Direct Visualization of Arterial Emboli in Moyamoya Syndrome
BackgroundHemodynamic insufficiency is often considered the cause of ischemic stroke in patients with moyamoya syndrome. While high-intensity transient signals (HITS) on transcranial Doppler (TCD) have been reported in this population, the relationship between these signals and ischemic symptoms is...
| Main Authors: | , , , , |
|---|---|
| Format: | Article |
| Language: | English |
| Published: |
Frontiers Media S.A.
2017-08-01
|
| Series: | Frontiers in Neurology |
| Subjects: | |
| Online Access: | http://journal.frontiersin.org/article/10.3389/fneur.2017.00425/full |
| _version_ | 1818537934152794112 |
|---|---|
| author | Julie G. Shulman Samuel Snider Henri Vaitkevicius Viken L. Babikian Viken L. Babikian Nirav J. Patel |
| author_facet | Julie G. Shulman Samuel Snider Henri Vaitkevicius Viken L. Babikian Viken L. Babikian Nirav J. Patel |
| author_sort | Julie G. Shulman |
| collection | DOAJ |
| description | BackgroundHemodynamic insufficiency is often considered the cause of ischemic stroke in patients with moyamoya syndrome. While high-intensity transient signals (HITS) on transcranial Doppler (TCD) have been reported in this population, the relationship between these signals and ischemic symptoms is not clearly established. Accordingly, current treatment is directed at improving perfusion.Clinical presentationWe present two patients with symptoms of cerebral ischemia and angiographic findings of moyamoya syndrome. In each case, ischemia may have been caused by either hypoperfusion or embolization. Patient A presented with multifocal right middle cerebral artery (MCA) territory infarctions and angiographic findings consistent with moyamoya disease. She underwent right superficial temporal artery–MCA bypass. Intra-operatively, embolic material was observed and recorded traveling through the recipient MCA branch artery on two occasions. Postoperative TCD demonstrated HITS that resolved with uptitration of antiplatelet therapy. Patient B presented with multifocal, embolic-appearing left MCA infarctions, and unilateral angiographic moyamoya syndrome. She was found to have HITS in the left MCA, which eventually resolved with a combination of antiplatelets and anticoagulation.ConclusionHemodynamic compromise may not be the only cause of brain infarction in patients with moyamoya syndrome. Observations from these two patients provide both direct visualization and TCD evidence of embolization as a potential etiology for brain ischemia. Future investigations into the role of antithrombotic agents should be considered. |
| first_indexed | 2024-12-11T18:57:07Z |
| format | Article |
| id | doaj.art-aec9628c5bf6462a8db4e46f470bb713 |
| institution | Directory Open Access Journal |
| issn | 1664-2295 |
| language | English |
| last_indexed | 2024-12-11T18:57:07Z |
| publishDate | 2017-08-01 |
| publisher | Frontiers Media S.A. |
| record_format | Article |
| series | Frontiers in Neurology |
| spelling | doaj.art-aec9628c5bf6462a8db4e46f470bb7132022-12-22T00:54:06ZengFrontiers Media S.A.Frontiers in Neurology1664-22952017-08-01810.3389/fneur.2017.00425291104Direct Visualization of Arterial Emboli in Moyamoya SyndromeJulie G. Shulman0Samuel Snider1Henri Vaitkevicius2Viken L. Babikian3Viken L. Babikian4Nirav J. Patel5Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, United StatesBrigham and Women’s Hospital, Department of Neurology, Harvard Medical School, Boston, MA, United StatesBrigham and Women’s Hospital, Department of Neurology, Harvard Medical School, Boston, MA, United StatesDepartment of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, United StatesVA Boston Healthcare System, Department of Neurology, Boston, MA, United StatesBrigham and Women’s Hospital, Department of Neurosurgery, Harvard Medical School, Boston, MA, United StatesBackgroundHemodynamic insufficiency is often considered the cause of ischemic stroke in patients with moyamoya syndrome. While high-intensity transient signals (HITS) on transcranial Doppler (TCD) have been reported in this population, the relationship between these signals and ischemic symptoms is not clearly established. Accordingly, current treatment is directed at improving perfusion.Clinical presentationWe present two patients with symptoms of cerebral ischemia and angiographic findings of moyamoya syndrome. In each case, ischemia may have been caused by either hypoperfusion or embolization. Patient A presented with multifocal right middle cerebral artery (MCA) territory infarctions and angiographic findings consistent with moyamoya disease. She underwent right superficial temporal artery–MCA bypass. Intra-operatively, embolic material was observed and recorded traveling through the recipient MCA branch artery on two occasions. Postoperative TCD demonstrated HITS that resolved with uptitration of antiplatelet therapy. Patient B presented with multifocal, embolic-appearing left MCA infarctions, and unilateral angiographic moyamoya syndrome. She was found to have HITS in the left MCA, which eventually resolved with a combination of antiplatelets and anticoagulation.ConclusionHemodynamic compromise may not be the only cause of brain infarction in patients with moyamoya syndrome. Observations from these two patients provide both direct visualization and TCD evidence of embolization as a potential etiology for brain ischemia. Future investigations into the role of antithrombotic agents should be considered.http://journal.frontiersin.org/article/10.3389/fneur.2017.00425/fullbrain ischemiacerebral revascularizationembolismmoyamoya diseasestroke |
| spellingShingle | Julie G. Shulman Samuel Snider Henri Vaitkevicius Viken L. Babikian Viken L. Babikian Nirav J. Patel Direct Visualization of Arterial Emboli in Moyamoya Syndrome Frontiers in Neurology brain ischemia cerebral revascularization embolism moyamoya disease stroke |
| title | Direct Visualization of Arterial Emboli in Moyamoya Syndrome |
| title_full | Direct Visualization of Arterial Emboli in Moyamoya Syndrome |
| title_fullStr | Direct Visualization of Arterial Emboli in Moyamoya Syndrome |
| title_full_unstemmed | Direct Visualization of Arterial Emboli in Moyamoya Syndrome |
| title_short | Direct Visualization of Arterial Emboli in Moyamoya Syndrome |
| title_sort | direct visualization of arterial emboli in moyamoya syndrome |
| topic | brain ischemia cerebral revascularization embolism moyamoya disease stroke |
| url | http://journal.frontiersin.org/article/10.3389/fneur.2017.00425/full |
| work_keys_str_mv | AT juliegshulman directvisualizationofarterialemboliinmoyamoyasyndrome AT samuelsnider directvisualizationofarterialemboliinmoyamoyasyndrome AT henrivaitkevicius directvisualizationofarterialemboliinmoyamoyasyndrome AT vikenlbabikian directvisualizationofarterialemboliinmoyamoyasyndrome AT vikenlbabikian directvisualizationofarterialemboliinmoyamoyasyndrome AT niravjpatel directvisualizationofarterialemboliinmoyamoyasyndrome |