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Huang C, Huang C, Zhan X. Predictive Factors for Seizures after Revascularization in Patients with Moyamoya Disease. World Neurosurg 2024; 182:e205-e209. [PMID: 37995995 DOI: 10.1016/j.wneu.2023.11.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/15/2023] [Accepted: 11/16/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Moyamoya disease (MMD) is a rare and complex cerebrovascular disorder that is diagnosed through imaging studies, such as computed tomography or magnetic resonance imagin, which show progressive narrowing of the terminal portion of the internal carotid arteries and the development of compensatory capillary collaterals. The objective of our study was to identify and clarify the predictive factors for seizures in patients with MMD. METHODS From January 2019 to March 2023, a total of 102 patients with MMD were enrolled in this study. Ten patients with seizures after surgery as the main presentation were included. Patients with epilepsy were compared to those without epilepsy in terms of their clinical characteristics. Multivariable analysis was applied to determine factors linked with postoperative seizures. RESULTS Ten patients developed seizures after revascularization for MMD. Logistic regression analysis revealed that early seizure (odds ratio [OR], 0.068; 95% CI, 0.014-0.342; P = 0.001), cortical involvement (OR, 9.593; 95% CI, 2.256-40.783; P = 0.002), and postoperative hyperperfusion (OR, 7.417; 95% CI, 1.077-51.093; P = 0.042) were significantly associated with seizures. In a multivariate analysis, it was found that early seizures were significantly associated with a higher likelihood of experiencing seizures (OR, 5.88; 95% CI, 1.01-33.96; P = 0.048), while patients who had seizures were more likely to have cortical involvement (OR, 8.90; 95% CI, 1.55-50.96; P = 0.014) or postoperative hyperperfusion (OR, 12.44; 95% CI, 1.21-127.74; P = 0.034). CONCLUSIONS Epilepsy in patients with MMD link with several clinical factors. In patients with MMD who undergo bypass surgery, early seizures, cortical involvement, and postoperative hyperperfusion are significant independent predictive factors for the development of epilepsy.
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Affiliation(s)
- Chaojue Huang
- Department of Neurosurgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Chong Huang
- Department of Neurosurgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xinli Zhan
- Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.
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Hao F, Han C, Lu M, Wang Y, Gao G, Wang Q, Liu S, Liu S, Wang M, Ren B, Zou Z, Yu D, Sun C, Zhang Q, Guo Q, Liu W, Sun Z, Cai J, Duan L. High-resolution MRI vessel wall enhancement in moyamoya disease: risk factors and clinical outcomes. Eur Radiol 2024:10.1007/s00330-023-10535-0. [PMID: 38172442 DOI: 10.1007/s00330-023-10535-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/20/2023] [Accepted: 11/25/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES Intracranial vessel wall enhancement (VWE) on high-resolution magnetic resonance imaging (HRMRI) is associated with the progression and poor prognosis of moyamoya disease (MMD). This study assessed potential risk factors for VWE in MMD. METHODS We evaluated MMD patients using HRMRI and traditional angiography examinations. The participants were divided into VWE and non-VWE groups based on HRMRI. Logistic regression was performed to compare the risk factors for VWE in MMD. The incidence of cerebrovascular events of the different subgroups according to risk factors was compared using Kaplan-Meier survival and Cox regression. RESULTS We included 283 MMD patients, 84 of whom had VWE on HRMRI. The VWE group had higher modified Rankin Scale scores at admission (p = 0.014) and a higher incidence of ischaemia and haemorrhage (p = 0.002) than did the non-VWE group. Risk factors for VWE included the ring finger protein 213 (RNF213) p.R4810K variant (odds ratio [OR] 2.01, 95% confidence interval [CI] 1.08-3.76, p = 0.028), hyperhomocysteinaemia (HHcy) (OR 5.08, 95% CI 2.34-11.05, p < 0.001), and smoking history (OR 3.49, 95% CI 1.08-11.31, p = 0.037). During the follow-up of 63.9 ± 13.2 months (median 65 months), 18 recurrent stroke events occurred. Cox regression showed that VWE and the RNF213 p.R4810K variant were risk factors for stroke. CONCLUSION The RNF213 p.R4810K variant is strongly associated with VWE and poor prognosis in MMD. HHcy and smoking are independent risk factors for VWE. CLINICAL RELEVANCE STATEMENT Vessel wall enhancement in moyamoya disease is closely associated with poor prognosis, especially related to the ring finger protein 213 p.R4810K variant, hyperhomocysteinaemia, and smoking, providing crucial risk assessment information for the clinic. KEY POINTS • The baseline presence of vessel wall enhancement is significantly associated with poor prognosis in moyamoya disease. • The ring finger protein 213 p.R4810K variant is strongly associated with vessel wall enhancement and poor prognosis in moyamoya disease. • Hyperhomocysteinaemia and smoking are independent risk factors for vessel wall enhancement in moyamoya disease.
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Affiliation(s)
- Fangbin Hao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Cong Han
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Mingming Lu
- Department of Radiology, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yue Wang
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, Liaoning, China
| | - Gan Gao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Qiannan Wang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Shitong Liu
- Chinese PLA Medical School, Beijing, China
- Department of Radiology, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Simeng Liu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Minjie Wang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Bin Ren
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Zhengxing Zou
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Dan Yu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Caihong Sun
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Qian Zhang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Qingbao Guo
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Wanyang Liu
- Department of Nutrition and Food Hygiene, School of Public Health, China Medical University, Shenyang, Liaoning, China
| | - Zhenghui Sun
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Jianming Cai
- Department of Radiology, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China.
| | - Lian Duan
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China.
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China.
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Guo Q, Fan YN, Wang QN, Li J, Han C, Zou Z, Liu S, Wang X, Yu D, Hao F, Gao G, Zhang Q, Pei S, Feng J, Yang R, Wang M, Fu H, Bao X, Duan L. Nomogram for Predicting Long-term Outcomes of Encephaloduroarteriosynangiosis in Toddlers with Moyamoya Disease: a Longitudinal and Cross-sectional Study. Transl Stroke Res 2023:10.1007/s12975-023-01213-w. [PMID: 37943490 DOI: 10.1007/s12975-023-01213-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 10/29/2023] [Accepted: 10/30/2023] [Indexed: 11/10/2023]
Abstract
We investigated the long-term outcomes of encephaloduroarteriosynangiosis (EDAS) for stroke prevention in toddlers with moyamoya disease (MMD) using nomogram. Between January 2005 and December 2018, 74 toddlers with MMD underwent surgery in the Fifth Medical Centre, Chinese PLA General Hospital, 69 were < 4 years of age and included in the analysis. The modified Rankin scale (mRS) during follow-up evaluated clinical outcomes. To measure the effectiveness of EDAS, the annual risk of symptomatic infarction within the operated brain hemispheres was calculated. The event-free survival rate was determined using Kaplan-Meier curves. A nomogram generated using multivariate logistic regression analysis identified potential predictors associated with unfavorable outcomes. Additionally, discrimination, calibration, and clinical utility were assessed. A favorable clinical outcome was observed in 81.2% of the patients. The operated hemispheres showed an annual risk of 0.87% of symptomatic infarction and 0.23% of hemorrhage. Moreover, the 10-year event-free survival rates were 92.8% and 97.0% for symptomatic infarction and hemorrhage. Multivariate logistic analysis indicated that onset with infarction, initial mRS ≥ 3, and perioperative adverse events had significant and independent associations with unfavorable outcomes. However, an age at diagnosis of ≥ 2 years showed an association with favorable outcomes. Using these four factors, our model attained a concordance index of 0.912 (95% confidence interval, 0.842-0.982), well-fitted calibration curve, and cutoff value of 0.212 for predicting unfavorable outcomes. EDAS may prevent recurrent stroke and improve overall long-term clinical outcomes in toddlers with MMD. The developed nomogram accurately predicted unfavorable outcomes and assisted surgeons in patient evaluation.
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Affiliation(s)
- Qingbao Guo
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Yan-Na Fan
- Department of Radiation Oncology, Senior Department of Oncology, the Fifth Medical Center of, PLA General Hospital, Beijing, China
| | - Qian-Nan Wang
- Department of Neurosurgery, the Eighth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jingjie Li
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Cong Han
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Zhengxing Zou
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Simeng Liu
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Xiaopeng Wang
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Dan Yu
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Fangbin Hao
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Gan Gao
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Qian Zhang
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Songtao Pei
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jie Feng
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Rimiao Yang
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Minjie Wang
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Heguan Fu
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Xiangyang Bao
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China.
| | - Lian Duan
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China.
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Chen X, Qin X, Wang J, Wang R, Guo X, Yao L. Effect of cerebral oxygen saturation monitoring in patients undergoing superficial temporal anterior-middle cerebral artery anastomosis for ischemic Moyamoya disease: a prospective cohort study. Front Neurol 2023; 14:1226455. [PMID: 37808481 PMCID: PMC10552867 DOI: 10.3389/fneur.2023.1226455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/24/2023] [Indexed: 10/10/2023] Open
Abstract
Objective Regional cerebral oxygen saturation (rSO2) is linked with blood pressure. This study evaluated the influence of perioperative rSO2 monitoring on the prognosis of ischemic Moyamoya disease (MMD) patients undergoing anastomosis surgery. Methods In this prospective cohort, patients with unilateral ischemic MMD of Suzuki stage ≥3 were included. The decision of rSO2 was made by the clinician and the patient. The rSO2 group maintained intraoperative rSO2 levels through the modulation of blood pressure, inhaled oxygen concentration, carbon dioxide in arterial blood, and red blood cell transfusion. The non-rSO2 group used conventional anesthesia practices. Perioperative mean arterial pressure (MAP), rSO2 values, neurological complications, and postoperative results were assessed. Results A total of 75 eligible patients were categorized into a rSO2 monitoring group (n = 30) and a non-rSO2 monitoring group (n = 45). For the rSO2 group, the preoperative rSO2 was significantly lower on the affected side (P < 0.05). After anastomosis, this value notably increased (P = 0.01). A moderate relationship was observed between perioperative rSO2 and MAP before, during, and after surgery, with correlation coefficients (r) of 0.536, 0.502, and 0.592 (P < 0.05). Post-surgery MAP levels differed between the groups, with the rSO2 group showing decreased levels compared to pre-surgery and the non-rOS2 group displaying elevated levels. Notably, the rSO2 group reported shorter hospitalizations and decreased neurological complications. Patients with a hypertension history found postoperative MAP influencing hospital stay duration. Conclusion Perioperative rSO2 surveillance enhanced cerebral perfusion and minimized postoperative complications in ischemic MMD patients. Thus, rSO2 monitoring is advocated for MMD patients undergoing vascular anastomosis.
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Affiliation(s)
- Xuanling Chen
- Department of Anesthesiology, Peking University International Hospital, Beijing, China
| | - Xuewei Qin
- Department of Anesthesiology, Peking University International Hospital, Beijing, China
| | - Jing Wang
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Rong Wang
- Department of Neurosurgery, Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hosptial, Beijing, China
| | - Lan Yao
- Department of Anesthesiology, Peking University International Hospital, Beijing, China
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Yuan K, Wang K, Zhang H, Zhou Y, Hao Q, Ye X, Liu X, Zhang Q, Zhang Y, Wang R, Zhao Y, Zhao Y. Nomogram to Predict Good Neoangiogenesis After Indirect Revascularization Surgery in Patients with Moyamoya Disease: a Case-control Study. Transl Stroke Res 2023:10.1007/s12975-023-01177-x. [PMID: 37453002 DOI: 10.1007/s12975-023-01177-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/04/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
Indirect bypass surgery is an effective treatment for moyamoya disease (MMD), but the success of the surgery depends on the formation of spontaneous collateral vessels, which cannot be accurately predicted before surgery. Developing a prediction nomogram model for neoangiogenesis in patients after indirect revascularization surgery can aid surgeons in identifying suitable candidates for indirect revascularization surgery. This retrospective observational study enrolled patients with MMD who underwent indirect bypass surgery from a multicenter cohort between December 2010 and December 2018. Data including potential clinical and radiological predictors were obtained from hospital records. A nomogram was generated based on a multivariate logistic regression analysis identifying potential predictors of good neoangiogenesis. A total of 263 hemispheres of 241 patients (mean ± SD age 24.38 ± 15.78 years, range 1-61 years) were reviewed, including 168 (63.9%) hemispheres with good postoperative collateral formation and 95 (36.1%) with poor postoperative collateral formation. Based on multivariate analysis, a nomogram was formulated incorporating four predictors, including age at operation, abundance of ICA moyamoya vessels, onset type, and Suzuki stage. The C-index for this nomogram was 0.80. Calibration curve and decision-making analysis validated the fitness and clinical application value of this nomogram. The nomogram developed in this study exhibits high accuracy in predicting good neoangiogenesis after indirect revascularization surgery in MMD patients. This model can be very helpful for clinicians when making decisions about surgical strategies for MMD patients in clinical practice.
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Affiliation(s)
- Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Ke Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Yunfan Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Qiang Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Xingju Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Qian Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Yan Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Rong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.
- Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Yahui Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.
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Guo Q, Pei S, Wang QN, Li J, Han C, Liu S, Wang X, Yu D, Hao F, Gao G, Zhang Q, Zou Z, Feng J, Yang R, Wang M, Fu H, Du F, Bao X, Duan L. Risk Factors for Preoperative Cerebral Infarction in Infants with Moyamoya Disease. Transl Stroke Res 2023:10.1007/s12975-023-01167-z. [PMID: 37314678 DOI: 10.1007/s12975-023-01167-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 06/15/2023]
Abstract
There have been few reports on the risk factors for preoperative cerebral infarction in childhood moyamoya disease (MMD) in infants under 4 years. The aim of this retrospective study is to identify clinical and radiological risk factors for preoperative cerebral infarction in infants under 4 years old with MMD, and the optimal timing for EDAS was also considered. We retrospectively analyzed the risk factors for preoperative cerebral infarction, confirmed by magnetic resonance angiography (MRA), in pediatric patients aged ˂4 years who underwent encephaloduroarteriosynangiosis between April 2005 and July 2022. The clinical and radiological outcomes were determined by two independent reviewers. In addition, potential risk factors for preoperative cerebral infarction, including infarctions at diagnosis and while awaiting surgery, were analyzed using a univariate model and multivariate logistic regression to identify independent predictors of preoperative cerebral infarction. A total of 160 hemispheres from 83 patients aged <4 years with MMD were included in this study. The mean age of all surgical hemispheres at diagnosis was 2.17±0.831 years (range 0.380-3.81 years). In the multivariate logistic regression model, we included all variables with P<0.1 in the univariate analysis. The multivariate logistic regression analysis indicated that preoperative MRA grade (odds ratio [OR], 2.05 [95% confidence interval [CI], 1.3-3.25], P=0. 002), and age at diagnosis (OR, 0.61 [95% CI, 0.4-0.92], P=0. 018) were predictive factors of infarction at diagnosis. The analysis further indicated that the onset of infarction (OR, 0.01 [95% CI, 0-0.08], P<0.001), preoperative MRA grade (OR, 1.7 [95% CI, 1.03-2.8], P=0.037), and duration from diagnosis to surgery (Diag-Op) (OR, 1.25 [95% CI, 1.11-1.41], P<0.001) were predictive factors for infarction while awaiting surgery. Moreover, the regression analysis indicated that family history (OR, 8.88 [95% CI, 0.91-86.83], P=0.06), preoperative MRA grade (OR, 8.72 [95% CI, 3.44-22.07], P<0.001), age at diagnosis (OR, 0.36 [95% CI, 0.14-0.91], P=0.031), and Diag-Op (OR, 1.38 [95% CI, 1.14-1.67], P=0.001) were predictive factors for total infarction. Therefore, during the entire treatment process, careful observation, adequate risk factor management, and optimal operation time are required to prevent preoperative cerebral infarction, particularly in pediatric patients with a family history, higher preoperative MRA grade, duration from diagnosis to operation longer than 3.53 months, and aged ˂3 years at diagnosis.
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Affiliation(s)
- Qingbao Guo
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Songtao Pei
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Qian-Nan Wang
- Department of Neurosurgery, the Eighth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jingjie Li
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Cong Han
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Simeng Liu
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Xiaopeng Wang
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Dan Yu
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Fangbin Hao
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Gan Gao
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Qian Zhang
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Zhengxing Zou
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jie Feng
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Rimiao Yang
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Minjie Wang
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Heguan Fu
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Feiyan Du
- Beijing Garrison Haidian 13th Retired Cadre Rest House, Beijing, China
| | - Xiangyang Bao
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China.
| | - Lian Duan
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China.
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Gao G, Wang QN, Hao FB, Wang XP, Liu SM, Wang MJ, Han C, Bao XY, Duan L. To explore the effectiveness of atorvastatin in the postoperative formation of collateral blood vessels after encephaloduroarteriosynangiosis in patients with moyamoya disease: a prospective double-blind randomized controlled study. Front Neurol 2023; 14:1169253. [PMID: 37332989 PMCID: PMC10270285 DOI: 10.3389/fneur.2023.1169253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/12/2023] [Indexed: 06/20/2023] Open
Abstract
Introduction The aim of this large, prospective, double-blind randomized controlled trial is to investigate the effect of atorvastatin on the formation of collateral blood vessels in patients after encephaloduroarteriosynangiosis (EDAS) and to provide a theoretical basis for clinical drug intervention. Specifically, we will determine whether atorvastatin has an effect on the development of collateral vascularization and on cerebral blood perfusion after revasculoplasty in patients with moyamoya disease (MMD). Methods and analysis Overall, 180 patients with moyamoya disease will be recruited and randomly assigned to the atorvastatin treatment group or the placebo control group in a 1:1 ratio. Before revascularization surgery, magnetic resonance imaging (MRI) scanning and digital subangiography (DSA) examination will be routinely performed on the enrolled patients. All patients will receive intervention via EDAS. According to the randomization results, patients in the experimental group will be treated with atorvastatin (20 mg/day, once a day, for 8 weeks) and patients in the control group will be treated with placebo (20 mg/day, once a day, for 8 weeks). All participants will return to the hospital for MRI scan and DSA examination 6 months after EDAS surgery. The primary outcome of this trial will be the difference in the formation of collateral blood vessels revealed by DSA examination at 6 months after EDAS surgery between the two groups. The secondary outcome will be an improvement in the dynamic susceptibility contrast sequence cerebral perfusion on MRI at 6 months after EDAS, compared to the preoperative baseline. Ethics and dissemination This study was approved by the Ethics Committee of the First Medical Center of the PLA General Hospital. All participates will voluntary provide written informed consent before participating in the trial. Clinical trial registration ClinicalTrials.gov, ChiCTR2200064976.
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Affiliation(s)
- Gan Gao
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Qian-Nan Wang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Fang-Bin Hao
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Xiao-Peng Wang
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Si-Meng Liu
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Min-Jie Wang
- Chinese PLA Medical School, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Cong Han
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Xiang-Yang Bao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Lian Duan
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
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Dorschel KB, Wanebo JE. Physiological and pathophysiological mechanisms of the molecular and cellular biology of angiogenesis and inflammation in moyamoya angiopathy and related vascular diseases. Front Neurol 2023; 14:661611. [PMID: 37273690 PMCID: PMC10236939 DOI: 10.3389/fneur.2023.661611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 01/16/2023] [Indexed: 06/06/2023] Open
Abstract
Rationale The etiology and pathophysiological mechanisms of moyamoya angiopathy (MMA) remain largely unknown. MMA is a progressive, occlusive cerebrovascular disorder characterized by recurrent ischemic and hemorrhagic strokes; with compensatory formation of an abnormal network of perforating blood vessels that creates a collateral circulation; and by aberrant angiogenesis at the base of the brain. Imbalance of angiogenic and vasculogenic mechanisms has been proposed as a potential cause of MMA. Moyamoya vessels suggest that aberrant angiogenic, arteriogenic, and vasculogenic processes may be involved in the pathophysiology of MMA. Circulating endothelial progenitor cells have been hypothesized to contribute to vascular remodeling in MMA. MMA is associated with increased expression of angiogenic factors and proinflammatory molecules. Systemic inflammation may be related to MMA pathogenesis. Objective This literature review describes the molecular mechanisms associated with cerebrovascular dysfunction, aberrant angiogenesis, and inflammation in MMA and related cerebrovascular diseases along with treatment strategies and future research perspectives. Methods and results References were identified through a systematic computerized search of the medical literature from January 1, 1983, through July 29, 2022, using the PubMed, EMBASE, BIOSIS Previews, CNKI, ISI web of science, and Medline databases and various combinations of the keywords "moyamoya," "angiogenesis," "anastomotic network," "molecular mechanism," "physiology," "pathophysiology," "pathogenesis," "biomarker," "genetics," "signaling pathway," "blood-brain barrier," "endothelial progenitor cells," "endothelial function," "inflammation," "intracranial hemorrhage," and "stroke." Relevant articles and supplemental basic science articles almost exclusively published in English were included. Review of the reference lists of relevant publications for additional sources resulted in 350 publications which met the study inclusion criteria. Detection of growth factors, chemokines, and cytokines in MMA patients suggests the hypothesis of aberrant angiogenesis being involved in MMA pathogenesis. It remains to be ascertained whether these findings are consequences of MMA or are etiological factors of MMA. Conclusions MMA is a heterogeneous disorder, comprising various genotypes and phenotypes, with a complex pathophysiology. Additional research may advance our understanding of the pathophysiology involved in aberrant angiogenesis, arterial stenosis, and the formation of moyamoya collaterals and anastomotic networks. Future research will benefit from researching molecular pathophysiologic mechanisms and the correlation of clinical and basic research results.
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Affiliation(s)
- Kirsten B. Dorschel
- Medical Faculty, Heidelberg University Medical School, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Germany
| | - John E. Wanebo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
- Department of Neuroscience, HonorHealth Research Institute, Scottsdale, AZ, United States
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9
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A Retrospective Study on Clinical Features of Childhood Moyamoya Disease. Pediatr Neurol 2023; 138:17-24. [PMID: 36335837 DOI: 10.1016/j.pediatrneurol.2022.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 07/16/2022] [Accepted: 08/19/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Childhood moyamoya disease (MMD) can lead to progressive and irreversible neurological impairment. Early age at onset is likely associated with a worst prognosis of the disease. The study aims to summarize the clinical characteristics of childhood MMD for supporting the diagnosis and treatment of early MMD. METHODS A retrospective study was conducted on children aged zero to 16 years who were diagnosed with MMD in the Department of Neurology and neurosurgery of our hospital from October 2016 to April 2020. The clinical characteristics of children with MMD were summarized for analysis, and the distribution of sex and initial attack type among different age groups was determined by data comparison. RESULTS The study surveyed 114 children (male to female sex ratio of 1:1.07) with MMD, and 6.1% of them had family history. The mean age of onset was 7.15 ± 3.30 years, and the peak age of onset was five to eight years. The most common initial attack type was transient ischemic attack (TIA) (62 cases, 54.4%) with limb weakness. The incidence of the initial attack type in the three age groups was varied (P < 0.05). The result of overall prognosis was good in 86 cases (89.6%). CONCLUSIONS In this study, MMD cases were mainly ischemic type and TIA was the most common initial attack type. Infant group was more prone to have cerebral infarction, whereas preschool and school-age groups tended to have TIA. The treatments and prognosis of the studied MMD cases were achieved with good outcomes.
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10
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Penn R, Harrar D, Sun LR. Seizures, Epilepsy, and Electroencephalography Findings in Pediatric Moyamoya Arteriopathy: A Scoping Review. Pediatr Neurol 2022; 142:95-103.e2. [PMID: 36577597 DOI: 10.1016/j.pediatrneurol.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 10/27/2022] [Accepted: 11/26/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Although seizures are known to occur in children with moyamoya arteriopathy, data regarding characteristics, prevalence, and predictive factors for their development are less established. This study aimed to systematically review literature addressing seizures, epilepsy, and electroencephalography findings in the pediatric moyamoya population. METHODS A scoping review was performed by searching PubMed and Ovid:Embase databases for articles that described seizures, epilepsy, and electroencephalography findings in patients aged 0 to 21 years with moyamoya arteriopathy. RESULTS The search yielded 43 total articles that addressed the following topics in childhood moyamoya: seizures as the presenting symptom, epilepsy characteristics and management, characteristic electroencephalography findings including rebuildup with discussion of proposed mechanisms, and potential predictive clinical factors for the development of seizures preoperatively and the persistence of epilepsy postoperatively. In the reviewed literature, 9% to 19% of children with moyamoya had epilepsy, with over half of the cases lacking radiographic evidence of ischemia. Young age was the most consistent clinical factor associated with both seizures as the presenting symptom and with moyamoya-related epilepsy. Multiple studies report that seizures, electroencephalographic background abnormalities, and the rebuildup phenomenon improve after successful revascularization surgery. CONCLUSIONS This scoping review provides a thorough investigation of the literature available to date on the clinical features of seizures in the pediatric moyamoya population. Literature on this topic is scarce and further studies assessing predictive factors for the development of epilepsy, prognosis as a result of having seizures, and seizure management in this population will help to fill existing knowledge gaps.
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Affiliation(s)
- Rachel Penn
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dana Harrar
- Children's National Hospital, Washington, District of Columbia
| | - Lisa R Sun
- Johns Hopkins University School of Medicine, Baltimore, Maryland.
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11
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Neuroimaging in Moyamoya angiopathy: Updated review. Clin Neurol Neurosurg 2022; 222:107471. [DOI: 10.1016/j.clineuro.2022.107471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/07/2022] [Accepted: 10/10/2022] [Indexed: 11/23/2022]
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12
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Xu R, Xie ME, Khalifeh J, Feghali J, Yang W, Kim J, Liew J, Tamargo RJ, Huang J. Timing of Revascularization in Ischemic Moyamoya Disease: Association of Early Versus Delayed Surgery with Perioperative and Long-Term Outcomes. World Neurosurg 2022; 166:e721-e730. [PMID: 35931338 DOI: 10.1016/j.wneu.2022.07.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/17/2022] [Accepted: 07/18/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Patients with nmoyamoya disease (MMD) who present primarily with ischemic stroke are known to have greater rates of perioperative strokes as compared with those who present with nonstroke symptoms. The optimal timing for revascularization for these patients remains unclear. METHODS From 1994 to 2015, 91 patients with MMD presented with signs and symptoms of an acute ischemic stroke with diffusion restriction correlate on magnetic resonance imaging, and these patients were subdivided into those who underwent early revascularization (<90 days from last stroke), versus those who underwent delayed revascularization (≥90 days after last stroke), based on evidence that most neurological recovery after stroke occurs during the first three months. Perioperative and long-term outcomes were compared between the 2 surgical cohorts. RESULTS In total, 27 patients underwent early revascularization, and 64 patients underwent delayed revascularization. Patients who underwent early revascularization had a statistically greater rate of perioperative stroke (P = 0.04) and perioperative mortality (P = 0.03), and overall complication rate (P = 0.049). At last follow-up of 5.2 ± 4.3 years, patients who underwent delayed revascularization had a lower mortality rate (P = 0.01) and a lower overall postoperative stroke incidence (P = 0.002). As a function of time, patients with MMD undergoing delayed revascularization had a statistically higher length of stroke-free survival (P = 0.005). CONCLUSIONS Patients with MMD who present with ischemic stroke are more likely to have perioperative strokes, overall perioperative complications, worse long-term mortality rates, and lower rates of stroke-free survival if revascularization surgery occurred within 90 days of last stroke.
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Affiliation(s)
- Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael E Xie
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jawad Khalifeh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jason Liew
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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13
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Bao XY, Wang QN, Wang XP, Yang RM, Zou ZX, Zhang Q, Li DS, Duan L. Recognition of the Effect of Indirect Revascularization for Moyamoya Disease: The Balance Between the Stage Progression and Neoangiogenesis. Front Neurol 2022; 13:861187. [PMID: 35599730 PMCID: PMC9121117 DOI: 10.3389/fneur.2022.861187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo explore the long-term progression of neoangiogenesis after indirect revascularization for moyamoya disease (MMD).MethodsWe enrolled patients who were diagnosed with MMD and treated by encephaloduroarteriosynangiosis (EDAS) surgery at our center from December 2002 through September 2009. A comparative study between short-term (6–12 months) and long-term (duration ≥ 8 years) follow-up angiographies was performed. The development of collateral circulation through EDAS was graded according to the system described by the Matsushima grade system.ResultsA total of 78 patients who received indirect EDAS were enrolled in the study. The mean age at the first operation was 26.9 ± 15.0 years. The Matsushima grades of the same hemisphere were higher at the long-term follow-up compared with the short-term follow-up. Importantly, no attenuation was observed in any hemisphere during the long-term follow-up. In total, 51 hemispheres (32.7%) and 26 hemispheres (16.6%) had progression during the short-term and the long-term follow-up, respectively. The ipsilateral Suzuki stage showed a significant negative correlation with progression pace. Furthermore, higher Suzuki stages were significantly correlated with the postsurgical Matsushima grade at both time points. A total of nine strokes (11.5%) occurred in 78 patients was reported at the long-term follow-up. The annual incidence rate of recurrent strokes was higher for the stage progression group than for the stable group.ConclusionFor patients with MMD, postsurgical neoangiogenesis after indirect bypass continuously improved with time. The short-term progression of the internal carotid artery (ICA) might be attributed to cerebral revascularization, while the long-term progression should be attributed to the natural progression of the disease.
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Affiliation(s)
- Xiang-Yang Bao
- Department of Neurosurgery, Chinese PLA General Hospital (Former Department of Neurosurgery, The Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
- *Correspondence: Xiang-Yang Bao
| | - Qian-Nan Wang
- Department of Neurosurgery, Chinese PLA General Hospital (Former Department of Neurosurgery, The Eighth Medical Center of Chinese PLA General Hospital), Beijing, China
| | - Xiao-Peng Wang
- Department of Neurosurgery, Chinese PLA General Hospital (Former Department of Neurosurgery, The Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
- Department of Neurosurgery, 307th Hospital of People's Liberation Army, 307 Clinical College, Anhui Medical University, Hefei, China
| | - Ri-Miao Yang
- Department of Neurosurgery, Chinese PLA General Hospital (Former Department of Neurosurgery, The Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
| | - Zheng-Xing Zou
- Department of Neurosurgery, Chinese PLA General Hospital (Former Department of Neurosurgery, The Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
| | - Qian Zhang
- Department of Neurosurgery, Chinese PLA General Hospital (Former Department of Neurosurgery, The Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
| | - De-Sheng Li
- Department of Neurosurgery, Chinese PLA General Hospital (Former Department of Neurosurgery, The Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
| | - Lian Duan
- Department of Neurosurgery, Chinese PLA General Hospital (Former Department of Neurosurgery, The Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
- Department of Neurosurgery, 307th Hospital of People's Liberation Army, 307 Clinical College, Anhui Medical University, Hefei, China
- Lian Duan
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14
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Bao XY, Fan YN, Wang QN, Wang XP, Yang RM, Zou ZX, Zhang Q, Li DS, Duan L, Yu XG. The Potential Mechanism Behind Native and Therapeutic Collaterals in Moyamoya. Front Neurol 2022; 13:861184. [PMID: 35557620 PMCID: PMC9086844 DOI: 10.3389/fneur.2022.861184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose To explore the genetic basis and molecular mechanism of native arteriogenesis and therapeutic synangiosis in moyamoya disease (MMD). Methods An angiography-based study using patients from a prospective trial of encephaloduroarteriosynangiosis (EDAS) surgery was performed. The spontaneous collaterals grades were evaluated according to the system described by a new grading system. Blood samples were collected from all the recruited patients before EDAS and during the second hospitalization 3 months post-EDAS. We performed Boolean analysis using a combination of specific cell surface markers of CD34briCD133+CD45dimKDR+. Genotyping of p.R4810K was also performed. The correlation of age, sex, initial symptoms at diagnosis, collateral grade, Suzuki stages, the RNF213 genotype, time to peak (TTP), and endothelial progenitor cell (EPC) count with good collateral circulation was evaluated. Results Eighty-five patients with MMD were included in this study. The mutation rate of RNF213 p.R4810K in our study was 25.9% (22/85). The heterozygous mutations were occurred significantly more frequently in the cases that were presented with infarction, worse neurological status, severe posterior cerebral artery (PCA) stenosis, and longer TTP delay. Further, the heterozygous mutations occurred significantly more frequently in the poor collateral stage group. Lower grades were significantly correlated with severe ischemia symptoms, worse neurological status, and a longer TTP delay. The post-operative angiographic findings showed that a good Matsushima grade was correlated with heterozygous mutations, a lower collateral stage, and a longer TTP delay. The CD34briCD133+CD45dimKDR+ cell count in patients 3 months post-EDAS was significantly higher as compared to the count before EDAS in the good Matsushima grade group. However, this change was not observed in the poor Matsushima grade group. Conclusions These data imply that mutations of RNF213 p.R4810K affect the establishment of spontaneous collateral circulation, and EPCs are involved in the process of formation of new EDAS collaterals.
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Affiliation(s)
- Xiang-Yang Bao
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
- Chinese PLA Medical School, Beijing, China
| | - Yan-Na Fan
- Department of Radiation Oncology, The Fifth Medical Center of Chinese PLA General Hospital (Former 307th Hospital of the PLA), Beijing, China
| | - Qian-Nan Wang
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - Xiao-Peng Wang
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - Ri-Miao Yang
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - Zheng-Xing Zou
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - Qian Zhang
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - De-Sheng Li
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
| | - Lian Duan
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
- *Correspondence: Lian Duan
| | - Xin-Guang Yu
- Department of Neurosurgery, Chinese People's Liberation Army of China (PLA) General Hospital, Beijing, China
- Chinese PLA Medical School, Beijing, China
- Xin-Guang Yu
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15
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Po' C, Nosadini M, Zedde M, Pascarella R, Mirone G, Cicala D, Rosati A, Cosi A, Toldo I, Colombatti R, Martelli P, Iodice A, Accorsi P, Giordano L, Savasta S, Foiadelli T, Sanfilippo G, Lafe E, Thyrion FZ, Polonara G, Campa S, Raviglione F, Scelsa B, Bova SM, Greco F, Cordelli DM, Cirillo L, Toni F, Baro V, Causin F, Frigo AC, Suppiej A, Sainati L, Azzolina D, Agostini M, Cesaroni E, De Carlo L, Di Rosa G, Esposito G, Grazian L, Morini G, Nicita F, Operto FF, Pruna D, Ragazzi P, Rollo M, Spalice A, Striano P, Skabar A, Lanterna LA, Carai A, Marras CE, Manara R, Sartori S. Pediatric Moyamoya Disease and Syndrome in Italy: A Multicenter Cohort. Front Pediatr 2022; 10:892445. [PMID: 35601411 PMCID: PMC9120837 DOI: 10.3389/fped.2022.892445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/05/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Moyamoya is a rare progressive cerebral arteriopathy, occurring as an isolated phenomenon (moyamoya disease, MMD) or associated with other conditions (moyamoya syndrome, MMS), responsible for 6-10% of all childhood strokes and transient ischemic attacks (TIAs). METHODS We conducted a retrospective multicenter study on pediatric-onset MMD/MMS in Italy in order to characterize disease presentation, course, management, neuroradiology, and outcome in a European country. RESULTS A total of 65 patients (34/65 women) with MMD (27/65) or MMS (38/65) were included. About 18% (12/65) of patients were asymptomatic and diagnosed incidentally during investigations performed for an underlying condition (incMMS), whereas 82% (53/65) of patients with MMD or MMS were diagnosed due to the presence of neurological symptoms (symptMMD/MMS). Of these latter, before diagnosis, 66% (43/65) of patients suffered from cerebrovascular events with or without other manifestations (ischemic stroke 42%, 27/65; TIA 32%, 21/65; and no hemorrhagic strokes), 18% (12/65) of them reported headache (in 4/12 headache was not associated with any other manifestation), and 26% (17/65) of them experienced multiple phenotypes (≥2 among: stroke/TIA/seizures/headache/others). Neuroradiology disclosed ≥1 ischemic lesion in 67% (39/58) of patients and posterior circulation involvement in 51% (30/58) of them. About 73% (47/64) of patients underwent surgery, and 69% (45/65) of them received aspirin, but after diagnosis, further stroke events occurred in 20% (12/61) of them, including operated patients (11%, 5/47). Between symptom onset and last follow-up, the overall patient/year incidence of stroke was 10.26% (IC 95% 7.58-13.88%). At last follow-up (median 4 years after diagnosis, range 0.5-15), 43% (26/61) of patients had motor deficits, 31% (19/61) of them had intellectual disability, 13% (8/61) of them had epilepsy, 11% (7/61) of them had behavioral problems, and 25% (13/52) of them had mRS > 2. The proportion of final mRS > 2 was significantly higher in patients with symptMMD/MMS than in patients with incMMS (p = 0.021). Onset age <4 years and stroke before diagnosis were significantly associated with increased risk of intellectual disability (p = 0.0010 and p = 0.0071, respectively) and mRS > 2 at follow-up (p = 0.0106 and p = 0.0009, respectively). CONCLUSIONS Moyamoya is a severe condition that may affect young children and frequently cause cerebrovascular events throughout the disease course, but may also manifest with multiple and non-cerebrovascular clinical phenotypes including headache (isolated or associated with other manifestations), seizures, and movement disorder. Younger onset age and stroke before diagnosis may associate with increased risk of worse outcome (final mRS > 2).
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Affiliation(s)
- Chiara Po'
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy.,Department of Women's and Children's Health, University of Padova, Padova, Italy.,Unit of Pediatrics, AULSS 2 Marca Trevigiana, Ca' Foncello Hospital, Treviso, Italy
| | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy.,Neuroimmunology Group, Paediatric Research Institute "Città della Speranza", Padova, Italy
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Rosario Pascarella
- Neuroradiology Unit, Arcispedale S. Maria Nuova AUSL Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Giuseppe Mirone
- Pediatric Neurosurgery Unit, Department of Neuroscience, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Domenico Cicala
- Pediatric Neuroradiology, Department of Neuroscience, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Anna Rosati
- Department of Neuroscience, Children's Hospital Anna Meyer, University of Firenze, Firenze, Italy
| | - Alessandra Cosi
- Department of Neuroscience, Children's Hospital Anna Meyer, University of Firenze, Firenze, Italy
| | - Irene Toldo
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Raffaella Colombatti
- Clinic of Pediatric Hematology Oncology, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Paola Martelli
- Child Neurology and Psychiatry Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Alessandro Iodice
- Child Neurology and Psychiatry Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Patrizia Accorsi
- Child Neurology and Psychiatry Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Lucio Giordano
- Child Neurology and Psychiatry Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Salvatore Savasta
- Pediatric Clinic, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Thomas Foiadelli
- Pediatric Clinic, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Giuseppina Sanfilippo
- Department of Diagnostic and Interventional Radiology and Neuroradiology, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Elvis Lafe
- Department of Diagnostic and Interventional Radiology and Neuroradiology, IRCSS Policlinico San Matteo, Pavia, Italy
| | - Federico Zappoli Thyrion
- Department of Diagnostic and Interventional Radiology and Neuroradiology, IRCSS Policlinico San Matteo, Pavia, Italy
| | - Gabriele Polonara
- Neuroradiology - Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Serena Campa
- Neuroradiology Unit, University Hospital "Ospedali Riuniti di Ancona, " Università Politecnica delle Marche, Ancona, Italy
| | | | - Barbara Scelsa
- Department of Pediatric Neurology, Vittore Buzzi Children's Hospital, Milan, Italy
| | - Stefania Maria Bova
- Department of Pediatric Neurology, Vittore Buzzi Children's Hospital, Milan, Italy
| | - Filippo Greco
- Pediatric Clinic, Department of Clinical and Experimental Medicine, University Hospital A.U.O. "Policlinico-San Marco" of Catania, Catania, Italy
| | - Duccio Maria Cordelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria dell'età Pediatrica, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Luigi Cirillo
- Neuroradiology Unit, IRCSS "Istituto delle Scienze Neurologiche di Bologna, " Ospedale Bellaria, Bologna, Italy
| | - Francesco Toni
- Neuroradiology Unit, IRCSS "Istituto delle Scienze Neurologiche di Bologna, " Ospedale Bellaria, Bologna, Italy
| | - Valentina Baro
- Academic Neurosurgery, Department of Neurosciences, University of Padova, Padova, Italy
| | - Francesco Causin
- Neuroradiology, Department of Neurological Sciences, University of Padova, Padova, Italy
| | - Anna Chiara Frigo
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Agnese Suppiej
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy.,Pediatric Section, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Laura Sainati
- Clinic of Pediatric Hematology Oncology, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Danila Azzolina
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Manuela Agostini
- Department of Pediatrics, Regina Margherita Children's Hospital, Torino, Italy
| | - Elisabetta Cesaroni
- Department of Child Neuropsychiatry, University Hospital Ospedali Riuniti, Ancona, Italy
| | - Luigi De Carlo
- Pediatric Section, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Gabriella Di Rosa
- Unit of Child Neurology and Psychiatry, Department of Human Pathology of the Adult and Developmental Age, Messina, Italy
| | - Giacomo Esposito
- Pediatric Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, Roma, Italy
| | - Luisa Grazian
- Unit of Pediatrics, AULSS 2 Marca Trevigiana, Ca' Foncello Hospital, Treviso, Italy
| | - Giovanna Morini
- Department of Pediatrics, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Francesco Nicita
- Unit of Neuromuscular and Neurodegenerative Disorders, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,Child Neurology Division, Department of Pediatrics, Sapienza University, Rome, Italy
| | - Francesca Felicia Operto
- Child and Adolescent Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | - Dario Pruna
- Neurology and Epileptology Unit, Department of Pediatric, ARNAS Brotzu, Cagliari, Italy
| | - Paola Ragazzi
- Department of Neurosurgery, "Regina Margherita" Children's Hospital, Torino, Italy
| | - Massimo Rollo
- Interventional Radiology Unit, Department of Imaging, Bambino Gesù Children's Hospital (IRCCS), Rome, Italy
| | - Alberto Spalice
- Department of Maternal Sciences, Sapienza University, Rome, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS "Istituto Giannina Gaslini", Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Aldo Skabar
- Department of Pediatrics, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | | | - Andrea Carai
- Pediatric Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, Roma, Italy
| | - Carlo Efisio Marras
- Pediatric Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, Roma, Italy
| | - Renzo Manara
- Neuroradiology Unit, Department of Neurological Sciences, University of Padova, Padova, Italy
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy.,Department of Women's and Children's Health, University of Padova, Padova, Italy.,Department of Neuroscience, University of Padova, Padova, Italy.,Neuroimmunology Group, Paediatric Research Institute "Città della Speranza", Padova, Italy
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16
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Wang QN, Bao XY, Zou ZX, Wang XP, Zhang Q, Li DS, Zhao YQ, Duan L. The role of atorvastatin in collateral circulation formation induced by encephaloduroarteriosynangiosis: a prospective trial. Neurosurg Focus 2021; 51:E9. [PMID: 34469867 DOI: 10.3171/2021.6.focus21112] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/21/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This prospective study was designed to confirm the role of atorvastatin in collateral circulation formation induced by encephaloduroarteriosynangiosis (EDAS) in patients with moyamoya disease (MMD). METHODS Patients who were diagnosed with MMD at the Department of Neurosurgery in the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China, between June 2017 and May 2018 were included. Blood samples were obtained from an antecubital vein and were analyzed using flow cytometry. Endothelial progenitor cells (EPCs) were defined as CD34brCD133+CD45dimKDR+. All patients included in the study underwent EDAS. Patients voluntarily chose whether to undergo atorvastatin treatment after EDAS. The correlation between atorvastatin and good postoperative collateral circulation was evaluated. RESULTS A total of 106 patients with MMD were included in this study. Fifty-three patients (50%) received atorvastatin treatment. The baseline characteristics did not display statistically significant differences between the atorvastatin-treated and non-atorvastatin groups. Seventy-eight (42.9%) of the 182 hemispheres investigated postoperatively were classified as grade A collateral circulation, 47 (25.8%) as grade B, and 57 (31.3%) as grade C. Multivariate analysis revealed that only atorvastatin was significantly correlated with good collateral circulation after EDAS (p = 0.041). CONCLUSIONS The results of this prospective clinical trial have indicated that atorvastatin administered at 20 mg daily is safe and effective for the formation of postoperative collateral induced by EDAS.
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Affiliation(s)
- Qian-Nan Wang
- 1Department of Neurosurgery, Chinese PLA General Hospital (former Department of Neurosurgery, the Eighth Medical Center of Chinese PLA General Hospital); and
| | - Xiang-Yang Bao
- 2Department of Neurosurgery, Chinese PLA General Hospital (former Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
| | - Zheng-Xing Zou
- 2Department of Neurosurgery, Chinese PLA General Hospital (former Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
| | - Xiao-Peng Wang
- 2Department of Neurosurgery, Chinese PLA General Hospital (former Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
| | - Qian Zhang
- 2Department of Neurosurgery, Chinese PLA General Hospital (former Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
| | - De-Sheng Li
- 2Department of Neurosurgery, Chinese PLA General Hospital (former Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
| | - Ya-Qun Zhao
- 1Department of Neurosurgery, Chinese PLA General Hospital (former Department of Neurosurgery, the Eighth Medical Center of Chinese PLA General Hospital); and
| | - Lian Duan
- 2Department of Neurosurgery, Chinese PLA General Hospital (former Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital), Beijing, China
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17
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Gupta SK, Narayanan R, Aggarwal A, Mohanty M, Ahuja C, Verma N, Praneeth K, Agarwal V. Outcome Following Surgical Revascularization in Patients of Moyamoya Disease with Focus on Graft Patency and Angiographic Changes. Neurol India 2021; 69:620-627. [PMID: 34169855 DOI: 10.4103/0028-3886.319228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Surgical revascularization is the mainstay of treatment in symptomatic patients of moyamoya disease (MMD). Objective The present study analyzed the postoperative angio-architecture in pediatric and adult patients of moyamoya disease. Material and Methods Patients with MMD, both ischemic and hemorrhagic, were subjected to surgery. A superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis was attempted in all. It was augmented by an encephalo-duro-myo-synangiosis), this was labelled as the combined surgical group. In patients where a direct bypass was not possible encephalo-duro-arterio-myo-synangiosis (EDAMS) was performed and these patients were put in the indirect surgery group. In the postoperative period, MRA was performed in all patients to look for (a) graft patency, (b) regression of moyamoya vessels, and (c) degree of surgical neovascularization (as quantified on adapted Matsushima and Inaba grading system). Results Eighty-two patients underwent 131 surgical revascularization procedures. A combined surgery (STA-MCA bypass and EDAMS) was performed in 100 hemispheres and indirect surgery (EDAMS) on 31 sides. In children less than 5 years of age, STA-MCA anastomosis was possible in more than 50% of patients. Clinical improvement was seen in 85.4% of patients. Postoperative MRA demonstrated a patent bypass graft in 97% of cases. Regression of moyamoya vessels was seen in half of the cases and good surgical revascularization (type A and B) was seen in more than 80% of hemispheres in the combined surgery and indirect surgery group. Conclusions Revascularization procedures led to a regression of moyamoya collaterals, appearance of surgical neo angiogenesis, and a graft patency rate of 97%. Surgical group with combined revascularization had a trend towards better collateral development.
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Affiliation(s)
- Sunil K Gupta
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajashekhar Narayanan
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Aggarwal
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manju Mohanty
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Chirag Ahuja
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Verma
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kokkula Praneeth
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivek Agarwal
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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18
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Alramadan A, Ul Haq A, Basindwah S, Alshail E. Seizure outcome in moyamoya after indirect revascularization in pediatric patients: Retrospective study and literature review. Surg Neurol Int 2021; 12:73. [PMID: 33767877 PMCID: PMC7982117 DOI: 10.25259/sni_633_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 01/16/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Moyamoya disease (MMD) is a unique cerebrovascular disorder characterized by progressive stenosis of anterior cerebral circulation. Moyamoya is not an uncommon disease in Saudi Arabia. Although a less common symptom of the disease, the incidence of seizure in MMD ranges from 6 to 30%. Indirect revascularization through Encephaloduroarteriosynangiosis technique is one of the surgical treatment options for MMD. In our cohort, we aim to evaluate seizure outcome in pediatric patients with moyamoya. Methods: Eleven patients with seizure as primary presentation for MMD over a period of 10 years were included in the study. All patients underwent EDAS surgery. All patients underwent pre- and postoperative assessment of multiple factors contributing to seizure outcome. Patients were evaluated for surgery control clinically and radiologically. Results: About 73% of MMD patients with seizures improved after EDAS surgery (P < 0.0005). Six patients out of 11 became seizure free. Patients with bilateral involvement of disease undergoing bilateral surgery had better seizure control than those undergoing unilateral surgery (P < 0.07). Conclusion: Patients with controlled seizure before surgery are more likely to be seizure free after intervention. Seizure outcome is favorable after indirect surgical revascularization in pediatric moyamoya patients.
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Affiliation(s)
- Abdullah Alramadan
- Department of Neurosurgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Anwar Ul Haq
- Department of Neurosurgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Sarah Basindwah
- Department of Neurosurgery, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Essam Alshail
- Department of Neurosurgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Failures in Revascularization for Pediatric Moyamoya Disease and Syndrome: A Scoping Review. World Neurosurg 2021; 149:204-214.e1. [PMID: 33618047 DOI: 10.1016/j.wneu.2021.02.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Moyamoya disease (MMD) and moyamoya syndrome (MMS) are a rare cause of stroke commonly managed surgically. We conducted a scoping review to identify the current scope of the literature regarding factors associated with failure of revascularization surgery for MMD and MMS in pediatric patients and to catalyze future research. METHODS A scoping review was conducted to explore failures of revascularization surgery for MMD and MMS in pediatric patients using the PubMed, Embase, and Scopus databases. Titles and abstracts returned from searches were screened for full-text review. Studies meeting inclusion criteria were reviewed in full, and relevant data were extracted. RESULTS Of 2450 resultant articles, 15 were included. Angiographic outcomes were reported for 900 hemispheres, of which 442 (49.1%) were denoted as Matsushima grade A, 299 (33.2%) as Matsushima grade B, and 159 (17.7%) as Matsushima grade C. Patients with MMS had poorer angiographic outcomes than did patients with MMD. Patients with poor neovascularization had a greater degree of moyamoya vessels on follow-up angiogram. Suzuki stage was not associated with angiographic outcome in individual patients. Angiographic outcomes differed by surgical approach and were not associated with clinical outcomes. Literature identifying factors was sparse. CONCLUSIONS The existing literature indicates that factors such as cause, degree of moyamoya vessels, and surgical approach may affect the likelihood of Matsushima grade C revascularization in pediatric patients with MMD and MMS. Future studies are necessary to definitively elucidate factors associated with failure of revascularization surgery for pediatric MMD.
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Clinical outcomes after revascularization for pediatric moyamoya disease and syndrome: A single-center series. J Clin Neurosci 2020; 79:137-143. [PMID: 33070883 DOI: 10.1016/j.jocn.2020.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 06/25/2020] [Accepted: 07/06/2020] [Indexed: 11/22/2022]
Abstract
Moyamoya is a progressive cerebrovascular arteriopathy that affects children of any age. The goal of this study was to determine imaging and clinical outcomes as well as complication rates in a pediatric cohort undergoing either a combined direct/indirect or indirect-only revascularization approach. Patients with moyamoya disease or syndrome ≤ 18 years of age at the time of initial surgery were identified, and clinical data were collected retrospectively. Over a 12-year period, 26 patients underwent revascularization procedures on 49 hemispheres with a median follow-up of 2.6 years from surgery. Median age at surgery was 7.3 years (range 1.4-18.0 years). Thirty-three hemispheres (67.3%) underwent combined revascularization with a direct bypass and encephalomyosynangiosis, and sixteen hemispheres (32.7%) underwent indirect-only revascularization. The rate of 30-day perioperative complication was 10.2%, and the rate of postoperative clinical stroke by end of follow-up was 10.2% by hemisphere. There was a 5.7% rate of intraoperative bypass failure requiring conversion to an indirect revascularization approach. On follow-up imaging, 96.9% of direct bypasses remained patent. On multivariate analysis, higher preoperative Pediatric Stroke Outcome Measure (PSOM) scores were associated with lower rates of good clinical outcome on follow-up (unit OR 0.03; p = 0.03). Patients with age < 5.4 years had lower rates of good clinical outcome on follow-up. In this North American cohort, both combined direct/indirect and indirect only revascularization techniques were feasible. However, younger children < 5.4 years of age have worse outcomes than older children, similar to east Asian cohorts.
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Endothelial Progenitor Cells Induce Angiogenesis: a Potential Mechanism Underlying Neovascularization in Encephaloduroarteriosynangiosis. Transl Stroke Res 2020; 12:357-365. [PMID: 32632776 DOI: 10.1007/s12975-020-00834-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/10/2020] [Accepted: 07/01/2020] [Indexed: 12/12/2022]
Abstract
Encephaloduroarteriosynangiosis (EDAS) is one of the most commonly used indirect vascular reconstruction methods. EDAS aids in the formation of collateral vessels from the extracranial to the intracranial circulation in patients with moyamoya disease (MMD). However, the underlying mechanism of collateral vessel formation is not well understood. Endothelial progenitor cells (EPCs) differentiate to form the vascular endothelial cells and play a very important role in angiogenesis. We designed this prospective clinical trial to investigate the presence of EPCs in patients with MMD and to explore the neovascularization mechanism mediated by the EPCs in EDAS. The patients who were diagnosed with MMD were recruited between February 5, 2017, and January 7, 2018. The blood samples were obtained from an antecubital vein and were analyzed using flow cytometry. EPCs were defined as CD34brCD133+CD45dimKDR+. All the patients enrolled in the study underwent EDAS. Cerebral arteriography was performed 6 months post-EDAS to assess the efficacy of synangiosis. The correlation between EPC count and good collateral circulation was evaluated. Among the 116 patients with MMD enrolled in this study, 73 were women and 43 were men. The average age of the patients was 33.8 ± 15.2 years. The EPC count of the patients with MMD was 0.071% ± 0.050% (expressed as percentage of the peripheral blood mononuclear cells). The EPC count in the good postoperative collateral circulation group was significantly higher (0.085% ± 0.054%) than that in the poor collateral circulation group (0.048% ± 0.034%) (P = 0.000). The age, modified Suzuki-Mugikura grade, and EPC count were significantly correlated with the good collateral circulation post-EDAS in the multivariate analysis (P = 0.018, P = 0.007, and P = 0.003, respectively). The formation of collateral vessels by EDAS is primarily driven by angiogenesis. The EPC count may be the most critical factor for collateral circulation. The therapeutic effect of EDAS is more likely to benefit younger or severe ischemic patients with MMD.
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Riordan CP, Storey A, Cote DJ, Smith ER, Scott RM. Results of more than 20 years of follow-up in pediatric patients with moyamoya disease undergoing pial synangiosis. J Neurosurg Pediatr 2019; 23:586-592. [PMID: 30835683 DOI: 10.3171/2019.1.peds18457] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 01/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There are limited data on the long-term outcomes for children undergoing surgical revascularization for moyamoya disease (MMD) in North America. The authors present a series of pediatric MMD patients who underwent a standard revascularization procedure, pial synangiosis, more than 20 years previously at a single institution by a single surgical team. METHODS This study is a retrospective review of all patients aged 21 years or younger treated for MMD at Boston Children's Hospital who were operated on more than 20 years previously by the senior author (R.M.S.). Radiographic and operative reports, outpatient clinical records, and communications with patients and families were reviewed to document current clinical status, ability to perform daily activities, and concurrent or new medical conditions. RESULTS A total of 59 patients (38 female [64.4%], 21 male [35.6%]; median age at surgery 6.2 years [IQR 0.5-21 years]) were identified who were diagnosed with MMD and underwent surgical revascularization procedures more than 20 years previously. Clinically, all but 2 patients (96.6%) presented with the following symptoms alone or in combination: 43 (73%) presented with stroke, 22 (37%) with transient ischemic attack, 12 (20%) with seizures, 7 (12%) with headache, 3 (5%) with choreiform movements, and 2 (3%) with hemorrhage; MMD was incidentally detected in 2 patients (3%). Five patients had unilateral MMD at presentation, but 3 of these ultimately progressed to develop bilateral MMD after an average of 16 months; therefore, pial synangiosis was ultimately performed in a total of 116 hemispheres during the study period. Clinical follow-up was available at a median interval of 20.6 years (IQR 16.1-23.2 years). Modified Rankin Scale scores were stable or improved in 43 of 50 patients with evaluable data; 45 of 55 are currently independent. There were 6 patient deaths (10.2%; 3 due to intracranial hemorrhage, 2 due to tumor-related complications, and 1 due to pulmonary artery stenosis), 4 of whom had a history of previous cranial radiation. One patient (1.7%) experienced a late stroke. Synangiosis vessels remained patent on all available late MRI and MRA studies. Four patients reported uneventful pregnancies and vaginal deliveries years following their revascularization procedures. CONCLUSIONS Revascularization for MMD by pial synangiosis appears to confer protection from stroke for pediatric patients over long-term follow-up. A history of cranial radiation was present in 4 of the 6 patients who died and in the lone patient with late stroke. Most patients can expect productive, independent lives following revascularization surgery in the absence of significant preoperative neurological deficits and comorbidities.
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