Hemorrhagic Transformation in Ischemic Moyamoya Disease: Clinical Characteristics, Radiological Features, and Outcomes

Antiplatelet therapy may improve the prognosis of patients with moyamoya disease: a 12-year retrospective study

OBJECTIVES

The clinical value of antiplatelet therapy (APT) for moyamoya disease (MMD) remains controversial. Our study attempts to clarify the value of APT in this disease.

METHODS

We collected basic information, treatment strategies, and prognostic information on patients with MMD from 2010 to 2022 at our center. The data were divided into two groups, depending on whether APT was used or not, and compared by Pearson Chi-Square, Fisher's exact test, or Wilcoxon rank-sum test. We used propensity scores or inverse probability of treatment weighting to balance the covariates. Following this, we performed a meta-analysis of APT use in MMD.

RESULTS

177 patients were enrolled, with a median follow-up of 41.1 months. APT did not affect the prognosis of patients with perioperative MMD, ischemic MMD, or asymptomatic MMD (P > 0.05), without increasing cerebral hemorrhagic risk. In contrast, APT was found to reduce mortality among patients with hemorrhagic MMD (P = 0.019), without affecting functional status, increasing stroke risk, or causing intracerebral hemorrhage (P > 0.05). But the small group cannot show the effect of APT. Our meta-analysis included nine articles involving 28,925 patients with MMD. It showed that APT could reduce stroke risk (odds ratio, OR = 0.57, 95% CI 0.49 to 0.65) and the Modified Rankin Scale (mRS) (weighted mean difference, WMD = - 0.07, 95% CI 0.14-0.00) during follow-up. The cohort study has limited weight (1.97% and 19.29%) in the meta-analysis.

CONCLUSION

Although the limited number of included documents, APT could be beneficial to the prognosis of MMD.

Clinical and Genetic Characteristics of Patients with Moyamoya Disease who Experienced Both Ischemic and Hemorrhagic Events

OBJECTIVE

Cerebrovascular events in moyamoya disease are mainly classified into ischemic or hemorrhagic onset. It is rare for one patient to develop both ischemia and hemorrhage in moyamoya disease; detailed clinical course and genetic characteristics of such patients have not been elucidated. We aimed to clarify the clinical features of patients with both ischemic and hemorrhagic cerebrovascular events.

METHODS

We analyzed the background factors, radiological features, and genotype of ring finger protein 213 c.14429 G > A (p.Arg4810Lys) of patients with moyamoya disease who visited our hospital between 1996 and 2020, and experienced both ischemic and hemorrhagic cerebrovascular events. Additionally, we analyzed factors that caused subsequent hemorrhage in adult-onset ischemic moyamoya disease.

RESULTS

Of 262 patients, 12 presented with both ischemia and hemorrhage, of which, 4 exhibited pediatric onset and 8 had adult onset. In pediatric-onset subjects, ischemia was the initial event in all cases. Hemorrhagic events occurred at a median of 24.7 years postoperatively in patients who had undergone bypass surgery. In adult-onset subjects, ischemia preceded hemorrhage in 7 patients. In males, the interval to subsequent hemorrhage was significantly shorter for adult-onset ischemic moyamoya disease, and the hazard ratio for hemorrhagic events was 5.45. The ring finger protein 213 p.Arg4810Lys heterozygous variant was present in 9 patients.

CONCLUSIONS

A majority of patients with moyamoya disease with both ischemia and hemorrhage experience an ischemic event first. Patients who developed ischemia in childhood may develop subsequent hemorrhage in approximately 20-25 years after bypass surgery. Male sex is a risk factor for a subsequent hemorrhagic event in adult-onset ischemic moyamoya disease.

Postoperative cerebral infarction after revascularization in patients with moyamoya disease: Incidence and risk factors

OBJECTIVES

Cerebral infarction is the major complication of revascularization surgery in patients with moyamoya disease (MMD), and we analyzed the possible causes of cerebral infarction after revascularization surgery for MMD.

METHODS

MMD patients who were admitted and underwent surgical revascularization at Shanghai Huashan Hospital from January 2019 to December 2021 were retrospectively analyzed.

RESULTS

A total of 815 patients and 890 revascularization surgeries (677 first revascularization surgeries and 213 second revascularization surgeries) were included in this study; 453 (50.9%) were performed on the left side and 437 (49.1%) on the right side, with 779 (87.5%) combined procedures and 111 (12.5%) indirect bypasses included. The mean patient age at the time of these procedures was 44.6 ± 11.7 years (range 6-72 years). Postoperative cerebral infarctions were observed in 46 (5.17%) surgeries, among which 31 occurred after left hemisphere revascularization surgeries, with an incidence of 6.84%, and 15 occurred after right hemisphere revascularization surgeries, with an incidence of 3.43%. Of these, 30 (65.2%) occurred in the operated hemispheres, 2 (4.3%) in the contralateral hemisphere and 13 (28.3%) in the bilateral hemisphere. There were 11 cases of massive infarction (23.9%). The incidence of postoperative infarction in patients undergoing the first revascularization was 6% (41/677) and 2.3% (5/213) in the second revascularization surgeries. Initial presentation as infarction (P < 0.001), initial presentation as hemorrhage (P < 0.001), hypertension (P = 0.018), diabetes (P = 0.006), 1st or 2nd surgery and surgical side (P = 0.007) were found to be related to postoperative cerebral infarction. Initial presentation as infarction (OR = 2.934, 95% CI 1.453-5.928, P = 0.003), initial presentation as hemorrhage (OR = 0.149, 95% CI 0.035-0.641, P = 0.011), and 1st or 2nd surgery and surgical side (OR = 1.66, 95% CI 1.106-2.491, P = 0.014) were independently associated with cerebral infarction after revascularization surgeries.

CONCLUSIONS

In patients with MMD undergoing surgical revascularization, initial presentation as infarction and first revascularization surgery performed on the left hemisphere are independent risk factors for postoperative cerebral infarction, whereas initial presentation as hemorrhage is a protective factor.

Modified pedicled temporoparietal fascial flap combined revascularization in adult moyamoya angiopathy

Background

Pedicled temporoparietal fascial flaps (TPFF), which are flexible, thin, and highly vascularized, have been tried for the moyamoya angiopathy (MMA) treatment. To reduce postoperative complications and improve prognosis, we performed surgical modification and followed up to observe the efficacy.

Methods

From February 2018 and June 2022, the clinical data of 31 adult MMA patients who underwent the modified TPFF combined revascularization were collected. The clinical outcomes and complications of the patients were recorded until the cut-off date of follow-up. The primary endpoints were the magnetic resonance perfusion (MRP), modified Rankin Scale (mRS) scores, and Matsushima Grade; the secondary endpoints were the clinical symptom outcome and Postoperative complications. Descriptive statistics and rank sum test to assess the therapeutic effect of the modified TPFF combined revascularization for adult MMA treatment.

Results

The clinical symptoms of MMA were alleviated in 26 patients and disappeared in five. In all patients, MRP showed improvement in cerebral perfusion on the operated side, and no deterioration or new cerebral infarction occurred during follow-up. Postoperative digital subtraction angiography (DSA) showed that the anastomotic site was patent, and the MMA collateral was decreased in all patients. Only 1 case (3%) of Matsushima grade C showed poor collateral compensation. The admission mRS score (1.54±0.66) of the ischemic MMA was significantly reduced compared with ≥6 months postoperatively (0.54±0.72, P<0.01). The admission mRS score (0.57±0.53) of the hemorrhagic MMA was reduced compared with ≥6 months postoperatively (0, P<0.05). Postoperative complications included epileptic seizures in 2 cases, a cerebral hyper-perfusion syndrome in 2 cases, intracranial rebleeding in 2 cases, skin necrosis in 1 case, and skin maceration in 1 case.

Conclusions

Modified TPFF combined revascularization might be a feasible and safe surgical technique for MMA, but it is still necessary to increase the sample size and extend the follow-up time to evaluate its efficacy. Ischemic MMA may have a more significant prognostic benefit than hemorrhagic MMA by this surgery.

Effects of Aspirin Therapy on Bypass Efficacy and Survival of Patients Receiving Direct Cerebral Revascularization

Background: Both patency maintenance and neoangiogenesis contribute to cerebrovascular bypass efficacy. However, the combined impact of the aforementioned two indicators on postoperative revascularization following superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass has been less well elucidated. Meanwhile, there is a paucity of evidence with conflicting results about postoperative aspirin therapy.

Objective: The objective of the study was to investigate the correlation between aspirin use and STA-MCA bypass efficacy, including patency, postoperative neoangiogenesis, and follow-up outcomes.

Methods: A total of 181 MMD patients (201 procedures) undergoing STA-MCA bypass at our institution (2017–2019) were retrospectively reviewed. The bypass efficacy level and postoperative complications were compared between aspirin and non-aspirin groups.

Results: Among 95 PS-matched pairs, the aspirin group presented a significantly more favorable bypass efficacy than the non-aspirin group [odds ratio (OR) 2.23, 95% confidence interval (CI) 1.11–4.61; p = 0.026]. Multivariate logistic regression analysis confirmed the profound impact of aspirin as an independent predictor of bypass efficacy [adjusted OR 2.91, 95% CI 1.34–6.68; p = 0.009]. A remarkable negative correlation was found between bypass efficacy and the rate of ischemic complications (Phi = −0.521). Postoperative aspirin therapy was associated with a non-significant trend toward a lower incidence of ischemic events [OR 0.73, 95% CI 0.23–2.19; p = 0.580]. No significant difference in bleeding rates was observed between aspirin and control groups [OR 1.00, 95% CI 0.12–8.48; p = 1.000].

Conclusion: Among patients undergoing STA-MCA bypass procedures, bypass efficacy is a good predictor of follow-up outcomes. Postoperative aspirin therapy can improve patency, neoangiogenesis, and overall bypass efficacy, thereby protecting against postoperative ischemic complications.

Clinical Trial Registration:http://www.chictr.org.cn/, identifier CTR2100046178.

Differences in Clinical Features among Different Onset Patterns in Moyamoya Disease

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.

Effects and safety of aspirin use in patients after cerebrovascular bypass procedures

Object

Superficial temporal artery to middle cerebral artery (STA-MCA) bypass is the most effective treatment for Moyamoya disease (MMD). In this study, we aimed to assess whether aspirin improves STA-MCA bypass patency and is safe in patients with MMD.

Methods

We performed a retrospective medical record review of patients with ischaemic-onset MMD who had undergone STA-MCA bypass at two hospitals between January 2011 and August 2018, to clarify the effects and safety of aspirin following STA-MCA bypass. The neurological status at the last follow-up (FU) was compared between patients with FU bypass patency and occlusion.

Results

Among 217 identified patients (238 hemispheres), the mean age was 41.4±10.2 years, and 51.8% were male; the indications for STA-MCA bypass were stroke (48.2%), followed by a transient ischaemic attack (44.0%). Immediate bypass patency was confirmed in all cases. During the FU period (1.5±1.5 y), 15 cases were occluded at FU imaging, resulting in an overall cumulative patency rate of 94%. The patency rates were 93% and 94% in the short-term FU group (n=131, mean FU time 0.5±0.2 years) and long-term FU group (n=107, mean FU time 4.1±3.5 years), respectively. The STA-MCA bypass patency rate in the aspirin group was higher than that in the non-aspirin group (98.7% vs 89.7%; HR 1.57; 95% CI 1.106 to 2.235; p=0.012). No significant difference in the FU haemorrhagic events was observed between the aspirin and non-aspirin groups.

Conclusions

Among adult patients with ischaemic-onset MMD undergoing STA-MCA bypass procedures, aspirin might increase the bypass patency rate, without increasing the bleeding risk. FU bypass patency may be associated with a better outcome. Additional studies, especially carefully designed prospective studies, are needed to address the role of aspirin after bypass procedures.

Moyamoya disease concurrent with dural arteriovenous fistula: A case report and literature review

Moyamoya disease (MMD) and dural arteriovenous fistula (DAVF) are two distinct types of intracranial lesion that share different pathogenic mechanisms. Under rare circumstances, patients with MMD have been reported to have concurrent DAVF. The present case study reports on a 47-year-old male admitted due to sudden headache. Head CT revealed hemorrhage of the right thalamus with ventricular extension. On CT angiography, the normal vasculature in the anterior and posterior circulation disappeared and was replaced by moyamoya-like vessels. The patient received conservative management and was discharged 3 days later. After three months, the patient was readmitted for acute cerebellar hemisphere infarction. Angiogram indicated that the DAVF (Cognard classification Ⅰ) was supplied by the left middle meningeal artery, occipital artery and posterior meningeal artery and drained into the transverse-sigmoid sinus and occipital sinus. Conservative management of the DAVF was adopted. The patient was stable and lived independently during a 4-year follow-up. A literature review of the reported cases was also performed to further characterize this rare entity. The management of DAVF concurrent with MMD depends on its clinical presentation and invasiveness. For patients with symptoms or cortical venous drainage, endovascular intervention should be performed. For asymptomatic DAVFs or those without cerebral venous drainage, close follow-up is a reasonable option.