Champagne bottle neck sign in a patient with Moyamoya syndrome

The angiographic presentation of European Moyamoya angiopathy

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.

Moyamoya Disease Associated with Graves' Disease and Down Syndrome: A Case Report and Literature Review

BACKGROUND

Moyamoya vessels are cerebral vasculopathies characterized by net-like collateral vessel formation at the cerebral basal area and stenosis of the terminal internal carotid artery, proximal middle cerebral artery, and anterior cerebral artery. A diagnosis of Moyamoya disease depends on the bilateral presence of Moyamoya vessels. Moyamoya disease associated with Graves' disease has rarely been reported to be a cause of ischemic events due to hyperthyroidism. However, there are extremely rare cases of Moyamoya disease with concurrent Graves' disease and Down syndrome. We aimed to report such a case, and to compare these cases' clinical features, pathogenesis, and treatment effects to those of the cases of concurrent Moyamoya disease and Graves' disease alone.

METHODS

We performed an English literature search using the PubMed database and the keywords Moyamoya, quasi-Moyamoya, Graves' disease, thyrotoxicosis, Down syndrome, and trisomy 21.

RESULTS

Only five cases of Moyamoya disease with Graves' disease and Down syndrome have been reported, including our own. Four patients were female (80%), and all underwent antithyroid therapy and experienced ischemic episodes, including transient ischemic attacks. At the time of their vascular accident, two patients were in a thyrotoxic state; only our patient was in a euthyroid state. The mean age was 15.6 years (standard deviation: 6.1), which was younger than the mean age of 31.4 years (standard deviation: 13) in patients with Moyamoya disease and Graves' disease alone. Down syndrome is commonly associated with abnormal vascular networks due to increased endostatin concentrations or immunological abnormalities such as those that occur in Graves' disease. Graves' disease accelerates the progression of Moyamoya disease and ischemic attacks due to atherosclerosis, enhances sympathetic nervous system activity and immunological changes. As compared to Moyamoya disease patients, patients with concurrent Graves' disease only and Moyamoya disease patients with concurrent Graves' disease and Down syndrome may experience accelerated disease progression or more frequent ischemic attacks.

CONCLUSION

Early imaging follow-ups and strict control of thyroid function are necessary in such cases; if ischemic attacks have already occurred, revascularization surgery may be effective.

Imaging Classification of Internal Carotid Artery Hypoplasia Based on Distal Ophthalmic Segment Occlusion

BACKGROUND

Internal carotid artery (ICA) hypoplasia (ICAH) is rare. The classification of ICAH is largely unclear. The aim of the study is to propose a new imaging classification for ICAH based on the occlusion of the distal ophthalmic segment and discuss the clinical and radiological differences between the different types.

MATERIALS AND METHODS

This was a retrospective study of patients with congenital ICAH diagnosed at the Department of Neurology of the China-Japan Friendship Hospital between June 2011 and June 2016. The patients underwent temporal bone computed tomography (CT), brain CT, cranial magnetic resonance imaging, transcranial Doppler, and head and neck CT angiography.

RESULTS

A total of 20 ICAH patients were divided into the distal occlusion (12 cases; 60%) and nondistal occlusion (8 cases; 40%) types based on whether the distal ophthalmic segment was occluded. The frequencies of collateral circulation from the circle of Willis (P = .01) and dilated cerebrovascular lesions (P = .001) in the distal occlusion type was higher than in the nondistal occlusion type. Five (25%) patients developed adverse cerebrovascular events during followup: 3 ischemic cases were of the nondistal occlusion type, and 2 cases with subarachnoid hemorrhage were of the distal occlusion type.

CONCLUSIONS

A novel classification of ICAH was revealed based on the occlusion of the distal ophthalmic segment. The 2 types may show differences in collateral circulation patterns, coexisting cerebrovascular abnormalities, and potential clinical outcomes.

Progressive stenosis and radiological findings of vasculitis over the entire internal carotid artery in moyamoya vasculopathy associated with graves' disease: a case report and review of the literature

Background

Moyamoya vasculopathy (MMV) associated with Graves’ disease (GD) is a rare condition resulting in ischemic stroke accompanied by thyrotoxicity. Radiological findings of vasculitis have been reported in the walls of distal internal carotid arteries (ICAs) in these patients; however, no reports have described in detail the processes of progression of the lesions in the proximal ICA. Moreover, treatments to prevent recurrence of ischemic stroke and progression of MMV have not yet been sufficiently elucidated.

Case presentation

We report a progressive case of MMV associated with GD and review the literature to clarify relationships among recurrence, progression, thyrotoxicity and treatment. Our patient developed cerebral infarction during thyrotoxicity with no obvious stenosis of ICAs. Five months later, transient ischemic attacks recurred with thyrotoxicity. Antiplatelet therapy and intravenous methylprednisolone stopped the attacks. Stenosis of the left ICA from the proximal to distal portion and champagne bottle neck sign (CBN) were found. She declined any surgery. Afterward, gradual progression with mild thyrotoxicity was observed. Eventually, we found smooth, circumferential, concentric wall thickening with diffuse gadolinium enhancement of the left ICA from the proximal to the distal portion on T1-weighted imaging, suggesting vasculitis radiologically. The clinical and radiological similarities to Takayasu arteritis encouraged us to provide treatment as for vasculitis of medium-to-large vessels. In a euthyroid state and after administration of prednisolone and methotrexate, improved flow in the cerebrovascular arteries on magnetic resonance angiography was observed. Based on our review of the literature, all cases with recurrence or progression were treated with anti-thyroid medication (ATM) alone and accompanied by thyrotoxicity. CBN was observed in all previous cases for which images of the proximal ICA were available.

Conclusions

We report the details of progressive stenosis from a very early stage and radiological findings of vasculitis over the entire ICA in MMV associated with GD. Cerebral infarction can occur with no obvious stenosis of the ICA. We treated the patient as per vasculitis of a medium-to-large vessel. Management of GD by ATM alone seems risky in terms of recurrence. Adequate management of GD and possible vasculitis may be important for preventing recurrence and progression.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1262-1) contains supplementary material, which is available to authorized users.

Proximal internal carotid artery stenosis associates with diffuse wall thickening in petrous arterial segment of moyamoya disease patients: a three-dimensional magnetic resonance vessel wall imaging study

PURPOSE

To investigate the association between proximal internal carotid artery (ICA) luminal narrowing and diffuse wall thickening (DWT) in ipsilateral petrous ICA in moyamoya disease (MMD) patients.

METHODS

Forty-one MMD (mean age 42.8 ± 11.0 years, 19 males) and 36 atherosclerotic patients (mean age 61.5 ± 7.1 years, 31 males) and 41 healthy controls were recruited and underwent carotid MR vessel wall imaging. The luminal narrowing of proximal ICA was evaluated by the diameter ratio of ICA to common carotid artery (DR_ICA/CCA). The wall thickness of petrous ICA was measured on T1-VISTA images. The enhancement degree of petrous ICA was recorded and graded into four grades (none to marked) on the CE-T1-VISTA images. The correlation between wall thickness in petrous ICA and DR_ICA/CCA was analyzed_. RESULTS: In total, 81 arteries of MMD patients and 64 arteries of atherosclerotic patients were included for analysis. The DR_ICA/CCA was significantly correlated with the wall thickness in petrous ICA in MMD (r = - 0.434, P < 0.001) and atherosclerotic groups (r = - 0.604, P < 0.001). Logistic regression analysis revealed that odds ratio (OR) of DR_ICA/CCA was 4.433 (95% CI 1.980-9.925, P < 0.001) and 2.212 (95% CI 1.253-3.905, P = 0.006) in MMD and atherosclerotic groups in discriminating petrous ICA DWT after adjusting for confounding factors. An increasing trend was found in prevalence of DWT and wall thickness with enhancement grades in petrous ICA in MMD (P = 0.02 and P = 0.01) and atherosclerotic groups (P < 0.001 and P < 0.001), respectively.

CONCLUSIONS

The proximal ICA luminal narrowing is significantly associated with wall thickness and diffuse wall thickening in ipsilateral petrous ICA in patients with carotid steno-occlusive diseases regardless of MMD or atherosclerosis.

Association Between Champagne Bottle Neck Sign of Internal Carotid Artery and Ipsilateral Hemorrhagic Stroke in Patients with Moyamoya Disease

OBJECTIVE

To assess association between champagne bottle neck sign (CBNS) in carotid artery and intracranial hemorrhage in patients with moyamoya disease (MMD).

METHODS

This retrospective study included 76 consecutive patients with MMD without definite risk factors associated with intracranial hemorrhage who underwent preoperative angiography from January 2016 to December 2017. CBNS was defined as luminal diameter ratio of internal carotid artery/common carotid artery ≤0.5 on angiography. The right and left cerebral hemisphere in each patient was separately identified as hemorrhagic and nonhemorrhagic. Association between CBNS and intracranial hemorrhage was analyzed.

RESULTS

Of 76 patients with MMD, intracranial hemorrhage was found in 44 of 152 (28.9%) hemispheres, and 6.8% (3/44) had multiple events. Comparing carotid arteries without intracranial hemorrhage in ipsilateral hemispheres, patients with intracranial hemorrhage in the ipsilateral hemisphere had significantly smaller luminal diameter ratio of internal carotid artery/common carotid artery (0.49 ± 0.11 vs. 0.55 ± 0.12, P < 0.01) and higher prevalence of CBNS (63.7% vs. 41.7%, P = 0.01). Comparing hemispheres with intracranial hemorrhage, patients with ipsilateral carotid artery CBNS had significantly higher prevalence of hemorrhage in posterior territories than patients without CBNS (57.1% vs. 23.1%, P = 0.05). Logistic regression revealed that CBNS was significantly associated with ipsilateral intracranial hemorrhage before (odds ratio = 2.45; 95% confidence interval, 1.19-5.05; P = 0.02) and after (odds ratio = 3.43; 95% confidence interval, 1.50-7.87; P < 0.01) adjusting for female sex, lenticulostriate anastomosis, and choroidal anastomosis.

CONCLUSIONS

CBNS is significantly associated with intracranial hemorrhage in the ipsilateral hemisphere in patients with MMD, particularly intracranial hemorrhage in posterior territories.

Clinical Significance of the Champagne Bottle Neck Sign in the Extracranial Carotid Arteries of Patients with Moyamoya Disease

BACKGROUND AND PURPOSE

The champagne bottle neck sign represents a rapid reduction in the extracranial ICA diameters and is a characteristic feature of Moyamoya disease. However, the clinical significance of the champagne bottle neck sign is unclear. We investigated the relationship between the champagne bottle neck sign and the clinical and hemodynamic stages of Moyamoya disease.

MATERIALS AND METHODS

We analyzed 14 patients with Moyamoya disease before revascularization (5 men, 9 women; age, 43.2 ± 19.3 years). The ratio of the extracranial ICA and common carotid artery diameters was determined using carotid ultrasonography or cerebral angiography; a ratio of < 0.5 was considered champagne bottle neck sign-positive. The clinical disease stage was determined using the Suzuki angiographic grading system. CBF and cerebral vasoreactivity also were measured.

RESULTS

The ICA/common carotid artery ratio (expressed as median [interquartile range]) decreased as the clinical stage advanced (stages I-II, 0.71 [0.60-0.77]; stages III-IV, 0.49 [0.45-0.57]; stages V-VI, 0.38 [0.34-0.47]; P < .001). Lower ICA/common carotid artery ratio tended to occur in symptomatic versus asymptomatic arteries (0.47 [0.40-0.53] versus 0.57 [0.40-0.66], respectively; P = .06). Although the ICA/common carotid artery ratio was not related to cerebral perfusion, it decreased as cerebral vasoreactivity decreased (P < .01). All champagne bottle neck sign-positive arteries were classified as Suzuki stage ≥III, 73% were symptomatic, and 89% exhibited reduced cerebral vasoreactivity. In contrast, all champagne bottle neck sign-negative arteries were Suzuki stage ≤III, 67% were asymptomatic, and all showed preserved cerebral vasoreactivity.

CONCLUSIONS

The champagne bottle neck sign was related to advanced clinical stage, clinical symptoms, and impaired cerebral vasoreactivity. Thus, detection of the champagne bottle neck sign might be useful in determining the clinical and hemodynamic stages of Moyamoya disease.

Acute Thyrotoxicosis of Graves Disease Associated with Moyamoya Vasculopathy and Stroke in Latin American Women: A Case Series and Review of the Literature

OBJECTIVE

Moyamoya disease is a cerebral vasculopathy characterized by stenosis of the terminal internal carotid artery, proximal middle cerebral artery, and anterior cerebral artery. There is an association between moyamoya vasculopathy and Graves disease, primarily in Asian populations. Here, we present the largest series of non-Asian, predominantly Latino patients with moyamoya vasculopathy in the setting of Graves thyrotoxicosis, as well as the largest review of the literature to date.

METHODS

We retrospectively analyzed patients presenting with stroke in the setting of clinical Graves disease to our institution from 2004 to 2014. Moyamoya vasculopathy was diagnosed by magnetic resonance angiography in all patients.

RESULTS

Eight patients with Graves disease thyrotoxicosis and moyamoya vasculopathy were identified. Six patients were effectively managed with aggressive medical management using antithyroid and antiplatelet medications. No recurrent strokes were noted once thyrotoxicosis was controlled. Intracranial bypass was necessary in 2 patients who failed medical management. Seventy-nine additional cases were reported from the literature. There was no significant difference in clinical improvement between medical therapy alone and medical therapy with neurosurgical prophylaxis (87.0% vs. 88.0%, respectively; P = 0.94).

CONCLUSIONS

Moyamoya vasculopathy associated with Graves disease thyrotoxicosis in non-Asian women may be more common than previously thought. In addition, our series suggests that thyrotoxicosis promotes the progression of vasculopathy. Based on our review, there is no significant difference in clinical improvement between proper medical and surgical therapies. Aggressive medical therapy should be considered first-line treatment for moyamoya vasculopathy with Graves thyrotoxicosis, with neurosurgical rescue reserved for medically refractory cases.