Management of haemorrhagic type moyamoya disease with intraventricular haemorrhage during pregnancy

Moyamoya Disease Diagnosed With Intracranial Hemorrhage After Cesarean Section Under Spinal Anesthesia: A Case Report

Moyamoya disease (MMD) is a rare non-inflammatory cerebral vasculopathy characterized by progressive stenosis of the internal carotid arteries, often bilaterally, and the formation of abnormal collateral vascular structures at the cranial base. A patient who underwent elective cesarean section (C/S) twice under spinal anesthesia and was diagnosed with MMD as a result of recurrent intracranial hemorrhage in the postpartum periods is presented. A 41-year-old female patient without any systemic comorbidity, gravida 2, parity 2, had her second cesarean section (C/S) operation under spinal anesthesia and was discharged on the third postoperative day without any problems. The patient had a mild headache that started from the occipital region and spread to the entire cranium on the same day. After applying to the emergency department at different times, she was discharged with conservative treatment. The patient had a severe headache and was admitted to the emergency room on the ninth postoperative day. The patient, who was diagnosed with intracranial hemorrhage after cranial imaging, was referred. Cranial angiography revealed advanced bilateral internal carotid artery symmetric occlusion and the basilar artery was preserved. According to the angiographic image, the patient was diagnosed with moyamoya disease and was followed up in the intensive care unit. The muscle strength of the patient, who had no cranial nerve pathology or lateralization findings, was evaluated as normal. Conservative management was applied in the intensive care unit. The patient was discharged with recommendations for neurosurgery and cardiovascular surgery after 12 days. In the postpartum period, especially in cases of headache that persists for a long time after dural puncture and does not have a postdural feature, intracranial hemorrhage should be considered until proven otherwise, and moyamoya disease also be considered in the differential diagnosis of intracranial hemorrhage. The approach to the patient in the perioperative period should focus on providing normotension, normocapnia, normothermia, and effective analgesia.

Indirect bypass for maternal symptomatic moyamoya in the first trimester of pregnancy: case report

There are no practice guidelines for the treatment of moyamoya disease in pregnant women. The need for such guidelines, however, is evidenced by the numerous case reports, case series, and systematic reviews in the literature highlighting an at-risk period for female moyamoya patients of childbearing age. Here the authors review and interpret the existing literature as it applies to their index patient and expand the literature in support of treating select patients during pregnancy. The authors describe what is to their knowledge the first case reported in the literature of a patient successfully treated with indirect surgical revascularization during the first trimester, who went on to deliver a healthy term baby without complications.

Moyamoya Disease in Pregnancy: A 20-Year Single-Center Experience and Literature Review

BACKGROUND

Pregnancy is a potential risk factor for stroke in women with Moyamoya disease. However, the rarity of the disease has limited clinical expertise to ensure a healthy pregnancy. The aim of the present study was to explore the possible risk factors for hemorrhagic and ischemic stroke in pregnant women with Moyamoya disease.

METHODS

A retrospective review of cases in our hospital during a 20-year period and a review of the reported data were conducted to investigate pregnancy-related cerebrovascular events in women with Moyamoya disease.

RESULTS

Thirty pregnancies in 20 women with Moyamoya disease were identified in the case review of our hospital. All were previously diagnosed cases, and no stroke had occurred during the study period. In the reported data review, pregnancy-related stroke in women with Moyamoya disease was identified in 54 (44 intracranial hemorrhage and 10 cerebral infarction). Intracranial hemorrhage occurred most commonly during the antepartum period (n = 39; 88.6%), with most events occurring at ≥24 weeks. Of the intracranial hemorrhage cases, 7 (15.9%) were complicated by hypertensive disorders of pregnancy, and 8 patients (18.2%) died of stroke. The onset of cerebral infarction was either in the antepartum (n = 4; 40.0%) or postpartum (n = 6; 60.0%) period. All postpartum cases occurred within 3-7 days after delivery.

CONCLUSION

Pregnancy-related stroke in patients with Moyamoya disease might be susceptible to gestational age. Intracranial hemorrhage is prone to occur during the antepartum period, especially at ≥24 weeks, and cerebral infarction tends to occur postpartum.

Moyamoya disease in pregnancy: a systematic review

BACKGROUND

Moyamoya disease (MMD) management during pregnancy poses a challenge to health care providers, and recommendations are outdated, vague, and controversial. We conducted a systematic review to investigate and present the available evidence.

METHOD

We searched five online databases and bibliographies of relevant published original studies to identify case reports, case series, cohort studies, and reviews reporting on patients diagnosed with MMD before, during, or shortly after pregnancy. We report and analyze the respective data.

RESULTS

Fifty-four relevant articles were identified. In the group of patients with MMD diagnosed prior to pregnancy, 68.7% had previously undergone bypass surgery, 64.5% delivered via cesarean section, 95.2% of mothers had good outcomes, and no bad fetal outcomes were reported. In patients first diagnosed with MMD due to a cerebrovascular accident during pregnancy, the mean gestational age on symptom onset was 28.7 weeks and 69.5% presented with cerebral hemorrhage. In this group, 57.2% received neurosurgical operative management, and 80% underwent cesarean section with 13.6% maternal mortality and 23.5% fetal demise. In patients diagnosed with MMD immediately postpartum, 46.6% suffered a cerebrovascular event within 3 days of delivery, 78.3% of which were ischemic. Only 15.3% underwent surgical hematoma evacuation and one patient (9%) expired.

CONCLUSIONS

MMD may coincide with pregnancy, but there is paucity of high-quality data. It appears that MMD is not a contraindication to pregnancy, if blood pressure and ventilation are properly managed. There is no clear evidence that bypass surgery before pregnancy or cesarean mode of delivery improve outcomes.

Neurologic Deterioration in Patients with Moyamoya Disease during Pregnancy, Delivery, and Puerperium

BACKGROUND

We reviewed our clinical experience of patients with moyamoya disease (MMD) who gave birth and assessed characteristics of those experiencing neurologic deterioration.

METHODS

The patients were classified into patients diagnosed with MMD during pregnancy and puerperium (group 1) and those diagnosed before pregnancy (group 2). We retrospectively reviewed patient characteristics, MMD treatment, neurologic symptoms before and during pregnancy and/after puerperium, obstetrical history, and delivery type in groups 1 and 2.

RESULTS

Group 1 included 2 patients with deterioration of pre-existing transient ischemic attacks (TIAs) and acute cerebral infarction and 1 patient with seizures and newly developed TIAs during pregnancy and/or puerperium. Group 2 included 20 patients with 23 pregnancies. In group 2, 4 patients had deterioration of TIAs during pregnancy and puerperium. There were significant differences between the cases without neurologic deterioration and with deterioration in group 2 (TIAs ≥10 before pregnancy, 0% vs. 75%, P = 0.002; severely reduced regional cerebrovascular reserve on single-photon emission computed tomography, 10.5% vs. 100%, P = 0.002; and surgical revascularization before pregnancy, 75% vs. 15.8%, P = 0.04). In groups 1 and 2, 6 of the 7 cases in which TIAs occurred or worsened during pregnancy or puerperium recovered to prepregnancy TIA levels after puerperium.

CONCLUSIONS

Patients with severely reduced regional cerebrovascular reserve on single-photon emission computed tomography and frequent TIAs before pregnancy may experience neurologic deterioration during pregnancy, delivery, and puerperium. Surgical revascularization before pregnancy may decrease neurologic deterioration during these periods.

Pregnancy outcomes in women with moyamoya disease: experiences at a single center in Korea

PURPOSE

Moyamoya disease (MMD) occurs predominantly in Korean and Japanese women. The aim of this study was to investigate clinical features and pregnancy outcomes in women with MMD.

MATERIALS AND METHODS

We conducted a retrospective chart review of women with MMD who visited our Department of Obstetrics and Gynecology between January 2005 and October 2013. For all study subjects, clinical features, demographic characteristics, and perinatal outcomes were recorded.

RESULTS

We identified 28 pregnancies in 22 patients who had been diagnosed with MMD. The mean maternal age at delivery was 31.9±3.5 years old. The mean gestational age at delivery was 38.0±0.9 weeks. Among the 28 pregnancies, 25 (92.5%) underwent cesarean section; 19 (76.0%) of them were performed under regional anesthesia and six (24.0%) under general anesthesia. The mean newborn weight was 3233.7±348.2 g. The 5-minute Apgar score in 85% of the newborns was higher than 8, with no other apparent complications. During the puerperal period, transient ischemic attack symptom or seizure occurred in 4 cases, although patients recovered within a few days.

CONCLUSION

For pregnant women with MMD, it is important to control blood pressure and prevent hyperventilation during the intrapartum period, and the best methods of delivery and anesthesia should be considered to avoid unfavorable sequelae. Additionally, a multidisciplinary approach (i.e., neurosurgery) is necessary to constantly manage underlying diseases.

Neurosurgery and pregnancy

BACKGROUND

Pregnant women with pathological conditions requiring a neurosurgical intervention pose a unique therapeutic challenge. Changes in normal physiology add to the complexity of patient management. We describe our experience in treating various neurosurgical diseases in parturient women.

METHODS

Thirty-four pregnant and early postpartum women were treated at our center between 2003 and 2010. The general guideline used in these patients (now deserving re-evaluation based on the presented data) was to postpone surgery until the patient reached term (weeks 34-38 of gestation) unless there was evidence of a life- or function-threatening condition, in which case surgery was promptly performed.

RESULTS

Sixteen patients underwent neurosurgical intervention during pregnancy between 11 to 34 weeks of gestation (7 tumor, 3 vascular, 2 VP shunt, 2 spinal, 2 trauma). Thirteen women underwent a neurosurgical procedure after delivery (12 tumor, 1 spine), and 5 women were treated conservatively (2 vascular lesions, 3 trauma). Three patients underwent abortions (one spontaneous and two elective). The other 31 women delivered at 30-42 weeks' gestation. Of 12 patients whose definitive neurosurgical procedure was initially delayed, 5 were not able to complete their pregnancy naturally. Of 21 patients that underwent a cesarean section (CS), 3 were performed urgently. Although two pairs of twins and two singletons had an initial low Apgar score (<7), the outcome for all the neonates was good. Neurosurgical outcome was satisfactory.

CONCLUSIONS

Our experience demonstrates the safety of neurosurgical intervention and anesthesia during pregnancy. Delaying intervention often resulted in maternal deterioration and urgent intervention. Thus, pregnancy by itself should not be considered a major contraindication for performing a neurosurgical procedure, which should be considered early rather than late in most patients.

Refractory High Intracranial Pressure following Intraventricular Hemorrhage due to Moyamoya Disease in a Pregnant Caucasian Woman

Intraventricular hemorrhage during pregnancy is usually followed by a poor recovery. When caused by moyamoya disease, ischemic or hemorrhagic episodes may complicate the management of high intracranial pressure. A 26-year-old Caucasian woman presented with generalized seizures and a Glasgow Coma Score (GCS) of 3 during the 36th week of pregnancy. The fetus was delivered by caesarean section. The brain CT in the mother revealed bilateral intraventricular hemorrhage, a callosal hematoma, hydrocephalus and right frontal ischemia. Refractory high intracranial pressure developed and required bilateral ventricular drainage and intensive care treatment with barbiturates and hypothermia. Magnetic resonance imaging and cerebral angiography revealed a moyamoya syndrome with rupture of the abnormal collateral vascular network as the cause of the hemorrhage. Intracranial pressure could only be controlled after the surgical removal of the clots after a large opening of the right ventricle. Despite an initially low GCS, this patient made a good functional recovery at one year follow-up. Management of refractory high intracranial pressure following moyamoya related intraventricular bleeding should require optimal removal of ventricular clots and appropriate control of cerebral hemodynamics to avoid ischemic or hemorrhagic complications.