J Korean Neurosurg Soc.  2019 Mar;62(2):136-143. 10.3340/jkns.2018.0101.

Hemorrhagic Moyamoya Disease : A Recent Update

• Fujimura M
• Tominaga T

• KMID: 2441557
• DOI: http://doi.org/10.3340/jkns.2018.0101

Abstract

Moyamoya disease (MMD) is a progressive cerebrovascular disease with unknown etiology, characterized by bilateral stenoocclusive changes at the terminal portion of the internal carotid artery and an abnormal vascular network formation at the base of the brain. MMD has an intrinsic nature to convert the vascular supply for the brain from internal carotid (IC) system to the external carotid (EC) system, as indicated by Suzuki's angiographic staging. Insufficiency of this "˜IC-EC conversion system' could result not only in cerebral ischemia, but also in intracranial hemorrhage from inadequate collateral anastomosis, both of which represent the clinical manifestation of MMD. Surgical revascularization prevents cerebral ischemic attack by improving cerebral blood flow, and recent evidence further suggests that extracranial-intracranial bypass could powerfully reduce the risk of re-bleeding in MMD patients with posterior hemorrhage, who were known to have extremely high re-bleeding risk. Although the exact mechanism underlying the hemorrhagic presentation in MMD is undetermined, most recent angiographic analysis revealed the characteristic angio-architecture related to high re-bleeding risk, such as the extension and dilatation of choroidal collaterals and posterior cerebral artery involvement. We sought to update the current management strategy for hemorrhagic MMD, including the outcome of surgical revascularization for hemorrhagic MMD in our institute. Further investigations will clarify the optimal surgical strategy to prevent hemorrhagic manifestation in patients with MMD.

Keyword

Moyamoya disease; Hemorrhage; Revascularization surgery; Angiography

MeSH Terms

Angiography
Brain
Brain Ischemia
Carotid Artery, Internal
Cerebrovascular Circulation
Cerebrovascular Disorders
Choroid
Dilatation
Hemorrhage
Humans
Intracranial Hemorrhages
Moyamoya Disease*
Posterior Cerebral Artery

Figure

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  Fig. 1. A : Representative finding of T2*-weighted magnetic resonance (MR) imaging of a 45-year old woman with hemorrhagic MMD. Among the multiple hemorrhages, posterior hemorrhage was evident on the left hemisphere (arrows). B : MR angiography demonstrating terminal internal carotid artery stenosis and abnormal vascular network formation bilaterally.

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  Fig. 2. Intra-operative view of microsurgical revascularization. Surgical view before (A), during (B), and after left superficial temporal artery-middle cerebral artery bypass (C and D). Indocyanine green video-angiography demonstrated apparently patent bypass with favorable distribution of bypass flow (D).

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  Fig. 3. A : Postoperative MR angiography demonstrating STA-MCA bypass as thick high signal intensity (arrow). B : N-isopropyl-p-[123I] iodpamphetamine single-photon emission computed tomography seven days after left STA-MCA bypass demonstrating marked improvement in cerebral blood flow on the hemisphere operated on (dotted circles). STA-MCA : superficial temporal artery-middle cerebral artery.

Reference

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