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Digital subtraction angiographic characteristics of progression of moyamoya disease 6 months prior to surgical revascularisation.

ABSTRACT: Background:Evidence on the natural angiographic course of moyamoya disease (MMD) is lacking. It takes about 6?months for waiting for revascularisation surgery. The issue of when to perform subtraction angiography (DSA) for follow-up remains unclear. We investigated the natural course of MMD by DSA and attempted to determine the best interval to perform the follow-up DSA. Methods:This is a single-centre cohort study of Chinese MMD inpatients treated from 1 January 2015 to 31 August 2019. Their angiographic findings were evaluated on Suzuki stage and collateral circulation between two follow-ups of the same hemisphere. Results:A total of 110 patients who met the criteria were enrolled in this study. After a median 6 months follow-up, five patients (4.5%) had progression, four females and one male. Time interval of progression ranged from 4 to 137 months with a mean of 61.4 months. Of five patients with progression, four had unilateral lesion (two ipsilateral and two contralateral) and one had bilateral lesions. Collateral circulation was changed in three of five patients. Conclusions:The angiographic evidence of progression in MMD was rare in the short-term follow-up, and most patients with progression had initial unilateral involvement. DSA re-examination may be not needed in patients with bilateral MMD, but needed in unilateral MMD.

SUBMITTER: Ge P

PROVIDER: S-EPMC7213515 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Digital subtraction angiographic characteristics of progression of moyamoya disease 6 months prior to surgical revascularisation.

Ge Peicong P Zhang Qian Q Ye Xun X Liu Xingju X Deng Xiaofeng X Wang Jia J Wang Rong R Zhang Yan Y Zhang Dong D Zhao Ji Zong JZ

Stroke and vascular neurology 20200227 1

<h4>Background</h4>Evidence on the natural angiographic course of moyamoya disease (MMD) is lacking. It takes about 6 months for waiting for revascularisation surgery. The issue of when to perform subtraction angiography (DSA) for follow-up remains unclear. We investigated the natural course of MMD by DSA and attempted to determine the best interval to perform the follow-up DSA.<h4>Methods</h4>This is a single-centre cohort study of Chinese MMD inpatients treated from 1 January 2015 to 31 August ...[more]

PMID: 32411414

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Project description:Moyamoya is a progressive steno-occlusive cerebrovascular pathology of unknown aetiology that usually involves the terminal portions of the internal carotid arteries and/or the proximal portions of the anterior and middle cerebral arteries bilaterally. The pre-operative Suzuki staging system and post-operative Matsushima grade are nearly universally used markers of natural history and surgical revascularization results, respectively, but their correlation with clinical and radiographic manifestations of moyamoya has not been systematically evaluated in a large cohort. This study evaluated the strength of correlations between pre- and post-operative angiographic parameters and clinical status among paediatric patients with moyamoya. The participants included 58 patients of mean age 11?years at the time of surgery who underwent bilateral indirect revascularization in the same procedure at Boston Children's Hospital, between January 2010 and December 2015. All included patients had available pre-operative and 1-year post-operative digital subtraction angiography. Clinical data included presenting symptoms, degree of functional incapacity, and peri-operative and long-term complications. Radiographic data included pre-operative Suzuki stage, degree of arterial stenosis, a novel collateral score, the presence of hypovascular territories on digital subtraction angiography, and post-operative Matsushima grade and evolution of stenosis. Chi-squared test and Pearson coefficient were used for correlation studies for categorical variables and Spearman's rho was used for correlation studies for continuous variables. Results showed that Suzuki stage, collateral score and degree of stenosis were insufficient to predict clinical presentation, pre-operative incapacity and radiographic presentation, whereas the presence of hypovascular territories was correlated with all of these. At 1-year follow-up, Matsushima grade was insufficient for predicting peri-operative or long-term complications, nor did it correlate with post-operative incapacity. The presence of hypovascular territories at 1-year follow-up was correlated with the incidence of post-operative ischaemic symptoms.

Project description:BackgroundMoyamoya disease is a rare chronic steno-occlusive cerebrovascular disease. It may have variable clinical symptoms associated with cerebral stroke, including motor paralysis, sensory disturbances, seizures, or headaches. However, patients with moyamoya disease rarely present with involuntary movement disorders, including limb-shaking syndrome, with no previous reports of limb-shaking syndrome occurring after revascularization procedures for this disease. Although watershed shifts can elicit transient neurological deterioration after revascularisation, symptoms originating from the contralateral hemisphere following the revascularization procedure are rare. Here, we report the case of moyamoya disease wherein the patient developed limb-shaking syndrome derived from the contralateral hemisphere after unilateral revascularisation.Case descriptionA 16-year-old girl presented with transient left upper and lower limb numbness and headache. Based on digital subtraction angiography, she was diagnosed with symptomatic moyamoya disease. Single-photon emission computed tomography (SPECT) showed decreased cerebral blood flow (CBF) on the right side, and she underwent direct and indirect bypasses on this side. Involuntary movements appeared in her right upper limb immediately postoperatively. SPECT showed decreased CBF to the bilateral frontal lobes. Subsequently, the patient was diagnosed with limb-shaking syndrome. After performing left-hemispheric revascularisation, the patient's symptoms resolved, and SPECT imaging confirmed improvements in CBF to the bilateral frontal lobes.ConclusionRevascularization for moyamoya disease can lead to watershed shifts, which can induce limb-shaking syndrome derived from abnormalities in the contralateral hemisphere of the revascularized side. For patients with new-onset limb-shaking syndrome after moyamoya revascularisation procedures, additional revascularization may be warranted for treatment of low perfusion areas.

Project description:PurposeTo evaluate diagnostic performance of three nonenhanced methods: variable-refocusing-flip angle (FA) fast spin-echo (SE)-based magnetic resonance (MR) angiography (variable FA MR) and constant-refocusing-FA fast SE-based MR angiography (constant-FA MR) and flow-sensitive dephasing (FSD)-prepared steady-state free precession MR angiography (FSD MR) for calf arteries, with dual-injection three-station contrast material-enhanced MR angiography (gadolinium-enhanced MR) as reference.Materials and methodsThis prospective study was institutional review board approved and HIPAA compliant, with informed consent. Twenty-one patients (13 men, eight women; mean age, 62.6 years) underwent calf-station variable-FA MR, constant-FA MR, and FSD MR at 1.5 T, with gadolinium-enhanced MR as reference. Image quality and stenosis severity were assessed in 13 segments per leg by two radiologists blinded to clinical data. Combined constant-FA MR and FSD MR reading was also performed. Methods were compared (logistic regression for correlated data) for diagnostic accuracy.ResultsOf 546 arterial segments, 148 (27.1%) had a hemodynamically significant (? 50%) stenosis. Image quality was satisfactory for all nonenhanced MR sequences. FSD MR was significantly superior to both other sequences (P < .0001), with 5-cm smaller field of view; 9.6% variable-FA MR, 9.6% constant-FA MR, and 0% FSD MR segmental evaluations had nondiagnostic image quality scores, mainly from high diastolic flow (variable-FA MR) and motion artifact (constant-FA MR). Stenosis sensitivity and specificity were highest for FSD MR (80.3% and 81.7%, respectively), compared with those for constant-FA MR (72.3%, P = .086; and 81.8%, P = .96) and variable-FA MR (75.9%, P = .54; and 75.6%, P = .22). Combined constant-FA MR and FSD MR had superior sensitivity (81.8%) and specificity (88.3%) compared with constant-FA MR (P = .0076), variable-FA MR (P = .0044), and FSD MR (P = .0013). All sequences had an excellent negative predictive value (NPV): 93.2%, constant-FA MR; 94.7%, variable-FA MR; 91.7%, FSD MR; and 92.9%, combined constant-FA MR and FSD MR.ConclusionAt 1.5 T, all evaluated nonenhanced MR angiographic methods demonstrated satisfactory image quality and excellent NPV for hemodynamically significant stenosis.Supplemental materialhttp://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12120859/-/DC1.

Project description:Objective: Extracranial-intracranial bypass is currently recognized as the optimal treatment for hemorrhagic-type moyamoya disease (MMD) which reduces incidence of rebleeding. Recent studies have reported the advantage of combined bypass over direct bypass for the general MMD patients. However, the effect of direct bypass and combined bypass surgery specifically for hemorrhagic-type MMD had not been investigated yet. Methods: Hemorrhagic-type MMD patients who underwent direct and combined bypass surgery with complete clinical and radiological documentation from a multicenter cohort between 2009 and 2017 were retrospectively included. Surgical methods included superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis (direct bypass), combined STA-MCA bypass with encephalodurosynangiosis (EDS), and combined STA-MCA bypass with encephaloduroarteriosynangiosis (EDAS). Matsushima standard on follow-up catheter angiography was used to assess surgical outcome. Modified Rankin Scale, incidence of rebleeding and ischemia during follow-up were recorded. Rebleeding-free survival rates between direct and combined bypass were compared by Kaplan-Meier analysis. Results: Sixty eight hemorrhagic-onset MMD patients were included in this study, among which 71 hemispheres were treated with surgery (direct bypass: 17; bypass+EDS: 24; bypass+EDAS: 30). Forty six (64.8%) hemispheres had satisfactory revascularization (Matsushima level 2-3) and 26 (36.6%) had poor neoangiogenesis. Matsushima level was not significantly different between surgical groups (P = 0.258). Good neoangiogenesis from dural grafts was achieved in 26 (36.6%) hemispheres, and good neoangiogenesis from STA grafts was only seen in 4 (out of 30, 12.5%) hemispheres. Multivariate analysis showed bypass patency [P < 0.001, OR (95%CI): 13.41 (3.28-54.80)] and dural neoangiogenesis [P < 0.001, OR (95%CI): 13.18 (3.26-53.36)] both independently contributed to good angiographic outcome. During follow-up, incidences of rebleeding or ischemic events, and re-bleeding free survival rate were not significantly different between surgical groups (P = 0.433, P = 0.559, and P = 0.997). However, patients who underwent combined bypass surgery had significantly lower mRS at follow-up comparing to patients who underwent direct bypass (P = 0.006). Conclusion: Combined bypass surgery and direct bypass surgery offered similar revascularization for hemorrhagic MMD. Bypass patency and dural angiogenesis both contributed to revascularization independently. The potential of indirect bypass to grow new vessels in hemorrhagic-MMD patients was generally limited, but dural leaflets offered better neoangiogenesis than STA grafts and was therefore recommended for surgical revascularization of hemorrhagic MMD.

Project description:Importance:Macular edema during infancy, a subclinical feature identified in premature infants by handheld spectral-domain optical coherence tomography (SD-OCT), has been associated with poorer visual acuity and neurodevelopmental outcomes. Features of macular edema on fluorescein angiography (FA) are needed to understand its pathophysiology, but to date have not been reported previously. Objective:To investigate the FA features of macular edema during infancy. Design, Setting, and Participants:A retrospective review was conducted of 8 infants at Duke Eye Center who received simultaneous SD-OCT and FA imaging from July 1, 2011, to June 30, 2017. Research and clinical care images were obtained during examination of the infants under anesthesia or at the bedside in the neonatal intensive care unit. Main Outcomes and Measures:Side-to-side comparison of research handheld SD-OCT images and clinically indicated FA. Results:Imaging was conducted at a mean (SD) of 42.8 (4.2) weeks' postmenstruation age in the 8 infants (1 [13%] female; 2 [25%] African American; 6 [75%] white). Examination of the FA and SD-OCT images found (1) no macular fluorescein leakage in 3 eyes of 2 infants with retinopathy of prematurity without macular edema and 1 eye with a single cyst, (2) equivocal fluorescein leakage in 2 eyes of 1 infant with mild macular edema, (3) late macular fluorescein leakage in 4 eyes of 2 infants with moderate to severe macular edema, and (4) macular fluorescein leakage from posterior preretinal neovascularization in the macula in 4 eyes of 3 infants with retinopathy of prematurity without macular edema. Conclusions and Relevance:This observation of fluorescein leakage in 4 infant eyes with macular edema provides new insights into the possible mechanisms of this subclinical finding. Macular fluorescein leakage could indicate a breakdown or delayed maturation of the blood-retinal barrier or dysfunction of the retinal pigment epithelium. Furthermore, the cross-sectional OCT view aids in identifying preretinal neovascularization, which can also cause focal macular leakage in these infants. This new perspective may improve our understanding and potentially guide future treatments of premature infants with subnormal vision.

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Digital subtraction angiographic characteristics of progression of moyamoya disease 6 months prior to surgical revascularisation.

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Digital subtraction angiographic characteristics of progression of moyamoya disease 6 months prior to surgical revascularisation.

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