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Muengtaweepongsa S, Panpattanakul V. Is medical management useful in Moyamoya disease? World J Clin Cases 2024; 12:466-473. [PMID: 38322475 PMCID: PMC10841962 DOI: 10.12998/wjcc.v12.i3.466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/24/2023] [Accepted: 01/05/2024] [Indexed: 01/18/2024] Open
Abstract
Moyamoya disease (MMD), characterized by progressive internal carotid artery stenosis and collateral vessel formation, prompts cerebral perfusion complications and is stratified into idiopathic and Moyamoya syndrome subtypes. A multifaceted approach toward MMD management addresses cerebral infarctions through revascularization surgery and adjunctive medical therapy, while also navigating risks such as intracranial hemorrhage and cerebral infarction resulting from arterial stenosis and fragile collateral vessels. Addressing antithrombotic management reveals a potential role for treatments like antiplatelet agents and anticoagulants, despite the ambiguous contribution of thrombosis to MMD-related infarctions and the critical balance between preventing ischemic events and averting hemorrhagic complications. Transcranial doppler has proven useful in thromboembolic detection, despite persisting challenges concerning the efficacy and safety of antithrombotic treatments. Furthermore, antihypertensive interventions aim to manage blood pressure meticulously, especially during intracerebral hemorrhage, with recommendations and protocols varying based on the patient's hypertension status. Additionally, lipid-lowering therapeutic strategies, particularly employing statins, are appraised for their possible beneficial role in MMD management, even as comprehensive data from disease-specific clinical trials remains elusive. Comprehensive guidelines and protocols to navigate the multifaceted therapeutic avenues for MMD, while maintaining a delicate balance between efficacy and safety, warrant further meticulous research and development. This protocol manuscript seeks to elucidate the various aspects and challenges imbued in managing and navigating through the complex landscape of MMD treatment.
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Affiliation(s)
- Sombat Muengtaweepongsa
- Center of Excellence in Stroke, Division of Neurology, Department of Medicine, Faculty of Medicine, Thammasat University, Rangsit Campus, Klonglaung 12120, Pathum Thani, Thailand
| | - Vatcharasorn Panpattanakul
- Division of Neurology, Department of Internal Medicine, School of Medicine, University of Phayao, Phayao 56000, Thailand
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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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Gao G, Liu SM, Hao FB, Wang QN, Wang XP, Wang MJ, Bao XY, Han C, Duan L. Factors Influencing Collateral Circulation Formation After Indirect Revascularization for Moyamoya Disease: a Narrative Review. Transl Stroke Res 2023:10.1007/s12975-023-01185-x. [PMID: 37592190 DOI: 10.1007/s12975-023-01185-x] [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: 06/29/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/19/2023]
Abstract
Indirect revascularization is one of the main techniques for the treatment of Moyamoya disease. The formation of good collateral circulation is a key measure to improve cerebral blood perfusion and reduce the risk of secondary stroke, and is the main method for evaluating the effect of indirect revascularization. Therefore, how to predict and promote the formation of collateral circulation before and after surgery is important for improving the success rate of indirect revascularization in Moyamoya disease. Previous studies have shown that vascular endothelial growth factor, endothelial progenitor cells, Caveolin-1, and other factors observed in patients with Moyamoya disease may play a key role in the generation of collateral vessels after indirect revascularization through endothelial hyperplasia and smooth muscle migration. In addition, mutations in the genetic factor RNF213 have also been associated with this process. This study summarizes the factors and mechanisms influencing collateral circulation formation after indirect revascularization in Moyamoya disease.
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Affiliation(s)
- Gan Gao
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China
| | - Si-Meng Liu
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China
| | - Fang-Bin Hao
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China
| | - Qian-Nan Wang
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China
| | - Xiao-Peng Wang
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China
| | - Min-Jie Wang
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China
| | - Xiang-Yang Bao
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China
| | - Cong Han
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China
| | - Lian Duan
- Department of Neurosurgery, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, 100071, Beijing, China.
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Yoo J, Jeon J, Baik M, Kim J. Association between statin therapy and the risk of stroke in patients with moyamoya disease: a nationwide cohort study. Stroke Vasc Neurol 2023; 8:276-283. [PMID: 36549762 PMCID: PMC10512045 DOI: 10.1136/svn-2022-001985] [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: 09/02/2022] [Accepted: 12/04/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Knowledge regarding the pharmacological treatment for moyamoya disease (MMD), a chronic and progressive cerebrovascular disease conferring greater stroke risk, is limited. In the present study, whether statin therapy is associated with a reduced risk of stroke in patients with MMD was investigated. METHODS This was a retrospective cohort study in which the occurrence of stroke in patients with newly diagnosed MMD was investigated using the nationwide health insurance database in Korea from January 2007 to March 2021. A multivariable Cox proportional hazards regression model was constructed for stroke, in which statin therapy after MMD diagnosis was treated as a time-dependent variable. Adjustment was done for sex, age, presence of comorbidities, concurrent stroke, revascularisation surgery and treatment with antiplatelets. RESULTS The present study included 13 373 newly diagnosed patients with MMD; 40.8% had a concurrent stroke at the time of MMD diagnosis. During the mean follow-up of 5.1±3.3 years, 631 patients (4.7%) suffered a stroke event (haemorrhagic stroke: 458 patients, ischaemic stroke: 173 patients). Statin therapy after MMD diagnosis was significantly associated with a reduced risk of stroke (adjusted HR 0.74; 95% CI 0.60 to 0.91, p=0.004). In the secondary outcome analysis, the risk of haemorrhagic stroke (adjusted HR 0.74; 95% CI 0.58 to 0.95, p=0.018) and ischaemic stroke (adjusted HR 0.75; 95% CI 0.52 to 1.08, p=0.124) were reduced with the statin treatment. Taking statins was also associated with a lower risk of all-cause mortality (adjusted HR 0.47; 95% CI 0.33 to 0.67, p<0.001). CONCLUSION In patients with MMD, statin therapy was associated with a reduced risk of subsequent stroke. The findings indicate statin treatment may be beneficial for patients with MMD, however the results should be confirmed in randomised controlled trials.
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Affiliation(s)
- Joonsang Yoo
- Department of Neurology, Yongin Severance Hospital, Yonsei College of Medicine, Yongin-si, Korea (the Republic of)
| | - Jimin Jeon
- Department of Neurology, Yongin Severance Hospital, Yonsei College of Medicine, Yongin-si, Korea (the Republic of)
| | - Minyoul Baik
- Department of Neurology, Yongin Severance Hospital, Yonsei College of Medicine, Yongin-si, Korea (the Republic of)
| | - Jinkwon Kim
- Department of Neurology, Yongin Severance Hospital, Yonsei College of Medicine, Yongin-si, Korea (the Republic of)
- Institute for Innovation in Digital Healthcare, Yonsei University, Seoul, Korea (the Republic of)
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Gao G, Wang QN, Hao FB, Wang XP, Liu SM, Wang MJ, Han C, Bao XY, Duan L. To explore the effectiveness of atorvastatin in the postoperative formation of collateral blood vessels after encephaloduroarteriosynangiosis in patients with moyamoya disease: a prospective double-blind randomized controlled study. Front Neurol 2023; 14:1169253. [PMID: 37332989 PMCID: PMC10270285 DOI: 10.3389/fneur.2023.1169253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/12/2023] [Indexed: 06/20/2023] Open
Abstract
Introduction The aim of this large, prospective, double-blind randomized controlled trial is to investigate the effect of atorvastatin on the formation of collateral blood vessels in patients after encephaloduroarteriosynangiosis (EDAS) and to provide a theoretical basis for clinical drug intervention. Specifically, we will determine whether atorvastatin has an effect on the development of collateral vascularization and on cerebral blood perfusion after revasculoplasty in patients with moyamoya disease (MMD). Methods and analysis Overall, 180 patients with moyamoya disease will be recruited and randomly assigned to the atorvastatin treatment group or the placebo control group in a 1:1 ratio. Before revascularization surgery, magnetic resonance imaging (MRI) scanning and digital subangiography (DSA) examination will be routinely performed on the enrolled patients. All patients will receive intervention via EDAS. According to the randomization results, patients in the experimental group will be treated with atorvastatin (20 mg/day, once a day, for 8 weeks) and patients in the control group will be treated with placebo (20 mg/day, once a day, for 8 weeks). All participants will return to the hospital for MRI scan and DSA examination 6 months after EDAS surgery. The primary outcome of this trial will be the difference in the formation of collateral blood vessels revealed by DSA examination at 6 months after EDAS surgery between the two groups. The secondary outcome will be an improvement in the dynamic susceptibility contrast sequence cerebral perfusion on MRI at 6 months after EDAS, compared to the preoperative baseline. Ethics and dissemination This study was approved by the Ethics Committee of the First Medical Center of the PLA General Hospital. All participates will voluntary provide written informed consent before participating in the trial. Clinical trial registration ClinicalTrials.gov, ChiCTR2200064976.
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Affiliation(s)
- Gan Gao
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Qian-Nan Wang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Fang-Bin Hao
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Xiao-Peng Wang
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Si-Meng Liu
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Min-Jie Wang
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Cong Han
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Xiang-Yang Bao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Lian Duan
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
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Dorschel KB, Wanebo JE. Physiological and pathophysiological mechanisms of the molecular and cellular biology of angiogenesis and inflammation in moyamoya angiopathy and related vascular diseases. Front Neurol 2023; 14:661611. [PMID: 37273690 PMCID: PMC10236939 DOI: 10.3389/fneur.2023.661611] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 01/16/2023] [Indexed: 06/06/2023] Open
Abstract
Rationale The etiology and pathophysiological mechanisms of moyamoya angiopathy (MMA) remain largely unknown. MMA is a progressive, occlusive cerebrovascular disorder characterized by recurrent ischemic and hemorrhagic strokes; with compensatory formation of an abnormal network of perforating blood vessels that creates a collateral circulation; and by aberrant angiogenesis at the base of the brain. Imbalance of angiogenic and vasculogenic mechanisms has been proposed as a potential cause of MMA. Moyamoya vessels suggest that aberrant angiogenic, arteriogenic, and vasculogenic processes may be involved in the pathophysiology of MMA. Circulating endothelial progenitor cells have been hypothesized to contribute to vascular remodeling in MMA. MMA is associated with increased expression of angiogenic factors and proinflammatory molecules. Systemic inflammation may be related to MMA pathogenesis. Objective This literature review describes the molecular mechanisms associated with cerebrovascular dysfunction, aberrant angiogenesis, and inflammation in MMA and related cerebrovascular diseases along with treatment strategies and future research perspectives. Methods and results References were identified through a systematic computerized search of the medical literature from January 1, 1983, through July 29, 2022, using the PubMed, EMBASE, BIOSIS Previews, CNKI, ISI web of science, and Medline databases and various combinations of the keywords "moyamoya," "angiogenesis," "anastomotic network," "molecular mechanism," "physiology," "pathophysiology," "pathogenesis," "biomarker," "genetics," "signaling pathway," "blood-brain barrier," "endothelial progenitor cells," "endothelial function," "inflammation," "intracranial hemorrhage," and "stroke." Relevant articles and supplemental basic science articles almost exclusively published in English were included. Review of the reference lists of relevant publications for additional sources resulted in 350 publications which met the study inclusion criteria. Detection of growth factors, chemokines, and cytokines in MMA patients suggests the hypothesis of aberrant angiogenesis being involved in MMA pathogenesis. It remains to be ascertained whether these findings are consequences of MMA or are etiological factors of MMA. Conclusions MMA is a heterogeneous disorder, comprising various genotypes and phenotypes, with a complex pathophysiology. Additional research may advance our understanding of the pathophysiology involved in aberrant angiogenesis, arterial stenosis, and the formation of moyamoya collaterals and anastomotic networks. Future research will benefit from researching molecular pathophysiologic mechanisms and the correlation of clinical and basic research results.
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Affiliation(s)
- Kirsten B. Dorschel
- Medical Faculty, Heidelberg University Medical School, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Germany
| | - John E. Wanebo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
- Department of Neuroscience, HonorHealth Research Institute, Scottsdale, AZ, United States
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Okazaki S, Yoshimoto T, Ohara M, Takagaki M, Nakamura H, Watanabe K, Gon Y, Todo K, Sasaki T, Araki H, Yamada T, Manabe S, Kishima H, Ihara M, Mochizuki H. Effect of the RNF213 p.R4810K Variant on the Progression of Intracranial Artery Stenosis: A 15-Year Follow-up Study. Neurol Genet 2022; 8:e200029. [PMID: 36324634 PMCID: PMC9621605 DOI: 10.1212/nxg.0000000000200029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/25/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND OBJECTIVES Intracranial artery stenosis is the predominant etiology of ischemic stroke in the Asian population. Furthermore, the presence of the RNF213 p.R4810K variant, which is a susceptibility gene for moyamoya disease, increases the risk of ischemic stroke attributable to large-artery atherosclerosis. Accordingly, we hypothesized that this genetic variant may affect the long-term outcome of intracranial artery stenosis in the East Asian population. We thus aimed to examine the effect of this variant on the long-term progression and prognosis of intracranial artery stenosis. METHODS Using a prospective database, we identified adult patients with intracranial artery stenosis who underwent periodic MRI examinations for >5 years. We evaluated stenosis progression using a validated visual grading system. We excluded patients diagnosed with moyamoya disease at the time of initial MRI. Genotyping of RNF213 p.R4810K was performed at the end of the follow-up period. RESULTS Among 52 eligible patients, 22 (42%) were carriers of the RNF213 p.R4810K variant. The median follow-up duration was 10.3 years. During the follow-up period, progression of intracranial artery stenosis was observed in 64% variant carriers and 27% noncarriers. There was a significant association of the variant with time to progression of intracranial artery stenosis (hazard ratio [HR] 3.31, 95% CI 1.38-7.90, p = 0.007), and time to the composite endpoint of symptomatic stroke and transient ischemic attack (HR 3.70, 95% CI 1.15-11.86, p = 0.028), but not to symptomatic stroke alone (HR 2.18, 95% CI 0.62-7.74, p = 0.23). Two variant carriers with progression were newly diagnosed with moyamoya disease. DISCUSSION Our findings indicated that the RNF213 p.R4810K variant increases the risk of intracranial artery stenosis progression.
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Ihara M, Yamamoto Y, Hattori Y, Liu W, Kobayashi H, Ishiyama H, Yoshimoto T, Miyawaki S, Clausen T, Bang OY, Steinberg GK, Tournier-Lasserve E, Koizumi A. Moyamoya disease: diagnosis and interventions. Lancet Neurol 2022; 21:747-758. [DOI: 10.1016/s1474-4422(22)00165-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 03/28/2022] [Accepted: 04/01/2022] [Indexed: 12/14/2022]
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Smith ER. Editorial. Growing research: how neurosurgeons can lead the development of nonsurgical treatments for moyamoya disease. Neurosurg Focus 2021; 51:E10. [PMID: 34469863 DOI: 10.3171/2021.6.focus21374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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