1
|
Tigchelaar SS, Wang AR, Vaca SD, Li Y, Steinberg GK. Incidence and Outcomes of Posterior Circulation Involvement in Moyamoya Disease. Stroke 2024; 55:1254-1260. [PMID: 38567531 DOI: 10.1161/strokeaha.123.044693] [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: 08/31/2023] [Accepted: 02/29/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Moyamoya disease (MMD) is a progressive, occlusive disease of the internal carotid arteries and their proximal branches, with the subsequent development of an abnormal vascular network that is rupture-prone. Steno-occlusive changes in the posterior cerebral arteries (PCAs) may contribute to worsened outcomes in patients with MMD; however, there is little information on the incidence and natural history of posterior circulation MMD (PCMMD). We describe clinical PCMMD characteristics in a large cohort of patients with MMD. METHODS We retrospectively reviewed patients with MMD treated between 1991 and 2019 at a large academic medical center. Demographics, perioperative outcomes, and radiological phenotypes were recorded for 770 patients. PCA disease was graded as either 0 (no disease), 1 (mild), 2 (moderate), or 3 (severe or occluded) based on cerebral angiography. Patients with angiographically confirmed MMD diagnosis with at least 6 months follow-up and completion of revascularization surgery were included; patients with intracranial atherosclerosis, intracranial dissection, vasculitis, and undefined inflammatory processes were excluded. The presence of stenosis/occlusion was graded radiographically to assess for disease progression and the prevalence of risk factors related to reduced progression-free survival. RESULTS In all, 686 patients met the inclusion criteria, with PCA disease identified in 282 (41.1%) patients. Of those 282 patients with PCMMD, disease severity ranged from 99 (35.1%) with mild, 72 (25.5%) with moderate, and 111 (39.4%) with severe. The total number of postoperative complications was significantly associated with PCMMD severity (P=0.0067). Additionally, PCMMD severity correlated with worse postoperative modified Rankin Scale scores (P<0.0001). At a mean follow-up of 6.0±3.9 (range, 0.1-25.0) years, a total of 60 (12.6%) patients showed new/worsening PCMMD. The overall postoperative, progression-free survival in patients with PCMMD was 95.4% at 1 year, 82.4% at 3 years, 68.8% at 5 years, and 28.3% at 10 years, with prognostic factors for progression including preoperative PCMMD status, history of tobacco use, and hypertension (P<0.0001, P<0.001, and P<0.0001, respectively). CONCLUSIONS PCA disease involvement in MMD is associated with higher rates of ischemic perioperative complications and worsened functional outcomes, likely due to reduced collateral flow. Ten-year progression of PCA disease is highly likely and should be monitored throughout follow-up; future studies will assess the impact of PCA disease progression on long-term outcomes.
Collapse
Affiliation(s)
- Seth S Tigchelaar
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Allan R Wang
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Silvia D Vaca
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Yiping Li
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| | - Gary K Steinberg
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
2
|
Luo S, Zhan W, Zhang L, Zeng C, Hong D, Fang P, Chen Q, Lin J. Ischemic patterns and their angiographic risk factors in adult patients with moyamoya disease. Ann Clin Transl Neurol 2023; 10:2386-2393. [PMID: 37830135 PMCID: PMC10723237 DOI: 10.1002/acn3.51927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 08/20/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023] Open
Abstract
OBJECTIVE The present study aims to determine whether angiographic differences increase the risk of ischemic pattern among adult patients with moyamoya disease (MMD). METHODS From January 2020 to December 2021, we retrospectively enrolled 123 ischemic or asymptomatic adult patients diagnosed as MMD. Angiographic changes including Suzuki stage, moyamoya vessels, anterior choroidal artery (AChoA) dilatation, lenticulostriate artery (LSA) dilatation, posterior communicating artery (PcomA) dilatation, and posterior cerebral artery (PCA) involvement were evaluated for all patients. RESULTS Among the 123 participants, 35 ischemic patients and 88 asymptomatic patients were analyzed. There was no significant difference of Suzuki stage, AChoA dilatation, LSA dilatation, and PcomA dilatation between ischemic group and asymptomatic group. The grading of moyamoya vessels differed significantly but was not a factor associated with ischemic pattern after adjusting multiple related confounders. However, the frequency of PCA steno-occlusive changes in ischemic patients was statistically higher than that in asymptomatic patients (54.3% vs 34.1%, p = 0.039). Furthermore, PCA involvement was a risk factor associated with ischemic form and remained statistically significant after the multivariate adjustment (p = 0.033, 95% CI 1.092-8.310). INTERPRETATION PCA involvement is closely related to the presentation of ischemic stroke but other angiographic features had no association with ischemic pattern in adult MMD.
Collapse
Affiliation(s)
- Si Luo
- Department of NeurologyThe First Affiliated Hospital of Nanchang UniversityNanchang330000JiangxiChina
| | - Wenjie Zhan
- Department of NeurologyThe First Affiliated Hospital of Nanchang UniversityNanchang330000JiangxiChina
| | - Lanjiao Zhang
- Department of NeurologyThe First Affiliated Hospital of Nanchang UniversityNanchang330000JiangxiChina
| | - Chenying Zeng
- Department of NeurologyThe First Affiliated Hospital of Nanchang UniversityNanchang330000JiangxiChina
| | - Daojun Hong
- Department of NeurologyThe First Affiliated Hospital of Nanchang UniversityNanchang330000JiangxiChina
| | - Pu Fang
- Department of NeurologyThe First Affiliated Hospital of Nanchang UniversityNanchang330000JiangxiChina
| | - Qianxi Chen
- Department of NeurologyThe First Affiliated Hospital of Nanchang UniversityNanchang330000JiangxiChina
| | - Jing Lin
- Department of NeurologyThe First Affiliated Hospital of Nanchang UniversityNanchang330000JiangxiChina
| |
Collapse
|
3
|
Ha EJ, Phi JH, Lee JY, Koh EJ, Kim KH, Wang KC, Cho BK, Kim SK. Long-Term Surgical Outcome of Indirect Bypass Surgery in Young Children With Moyamoya Disease. Neurosurgery 2023; 93:901-909. [PMID: 37561505 DOI: 10.1227/neu.0000000000002489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/13/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND The prognosis of moyamoya disease (MMD) in young children (younger than 4 years) is worse than that of older adults. The effectiveness of surgery is still inconclusive. OBJECTIVE To evaluate long-term outcomes after indirect bypass in young children with MMD. METHODS A total of 1417 MMD children underwent indirect bypass from August 1988 to October 2020. This study included 135 patients who were younger than 4 years at the time of surgery. The clinical features and surgical outcomes of these patients were assessed. We analyzed the long-term outcome of 102 children who were followed up for more than 5 years (mean: 18.8 years, range: 5-27.3 years). Cross-sectional analysis was performed to evaluate overall outcomes based on the Lansky Play Performance Scale (LPS). The annual risk of symptomatic stroke after 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 (LPS ≥ 80) in 88% of the patients. The overall postoperative adverse event rate was 15%, including 1 death. At the last follow-up, 86% of patients who had seizures at diagnosis were seizure-free. During the follow-up, there were 3 symptomatic infarctions on the operated hemisphere (postoperative 3, 3, and 10 months each). There was no hemorrhagic event. The annual infarction rate was 0.16% per person-year. The 20-year event-free survival rates for symptomatic infarction were 97%. CONCLUSION Indirect bypass could provide a satisfactory long-term outcome and prevent recurrent stroke in young children with MMD.
Collapse
Affiliation(s)
- Eun Jin Ha
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul , Republic of Korea
| | - Ji Hoon Phi
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
| | - Ji Yeoun Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
- Department of Anatomy and Cell Biology, Seoul National University College of Medicine, Seoul , Republic of Korea
| | - Eun Jung Koh
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
| | - Kyung Hyun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
| | - Kyu-Chang Wang
- Center for Rare Cancers, National Cancer Center, Goyang , Gyeonggi-do , Republic of Korea
| | - Byung-Kyu Cho
- Department of Neurosurgery, Armed Forces Capital Hospital, Seongnam , Gyeonggi-do , Republic of Korea
| | - Seung-Ki Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
| |
Collapse
|
4
|
Kim JW, Phi JH, Lee JY, Koh EJ, Kim KH, Kim HS, Kim SK. Comparison of Bifrontal Craniotomy and Multiple Burr Hole Encephalogaleoperiosteal-Synangiosis for Pediatric Moyamoya Disease: An Experience of 346 Patients. Neurosurgery 2023; 93:824-834. [PMID: 37057917 DOI: 10.1227/neu.0000000000002499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/23/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Moyamoya disease (MMD) is a steno-occlusive disease treated with revascularization surgery. Craniotomy and multiple burr hole encephalogaleoperiosteal-synangiosis (EGPS) are used for revascularization of the anterior cerebral artery territory. The aim of this study was to compare the clinical outcome between the 2 surgical methods in pediatric patients with MMD. METHODS A retrospective review of patients with MMD who underwent bifrontal indirect bypass surgery was performed. Clinical features, perioperative data, and angiographic, perfusion, and functional outcomes were compared between the 2 groups. Propensity score matching was performed to compare the perioperative characteristics and clinical outcomes. RESULTS A total of 346 patients were included in this study, 111 patients underwent bifrontal craniotomy EGPS, and 235 patients had bifrontal multiple burr hole EGPS. An insignificant higher rate of postoperative infarction (11.7% vs 5.5%, P = .072) and more postoperative hemorrhage occurred in the craniotomy EGPS group (3.6% vs 0%, P = .004). Of the 83 patients selected with propensity score matching for each group, the duration of operation was shorter ( P < .001) and the amount of intraoperative bleeding was significantly less in the multiple burr hole EGPS group ( P = .008). There was no difference in clinical outcomes between the 2 groups. CONCLUSION Bifrontal multiple burr hole EGPS has benefits over craniotomy with shorter surgical time, less intraoperative bleeding, fewer postoperative complications, and comparable perfusion and functional outcomes. Multiple burr hole EGPS is a safe and effective method that might be considered for revascularization of the anterior cerebral artery territory in pediatric patients with MMD.
Collapse
Affiliation(s)
- Joo Whan Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
| | - Ji Hoon Phi
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul , Republic of Korea
| | - Ji Yeoun Lee
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Neural Development and Anomaly Laboratory, Department of Anatomy and Cell Biology, Seoul National University College of Medicine, Seoul , Republic of Korea
| | - Eun Jung Koh
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
| | - Kyung Hyun Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
| | - Hee-Soo Kim
- Division of Pediatric Anesthesiology and Pain Medicine, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul , Republic of Korea
| |
Collapse
|
5
|
Couldwell MW, Cheshier S, Taussky P, Mortimer V, Couldwell WT. Right frontotemporal craniotomy for ECA-to-MCA direct and indirect bypass and occipital artery indirect bypass to the posterior circulation: case report. J Neurosurg Pediatr 2020; 27:180-184. [PMID: 33254140 DOI: 10.3171/2020.7.peds20181] [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: 03/16/2020] [Accepted: 07/06/2020] [Indexed: 11/06/2022]
Abstract
Moyamoya is an uncommon disease that presents with stenoocclusion of the major vasculature at the base of the brain and associated collateral vessel formation. Many pediatric patients with moyamoya present with transient ischemic attacks or complete occlusions. The authors report the case of a 9-year-old girl who presented with posterior fossa hemorrhage and was treated with an emergency suboccipital craniotomy for evacuation. After emergency surgery, an angiogram was performed, and the patient was diagnosed with moyamoya disease. Six months later, the patient was treated for moyamoya using direct and indirect revascularization; after surgery there was excellent vascularization in both regions of the bypass and no further progression of moyamoya changes. This case illustrates a rare example of intracerebral hemorrhage associated with moyamoya changes in the posterior vascularization in a pediatric patient and subsequent use of direct and indirect revascularization to reduce the risk of future hemorrhage and moyamoya progression.
Collapse
Affiliation(s)
- Mitchell W. Couldwell
- Department of Neurological Surgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Samuel Cheshier
- Department of Neurological Surgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Philipp Taussky
- Department of Neurological Surgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Vance Mortimer
- Department of Neurological Surgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - William T. Couldwell
- Department of Neurological Surgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| |
Collapse
|
6
|
Fiaschi P, Scala M, Piatelli G, Tortora D, Secci F, Cama A, Pavanello M. Limits and pitfalls of indirect revascularization in moyamoya disease and syndrome. Neurosurg Rev 2020; 44:1877-1887. [PMID: 32959193 PMCID: PMC8338852 DOI: 10.1007/s10143-020-01393-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/11/2020] [Accepted: 09/15/2020] [Indexed: 11/28/2022]
Abstract
Moyamoya vasculopathy is a rare chronic cerebrovascular disorder characterized by the stenosis of the terminal branches of the internal carotid arteries and the proximal tracts of anterior and middle cerebral arteries. Although surgical revascularization does not significantly change the underlying pathogenic mechanisms, it plays a pivotal role in the management of affected individuals, allowing to decrease the risk of ischemic and hemorrhagic complications. Surgical approaches may be direct (extracranial-intracranial bypass), indirect, or a combination of the two. Several indirect techniques classifiable according to the tissue (muscle, periosteum, galea, dura mater, and extracranial tissues) or vessel (artery) used as a source of blood supply are currently available. In this study, we reviewed the pertinent literature and analyzed the advantages, disadvantages, and pitfalls of the most relevant indirect revascularization techniques. We discussed the technical aspects and the therapeutical implications of each procedure, providing a current state-of-the-art overview on the limits and pitfalls of indirect revascularization in the treatment of moyamoya vasculopathy.
Collapse
Affiliation(s)
- Pietro Fiaschi
- Department of Neurosurgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Marcello Scala
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy. .,Department of Neurosurgery, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini, Genoa, Italy.
| | - Gianluca Piatelli
- Department of Neurosurgery, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini, Genoa, Italy
| | - Domenico Tortora
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Francesca Secci
- Department of Neurosurgery, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini, Genoa, Italy
| | - Armando Cama
- Department of Neurosurgery, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini, Genoa, Italy
| | - Marco Pavanello
- Department of Neurosurgery, IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini, Genoa, Italy
| |
Collapse
|
7
|
Lee J, Kim SK, Kang HG, Ha IS, Wang KC, Lee JY, Phi JH. High prevalence of systemic hypertension in pediatric patients with moyamoya disease years after surgical treatment. J Neurosurg Pediatr 2019; 25:131-137. [PMID: 31703203 DOI: 10.3171/2019.9.peds1986] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 09/10/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although an association between moyamoya disease (MMD) and renovascular hypertension has been acknowledged, the literature on systemic hypertension without renal artery stenosis among patients with MMD is scarce. The authors aimed to evaluate the prevalence and risk factors of hypertension using data from MMD patients who visited an outpatient clinic of a pediatric neurosurgical department in 2016. METHODS The authors evaluated the blood pressure (BP) of pediatric MMD patients at their postsurgical appointment following the American Academy of Pediatrics clinical practice guideline on high BP, in which hypertension was defined as BP measurements higher than the value of age-, sex-, and height-specific 95th percentile of the general population from at least 3 separate visits. Growth of patients was determined using 2017 Korean National Growth Charts for children and adolescents. The cutoff value of the 95th percentile of BP was determined by referring to normative BP tables of Korean children and adolescents. A logistic regression model was used to assess the associations between patients' clinical characteristics and prevalent hypertension. RESULTS In total, 131 surgically treated pediatric MMD patients were included, of whom 38.9% were male and the median age at diagnosis was 8.0 years (range 1.2-15.0 years). The definition of hypertension was met in 38 patients, with a prevalence of 29.0% (95% CI 21.2%-36.8%). A tendency was observed for a higher prevalence of hypertension in male patients (31.4%), in patients with posterior cerebral artery (PCA) involvement (47.8%), and in cases in which infarction was shown on initial MRI (37.3%). Age at diagnosis (adjusted OR [aOR] 0.82, 95% CI 0.70-0.97), PCA involvement (aOR 3.81, 95% CI 1.29-11.23), body mass index (aOR 1.30, 95% CI 1.13-1.51), and years of follow-up since surgery (aOR 0.80, 95% CI 0.68-0.94) were related to systemic hypertension. CONCLUSIONS A high prevalence of hypertension was demonstrated in pediatric MMD patients. Therefore, adequate attention should be paid to reduce BP and prevent subsequent events.
Collapse
Affiliation(s)
- Joongyub Lee
- 1Department of Prevention and Management, Inha University Hospital, School of Medicine, Inha University
- 2Incheon Regional Cardiocerebrovascular Disease Center, Incheon
| | | | - Hee Gyung Kang
- 4Department of Pediatrics, Seoul National University Children's Hospital; and
| | - Il-Soo Ha
- 4Department of Pediatrics, Seoul National University Children's Hospital; and
| | | | - Ji Yeoun Lee
- 3Division of Pediatric Neurosurgery and
- 5Department of Anatomy, Seoul National University College of Medicine, Seoul, Korea
| | | |
Collapse
|
8
|
Rosi A, Riordan CP, Smith ER, Scott RM, Orbach DB. Clinical status and evolution in moyamoya: which angiographic findings correlate? Brain Commun 2019; 1:fcz029. [PMID: 32954269 PMCID: PMC7425301 DOI: 10.1093/braincomms/fcz029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/20/2019] [Accepted: 08/12/2019] [Indexed: 11/23/2022] Open
Abstract
Moyamoya is a progressive steno-occlusive cerebrovascular pathology of unknown aetiology that usually involves the terminal portions of the internal carotid arteries and/or the proximal portions of the anterior and middle cerebral arteries bilaterally. The pre-operative Suzuki staging system and post-operative Matsushima grade are nearly universally used markers of natural history and surgical revascularization results, respectively, but their correlation with clinical and radiographic manifestations of moyamoya has not been systematically evaluated in a large cohort. This study evaluated the strength of correlations between pre- and post-operative angiographic parameters and clinical status among paediatric patients with moyamoya. The participants included 58 patients of mean age 11 years at the time of surgery who underwent bilateral indirect revascularization in the same procedure at Boston Children’s Hospital, between January 2010 and December 2015. All included patients had available pre-operative and 1-year post-operative digital subtraction angiography. Clinical data included presenting symptoms, degree of functional incapacity, and peri-operative and long-term complications. Radiographic data included pre-operative Suzuki stage, degree of arterial stenosis, a novel collateral score, the presence of hypovascular territories on digital subtraction angiography, and post-operative Matsushima grade and evolution of stenosis. Chi-squared test and Pearson coefficient were used for correlation studies for categorical variables and Spearman’s rho was used for correlation studies for continuous variables. Results showed that Suzuki stage, collateral score and degree of stenosis were insufficient to predict clinical presentation, pre-operative incapacity and radiographic presentation, whereas the presence of hypovascular territories was correlated with all of these. At 1-year follow-up, Matsushima grade was insufficient for predicting peri-operative or long-term complications, nor did it correlate with post-operative incapacity. The presence of hypovascular territories at 1-year follow-up was correlated with the incidence of post-operative ischaemic symptoms.
Collapse
Affiliation(s)
- Andrea Rosi
- Department of Experimental and Clinical Sciences, Careggi University Hospital, University of Florence, 3 Largo Giovanni Alessandro Brambilla, 50134 Florence, Italy
| | - Coleman P Riordan
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - R Michael Scott
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Darren B Orbach
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.,Neurointerventional Radiology Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| |
Collapse
|
9
|
Lin YH, Kuo MF, Lu CJ, Lee CW, Yang SH, Huang YC, Liu HM, Chen YF. Standardized MR Perfusion Scoring System for Evaluation of Sequential Perfusion Changes and Surgical Outcome of Moyamoya Disease. AJNR Am J Neuroradiol 2019; 40:260-266. [PMID: 30655253 DOI: 10.3174/ajnr.a5945] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 12/01/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Simple-but-precise evaluation of cerebral perfusion is crucial for the treatment of Moyamoya disease. We aimed to develop a standardized scoring system for MR perfusion suitable for Moyamoya disease evaluation and investigate the postoperative serial changes and outcome predictors. MATERIALS AND METHODS From January 2013 to December 2016, patients diagnosed with Moyamoya disease and receiving indirect revascularization were recruited prospectively. Clinical data and serial imaging studies were analyzed. The TTP maps were standardized using cerebellar reference values. We developed a scoring system of standardized TTP maps: 14 points for each hemisphere with higher points indicating better perfusion. RESULTS In total, 24 children (4-17 years of age, 41 hemispheres) and 20 adults (18-51 years of age, 34 hemispheres) were included. The mean preoperative TTP scores were higher in children (7.34 ± 3.90) than in adults (4.88 ± 3.24). The standardized TTP maps revealed dynamic improvement with an increase in the corresponding scores at the 1-, 3-, and 6-month postoperative follow-ups; the scores stabilized after 6 months. The mean improvement in the 6-month scores of the pediatric and adult groups was 4.15 ± 3.55 and 6.03 ± 3.04, respectively. The 6-month TTP score improvements were associated with Matsushima grades. If we took score improvement as the outcome, the preoperative TTP score was the only significant predictor in multivariable analysis. CONCLUSIONS The standardized TTP maps and scoring system facilitated the quantification of the sequential perfusion changes during Moyamoya disease treatment. The preoperative perfusion status was the only predictor of indirect revascularization outcome.
Collapse
Affiliation(s)
- Y-H Lin
- From the Department of Medical Imaging (Y.-H.L., C.-J.L., C.-W.L., Y.-F.C.)
| | - M-F Kuo
- Division of Neurosurgery (M.-F.K., S.-H.Y.), Department of Surgery, National Taiwan University Hospital, Taiwan
| | - C-J Lu
- From the Department of Medical Imaging (Y.-H.L., C.-J.L., C.-W.L., Y.-F.C.)
| | - C-W Lee
- From the Department of Medical Imaging (Y.-H.L., C.-J.L., C.-W.L., Y.-F.C.)
| | - S-H Yang
- Division of Neurosurgery (M.-F.K., S.-H.Y.), Department of Surgery, National Taiwan University Hospital, Taiwan
| | - Y-C Huang
- Department of Medical Imaging (Y.-C.H.), Min-Sheng General Hospital, Taoyuan, Taiwan
| | - H-M Liu
- Department of Radiology (H.-M.L.), Fu Jen Catholic University Hospital, New Taipei City, Taiwan
| | - Y-F Chen
- From the Department of Medical Imaging (Y.-H.L., C.-J.L., C.-W.L., Y.-F.C.)
| |
Collapse
|
10
|
Bao XY, Fan YN, Liu Y, Wang QN, Zhang Y, Zhu B, Liu B, Duan L. Circulating endothelial progenitor cells and endothelial cells in moyamoya disease. Brain Behav 2018; 8:e01035. [PMID: 30141248 PMCID: PMC6160662 DOI: 10.1002/brb3.1035] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 04/27/2018] [Accepted: 05/25/2018] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION There is no well-recognized biomarker for accurately predicting outcome in the presence of moyamoya disease (MMD), a progressive occlusive cerebrovascular disease of the internal carotid arteries or their branches. The aim of this study was to investigate the presence of endothelial progenitor cells (EPCs) and circulating endothelial cells (CECs) in MMD and correlate the findings with clinical features. METHODS Patients with MMD (n = 66) were compared with healthy controls (n = 81). Blood samples were obtained from an antecubital vein and analyzed using flow cytometry. EPCs were defined as CD31+ CD45dim CD34br CD133+ and CECs as CD31br CD45- CD34dim CD133- . Univariate and multivariate linear regression analyses were carried out. RESULTS The CEC counts were significantly higher in the patients than in the controls (p = 0.008). In multivariate analysis, EPC counts were independently associated with age of patients with MMD (p = 0.049) and CEC counts were independently negatively associated with concomitant disease such as hypertension, diabetes mellitus, and coronary heart disease (p = 0.034). CONCLUSIONS This is the first study to investigate the presence of CECs in the plasma of patients with MMD, and the amount of CECs was negatively correlated with concomitant disease in these patients.
Collapse
Affiliation(s)
- Xiang-Yang Bao
- Department of Neurosurgery, The Center for Cerebral Vascular Disease, PLA, 307th Hospital, PLA, Beijing, China
| | - Yan-Na Fan
- Center of Interventional Radiology for Oncology, 307th Hospital, PLA, Beijing, China
| | - Yi Liu
- Lab of Tumor Molecular, 307th Hospital, PLA, Beijing, China
| | - Qian-Nan Wang
- Department of Neurosurgery, The Center for Cerebral Vascular Disease, PLA, 307th Hospital, PLA, Beijing, China
| | - Yong Zhang
- Department of Neurosurgery, The Center for Cerebral Vascular Disease, PLA, 307th Hospital, PLA, Beijing, China
| | - Bing Zhu
- Department of Neurosurgery, The Center for Cerebral Vascular Disease, PLA, 307th Hospital, PLA, Beijing, China
| | - Bing Liu
- Lab of Tumor Molecular, 307th Hospital, PLA, Beijing, China
| | - Lian Duan
- Department of Neurosurgery, The Center for Cerebral Vascular Disease, PLA, 307th Hospital, PLA, Beijing, China
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Lee SU, Oh CW, Kwon OK, Bang JS, Ban SP, Byoun HS, Kim T. Surgical Treatment of Adult Moyamoya Disease. Curr Treat Options Neurol 2018; 20:22. [PMID: 29808372 DOI: 10.1007/s11940-018-0511-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Moyamoya disease (MMD) is being increasingly diagnosed with the development of radiological surveillance technology and increased accessibility to medical care. Accordingly, there have been several recent reports on treatment outcomes in MMD. In this review, we summarize recent advances in surgical treatment and outcomes of adult MMD, while addressing related controversies. RECENT FINDINGS Recent studies suggest that revascularization surgery leads to significantly more favorable outcomes for stroke prevention, angiographic and hemodynamic changes, and clinical outcomes than does conservative treatment for adult patients with ischemic MMD. Moreover, direct revascularization methods should be considered as the first-line treatment over indirect methods, although the latter may be considered if a direct method is not possible. In cases of hemorrhagic MMD, several studies have demonstrated that surgical treatment is more effective than conservative treatment in preventing further hemorrhage. In addition to revascularization surgery, endovascular treatment is emerging as a breakthrough therapy for hemorrhagic MMD. Accumulating evidence regarding the surgical treatment of adult MMD suggests the benefit of revascularization over conservative management for both ischemic and hemorrhagic patients. However, the benefit of revascularization in asymptomatic adult MMD remains unclear.
Collapse
Affiliation(s)
- Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro Jongno-Gu, Seoul, 03080, Republic of Korea
| | - O-Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Seung Pil Ban
- Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Hyoung Soo Byoun
- Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea. .,Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro Jongno-Gu, Seoul, 03080, Republic of Korea.
| |
Collapse
|
13
|
Chong S, Park JD, Chae JH, Cheon JE, Kim SK, Phi JH, Lee JY, Paeng JC, Wang KC. Extensive brain infarction involving deep structures during an acetazolamide-challenged single-photon emission computed tomography scan in a patient with moyamoya disease. Childs Nerv Syst 2017; 33:2029-2033. [PMID: 28689345 DOI: 10.1007/s00381-017-3512-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 06/27/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Acetazolamide-challenged brain single-photon emission computed tomography (SPECT) is used for the evaluation of cerebral perfusion in cerebrovascular diseases including moyamoya disease (MMD). Not a few patients experience adverse side effects during the acetazolamide-challenged brain SPECT, but most of the symptoms are mild and transient. To our knowledge, this is the first case report of severe brain infarction leading to death during the examination of an acetazolamide-challenged brain SPECT in a patient with MMD. CASE PRESENTATION An 11-year-old girl who had been diagnosed of MMD demonstrated sudden tonic movement during an acetazolamide-challenged brain SPECT as the preoperative examination for the second surgery. She had not experienced any adverse effect during the previous SPECT study and her first indirect bypass surgery on both left side and bifrontal area was uneventful. After she had seizures twice, she became unconscious and her pupils were dilated and fixed. Acute infarction involving bilateral occipital lobes, thalami, brainstem, and cerebellum was observed on brain magnetic resonance images which led to brain death. CONCLUSION We report a mortality case of patient with MMD after the administration of acetazolamide during the examination of brain SPECT that was accompanied by an extensive acute infarction involving the bilateral occipital lobes and thalami, brainstem, and cerebellum. Physicians should be aware of this rare but serious complication.
Collapse
Affiliation(s)
- Sangjoon Chong
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Jong Hee Chae
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Jung-Eun Cheon
- Division of Pediatric Radiology, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Ji Hoon Phi
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Ji Yeoun Lee
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Anatomy, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Jin Chul Paeng
- Department of Nuclear Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - Kyu-Chang Wang
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| |
Collapse
|
14
|
Kim T, Oh CW, Bang JS, Kim JE, Cho WS. Moyamoya Disease: Treatment and Outcomes. J Stroke 2016; 18:21-30. [PMID: 26846757 PMCID: PMC4747064 DOI: 10.5853/jos.2015.01739] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 01/17/2016] [Accepted: 01/17/2016] [Indexed: 11/23/2022] Open
Abstract
Although the pathogenesis of moyamoya disease (MMD) has not been fully elucidated, the effectiveness of surgical revascularization in preventing stroke has been addressed by many studies. The main mechanism of surgical revascularization is augmenting the intracranial blood flow using an external carotid system by either direct bypass or pial synangiosis. This can improve resting cerebral blood flow as well as vascular reserve capacity. For direct revascularization, the superficial temporal artery is used as the donor artery in most cases, although the occipital artery may be used in limited cases. Usually, the cortical branch of the middle cerebral artery is selected as the recipient of direct anastomosis. As for indirect revascularization, various techniques using different kinds of connective tissues have been introduced. In some cases, reinforcing the anterior cerebral artery and the posterior cerebral artery territories can be considered. The effectiveness of surgical revascularization for preventing ischemic stroke had been generally accepted by many studies. However, for preventing hemorrhagic stroke, new evidence has been added by a recent randomized controlled trial. The incidence of peri-operative complications such as stroke and hyperperfusion syndrome seems to be high due to the nature of the disease and technical demands for treatment. Preventing and adequately managing these complications are essential for ensuring the benefits of surgery.
Collapse
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
| | - Chang Wan Oh
- 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
| | - Jeong Eun Kim
- 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
| |
Collapse
|
15
|
Kim JS. Moyamoya Disease: Epidemiology, Clinical Features, and Diagnosis. J Stroke 2016; 18:2-11. [PMID: 26846755 PMCID: PMC4747069 DOI: 10.5853/jos.2015.01627] [Citation(s) in RCA: 257] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/24/2015] [Accepted: 12/28/2015] [Indexed: 11/29/2022] Open
Abstract
Moyamoya disease (MMD) is a chronic, occlusive cerebrovascular disease characterized by progressive stenosis at the terminal portion of the internal carotid artery and an abnormal vascular network at the base of the brain. Although its etiology remains unknown, recent genetic studies identified RNF213 in the 17q25-ter region as an important susceptibility gene of MMD among East Asian populations. Possibly because of genetic differences, MMD is relatively common in people living in East Asian countries such as Korea and Japan, compared to those in the Western Hemisphere. The prevalence of MMD appears to be slightly lower among Chinese, compared to Koreans or Japanese. There are two peaks of incidence with different clinical presentations, at around 10 years and 30-40 years. The peak appears to occur later in women than men. In children, ischemic symptoms, especially transient ischemic attacks, are predominant. Intellectual decline, seizures, and involuntary movements are also more common in this age group. In contrast, adult patients present with intracranial hemorrhage more often than pediatric patients. In patients with MMD, intracerebral hemorrhage is more often accompanied by intraventricular hemorrhage than in patients with hypertensive intracerebral hemorrhage. These different age peaks and different clinical presentations in each age group are also observed in MMD patients in the USA. Catheter angiography is the diagnostic method of choice. Magnetic resonance (MR) angiography and computed tomographic angiography are noninvasive diagnostic methods. High-resolution vessel wall MR imaging also helps diagnose MMD by revealing concentric vessel wall narrowing with basal collaterals.
Collapse
Affiliation(s)
- Jong S Kim
- Stroke Center and Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
| |
Collapse
|