The main epidemiological, clinical and morphological features of moyamoya disease in Yugoslavia

Clinical and immunopathological features of Moyamoya disease

BACKGROUND

Moyamoya disease (MMD) is a cerebrovascular disease characterized by progressive stenosis or occlusion of the terminal portion of internal carotid arteries and the formation of a vascular network at the base of the brain. The pathogenesis of MMD is still unclear.

METHODOLOGY/PRINCIPAL FINDINGS

We retrospectively analyzed clinical data for 65 consecutive patients with MMD in our institutions and evaluated the histopathological and immunohistochemical findings of intracranial vessels from 3 patients. The onset age distribution was found to have 1 peak at 40-49 year-old age group, no significant difference was observed in the female-to-male ratio (F/M = 1.2). Intracranial hemorrhage was the predominant disease type (75%). Positive family history was observed in 4.6% of patients. Histopathological findings were a narrowed lumen due to intimal fibrous thickening without significant inflammatory cell infiltration, and the internal elastic lamina was markedly tortuous and stratified. All 3 autopsy cases showed vacuolar degeneration in the cerebrovascular smooth muscle cells. Immunohistochemical study showed the migration of smooth muscle cells in the thickened intima, and aberrant expression of IgG and S100A4 protein in vascular smooth muscle cells. The Complement C3 immunoreactivity was negative.

CONCLUSION/SIGNIFICANCE

This study indicated that aberrant expression of IgG and S100A4 protein in intracranial vascular wall of MMD patients, which suggested that immune-related factors may be involved in the functional and morphological changes of smooth muscle cells, and finally caused the thickened intima. A possible mechanism is that deposits of IgG in the damaged internal elastic lamina may underlie the disruption of internal elastic lamina, which facilitated S100A4 positive SMCs migrated into intima through broken portions of the internal elastic lamina, resulting in lumen stenosis or occlusion, leading to compensatory small vessels proliferation.

Monogenic vessel diseases related to ischemic stroke: a clinical approach

The identification of stroke cases caused by monogenic disorders is important both for therapeutic decisions and genetic counselling, although they represent less than 1% of all stroke patients. The purpose of this review is to summarize genetic, pathological, and clinical features of single-gene disorders related to ischemic stroke. The following monogenic disorders are considered: cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy, cerebral autosomal-recessive arteriosclerosis with subcortical infarcts and leukoencephalopathy, hereditary endotheliopathy with retinopathy, nephropathy, and stroke, Fabry disease, pseudoxanthoma elasticum, Neurofibromatosis type 1, familial MoyaMoya disease, Ehlers-Danlos syndrome type IV, Marfan syndrome. For each monogenic disorder, mode of inheritance, pathophysiological aspects, clinical phenotype, and diagnostic tools are carefully described. Furthermore, the classification of monogenetic disorders is presented according to stroke mechanisms, which include small vessel diseases, large artery diseases, and arterial dissections. This review could be useful to identify specific diagnostic pathways for patients with a suspicion of monogenic disease.

Hemorrhage predisposing to cerebral infarction in children with moyamoya disease

Two children with a new diagnosis of hemorrhagic type moyamoya disease experienced cerebral infarction after intraventricular hemorrhage. The patients developed ischemia 15 and 2 days after the initial diagnosis of hemorrhage. No provocative factor such as hypoperfusion was identified, but both patients exhibited signs of increased intracranial pressure on computed tomographic scan before infarction. Increased intracranial pressure in the setting of hemorrhage may be a risk factor for ischemic complications in patients with moyamoya disease. The optimal acute management of these patients requires further study.

Adult unilateral moyamoya disease with familial occurrence in two definite cases: a case report and review of the literature

We documented an interesting case of adult "unilateral (probable)" moyamoya disease displaying familial occurrence in two "definite" cases. A 55-year-old female presented with motor aphasia, involuntary movement of the right hand and right homonymous hemianopia due to cerebral infarction. Cerebral angiography revealed typical angiographic findings on the left side and normal findings on the right side; consequently, the patient was diagnosed with probable moyamoya disease. Previously, her mother and nephew had been diagnosed with definite moyamoya disease with bilateral involvement. The patient continued to exhibit unilateral involvement on angiography for more than 4 years. Clinical features such as absence of familial occurrence suggest that most cases of probable moyamoya disease are distinct from definite cases, especially in adults. To the best of our knowledge, this report appears to be the first involving an adult probable case characterized by familial occurrence. The literature pertaining to adult probable moyamoya disease was reviewed and the etiology of this disease was discussed.