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Oakley CI, Lanzino G, Klaas JP. Neuropsychiatric Symptoms of Moyamoya Disease: Considerations for the Clinician. Neuropsychiatr Dis Treat 2024; 20:663-669. [PMID: 38532905 PMCID: PMC10964779 DOI: 10.2147/ndt.s440975] [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: 12/06/2023] [Accepted: 03/06/2024] [Indexed: 03/28/2024] Open
Abstract
Neurocognitive impairment in moyamoya disease is common, under recognized, and potentially devastating. The purpose of this paper is to provide an updated overview on this topic for the practicing clinician. We searched PubMed for keywords including cognitive impairment, neurocognitive dysfunction, and neuropsychological recovery in moyamoya disease. We summarized the literature to provide a concise review of the treatment and management of neuropsychiatric symptoms associated with moyamoya disease. Neuropsychiatric sequelae have conventionally been attributed to chronic cerebral hypoperfusion and/or stroke. Cognitive dysfunction in adults with moyamoya disease is most commonly in the form of impaired executive function, whereas intelligence is the predominant impairment in children with moyamoya disease. Pharmacotherapy for treatment of the neuropsychiatric symptoms associated with moyamoya disease is appropriate and can improve quality of life; however, careful consideration is needed to avoid adverse cerebrovascular events. It remains unclear as to whether surgical revascularization improves or stabilizes cognitive performance and outcomes. Additional prospective studies are warranted to better understand the long-term impact of revascularization on cognitive functioning in moyamoya disease.
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Affiliation(s)
| | | | - James P Klaas
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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Batista S, Koester S, Bishay AE, Bertani R, Oberman DZ, de Abreu LV, Bocanegra-Becerra JE, Amaral D, Isaacs AM, Dewan M, Figueiredo EG. Complications associated with combined direct and indirect bypass in Moyamoya Disease: A meta-analysis. Neurosurg Rev 2024; 47:58. [PMID: 38244093 DOI: 10.1007/s10143-024-02285-4] [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: 06/30/2023] [Revised: 12/10/2023] [Accepted: 01/06/2024] [Indexed: 01/22/2024]
Abstract
Bypass revascularization helps prevent complications in Moyamoya Disease (MMD). To systematically review complications associated with combined direct and indirect (CB) bypass in MMD and analyze differences between the adult and pediatric populations. A systematic literature review was conducted per PRISMA guidelines. PUBMED, Cochrane Library, Web of Science, and CINAHL, were queried from January 1980 to March 2022. Complications were defined as any event in the immediate post-surgical period of a minimum 3 months follow-up. Exclusion criteria included lack of surgical complication reports, non-English articles, and CB unspecified or reported separately. 18 final studies were included of 1580 procured. 1151 patients (per study range = 10-150, mean = 63.9) were analyzed. 9 (50.0%) studies included pediatric patients. There were 32 total hemorrhagic, 74 total ischemic and 16 total seizure complications, resulting in a rate of 0.04 (95% CI 0.03, 0.06), 0.7 (95% CI 0.04, 0.10) and 0.03 (95% CI 0.02, 0.05), respectively. The rate of hemorrhagic complications in the pediatric showed no significant difference from the adult subgroup (0.03 (95% CI 0.01-0.08) vs. 0.06 (95% CI 0.04-0.10, p = 0.19), such as the rate of ischemic complications (0.12 (95% CI 0.07-0.23) vs. 0.09 (95% CI 0.05-0.14, p = 0.40). Ischemia is the most common complication in CB for MMD. Pediatric patients had similar hemorrhagic and ischemic complication rates compared to adults.
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Affiliation(s)
- Sávio Batista
- School of Medicine, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373, Cidade Universitária, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-590, Brazil
| | | | | | - Raphael Bertani
- Department of Neurosurgery, University of São Paulo, São Paulo, Brazil
| | | | - Livia V de Abreu
- School of Medicine, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373, Cidade Universitária, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-590, Brazil.
| | | | - Dillan Amaral
- School of Medicine, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373, Cidade Universitária, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-590, Brazil
| | - Albert M Isaacs
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael Dewan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Yamao Y, Funaki T, Yamada H, Okawa M, Mineharu Y, Kikuchi T, Fushimi Y, Kataoka H, Yoshida K, Takahashi JC, Miyamoto S, Arakawa Y. "Transcallosal" periventricular anastomosis in moyamoya disease: the fourth periventricular anastomosis and a potential predictor of hemorrhage. J Stroke Cerebrovasc Dis 2023; 32:107428. [PMID: 37924782 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107428] [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: 07/04/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 11/06/2023] Open
Abstract
OBJECTIVES Choroidal anastomosis is a risk factor for hemorrhage in moyamoya disease. One variant of choroidal anastomosis, "transcallosal anastomosis," originates from the medial posterior choroidal artery, and penetrates the corpus callosum to reconstruct the pericallosal artery. We aimed to investigate the prevalence and the bleeding rate of transcallosal anastomosis using sliding thin-slab maximum intensity projection reformatted from magnetic resonance angiography (MRA). MATERIALS AND METHODS This study included 222 patients. We defined transcallosal anastomosis grades (0-2) and the stenosis of the anterior (ACA, 0-2), middle (MCA, 1-3), and posterior cerebral artery (PCA, 0-2) by MRA scores, independently by two coauthors. RESULTS Grade-2 transcallosal anastomosis was detected in 21 patients (9.5 %). There were no correlations of the incidence of transcallosal anastomosis with previous bypass surgery (P = 0.23). Multivariate analysis revealed a significantly higher incidence in hemorrhagic onset and younger age (odds ratio [OR] 3.77, and 0.97). Transcallosal anastomosis had statistically significant correlation with ACA and PCA scores (P = 0.01 and 0.03), but not with MCA scores (P = 0.1). In multivariate analysis, ACA scores 1 and 2 were significantly higher (OR, 15.44 and 11.17), and PCA score 1 was also higher (OR, 3.07), but PCA score 2 was not. Interrater agreement for judgment of transcallosal anastomosis grade was strong (κ = 0.89). Two patients with Grade-2 transcallosal anastomosis had late hemorrhage in the corpus callosum (bleeding rate: 2.5 % per year). CONCLUSIONS Transcallosal anastomosis may be associated with both advanced ACA and moderate PCA stenosis, and cause hemorrhage at the corpus callosum.
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Affiliation(s)
- Yukihiro Yamao
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Takeshi Funaki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroki Yamada
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masakazu Okawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yohei Mineharu
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takayuki Kikuchi
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasutaka Fushimi
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazumichi Yoshida
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Japan
| | - Jun C Takahashi
- Department of Neurosurgery, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan; Moyamoya Disease Support Center, Kyoto University Hospital, Kyoto, Japan; Stroke Support Center, Kyoto University Hospital, Kyoto, Japan
| | - Yoshiki Arakawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Ishii D, Maeda Y, Kuwabara M, Hosogai M, Kume S, Hara T, Kondo H, Horie N. Pulsatility index of superficial temporal artery was associated with cerebral infarction after direct bypass surgery for moyamoya disease. J Stroke Cerebrovasc Dis 2023; 32:107346. [PMID: 37708702 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107346] [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: 08/21/2023] [Revised: 09/03/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVE Direct bypass surgery by superficial temporal artery (STA) - middle cerebral artery anastomosis is an established procedure for moyamoya disease (MMD). However, some patients may develop cerebral infarction (CI) due to the watershed shift phenomenon after the surgery. This study sought to investigate the correlation between the postoperative changes of STA flow as well as cerebral blood flow (CBF) and the incidence of CI after direct bypass surgery for MMD. METHODS We conducted a retrospective study of 62 hemispheres in 50 subjects who underwent direct bypass surgery for MMD. All subjects underwent pre- and post-operative MR imaging, ultrasound evaluation of STA, and single-photon emission computed tomography. The presence of CI was correlated with preoperative CBF, the delta difference of each value of the STA between before and after the surgery, and the postoperative increase ratio of CBF. RESULTS All bypass procedures were patent, and CI was observed in 4 cases (6.4%). There was no significant association between the incidence of CI and both pre- and post-operative CBF. However, there was a significant difference in delta pulsatility index (PI) of the STA between cases with or without CI (-0.38±0.22 and -0.87±0.63, respectively, p=0.03). Whereas, other factors did not show any significant differences between those with or without CI. CONCLUSIONS A relatively high postoperative PI of the STA was significantly associated with the incidence of CI after direct bypass surgery for MMD. A larger study is needed to confirm these findings.
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Affiliation(s)
- Daizo Ishii
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Yuyo Maeda
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masashi Kuwabara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masahiro Hosogai
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinji Kume
- Department of Clinical Laboratory, Hiroshima University Hospital, Hiroshima, Japan
| | - Takeshi Hara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroshi Kondo
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Maeda Y, Okazaki T, Kume S, Kawano R, Takauchi K, Hara T, Kuwabara M, Hiroshi K, Daizo I, Horie N. Flow volume mismatch dramatically affects transient neurologic symptoms after direct bypass in Moyamoya disease. Neurosurg Rev 2023; 46:274. [PMID: 37847310 DOI: 10.1007/s10143-023-02181-3] [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: 06/12/2023] [Revised: 09/21/2023] [Accepted: 10/05/2023] [Indexed: 10/18/2023]
Abstract
Transient neurological events (TNEs) occur after bypass surgery in Moyamoya disease (MMD); however, their pathology remains unknown. To elucidate the pathophysiology of TNEs, we investigated their relationship with perioperative superficial temporal artery (STA) blood flow volume, which was evaluated using ultrasonography. Forty-nine patients with MMD, who underwent direct bypass surgery, were included and stratified into TNE and non-TNE groups, respectively. The STA blood flow volume was evaluated at four time points (preoperatively and 2-4, 7, and 10-14 days postoperatively), and a change in volume during the postoperative period was defined as a flow volume mismatch. We investigated the association between ultrasonographic findings of flow volume mismatch and TNEs and magnetic resonance imaging findings, such as the cortical hyperintensity belt (CHB) sign, using univariate and path analyses. The STA blood flow volume increased immediately postoperatively, gradually decreasing over time, in both groups. The TNE group showed a significant increase in blood flow volume 2-4 days postoperatively (P = 0.042). Flow volume mismatch was significantly larger in the TNE group than in the non-TNE group (P = 0.020). In the path analysis, STA flow volume mismatch showed a positive association with the CHB sign (P = 0.023) and TNEs (P = 0.000). Additionally, the CHB sign partially mediated the association between STA flow volume mismatch and TNEs. These results suggest that significantly high STA blood flow volume changes occurring during the acute postoperative period after direct bypass surgery in MMD are correlated with TNEs and the CHB sign, suggesting involvement in the pathophysiology of TNEs.
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Affiliation(s)
- Yuyo Maeda
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima, 734-8551, Japan.
| | - Takahito Okazaki
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Shinji Kume
- Department of Clinical Laboratory, Hiroshima University Hospital, Hiroshima, Japan
| | - Reo Kawano
- Innovation Center for Translational Research, National Center for Geriatrics and Gerontology, Aichi, Japan
| | - Komei Takauchi
- Department of Radiology, Hiroshima University Hospital, Hiroshima, Japan
| | - Takeshi Hara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Masashi Kuwabara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Kondo Hiroshi
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Ishii Daizo
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima, 734-8551, Japan
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Kuroda S, Yamamoto S, Funaki T, Fujimura M, Kataoka H, Hishikawa T, Takahashi J, Endo H, Nariai T, Osato T, Saito N, Sato N, Hori E, Ito YM, Miyamoto S. Five-Year Stroke Risk and Its Predictors in Asymptomatic Moyamoya Disease: Asymptomatic Moyamoya Registry (AMORE). Stroke 2023; 54:1494-1504. [PMID: 37216455 DOI: 10.1161/strokeaha.122.041932] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 03/30/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Long-term outcomes are unknown in patients with asymptomatic moyamoya disease. In this report, we aimed to clarify their 5-year risk of stroke and its predictors. METHODS We are conducting a multicenter, prospective cohort study (Asymptomatic Moyamoya Registry) in Japan. Participants were eligible if they were 20 to 70 years, had bilateral or unilateral moyamoya disease, experienced no episodes suggestive of TIA and stroke; and were functionally independent (modified Rankin Scale score 0-1). Demographic and radiological information was collected at enrollment. In this study, they are still followed up for 10 years. In this interim analysis, we defined the primary end point as a stroke occurring during a 5-year follow-up period. Independent predictors for stroke were also determined, using a stratification analysis method. RESULTS Between 2012 and 2015, we enrolled 109 patients, of whom 103 patients with 182 involved hemispheres completed the 5-year follow-up. According to the findings on DSA and MRA, 143 hemispheres were judged as moyamoya disease and 39 hemispheres as questionable manifestations (isolated middle cerebral artery stenosis). The patients with questionable hemispheres were significantly older, more often male, and more frequently had hypertension than those with moyamoya hemisphere. Moyamoya hemispheres developed 7 strokes, including 6 hemorrhagic and 1 ischemic stroke, during the first 5 years. The annual risk of stroke was 1.4% per person, 0.8% per hemisphere, and 1.0% per moyamoya hemisphere. Independent predictor for stroke was Grade-2 choroidal anastomosis (hazard ratio, 5.05 [95% CI, 1.24-20.6]; P=0.023). Furthermore, microbleeds (hazard ratio, 4.89 [95% CI, 1.13-21.3]; P=0.0342) and Grade-2 choroidal anastomosis (hazard ratio, 7.05 [95% CI, 1.62-30.7]; P=0.0093) significantly predicted hemorrhagic stroke. No questionable hemispheres developed any stroke. CONCLUSIONS The hemispheres with asymptomatic moyamoya disease may carry a 1.0% annual risk of stroke during the first 5 years, the majority of which are hemorrhagic stroke. Grade-2 choroidal anastomosis may predict stroke, and the microbleeds and Grade-2 choroidal anastomosis may carry the risk for hemorrhagic stroke. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: UMIN000006640.
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Affiliation(s)
- Satoshi Kuroda
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan (S.K., S.Y., E.H.)
| | - Shusuke Yamamoto
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan (S.K., S.Y., E.H.)
| | - Takeshi Funaki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan (T.F., S.M.)
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan (M.F.)
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan (H.K.)
| | - Tomohito Hishikawa
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Japan (T.H.)
| | - Jun Takahashi
- Department of Neurosurgery, Kindai University School of Medicine, Sayama, Japan (J.T.)
| | - Hidenori Endo
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan (H.E.)
| | - Tadashi Nariai
- Department of Neurosurgery, Tokyo Medical and Dental University, Japan (T.N.)
| | - Toshiaki Osato
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan (T.O.)
| | - Nobuhito Saito
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Japan (N. Saito)
| | - Norihiro Sato
- Clinical Research and Medical Innovation Center (N. Sato), Hokkaido University Hospital, Sapporo, Japan
| | - Emiko Hori
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan (S.K., S.Y., E.H.)
| | - Yoichi M Ito
- Data Science Center, Promotion Unit, Institute of Health Science Innovation for Medical Care (Y.M.I.), Hokkaido University Hospital, Sapporo, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan (T.F., S.M.)
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Fujioka M, Hara S, Mukawa M, Karakama J, Inaji M, Tanaka Y, Nariai T, Maehara T. Changes in the clinical spectrum of pediatric moyamoya disease over 40 years. Childs Nerv Syst 2023; 39:1215-1223. [PMID: 36790492 DOI: 10.1007/s00381-023-05852-0] [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: 06/09/2022] [Accepted: 01/14/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE To investigate the chronological changes in the clinical presentation and long-term prognosis of pediatric-onset moyamoya disease in our institute over 40 years. METHODS We evaluated 282 pediatric-onset (≤ 15 years old) moyamoya disease patients who visited our institute from 1981 to 2020 (divided into the former period, 1981-2000, and the latter period, 2001-2020). Differences in the clinical presentation and the long-term outcome were compared between the periods. Multivariate analysis was also performed to reveal the risk factors for poor long-term outcomes. RESULTS Compared to the former period, the total number of patients, the onset age and both the number of patients with family history and relatively older patients without symptoms or with headache were greater in the latter period (p < 0.05). The number of patients with poor long-term outcomes was significantly lower in the latter period (24.9% vs. 6.7%, p < 0.01). Multivariate analysis revealed that stroke onset, late cerebrovascular events and postoperative complications were independent risk factors for poor long-term outcomes (odds ratio = 31.4, 40.8 and 5.4, respectively). CONCLUSIONS Over the last 40 years, the number of pediatric moyamoya disease patients has increased, especially in relatively older patients with mild presentation and favorable long-term outcomes. In clinical studies, these chronological changes and the inclusion period of the participants need to be accounted for. Whether the increased diagnostic rate in the recent era has led to a decrease in late cerebrovascular events and favorable outcomes throughout life remains unknown and should be evaluated in the future.
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Affiliation(s)
- Mai Fujioka
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shoko Hara
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Maki Mukawa
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Jun Karakama
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Motoki Inaji
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoji Tanaka
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tadashi Nariai
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Taketoshi Maehara
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
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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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9
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Kronenburg A, Deckers PT, van den Berg E, van Schooneveld MM, Vonken EJ, van der Zwan A, van Berckel BNM, Yaqub M, Otte W, Klijn CJM, Braun KPJ. The profile of cognitive impairment and hemodynamic compromise in moyamoya: a single-center prospective cohort study. J Neurosurg 2023; 138:173-184. [PMID: 35523260 DOI: 10.3171/2022.3.jns212844] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/16/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Patients with moyamoya vasculopathy often experience cognitive impairments. In this prospective single-center study, the authors investigated the profile of neurocognitive impairment and its relation with the severity of ischemic brain lesions and hemodynamic compromise. METHODS Patients treated in a Dutch tertiary referral center were prospectively included. All patients underwent standardized neuropsychological evaluation, MRI, digital subtraction angiography, and [15O]H2O-PET (to measure cerebrovascular reactivity [CVR]). The authors determined z-scores for 7 cognitive domains and the proportion of patients with cognitive impairment (z-score < -1.5 SD in at least one domain). The authors explored associations between patient characteristics, imaging and CVR findings, and cognitive scores per domain by using multivariable linear regression and Bayesian regression analysis. RESULTS A total of 40 patients (22 children; 75% females) were included. The median age for children was 9 years (range 1-16 years); for adults it was 39 years (range 19-53 years). Thirty patients (75%) had an infarction, and 31 patients (78%) had impaired CVR (steal phenomenon). Six of 7 cognitive domains scored below the population norm. Twenty-nine patients (73%) had cognitive impairment. Adults performed better than children in the cognitive domain visuospatial functioning (p = 0.033, Bayes factor = 4.0), and children performed better in processing speed (p = 0.041, Bayes factor = 3.5). The authors did not find an association between infarction, white matter disease, or CVR and cognitive domains. CONCLUSIONS In this Western cohort, cognitive functioning in patients with moyamoya vasculopathy was below the population norm, and 73% had cognitive impairment in at least one domain. The cognitive profile differed between adults and children. The authors could not find an association with imaging findings.
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Affiliation(s)
- Annick Kronenburg
- 1Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht
| | - Pieter T Deckers
- 1Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht
| | | | | | | | - Albert van der Zwan
- 1Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht
| | | | - Maqsood Yaqub
- 5Department of Nuclear Medicine & PET Research, Amsterdam UMC, Amsterdam
| | - Willem Otte
- 6Department of Pediatric Neurology, UMC Utrecht Brain Center, Utrecht; and
| | - Catharina J M Klijn
- 1Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht
- 7Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Center for Neuroscience, Radboud UMC, Nijmegen, The Netherlands
| | - Kees P J Braun
- 1Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht
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10
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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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11
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Silva AHD, Bhate S, Ganesan V, Thompson D, James G. Surgical revascularization for pediatric moyamoya: the role of surgical mentorship in sustaining and developing a neurovascular service. J Neurosurg Pediatr 2022; 30:89-98. [PMID: 36303484 DOI: 10.3171/2022.3.peds21590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 03/31/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Obtaining operative experience for the treatment of rare conditions in children represents a challenge for pediatric neurosurgeons. Starting in November 2017, a surgeon was mentored in surgical revascularization (SR) for pediatric moyamoya with a view to service development and sustainability. The aim of this audit was to evaluate early outcomes of SR for pediatric moyamoya during and following a surgical mentorship. METHODS A retrospective cohort study with chart/database review of consecutive moyamoya surgeries performed by a new attending surgeon (between November 2017 and March 2020) was compared to a previously published cohort from the authors' institution in terms of clinical and angiographic outcomes, complications, operating time, and length of stay. A standardized technique of encephaloduroarteriomyosynangiosis with the superficial temporal artery was used. RESULTS Twenty-two children underwent 36 indirect SRs during the study period. Patient demographics were similar between cohorts. The first group of 6 patients had 11 SRs performed jointly by the new attending surgeon mentored by an established senior surgeon (group A), followed by 10 patients with 16 SRs performed independently by the new attending surgeon (group B). The last 6 patients had 9 SRs with the new attending surgeon mentoring a senior fellow (group C) in performing SR. Good angiographic collateralization (Matsushima grades A and B) was observed in 80% of patients, with similar proportions across all 3 groups. A total of 18/19 symptomatic patients (95%) derived symptomatic benefit. There was no perioperative death and, compared to the historical cohort, a similar proportion had a recurrent arterial ischemic event (i.e., acute ischemic stroke) necessitating a second SR (1/22 vs 3/73). Operative times were longest in group C, with no difference in length of hospital stay among the 3 groups. CONCLUSIONS Early outcomes demonstrate the feasibility of mentorship for safely incorporating new neurosurgeons in sustaining and developing a tertiary-level surgical service.
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Affiliation(s)
- Adikarige Haritha Dulanka Silva
- 1Department of Neurosurgery, Great Ormond Street Hospital for Children NHS Foundation Trust.,3Great Ormond Street Institute of Child Health, University College London, United Kingdom
| | - Sanjay Bhate
- 2Department of Paediatric Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust; and.,3Great Ormond Street Institute of Child Health, University College London, United Kingdom
| | - Vijeya Ganesan
- 2Department of Paediatric Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust; and.,3Great Ormond Street Institute of Child Health, University College London, United Kingdom
| | - Dominic Thompson
- 1Department of Neurosurgery, Great Ormond Street Hospital for Children NHS Foundation Trust.,3Great Ormond Street Institute of Child Health, University College London, United Kingdom
| | - Greg James
- 1Department of Neurosurgery, Great Ormond Street Hospital for Children NHS Foundation Trust.,3Great Ormond Street Institute of Child Health, University College London, United Kingdom
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12
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Kusano Y, Funaki T, Ueda K, Nishida N, Tanaka K, Miyamoto S, Matsuda S. Characterizing the neurocognitive profiles of children with moyamoya disease using the Das Naglieri cognitive assessment system. Sci Rep 2022; 12:3638. [PMID: 35256691 PMCID: PMC8901907 DOI: 10.1038/s41598-022-07699-y] [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: 09/16/2021] [Accepted: 02/23/2022] [Indexed: 11/10/2022] Open
Abstract
Although cognitive impairment is well-documented in children with moyamoya disease (MMD), selective decline in specific neurocognitive domains remains controversial. The purpose of this study was to characterize the neurocognitive profile of children with MMD using the Das Naglieri Cognitive Assessment System (CAS) and the Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV). We analyzed the neurocognitive data of 30 children (median age, 7 years) with MMD who were assessed with the CAS and the WISC-IV before surgery. We focused on the comparison of standard scores and intraindividual differences across domains. The CAS scores significantly varied across four measures (standard scores, p < 0.001; intraindividual differences, p < 0.001). Post-hoc analyses revealed that the standard scores and intraindividual differences for successive processing were significantly lower than those for planning and attention. The WISC-IV scores did not significantly vary among the four measures, although the working memory index was the lowest among the four measures. The within-individual weakness in successive processing, a form of working memory function, may be a distinct characteristic of children with MMD. The CAS may be more sensitive than the WISC-IV for detecting this selective neurocognitive weakness in children with MMD.
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Affiliation(s)
- Yusuke Kusano
- Advanced Occupational Therapy, Department of Human Health Sciences, Kyoto University Graduate School of Medicine, 53 Kawahara-cho Syogoin Sakyo-ku, Kyoto, Japan. .,Rehabilitation Unit, Kyoto University Hospital, 54 Kawahara-cho Syogoin Sakyo-ku, Kyoto, Japan.
| | - Takeshi Funaki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Keita Ueda
- Department of Psychiatry, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Faculty of Health Sciences, Department of Medical Welfare, Kyoto Koka Women's University, Kyoto, Japan
| | - Noyuri Nishida
- Rehabilitation Unit, Kyoto University Hospital, 54 Kawahara-cho Syogoin Sakyo-ku, Kyoto, Japan
| | - Kanade Tanaka
- Rehabilitation Unit, Kyoto University Hospital, 54 Kawahara-cho Syogoin Sakyo-ku, Kyoto, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shuichi Matsuda
- Rehabilitation Unit, Kyoto University Hospital, 54 Kawahara-cho Syogoin Sakyo-ku, Kyoto, Japan.,Department of Orthopedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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13
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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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14
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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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15
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Araki Y, Uda K, Yokoyama K, Kanamori F, Kurimoto M, Shiba Y, Mamiya T, Nishihori M, Takeuchi K, Tanahashi K, Nagata Y, Nishimura Y, Okamoto S, Sumitomo M, Izumi T, Saito R. Challenging direct bypass surgery for very young children with moyamoya disease: technical notes. Neurosurg Rev 2021; 45:1799-1807. [PMID: 34718925 DOI: 10.1007/s10143-021-01685-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/21/2021] [Accepted: 10/26/2021] [Indexed: 11/27/2022]
Abstract
Cerebral revascularization for moyamoya disease (MMD) is an effective treatment for improving cerebral ischaemia and preventing rebleeding. Although direct bypass surgery is commonly performed on older children and adults, it is challenging in very young children due to the high difficulty level of the procedure. The subjects were MMD patients under 3 years of age on whom surgery was performed by a single surgeon (Y.A.). Preoperative clinical findings, information related to direct bypass surgery, bypass patency, and the incidence of postoperative stroke were investigated. Combined revascularization, including direct bypass surgery, was performed on 3 MMD patients (3 sides) under 3 years of age. The average diameter of the grafts used in direct bypass was 0.8 mm. The average recipient diameter was 0.8 ± 0.17 (range 0.6-1) mm. In all cases, the anastomotic procedure was completed using 11-0 monofilament nylon thread, and patency was confirmed. Direct bypass for MMD patients under 3 years old is technically challenging. However, despite the anatomical differences between very young children and elderly individuals, direct bypass surgery could certainly be completed. In addition, a rapid recovery from cerebral blood flow insufficiency could yield a promising neurological outcome.
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Affiliation(s)
- Yoshio Araki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, Japan.
| | - Kenji Uda
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, Japan
| | - Kinya Yokoyama
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, Japan
| | - Fumiaki Kanamori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, Japan
| | - Michihiro Kurimoto
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, Japan
| | - Yoshiki Shiba
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, Japan
| | - Takashi Mamiya
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, Japan
| | - Masahiro Nishihori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, Japan
| | - Kazuhito Takeuchi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, Japan
| | - Kuniaki Tanahashi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, Japan
| | - Yuichi Nagata
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, Japan
| | - Yusuke Nishimura
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, Japan
| | - Sho Okamoto
- Aichi Rehabilitation Hospital, 1-1 Nishigara, Ehara Town, Nishio City, Aichi, Japan
| | - Masaki Sumitomo
- Department of Neurosurgery, Toyota Kosei Hospital, 500-1 Ibobara, Josui-cho, Toyota City, Aichi, Japan
| | - Takashi Izumi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Aichi, Japan
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16
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Kawanami K, Kokubo Y, Sato S, Itagaki H, Sonoda Y. A case report: An increased oxygen extraction fraction in remote ischemic lesions after revascularization for moyamoya disease with a progression of posterior cerebral artery stenosis. Acta Radiol Open 2021; 10:20584601211047241. [PMID: 34603748 PMCID: PMC8485292 DOI: 10.1177/20584601211047241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/30/2021] [Indexed: 11/16/2022] Open
Abstract
The cerebral metabolism, such as the oxygen extraction fraction (OEF), in remote ischemic lesions following revascularization for moyamoya disease (MMD) has not yet been fully elucidated. We herein report a patient with an increased OEF in a remote ischemic lesion after revascularization in a case of adult-onset MMD. A 21-year-old woman suffered from a left parietal lobe infarction due to MMD. At 2 months after onset, left superficial temporal artery (STA)–middle cerebral artery (MCA) bypass and encephalo-myo-synangiosis (EMS) were performed. The postoperative course was uneventful. 15O-positron emission tomography (PET) performed at 2 months after the first operation revealed an increased OEF in the contralateral (right) frontal lobe that was suspected of being possible remote ischemia. The patient underwent right STA-MCA bypass and EMS. 15O-PET at 14 days after the second operation revealed an increased OEF in the contralateral (left) occipital lobe that was suspected of potentially being remote ischemia caused by a watershed shift. Two years after the second surgery, left occipital artery (OA)–posterior cerebral artery (PCA) anastomosis and EMS were performed due to transient right hemianopsia. Neither rebleeding nor ischemic complications occurred 2 years after the third surgery. We need to be alert for the possible progression of PCA stenosis in MMD after revascularization. It might induce remote ischemia after revascularization. OA–PCA bypass is therefore considered to be an effective treatment option in such cases.
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Affiliation(s)
- Kanako Kawanami
- Department of Neurosurgery, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Yasuaki Kokubo
- Department of Neurosurgery, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Shinji Sato
- Department of Neurosurgery, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Hiroshi Itagaki
- Department of Neurosurgery, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Yukihiko Sonoda
- Department of Neurosurgery, Faculty of Medicine, Yamagata University, Yamagata, Japan
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Hirano Y, Miyawaki S, Imai H, Hongo H, Teranishi Y, Dofuku S, Ishigami D, Ohara K, Koizumi S, Ono H, Nakatomi H, Saito N. Differences in Clinical Features among Different Onset Patterns in Moyamoya Disease. J Clin Med 2021; 10:jcm10132815. [PMID: 34202349 PMCID: PMC8267932 DOI: 10.3390/jcm10132815] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 12/02/2022] Open
Abstract
Moyamoya disease is characterized by severe stenosis at the ends of the bilateral internal carotid arteries and the development of collateral circulation. The disease is very diverse in terms of age at onset, onset patterns, radiological findings, and genetic phenotypes. The pattern of onset is mainly divided into ischemic and hemorrhagic onsets. Recently, the opportunity to identify asymptomatic moyamoya disease, which sometimes manifests as nonspecific symptoms such as headache and dizziness, through screening with magnetic resonance imaging has been increasing. Various recent reports have investigated the associations between the clinical features of different onset patterns of moyamoya disease and the corresponding imaging characteristics. In this article, we have reviewed the natural history, clinical features, and imaging features of each onset pattern of moyamoya disease.
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Affiliation(s)
- Yudai Hirano
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
- Department of Neurosurgery, Fuji Brain Institute and Hospital Fujinomiya, Shizuoka 418-0021, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
- Correspondence: ; Tel.: +81-35-800-8853
| | - Hideaki Imai
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
- Department of Neurosurgery, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Shinjuku-ku, Tokyo 162-8543, Japan
| | - Hiroki Hongo
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
| | - Yu Teranishi
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
| | - Shogo Dofuku
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
| | - Daiichiro Ishigami
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
| | - Kenta Ohara
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
| | - Satoshi Koizumi
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
| | - Hideaki Ono
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
- Department of Neurosurgery, Fuji Brain Institute and Hospital Fujinomiya, Shizuoka 418-0021, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
- Department of Neurosurgery, Kyorin University Hospital, Mitaka, Tokyo 181-8611, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; (Y.H.); (H.I.); (H.H.); (Y.T.); (S.D.); (D.I.); (K.O.); (S.K.); (H.O.); (H.N.); (N.S.)
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18
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Hayashi T, Kimiwada T, Karibe H, Shirane R, Sasaki T, Metoki H, Tominaga T. Preoperative Risks of Cerebral Infarction in Pediatric Moyamoya Disease. Stroke 2021; 52:2302-2310. [PMID: 33971740 DOI: 10.1161/strokeaha.120.032699] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Toshiaki Hayashi
- Department of Neurosurgery, Miyagi Children's Hospital, Sendai, Japan (T.H., T.K., R.S.)
| | - Tomomi Kimiwada
- Department of Neurosurgery, Miyagi Children's Hospital, Sendai, Japan (T.H., T.K., R.S.)
| | - Hiroshi Karibe
- Department of Neurosurgery, Sendai City Hospital, Japan (H.K.)
| | - Reizo Shirane
- Department of Neurosurgery, Miyagi Children's Hospital, Sendai, Japan (T.H., T.K., R.S.)
| | - Tatsuya Sasaki
- Department of Neurosurgery (T.S.), Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Hirohito Metoki
- Division of Public Health, Hygiene and Epidemiology (H.M.), Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan (T.T.)
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19
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Iwaki K, Takagishi S, Arimura K, Murata M, Chiba T, Nishimura A, Ren N, Iihara K. A Novel Hyperspectral Imaging System for Intraoperative Prediction of Cerebral Hyperperfusion Syndrome after Superficial Temporal Artery-Middle Cerebral Artery Anastomosis in Patients with Moyamoya Disease. Cerebrovasc Dis 2021; 50:208-215. [PMID: 33596563 DOI: 10.1159/000513289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/15/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Postoperative cerebral hyperperfusion syndrome (CHS) may occur after superficial temporal artery (STA)-middle cerebral artery (MCA) bypass for moyamoya disease (MMD). Predicting postoperative CHS is challenging; however, we previously reported the feasibility of using a hyperspectral camera (HSC) for monitoring intraoperative changes in brain surface hemodynamics during STA-MCA bypass. OBJECTIVE To investigate the utility of HSC to predict postoperative CHS during STA-MCA bypass for patients with MMD. METHODS Hyperspectral images of the cerebral cortex of 29 patients with MMD who underwent STA-MCA bypass were acquired by using an HSC before and after anastomosis. We then analyzed the changes in oxygen saturation after anastomosis and assessed its correlation with CHS. RESULTS Five patients experienced transient neurological deterioration several days after surgery. 123I-N-Isopropyl-iodoamphetamine single-photon emission computed tomography scan results revealed an intense, focal increase in cerebral blood flow at the site of anastomosis without any cerebral infarction. Patients with CHS showed significantly increased oxygen saturation (SO2) in the cerebral cortex after anastomosis relative to those without CHS (33 ± 28 vs. 8 ± 14%, p < 0.0001). Receiver operating characteristic analysis results show that postoperative CHS likely occurs when the increase rate of cortical SO2 value is >15% (sensitivity, 85.0%; specificity, 81.3%; area under curve, 0.871). CONCLUSIONS This study indicates that hyperspectral imaging of the cerebral cortex may be used to predict postoperative CHS in patients with MMD undergoing STA-MCA bypass.
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Affiliation(s)
- Katsuma Iwaki
- Department of Neurosurgery, Kyushu University, Fukuoka, Japan
| | - Soh Takagishi
- Department of Neurosurgery, Kyushu University, Fukuoka, Japan
| | - Koichi Arimura
- Department of Neurosurgery, Kyushu University, Fukuoka, Japan,
| | - Masaharu Murata
- Center for Advanced Medical Innovation, Kyushu University, Fukuoka, Japan.,Department of Advanced Medical Initiatives, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toru Chiba
- PENTAX Lifecare Division Medical Instrument SBU, HOYA Corporation, Tokyo, Japan
| | - Ataru Nishimura
- Department of Neurosurgery, Kyushu University, Fukuoka, Japan
| | - Nice Ren
- Department of Neurosurgery, Kyushu University, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Kyushu University, Fukuoka, Japan
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20
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Saito H, Kashiwazaki D, Uchino H, Yamamoto S, Houkin K, Kuroda S. Specific clinical features and one-stage revascularization surgery for moyamoya disease with severe cerebral ischemia in the territory of posterior cerebral artery. Acta Neurochir (Wien) 2021; 163:583-592. [PMID: 32929541 DOI: 10.1007/s00701-020-04580-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There are no reports describing the surgical procedure for moyamoya disease (MMD) patients with severe cerebral ischemia in the territory of the posterior cerebral artery (PCA) at initial presentation. In this study, therefore, we describe their clinical and radiological features and clinical results of one-stage revascularization surgery for both anterior and posterior circulation. METHODS This study included 6 MMD patients who had severe cerebral ischemia in the PCA territory and underwent one-stage revascularization surgery for both anterior and posterior circulation. Of these, one patient underwent it on both sides. Their clinical and radiological data were precisely analyzed. Compared with usual procedure, craniotomy was extended towards the temporo-parietal area more widely. The parietal branch of superficial temporal artery (STA) was anastomosed to the angular or posterior temporal artery, while the frontal branch was anastomosed to the frontal branch of MCA. Ultimate indirect bypass was added. Their clinical and radiological outcomes were evaluated. RESULTS Their neurological symptoms included visual and speech disturbance as well as numbness of the extremities. Cerebral infarct was distributed in the posterior temporal, parietal, and/or occipital lobe. Cerebral hemodynamics and metabolism were also impaired in the same regions. These findings were completely different from those in MMD patients without PCA lesion. Postoperative course was uneventful, and none of them recurred stroke during a mean follow-up period of 10.5 years. Surgical collaterals widely provided blood flow to the entire hemispheres, including the occipital lobe. Cerebral hemodynamics and metabolism markedly improved after surgery. CONCLUSION One-stage revascularization surgery for both anterior and posterior circulation is feasible and effective to prevent future stroke in MMD patients with severe cerebral ischemia in the PCA territory at initial presentation.
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21
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Nakamura A, Kawashima A, Andrade-Barazarte H, Funatsu T, Hernesniemi J, Kawamata T. Occipital artery to middle cerebral artery bypass in pediatric moyamoya disease: rescue therapy after failed revascularization. J Neurosurg Pediatr 2021; 27:429-436. [PMID: 33450732 DOI: 10.3171/2020.8.peds20424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients with pediatric moyamoya disease (PMMD) showing recurrent symptoms or decreased cerebral blood flow after initial revascularization therapy may require additional revascularization to improve their clinical condition. The authors evaluated the clinical and hemodynamic benefits of an occipital artery (OA)-middle cerebral artery (MCA) bypass for patients with PMMD who have undergone an initial revascularization procedure. METHODS The authors retrospectively identified 9 patients with PMMD who had undergone OA-MCA bypass between March 2013 and December 2017, and who had received a previous superficial temporal artery-MCA bypass. The following clinical data were collected: initial revascularization procedure, symptoms (presence or recurrence), pre- and postoperative cerebral blood flow and cerebrovascular reactivity (CVR) changes, posterior cerebral artery (PCA) stenosis, PCA-related and nonrelated symptoms, and latest follow-up. RESULTS Preoperatively, all patients (n = 9) suffered non-PCA-related recurrent symptoms, and 4 had PCA-related symptoms. At 1-year follow-up, all patients with PCA-related symptoms showed complete recovery. Additionally, 8 (89%) patients with non-PCA symptoms experienced improvement. Only 1 (11%) patient showed no improvement after the surgical procedure. The mean pre- and postoperative CVR values of the MCA territory were 14.8% and 31.3%, respectively, whereas the respective mean CVR values of the PCA territory were 22.8% and 40.0%. CONCLUSIONS The OA-MCA bypass is an effective rescue therapy to improve the clinical condition and hemodynamic changes caused by PMMD in patients who experience recurrent symptoms after initial revascularization.
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Affiliation(s)
- Akikazu Nakamura
- 1Department of Neurosurgery, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba, Japan
| | - Akitsugu Kawashima
- 1Department of Neurosurgery, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba, Japan
| | - Hugo Andrade-Barazarte
- 2Department of Neurosurgery, Juha Hernesniemi International Center for Neurosurgery, Henan People's Provincial Hospital, University of Zhengzhou, China; and
| | - Takayuki Funatsu
- 3Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Juha Hernesniemi
- 2Department of Neurosurgery, Juha Hernesniemi International Center for Neurosurgery, Henan People's Provincial Hospital, University of Zhengzhou, China; and
| | - Takakazu Kawamata
- 3Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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22
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Wang Y, Yang L, Wang X, Zeng F, Zhang K, Zhang Q, Liu M, Liu S, Shang M, Li Q, Yang Y, Liang M, Liu W. Meta-analysis of genotype and phenotype studies to confirm the predictive role of the RNF213 p.R4810K variant for moyamoya disease. Eur J Neurol 2020; 28:823-836. [PMID: 33175469 DOI: 10.1111/ene.14635] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/29/2020] [Accepted: 11/04/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this meta-analysis study was to assess the predictive effects of RNF213 p.R4810K on phenotype in moyamoya disease (MMD). METHODS Electronic databases (e.g., Pubmed and EMBASE) were searched, and relevant articles published up to August 2020 were retrieved. Review Manager 5.3 and Stata 12.0 were used for all statistical analyses. Pooled odds ratios, with 95% confidence intervals, and three comparison models were evaluated to analyze the association between RNF213 pR4810K variant and clinical characteristics of MMD patients using a fixed-effects model. RESULTS A total of 2798 patients with MMD were selected and the effects of the heterozygous or homozygous RNF213 p.R4810K variant on 18 clinical features were identified. There were more patients aged <15 years in the GA and AA groups (AA vs GA: p = 0.009; AA vs GG: p = 0.003; GA vs GG: p = 0.001). Among homozygous patients, the majority experienced MMD onset before the age of 4 years (AA vs. GA: p < 0.00001; AA vs GG: p < 0.00001). The frequency of infarctions and transient ischemic attack was significantly higher in homozygotes and heterozygotes,respectively. However, the frequency of intracerebral/intraventricular hemorrhage was lower in patients with the GA than the GG genotype. More MMD patients with AA and GA genotypes had a family history of the disease (p = 0.003, p < 0.00001, respectively). Posterior cerebral artery involvement was more common in patients with the GA genotype (p < 0.00001). CONCLUSION The homozygous or heterozygous RNF213 variant may be an efficient biomarker with which to classify different clinical phenotypes of MMD.
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Affiliation(s)
- Yue Wang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Luping Yang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Xiaotong Wang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Fanxin Zeng
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Kaili Zhang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Qian Zhang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Mengwei Liu
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Shan Liu
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Mengke Shang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Qian Li
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Yuetian Yang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Man Liang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
| | - Wanyang Liu
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, China
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Wang G, Wen Y, Faleti OD, Zhao Q, Liu J, Zhang G, Li M, Qi S, Feng W, Lyu X. A Panel of Exosome-Derived miRNAs of Cerebrospinal Fluid for the Diagnosis of Moyamoya Disease. Front Neurosci 2020; 14:548278. [PMID: 33100957 PMCID: PMC7546773 DOI: 10.3389/fnins.2020.548278] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 09/04/2020] [Indexed: 12/13/2022] Open
Abstract
Background Moyamoya disease (MMD) is an important cause of stroke in children and young adults in Asia. To date, diagnosis remains challenging due to varying clinical manifestations and unknown pathogenesis. The study aims to identify cerebrospinal fluid (CSF) exosomal microRNAs (exomiRs) that can serve as a novel diagnostic biomarker for diagnosis and assess its clinical applications. Methods CSF samples were taken from 31 MMD patients and 31 healthy controls. Initial screening of miRNA expression was performed on samples pooled from MMD patients and controls using microarray and validated using quantitative reverse transcription polymerase chain reaction (qRT-PCR). The diagnostic accuracy of the potential exosomal miRNAs was evaluated using receiver operating characteristic curve analyses in an independent patient cohort. The potential pathways regulated by the miRNAs was also determined using bioinformatics analysis. Results The microarray results demonstrated that six exomiRs were dysregulated in the MMD patients compared to the controls. Using qRT-PCR, we validated four of the miRNAs (miR-3679-5p, miR-6165, miR-6760-5p, and miR-574-5p) as a biomarker for MMD diagnosis. The four exomiRs showed enhanced sensitivity (75%) and specificity (93.75%) in terms of differentiating MMD patients from healthy subjects [area under the curve (AUC) = 0.9453]. Pathway enrichment analysis for potential targets of six exomiRs identified proteins involved in cell adhesion and junction formation in the brain. Conclusions We identified a novel and highly sensitive exomiRs signature for MMD detection and explored its potential targets using bioinformatics analysis.
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Affiliation(s)
- Gang Wang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yunyu Wen
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Oluwasijibomi Damola Faleti
- Department of Laboratory Medicine, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
| | - Qingshun Zhao
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jingping Liu
- Department of Laboratory Medicine, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
| | - Guozhong Zhang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Mingzhou Li
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Songtao Qi
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wenfeng Feng
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaoming Lyu
- Department of Laboratory Medicine, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
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24
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Nakamura A, Kawashima A, Nomura S, Kawamata T. Measurement of Intraoperative Graft Flow Predicts Radiological Hyperperfusion during Bypass Surgery in Patients with Moyamoya Disease. Cerebrovasc Dis Extra 2020; 10:66-75. [PMID: 32726777 PMCID: PMC7443641 DOI: 10.1159/000508827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 05/20/2020] [Indexed: 12/04/2022] Open
Abstract
Introduction Moyamoya disease (MMD) is a rare cerebrovascular disease associated with cerebral infarction or hemorrhage. Hyperperfusion is the most significant complication of direct bypass surgery. Previous research has shown that an increase in cerebral blood flow (CBF) is strongly related to symptomatic hyperperfusion and highlighted the importance of postoperative assessment of CBF. Objective The principal aims of this study were to quantitatively analyze the relationship between intraoperative graft flow and increase in CBF and to evaluate the effectiveness of intraoperative graft flow measurement during bypass surgery for patients with MMD. Methods This study included 91 surgeries in 67 consecutive adult patients with MMD who underwent direct revascularization surgery at our institution between November 2013 and September 2018. Intraoperative graft flow of the branches and main trunk was measured in all patients, after anastomosis had been established. Postoperative CBF measurements were performed under sedation, immediately after surgery. Radiological hyperperfusion was defined as focal high uptake, as determined by CBF imaging immediately after surgery. Patients were divided into two groups (radiological hyperperfusion and nonradiological hyperperfusion groups), and the relationship between intraoperative graft flow and radiological hyperperfusion was analyzed. Results Significant differences were observed between the radiological hyperperfusion and nonradiological hyperperfusion groups in terms of intraoperative graft flow of both the branch (median 72 vs. 42 mL/min, respectively; p < 0.01) and main trunk (median 113 vs. 68 mL/min, respectively; p < 0.01). A receiver-operating characteristic analysis was performed to test the utility of intraoperative flow as a quantitative measure. We set the cutoff values for the intraoperative branch and main trunk flow at 57 mL/min (sensitivity: 0.707, specificity: 0.702; area under the curve [AUC]: 0.773; 95% confidence interval [CI]: 0.675–0.871) and 84 mL/min (sensitivity: 0.667, specificity: 0.771; AUC: 0.78; 95% CI: 0.685–0.875), respectively. Conclusions Measuring intraoperative graft flow during bypass surgery may be an effective means of predicting hyperperfusion and could serve to facilitate early therapeutic intervention such as strict blood pressure control.
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Affiliation(s)
- Akikazu Nakamura
- Department of Neurosurgery, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan
| | - Akitsugu Kawashima
- Department of Neurosurgery, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan,
| | - Shunsuke Nomura
- Department of Neurosurgery, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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25
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Kuroda S, Nakayama N, Yamamoto S, Kashiwazaki D, Uchino H, Saito H, Hori E, Akioka N, Kuwayama N, Houkin K. Late (5-20 years) outcomes after STA-MCA anastomosis and encephalo-duro-myo-arterio-pericranial synangiosis in patients with moyamoya disease. J Neurosurg 2020; 134:909-916. [PMID: 32168480 DOI: 10.3171/2019.12.jns192938] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/17/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical revascularization is known to reduce the incidence of further ischemic and hemorrhagic events in patients with moyamoya disease, but the majority of previous studies report only short-term (< 5 years) outcomes. Therefore, in this study the authors aimed to evaluate late (5-20 years) outcomes of moyamoya patients after superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis and indirect bypass (encephalo-duro-myo-arterio-pericranial synangiosis [EDMAPS]). METHODS Cumulative incidences of late morbidity/mortality and disease progression were evaluated among 93 patients who underwent STA-MCA anastomosis and EDMAPS. All of the patients were prospectively followed up for longer than 5 years postsurgery (10.5 ± 4.4 years). There were 35 pediatric and 58 adult patients. Initial presentation included transient ischemic attack/ischemic stroke in 80 patients and hemorrhagic stroke in 10 patients, and 3 patients were asymptomatic. Surgery was performed in a total of 141 hemispheres. Follow-up MRI/MRA was performed within a 6- or 12-month interval during the follow-up periods. RESULTS During the follow-up periods, 92/93 patients were free from any stroke or death, but 1 patient had a recurrence of hemorrhagic stroke (0.10% per patient-year). Disease progression occurred in the territory of the contralateral carotid or posterior cerebral artery (PCA) in 19 hemispheres of 15 patients (1.5% per patient-year). The interval between initial surgery and disease progression varied widely, from 0.5 to 15 years. Repeat bypass surgery for the anterior and posterior circulation resolved ischemic attacks in all 10 patients. CONCLUSIONS The study results indicate that STA-MCA anastomosis and EDMAPS would be the best choice to prevent further ischemic and hemorrhagic stroke for longer than 10 years on the basis of the demonstrated widespread improvement in cerebral hemodynamics in both the MCA and ACA territories in the study patients. However, after 10 years postsurgery regular follow-up is essential to detect disease progression in the territory of the contralateral carotid artery and PCA and prevent late cerebrovascular events.
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Affiliation(s)
- Satoshi Kuroda
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and.,2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Naoki Nakayama
- 2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Shusuke Yamamoto
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
| | - Daina Kashiwazaki
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
| | - Haruto Uchino
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and.,2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hisayasu Saito
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and.,2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Emiko Hori
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
| | - Naoki Akioka
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
| | - Naoya Kuwayama
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
| | - Kiyohiro Houkin
- 2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Kaseka ML, Dlamini N, Westmacott R. Ischemic sequelae and other vascular diseases. HANDBOOK OF CLINICAL NEUROLOGY 2020; 173:485-492. [PMID: 32958192 DOI: 10.1016/b978-0-444-64150-2.00033-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Although pediatric stroke is associated with higher survival rates compared with adult stroke, a substantial body of evidence indicates significant neuropsychologic morbidity in pediatric stroke survivors. Neuroplasticity does not guarantee good outcome in children. The general trends observed in the literature are reviewed as is the profile observed in common causes of pediatric stroke: congenital heart disease, moyamoya disease, and sickle cell disease. The neuropsychologic profile of pediatric stroke patients is heterogeneous due to the multiplicity of associated causes. Stroke in early infancy and large strokes are associated with cognitive impairment while more limited disorders, such as phasic deficit, are observed in childhood stroke. Executive dysfunction is common in pediatric stroke, but social interaction skills are usually preserved. Congenital heart disease and sickle cell disease are associated with global neuropsychologic dysfunction while cognition is usually preserved in moyamoya. Executive dysregulation is instead more frequently reported in this population. Further study of maladaptive processes after pediatric stroke will allow identification of predictors of functional and neuropsychologic outcomes and permit personalization of care.
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Affiliation(s)
- Matsanga Leyila Kaseka
- Department of Pediatrics, Division of Neurology, Hospital for Sick Children, Toronto, ON, Canada.
| | - Nomazulu Dlamini
- Department of Pediatrics, Division of Neurology, Hospital for Sick Children, Toronto, ON, Canada
| | - Robyn Westmacott
- Department of Psychology, Division of Neurology, Hospital for Sick Children, Toronto, ON, Canada
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27
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Yang J, Song GF, Li HB, Zhang SH, Yang FY. Clinical efficacy of extracranial-intracranial bypass for the treatment of adult patients with moyamoya disease: A protocol of systematic review of randomized controlled trials. Medicine (Baltimore) 2019; 98:e18211. [PMID: 31804345 PMCID: PMC6919537 DOI: 10.1097/md.0000000000018211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Moyamoya disease (MMD) is a major health concern associated with blocked arteries at the base of the brain. The aim of this study will synthesize the current evidence of the efficacy and safety of extracranial-intracranial bypass (EIB) for the treatment of adult patients with MMD. METHODS A systematically and comprehensively literature search will be performed in PubMed, EMBASE, Web of Science, CENTRAL, CINAHL, AMED, CBM, and CNKI to identify relevant randomized controlled trails (RCTs) investigating the efficacy and safety of EIB for treating MMD. We will search all above electronic databases from their inception to the July 30, 2019. Two review authors will independently perform study selection, data extraction, and conduct risk of bias evaluation using Cochrane risk of bias tool. We will also explore heterogeneity across studies. RevMan 5.3 software will be applied for statistical analysis performance. RESULTS This study will evaluate the efficacy and safety of EIB for the treatment of adult patients with MMD. CONCLUSION The results of this study will provide latest evidence of the efficacy and safety of EIB for MMD. DISSEMINATION AND ETHICS This study is based on published studies, thus, no ethical consideration is needed. The results of this study are expected to be published in peer-reviewed journals or will be presented on conference meeting.Systematic review registration: PROSPERO CRD42019155839.
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Affiliation(s)
| | | | | | | | - Fu-yi Yang
- Department of Neurology, First Affiliated Hospital of Jiamusi University, Jiamusi, China
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28
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Funaki T, Kataoka H, Yoshida K, Kikuchi T, Mineharu Y, Okawa M, Yamao Y, Miyamoto S. The Targeted Bypass Strategy for Preventing Hemorrhage in Moyamoya Disease: Technical Note. Neurol Med Chir (Tokyo) 2019; 59:517-522. [PMID: 31656238 PMCID: PMC6923163 DOI: 10.2176/nmc.tn.2019-0162] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Although direct bypass is effective at preventing intracranial hemorrhage in moyamoya disease, the optimal strategy for achieving this purpose has rarely been addressed. The tailored targeting bypass strategy is a novel technical modification of direct bypass focused on hemorrhage prevention. The strategy is based on the promising theory of periventricular anastomosis, which explains the mechanism of hemorrhage in moyamoya disease. The strategy is defined as the use of multi-imaging modalities to predetermine in a tailored manner a target vessel at the point at which the medullary artery directly extends from the periventricular anastomosis of interest. Direct bypass with a wide craniotomy was performed on 13 hemispheres in eight patients according to this strategy. Marked shrinkage of the periventricular anastomosis of interest was observed in all but one hemisphere after surgery, and no new hemorrhages have occurred as of this writing. The present case series illustrates the technical aspects and preliminary results of the tailored targeting bypass strategy, an approach that might expand the potential of direct bypass in preventing hemorrhage.
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Affiliation(s)
- Takeshi Funaki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
| | - Hiroharu Kataoka
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
| | - Kazumichi Yoshida
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
| | - Takayuki Kikuchi
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
| | - Yohei Mineharu
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
| | - Masakazu Okawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
| | - Yukihiro Yamao
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
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29
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Vadivelu S, Harker P, Zuccarello M. Letter to the Editor. Moyamoya: patient selection rather than de-selection in the very young. J Neurosurg Pediatr 2019; 25:94-95. [PMID: 31561228 DOI: 10.3171/2019.6.peds19346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Sudhakar Vadivelu
- 1Cincinnati Children's Hospital Medical Center, Cincinnati, OH; and
- 2University of Cincinnati College of Medicine, Cincinnati, OH
| | - Pablo Harker
- 1Cincinnati Children's Hospital Medical Center, Cincinnati, OH; and
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30
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Ha EJ, Kim KH, Wang KC, Phi JH, Lee JY, Choi JW, Cho BK, Yang J, Byun YH, Kim SK. Long-Term Outcomes of Indirect Bypass for 629 Children With Moyamoya Disease: Longitudinal and Cross-Sectional Analysis. Stroke 2019; 50:3177-3183. [PMID: 31551037 DOI: 10.1161/strokeaha.119.025609] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- In pediatric moyamoya disease, there are few reports on the efficacy of surgical intervention for stroke prevention. We evaluated the long-term outcomes of indirect bypass surgery on a relatively large number of children with moyamoya disease in a single center. Methods- From August 1988 to December 2012, 772 children underwent indirect bypass surgery. This study included 629 patients who were followed up for >5 years, excluding patients with moyamoya syndrome. The mean clinical follow-up duration was 12 years (range, 5-29 years). Cross-sectional analysis was performed based on either Karnofsky Performance Scale or Lansky Play Performance Scale to evaluate overall clinical outcomes and factors associated with unfavorable outcomes. To analyze the longitudinal effect of surgery, the annual risk of symptomatic infarction or hemorrhage on the operated hemisphere after indirect bypass surgery was calculated with a person-year method, and the event-free survival rate was evaluated using the Kaplan-Meier method. Results- The overall clinical outcome was favorable in 95% of the patients. The annual risks of symptomatic infarction and hemorrhage on the operated hemispheres were 0.08% and 0.04%, respectively. Furthermore, the 10-year event-free survival rates for symptomatic infarction and hemorrhage were 99.2% and 99.8%. Conclusions- Indirect bypass surgery could provide satisfactory long-term improvement in overall clinical outcome and prevention of recurrent stroke in children with moyamoya disease.
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Affiliation(s)
- Eun Jin Ha
- From the Department of Neurosurgery, Seoul National University Hospital (E.J.H., K.H.K., K.-C.W., J.H.P., J.Y.L., J.Y., Y.H.B., S.-K.K.), Seoul National University College of Medicine, Republic of Korea.,Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Republic of Korea (E.J.H., K.H.K., K.-C.W., J.H.P., J.Y.L., J.Y., Y.H.B., S.-K.K.).,Critical Care Center, Seoul National University Hospital, Republic of Korea (E.J.H.)
| | - Kyung Hyun Kim
- From the Department of Neurosurgery, Seoul National University Hospital (E.J.H., K.H.K., K.-C.W., J.H.P., J.Y.L., J.Y., Y.H.B., S.-K.K.), Seoul National University College of Medicine, Republic of Korea.,Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Republic of Korea (E.J.H., K.H.K., K.-C.W., J.H.P., J.Y.L., J.Y., Y.H.B., S.-K.K.)
| | - Kyu-Chang Wang
- From the Department of Neurosurgery, Seoul National University Hospital (E.J.H., K.H.K., K.-C.W., J.H.P., J.Y.L., J.Y., Y.H.B., S.-K.K.), Seoul National University College of Medicine, Republic of Korea.,Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Republic of Korea (E.J.H., K.H.K., K.-C.W., J.H.P., J.Y.L., J.Y., Y.H.B., S.-K.K.)
| | - Ji Hoon Phi
- From the Department of Neurosurgery, Seoul National University Hospital (E.J.H., K.H.K., K.-C.W., J.H.P., J.Y.L., J.Y., Y.H.B., S.-K.K.), Seoul National University College of Medicine, Republic of Korea.,Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Republic of Korea (E.J.H., K.H.K., K.-C.W., J.H.P., J.Y.L., J.Y., Y.H.B., S.-K.K.)
| | - Ji Yeoun Lee
- From the Department of Neurosurgery, Seoul National University Hospital (E.J.H., K.H.K., K.-C.W., J.H.P., J.Y.L., J.Y., Y.H.B., S.-K.K.), Seoul National University College of Medicine, Republic of Korea.,Department of Anatomy (J.Y.L.), Seoul National University College of Medicine, Republic of Korea.,Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Republic of Korea (E.J.H., K.H.K., K.-C.W., J.H.P., J.Y.L., J.Y., Y.H.B., S.-K.K.)
| | - Jung Won Choi
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (J.W.C.)
| | - Byung-Kyu Cho
- Department of Neurosurgery, Armed Forces Capital Hospital, Seongnam, Republic of Korea (B.-K.C.)
| | - Jeyul Yang
- From the Department of Neurosurgery, Seoul National University Hospital (E.J.H., K.H.K., K.-C.W., J.H.P., J.Y.L., J.Y., Y.H.B., S.-K.K.), Seoul National University College of Medicine, Republic of Korea.,Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Republic of Korea (E.J.H., K.H.K., K.-C.W., J.H.P., J.Y.L., J.Y., Y.H.B., S.-K.K.)
| | - Yoon Hwan Byun
- From the Department of Neurosurgery, Seoul National University Hospital (E.J.H., K.H.K., K.-C.W., J.H.P., J.Y.L., J.Y., Y.H.B., S.-K.K.), Seoul National University College of Medicine, Republic of Korea.,Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Republic of Korea (E.J.H., K.H.K., K.-C.W., J.H.P., J.Y.L., J.Y., Y.H.B., S.-K.K.)
| | - Seung-Ki Kim
- From the Department of Neurosurgery, Seoul National University Hospital (E.J.H., K.H.K., K.-C.W., J.H.P., J.Y.L., J.Y., Y.H.B., S.-K.K.), Seoul National University College of Medicine, Republic of Korea.,Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Republic of Korea (E.J.H., K.H.K., K.-C.W., J.H.P., J.Y.L., J.Y., Y.H.B., S.-K.K.)
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Ravindran K, Wellons JC, Dewan MC. Surgical outcomes for pediatric moyamoya: a systematic review and meta-analysis. J Neurosurg Pediatr 2019; 24:663-672. [PMID: 31518973 DOI: 10.3171/2019.6.peds19241] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/13/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The optimal revascularization for pediatric moyamoya for reducing the incidence of future stroke events remains to be determined. METHODS The authors conducted a search of PubMed, MEDLINE, Embase, and Web of Science electronic databases from inception until January 2019. The primary endpoint was the presence of a future ischemic stroke event. Secondary endpoints were angiographic outcomes as measured by postoperative Matsushima grade and clinical symptom persistence. Patients who underwent either direct or combined direct/indirect revascularization were classified into the direct cohort. Data from each study on presence of postoperative stroke events were used to generate standardized mean differences and 95% confidence intervals, which were combined using inverse variance-weighted averages of standardized mean differences in a random effects model. RESULTS Twenty-nine studies met the inclusion criteria for analysis, comprising 2258 patients (1011 males, mean age 8.3 ± 1.8 years) who were followed up clinically for an average of 71.4 ± 51.3 months. One hundred fifty-four patients underwent direct bypass alone, 680 patients underwent either direct or combined direct/indirect revascularization procedures, while 1424 patients underwent indirect bypass alone. The frequencies of future stroke events in patients undergoing direct bypass alone, combined bypass, or indirect bypass alone were 1 per 190.3 patient-years, 1 per 108.9 patient-years, and 1 per 61.1 patient-years, respectively, in each cohort. The estimated stroke rates were 9.0% with indirect revascularization, 4.5% with direct revascularization alone, and 6.0% with combined revascularization. A forest plot did not reveal any significant differences in the incidence of future stroke events or angiographic outcomes following direct-only, combined, or indirect-only revascularization. CONCLUSIONS Direct, indirect, and combined indirect/direct bypass techniques are all effective revascularization options for pediatric moyamoya disease. A relative paucity of granular studies-and inherent surgical selection bias-limits direct comparison between interventions. Suitably designed prospective cohort studies may be useful in identifying patients likely to receive benefit from specific procedures.
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Affiliation(s)
| | - John C Wellons
- 2Division of Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael C Dewan
- 2Division of Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
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JIANG ZHIQUN, CHEN YAN, ZENG CHUNHUI, FENG JIUGENG, WAN YILV, WEI MINJUN. RATIONALIZATION OF SURGICAL TREATMENT FOR HEMORRHAGIC MOYAMOYA DISEASE: FROM LABORATORY BENCH RESEARCH, BIOMECHANICS TO META-ANALYSIS. J MECH MED BIOL 2019. [DOI: 10.1142/s0219519419500350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background and purpose: Surgery is recommended as the treatment of choice for hemorrhagic Moyamoya disease (MMD). The rationale of surgery and the choice of procedure are poorly understood. The aim of this paper is to present latest evidence, from cellular, biomechanical and population data, surgical treatment options and their effect on the outcome of hemorrhagic MMD. Methods: We systematically reviewed the latest evidence from cellular, biomechanical and populational studies including our own meta-analysis for rationalization of management of MMD. We searched major databases from inception to latest articles available till October 2018. All major breakthroughs including basic research to randomized controlled trials (RCTs) and human case–control studies related to hemorrhagic MMD were included. Our meta-analysis was performed in accordance to the standard Cochrane. Result: Evidence at cellular, biomechanical and RCT levels was presented. For our meta-analysis, we included eight studies, totaling at 632 patients. Our results rationalized the use of surgical methods in support of surgical management of MMD. We showed that surgery in MMD resulted in a significant lower risk of future stroke ([Formula: see text], 95% [Formula: see text]–0.38). Among different surgical methods, the indirect bypass group had a lower risk for sedentary stroke risk reduction compared with the direct bypass group (RR[Formula: see text]=[Formula: see text]3.36, 95% CI[Formula: see text]=[Formula: see text]1.53–7.36). No significant differences were observed in perioperative complications between the two methods. Conclusion: Surgery remains a mainstay for the management of MMD. We concluded that current evidence in biomechanical and our own meta-analysis is in support of surgery being an effective management of hemorrhagic MMD. We deduced insights into research for early detection, characterization and follow up of patients with MMD.
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Affiliation(s)
- ZHI-QUN JIANG
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang 330006, P. R. China
| | - YAN CHEN
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang 330006, P. R. China
| | - CHUN-HUI ZENG
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang 330006, P. R. China
| | - JIU-GENG FENG
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang 330006, P. R. China
| | - YI-LV WAN
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang 330006, P. R. China
| | - MIN-JUN WEI
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang 330006, P. R. China
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Lu J, Zhao Y, Ma L, Chen Y, Li M, Chen X, Ye X, Wang R, Zhao Y. Predictors and clinical features of transient neurological events after combined bypass revascularization for moyamoya disease. Clin Neurol Neurosurg 2019; 186:105505. [PMID: 31622898 DOI: 10.1016/j.clineuro.2019.105505] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/24/2019] [Accepted: 08/28/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Transient neurological events (TNEs) are frequently observed after revascularization surgery for moyamoya disease (MMD). However, clinical features and pathophysiology of TNEs in MMD are still unclear. This study was aimed to clarify the incidence and time course of TNEs and to determine the independent predictors of TNEs in MMD. PATIENTS AND METHODS A total of 195 hemispheres in 171 consecutive patients with MMD who had undergone combined direct and indirect bypass surgery were analyzed. Preoperative clinical characteristics and radiographic features were recorded. The incidence and clinical feature of postoperative TNEs were evaluated. Multivariate logistic regression analyses were performed to identify the risk factors for postoperative TNEs. Outcomes were compared between patients who had TNEs with those without TNEs at the time of discharge. RESULTS Postoperative TNEs were detected in 40 (20.5%) of 195 operated hemispheres, including 17 (42.5%) aphasia, 9 numbness of the extremities (22.5%), 6 seizures (15%), 5 motor weakness (12.5%), 4 dysarthria (10%) and 6 others (15%). The incidence of TNEs was significantly higher in adult patients than in pediatric ones. Multivariate analysis revealed that female, left-sided surgery and the presence of the edematous lesion was an independent predictor of TNEs after surgery in MMD (OR, 3.0; 95% CI, 1.1-8.2; P = 0.03, OR, 2.9; 95% CI, 1.2-7.0; P = 0.02 and OR, 17.4; 95% CI, 5.7-53.0; P < 0.01, respectively). DSA stage (OR 0.05, 95% CI 0.0-0.5, p = 0.005; OR 0.08, 95% CI 0.0-0.4, p = 0.008), PCA involvement (OR 2.75, 95% CI 1.0-7.4, p = 0.046), left-sided surgery (OR 2.73, 95% CI 1.2-6.5, p = 0.022) and edematous lesion (OR 21.2, 95% CI 7.6-59.7, <0.001) were significantly associated with TNE severity. Compared with patients without postoperative TNEs, no significant differences in mRS score between the two groups were detected. CONCLUSIONS Female, left-sided surgery and edematous lesion were independent risk factors for postoperative TNEs; the left-sided surgery and edematous lesion were also independently associated with the severity of TNE. Although patients with postoperative TNEs had worse neurological status during the perioperative period, postoperative TNEs had no associations with worse mRS score at the time of discharge.
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Affiliation(s)
- Junlin Lu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Yahui Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Mingtao Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Rong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, PR China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, PR China; Department of Neurosurgery, Peking University International Hospital, Beijing, PR China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, PR China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, PR China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, PR China; Department of Neurosurgery, Peking University International Hospital, Beijing, PR China.
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Restoration of periventricular vasculature after direct bypass for moyamoya disease: intra-individual comparison. Acta Neurochir (Wien) 2019; 161:947-954. [PMID: 30880348 DOI: 10.1007/s00701-019-03866-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 03/03/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND While periventricular anastomosis, a unique abnormal vasculature in moyamoya disease, has been studied in relation to intracranial hemorrhage, no study has addressed its change after bypass surgery. The authors sought to test whether direct bypass surgery could restore normal periventricular vasculature. METHODS Patients who had undergone direct bypass surgery for moyamoya disease at a single institution were eligible for the study. Baseline, postoperative, and follow-up magnetic resonance angiography (MRA) scans were scheduled before surgery, after the first surgery, and 3 to 6 months after contralateral second surgery, respectively. Sliding-thin-slab maximum-intensity-projection coronal MRA images of periventricular anastomoses were scored according to the three subtypes (lenticulostriate, thalamic, and choroidal anastomosis). Baseline and postoperative MRA images were compared to obtain a matched comparison of score changes in the surgical and nonsurgical hemispheres within individuals (intra-individual comparison). RESULTS Of 110 patients, 42 were identified for intra-individual comparisons. The periventricular anastomosis score decreased significantly in the surgical hemispheres (median, 2 versus 1; p < 0.001), whereas the score remained unchanged in the nonsurgical hemispheres (median, 2 versus 2; p = 0.57); the score change varied significantly between the surgical and nonsurgical hemispheres (p < 0.001). Of the 104 periventricular-anastomosis-positive hemispheres undergoing surgery, 47 (45.2%) were assessed as negative in the follow-up MRA. Among the subtypes, choroidal anastomosis was most likely to be assessed as negative (79.7% of positive hemispheres). CONCLUSIONS Periventricular vasculature can be restored after direct bypass. The likelihood of correction of choroidal anastomosis is a subject requiring further studies.
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Kronenburg A, van den Berg E, van Schooneveld MM, Braun KPJ, Calviere L, van der Zwan A, Klijn CJM. Cognitive Functions in Children and Adults with Moyamoya Vasculopathy: A Systematic Review and Meta-Analysis. J Stroke 2018; 20:332-341. [PMID: 30309228 PMCID: PMC6186911 DOI: 10.5853/jos.2018.01550] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 09/03/2018] [Indexed: 11/11/2022] Open
Abstract
Background and Purpose Patients with moyamoya vasculopathy (MMV) may experience cognitive impairment, but its reported frequency, severity, and nature vary. In a systematic review and metaanalysis, we aimed to assess the presence, severity, and nature of cognitive impairments in children and adults with MMV.
Methods We followed the MOOSE guidelines for meta-analysis and systematic reviews of observational studies. We searched Ovid Medline and Embase for studies published between January 1, 1969 and October 4, 2016. Independent reviewers extracted data for mean intelligence quotient (IQ) and standardized z-scores for cognitive tests, and determined percentages of children and adults with cognitive deficits, before and after conservative or surgical treatment. We explored associations between summary measures of study characteristics and cognitive impairments by linear regression analysis.
Results We included 17 studies (11 studies reporting on 281 children, six on 153 adults). In children, the median percentage with impaired cognition was 30% (range, 13% to 67%); median IQ was 98 (range, 71 to 107). Median z-score was –0.39 for memory, and –0.43 for processing speed. In adults, the median percentage with impaired cognition was 31% (range, 0% to 69%); median IQ was 95 (range, 94 to 99). Median z-scores of cognitive domains were between –0.9 and –0.4, with multiple domains being affected. We could not identify determinants of cognitive impairment.
Conclusions A large proportion of children and adults with MMV have cognitive impairment, with modest to large deficits across various cognitive domains. Further studies should investigate determinants of cognitive deficits and deterioration, and the influence of revascularization treatment on cognitive functioning.
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Affiliation(s)
- Annick Kronenburg
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands
| | - Esther van den Berg
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Monique M van Schooneveld
- Sector of Neuropsychology, Department of Pediatric Psychology, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht, The Netherlands
| | - Kees P J Braun
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands
| | - Lionel Calviere
- Department of Vascular Neurology, University Hospital of Toulouse, Toulouse, France
| | - Albert van der Zwan
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center (UMC) Utrecht, Utrecht, The Netherlands.,Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Center for Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands
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Ovsyannikov KS, Dubovoy AV, Galaktionov DM. Combined (direct and indirect) revascularization in adult patients with moyamoya disease. ACTA ACUST UNITED AC 2018. [DOI: 10.17650/1683-3295-2018-20-3-57-66] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The study objective is to analyze the results of combined (direct and indirect) brain revascularization in adult patients with moyamoya disease. Materials and methods. From February 2015 to August 2016, 12 operations were performed on 12 hemispheres in 7 patients (2 men, 5 women) with moyamoya disease. Six patients had bilateral disease, 1 – unilateral. The age of patients ranged from 25 to 60 year old, the average – 41 year old. Multislice computed tomography (MSCT) perfusion imaging of the brain with a stress test was made in every patient, MSCT angiography of the extraand intracranial arteries was perfomed. Stages of the disease were determined according to the Suzuki–Takaku classification: stage III was revealed in 5 patients, stage IV – in 2. To evaluate the clinical course of the disease the Matsushima classification was used: type VI – in 2 cases, type III – in 2, type IV – in 1, type V – in 1. In 1 case, the pathological vascular network of 1 hemisphere was detected by accident. Extracranial-intracranial (EC–IC) bypass and encephaloduromyosynangiosis (EDMS) was used in 3 cases; a double-barreled EC–IC bypass and EDMS – in 3; a double-barreled EC–IC bypass and encephaloduroperiosteomyosynangiosis – in 1; EC–IC bypass and encephaloduroarteriomyosynangiosis (EDAMS) – in 3. In 1 case was perfomed EC–IC bypass and encephaloduroperiosteosynangiosis. Only indirect revascularization was performed in 1 case – EDAMS. We assessed the neurological status in the follow-up period (5–11 months); MSCT angiography and MSCT perfusion imaging of the brain were performed. Results. All patients in follow-up period demonstrated the increase of cerebrovascular reserve according to MSCT perfusion imaging of the brain with stress tests. Stroke, epilepsy, surgical complications were not detected in the postoperative period. In 1 case, the left-hand monoparesis regressed.Conclusion. The combined (direct and indirect) revascularization may be effective in adult patients with moyamoya disease. To obtain more objective conclusions it is necessary to analyze the long-term results of interventions.
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Affiliation(s)
- K. S. Ovsyannikov
- Federal Neurosurgical Center (Novosibirsk), Ministry of Health of Russia
| | - A. V. Dubovoy
- Federal Neurosurgical Center (Novosibirsk), Ministry of Health of Russia
| | - D. M. Galaktionov
- Federal Neurosurgical Center (Novosibirsk), Ministry of Health of Russia
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Zhang Y, Bao XY, Duan L, Yang WZ, Li DS, Zhang ZS, Han C, Zhao F, Zhang Q, Wang QN. Encephaloduroarteriosynangiosis for pediatric moyamoya disease: long-term follow-up of 100 cases at a single center. J Neurosurg Pediatr 2018; 22:173-180. [PMID: 29856299 DOI: 10.3171/2018.2.peds17591] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The object of this study was to summarize the long-term effect of encephaloduroarteriosynangiosis (EDAS) for the treatment of pediatric moyamoya disease (MMD) and to investigate factors influencing the clinical outcomes of EDAS. METHODS Clinical features, angiographic findings, and clinical outcomes were analyzed among MMD patients younger than 18 years who had been treated with EDAS between 2002 and 2007 at the authors' institution. The Kaplan-Meier method was used to estimate stroke risk after EDAS. Predictors of neurological outcome were assessed. RESULTS One hundred fifteen patients were identified. The mean age at symptom onset was 7.3 ± 4.0 years. The incidence of familial MMD was 11.3%. The female/male ratio was 1:1.16. A total of 232 EDAS procedures were performed, and the incidence of postoperative complications was 3%. Postoperative digital subtraction angiography was performed in 54% of the patients, and about 80% of the hemispheres showed good or excellent results. Neovascularization showed significant correlations with delay time (from symptom onset to first operation), Suzuki stage, and preoperative stroke (all p < 0.05). Clinical follow-up was available in 100 patients with a mean follow-up of 124.4 ± 10.5 months. Ten-year cumulative survival was 96.5% after surgery, and the risk of stroke was 0.33%/person-year. An independent life with no significant disability was reported by 92% of the patients. A good outcome correlated with a low Suzuki stage (p = 0.001). Older children and those without preoperative stroke had better clinical outcomes (p < 0.05). CONCLUSIONS On the basis of long-term follow-up data, the authors concluded that EDAS is a safe and effective treatment for pediatric MMD, can reduce the risk of subsequent neurological events, and can improve quality of life. The risk of ischemia-related complications was higher in younger patients, and older children showed better outcomes. Compensation was greater with more prominent cerebral ischemia. The long-term clinical outcome largely depended on the presence and extent of preoperative stroke.
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Affiliation(s)
- Yong Zhang
- 1Department of Neurosurgery, 307th Hospital of People's Liberation Army, 307 Clinical College, Anhui Medical University; and.,2Department of Neurosurgery, 307th Hospital of People's Liberation Army, The Center for Cerebral Vascular Disease, PLA, Beijing, People's Republic of China
| | - Xiang-Yang Bao
- 2Department of Neurosurgery, 307th Hospital of People's Liberation Army, The Center for Cerebral Vascular Disease, PLA, Beijing, People's Republic of China
| | - Lian Duan
- 1Department of Neurosurgery, 307th Hospital of People's Liberation Army, 307 Clinical College, Anhui Medical University; and.,2Department of Neurosurgery, 307th Hospital of People's Liberation Army, The Center for Cerebral Vascular Disease, PLA, Beijing, People's Republic of China
| | - Wei-Zhong Yang
- 2Department of Neurosurgery, 307th Hospital of People's Liberation Army, The Center for Cerebral Vascular Disease, PLA, Beijing, People's Republic of China
| | - De-Sheng Li
- 2Department of Neurosurgery, 307th Hospital of People's Liberation Army, The Center for Cerebral Vascular Disease, PLA, Beijing, People's Republic of China
| | - Zheng-Shan Zhang
- 2Department of Neurosurgery, 307th Hospital of People's Liberation Army, The Center for Cerebral Vascular Disease, PLA, Beijing, People's Republic of China
| | - Cong Han
- 2Department of Neurosurgery, 307th Hospital of People's Liberation Army, The Center for Cerebral Vascular Disease, PLA, Beijing, People's Republic of China
| | - Feng Zhao
- 2Department of Neurosurgery, 307th Hospital of People's Liberation Army, The Center for Cerebral Vascular Disease, PLA, Beijing, People's Republic of China
| | - Qian Zhang
- 2Department of Neurosurgery, 307th Hospital of People's Liberation Army, The Center for Cerebral Vascular Disease, PLA, Beijing, People's Republic of China
| | - Qian-Nan Wang
- 2Department of Neurosurgery, 307th Hospital of People's Liberation Army, The Center for Cerebral Vascular Disease, PLA, Beijing, People's Republic of China
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Ohkura A, Negoto T, Aoki T, Noguchi K, Okamoto Y, Komatani H, Kawano T, Mukasa A, Morioka M. Stenotic changes of the posterior cerebral artery are a major contributing factor for cerebral infarction in moyamoya disease. Surg Neurol Int 2018; 9:105. [PMID: 29930871 PMCID: PMC5991280 DOI: 10.4103/sni.sni_18_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/28/2018] [Indexed: 11/04/2022] Open
Abstract
Background Some patients with moyamoya disease (MMD) show broad infarction with moderate internal carotid artery (ICA) stenosis, whereas others with complete ICA occlusion show no infarction. This suggests that other factors contribute to the occurrence of infarction. Contributing factors predictive of cerebral infarcts must be identified for the prevention of infarction and the consequent neurological deficits. Methods We examined data from 93 patients with confirmed MMD for the presence of infarction (n = 72), transient ischemic attack (TIA, n = 41), asymptomatic presentation (n = 51), or hemorrhage (n = 22) in 186 bilateral cerebral hemispheres. We analyzed the relationship between the occurrence of infarction and several clinical factors, such as steno-occlusive status or the site of the ICA and posterior cerebral artery (PCA). Results The incidence of PCA steno-occlusive lesions was significantly higher in infarcted (77.8%) than in non-infarcted hemispheres (TIA, 14.6%; asymptomatic, 9.8%; hemorrhagic 9.1%; P < 0.01). The steno-occlusive site of ICA was also a significant factor (P < 0.05). There was no significant correlation between the occurrence of infarction and the steno-occlusive status of the ICA or grade of the moyamoya vessels. Multivariate statistical analysis demonstrated that the PCA steno-occlusive changes were an important contributing factor for infarction (P < 0.0001). Conclusions This is the multivariate statistical analysis study identifying PCA steno-occlusive lesions as the most important independent factor that is predictive to cerebral infarction in moyamoya patients. The prediction and inhibition of PCA steno-occlusive changes may help to prevent cerebral infarction.
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Affiliation(s)
- Akira Ohkura
- Department of Neurosurgery, Saiseikai Fukuoka General Hospital, Chuo-ku, Fukuoka, Japan
| | - Tetsuya Negoto
- Department of Neurosurgery, Kurume University, School of Medicine, Kurume, Japan
| | - Takachika Aoki
- Department of Neurosurgery, Kurume University, School of Medicine, Kurume, Japan
| | - Kei Noguchi
- Department of Neurosurgery, Kurume University, School of Medicine, Kurume, Japan
| | - Yuji Okamoto
- Department of Neurosurgery, Saiseikai Yahata General Hospital, Yahatahigashi-ku, Kitakyushu, Japan
| | - Hideki Komatani
- Department of Neurosurgery, Saiseikai Yahata General Hospital, Yahatahigashi-ku, Kitakyushu, Japan
| | - Takayuki Kawano
- Department of Neurosurgery, Kumamoto University School of Medicine, Kumamoto, Japan
| | - Akitake Mukasa
- Department of Neurosurgery, Kumamoto University School of Medicine, Kumamoto, Japan
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University, School of Medicine, Kurume, Japan
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Funaki T, Takahashi JC, Miyamoto S. Late Cerebrovascular Events and Social Outcome after Adolescence: Long-term Outcome of Pediatric Moyamoya Disease. Neurol Med Chir (Tokyo) 2018; 58:240-246. [PMID: 29780072 PMCID: PMC6002682 DOI: 10.2176/nmc.ra.2018-0026] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
In this article, the authors review the literature related to long-term outcome of pediatric moyamoya disease, focusing on late cerebrovascular events and social outcome of pediatric patients once they reach adulthood. Late-onset de novo hemorrhage is rare but more serious than recurrence of ischemic stroke. Long-term follow-up data on Asian populations suggest that the incidence of de novo hemorrhage might increase at age 20 or later, even more than 10 years after bypass surgery. Social adaptation difficulty, possibly related to cognitive impairment caused by frontal ischemia, continues in 10-20% of patients after they reach adulthood, even if no significant disability is present in daily life. A treatment strategy aimed at improving long-term outcome and careful follow-up might be required.
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Affiliation(s)
- Takeshi Funaki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
| | - Jun C Takahashi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
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Cikla U, Sahin B, Hanalioglu S, Ahmed AS, Niemann D, Baskaya MK. A novel, low-cost, reusable, high-fidelity neurosurgical training simulator for cerebrovascular bypass surgery. J Neurosurg 2018; 130:1663-1671. [PMID: 29749910 DOI: 10.3171/2017.11.jns17318] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 11/14/2017] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Cerebrovascular bypass surgery is a challenging yet important neurosurgical procedure that is performed to restore circulation in the treatment of carotid occlusive diseases, giant/complex aneurysms, and skull base tumors. It requires advanced microsurgical skills and dedicated training in microsurgical techniques. Most available training tools, however, either lack the realism of the actual bypass surgery (e.g., artificial vessel, chicken wing models) or require special facilities and regulations (e.g., cadaver, live animal, placenta models). The aim of the present study was to design a readily accessible, realistic, easy-to-build, reusable, and high-fidelity simulator to train neurosurgeons or trainees on vascular anastomosis techniques even in the operating room. METHODS The authors used an anatomical skull and brain model, artificial vessels, and a water pump to simulate both extracranial and intracranial circulations. They demonstrated the step-by-step preparation of the bypass simulator using readily available and affordable equipment and consumables. RESULTS All necessary steps of a superficial temporal artery-middle cerebral artery bypass surgery (from skin opening to skin closure) were performed on the simulator under a surgical microscope. The simulator was used by both experienced neurosurgeons and trainees. Feedback survey results from the participants of the microsurgery course suggested that the model is superior to existing microanastomosis training kits in simulating real surgery conditions (e.g., depth, blood flow, anatomical constraints) and holds promise for widespread use in neurosurgical training. CONCLUSIONS With no requirement for specialized laboratory facilities and regulations, this novel, low-cost, reusable, high-fidelity simulator can be readily constructed and used for neurosurgical training with various scenarios and modifications.
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[Revascularization experience and results in ischaemic cerebrovascular disease: Moyamoya disease and carotid occlusion]. Neurocirugia (Astur) 2018; 29:170-186. [PMID: 29550248 DOI: 10.1016/j.neucir.2018.01.006] [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: 12/20/2017] [Revised: 01/24/2018] [Accepted: 01/31/2018] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Cerebral revascularization techniques are an indispensable tool in the current armamentarium of vascular neurosurgeons. We present revascularization surgery experience and results in both moyamoya disease and occlusive cerebral ischaemia. PATIENTS AND METHODS Patients with ischaemic occlusive disease and moyamoya disease who underwent microsurgical revascularization between October 2014 and September 2017 were analysed. RESULTS In the study period, 23 patients with occlusive ischaemic disease underwent microsurgical revascularization. Three patients presented with serious postoperative complications (2 intraparenchymal haemorrhages in the immediate postoperative period and one thrombosis of the femoral artery). All patients, except one, achieved normalization of the cerebral hemodynamic reserve (CHR) in the SPECT study. Twenty patients had a good neurological result, with no ischaemic recurrence of the revascularized territory. Among patients with moyamoya, 20 had moyamoya disease and 5 had moyamoya syndrome with unilateral involvement. Five patients were treated at paediatric age. Haemorrhagic onset occurred in 2 patients. The CHR study showed hemodynamic compromise in all patients. Cerebral SPECT at one year showed resolution of the hemodynamic failure in all patients. There have been 4 postoperative complications (acute subdural hematoma, two subdural collections and one dehiscence of the surgical wound). No patient presented with neurological worsening at 6 and 12months of follow-up. CONCLUSIONS Cerebral revascularization through end-to-side anastomosis between the superficial temporal artery and a cortical branch of the middle cerebral artery is an indisputable technique in the treatment of moyamoya disease and possibly in a subgroup of patients with symptomatic occlusive ischaemic cerebrovascular disease.
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Tho-Calvi SC, Thompson D, Saunders D, Agrawal S, Basu A, Chitre M, Chow G, Gibbon F, Hart A, Tallur KK, Kirkham F, Kneen R, McCullagh H, Mewasingh L, Vassallo G, Vijayakumar K, Wraige E, Yeo TH, Ganesan V. Clinical features, course, and outcomes of a UK cohort of pediatric moyamoya. Neurology 2018; 90:e763-e770. [DOI: 10.1212/wnl.0000000000005026] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 11/17/2017] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo describe characteristics and course of a large UK cohort of children with moyamoya from multiple centers and examine prognostic predictors.MethodsRetrospective review of case notes/radiology, with use of logistic regression to explore predictors of outcome.ResultsEighty-eight children (median presentation age 5.1 years) were included. Thirty-six presented with arterial ischemic stroke (AIS) and 29 with TIA. Eighty had bilateral and 8 unilateral carotid circulation disease; 29 patients had posterior circulation involvement. Acute infarction was present in 36/176 hemispheres and chronic infarction in 86/176 hemispheres at the index presentation. Sixty-two of 82 with symptomatic presentation had at least one clinical recurrence. Fifty-five patients were treated surgically, with 37 experiencing fewer recurrences after surgery. Outcome was categorized as good using the Recovery and Recurrence Questionnaire in 39/85 patients. On multivariable analysis, presentation with TIA (odds ratio [OR] 0.09, 95% confidence interval [CI] 0.02–0.35), headache (OR 0.10, 95% CI 0.02–0.58), or no symptoms (OR 0.08, 95% CI 0.01–0.68) was less likely to predict poor outcome than AIS presentation. Posterior circulation involvement predicted poor outcome (OR 4.22, 95% CI 1.23–15.53). Surgical revascularization was not a significant predictor of outcome.ConclusionsMoyamoya is associated with multiple recurrences, progressive arteriopathy, and poor outcome in half of patients, especially with AIS presentation and posterior circulation involvement. Recurrent AIS is rare after surgery. Surgery was not a determinant of overall outcome, likely reflecting surgical case selection and presentation clinical status.
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TOMINAGA T, SUZUKI N, MIYAMOTO S, KOIZUMI A, KURODA S, TAKAHASHI JC, FUJIMURA M, HOUKIN K. Recommendations for the Management of Moyamoya Disease: A Statement from Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) [2nd Edition]. ACTA ACUST UNITED AC 2018. [DOI: 10.2335/scs.46.1] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Teiji TOMINAGA
- On behalf of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) Research on Intractable Diseases of the Ministry of Health, Labour and Welfare
| | - Norihiro SUZUKI
- On behalf of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) Research on Intractable Diseases of the Ministry of Health, Labour and Welfare
| | - Susumu MIYAMOTO
- On behalf of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) Research on Intractable Diseases of the Ministry of Health, Labour and Welfare
| | - Akio KOIZUMI
- On behalf of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) Research on Intractable Diseases of the Ministry of Health, Labour and Welfare
| | - Satoshi KURODA
- On behalf of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) Research on Intractable Diseases of the Ministry of Health, Labour and Welfare
| | - Jun C. TAKAHASHI
- On behalf of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) Research on Intractable Diseases of the Ministry of Health, Labour and Welfare
| | - Miki FUJIMURA
- On behalf of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) Research on Intractable Diseases of the Ministry of Health, Labour and Welfare
| | - Kiyohiro HOUKIN
- On behalf of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) Research on Intractable Diseases of the Ministry of Health, Labour and Welfare
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Efficacy of Surgical Treatment on the Recurrent Stroke Prevention for Adult Patients With Hemorrhagic Moyamoya Disease. J Craniofac Surg 2017; 28:2113-2116. [DOI: 10.1097/scs.0000000000004004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Ishii D, Okazaki T, Matsushige T, Shinagawa K, Ichinose N, Sakamoto S, Kurisu K. Postoperative Dilatation of Superficial Temporal Artery Associated with Transient Neurologic Symptoms After Direct Bypass Surgery for Moyamoya Angiopathy. World Neurosurg 2017; 106:435-441. [PMID: 28720528 DOI: 10.1016/j.wneu.2017.07.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 07/06/2017] [Accepted: 07/07/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE In moyamoya angiopathy, transient neurologic symptoms (TNS) are occasionally observed after superficial temporal artery (STA)-middle cerebral artery direct bypass surgery. The purpose of this study was to investigate the correlation between TNS and postoperative magnetic resonance imaging as well as perform a perfusion study. METHODS We reviewed 52 hemispheres in 33 consecutive patients with moyamoya angiopathy. TNS were defined as reversible neurologic dysfunction without any apparent intracranial infarction or hemorrhage. All patients underwent magnetic resonance imaging and single-photon emission computed tomography before and within 5 days after surgery. Maximum diameter of STA on time-of-flight magnetic resonance angiography and the dilatation ratio of STA were calculated. The presence of signal changes on fluid-attenuated inversion recovery images and regional cerebral blood flow were also evaluated. RESULTS TNS were observed in 13 of 52 (25%) cases 1-16 days after surgery. The mean preoperative STA dilatation, postoperative STA dilatation, and dilatation ratio of STA were 1.33 mm ± 0.27, 1.67 mm ± 0.30, and 29.31% ± 28.13%. Postoperative intraparenchymal cortical hyperintensity lesions and high-intensity signals in the cortex sulci (ivy sign) were detected in 24 (46.2%) cases and 29 (55.8%) cases, respectively. Univariate analyses demonstrated no association between TNS and postoperative signal change on fluid-attenuated inversion recovery images as well as cerebral blood flow. Only >1.5-fold dilatation of STA was significantly correlated with TNS (P < 0.0001). CONCLUSIONS STA dilatation was correlated with TNS after direct bypass surgery for moyamoya angiopathy.
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Affiliation(s)
- Daizo Ishii
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Takahito Okazaki
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toshinori Matsushige
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Katsuhiro Shinagawa
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobuhiko Ichinose
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shigeyuki Sakamoto
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kaoru Kurisu
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Komura S, Mikami T, Sugino T, Suzuki Y, Komatsu K, Wanibuchi M, Mikuni N. Complementary Relation Between Direct and Indirect Bypass in Progress of Collateral Circulation in Moyamoya Disease. World Neurosurg 2017; 104:197-204. [PMID: 28478244 DOI: 10.1016/j.wneu.2017.04.122] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/17/2017] [Accepted: 04/18/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND One of the important aims of surgery for moyamoya disease is to establish indirect revascularization. The purpose of this study was to assess the progress of the middle meningeal artery (MMA) after our novel preservation method and to evaluate the relation between direct and indirect bypass in the chronic stage. METHODS A total of 24 hemispheric sides of 19 patients with moyamoya disease were included in this study. Craniotomy was performed with preservation of the MMA during the procedure, then direct bypass was carried out. The relationship between anatomic variations of the MMA and success rate of preserving the MMA during craniotomy was noted. The alteration of the MMA and superficial temporal artery (STA) diameters was then evaluated using magnetic resonance imaging, and the correlation between the MMA and the STA in the chronic stage was examined. RESULTS In total, the MMA was preserved during craniotomy in 20 hemispheric sides (83.3%). During the 3-year follow-up period, the MMA and STA diameters were significantly increased. At 3 years after surgery, the alteration of the MMA diameter was significantly more marked in pediatric cases than in adult cases, and MMA diameter was moderately but significantly negatively correlated with STA diameter. CONCLUSIONS In moyamoya disease, the MMA could be developed as a pathway for indirect revascularization even after simple preservation, especially in pediatric patients. The progress of the MMA and the STA occurs through their synergistic interaction, and the balance might be decided based on their complementary relations in the chronic stage.
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Affiliation(s)
- Shoichi Komura
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Takeshi Mikami
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan.
| | - Toshiya Sugino
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Yuto Suzuki
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Katsuya Komatsu
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | | | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
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Indocyanine green visualization of middle meningeal artery before craniotomy during surgical revascularization for moyamoya disease. Acta Neurochir (Wien) 2017; 159:567-575. [PMID: 28050720 DOI: 10.1007/s00701-016-3060-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 12/20/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The middle meningeal artery (MMA) is well known to function as an important collateral channel to the territory of the anterior cerebral artery in moyamoya disease. This study was aimed to evaluate whether indocyanine green (ICG) videoangiography could visualize the anterior branch of the MMA before craniotomy during surgical revascularization for moyamoya disease. METHODS This study included 19 patients who developed TIA, ischemic stroke or hemorrhagic stroke due to moyamoya disease. Plain CT scan and three-dimensional time-of-flight MR angiography were performed in all patients before surgery. All of them underwent superficial temporal artery to middle temporal artery anastomosis and indirect bypass on 27 sides in total. RESULTS ICG videoangiography could clearly visualize the anterior branch of the MMA in 10 (37%) of 27 sides. The patients with a "visible" MMA are significantly younger than those without. Radiological analysis revealed that ICG videoangiography could visualize it through the cranium when the diameter of the MMA is >1.3 mm and the sphenoid bone thickness over the MMA is <3.0 mm. The MMA could be preserved during craniotomy in all "visible" MMAs, but not in 4 (23.5%) of 17 "invisible" MMAs. The results strongly suggest that ICG videoangiography can visualize the anterior branch of the MMA before craniotomy in about one-third of patients with a large-diameter MMA (>1.3 mm) and thin sphenoid bone (<3.0 mm). CONCLUSION ICG videoangiography is a safe and valuable technique to preserve the anterior branch of the MMA during craniotomy for moyamoya disease.
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Kim T, Bang JS, Kwon OK, Hwang G, Kim JE, Kang HS, Cho WS, Jung C, Oh CW. Hemodynamic Changes after Unilateral Revascularization for Moyamoya Disease: Serial Assessment by Quantitative Magnetic Resonance Angiography. Neurosurgery 2017; 81:111-119. [DOI: 10.1093/neuros/nyw035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/10/2016] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND: Ultrasonic flow meters and quantitative magnetic resonance angiography quantitatively assess flow during hemodynamic evaluation of cerebral ischemia. Although their reliability and reproducibility have been verified, their clinical impact in moyamoya disease has rarely been reported.
OBJECTIVE: To investigate flow measurement outcomes in moyamoya disease patients pre- and postoperatively through a retrospective observational study.
METHODS: We evaluated 41 patients undergoing their first revascularization surgery who were followed ≥6 mo. Hemodynamic parameters were recorded preoperatively, at 1 and 6 mo postoperatively, and at the last follow-up. Demographic factors, Suzuki stage, and stroke development were also analyzed.
RESULTS: Patients’ median age was 37 yr (interquartile range [IQR], 27-43), and 16 (39.0%) patients were men. During follow-up, 9 (22.0%) patients experienced postoperative stroke (4 major strokes). Hemodynamic status was improved in 34 (82.9%) patients at the 6-mo follow-up. Median intraoperative flow was 41 mL/min (IQR, 25-59). Bypass flow peaked at 6 mo (median, 67 mL/min; IQR, 35-99). At the 1- and 6-mo follow-ups, ipsilateral hemispheric flow was significantly increased. The median proportion of posterior circulation at 6 mo was 44.4%, significantly lower than the preoperative proportion (50.1%). Abundant intraoperative bypass flow was associated with hemodynamic improvement, while low contralateral hemispheric flow was related with immediate postoperative ischemic stroke.
CONCLUSION: Ipsilateral hemispheric flow was increased during 6-mo follow-up, and posterior circulation flow burden was diminished. Abundant intraoperative bypass flow was associated with postoperative hemodynamic improvement. Low preoperative contralateral hemispheric flow was related with immediate postoperative ischemic stroke.
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Affiliation(s)
- Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - O-Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Gyojun Hwang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
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Gupta R, M. Moore J, Adeeb N, Griessenauer CJ, Patel AS, Chua MH, Thomas AJ, Ogilvy CS. Clinical presentation, progression, and treatment outcomes of moyamoya disease in the elderly. Acta Neurochir (Wien) 2016; 158:2409-2414. [PMID: 27757556 DOI: 10.1007/s00701-016-2993-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 10/06/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Moyamoya disease is a vascular disorder characterized by progressive stenosis of the internal carotid artery. The presentation, progression, treatment options, and post-operative clinical outcomes for elderly (60 and older) Moyamoya patients have never been reported. METHODS A retrospective analysis of all patients who were diagnosed with Moyamoya disease by the senior authors between 1991 and 2016 was performed. Patients who were 60 years or older at the time of surgery or last follow-up were further evaluated. RESULTS Seventy patients were diagnosed with probable or definite Moyamoya disease during the study period (1991-2016). Eight patients (11.4 %; six females: two males; median age 63; range, 60-71 years) were found to be 60 years or older at the time of surgery or last follow-up and were included in the study. All patients had a modified Rankin scale (mRS) of either one or two (median 1) pre-operatively. Six patients (75 %) underwent surgical treatment on a total on seven hemispheres. Post-surgery, one patient had an improved mRS score, three had no changes, and two had worsening in their mRS scores. Both patients who did not undergo surgical interventions suffered from intra-parenchymal hemorrhages post-diagnosis. CONCLUSIONS Moyamoya disease is most commonly seen in young and middle-aged patients. Presentation in the elderly (defined as 60 years and older in this study) is rare, and has never been reported in the literature. In this study, both direct and indirect revascularization procedures demonstrated potential benefit in some of these patients, with stabilization of progressive symptoms.
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Nagm A, Horiuchi T, Yanagawa T, Hongo K. Risky Cerebrovascular Anatomic Orientation: Implications for Brain Revascularization. World Neurosurg 2016; 96:610.e15-610.e20. [DOI: 10.1016/j.wneu.2016.09.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/03/2016] [Accepted: 09/06/2016] [Indexed: 10/21/2022]
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