The Safety and Efficacy of Induced Hypertension and Hypervolemia in Preventing Neurological Complications After Combined Direct and Indirect Bypass in Hemorrhagic Onset Moyamoya Disease

Background: Modern case series often focus on emphasizing low complication rates, “safety,” and “efficacy.” Although patients may not suffer significant or obviously apparent neurological complications, many lessons are buried in the “no complications” cohort. Methods: The junior author’s prospectively maintained caselog was reviewed over a 1-year period for both symptomatic and “minor”/technical complications of neurointerventional cases, the latter referring to an intraprocedural inability to treat a lesion, suboptimal result, or potentially morbid angiographic occurrence/finding that did not result in permanent neurological morbidity – neurointerventional “near morbidity” (NNM). Results: Of 602 treatments performed over the reviewed period, 163 were interventional neuroendovascular procedures. The most common neuroendovascular procedure performed was stroke thrombectomy (67 cases). Major neurological complications, defined as symptomatic stroke or hemorrhage, occurred in 7 cases (4%). NNM, consisting of instructive, technical issues arose in an additional 9 cases that did not result in neurological morbidity (6%). Overall, in 20/163 cases (12%), there were either major neurological complications, NNM, groin complications, or major medical complications. Conclusions: “Minor”/technical complications – NNM – can be as instructive and illustrative as major complications despite not resulting in permanent morbidity. In reviewing case series, particularly early in one’s career, these cases should be highlighted.

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The Risk for Future Cerebrovascular Disease in Pregnant Women With Moyamoya Disease: A Nationwide Population-Based Study in South Korea

10.21203/rs.3.rs-516466/v1 ◽

2021 ◽

Author(s):

Yeonseong Jeong ◽

Yun Ji Jung ◽

Eunjin Noh ◽

Geum Joon Cho ◽

Min-Jeong Oh ◽

...

Keyword(s):

Diabetes Mellitus ◽

Health Insurance ◽

Gestational Diabetes ◽

Gestational Diabetes Mellitus ◽

Cerebrovascular Disease ◽

Moyamoya Disease ◽

Chronic Hypertension ◽

Pregnancy Induced Hypertension ◽

Increased Risk ◽

Induced Hypertension

Abstract Background: Physiologic changes during pregnancy affect the development of postpartum cerebrovascular disease (CVD) in women with Moyamoya disease (MMD). Due to the rare prevalence of MMD and large regional variations, large-scale studies on the risk of CVD after delivery have not been conducted. The aim of this study was to evaluate whether women with MMD have an increased risk of CVD after delivery.Methods: Research data was collected from the National Health Insurance Claims Database of the Health Insurance Review and Assessment Service. Patients delivered in Korea from 2007 to 2014 were enrolled. We classified women as CVD if they were diagnosed with stroke and/or cerebral infarction and/or intracranial hemorrhage and/or subarachnoid hemorrhage between delivery and December 31, 2016. To evaluate adjusted hazard ratio for CVD in women with MMD, we used multivariate Cox proportional hazard regression.Results: Among 3,611,216 Korean women who had delivery, 382 had Moyamoya disease. When compared to women without MMD, women with MMD had a higher prevalence of pregestational diabetes and chronic hypertension. Also, women with MMD had a significantly higher incidence of cesarean section, pregnancy-induced hypertension, and gestational diabetes mellitus (p<0.0001, <0.0001, 0.02, respectively). Among women with MMD, a total of 246(64.4%) women developed CVD within the follow-up postpartum period, and 87.8% occurred within 2 years of postpartum. Women with MMD were associated with an increased risk of CVD in later (adjusted HR 108.24; 95% CI, 95.37-122.86) after adjusting for maternal age, parity, pregnancy-induced hypertension, gestational diabetes mellitus, pregestational diabetes, chronic hypertension.Conclusion: Our study showed that the incidence of CVD after delivery was higher in women with MMD. Therefore, we have to have more cautions of women with MMD and provide long-term postpartum surveillance

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Abstract WMP37: Burden of Neurological Complications Among Patients With Moyamoya Disease (MMD) Treated With Revascularization

Stroke ◽

10.1161/str.51.suppl_1.wmp37 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Smit D Patel ◽

Fadar O Otite ◽

Jussie Lima ◽

Schweta Rane ◽

Rupak Desai ◽

...

Keyword(s):

Treatment Group ◽

Moyamoya Disease ◽

Readmission Rate ◽

Neurological Complications ◽

Continuous Variables ◽

Post Discharge ◽

Chi Square ◽

Chi Square Test ◽

Student’S T ◽

Index Cases

Introduction: Moyamoya disease is a chronic steno-occlusive vasculopathy involving the circle of Willis and typically presents with ischemic or hemorrhagic stroke. Prior studies suggest that either direct or indirect extracranial-intracranial bypass (EC-IC) is an effective treatment for MMD. However, the burden of post-discharge neurological complications after the procedure is unknown. Our study aims to identify the 90 readmission rate (90-DRR) and neurological complications upon readmission in revascularization and untreated MMD patients. Method: We analyzed the data from the Nationwide Readmission Database (NRD) from 2010-2015. MMD was ascertained by ICD-9 discharge code 437.5 and revascularization (EC-IC) using 39.28. SAS 9.4 was used for data analysis with categorical and continuous variables tested using the Rao Scott Chi-square test and Student’s t-test respectively. Result: Among total 4,902 MMD index events, 1,840 had a revascularization procedure and 3,062 did not. The 90-DRR for the treatment group was 14.72% (readmitted N=271/Index cases N=1,840) vs. 34.75% (readmitted N=1,064/Index cases N=3,062) for the non-revascularization group (P <0.0001). Baseline characteristics of MMD with revascularization were mean age (Mean±SE) 41±0.6 vs. 40±0.5 (P=0.20), Charlson comorbidity index (CCI) 1.6±0.04 vs. 1.8±0.05 (P=0.0004), female: male 3:1. Cause-specific readmission rate in both groups was reported as per table. Conclusion: Our analysis shows that patients treated with revascularization had significantly fewer 90-day readmissions when compared to untreated patients. MMD and ischemic stroke were the top reasons for readmission within the 90 days of discharge for both groups. A seizure was reported higher in the treatment group.

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The use of nitroglycerin for treatment of progressive moyamoya disease: A prospective pilot study of safety and efficacy

Journal of Pediatric Neurology ◽

10.1055/s-0035-1557375 ◽

2015 ◽

Vol 05 (02) ◽

pp. 101-109

Author(s):

John Reavey-Cantwell ◽

Rebecca Dettorre ◽

Ronald Quisling ◽

Robert Mericle

Keyword(s):

Pilot Study ◽

Moyamoya Disease ◽

Safety And Efficacy ◽

Prospective Pilot Study

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Moyamoya Disease in Infancy: Application of a Novel Indirect Revascularization Technique for Bihemispheric Cortical Synangiosis

Neurosurgery ◽

10.1093/neuros/nyz310_452 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Danielle DeBacker Dang ◽

John V Dang ◽

Duaa AbdelHameid ◽

Seth Mansinghani ◽

Leon E Moores

Keyword(s):

Moyamoya Disease ◽

Literature Search ◽

Case Series ◽

Combined Approach ◽

Pial Surface ◽

Frontal Pole ◽

Safety And Efficacy ◽

Indirect Revascularization ◽

Cerebral Arteriopathy ◽

Scalp Incision

Abstract INTRODUCTION Moyamoya disease (MMD) is a rare progressive cerebral arteriopathy characterized by nonatherosclerotic steno-occlusive lesions of the Circle of Willis. Presentation in infancy is rare and usually presents with ischemic stroke. We present a 7-mo old female with bilateral MMD who presented for indirect revascularization after 2 successive strokes in multiple vascular territories. METHODS We demonstrate a novel indirect revascularization technique in infant MMD whereby the patient's multifocal ischemic burden and STA caliber precluded arterial and myosynangiosis. We instead utilized bihemispheric pericranium for revascularization of bilateral oligemic cerebrum. Through a bicoronal scalp incision and inverted T-shaped pericranial incision, large anteriorly-based pericranial flaps were applied to the exposed pial surface using bilateral hemicraniotomies. Synangiosis extended from the frontal pole into parieto-occipital territories. We additionally performed a literature search on bypass approaches used for infant MMD. RESULTS A total of 10 infant MMD cases have been reported in the literature. Our case represents the only use of a pericranial graft in an infant without a combined approach. Pial synangiosis, EDAS, and conservative management represent techniques described in this population. Two case series utilized pericranial flaps with EDAS, however, no infants were included nor did revascularization extend beyond traditional margins. Our patient remains stroke and seizure-free for at least 16-months. She is ambulating independently and meeting her pediatric milestones. CONCLUSION Indirect revascularization is favored in pediatric MMD with approaches primarily utilizing native vessel donor grafts. Bilateral revascularization is performed in a delayed, sequential fashion if indicated. Further, collateralization is limited by the anatomical graft parameters, making hemispheric pathology difficult to comprehensively treat with these approaches. Our case demonstrates the safety and efficacy of utilizing a large bihemispheric pericranial flap on its native pedicle with bilateral hemicraniotomies for revascularization of multiple cerebrovascular territories in severe infant MMD. Our technique also allows for preservation of critical native vessels should the need for reoperation arise.

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Risks of the Consumption of Beverages Containing Quinine

Psychological Reports ◽

10.2466/pr0.2003.93.3f.1022 ◽

2003 ◽

Vol 93 (3_suppl) ◽

pp. 1022-1024 ◽

Cited By ~ 2

Author(s):

James Robert Brašić

Keyword(s):

Older Women ◽

Evaluation Process ◽

Altered Mental Status ◽

The United States ◽

Neurological Complications ◽

Women Psychologists ◽

Safety And Efficacy ◽

United States Food ◽

States Food ◽

Tonic Water

Although the United States Food and Drug Administration banned its use for nocturnal leg cramps due to lack of safety and efficacy, quinine is widely available in beverages including tonic water and bitter lemon. Numerous anecdotal reports suggest that products containing quinine may produce neurological complications, including confusion, altered mental status, seizures, and coma, particularly in older women. Psychologists need to inquire about consumption of quinine-containing beverages as part of an evaluation process.

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Posterior Reversible Encephalopathy Syndrome as a Complication of Induced Hypertension in Subarachnoid Hemorrhage: A Case-Control Study

Neurosurgery ◽

10.1093/neuros/nyy240 ◽

2018 ◽

Vol 85 (2) ◽

pp. 223-230 ◽

Cited By ~ 9

Author(s):

Michelle L Allen ◽

Tobias Kulik ◽

Salah G Keyrouz ◽

Rajat Dhar

Keyword(s):

Subarachnoid Hemorrhage ◽

Posterior Reversible Encephalopathy Syndrome ◽

Additional Data ◽

Delayed Cerebral Ischemia ◽

Neurological Complications ◽

Posterior Reversible Encephalopathy ◽

Induced Hypertension ◽

The Face ◽

Reversible Encephalopathy ◽

Control Study

Abstract BACKGROUND Induced hypertension (IH) remains the mainstay of medical management for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH). However, raising blood pressure above normal levels may be associated with systemic and neurological complications, of which posterior reversible encephalopathy syndrome (PRES) has been increasingly recognized. OBJECTIVE To ascertain the frequency and predisposing factors for PRES during IH therapy. METHODS We identified 68 patients treated with IH from 345 SAH patients over a 3-yr period. PRES was diagnosed based on clinical suspicion, confirmed by imaging. We extracted additional data on IH, including baseline and highest target mean arterial pressure (MAP), comparing PRES to IH-treated controls. RESULTS Five patients were diagnosed with PRES at median 6.6 d (range 1-8 d) from vasopressor initiation. All presented with lethargy, 3 had new focal deficits, and 1 had a seizure. Although baseline MAP (prior to DCI) did not differ between cases and controls, both MAP immediately prior to IH (112 vs 90) and highest MAP targeted were greater (140 vs 120 mm Hg, both P < .01). Magnitude of MAP elevation was greater (54 vs 34 above baseline, P = .004) while degree of IH was not (37 vs 38 above pre-IH MAP). All 4 surviving PRES patients had complete resolution with IH discontinuation. CONCLUSION PRES was diagnosed in 7% of SAH patients undergoing IH therapy, most often when MAP was raised well above baseline to levels that exceed traditional autoregulatory thresholds. High suspicion for this reversible disorder appears warranted in the face of unexplained neurological deterioration during aggressive IH.

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