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Recognised in Japan in the 1960s, this is a progressive occlusive cerebral arteritis affecting the distal internal carotid arteries near the circle of Willis. Moyamoya is Japanese for 'puff of smoke' and describes the appearance of the resultant network of abnormal small collateral vessels seen on angiography. There is a familial form (about 15% of patients) which links to a gene on chromosome 17q25 - although the exact underlying cause remains unknown.
Recent research has identified the presence of increased numbers of endothelial progenitor cells (specifically outgrowth cells) compared to controls. This could be developed as a diagnostic test in the future.
Moyamoya disease (MMD) is a rare condition, although asymptomatic patients may remain undetected. A four-year study in Japan from 2002-2006 found that the detection rate per year was 0.94 patients per 100,000 people. The prevalence was 10.5 patients per 100,000. There was a female to male ratio of 2.18:1. The incidence of asymptomatic patients was 17.8%. There were two peaks of onset between 45 and 49 years and between 5 and 9 years.
Initially thought to be a disease occurring primarily in Asian countries, the number of patients diagnosed in Europe is increasing due to increased awareness of the condition.
Generally, the clinical features are those associated with transient ischaemic attacks (TIAs) (more common with children) and stroke (haemorrhagic - more typical in adults). They include headache, hemiparesis, seizures, disturbed consciousness, speech deficits (aphasia), sensory and cognitive impairments, involuntary movements and vision problems.
- Cerebrovascular event.
- Basilar artery thrombosis.
- Subarachnoid haemorrhage.
- Blood dyscrasias.
- Cavernous sinus syndromes.
- Cerebral aneurysms.
- Dissection syndromes.
- Fibromuscular dysplasia.
- Intracranial haemorrhage.
- Anderson-Fabry disease.
- Mitochondrial myopathy, encephalopathy, lactacidosis, stroke (MELAS).
- Methylmalonic acidaemia.
- Propionic acidaemia.
- Neurofibromatosis types 1 and 2.
- Pituitary tumours.
- Polyarteritis nodosa.
- Temporal/giant cell arteritis.
- Tolosa-Hunt syndrome (painful ophthalmoplegia caused by nonspecific inflammation of the cavernous sinus or superior orbital fissure).
Associations have been made with leptospirosis, tuberculosis, certain anaemias and vascular disorders causing intimal thickening including hypertension and atherosclerosis.
Moyamoya disease (MMD) is also more common in association with a mixed bag of congenital syndromes (Down's syndrome, Turner's syndrome, Marfan's syndrome, Apert's syndrome) and diseases (neurofibromatosis type I, tuberous sclerosis, Hirschsprung's disease).
- If a patient has had a cerebrovascular event and the aetiology is unclear, a hypercoagulability profile should be arranged including protein C, protein S, antithrombin III, homocysteine and factor V Leiden levels.
- A raised ESR may rule out vasculitis, but a normal ESR does not exclude this diagnosis.
- The gold standard test is radio-imaging.
- Findings suggestive of the diagnosis of moyamoya disease (MMD) on CT scanning or magnetic resonance angiography (MRA) include:
- Stenosis or occlusion at the terminal portion of the internal carotid artery or the proximal portion of the anterior or middle cerebral arteries.
- Abnormal vascular networks in the vicinity of the occluded or stenosed areas.
- The presence of these findings bilaterally.
- An enhancement of MRI, which produces a whole-brain histogram of diffusion tensor imaging (WBH-DTI), may be helpful in identifying moyamoya patients who have had a cerebral infarction from those who have not.
There is little evidence that the disease process per se can be modified by drug therapy. If cerebral haemorrhage has occurred, strict control of blood pressure should be instituted. Patients who have sustained an ischaemic stroke or TIA should have the appropriate antiplatelet or anticoagulant therapy.
Procedures to enhance cerebral flow produce variable results. One study suggested that the surgical technique needs to be tailored to the needs of the individual patient. Indirect revascularisation techniques, which rely on the development of collateral vessels to circumvent the block, seem to produce the best results in paediatric patients. The most common technique, known as encephaloduroarteriomyosynangiosis (EDAMS) involves repositioning the richly vascularised temporalis muscle and the temporal artery along the lateral brain surface and suturing them to the dura. For adult patients the best technique seems to be direct shunting between the superficial temporal artery and the middle cerebral artery.
The prognosis for pregnant patients with moyamoya disease is generally good. However if the woman is diagnosed having presented with a stroke during the course of pregnancy or delivery, the prognosis is poor. Most deaths are the result of haemorrhage.
There is no evidence to suggest vaginal delivery should be avoided.
Surgery improves the prognosis for patients presenting with cerebral ischaemia. However, for patients presenting with haemorrhage, the prognosis is poor. Progressive neurological deterioration and disability occur.
One study found that 30% of patients with unilateral disease developed arteriopathy on the other side within an average period of 2.2 years. Risk factors included contralateral abnormalities on initial imaging, congenital cardiac anomaly, previous cranial irradiation, Asian ancestry, and familial disease. The study recommended monitoring by using MRI and MRA at regular intervals for such patients.
Death is generally from haemorrhage in approximately 5% of children and 10% of adults.
Further reading and references
Czabanka M, Pena-Tapia P, Schubert GA, et al; Characterization of cortical microvascularization in adult moyamoya disease. Stroke. 2008 Jun39(6):1703-9. Epub 2008 Apr 10.
Kuroda S, Houkin K; Moyamoya disease: current concepts and future perspectives. Lancet Neurol. 2008 Nov7(11):1056-66.
Jung KH, Chu K, Lee ST, et al; Circulating endothelial progenitor cells as a pathogenetic marker of moyamoya disease. J Cereb Blood Flow Metab. 2008 Nov28(11):1795-803. Epub 2008 Jul 9.
Baba T, Houkin K, Kuroda S; Novel epidemiological features of moyamoya disease. J Neurol Neurosurg Psychiatry. 2008 Aug79(8):900-4. Epub 2007 Dec 12.
Khan N, Yonekawa Y; Moyamoya angiopathy in Europe: the beginnings in Zurich, practical lessons learned, increasing awareness and future perspectives. Acta Neurochir Suppl. 2008103:127-30.
Mori N, Miki Y, Fushimi Y, et al; Cerebral infarction associated with moyamoya disease: histogram-based Magn Reson Imaging. 2008 Jul26(6):835-40. Epub 2008 May 7.
Isono M, Ishii K, Kamida T, et al; Long-term outcomes of pediatric moyamoya disease treated by encephalo-duro-arterio-synangiosis. Pediatr Neurosurg. 2002 Jan36(1):14-21.
Ishii K, Fujiki M, Kobayashi H; Invited article: surgical management of Moyamoya disease. Turk Neurosurg. 2008 Apr18(2):107-13.
Zipfel GJ, Fox DJ Jr, Rivet DJ; Moyamoya disease in adults: the role of cerebral revascularization. Skull Base. 2005 Feb15(1):27-41.
Takahashi JC, Miyamoto S; Moyamoya disease: recent progress and outlook. Neurol Med Chir (Tokyo). 201050(9):824-32.
Smith ER, Scott RM; Progression of disease in unilateral moyamoya syndrome. Neurosurg Focus. 200824(2):E17.
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