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Mitchell DL, Shlobin NA, LoPresti MA, Scoville JP, Winterhalter E, Lam S. Post-Surgical Cognitive Outcomes of Moyamoya Disease: A Systematic Review. World Neurosurg 2023; 178:181-190.e1. [PMID: 37506837 DOI: 10.1016/j.wneu.2023.07.099] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Moyamoya disease (MMD) is an occlusive arteriopathy leading to stroke. Progressive if left untreated, revascularization surgery has become the mainstay of treatment. Although clinical and radiographic outcomes of MMD after intervention are well-characterized, cognitive outcomes in pediatric patients remain unclear. We aimed to examine postoperative cognitive outcomes in children with MMD, examine factors associated with cognitive changes after intervention, and define the effect of revascularization surgery on cognitive outcomes. METHODS A systematic review was conducted following PRISMA guidelines searching PubMed, Embase, and Scopus databases. Articles met inclusion criteria if they studied pediatric patients undergoing revascularization surgery for MMD and examined cognitive outcomes either qualitatively or quantitatively. All data extracted from included articles was examined descriptively. RESULTS Of 1091 resultant articles, 12 articles containing 446 patients were included. Surgery was associated with maintained or improved full scale intellectual quotient (IQ), performance IQ, perceptual IQ, memory quotient and verbal memory. However, 70% of patients had impaired cognitive function, with associated poor school performance. Improvements in cognition were associated with increased cerebral blood flow, particularly to the middle cerebral artery, due to the development of collaterals. Female sex, shorter duration from symptom onset to surgery, and surgery after age 7 were predictive of cognitive improvement. Completed ischemic stroke prior to surgery was associated with poorer cognitive outcomes. CONCLUSIONS Although children with MMD have improved cognitive outcomes following revascularization overall, a distinct subset experience cognitive impairment. Consideration of patient-specific and treatment-related factors is important to enable proper risk stratification and inform management approaches.
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Affiliation(s)
- Devon L Mitchell
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Lurie Children's Hospital, Chicago, Illinois, USA
| | - Nathan A Shlobin
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Lurie Children's Hospital, Chicago, Illinois, USA
| | - Melissa A LoPresti
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Lurie Children's Hospital, Chicago, Illinois, USA
| | - Jonathan P Scoville
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Lurie Children's Hospital, Chicago, Illinois, USA
| | - Emily Winterhalter
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Lurie Children's Hospital, Chicago, Illinois, USA
| | - Sandi Lam
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Lurie Children's Hospital, Chicago, Illinois, USA.
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Ha EJ, Phi JH, Lee JY, Koh EJ, Kim KH, Wang KC, Cho BK, Kim SK. Long-Term Surgical Outcome of Indirect Bypass Surgery in Young Children With Moyamoya Disease. Neurosurgery 2023; 93:901-909. [PMID: 37561505 DOI: 10.1227/neu.0000000000002489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/13/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND The prognosis of moyamoya disease (MMD) in young children (younger than 4 years) is worse than that of older adults. The effectiveness of surgery is still inconclusive. OBJECTIVE To evaluate long-term outcomes after indirect bypass in young children with MMD. METHODS A total of 1417 MMD children underwent indirect bypass from August 1988 to October 2020. This study included 135 patients who were younger than 4 years at the time of surgery. The clinical features and surgical outcomes of these patients were assessed. We analyzed the long-term outcome of 102 children who were followed up for more than 5 years (mean: 18.8 years, range: 5-27.3 years). Cross-sectional analysis was performed to evaluate overall outcomes based on the Lansky Play Performance Scale (LPS). The annual risk of symptomatic stroke after surgery was calculated with a person-year method, and the event-free survival rate was evaluated using the Kaplan-Meier method. RESULTS The overall clinical outcome was favorable (LPS ≥ 80) in 88% of the patients. The overall postoperative adverse event rate was 15%, including 1 death. At the last follow-up, 86% of patients who had seizures at diagnosis were seizure-free. During the follow-up, there were 3 symptomatic infarctions on the operated hemisphere (postoperative 3, 3, and 10 months each). There was no hemorrhagic event. The annual infarction rate was 0.16% per person-year. The 20-year event-free survival rates for symptomatic infarction were 97%. CONCLUSION Indirect bypass could provide a satisfactory long-term outcome and prevent recurrent stroke in young children with MMD.
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Affiliation(s)
- Eun Jin Ha
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul , Republic of Korea
| | - Ji Hoon Phi
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
| | - Ji Yeoun Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
- Department of Anatomy and Cell Biology, Seoul National University College of Medicine, Seoul , Republic of Korea
| | - Eun Jung Koh
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
| | - Kyung Hyun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
| | - Kyu-Chang Wang
- Center for Rare Cancers, National Cancer Center, Goyang , Gyeonggi-do , Republic of Korea
| | - Byung-Kyu Cho
- Department of Neurosurgery, Armed Forces Capital Hospital, Seongnam , Gyeonggi-do , Republic of Korea
| | - Seung-Ki Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul , Republic of Korea
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul , Republic of Korea
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Lee KS, Zhang JJY, Bhate S, Ganesan V, Thompson D, James G, Silva AHD. Surgical revascularizations for pediatric moyamoya: a systematic review, meta-analysis, and meta-regression analysis. Childs Nerv Syst 2023; 39:1225-1243. [PMID: 36752913 PMCID: PMC10167165 DOI: 10.1007/s00381-023-05868-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/28/2023] [Indexed: 02/09/2023]
Abstract
INTRODUCTION There is no clear consensus regarding the technique of surgical revascularization for moyamoya disease and syndrome (MMD/MMS) in the pediatric population. Previous meta-analyses have attempted to address this gap in literature but with methodological limitations that affect the reliability of their pooled estimates. This meta-analysis aimed to report an accurate and transparent comparison between studies of indirect (IB), direct (DB), and combined bypasses (CB) in pediatric patients with MMD/MMS. METHODS In accordance with PRISMA guidelines, systematic searches of Medline, Embase, and Cochrane Central were undertaken from database inception to 7 October 2022. Perioperative adverse events were the primary outcome measure. Secondary outcomes were rates of long-term revascularization, stroke recurrence, morbidity, and mortality. RESULTS Thirty-seven studies reporting 2460 patients and 4432 hemispheres were included in the meta-analysis. The overall pooled mean age was 8.6 years (95% CI: 7.7; 9.5), and 45.0% were male. Pooled proportions of perioperative adverse events were similar between the DB/CB and IB groups except for wound complication which was higher in the former group (RR = 2.54 (95% CI: 1.82; 3.55)). Proportions of post-surgical Matsushima Grade A/B revascularization favored DB/CB over IB (RR = 1.12 (95% CI 1.02; 1.24)). There was no significant difference in stroke recurrence, morbidity, and mortality. After meta-regression analysis, year of publication and age were significant predictors of outcomes. CONCLUSIONS IB, DB/CB are relatively effective and safe revascularization options for pediatric MMD/MMS. Low-quality GRADE evidence suggests that DB/CB was associated with better long-term angiographic revascularization outcomes when compared with IB, although this did not translate to long-term stroke and mortality benefits.
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Affiliation(s)
- Keng Siang Lee
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK.
- Great Ormond Street Institute of Child Health, University College London, London, UK.
- Department of Neurosurgery, King's College Hospital, London, UK.
- Department of Basic and Clinical Neurosciences, Maurice, Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
- Bristol Medical School, University of Bristol, Bristol, UK.
| | - John J Y Zhang
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Sanjay Bhate
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Vijeya Ganesan
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Dominic Thompson
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Greg James
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Adikarige Haritha Dulanka Silva
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
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Kusano Y, Funaki T, Ueda K, Nishida N, Tanaka K, Miyamoto S, Matsuda S. Characterizing the neurocognitive profiles of children with moyamoya disease using the Das Naglieri cognitive assessment system. Sci Rep 2022; 12:3638. [PMID: 35256691 PMCID: PMC8901907 DOI: 10.1038/s41598-022-07699-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 02/23/2022] [Indexed: 11/10/2022] Open
Abstract
Although cognitive impairment is well-documented in children with moyamoya disease (MMD), selective decline in specific neurocognitive domains remains controversial. The purpose of this study was to characterize the neurocognitive profile of children with MMD using the Das Naglieri Cognitive Assessment System (CAS) and the Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV). We analyzed the neurocognitive data of 30 children (median age, 7 years) with MMD who were assessed with the CAS and the WISC-IV before surgery. We focused on the comparison of standard scores and intraindividual differences across domains. The CAS scores significantly varied across four measures (standard scores, p < 0.001; intraindividual differences, p < 0.001). Post-hoc analyses revealed that the standard scores and intraindividual differences for successive processing were significantly lower than those for planning and attention. The WISC-IV scores did not significantly vary among the four measures, although the working memory index was the lowest among the four measures. The within-individual weakness in successive processing, a form of working memory function, may be a distinct characteristic of children with MMD. The CAS may be more sensitive than the WISC-IV for detecting this selective neurocognitive weakness in children with MMD.
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Affiliation(s)
- Yusuke Kusano
- Advanced Occupational Therapy, Department of Human Health Sciences, Kyoto University Graduate School of Medicine, 53 Kawahara-cho Syogoin Sakyo-ku, Kyoto, Japan. .,Rehabilitation Unit, Kyoto University Hospital, 54 Kawahara-cho Syogoin Sakyo-ku, Kyoto, Japan.
| | - Takeshi Funaki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Keita Ueda
- Department of Psychiatry, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Faculty of Health Sciences, Department of Medical Welfare, Kyoto Koka Women's University, Kyoto, Japan
| | - Noyuri Nishida
- Rehabilitation Unit, Kyoto University Hospital, 54 Kawahara-cho Syogoin Sakyo-ku, Kyoto, Japan
| | - Kanade Tanaka
- Rehabilitation Unit, Kyoto University Hospital, 54 Kawahara-cho Syogoin Sakyo-ku, Kyoto, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shuichi Matsuda
- Rehabilitation Unit, Kyoto University Hospital, 54 Kawahara-cho Syogoin Sakyo-ku, Kyoto, Japan.,Department of Orthopedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Canavero I, Vetrano IG, Zedde M, Pascarella R, Gatti L, Acerbi F, Nava S, Ferroli P, Parati EA, Bersano A. Clinical Management of Moyamoya Patients. J Clin Med 2021; 10:3628. [PMID: 34441923 DOI: 10.3390/jcm10163628] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 01/01/2023] Open
Abstract
Moyamoya angiopathy (MMA) is a peculiar cerebrovascular condition characterized by progressive steno-occlusion of the terminal part of the internal carotid arteries (ICAs) and their proximal branches, associated with the development of a network of fragile collateral vessels at the base of the brain. The diagnosis is essentially made by radiological angiographic techniques. MMA is often idiopathic (moyamoya disease-MMD); conversely, it can be associated with acquired or hereditary conditions (moyamoya Syndrome-MMS); however, the pathophysiology underlying either MMD or MMS has not been fully elucidated to date, and this poor knowledge reflects uncertainties and heterogeneity in patient management. MMD and MMS also have similar clinical expressions, including, above all, ischemic and hemorrhagic strokes, then headaches, seizures, cognitive impairment, and movement disorders. The available treatment strategies are currently shared between idiopathic MMD and MMS, including pharmacological and surgical stroke prevention treatments and symptomatic drugs. No pharmacological treatment able to reverse the progressive disappearance of the ICAs has been found to date in both idiopathic and syndromic cases. Antithrombotic agents are usually prescribed in ischemic MMA, although the coexisting hemorrhagic risk should be considered. Surgical revascularization techniques, which are currently the best available treatment in symptomatic MMA, are associated with good long-term outcomes and reduced ischemic and hemorrhagic risks. Given the lack of dedicated randomized clinical trials, current treatment is mainly based on observational studies and physicians’ and surgeons’ expertise.
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Kaseka ML, Dlamini N, Westmacott R. Ischemic sequelae and other vascular diseases. Handb Clin Neurol 2020; 173:485-492. [PMID: 32958192 DOI: 10.1016/b978-0-444-64150-2.00033-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Although pediatric stroke is associated with higher survival rates compared with adult stroke, a substantial body of evidence indicates significant neuropsychologic morbidity in pediatric stroke survivors. Neuroplasticity does not guarantee good outcome in children. The general trends observed in the literature are reviewed as is the profile observed in common causes of pediatric stroke: congenital heart disease, moyamoya disease, and sickle cell disease. The neuropsychologic profile of pediatric stroke patients is heterogeneous due to the multiplicity of associated causes. Stroke in early infancy and large strokes are associated with cognitive impairment while more limited disorders, such as phasic deficit, are observed in childhood stroke. Executive dysfunction is common in pediatric stroke, but social interaction skills are usually preserved. Congenital heart disease and sickle cell disease are associated with global neuropsychologic dysfunction while cognition is usually preserved in moyamoya. Executive dysregulation is instead more frequently reported in this population. Further study of maladaptive processes after pediatric stroke will allow identification of predictors of functional and neuropsychologic outcomes and permit personalization of care.
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Affiliation(s)
- Matsanga Leyila Kaseka
- Department of Pediatrics, Division of Neurology, Hospital for Sick Children, Toronto, ON, Canada.
| | - Nomazulu Dlamini
- Department of Pediatrics, Division of Neurology, Hospital for Sick Children, Toronto, ON, Canada
| | - Robyn Westmacott
- Department of Psychology, Division of Neurology, Hospital for Sick Children, Toronto, ON, Canada
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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] [What about the content of this article? (0)] [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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Funaki T, Takahashi JC, Miyamoto S. Late Cerebrovascular Events and Social Outcome after Adolescence: Long-term Outcome of Pediatric Moyamoya Disease. Neurol Med Chir (Tokyo) 2018; 58:240-246. [PMID: 29780072 PMCID: PMC6002682 DOI: 10.2176/nmc.ra.2018-0026] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
In this article, the authors review the literature related to long-term outcome of pediatric moyamoya disease, focusing on late cerebrovascular events and social outcome of pediatric patients once they reach adulthood. Late-onset de novo hemorrhage is rare but more serious than recurrence of ischemic stroke. Long-term follow-up data on Asian populations suggest that the incidence of de novo hemorrhage might increase at age 20 or later, even more than 10 years after bypass surgery. Social adaptation difficulty, possibly related to cognitive impairment caused by frontal ischemia, continues in 10-20% of patients after they reach adulthood, even if no significant disability is present in daily life. A treatment strategy aimed at improving long-term outcome and careful follow-up might be required.
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Affiliation(s)
- Takeshi Funaki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
| | - Jun C Takahashi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
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Abstract
This study aimed to describe children with moyamoya disease from an international multicenter stroke database, and explore risk factors for stroke recurrence. We reviewed data of children >28-days old with moyamoya disease enrolled in the International Pediatric Stroke Study from January 2003 to March 2013. A total of 174 children from 32 sites and 14 countries had moyamoya disease; median age 7.4 years, 49% male. Of these, 90% presented with ischemic stroke, 7.5% with transient ischemic attack, and 2.5% with hemorrhagic stroke. One-third of patients had moyamoya syndrome. Stroke recurrence was 20% over median follow-up of 13 months; 9% had multiple recurrences. Children treated with surgical revascularization were less likely to have stroke recurrence ( P = .046). Moyamoya disease accounted for 8% of arterial strokes in this international pediatric stroke registry. One-third of pediatric patients with moyamoya disease have an underlying syndromic condition. Surgical revascularization is effective at reducing the incidence of stroke recurrence.
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Affiliation(s)
- Sarah Lee
- 1 Department of Neurology & Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Michael J Rivkin
- 2 Departments of Neurology, Psychiatry and Radiology, Boston Children's Hospital, Boston, MA, USA
| | - Adam Kirton
- 3 Department of Pediatrics, Alberta Children's Hospital Research Institute, University of Calgary, Alberta, Canada
| | - Gabrielle deVeber
- 4 Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jorina Elbers
- 1 Department of Neurology & Neurological Sciences, Stanford University, Stanford, CA, USA
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Abstract
OBJECTIVE To retrospectively evaluate the midterm therapeutic effect of enlarged encephalo-duro-myo-synangiosis (EDMS) for moyamoya disease (MMD) in young children. METHODS Seventy-seven children diagnosed with MMD by digital subtraction angiography (DSA) or magnetic resonance angiography (MRA) were treated between January 2011 and December 2014 in our center. Their clinical features, imaging, and operative reports were analyzed. RESULTS Four patients presented with intracerebral hemorrhage, whereas 73 presented with ischemic symptoms. Revascularization procedures were performed unilaterally on 11 left hemispheres and 9 right hemispheres, and 57 had bilateral surgeries. The average length of surgery was 143 ± 24 minutes, with 28 ± 9 mL of blood loss. The mean period of follow-up was 28.43 ± 15.31 months. Cerebral blood flow increased 3 months after the operations in the previously affected regions. Collateralization from the deep temporal artery, superficial temporal artery, and the middle meningeal artery was found by DSA or MRA. In cases where single-photon emission computed tomography was obtained, it demonstrated better perfusion postoperatively. The ischemic symptoms were relieved in 118 (88.06%) hemispheres, and remained stable in 5 (3.73%) hemispheres. There were 12 radiographic cerebral infarctions (8.96%) within 1 month postoperatively. CONCLUSIONS Enlarged EDMS is safe and effective for MMD in young children. Extensive and multilayered revascularization could significantly preserve neurologic function. The long-term effect on posterior circulation disease development needs further investigation.
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Affiliation(s)
- Wenjun Shen
- Department of Pediatric Neurosurgery, Children's Hospital of Fudan University, Shanghai, China.
| | - Bin Xu
- Department of Neurosurgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Hao Li
- Department of Pediatric Neurosurgery, Children's Hospital of Fudan University, Shanghai, China
| | - Xiaofeng Gao
- Department of Pediatric Neurosurgery, Children's Hospital of Fudan University, Shanghai, China
| | - Yujun Liao
- Department of Neurosurgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Wei Shi
- Department of Pediatric Neurosurgery, Children's Hospital of Fudan University, Shanghai, China
| | - Rui Zhao
- Department of Pediatric Neurosurgery, Children's Hospital of Fudan University, Shanghai, China
| | - Yi Zhang
- Department of Pediatric Neurosurgery, Children's Hospital of Fudan University, Shanghai, China
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Kim T, Bang JS, Kwon OK, Hwang G, Kim JE, Kang HS, Cho WS, Jung C, Oh CW. Hemodynamic Changes after Unilateral Revascularization for Moyamoya Disease: Serial Assessment by Quantitative Magnetic Resonance Angiography. Neurosurgery 2017; 81:111-119. [DOI: 10.1093/neuros/nyw035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/10/2016] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND: Ultrasonic flow meters and quantitative magnetic resonance angiography quantitatively assess flow during hemodynamic evaluation of cerebral ischemia. Although their reliability and reproducibility have been verified, their clinical impact in moyamoya disease has rarely been reported.
OBJECTIVE: To investigate flow measurement outcomes in moyamoya disease patients pre- and postoperatively through a retrospective observational study.
METHODS: We evaluated 41 patients undergoing their first revascularization surgery who were followed ≥6 mo. Hemodynamic parameters were recorded preoperatively, at 1 and 6 mo postoperatively, and at the last follow-up. Demographic factors, Suzuki stage, and stroke development were also analyzed.
RESULTS: Patients’ median age was 37 yr (interquartile range [IQR], 27-43), and 16 (39.0%) patients were men. During follow-up, 9 (22.0%) patients experienced postoperative stroke (4 major strokes). Hemodynamic status was improved in 34 (82.9%) patients at the 6-mo follow-up. Median intraoperative flow was 41 mL/min (IQR, 25-59). Bypass flow peaked at 6 mo (median, 67 mL/min; IQR, 35-99). At the 1- and 6-mo follow-ups, ipsilateral hemispheric flow was significantly increased. The median proportion of posterior circulation at 6 mo was 44.4%, significantly lower than the preoperative proportion (50.1%). Abundant intraoperative bypass flow was associated with hemodynamic improvement, while low contralateral hemispheric flow was related with immediate postoperative ischemic stroke.
CONCLUSION: Ipsilateral hemispheric flow was increased during 6-mo follow-up, and posterior circulation flow burden was diminished. Abundant intraoperative bypass flow was associated with postoperative hemodynamic improvement. Low preoperative contralateral hemispheric flow was related with immediate postoperative ischemic stroke.
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Affiliation(s)
- Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - O-Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Gyojun Hwang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
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Macyszyn L, Attiah M, Ma TS, Ali Z, Faught R, Hossain A, Man K, Patel H, Sobota R, Zager EL, Stein SC. Direct versus indirect revascularization procedures for moyamoya disease: a comparative effectiveness study. J Neurosurg 2016; 126:1523-1529. [PMID: 27471892 DOI: 10.3171/2015.8.jns15504] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Moyamoya disease (MMD) is a chronic cerebrovascular disease that can lead to devastating neurological outcomes. Surgical intervention is the definitive treatment, with direct, indirect, and combined revascularization procedures currently employed by surgeons. The optimal surgical approach, however, remains unclear. In this decision analysis, the authors compared the effectiveness of revascularization procedures in both adult and pediatric patients with MMD. METHODS A comprehensive literature search was performed for studies of MMD. Using complication and success rates from the literature, the authors constructed a decision analysis model for treatment using a direct and indirect revascularization technique. Utility values for the various outcomes and complications were extracted from the literature examining preferences in similar clinical conditions. Sensitivity analysis was performed. RESULTS A structured literature search yielded 33 studies involving 4197 cases. Cases were divided into adult and pediatric populations. These were further subdivided into 3 different treatment groups: indirect, direct, and combined revascularization procedures. In the pediatric population at 5- and 10-year follow-up, there was no significant difference between indirect and combination procedures, but both were superior to direct revascularization. In adults at 4-year follow-up, indirect was superior to direct revascularization. CONCLUSIONS In the absence of factors that dictate a specific approach, the present decision analysis suggests that direct revascularization procedures are inferior in terms of quality-adjusted life years in both adults at 4 years and children at 5 and 10 years postoperatively, respectively. These findings were statistically significant (p < 0.001 in all cases), suggesting that indirect and combination procedures may offer optimal results at long-term follow-up.
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Affiliation(s)
- Luke Macyszyn
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark Attiah
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tracy S Ma
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zarina Ali
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ryan Faught
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alisha Hossain
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karen Man
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hiren Patel
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rosanna Sobota
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric L Zager
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sherman C Stein
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Rashad S, Fujimura M, Niizuma K, Endo H, Tominaga T. Long-term follow-up of pediatric moyamoya disease treated by combined direct–indirect revascularization surgery: single institute experience with surgical and perioperative management. Neurosurg Rev 2016; 39:615-23. [DOI: 10.1007/s10143-016-0734-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Revised: 02/16/2016] [Accepted: 03/06/2016] [Indexed: 10/21/2022]
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14
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Abstract
Although the pathogenesis of moyamoya disease (MMD) has not been fully elucidated, the effectiveness of surgical revascularization in preventing stroke has been addressed by many studies. The main mechanism of surgical revascularization is augmenting the intracranial blood flow using an external carotid system by either direct bypass or pial synangiosis. This can improve resting cerebral blood flow as well as vascular reserve capacity. For direct revascularization, the superficial temporal artery is used as the donor artery in most cases, although the occipital artery may be used in limited cases. Usually, the cortical branch of the middle cerebral artery is selected as the recipient of direct anastomosis. As for indirect revascularization, various techniques using different kinds of connective tissues have been introduced. In some cases, reinforcing the anterior cerebral artery and the posterior cerebral artery territories can be considered. The effectiveness of surgical revascularization for preventing ischemic stroke had been generally accepted by many studies. However, for preventing hemorrhagic stroke, new evidence has been added by a recent randomized controlled trial. The incidence of peri-operative complications such as stroke and hyperperfusion syndrome seems to be high due to the nature of the disease and technical demands for treatment. Preventing and adequately managing these complications are essential for ensuring the benefits of surgery.
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Affiliation(s)
- Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
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15
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Koizumi A, Kobayashi H, Hitomi T, Harada KH, Habu T, Youssefian S. A new horizon of moyamoya disease and associated health risks explored through RNF213. Environ Health Prev Med 2016; 21:55-70. [PMID: 26662949 DOI: 10.1007/s12199-015-0498-7] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 11/18/2015] [Indexed: 01/27/2023] Open
Abstract
The cerebrovascular disorder moyamoya disease (MMD) was first described in 1957 in Japan, and is typically considered to be an Asian-specific disease. However, it is globally recognized as one of the major causes of childhood stroke. Although several monogenic diseases are known to be complicated by Moyamoya angiopathy, the ring finger protein 213 gene (RNF213) was identified as a susceptibility gene for MMD. RNF213 is unusual, because (1) it induces MMD with no other recognizable phenotypes, (2) the RNF213 p.R4810K variant is an Asian founder mutation common to Japanese, Korean and Chinese with carrier rates of 0.5–2 % of the general population but a low penetrance, and (3) it encodes a relatively largest proteins with a dual AAA+ ATPase and E3 Ligase activities. In this review, we focus on the genetics and genetic epidemiology of RNF213, the pathology of RNF213 R4810K, and the molecular functions of RNF213, and also address the public health contributions to current unresolved issues of MMD. We also emphasize the importance of a more updated definition for MMD, of qualified cohort studies based on genetic epidemiology and an awareness of the ethical issues associated with genetic testing of carriers.
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16
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Shim KW, Park EK, Kim JS, Kim DS. Cognitive Outcome of Pediatric Moyamoya Disease. J Korean Neurosurg Soc 2015; 57:440-4. [PMID: 26180613 PMCID: PMC4502242 DOI: 10.3340/jkns.2015.57.6.440] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 04/07/2015] [Accepted: 04/09/2015] [Indexed: 11/27/2022] Open
Abstract
Quality of life is the current trend and issue for the most of human diseases. In moyamoya disease (MMD), surgical revascularization has been recognized as the possible assistance to reduce the neurological insult. However, the progressive nature of the disease has been invincible so far. To improve the quality of life of MMD patients not only the protection from the neurological insult but also the maintenance or improvement of cognitive function is inevitable. For pediatric MMD patients, younger age or longer duration of disease is the key factor among the prognostic factors for bad neurological outcomes. Hence, 'the earlier, the better' is the most precious rule for treatment. Protection from neurological insult is very critical and foremost important to improve cognitive outcome. Clinicians need to know the neuropsychological profile of MMD patients for the care of whole person and make an effort to protect the patients from neurological insults to maintain or improve it.
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Affiliation(s)
- Kyu-Won Shim
- Department of Pediatric Neurosurgery, Moyamoya Disease Clinic, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Eun-Kyung Park
- Department of Pediatric Neurosurgery, Moyamoya Disease Clinic, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ju-Seong Kim
- Department of Pediatric Neurosurgery, Moyamoya Disease Clinic, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Seok Kim
- Department of Pediatric Neurosurgery, Moyamoya Disease Clinic, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
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17
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Funaki T, Takahashi JC, Takagi Y, Yoshida K, Araki Y, Kikuchi T, Kataoka H, Iihara K, Sano N, Miyamoto S. Incidence of late cerebrovascular events after direct bypass among children with moyamoya disease: a descriptive longitudinal study at a single center. Acta Neurochir (Wien) 2014; 156:551-9; discussion 559. [PMID: 24363147 DOI: 10.1007/s00701-013-1975-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 12/04/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND The potential for late cerebrovascular events following surgical revascularization presents a challenge in the treatment of pediatric moyamoya disease. Limited information is available on the incidence of such events after direct bypass. The objective of this descriptive study was to examine the incidence of late cerebrovascular events after direct bypass for pediatric moyamoya disease. METHODS The study cohort comprised consecutive patients with moyamoya disease who had undergone direct bypass at less than 18 years of age in the authors' institute between 1978 and 2003. They were prospectively followed until the end of the study period or, if applicable, the time of death. RESULTS Fifty-six of 58 enrolled patients (96.6%) were followed for a mean period of 18.1 years. Four patients experienced late cerebrovascular events, comprising one stroke and three hemorrhages, an average of 13 years after surgery, one of whom experienced a fatal second hemorrhage. The only late ischemic stroke in the cohort occurred after a severe head injury and emergent craniotomy. The incidence of late cerebrovascular events was 0.41% per year (95% confidence interval, 0.15-1.08); 10-year, 20-year, and 30-year cumulative incidences were 1.8%, 7.3%, and 13.1%, respectively. CONCLUSIONS Despite the efficacy of surgical revascularization, pediatric patients remain at risk of future cerebrovascular events, especially hemorrhage, after reaching adulthood and thus require careful long-term follow-up.
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Affiliation(s)
- Takeshi Funaki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan,
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18
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Abstract
[Purpose] This observational study provides a retrospective description of changes in motor
function of a 10 year old child who suffered from motor weakness caused by Moyamoya
disease (MMD) over an approximately 3 year follow-up observation period. [Methods] The
child was diagnosed as MMD due to multifocal encephalomalacia in both frontal and parietal
cortices. After the ischemic attack, the child received physical therapy the based on
stroke rehabilitation, including muscle strengthening exercises, training of functional
activity/ADL, and neurodevelopmental treatment. [Results] The child’s MRI showed areas of
ischemic infarction in both the frontal and parietal lobes. Steno-occlusive findings for
both the anterior cerebral artery and middle cerebral artery were observed on cerebral
angiography. Regarding changes of motor function during the three-year follow-up,
significant improvements, in the Motricity index, Modified Brunnstrom Classification,
manual function test, and functional ambulatory category were observed. [Conclusion] The
basic motor function and functional abilities of the child showed improvement with
conservative treatment over approximately three years. The functional motor ability of
children with MMD may be similar to the recovery progression of pediatric stroke patients,
if there is no re-occurrence of ischemia.
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Affiliation(s)
- Ki Seok Nam
- Department of Physical Therapy, College of Science and Technology, Yeungnam University, Republic of Korea
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19
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Funaki T, Takahashi JC, Takagi Y, Yoshida K, Araki Y, Kikuchi T, Kataoka H, Iihara K, Miyamoto S. Impact of posterior cerebral artery involvement on long-term clinical and social outcome of pediatric moyamoya disease. J Neurosurg Pediatr 2013; 12:626-32. [PMID: 24138143 DOI: 10.3171/2013.9.peds13111] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In the study of pediatric moyamoya disease, information on long-term social outcomes and risk factors for unfavorable social outcomes remains insufficient. The authors analyzed the long-term results of surgical revascularization for pediatric patients with moyamoya disease to determine whether the involvement of a stenoocclusive lesion in the posterior cerebral artery (PCA), relatively common in pediatric moyamoya disease, represents an underlying predictor for unfavorable social outcomes. METHODS Prospectively collected data on 61 consecutive patients with moyamoya disease who had undergone combined bypass surgery were analyzed. Neuroradiological features and other baseline clinical factors were incorporated into univariate and multivariate analyses to determine any association with an unfavorable social outcome, defined as difficulty attending regular school or obtaining regular employment. RESULTS Posterior cerebral artery involvement detected by angiography on admission was noted in 22 (36.1%) of the 61 patients. Follow-up data were acquired in 56 patients (91.8%), and the mean follow-up period was 15.8 years. While transient ischemic attacks were eliminated in 52 (92.9%) of these 56 patients after surgery, and late-onset ischemic stroke was observed in only 1 patient during the follow-up period, 10 (17.9%) experienced an unfavorable social outcome. Although younger age at onset, longer duration between onset and surgery, infarction present on preoperative neuroradiological images, and PCA involvement had been identified as risk factors for an unfavorable social outcome in univariate analysis, only infarction present on preoperative images and PCA involvement remained statistically significant after multivariate adjustment. CONCLUSIONS Posterior cerebral artery involvement can be considered one of the underlying risk factors for unfavorable social outcome and should be studied further to improve social outcome in pediatric moyamoya disease.
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Affiliation(s)
- Takeshi Funaki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto
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Kim YO, Joo SP, Seo BR, Rho YI, Yoon W, Woo YJ. Early clinical characteristics according to developmental stage in children with definite moyamoya disease. Brain Dev 2013; 35:569-74. [PMID: 22951249 DOI: 10.1016/j.braindev.2012.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 07/31/2012] [Accepted: 08/01/2012] [Indexed: 10/27/2022]
Abstract
The objective is to clarify the early clinical characteristics in childhood moyamoya disease (MD). Epidemiologic characteristics, symptoms and diagnostic rates were assessed in 64 children (0-18 years) with definite MD according to developmental stage: infancy (5; 0-1 years); toddlerhood/preschool age (22; 2-5 years); school age (29; 6-10 years); and adolescence (8; 11-18 years). The median ages at onset was 6.25 years and the female to male ratio was 1.9 (~2.5 in toddlerhood/preschool age and in adolescence, P=0.71). Previous headache was observed in 23% (14/64): frequently in school age (38%, P=0.02) and within 6 months before main symptoms (6/11). As an initial symptom, weakness was observed in 78% (50/64) mainly as transient ischemic attack (TIA, 61%) in limbs (90%) and unilaterally (82%). TIA was less frequent in infancy (40%, P=0.04). Seizure was observed in 27% (17/64): frequently in infancy (100%, P<0.01), as the focal type (71%), and in the right extremity (3:1). Isolated seizures without other symptoms was frequent in children ~5 years (P<0.01). Severe headache associated with MD was observed in 14% (9/64). Provoking events were positive in 42% (27/64): in school age, frequently during eating (28%); and in toddlerhood/preschool age, during crying (27%). The diagnostic rates at 3 and 12 months from symptom-onset were 39% (80% during infancy vs. 28% in school age, P=0.14) and 67%, respectively. Symptomatic progression at diagnosis was observed in 38% (24/64). Initial clinical characteristics in childhood definite MD differed according to developmental stage and from at diagnosis.
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Affiliation(s)
- Young Ok Kim
- Department of Pediatrics, School of Medicine, Chonnam National University, Gwangju, Republic of Korea.
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