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Giroud M, Planton M, Darcourt J, Raposo N, Brandicourt P, Mirabel H, Hervé D, Viguier A, Albucher JF, Pariente J, Olivot JM, Bonneville F, Péran P, Calviere L. MRI hypoperfusion as a determinant of cognitive impairment in adults with Moyamoya angiopathy. Eur Stroke J 2024:23969873241240829. [PMID: 38501882 DOI: 10.1177/23969873241240829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
INTRODUCTION In Moyamoya angiopathy (MMA), mechanisms underlying cognitive impairment remain debated. We aimed to assess the association of cognitive impairment with the degree and the topography of cerebral hypoperfusion in MMA. METHODS A retrospective analysis of neuropsychological and perfusion MRI data from adults with MMA was performed. Ischemic and haemorrhagic lesion masks were created to account for cerebral lesions in the analysis of cerebral perfusion. Whole brain volume of hypoperfused parenchyma was outlined on perfusion maps using different Tmax thresholds from 4 to 12 s. Regional analysis produced mean Tmax values at different regions of interest. Analyses compared perfusion ratios in patients with and without cognitive impairment, with multivariable logistic regression analysis to identify predictive factors. RESULTS Cognitive impairment was found in 20/48 (41.7%) patients. Attention/processing speed and memory were equally impaired (24%) followed by executive domain (23%). After adjustment, especially for lesion volume, hypoperfused parenchyma volume outlined by Tmax > 4 s or Tmax > 5 s thresholds was an independent factor of cognitive impairment (OR for Tmax > 4 s = 1.06 [CI 95% 1.008-1.123]) as well as attention/processing speed (OR for Tmax > 4 s = 1.07 [CI 95% 1.003-1.133]) and executive domains (OR for Tmax > 5 s = 1.08 [CI 95% 1.004-1.158]). Regarding cognitive functions, patients with processing speed and flexibility impairment had higher frontal Tmax compared to other ROIs and to patients with normal test scores. DISCUSSION Cerebral hypoperfusion emerged as an independent factor of cognitive impairment in MMA particularly in attention/processing speed and executive domains, with a strong contribution of frontal areas. CONCLUSION Considering this association, revascularization surgery could improve cognitive impairment.
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Affiliation(s)
- Marine Giroud
- Neurology Department, Toulouse University Hospital, Toulouse, France
| | - Mélanie Planton
- Neurology Department, Toulouse University Hospital, Toulouse, France
- ToNIC, Toulouse NeuroImaging Center, Toulouse University, Toulouse, France
| | - Jean Darcourt
- Neuroradiology Department, Toulouse University Hospital, Toulouse, France
| | - Nicolas Raposo
- Neurology Department, Toulouse University Hospital, Toulouse, France
- ToNIC, Toulouse NeuroImaging Center, Toulouse University, Toulouse, France
| | | | - Hélène Mirabel
- Neurology Department, Toulouse University Hospital, Toulouse, France
| | - Dominique Hervé
- Neurology Department, Hospital Paris Lariboisière, Paris, France
| | - Alain Viguier
- Neurology Department, Toulouse University Hospital, Toulouse, France
- ToNIC, Toulouse NeuroImaging Center, Toulouse University, Toulouse, France
| | - Jean-François Albucher
- Neurology Department, Toulouse University Hospital, Toulouse, France
- ToNIC, Toulouse NeuroImaging Center, Toulouse University, Toulouse, France
| | - Jérémie Pariente
- Neurology Department, Toulouse University Hospital, Toulouse, France
- ToNIC, Toulouse NeuroImaging Center, Toulouse University, Toulouse, France
| | - Jean Marc Olivot
- Neurology Department, Toulouse University Hospital, Toulouse, France
- ToNIC, Toulouse NeuroImaging Center, Toulouse University, Toulouse, France
| | - Fabrice Bonneville
- ToNIC, Toulouse NeuroImaging Center, Toulouse University, Toulouse, France
- Neuroradiology Department, Toulouse University Hospital, Toulouse, France
| | - Patrice Péran
- ToNIC, Toulouse NeuroImaging Center, Toulouse University, Toulouse, France
| | - Lionel Calviere
- Neurology Department, Toulouse University Hospital, Toulouse, France
- ToNIC, Toulouse NeuroImaging Center, Toulouse University, Toulouse, France
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Zerweck L, Pohmann R, Klose U, Martirosian P, Haas P, Ernemann U, Khan N, Roder C, Hauser TK, Hennersdorf F. Evaluation of the contribution of individual arteries to the cerebral blood supply in patients with Moyamoya angiopathy: comparison of vessel-encoded arterial spin labeling and digital subtraction angiography. Neuroradiology 2024:10.1007/s00234-024-03338-7. [PMID: 38492021 DOI: 10.1007/s00234-024-03338-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/11/2024] [Indexed: 03/18/2024]
Abstract
PURPOSE Vessel-encoded arterial spin labeling (VE-ASL) is able to provide noninvasive information about the contribution of individual arteries to the cerebral perfusion. The aim of this study was to compare VE-ASL to the diagnostic standard digital subtraction angiography (DSA) with respect to its ability to visualize vascular territories. METHODS In total, 20 VE-ASL and DSA data sets of 17 patients with Moyamoya angiopathy with and without revascularization surgery were retrospectively analyzed. Two neuroradiologists independently assessed the agreement between VE-ASL and DSA using a 4-point Likert scale (no- very high agreement). Additionally, grading of the vascular supply of subterritories (A1-A2, M1-M6) on the VE-ASL images and angiograms was performed. The intermodal agreement was calculated for all subterritories in total and for the subdivision into without and after revascularization (direct or indirect bypass). RESULTS There was a very high agreement between the VE-ASL and the DSA data sets (median = 1, modus = 1) with a substantial inter-rater agreement (kw = 0.762 (95% CI 0.561-0.963)). The inter-modality agreement between VE-ASL and DSA in vascular subterritories was almost perfect for all subterritories (k = 0.899 (0.865-0.945)), in the subgroup of direct revascularized subterritories (k = 0.827 (0.738-0.915)), in the subgroup of indirect revascularized subterritories (k = 0.843 (0.683-1.003)), and in the subgroup of never revascularized subterritories (k = 0.958 (0.899-1.017)). CONCLUSION Vessel-encoded ASL seems to be a promising non-invasive method to depict the contributions of individual arteries to the cerebral perfusion before and after revascularization surgery.
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Affiliation(s)
- Leonie Zerweck
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
| | - Rolf Pohmann
- Magnetic Resonance Center, Max-Planck-Institute for Biological Cybernetics, Tuebingen, Germany
| | - Uwe Klose
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Petros Martirosian
- Section on Experimental Radiology, Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Tuebingen, Germany
| | - Patrick Haas
- Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Ulrike Ernemann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Nadia Khan
- Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany
- Moyamoya Center, University Children's Hospital, Zurich, Switzerland
| | - Constantin Roder
- Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Till-Karsten Hauser
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Florian Hennersdorf
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
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Soler-Rico M, Di Santo M, Vaz G, Joris V, Fomekong E, Guillaume S, Van Boven M, Raftopoulos C. How to reduce the complication rate of multiple burr holes surgery in moyamoya angiopathy. Acta Neurochir (Wien) 2023; 165:3613-3622. [PMID: 37993630 DOI: 10.1007/s00701-023-05876-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/16/2023] [Indexed: 11/24/2023]
Abstract
PURPOSE This study is aimed at analyzing clinical outcome, absence of stroke recurrence, revascularization, and complications and long-term follow-up in the surgical treatment of moyamoya angiopathy (MMA) using the multiple burr holes (MBH) technique with dura opening and arachnoid preservation as a single procedure. To the best of our knowledge, this is the first to describe an MBH technique with arachnoid preservation. METHOD We retrospectively reviewed all patients operated from June 2001 to March 2021, for a symptomatic and progressive MMA operated with opening of the dura but arachnoid preservation. Clinical examinations were obtained in all patients, and radiological monitoring was performed by cerebral 3D-magnetic resonance angiography (MRA) with perfusion or single-photon emission computed tomography (SPECT) with acetazolamide. RESULTS In total, 21 consecutive patients (6 children and 15 adults) were included with a mean age of 7.4 years in the pediatric group and 36.9 years in the adult group. Initial presentation was permanent ischemic stroke in 15 cases, transient ischemic attack (TIA) in 5 cases, and cerebral hemorrhage in one case. The MBH with dura opening and arachnoid preservation was performed bilaterally in 9 cases (43%) and unilaterally in 12 cases (57%). One patient died due to intraoperative bilateral ischemic stroke. Of the 20 other patients, 30% demonstrated clinical stability and 70% showed partial or complete recovery. Although one patient experienced a perioperative stroke, we did not observe any pseudomeningocele or postoperative ischemic stroke (IS) recurrence in all surviving cases during the average follow-up period of 55.5 months (range: 1-195). These outcomes emphasize the importance of preoperative monitoring to ensure the effectiveness and safety of the intervention. Postoperative angiography studies showed revascularization in 96.3% of treated hemispheres (100% in the adult group vs 80% in the pediatric group). CONCLUSIONS Our results on this small cohort suggest that the MBH technique with opening of the dura and arachnoids preservation can prevent recurrent strokes and reduce the risk of pseudomeningocele.
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Affiliation(s)
- M Soler-Rico
- Neurosurgery Department, St-Luc Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - M Di Santo
- Neurosurgery Department, St-Luc Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - G Vaz
- Neurosurgery Department, St-Luc Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - V Joris
- Neurosurgery Department, St-Luc Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - E Fomekong
- Neurosurgery Department, St-Luc Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - S Guillaume
- Medical Imaging Department, St-Luc Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - M Van Boven
- Anesthesiology Department, St-Luc Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - C Raftopoulos
- Neurosurgery Department, St-Luc Hospital, Université Catholique de Louvain, Brussels, Belgium.
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Strunk D, Diehl RR, Veltkamp R, Meuth SG, Kraemer M. Progression of initially unilateral Moyamoya angiopathy in Caucasian Europeans. J Neurol 2023; 270:4415-4422. [PMID: 37261501 DOI: 10.1007/s00415-023-11793-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/20/2023] [Accepted: 05/20/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Moyamoya angiopathy (MMA) is a rare cause of stroke in Caucasians, but it is much more frequent in East Asia. Since 2021, diagnostic criteria not only comprise bilateral, but also unilateral MMA. Hitherto, progression of unilateral MMA has predominantly been described in East Asians. Our study aimed to analyze the occurrence and characteristics of progression of initially unilateral MMA in Caucasian Europeans. METHODS By retrospective analysis of medical records of 200 European Caucasians with MMA, admitted to our German center between 2010 and 2022, cases of unilateral MMA and its progression, i.e. progressive ipsi- or novel contralateral arterial stenosis, during follow-up were identified. Kruskal Wallis Test and Fisher's Exact Test were used to identify statistically significant differences between progressive and stable patients concerning demographic, clinical, laboratory, and radiographic features. RESULTS Our cohort comprised 63 patients with initially unilateral MMA. Fourteen (22.2%) had an ipsi- (n = 3, 21.4%) or contralateral (n = 11, 78.6%) progression. Mean age of patients with progressive MMA at symptom onset was 32 ± 14.1 years. The ratio of women to men in this subgroup was 2.5:1. Mean follow-up period was 5.4 ± 3.7 years, mean age at progression was 39.9 ± 12.7 years. Mean time interval between penultimate follow-up and progression was 4.8 ± 4.5 years. Patients with progression showed affection of the posterior cerebral artery (p = 0.009) and suffered from vertigo (p = 0.009) significantly more often. CONCLUSION Unilateral MMA progresses in a substantial proportion in European Caucasians. Long-term follow-up is required due to potential late progression with consecutive symptoms and the need for bypass surgery.
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Affiliation(s)
- Daniel Strunk
- Department of Neurology, European Reference Center for Moyamoya Angiopathy (VASCERN, ERN), Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45131, Essen, Germany
| | - Rolf R Diehl
- Department of Neurology, European Reference Center for Moyamoya Angiopathy (VASCERN, ERN), Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45131, Essen, Germany
| | - Roland Veltkamp
- Department of Neurology, European Reference Center for Moyamoya Angiopathy (VASCERN, ERN), Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45131, Essen, Germany
- Department of Brain Sciences, Imperial College London, London, UK
| | - Sven G Meuth
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Markus Kraemer
- Department of Neurology, European Reference Center for Moyamoya Angiopathy (VASCERN, ERN), Alfried Krupp Hospital, Alfried-Krupp-Straße 21, 45131, Essen, Germany.
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany.
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Focke JK, Kraemer M. A familial missense ACTA2 variant p.Arg198Cys leading to Moyamoya-like arteriopathy with straight course of the intracranial arteries, aortic aneurysm and lethal aortic dissection. Neurol Res Pract 2023; 5:38. [PMID: 37587538 PMCID: PMC10433546 DOI: 10.1186/s42466-023-00268-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 07/07/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Cerebral vasculopathies frequently lead to severe medical conditions such as stroke or intracranial hemorrhage and have a broad range of possible etiologies that require different therapeutic regimens. However, vasculopathies sometimes present with characteristic angiographic findings, that - if recognized - can guide a more specific diagnostic work-up. Certain ACTA2 variants are associated with a distinctive cerebrovascular phenotype characterized by an anomalously straight course of intracranial arteries, dilatation of proximal ICA and stenosis of distal ICA, in the absence of a compensatory basal collateral network found in Moyamoya disease. Until recently, this ACTA2 cerebral arteriopathy has been reported only in ACTA2 variants impairing Arg179. METHODS AND MATERIALS We report a familial case of a missense ACTA2 variant p.Arg198Cys with angiographic features of an ACTA2 cerebral arteriopathy. We analyzed the neuroimaging features of all four variant carrying family members and discussed the cerebrovascular abnormalities we found on the background of the current literature on ACTA2 arteriopathies. RESULTS Neuroimaging of the variant carriers revealed angiographic abnormalities characteristic for ACTA2 cerebral arteriopathy such as stenoses of the terminal internal carotid artery, occlusion of the proximal middle cerebral artery and an anomalously straight course of the intracranial arteries. In our index patient catheter angiography showed a Moyamoya-like basal collateral network alongside with the above-mentioned features of an ACTA2 cerebral arteriopathy. The detected missense ACTA2 variant p.Arg198Cys was not known to be associated a cerebral arteriopathy, so far. One of the patients later died from aortic dissection - a common vascular complication of ACTA2 variants. CONCLUSION The familial case expands the phenotype of the detected ACTA2 variant p.Arg198Cys and hereby broadens the range of ACTA2 variants associated with a cerebral arteriopathy. Further, it emphasizes the importance of an interdisciplinary approach of vasculopathies.
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Affiliation(s)
- Jan K Focke
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany.
| | - Markus Kraemer
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
- Department of Neurology, Heinrich-Heine-University Hospital, Düsseldorf, Germany
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Das S, Ray BK, Dubey S. Temporal lobe epilepsy with nocturnal wandering leading to discovery of Moyamoya Angiopathy. Acta Neurol Belg 2023; 123:279-81. [PMID: 34704169 DOI: 10.1007/s13760-021-01830-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 10/21/2021] [Indexed: 10/20/2022]
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Das S, Ray BK, Pandit A, Ghosh R, Diehl R, Dubey S, Kraemer M. Profile of precipitating factors and its implication in 160 Indian patients with Moyamoya angiopathy. J Neurol 2023; 270:1654-61. [PMID: 36477636 DOI: 10.1007/s00415-022-11499-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Moyamoya angiopathy (MMA) has been known to manifest with myriad of neurological manifestations, often in association with various precipitating factors. This is the first study to systematically analyze the precipitating triggers to neurological symptoms done on the largest cohort of MMA in India. METHODS A single-centered, cross-sectional observational study, recruiting 160 patients with consecutive angiographically proven MMA over a period of 5 years (2016-2021), was undertaken to evaluate the profile of immediate precipitating factors in temporal association to the neurological symptoms, along with their clinical and radiological characteristics. SPSS 25 was used for statistical analysis. RESULTS Among the 160 patients (Adult-85, children-75), precipitating factors were seen in 41.3%, significantly higher in children (52%) than adults (31.8%) (p value: 0.011). The commonest triggers included fever (18.8%), emotional stress (8.1%), heavy exercise and diarrhea (6.3% each). Cold bath triggered MMA symptoms in 1.3%. Fever (p value: 0.008) and persistent crying (p value: 0.010) triggered neurological symptoms more commonly in children than in adults. Amongst MMA patients with precipitating factors, the commonest MMA presentation included cerebral infarction type (37.9%) and TIA (31.8%). The majority of precipitating factors that preceded an ischemic event were BP-lowing ones (54.7%). CONCLUSION Neurological symptoms of MMA are commonly associated with several precipitating factors, including the lesser known triggers like cold bath. The frequency and profile precipitating factors varies with the age of presentation and type of MMA. It can serve as an early clue to the diagnosis of MMA and its careful avoidance can be largely beneficial in limiting the distressing transient neurological symptoms.
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Das S, Ray BK, Pandit A, Ghosh R, Chakraborty AP, Dubey S. Thalassemia and Moyamoya Syndrome: Epidemiology and long-term outcome. Eur J Paediatr Neurol 2022; 41:63-70. [PMID: 36368232 DOI: 10.1016/j.ejpn.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/03/2022] [Accepted: 10/12/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Moyamoya Angiopathy (MMA) is a chronic, progressive intracranial vasculopathy. Unlike Sickle-cell-disease, thalassemia-syndrome has rarely been described in association with MMA. This study was aimed to analyze the demographic, clinical, radiological features and long-term outcome (and possible factors influencing prognosis) of Moyamoya Syndrome (MMS) in the largest cohort of thalassemia-related-to-MMS. MATERIALS & METHODS A single-centered, observational study with longitudinal follow-up was undertaken for 12 cases of MMS-related-to-thalassemia-syndrome amongst 160 consecutive MMA patients. The baseline demographic, clinical and radiological characteristics were noted; and were longitudinally followed-up to assess disease progression (clinical or radiological). Fifteen previously reported cases of thalassemia and MMA were retrieved by literature search in PubMed and Google-Scholar using keywords "Moyamoya" AND "thalassemia". RESULTS The mean age at diagnosis of thalassemia-syndrome and diagnosis of MMS were 6.4 ± 6.55 years (mean ± SD) and 10.4 ± 8.68 years respectively in our 12 cases; 3.2 ± 2.25 years and 10.6 ± 6.1 years respectively in the previously reported 15 cases. Cerebral ischemic insult was the predominant brain lesion at base-line, noted in 91.7% of our cases and 80% of the previous cases. The mean hemoglobin, transfusion-dependency and previous splenectomy were seen in 8.7 ± 3.02 gm%, 33.3% and 8.3% of our cases respectively; 7.0 ± 3.04 gm%, 53.9% and 18.2% of previous cases. All our cases were medically managed for mean follow-up of 28.3 ± 13.9 months, none had evidence of angiographic progression, 1 of our 12 cases (8.3%) had new onset neuro-deficit and subsequent mortality, rest 11 of the 12 cases (91.7%) didn't have any appearance of silent cerebral infarction or evidence of progression of brain atrophy. Among the 15 previous cases, 5 out of 9 medically managed cases and 1 revascularized case described no further clinical recurrence. CONCLUSION Thalassemia-related-MMS may not be so rare. Future development of consensus guidelines in diagnosing and managing cases of MMS-associated-with-thalassemia is of essence.
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Affiliation(s)
- Shambaditya Das
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India.
| | - Biman Kanti Ray
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India.
| | - Alak Pandit
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India.
| | - Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, India.
| | - Arka Prava Chakraborty
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India.
| | - Souvik Dubey
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India.
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Das S, Ray BK, Pandit A, Kumar S, Dubey S. Multiple sclerosis and Moyamoya angiopathy: Mimic and misdiagnosis. Mult Scler Relat Disord 2022; 66:104036. [PMID: 35858500 DOI: 10.1016/j.msard.2022.104036] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 06/24/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022]
Abstract
Moyamoya Angiopathy (MMA) is frequently not considered in differential diagnosis of Multiple Sclerosis (MS). This is the first study to prospectively analyze rate of misdiagnosis of MMA as MS and its clinical implications. Of the 160 angiographically proven MMA, 5 patients had an initial misdiagnosis of MS (3.13%). These 5 cases had female-predominance (80%).Out of the 5 cases, 4 cases (80%) presented with hemiparesis; 3 cases (60%) had an immediate precipitating factor. Radiologically, presence of both periventricular and juxtacortical white-matter-lesions was seen in 4 out of 5 cases (80%);none had infratentorial/spinal lesion, while all 5 cases had presence of "Ivy" sign and abnormal flow voids. Differentiation relies on careful evaluation of clinico-radiological features. MMA should be considered as a rare but important differential to MS.
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Affiliation(s)
- Shambaditya Das
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Biman Kanti Ray
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Alak Pandit
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Swati Kumar
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Souvik Dubey
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India.
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Ghosh R, Das S, Roy D, Ray A, Benito-León J. Moyamoya angiopathy in a case of Klinefelter syndrome. Childs Nerv Syst 2022; 38:1195-1199. [PMID: 34628529 DOI: 10.1007/s00381-021-05371-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 09/20/2021] [Indexed: 11/29/2022]
Abstract
Moyamoya angiopathy, a rare cerebrovascular condition, can be primary (moyamoya disease) or secondary (moyamoya syndrome). Genetic factors, such as the ring finger protein 213 (RNF213), have been associated with moyamoya disease. However, X-linked moyamoya angiopathy/moyamoya syndrome and hypergonadotropic hypogonadism associated with moyamoya syndrome are rare. We report a case of a 14-year-old boy who presented with transient bilateral hemiparesis, recurrent seizures and cognitive decline. He previously had surgery for left-sided cryptorchidism and had been diagnosed with "epileptic attacks" or "functional movement disorders" in previous hospital admissions. Magnetic resonance angiography of the brain showed narrowing of supraclinoid portion of internal carotid arteries, as well as of middle and anterior cerebral arteries, and the presence of multiple collaterals. These findings were suggestive of moyamoya angiopathy. Laboratory investigations and karyotyping revealed a diagnosis of Klinefelter syndrome. This case presents a unique association of moyamoya angiopathy and Klinefelter syndrome in a boy from a poor socio-economic background, where the diagnosis and adequate treatment were delayed due to a lack of awareness and expertise.
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Affiliation(s)
- Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College & Hospital, Burdwan, West Bengal, India
| | - Shambaditya Das
- Department of Neuromedicine, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India
| | - Dipayan Roy
- Department of Biochemistry, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
- Indian Institute of Technology (IIT), Madras, Tamil Nadu, India
| | - Adrija Ray
- R G Kar Medical College & Hospital, Kolkata, West Bengal, India
| | - Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain.
- Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain.
- Department of Medicine, Complutense University, Madrid, Spain.
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Das S, Ray BK, Ghosh R, Sengupta S, Pandit A, Dubey S. Impact of COVID-19 pandemic in natural course of Moyamoya Angiopathy: an experience from tertiary-care-center in India. Egypt J Neurol Psychiatr Neurosurg 2021; 57:166. [PMID: 34924748 PMCID: PMC8665313 DOI: 10.1186/s41983-021-00412-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/03/2021] [Indexed: 12/23/2022] Open
Abstract
Background COVID-19 mediated immune dysregulation and cytokine storm can precipitate and aggravate Moyamoya angiopathy (MMA), influencing its disease course. This index study was undertaken to prospectively evaluate the status of neurological symptoms of MMA in relation to COVID-19 affection. Methodology and results Follow-up MMA patients of institute’s Stroke-clinic were telephonically interview from 24th March to 30th September, 2020. The first call familiarized them with COVID-19 symptoms and neurological manifestations of MMA, followed by monthly-calls with predesigned questionnaire. Patients with suggestion of COVID-19 underwent nasopharyngeal-swab-testing for COVID-19 Reverse transcription-polymerase chain reaction (RT-PCR) positive cases were subjected to antibody levels for COVID-19 Enzyme-linked immunoassay (ELISA) 8–12 weeks after recovery. During symptomatic phase till 14 days of asymptomatic, they were contacted daily/alternate day. Any new onset/worsening of neurological symptoms were noted. The baseline clinico-radiological details were obtained from stroke-clinic registery. Subsequently, all data were analyzed and compared using descriptive statistics. Seventy four of 104 MMA patients could be contacted and enrolled. The mean age, time since last follow-up and compliance to previously prescribed medication were 23.5 ± 16.1 years, 9.2 ± 1.7 months and 90.5% (n = 67), respectively. Aggravation/new onset neurological symptom were seen in 64.3% (n = 9) of COVID-19 positive MMA (n = 14), of which 8 were seen among the 11 pediatric COVID-19 positive MMA [(Transient ischemic attacks) TIA-4, TIA with headache-1, seizure-2, stroke causing mortality-1]. Conclusion COVID-19 infection can potentiate MMA causing significant morbidity and mortality, especially in children. Providing optimal care for severe diseases (such as MMA) in developing countries during pandemic remains a challenge.
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Affiliation(s)
- Shambaditya Das
- Department of Neurology, Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, 52 1/A Sambhu Nath Pandit Road, Bhowanipore, Kolkata, West Bengal 700020 India
| | - Biman Kanti Ray
- Department of Neurology, Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, 52 1/A Sambhu Nath Pandit Road, Bhowanipore, Kolkata, West Bengal 700020 India
| | - Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal India
| | - Samya Sengupta
- Department of General Medicine, Apollo Gleneagles Hospital, Kolkata, West Bengal India
| | - Alak Pandit
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal India
| | - Souvik Dubey
- Department of Neurology, Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, 52 1/A Sambhu Nath Pandit Road, Bhowanipore, Kolkata, West Bengal 700020 India
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Hackenberg A, Battilana B, Hebeisen M, Steinfeld R, Khan N. Preoperative clinical symptomatology and stroke burden in pediatric moyamoya angiopathy: Defining associated risk variables. Eur J Paediatr Neurol 2021; 35:130-136. [PMID: 34715507 DOI: 10.1016/j.ejpn.2021.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 10/11/2021] [Accepted: 10/13/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To evaluate the preoperative clinical and magnetic resonance imaging and angiography (MRI-MRA) characteristics in pediatric moyamoya patients. METHODS Analysis included 100 children with moyamoya angiopathy referred to our moyamoya center for preoperative evaluation. Clinical symptoms, neurological status using Pediatric Stroke Outcome Measurement (PSOM) and degree of disability on modified Rankin scale score (mRS) were evaluated. MRI-MRA evaluation included the assessment of ischemic lesions and involvement of posterior circulation. Data were analyzed for moyamoya disease (MMD), moyamoya syndrome (MMS) and age at disease onset. RESULTS Stroke was a common presentation in both MMD and MMS patients. TIAs and headaches/migraine were more frequent in MMD. There was no evidence of a difference in stroke burden on MRI as well as in PCA involvement between the two subgroups. Children <2 years had higher odds of having a stroke (OR 15.5, 95% CI 3.8-62.4, p < 0.001), recurrent stroke (OR 11.8, 95%CI 2.9-46.7, p < 0.001) and unfavorable mRS (≥2) (OR 4.2, 95% CI 1.3-13.7, p = 0.01) when compared to those >5 years of age. There was some evidence of association of PCA involvement with recurrent strokes (OR 3.1, CI 1.0-9.6, p = 0.05), a poor PSOM (OR 3.0, 95% CI 1.1-8.2, p = 0.04) and mRS (OR 3.1, 95% CI 1.2-8.3, p = 0.02). CONCLUSION Stroke seems to be a common presentation in both MMD and MMS patients. Early age at symptom onset and involvement of posterior circulation seem to be important risk factors for a high stroke burden and an unfavorable PSOM and mRS.
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Affiliation(s)
- Annette Hackenberg
- Department of Pediatric Neurology, University Children's Hospital, University of Zurich, Switzerland; Moyamoya Center, University Children's Hospital, University of Zurich, Switzerland.
| | - Bianca Battilana
- Moyamoya Center, University Children's Hospital, University of Zurich, Switzerland
| | - Monika Hebeisen
- Moyamoya Center, University Children's Hospital, University of Zurich, Switzerland; Department of Biostatistics, Institute of Epidemiology, Biostatistics and Prevention, University of Zurich, Switzerland
| | - Robert Steinfeld
- Department of Pediatric Neurology, University Children's Hospital, University of Zurich, Switzerland
| | - Nadia Khan
- Moyamoya Center, University Children's Hospital, University of Zurich, Switzerland
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Abstract
Background and purpose Little is known about the angiographic presentation of Moyamoya angiopathy (MMA) in non-Asian patients. Methods Conventional cerebral angiograms from 155 Caucasian patients diagnosed as MMA were analyzed with respect to extracranial champagne bottle neck sign, Suzuki stages, collateral status, as well as presence of aneurysms and posterior cerebral artery stenosis. Results In 84 of 155 angiograms, the extracranial carotid artery was visualized, in 65 of them (77.4%), a champagne bottle neck sign was noted. Of the 278 analyzable hemispheres, 13.7%,11.2%, 37.8%, 27.3%, 8.6%, and 1.4% were classified as Suzuki stage I, stage II, stage III, stage IV, stage V, and stage VI, respectively. Among 280 hemispheres, in 53 hemispheres (18.9%) isolated basal collaterals (pathway I) and in 104 hemispheres (37.1%) choroidal and pericallosal collaterals (including basal collaterals, pathway II) were found. In 74 hemispheres (26.4%) ethmoidal collaterals (pathways III), and in 17 hemispheres (6.1%) vault collaterals were visualized. Patients with higher Suzuki stages IV–VI (p = 0.008) and ethmoidal collaterals (p < 0.001) suffered more often from cerebral hemorrhage. Transient ischemic attacks occurred more frequently in patients with Suzuki stage I to III (p < 0.001). In 10 of 155 patients (6.5%), the angiogram revealed a cerebral aneurysm. In 13 patients (8.4%), a stenotic P1 segment of the posterior cerebral artery was found. Conclusions This is so far the largest observational study about angiography in Caucasian European MMA patients. A comparison with Asian data indicates similarity of disease in Caucasian and Asian patients.
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Affiliation(s)
- Sara Pilgram-Pastor
- Department of Neuroradiology, Alfried Krupp Hospital, Essen, Germany
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - René Chapot
- Department of Neuroradiology, Alfried Krupp Hospital, Essen, Germany
| | - Markus Kraemer
- Department of Neurology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany.
- Department of Neurology, Alfried Krupp Von Bohlen Und Halbach Hospital, Alfried-Krupp-Str. 21, 45117, Essen, Germany.
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Das S, Ghosh R, Dubey S, Pandit A, Ray BK, Kraemer M. Limb-shaking TIA in Moyamoya angiopathy. Clin Neurol Neurosurg 2021; 207:106783. [PMID: 34225004 DOI: 10.1016/j.clineuro.2021.106783] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/06/2021] [Accepted: 06/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Limb shaking TIA(LS-TIA) is an rare manifestation seen in high grade steno-occlusive carotid disease. LS-TIA is rarely recognized as a presenting manifestation of MMA and has never been previously studied prospectively in MMA cohort. METHODS Of 104 cases of MMA collected in our Indian center in last 4 years, 5 new patients had LS-TIA. MMA was diagnosed by MR angiography and LS-TIA was confirmed by three different neurologist by detailed scrutiny of history, neurological examination and EEG-recording (to rule out seizure). Seven previously reported cases of LS-TIA in MMA were retrieved by literature search in PubMed using keywords "Moyamoya" AND "Limb shaking TIA", "Moyamoya" AND "Limb shaking". Subsequently all data were analyzed and compared using descriptive statistics. RESULTS Analysis of our 5 cases and those 7 found in the literature showed mean age at the time of diagnosis of MMA was 12.2 ± 8.9(Mean ± S.D.) years in our cases and 32.7 ± 13.6 years in previous cases. The commonest precipitating factors included prolonged crying and hyperventilation(3 of 5 our cases each) and exercise (3 of 7 previous cases). CT-perfusion demonstrated frontal white matter hypoperfusion in 2 of our 5 cases, corroborative with fronto-parietal hypoperfusion in previous cases. Medical management showed decreased symptoms in 4 of our 5 cases in a follow-up of 15.8 ± 11.6 months, while all previous patients had underwent revascularization surgery with resolution of symptoms. CONCLUSION LS-TIA in MMA may not be so uncommon, especially in children. Early recognition is imperative to avoid future catastrophe. Steno-occlusive posterior circulation lesions might be an independent predictor of development of LS-TIA in MMA. In a resource-limited setting, careful avoidance of triggers and anti-platelet therapy can lead to decreased symptomatology of LS-TIA in MMA.
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Affiliation(s)
- Shambaditya Das
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India.
| | - Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, India.
| | - Souvik Dubey
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India.
| | - Alak Pandit
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India.
| | - Biman Kanti Ray
- Department of Neurology, Institute of Post Graduate Medical Education & Research, Bangur Institute of Neurosciences, Kolkata, India.
| | - Markus Kraemer
- Department of Neurology, Alfried Krupp Von Bohlen Und Halbach, Hospital, Alfried-Krupp-Str. 21, 45117 Essen, Germany; Heinrich Heine University of Duesseldorf, Medical Faculity, Duesseldorf, Germany.
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15
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Tinelli F, Nava S, Arioli F, Bedini G, Scelzo E, Lisini D, Faragò G, Gioppo A, Ciceri EF, Acerbi F, Ferroli P, Vetrano IG, Esposito S, Saletti V, Pantaleoni C, Zibordi F, Nardocci N, Zedde ML, Pezzini A, Di Lazzaro V, Capone F, Dell'Acqua ML, Vajkoczy P, Tournier-Lasserve E, Parati EA, Bersano A, Gatti L. Vascular Remodeling in Moyamoya Angiopathy: From Peripheral Blood Mononuclear Cells to Endothelial Cells. Int J Mol Sci 2020; 21:E5763. [PMID: 32796702 DOI: 10.3390/ijms21165763] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/30/2020] [Accepted: 08/06/2020] [Indexed: 12/13/2022] Open
Abstract
The pathophysiological mechanisms of Moyamoya angiopathy (MA), which is a rare cerebrovascular condition characterized by recurrent ischemic/hemorrhagic strokes, are still largely unknown. An imbalance of vasculogenic/angiogenic mechanisms has been proposed as one possible disease aspect. Circulating endothelial progenitor cells (cEPCs) have been hypothesized to contribute to vascular remodeling of MA, but it remains unclear whether they might be considered a disease effect or have a role in disease pathogenesis. The aim of the present study was to provide a morphological, phenotypical, and functional characterization of the cEPCs from MA patients to uncover their role in the disease pathophysiology. cEPCs were identified from whole blood as CD45dimCD34+CD133+ mononuclear cells. Morphological, biochemical, and functional assays were performed to characterize cEPCs. A significant reduced level of cEPCs was found in blood samples collected from a homogeneous group of adult (mean age 46.86 ± 11.7; 86.36% females), Caucasian, non-operated MA patients with respect to healthy donors (HD; p = 0.032). Since no difference in cEPC characteristics and functionality was observed between MA patients and HD, a defective recruitment mechanism could be involved in the disease pathophysiology. Collectively, our results suggest that cEPC level more than endothelial progenitor cell (EPC) functionality seems to be a potential marker of MA. The validation of our results on a larger population and the correlation with clinical data as well as the use of more complex cellular model could help our understanding of EPC role in MA pathophysiology.
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16
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Das S, Dubey S, Acharya M, Ghosh R, Chatterjee S, Hazra A, Lahiri D, Segupta S, Chatterjee S, Das G, Sarkar N, Ray BK, Kraemer M. The disease presentation of Moyamoya angiopathy in Eastern India. J Stroke Cerebrovasc Dis 2020; 29:104957. [PMID: 32689603 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104957] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/18/2020] [Accepted: 05/12/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Clinical spectrum of Moyamoya angiopathy (MMA) differs across populations with different ethnicity. This study, the largest one done among Indian population was undertaken to assess clinico-radiological profile of MMA patients in eastern India. METHODS A single centre cross-sectional study was undertaken among 76 MMA cases. Each patient was evaluated for epidemiological, clinical and radiological characteristics. SPSS 25 was used for statistical analysis. P < 0.05 was taken as statistically significant. RESULTS 36 (47.4%) were children without gender preponderance. There were female predominance among adults (male:female = 1:2.33). Mean age at onset of first neurological symptoms for children was 4.2 ± 2.0years, followed by 34.9 ± 58.2months of latency with final diagnosis at the mean age of 7.4 ± 3.5years. For adults, mean age of onset of first neurological symptoms was 31.5 ± 12.3years, followed by 14.7 ± 41.7months time gap and diagnosed at the mean age of 33.5 ± 12.5years. There was a statistically significant difference between child and adult regarding the diagnostic latency (p = 0.035). Fixed motor weakness (FMW) was the predominant symptom across the whole disease course. Among children predominant first neurological symptom was fixed motor weakness (FMW) (52.8%), followed by seizures (22.2%). FMW was predominant (55%) first neurological complaint, followed by headache (22.5%) among adults. Seizure was more prevalent among children both as first (p = 0.002) and presenting symptom at the time of diagnosis (p = 0.048). Over the course of the disease seizure was more common among children (p = 0.001), while headache was more common among adults (p = 0.017). Recurrence of symptoms was more common among children (p = 0.059). Infarcts were more common among children (91.7%) than adults (72.5%), while hemorrhage was seen only among adults (25%) (p = 0.004). Isolated cerebral cortex was involved more commonly among children (59.4%) than adults (36.1%), while isolated subcortical involvement was seen only among adults (19.4%) (p = 0.016). Majority of the MMA cases were of Suzuki stage 4 (39.5%) and 5 (27.6%). Brain atrophy was associated with diagnostic latency (p = 0.009). CONCLUSION Indian Moyamoya presents similar to disease presentation in Caucasian and Japanese patients. It is a frequently overlooked cause of stroke in young, often with various non-motor presentations, failure to recognize which leads to delay in diagnosis. Radiological burden disproportionate to number of acute vascular events, with subtle neurological manifestations like headache or seizure, often with cognitive decline, should raise suspicion of MMA.
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Affiliation(s)
- Shambaditya Das
- Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research& SSKM Hospital, Kolkata, West Bengal, India
| | - Souvik Dubey
- Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research& SSKM Hospital, Kolkata, West Bengal, India
| | - Mrinal Acharya
- Department of Neurology, Malda Medical College and Hospital, Malda, West Bengal, India
| | - Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India
| | - Subhankar Chatterjee
- Department of General Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Avijit Hazra
- Department of Pharmacology, Institute of Post Graduate Medical Education and Research & SSKM Hospital, Kolkata, West Bengal, India
| | - Durjoy Lahiri
- Department of Neuromedicine, R.G. Kar Medical College & Hospital, Kolkata, West Bengal, India
| | - Samya Segupta
- Department of Medicine, Apollo Gleneagles Hospital, Kolkata, West Bengal, India
| | - Subham Chatterjee
- Institute of Psychiatry, Institute of Post Graduate Medical Education and Research & SSKM Hospital, Kolkata, West Bengal, India
| | - Goutam Das
- Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research& SSKM Hospital, Kolkata, West Bengal, India
| | - Niladri Sarkar
- Department of General Medicine, Institute of Post Graduate Medical Education and Research & SSKM Hospital, Kolkata, West Bengal, India
| | - Biman Kanti Ray
- Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research& SSKM Hospital, Kolkata, West Bengal, India.
| | - Markus Kraemer
- Department of Neurology, Alfried Krupp Von Bohlen Und Halbach Hospital, Alfried-Krupp-Str. 21, 45117, Essen, Germany and Heinrich Heine University of Duesseldorf, Medical Faculity, Duesseldorf, Germany
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17
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Ghosh R, Dubey S, Kanti Ray B, Chatterjee S, Benito-León J. COVID-19 Presenting With Thalamic Hemorrhage Unmasking Moyamoya Angiopathy. Can J Neurol Sci 2020; 47:849-51. [PMID: 32493536 DOI: 10.1017/cjn.2020.117] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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18
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Savolainen M, Pekkola J, Mustanoja S, Tyni T, Hernesniemi J, Kivipelto L, Tatlisumak T. Moyamoya angiopathy: radiological follow-up findings in Finnish patients. J Neurol 2020; 267:2301-2306. [PMID: 32322979 PMCID: PMC7358936 DOI: 10.1007/s00415-020-09837-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/12/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Moyamoya angiopathy (MMA) is a chronic progressive disorder, but imaging changes observed over time are not yet characterized in European populations. We analyzed the progression of MMA with magnetic resonance imaging and angiography (MRI and MRA) in our Finnish MMA registry. Stage classification based on MRA findings was used to evaluate the progress of the disease. METHODS 32 patients with MMA were evaluated with MRI and MRA and compared to previous imaging. The follow-up imaging was done 103 (range 6-380) months after the MMA diagnosis, and 64 (range 6-270) months after the previous imaging. We graded the disease stage according to the previously described MRA grading scale. RESULTS No acute lesions, including silent ischemic strokes were found in the follow-up image compared to latest available previous image. One patient had an asymptomatic intracerebral hemorrhage since the last imaging. Ivy sign was observed in 22% of the patients in the follow-up image. Six percent (n = 2) had microhemorrhages and 9% (n = 3) white matter lesions in the follow-up imaging. The MRA grade was evaluated from the follow-up images and it was 3 and 2.5 points (right and left, respectively). Fifty-six percent (n = 18) had old ischemic lesions in the follow-up image. Majority (71%) of the old ischemic lesions were large anterior circulation infarcts. CONCLUSIONS A slow progression of MMA-related changes on MRI/MRA was found, being in line with our previous reports suggesting a rather benign course of the disease in the Finnish population.
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Affiliation(s)
- Marika Savolainen
- Department of Neurology, South Karelia Central Hospital, Valto Käkelän katu 1, 53130, Lappeenranta, Finland. .,Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Johanna Pekkola
- Department of Radiology, HUS Medical Imaging Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Satu Mustanoja
- Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tiina Tyni
- Department of Child Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Juha Hernesniemi
- Juha Hernesniemi International Center for Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
| | - Leena Kivipelto
- Clinical Neurosciences, Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Clinical Neurosciences, Institute of Neuroscience and Physiology, Department of Neurology, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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Bersano A, Kraemer M, Burlina A, Mancuso M, Finsterer J, Sacco S, Salvarani C, Caputi L, Chabriat H, Oberstein SL, Federico A, Lasserve ET, Hunt D, Dichgans M, Arnold M, Debette S, Markus HS. Heritable and non-heritable uncommon causes of stroke. J Neurol 2020; 268:2780-2807. [PMID: 32318851 DOI: 10.1007/s00415-020-09836-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 12/15/2022]
Abstract
Despite intensive investigations, about 30% of stroke cases remains of undetermined origin. After exclusion of common causes of stroke, there is a number of rare heritable and non-heritable conditions, which often remain misdiagnosed, that should be additionally considered in the diagnosis of cryptogenic stroke. The identification of these diseases requires a complex work up including detailed clinical evaluation for the detection of systemic symptoms and signs, an adequate neuroimaging assessment and a careful family history collection. The task becomes more complicated by phenotype heterogeneity since stroke could be the primary or unique manifestation of a syndrome or represent just a manifestation (sometimes minor) of a multisystem disorder. The aim of this review paper is to provide clinicians with an update on clinical and neuroradiological features and a set of practical suggestions for the diagnostic work up and management of these uncommon causes of stroke. The identification of these stroke causes is important to avoid inappropriate and expensive diagnostic tests, to establish appropriate management measures, including presymptomatic testing, genetic counseling, and, if available, therapy. Therefore, physicians should become familiar with these diseases to provide future risk assessment and family counseling.
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Affiliation(s)
- A Bersano
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
| | - M Kraemer
- Department of Neurology Alfried, Krupp-Hospital, Essen, Germany.,Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - A Burlina
- Neurological Unit, St. Bassano Hospital, Bassano del Grappa, Italy
| | - M Mancuso
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Pisa, Italy
| | - J Finsterer
- Krankenanstalt Rudolfstiftung, Messerli Institute, Vienna, Austria
| | - S Sacco
- Department of Neurology, Avezzano Hospital, University of L'Aquila, L'Aquila, Italy
| | - C Salvarani
- University of Modena and Reggio Emilia, and Azienda USL-IRCCS, Reggio Emilia, Italy
| | - L Caputi
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - H Chabriat
- Department of Neurology and CERVCO, DHU Neurovasc, INSERM U1141, University of Paris, Paris, France
| | - S Lesnik Oberstein
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - A Federico
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - E Tournier Lasserve
- Department of Genetics, Lariboisière Hospital and INSERM U1141, Paris-Diderot University, Paris, France
| | - D Hunt
- MRC Human Genetics Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, EH4 2XU, UK
| | - M Dichgans
- Institute for Stroke and Dementia Research, Klinikum Der Universität München, Munich, Germany
| | - M Arnold
- Inserm Centre Bordeaux Population Health (U1219), University of Bordeaux, Bordeaux, France
| | - S Debette
- Department of Neurology, INSELSPITAL, University Hospital Bern, Bern, Switzerland
| | - H S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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20
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Sander O, Schwitalla JC, Ringelstein M, Aktas O, Schneider M, Berlit P, Hartung HP, Albrecht P, Kraemer M. Capillary microscopy in Europeans with idiopathic Moyamoya angiopathy. Microcirculation 2020; 27:e12616. [PMID: 32108981 DOI: 10.1111/micc.12616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/13/2020] [Accepted: 02/21/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE In Europe, MMA is a very rare non-inflammatory vasculopathy. MMA is an important differential diagnosis of cerebral vasculitis. Systemic manifestations, such as livedo racemosa or renal artery stenosis, associated with Moyamoya variants suggest the involvement also of non-cerebral vessels. Hypothetically, capillary microscopy could be a promising non-invasive screening method to visualize microcirculation, for example prior to cerebral angiography. METHODS Standardized capillary microscopic images were taken in European patients with MMA and subsequently evaluated in a blinded analysis, using data obtained from a large NP cohort and a large SLE cohort by the same blinded Investigator as controls. RESULTS Twenty-four European MMD patients and 14 healthy accompanying controls were included in this study. The results were compared to 116 SLE patients and 754 NP subjects. In MMD patients, no capillary morphological differences were found in comparison with NP, in particular no density reduction or increased neoangiogenesis. The pattern observed in the SLE cohort was clearly distinct from NP and MMD with regard to vascular density, vascular damage, and neoangiogenesis. CONCLUSIONS MMD is not associated with microvascular changes of the nailfold capillaries. In this respect, it is clearly distinct from SLE.
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Affiliation(s)
- Oliver Sander
- Department of Rheumatology and Hiller Research Institute, Medical Faculty, University Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - Jan Claudius Schwitalla
- Department of General Zoology and Neurobiology, Ruhr-University Bochum, Bochum, Germany.,Department of Neurology, Alfried Krupp Hospital, Essen, Germany
| | - Marius Ringelstein
- Department of Neurology, Medical Faculty, University Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, University Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - Matthias Schneider
- Department of Rheumatology and Hiller Research Institute, Medical Faculty, University Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - Peter Berlit
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, University Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - Philipp Albrecht
- Department of Neurology, Medical Faculty, University Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - Markus Kraemer
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany.,Department of Neurology, Medical Faculty, University Hospital, Heinrich-Heine-University, Düsseldorf, Germany
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21
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Ravina K, Kim PE, Rennert RC, Wolfswinkel EM, Strickland BA, Carey JN, Russin JJ. Lessons Learned from the Initial Experience with Pedicled Temporoparietal Fascial Flap for Combined Revascularization In Moyamoya Angiopathy: A Case Series. World Neurosurg 2019; 132:e259-e273. [PMID: 31491577 DOI: 10.1016/j.wneu.2019.08.182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/18/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The pedicled temporoparietal fascial flap (TPFF) with a direct superficial temporal (STA) artery to middle cerebral artery (MCA) bypass is a novel combined revascularization approach for moyamoya angiopathy (MMA). With this case series, we aim to report the initial experience with pedicled TPFF combined revascularization for MMA treatment. METHODS Data from 14 consecutive patients undergoing pedicled TPFF combined revascularization for MMA between May 2016 and December 2018 were retrospectively reviewed. Patients admitted with acute ischemia or a modified Rankin Scale (mRS) score >3 were considered high risk. RESULTS Mean ± standard deviation age on surgery was 41.9 ± 15.4 years. Three of 14 patients (21.4%) presented with an mRS score >3. Nine of 14 patients (64.3%) presented with ischemic stroke, 4 of whom (44.4%) had acute ischemia. Direct anastomosis patency was confirmed in all cases postoperatively. Mean hospitalization time was 13 ± 9.3 days and mean follow-up time was 14.1 ± 9.3 months. From admission to follow-up, neurologic status improved in 8 patients (57.1%) and stabilized in 6 patients (42.9%). Overall, 11/14 patients (78.6%) achieved good functional outcome (mRS score ≤2). All patients achieved some radiographic collateral development, with 5 (71.5%) graded as Matsushima A and B. Three patients developed new radiographic ischemia and 3 experienced wound complications, all in the high-risk group. CONCLUSIONS The TPFF combined approach is a viable strategy for revascularization in MMA. This technique may be suboptimal in patients presenting with acute ischemia and/or mRS score >3.
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Affiliation(s)
- Kristine Ravina
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Paul E Kim
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of California at San Diego, San Diego, California, USA
| | - Erik M Wolfswinkel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ben A Strickland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jonathan J Russin
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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22
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Hadisurya J, Guey S, Grangeon L, Wieczorek D, Corpechot M, Schwitalla JC, Kraemer M. Moyamoya angiopathy in PHACE syndrome not associated with RNF213 variants. Childs Nerv Syst 2019; 35:1231-7. [PMID: 31037424 DOI: 10.1007/s00381-019-04145-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/02/2019] [Indexed: 10/26/2022]
Abstract
Moyamoya angiopathy is a rare vasculopathy with stenosis and/or occlusion of bilateral intracranial parts of internal carotid arteries and/or proximal parts of middle and anterior cerebral arteries. PHACE syndrome is characterized by large segmental hemangiomas in the cervical-facial region. Both conditions are known to be associated in rare cases. Recently, it was discussed in the literature that RNF213 variants could be etiologically involved in this association. Here, we describe a childhood case with this rare co-occurrence in which we did not identify any rare RNF213 variant. The clinical and genetic backgrounds are discussed.
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23
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Savolainen M, Mustanoja S, Pekkola J, Tyni T, Uusitalo AM, Ruotsalainen S, Poutiainen E, Hernesniemi J, Kivipelto L, Tatlisumak T. Moyamoya angiopathy: long-term follow-up study in a Finnish population. J Neurol 2019; 266:574-81. [PMID: 30560456 DOI: 10.1007/s00415-018-9154-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/05/2018] [Accepted: 12/08/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND PURPOSE Moyamoya angiopathy (MMA) is a chronic cerebrovascular disorder predominantly starting in childhood or early adulthood and thus affects the whole lifetime. Little is known on MMAs long-term outcomes in European patients. We report long-term follow-up data on Finnish MMA patients. METHODS We included patients from our Helsinki University Hospital MMA database and arranged long-term follow-up visits for all the patients. This follow-up included a review of the medical records accumulated in due time, detailed neurological and neuropsychological evaluation, and outcome measures modified Rankin Scale (mRS) and Barthel Index (BI). RESULTS There were 61 MMA patients with a mean follow-up period of 9.5 years (SD 6.7 years; range 1.3-35.4 years; 581 patient-years). Only two patients had died and two-thirds (n = 40, 65.6%) had no new events during the follow-up period. Eight patients (13.1%) had an ischemic and five patients (8.2%) a hemorrhagic stroke during the follow-up. There were no differences between operated (n = 26) and conservatively (n = 35) treated groups regarding recurrent events or the outcome measured with mRS or BI. Finnish MMA patients reported significantly poorer physical and psychological health aspects of QOL when compared to the general Finnish population. Symptoms of low mood were found in 27 (56%) patients. CONCLUSIONS Finnish MMA patients have a benign and stable course with a ~3.5 % annual stroke risk. We found no differences in the clinical outcomes between the operated and conservative groups, however, the psychosocial well-being requires more attention in MMA patients.
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24
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Ishii D, Matsushige T, Okazaki T, Shinagawa K, Sakamoto S, Oshita J, Kurisu K. Marked Changes in Blood-Brain Barrier Biomarkers After Direct Bypass Surgery for Moyamoya Angiopathy: Preliminary Study. World Neurosurg 2018; 120:e611-e616. [PMID: 30165210 DOI: 10.1016/j.wneu.2018.08.134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 08/16/2018] [Accepted: 08/17/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The blood-brain barrier (BBB) of patients with moyamoya angiopathy (MMA) is unstable, which may contribute to transient neurologic symptoms (TNS) after direct bypass surgery. However, BBB-related proteins have never been investigated. The purpose of this study was to evaluate the perioperative serum levels of biomarkers representing BBB function in MMA patients based on the hypothesis that postoperative hemodynamic change may disrupt the BBB. METHODS A total of 12 hemispheres in 11 patients with MMA were prospectively examined. Direct revascularization surgery was performed for all cases. The serum levels of tight junction (occludin and claudin 5), adherens junction (vascular endothelial-cadherin) proteins, and matrix metalloproteinase (MMP)-2 and MMP-9 were measured quantitatively 1 day before surgery and on postoperative days 1, 4, and 7. RESULTS Successful patency of the direct bypass was achieved in all. The serum level of occludin was significantly increased on postoperative day 1, and the levels in 2 cases with TNS were markedly elevated over 10-fold higher than baseline. Furthermore, the postoperative MMP-9 levels were significantly elevated on each day. On the other hand, there was no significant fluctuation in claudin 5, vascular endothelial-cadherin, and MMP-2 level. CONCLUSIONS Marked changes in biomarkers representing the tight junction of the BBB were observed. These preliminary results suggest that marked hemodynamic change and TNS in some patients are associated with disruption of the BBB after direct bypass surgery for MMA.
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Affiliation(s)
- Daizo Ishii
- 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.
| | - Takahito Okazaki
- 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
| | - Shigeyuki Sakamoto
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Jumpei Oshita
- 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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25
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Kraemer M, Karakaya R, Matsushige T, Graf J, Albrecht P, Hartung HP, Berlit P, Laumer R, Diesner F. Efficacy of STA-MCA bypass surgery in moyamoya angiopathy: long-term follow-up of the Caucasian Krupp Hospital cohort with 81 procedures. J Neurol 2018; 265:2425-2433. [PMID: 30155735 DOI: 10.1007/s00415-018-9031-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 08/18/2018] [Accepted: 08/20/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Despite the consensus on the efficacy of revascularizing surgery in moyamoya angiopathy (MA) in Asia, the indication in Caucasian moyamoya patients is controversially discussed. OBJECTIVE The efficacy of revascularizing surgery in adult European patients with MA should be clarified. METHODS This study retrospectively analyzed the rate of further strokes and hemorrhages as well as MRI and Duplex ultrasound features during long-term follow up after STA-MCA bypass. RESULTS Eighty-one STA-MCA bypass procedures in 54 patients with MA operated in one single German institution were analyzed. All 54 patients (100%) were Caucasians. After two diffusion restricted spots in MRI perioperatively (2.5%) and short-lasting symptoms directly after surgery, no patient experienced further new symptoms related to stroke or hemorrhages nor no new gliotic scars or microbleeds on MRI for 38.2 months. Duplex ultrasound 3 months after surgery documented bypass patency in 100% and sonographic sign for good relevance of the bypass in 96.2%. In addition, the diameter of the donor vessel had increased in 89.9% as an indicator for the relevance of the bypass. Semi-quantitative analysis of perfusion changes in the operated hemispheres demonstrated an increase in perfusion in the MCA territory in 56 of 74 (75.7%) hemispheres 36.7 months after surgery. In MRA images, a reduction of typical moyamoya collaterals was found in 65 of 79 hemispheres (82.3%) after a mean of 37.2 months. CONCLUSION Direct STA-MCA bypass is an effective therapy in Caucasian patients with hemodynamically compromised MA.
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Affiliation(s)
- Markus Kraemer
- Department of Neurology, Alfried Krupp von Bohlen und Halbach Hospital, Alfried-Krupp-Strasse 21, 45117, Essen, Germany. .,Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - Rusen Karakaya
- Department of Neurology, Alfried Krupp von Bohlen und Halbach Hospital, Alfried-Krupp-Strasse 21, 45117, Essen, Germany
| | - Toshinori Matsushige
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Jonas Graf
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Philipp Albrecht
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Peter Berlit
- Department of Neurology, Alfried Krupp von Bohlen und Halbach Hospital, Alfried-Krupp-Strasse 21, 45117, Essen, Germany
| | - Rudolf Laumer
- Department of Neurosurgery, Alfried Krupp Hospital, Alfried-Krupp-Strasse 21, 45130, Essen, Germany
| | - Frank Diesner
- Department of Neurosurgery, Alfried Krupp Hospital, Alfried-Krupp-Strasse 21, 45130, Essen, Germany
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26
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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27
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Kraemer M, Trakolis L, Platzen J, Schwitalla JC, Bersano A, Albrecht P, Schlamann M, Berlit P. Movement symptoms in European Moyamoya angiopathy - First systematic questionnaire study. Clin Neurol Neurosurg 2017; 152:52-6. [PMID: 27898361 DOI: 10.1016/j.clineuro.2016.11.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/19/2016] [Accepted: 11/22/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Movement disorders are a rare manifestation of Moyamoya angiopathy (MMA). Data on prevalence and clinical presentation are warranted. Possible involuntary movements include focal motor seizures, tremor, limb-shaking transient ischemic attacks, choreiform and spastic or dystonic movement disorders. PATIENTS AND METHODS We developed a questionnaire to systematically assess movement disorders in MMA. Patients' history of involuntary movements and their clinical presentation were assessed systematically by interview. Additionally, demographic data were assessed as well as localization of movements, possible trigger factors and the presence of other symptoms. RESULTS The questionnaire was administered to 63 European patients with MMA. The response rate was high with 93.6% participating patients. Twenty-eight patients (47.4%) reported involuntary movement disorders including periodic tremor, irregular jerks, involuntary movements with loopy or pranced character, stiffness and muscle cramps. From those patients, 16 (57.1%) individuals had the symptoms prior to the diagnosis of MMA. The most common involuntary movements were irregular jerks witnessed by 17 (60.7%) patients, followed by stiffness and muscle cramps in 10 (35.7%). Eight (28.6%) Patients suffered from unintended loopy and pranced character, while 4 individuals (14.3%) remembered periodic tremor. Of the 28 patients who witnessed movement disorders, 23 had undergone revascularization surgery (82.1%). From the latter subgroup, movement disorders were reversed in 7 out of 12 patients (58.3%) with irregular jerks and 4 out of 7 patients (57.1%) with unintended loopy and pranced character. CONCLUSIONS Our study elucidates the high incidence of movement disorders in an unselected consecutively recruited cohort of European MMA patients.
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28
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Kraemer M, Lee SI, Ayzenberg I, Schwitalla JC, Diehl RR, Berlit P, Bosche B, Katsarava Z, Obermann M. Headache in Caucasian patients with Moyamoya angiopathy - a systematic cohort study. Cephalalgia 2016; 37:496-500. [PMID: 27112705 DOI: 10.1177/0333102416643516] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Headache is common in patients with Moyanoya angiopathy (MMA), but usually underestimated in its management and not well characterized. Methods A validated self-administered headache screening questionnaire and a telephone interview were used in order to investigate headache characteristics, frequency and pain intensity in a large cohort of 55 German patients with MMA. Results Thirty-seven patients (67.3%) had suffered from headache in the past year. Headache intensity was rated 3.2 ± 1.3 on a verbal rating scale from 0 to 10. Seventeen patients (47.9%) reported migraine-like headache, 10 patients (27.0%) reported tension type-like headache and 10 patients (27.0%) had a combination of both. The majority of patients with migraine-like headache ( n = 10, 58.8%) described migrainous aura. Headache frequency and intensity improved significantly after revascularization surgery; however, nine patients developed new-onset headache postoperatively. Conclusion Headache is very common in MMA, often with a migraine-like phenotype. Tension type-like headache was also found in 27% of patients, which is a new finding that has not been reported before.
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Affiliation(s)
- Markus Kraemer
- 1 Department of Neurology, Alfried-Krupp-Hospital Essen, Germany
| | - Sie-In Lee
- 1 Department of Neurology, Alfried-Krupp-Hospital Essen, Germany
| | - Ilya Ayzenberg
- 2 Department of Neurology, St. Josef Hospital, Ruhr University of Bochum, Bochum, Germany
| | | | - Rolf R Diehl
- 1 Department of Neurology, Alfried-Krupp-Hospital Essen, Germany
| | - Peter Berlit
- 1 Department of Neurology, Alfried-Krupp-Hospital Essen, Germany
| | - Bert Bosche
- 3 Department of Neurology and Headache Center, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Zaza Katsarava
- 4 Department of Neurology, Evangelic Hospital Unna, Germany
| | - Mark Obermann
- 3 Department of Neurology and Headache Center, University Hospital Essen, University of Duisburg-Essen, Germany.,5 Center for Neurology, Asklepios Hospitals Schildautal, Seesen, Germany
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