Rapid progression of unilateral moyamoya disease

Potential predictors for progression of moyamoya disease: A systematic review and meta-analysis

Background

The progress of Moyamoya disease (MMD) is often accompanied by the occurrence of new ischemia or hemorrhagic events, which was difficult to predict. This systematic review and meta-analysis aimed to identify predictors for progression in MMD patients.

Methods

We searched PubMed, Web of Science, Cochrane Library, and Embase databases up to December 10th, 2022 for randomized controlled trials, case-control studies, or cohort studies reporting predictors of disease progression in MMD patients. The results of each predictor were pooled by meta-analysis and further analyzed by subgroup analysis for predictors of unilateral to bilateral progression of MMD.

Results

A total of 842 patients from 12 studies were included. The estimated pooled means indicated lower age (standard mean difference [SMD]: -0.29, 95% confidence interval [CI]: -0.55 to -0.03; P = 0.03), family history (odds ratio [OR] 3.97, 95% CI: 1.96 to 8.03; P < 0.001) and contralateral abnormality (OR 3.95, 95% CI: 1.10 to 14.20; P = 0.04) were associated with progression in MMD patients. Subgroup analyses indicated that the same three factors were associated with the progression of unilateral to bilateral MMD.

Conclusions

This meta-analysis revealed that lower age, family history and contralateral abnormality were associated with progression in MMD patients. The same three factors are associated with the progression of unilateral to bilateral MMD. Further studies are needed to validate our results.

Cerebral Revascularization Accelerates the Angiographic Staging Progression of the Operated Hemisphere in a Pediatric Patient With Moyamoya Disease

BACKGROUND AND OBJECTIVE

Angiographic staging progression in the operated hemisphere of patient with moyamoya disease (MMD) is a common phenomenon that neurosurgeons may encounter. However, few studies have been carried out to demonstrate the correlation between the operation and angiographic staging progression. This study aimed to reveal whether cerebral revascularization would affect the stage progression in patient with MMD.

METHODS

A total of 20 pediatric patients with bilateral MMD were included in this study. All enrolled patients were at the similar Suzuki angiographic staging on bilateral hemispheres and cerebral revascularization was performed in unilateral hemisphere. Angiographic examination was performed in the first year after the operation to evaluate the progression of the lesions.

RESULTS

Cerebral revascularizations including direct bypass or encephaloduroarteriosynangiosis were performed in 20 hemispheres. During the follow-up, the incidence of stage progression in the operated hemisphere was significantly higher than in the contralateral side (80.0% versus 20.0%, respectively; P = 0.036) and the interval of disease progression was significantly shorter in the operated side than in the contralateral side (mean interval time, 7.3 versus 10 months). Earlier Suzuki stage on hemisphere represented faster pace of stage progression compared with server Suzuki stage (OR = -0.612, P = 0.004), while neoformative collaterals had not significant correlation with the progression pace. The leptomeningeal collaterals from the posterior circulation decreased in almost all operated hemisphere, while gradually increasing in the contralateral hemisphere. Symptoms were improved in all patients after operation.

CONCLUSION

Cerebral revascularization would significantly accelerate the angiographic staging progression on the treated hemisphere, while it would not cause the deterioration of the patient's condition. The progression pace was associated with Suzuki stage.

Conventional Computed Tomography and Axial Magnetic Resonance T2-Weighted Imaging of Horizontal Segment of Middle Cerebral Artery in Moyamoya Disease or Syndrome in Adult Patients

BACKGROUND

Moyamoya disease or syndrome (MMD or MMS) is a cerebrovascular disease characterized by stenosis or occlusion of the distal portion of the internal carotid arteries, with ultimate spread to the proximal portion of the anterior cerebral arteries and middle cerebral arteries (MCAs). In the present study, we wanted to evaluate the usefulness of conventional computed tomography (CT) and axial magnetic resonance (MR) T2-weighted imaging (T2WI) for the examination of horizontal segments of the MCAs (ie, M1 segments) in patients diagnosed with MMD or MMS.

METHODS

This study enrolled 29 patients (n = 11 men; n = 18 women), who underwent conventional CT and/or MR T2WI. CT angiography, MR angiography, or digital subtraction angiography was used as a reference. CT and MR imaging data were reviewed by 2 experienced radiologists, who analyzed and recorded stenosis or occlusions of the M1 segments. We performed statistical analyses to compare the diagnostic accuracy of both techniques on M1 segments in MMD or MMS.

RESULTS

Fifty-three steno-occlusive changes of M1 segments were revealed by angiography in the 29 patients. T2W-MRI allowed the identification of moyamoya vessels with 100% success rate. Stenosis and occlusion of M1 segments were better visualized on axial T2W-MRI compared to conventional CT (94.59% versus 71.43%; P = .008).

CONCLUSIONS

Our study showed that conventional CT and axial T2W-MRI could be used to identify the steno-occlusive changes of the horizontal segment of the MCA in MMD or MMS, which may have a significant impact on the accurate diagnosis of this disease at its early stage.

Unstable moyamoya disease: clinical features and impact on perioperative ischemic complications

OBJECT

Unstable moyamoya disease, reasonably defined as cases exhibiting either rapid disease progression or repeated ischemic stroke, represents a challenge in the treatment of moyamoya disease. Despite its overall efficacy, direct bypass for such unstable disease remains controversial in terms of safety. This study aims to reveal factors associated with unstable disease and to assess its impact on postoperative silent or symptomatic ischemic lesions.

METHODS

This retrospective cohort study included both pediatric and adult patients with moyamoya disease who had undergone 140 consecutive direct bypass procedures at Kyoto University Hospital. “Unstable moyamoya disease” was defined as either the rapid progression of a steno-occlusive lesion or repeat ischemic stroke, either occurring within 6 months of surgery. The extent of progression was determined through a comparison of the findings between 2 different MR angiography sessions performed before surgery. The clinical variables of the stable and unstable disease groups were compared, and the association between unstable disease and postoperative diffusion-weighted imaging (DWI)–detected lesion was assessed through univariate and multivariate analyses with generalized estimating equations.

RESULTS

Of 134 direct bypass procedures performed after patients had undergone at least 2 sessions of MR angiography, 24 (17.9%) were classified as cases of unstable disease. Age younger than 3 years (p = 0.029), underlying disease causing moyamoya syndrome (p = 0.049), and radiographic evidence of infarction (p = 0.030) were identified as factors associated with unstable disease. Postoperative DWI-defined lesions were detected after 13 of 140 procedures (9.3%), although only 4 lesions (2.9%) could be classified as a permanent complication. The incidence of postoperative DWI-detected lesions in the unstable group was notable at 33.3% (8 of 24). Univariate analysis revealed that unstable disease (p < 0.001), underlying disease (p = 0.028), and recent stroke (p = 0.012) were factors associated with DWI-detected lesions. Unstable disease remained statistically significant after adjustment for covariates in both the primary and sensitivity analyses (primary analysis: OR 6.62 [95% CI 1.79–24.5]; sensitivity analysis: OR 5.36 [95% CI 1.47–19.6]).

CONCLUSIONS

Unstable moyamoya disease, more prevalent in younger patients and those with underlying disease, is a possible risk factor for perioperative ischemic complications. Recognition of unstable moyamoya disease may contribute to an improved surgical result through focused perioperative management based on appropriate surgical risk stratification.

Rapid progression of cerebral infarction after intraventricular hemorrhage in adult moyamoya disease

The authors present a rare case of adult moyamoya disease in which a patient experienced rapid progression of cerebral infarction after intraventricular hemorrhage (IVH). A healthy 39-year-old woman was admitted to our hospital with sudden headache, a decreased level of consciousness and mild tetraparesis. Initial magnetic resonance imaging revealed small cerebral infarction and IVH. Although the patient underwent conservative therapy including hypervolemia, hemodilution, keeping moderate hypertension and administration of a free radical scavenger, she showed a fulminant clinical course of cerebral infarction. The authors discuss the possible pathophysiology and suggest the treatment for such cases.