Cerebrovascular events after surgery versus conservative therapy for moyamoya disease: a meta-analysis

Long-term outcomes after revascularization surgery for adult moyamoya disease: Protocol for systematic review and meta-analysis

INTRODUCTION

Moyamoya disease (MMD) commonly presents with cerebral ischemia or hemorrhage. Revascularization surgery, including direct, indirect, and combined bypasses, remains the mainstay of MMD treatment aiming to reduce stroke recurrence. However, the long-term outcomes of these interventions are still controversial. Herein, we designed the protocol for a systematic review and meta-analysis comparing the three different revascularization surgeries in adult MMD patients for more than 5 years long-term outcomes.

METHODS

Our systematic review and meta-analysis protocol follows the PRISMA-P guidelines. Bypass surgeries for MMD will be included only if the follow-up time is more than 5 years. The primary outcome is the incidence of recurrent cerebral ischemia or hemorrhage. The secondary outcomes include functional outcomes evaluated by the Moyamoya Disease outcome category, mortality, and angiographic outcomes such as bypass patency, and collateral formation.

RESULTS

Studies on the postoperative outcomes of revascularization surgeries to treat adult MMD patients will be included and analyzed. This systematic review and meta-analysis will offer evidence to clinicians and researchers on the long-term outcomes of revascularization surgeries in adult MMD patients and help to optimize the selection of bypass modality.

Machine learning model for predicting stroke recurrence in adult stroke patients with moyamoya disease and factors of stroke recurrence

OBJECT

The aim of this study was at building an effective machine learning model to contribute to the prediction of stroke recurrence in adult stroke patients subjected to moyamoya disease (MMD), while at analyzing the factors for stroke recurrence.

METHODS

The data of this retrospective study originated from the database of JiangXi Province Medical Big Data Engineering & Technology Research Center. Moreover, the information of MMD patients admitted to the second affiliated hospital of Nanchang university from January 1st, 2007 to December 31st, 2019 was acquired. A total of 661 patients from January 1st, 2007 to February 28th, 2017 were covered in the training set, while the external validation set comprised 284 patients that fell into a scope from March 1st, 2017 to December 31st, 2019. First, the information regarding all the subjects was compared between the training set and the external validation set. The key influencing variables were screened out using the Lasso Regression Algorithm. Furthermore, the models for predicting stroke recurrence in 1, 2, and 3 years after the initial stroke were built based on five different machine learning algorithms, and all models were externally validated and then compared. Lastly, the CatBoost model with the optimal performance was explained using the SHapley Additive exPlanations (SHAP) interpretation model.

RESULT

In general, 945 patients suffering from MMD were recruited, and the recurrence rate of acute stroke in 1, 2, and 3 years after the initial stroke reached 11.43%(108/945), 18.94%(179/945), and 23.17%(219/945), respectively. The CatBoost models exhibited the optimal prediction performance among all models; the area under the curve (AUC) of these models for predicting stroke recurrence in 1, 2, and 3 years was determined as 0.794 (0.787, 0.801), 0.813 (0.807, 0.818), and 0.789 (0.783, 0.795), respectively. As indicated by the results of the SHAP interpretation model, the high Suzuki stage, young adults (aged 18-44), no surgical treatment, and the presence of an aneurysm were likely to show significant correlations with the recurrence of stroke in adult stroke patients subjected to MMD.

CONCLUSION

In adult stroke patients suffering from MMD, the CatBoost model was confirmed to be effective in stroke recurrence prediction, yielding accurate and reliable prediction outcomes. High Suzuki stage, young adults (aged 18-44 years), no surgical treatment, and the presence of an aneurysm are likely to be significantly correlated with the recurrence of stroke in adult stroke patients subjected to MMD.

Longitudinal evaluation of cerebral perfusion evolution after revascularization surgery in moyamoya disease by CT perfusion

OBJECTIVE

To assess the longitudinal evolution of cerebral perfusion after revascularization surgery in patients with moyamoya disease (MMD) by CT perfusion (CTP).

MATERIALS AND METHODS

Thirty-one clinically confirmed MMD patients (12 males and 19 females, average age: 33.26 y, Suzuki stages 3 and 4: 19 and 11, respectively) who underwent revascularization surgery (bilateral (n=13) or unilateral (n=18)) were studied retrospectively. All patients underwent CTP examinations before and in the week after surgery and long-term (>3 months). CTP metrics (CBF, CBV, MTT, TTP, and delay TTP) were derived. The corresponding CTP metric values of the ROIs, which were manually drawn in the white matter (WM) and gray matter (GM), were recorded.

RESULTS

Six patients developed a new or progressive cerebral infarction/hemorrhage. In all patients, compared with the preoperative level, the TTP of GM and WM decreased in the short term after the surgery (P ≤ 0.005). Concurrently, the WM CBF increased significantly a week after surgery (P =0.02). However, in the long-term follow-up, the CBV and CBF in the GM and WM decreased to equal to or lower than the preoperative level, especially for CBV in the WM (P =0.012). Furthermore, cerebral perfusion began to decrease in the sixth month, and a continuous decline was observed over the next two months. It returned to the presurgical level after one year. In addition, the improvement in postsurgical perfusion was greater in Suzuki stage 3 patients than stage 4 patients.

CONCLUSION

Cerebral perfusion in patients with MMD improved shortly after surgery. However, in the long-term, brain perfusion decreased, most seriously in 6-8 months postoperatively, which might indicate that patients with MMD need timely follow-up and long-term intervention.

Combination of intraoperative indocyanine green video-angiography FLOW 800 and computed tomography perfusion to assess the risk of cerebral hyperperfusion syndrome in chronic internal carotid artery occlusion patients after revascularization surgery

Background and purpose

To study the changes of corticocerebral hemodynamics in surgical area and postoperative hyperperfusion syndrome in patients with chronic internal carotid artery occlusion (CICAO) by intraoperative indocyanine green videoangiography (ICGA)-FLOW 800 and CT perfusion after superficial temporal artery (STA)-middle cerebral artery (MCA) bypass surgery.

Methods

From October 2019 to January 2021, 77 patients diagnosed with CICAO underwent direct bypass surgery at Huadong hospital (affiliated with Fudan University) were enrolled. Regions of interest (ROIs) at STA, proximal MCA (PMCA), distal MCA (DMCA), cortical blood capillary (CBC), and cortical vein (CV) were identified after anastomosis by ICGV-FLOW 800 including peak fluorescence intensity (PFI), time to peak (TTP), and area under the time curve (AUC) of fluorescence intensity. All patients underwent perfusion-weighted CT before bypass surgery and those patients with HPS were verified by CTP after bypass.

Results

14 patients with HPS were verified by perfusion-weighted CT after bypass. In HPS group, the AUCTTP of DMCA was significantly larger (T = -3.301, p = 0.004) and TTP of CBC was shorter (T = -2.929, p = 0.005) than patients in non-HPS group. The larger AUCTTP of DMCA (OR = 3.024, 95%CI 1.390-6.578, p = 0.0050) was an independent risk factor by further multivariate logistic regression analysis.

Conclusion

The hemodynamic changes of cortical vessels during STA-MCA bypass surgery could be recorded accurately by ICGV-FLOW 800. Furthermore, the increased AUCTTP of DMCA and shorter TTP of CBC may be potential risk factors of HPS.

Cerebral Vasculopathy in Children with Neurofibromatosis Type 1

Cerebrovascular abnormalities are a severe and often underrecognized complication of childhood neurofibromatosis type 1 (NF1). There are no prospective studies of cerebral vasculopathy in NF1; thus, the estimated frequency of vasculopathy varies between studies. The data is difficult to interpret due to the retrospective data collection and variability in whether imaging is done based on screening/surveillance or due to acute neurologic symptoms. The prevalent NF1-associated cerebral vasculopathy is moyamoya syndrome (MMS). Vascular changes can present without symptoms or with acute TIA or stroke-like symptoms or a range of progressive neurologic deficits. Advanced imaging may enhance sensitivity of neuroimaging in children. Medical and/or surgical interventions may prevent short- and long-term complications. Challenges for establishment of a screening protocol for cerebral vasculopathy in children with NF1 include the relatively large number of patients with NF1, the potential need for sedation to achieve quality imaging and the broad age range at time of detection for cerebral vascular changes. The goal of this review is to present the epidemiology, clinical presentation, imaging features and medical/surgical management of cerebral arteriopathies in children with NF1.

Three-Dimensional Arterial Spin Labeling for the Evaluation of the Cerebral Hemodynamics in Ischemic and Hemorrhagic Moyamoya Disease

INTRODUCTION

Moyamoya disease (MMD) is a vascular disease with significant risk of mortality due to ischemia or hemorrhage in the brain. The goal of the study was to explore three-dimensional arterial spin labeling (3D-ASL) to improve evaluation of cerebral hemodynamics in patients with MMD.

METHODS

Our study included 54 cases of ischemic MMD and 42 cases of hemorrhagic MMD. Dynamic susceptibility contrast-enhanced perfusion-weighted imaging (DSC-PWI) and 3D-ASL were performed at 3.0 T. Based on these scans, cerebral blood flow (CBF), mean transit time (MTT), and time to peak (TTP) were calculated and compared between patients with different disease subtypes. Receiver operating characteristics analysis was used to assess the diagnostic sensitivity and specificity of different imaging procedures and parameters.

RESULTS

Our data suggested that CBF in the lesion area was more severely reduced in patients with hemorrhagic MMD than in those with ischemic MMD. The CBF parameter in 3D-ASL diagnosed hemorrhagic and ischemic MMD with a significant sensitivity and specificity of 80.59% and 57.41%, respectively, with an area under the curve (AUC) of 0.75. We also found that the relative CBF of 3D-ASL was more pronounced decreased and the relative MTT and TTP of DSC-PWI were significantly increased in patients with hemorrhagic MMD than those with ischemic MMD. Specificity and sensitivity and AUC of 3D-ASL were better than the comparison of absolute values from DSC-PWI scans.

CONCLUSION

Our study indicated that 3D-ASL is powerful in differentiating patients with cerebral ischemic or hemorrhagic MMD, providing another diagnostic tool that could potentially improve precision medicine to monitoring MMD patients.

Association of moyamoya vasculopathy with autoimmune disease: a systematic review and pooled analysis

Despite more than six decades of extensive research, the etiology of moyamoya disease (MMD) remains unknown. Inflammatory or autoimmune (AI) processes have been suggested to instigate or exacerbate the condition, but the data remains mixed. The objective of the present systematic review was to summarize the available literature investigating the association of MMD and AI conditions as a means of highlighting potential treatment strategies for this subset of moyamoya patients. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the PubMed, Embase, Scopus, Web of Science, and Cochrane databases were queried to identify studies describing patients with concurrent diagnoses of MMD and AI disease. Data were extracted on patient demographics, clinical outcomes, and treatment. Stable or improved symptoms were considered favorable outcomes, while worsening symptoms and death were considered unfavorable. Quantitative pooled analysis was performed with individual patient-level data. Of 739 unique studies identified, 103 comprising 205 unique patients (80.2% female) were included in the pooled analysis. Most patients (75.8%) identified as Asian/Pacific Islanders, and the most commonly reported AI condition was Graves' disease (57.6%), with 55.9% of these patients presenting in a thyrotoxic state. Of the 148 patients who presented with stroke, 88.5% of cases (n = 131) were ischemic. Outcomes data was available in 152 cases. There were no significant baseline differences between patients treated with supportive therapy alone and those receiving targeted immunosuppressant therapy. Univariable logistic regression showed that surgery plus medical therapy was more likely than medical therapy alone to result in a favorable outcome. On subanalysis of operated patients, 94.1% of patients who underwent combined direct and indirect bypass reported favorable outcomes, relative to 76.2% of patients who underwent indirect bypass and 82% who underwent direct bypass (p < 0.05). On univariable analysis, the presence of multiple AI disorders was associated with worse outcomes relative to having a single AI disorder. Autoimmune diseases have been uncommonly reported in patients with MMD, but the presence of multiple AI comorbidities portends poorer prognosis. The addition of surgical intervention appears to improve outcomes and for patients deemed surgical candidates, combined direct and indirect bypass appears to offer better outcomes that direct or indirect bypass alone.

Idiopathic steno-occlusive disease with bilateral internal carotid artery occlusion: A Case Report

BACKGROUND

Moyamoya disease (MMD) is a rare cause of acute stroke and transient ischemic attacks in children. We described clinical, diagnostic features and follow-ups of a young child with acute stroke.

CASE SUMMARY

We report a 4-year-old girl with left hemiparesis after an acute ischemic stroke. Her history was also significant for repeated left or right focal motor seizures, generalized tonic-clonic convulsions and transient ischemic attacks. Her magnetic resonance imaging and computed tomography (CT) of the brain and magnetic resonance angiography, CT angiography and venography on the cerebral vessels revealed evidence of bilateral fronto-parietal ischemic infarctions, occlusion of the right and left internal carotid arteries started at its bifurcation and non-visualization of right and left anterior and middle cerebral arteries. There was evidence of progression in angiography manifested as development of collaterals from the basal perforating vessels, increase in the extent of large intracranial arterial stenosis/occlusion and extensive collateral circulation with predominance from the posterior circulation. Physical and neurological evaluation and comprehensive laboratory investigations excluded an obvious comorbid disease or risk factor for the child’s condition. The diagnosis of MMD was highly suggested as a cause of the child’s steno-occlusive condition. She was treated symptomatically with levetiracetam, an antiepileptic medication. Aspirin was prescribed for secondary prevention. Her clinical manifestations were improved during the three years of follow-up. Revascularization surgery was postponed.

CONCLUSION

Up to our knowledge, this is the first report for MMD in a child in our country. The clinical improvement and the stabilization of the child’s condition over the 3 years of follow-up could be attributed to the rapid and extensive recruitment of collaterals and absence of risk factors or comorbidities. Revascularization surgery is highly recommended.

Identification of moyamoya disease based on cerebral oxygen saturation signals using machine learning methods

Moyamoya is a cerebrovascular disease with a high mortality rate. Early detection and mechanistic studies are necessary. Near-infrared spectroscopy (NIRS) was used to study the signals of the cerebral tissue oxygen saturation index (TOI) and the changes in oxygenated and deoxygenated hemoglobin concentrations (HbO and Hb) in 64 patients with moyamoya disease and 64 healthy volunteers. The wavelet transforms (WT) of TOI, HbO and Hb signals, as well as the wavelet phase coherence (WPCO) of these signals from the left and right frontal lobes of the same subject, were calculated. Features were extracted from the spontaneous oscillations of TOI, HbO and Hb in five physiological activity-related frequency segments. Machine learning models based on support vector machine (SVM), random forest (RF) and extreme gradient boosting (XGBoost) have been built to classify the two groups. For 20-min signals, the 10-fold cross-validation accuracies of SVM, RF and XGBoost were 87%, 85% and 85%, respectively. For 5-min signals, the accuracies of the three methods were 88%, 88% and 84%, respectively. The method proposed in this article has potential for detecting and screening moyamoya with high proficiency. Evaluating the cerebral oxygenation with NIRS shows great potential in screening moyamoya diseases.

Moyamoya Disease in an adult female from Nepal: A case report

INTRODUCTION AND IMPORTANCE

Moyamoya is a progressive vasoocclusive disease of large intracranial arteries with characteristic collaterals formation. It has a bimodal distribution and more frequent in females compared to males.

CASE PRESENTATION

We present a case of 38 years female who presented with a loss of consciousness following headache. She was investigated with a head CT, cerebral angiogram, and digital subtraction angiography which led to a diagnosis of Moyamoya disease. She was treated conservatively and scheduled for follow-up.

CLINICAL DISCUSSION

Although ischemic attacks are the common presenting symptoms in cases of Moyamoya disease, hemorrhagic forms are seen too especially among adults compared to children. Identifying Moyamoya disease can significantly affect the treatment options and give insight into managing the chronic nature of the disease to both the physicians and patients.

CONCLUSION

This case highlights the importance of searching for underlying cause in a young female presenting with intracranial haemorrhage for the first time and keeping Moyamoya disease as a differential.

Development and Validation of a Nomogram to Predict the Individual Future Stroke Risk for Adult Patients With Moyamoya Disease: A Multicenter Retrospective Cohort Study in China

Background: Studies exploring the predictive performance of major risk factors associated with future stroke events are insufficient, and a useful tool to predict individual risk is not available. Therefore, personalized advice for preventing future stroke in patients with moyamoya disease (MMD) cannot provide evidence-based recommendations. The aim of this study was to develop a novel nomogram with reliable validity to predict the individual risk of future stroke for adult MMD patients.

Methods: This study included 450 patients from seven medical centers between January 2013 and December 2018. Follow-ups were performed via clinical visits and/or telephone interviews from initial discharge to December 2019. The cohort was randomly assigned to a training set (2/3, n = 300) for nomogram development and a test set (1/3, n = 150) for external validation. The Kaplan-Meier analyses and receiver operating characteristic (ROC) curves were applied to assess the clinical benefits of this nomogram.

Results: Diabetes mellitus, a family history of MMD, a past history of stroke or transient ischemic attack, clinical manifestation, and treatment were identified as major risk factors via the least absolute shrinkage and selection operator (LASSO) method. A nomogram including these predictors was established via a multivariate Cox regression model, which displayed excellent discrimination [Harrell's concordance index (C-index), 0.85; 95% confidence interval (CI): 0.75–0.96] and calibration. In the external validation, the nomogram was found to have good discrimination (C-index, 0.81; 95% CI: 0.68–0.94) and calibration. In the subgroup analysis, this predictive nomogram also showed great performance in both ischemic-type (C-index, 0.90; 95% CI: 0.77–1.00) and hemorrhagic-type MMD (C-index, 0.72; 95% CI: 0.61–0.83). Furthermore, the nomogram was shown to have potential in clinical practice through Kaplan-Meier analyses and ROC curves.

Conclusions: We developed a novel nomogram incorporating several clinical characteristics with relatively good accuracy, which may have considerable potential for evaluating individual future stroke risk and providing useful management recommendations for adult patients with MMD in clinical practice.

Delayed Anastomotic Occlusion after Direct Revascularization in Adult Hemorrhagic Moyamoya Disease

Delayed anastomotic occlusion occurred in a considerable proportion of hemorrhagic moyamoya disease (MMD) patients undergoing direct revascularization. This study aimed to investigate the predictors and outcomes of delayed anastomotic occlusion in adult hemorrhagic MMD. The authors retrospectively reviewed 87 adult hemorrhagic MMD patients. Univariate and multivariate logistic regression analyses were performed. After an average of 9.1 ± 6.9 months of angiographic follow-up, the long-term graft patency rates were 79.8%. The occluded group had significantly worse angiogenesis than the non-occluded group (p < 0.001). However, the improvement of dilated anterior choroidal artery–posterior communicating artery was similar (p = 0.090). After an average of 4.0 ± 2.5 years of clinical follow-up, the neurological statues and postoperative annualized rupture risk were similar between the occluded and non-occluded groups (p = 0.750; p = 0.679; respectively). In the multivariate logistic regression analysis, collateral circulation Grade III (OR, 4.772; 95% CI, 1.184–19.230; p = 0.028) and preoperative computed tomography perfusion (CTP) Grade I–II (OR, 4.129; 95% CI, 1.294–13.175; p = 0.017) were independent predictors of delayed anastomotic occlusion. Delayed anastomotic occlusion in adult hemorrhagic MMD might be a benign phenomenon. Good collateral circulation (Grade III) and compensable preoperative intracranial perfusion (CTP Grade I–II) are independent predictors for this phenomenon. Moreover, the delayed anastomotic occlusion has no significant correlations with the long-term angiographic and neurological outcomes, except neoangiogenesis.

Surgical revascularization for Moyamoya disease in the United States: A cost-effectiveness analysis

Objective

Moyamoya disease (MMD) is a vasculopathy of the internal carotid arteries with ischemic and hemorrhagic sequelae. Surgical revascularization confers upfront peri-procedural risk and costs in exchange for long-term protective benefit against hemorrhagic disease. The authors present a cost-effectiveness analysis (CEA) of surgical versus non-surgical management of MMD.

Methods

A Markov Model was used to simulate a 41-year-old suffering a transient ischemic attack (TIA) secondary to MMD and now faced with operative versus nonoperative treatment options. Health utilities, costs, and outcome probabilities were obtained from the CEA registry and the published literature. The primary outcome was incremental cost-effectiveness ratio which compared the quality adjusted life years (QALYs) and costs of surgical and nonsurgical treatments. Base-case, one-way sensitivity, two-way sensitivity, and probabilistic sensitivity analyses were performed with a willingness to pay threshold of $50,000.

Results

The base case model yielded 3.81 QALYs with a cost of $99,500 for surgery, and 3.76 QALYs with a cost of $106,500 for nonsurgical management. One-way sensitivity analysis demonstrated the greatest sensitivity in assumptions to cost of surgery and cost of admission for hemorrhagic stroke, and probabilities of stroke with no surgery, stroke after surgery, poor surgical outcome, and death after surgery. Probabilistic sensitivity analyses demonstrated that surgical revascularization was the cost-effective strategy in over 87.4% of simulations.

Conclusions

Considering both direct and indirect costs and the postoperative QALY, surgery is considerably more cost-effective than non-surgical management for adults with MMD.

Moyamoya Disease: A Review of Current Literature

Moyamoya disease (MMD) is an infrequent disease of cerebral vasculature characterized by long-standing and progressive occlusion of large intracranial arteries. It is seen predominantly in the East Asian population. Most of the cases of MMD are sporadic, but there is a small percentage that is familial. The mode of inheritance is reported to be autosomal dominant with incomplete penetrance. Studies show that the susceptibility gene of MMD is located on chromosome 17. The clinical presentation is variable and is influenced by the age and geographic region of the patient. Children mainly present with ischemia-related neurologic episodes whereas MMD in adults can manifest as either an ischemic event or an intracranial hemorrhage (ICH). The gold standard investigation for diagnosis is cerebral angiography which reveals a smoky appearance of arteries at the base of the skull, thus granting the disease its name. The treatment is mostly surgical and includes direct and indirect revascularization procedures, which prevent the recurrence of both ischemic and hemorrhagic strokes. However, combination revascularization procedures are now on the rise due to studies showing better long-term outcomes. The aim of the article is to critically analyze the current literature and updates on various aspects of MMD including, but not limited to, etiology, diagnosis, and treatment.

A critical appraisal of bypass surgery in moyamoya disease

Moyamoya disease (MMD) is a complex cerebrovascular disorder about which little is known. Conventionally, revascularization surgery is recommended for patients, despite an absence of conclusive data from adequate clinical trials. Underscoring the uncertainty that exists in treating MMD patients, investigators continue to present data comparing revascularization with conservative or medical management, most of which originates from East Asia where MMD is most prevalent. The purpose of this manuscript is to review contemporary large case series, randomized trials, and recent meta-analyses that compare surgical and medical treatments in adult patients with MMD, and to critically analyze the modern literature in the context of current practice standards. Data from the available literature is limited, but revascularization seems superior to conservative therapy in adult patients presenting with hemorrhage, and in preventing future hemorrhages. Conversely, evidence that surgery is superior to medical therapy is not convincing in adult patients presenting with cerebral ischemia, or for the prevention of future ischemic events. In contrast to East Asian populations, MMD in Europe and in the Americas is predominantly an ischemic disease that presents in adulthood. Adequate multinational trials are warranted.