for ipsilateral stroke more than 1 month after revascularization. CONCLUSIONS MMD patients who have a stroke within 1 month after cerebral revascularization are at high risk for late strokes. Less effective revascularization or remarkable residual MMV are risk factors for late stroke events. Additional revascularization may be considered for patients in such situations. CLINICAL TRIAL REGISTRATION This study was approved by the Bioethics Review Committee of Nagoya University Hospital for the treatment and prognosis of Moyamoya disease (2016-0327).
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Deckers PT, van Hoek W, Kronenburg A, Yaqub M, Siero JCW, Bhogal AA, van Berckel BNM, van der Zwan A, Braun KPJ. Contralateral improvement of cerebrovascular reactivity and TIA frequency after unilateral revascularization surgery in moyamoya vasculopathy. NEUROIMAGE-CLINICAL 2021; 30:102684. [PMID: 34215154 PMCID: PMC8102652 DOI: 10.1016/j.nicl.2021.102684] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/24/2021] [Accepted: 04/18/2021] [Indexed: 11/17/2022]
Abstract
Contralateral cerebrovascular reactivity may improve after unilateral surgery in moyamoya. TIA frequency from the contralateral hemisphere can decrease after unilateral moyamoya surgery. These findings support staged rather than direct bilateral surgery in moyamoya.
Objective Moyamoya vasculopathy is a rare, often bilateral disease characterized by progressive stenosis and occlusion of the distal internal carotid artery, leading to a progressive deterioration of cerebrovascular reactivity (CVR) and increased risk of transient ischemic attacks (TIAs), infarction and hemorrhage. Surgical revascularization is a widely accepted symptomatic treatment, often performed bilaterally in one or two stages. To possibly further optimize treatment strategy, we investigated the effect of unilateral revascularization surgery on the CVR of, and TIA frequency originating from, the contralateral hemisphere. Methods From our database of 143 moyamoya vasculopathy patients we selected those with bilateral disease, who underwent hemodynamic imaging ([15O]H2O positron emission tomography (PET)-CT with acetazolamide challenge) before and 14 months (median) after unilateral revascularization. We evaluated CVR in three regions per hemisphere, and averaged these per hemisphere for statistical comparison. Conservatively treated patients were showed as a comparison group. To examine TIA frequency, we selected patients who presented with TIAs that (also) originated from the contralateral – not to be operated – hemisphere. We scored changes in CVR and TIA frequency of the ipsilateral and contralateral hemisphere over time. Results Seven surgical and seven conservative patients were included for CVR comparison. Of the 20 scored contralateral regions in the surgical group, 15 showed improved CVR after unilateral revascularization, while 5 remained stable. The averaged scores improved significantly for both hemispheres. In conservatively treated patients, however, only 3 of the 20 scored regions improved in the least-affected (contralateral) hemispheres, and 9 deteriorated. From the 6 patients with contralateral TIAs at presentation, 4 had a decreased TIA frequency originating from the contralateral hemisphere after unilateral surgery, while 2 patients remained stable. Conclusion Both CVR and TIA frequency in the contralateral hemisphere can improve after unilateral revascularization surgery in bilateral MMV.
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Affiliation(s)
- Pieter T Deckers
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht, the Netherlands.
| | - Wytse van Hoek
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht, the Netherlands
| | - Annick Kronenburg
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht, the Netherlands
| | - Maqsood Yaqub
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Jeroen C W Siero
- Imaging Division, Department of Radiology, Utrecht Center for Image Sciences, University Medical Center Utrecht, Utrecht the Netherlands; Spinoza Centre for Neuroimaging, Amsterdam, the Netherlands
| | - Alex A Bhogal
- Imaging Division, Department of Radiology, Utrecht Center for Image Sciences, University Medical Center Utrecht, Utrecht the Netherlands
| | - Bart N M van Berckel
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Albert van der Zwan
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht, the Netherlands
| | - Kees P J Braun
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht, the Netherlands
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