Efficacy and Safety of Antiplatelet Agents for Adult Patients With Ischemic Moyamoya Disease

Abstract

Background: The use of antiplatelet agents in ischemic moyamoya disease (MMD) is controversial. This study aimed to investigate the effectiveness and safety of antiplatelet therapy compared with conservative treatment and surgical revascularization in ischemic MMD patients.Methods: Ischemic MMD patients were retrospectively enrolled from eight clinical sites from January 2013 to December 2018. Follow-up was performed through clinical visits and/or telephone interviews from first discharge to December 2019. The primary outcome was the episodes of further ischemic attacks, and the secondary outcome was the individual functional status. Risk factors for future stroke were identified by the LASSO-Cox regression model. Propensity score matching was applied to assemble a cohort of patients with similar baseline characteristics using the TriMatch package.Results: Among 217 eligible patients, 159 patients were included in the analyses after a 1:1:1 propensity score matching. At a mean follow-up of 33 months, 12 patients (7.5%) developed further incident cerebral ischemic events (surgical:antiplatelet:conservative = 1:3:8; p = 0.030), 26 patients (16.4%) developed a poor functional status (surgical:antiplatelet:conservative = 7:12:7; p = 0.317), and 3 patients (1.8%) died of cerebral hemorrhage (surgical:antiplatelet:conservative = 1:2:0; p = 0.361). The survival curve showed that the risk of further cerebral ischemic attacks was lowest with surgical revascularization, while antiplatelet therapy was statistically significant for preventing recurrent risks compared with conservative treatment (χ2 = 8.987; p = 0.011). No significant difference was found in the functional status and bleeding events. The LASSO-Cox regression model revealed that a family history of MMD (HR = 6.93; 95% CI: 1.28–37.52; p = 0.025), a past history of stroke or transient ischemic attack (HR = 4.35; 95% CI: 1.09–17.33; p = 0.037), and treatment (HR = 0.05; 95% CI: 0.01–0.32; p = 0.001) were significantly related to the risk of recurrent strokes.Conclusions: Antiplatelet agents were effective and safe in preventing further cerebral ischemic attacks in adult patients with ischemic MMD. They may be a replacement therapy for patients with surgical contraindications and for patients prior to revascularization.

Spatially separate cerebral infarction in the posterior cerebral artery territory after combined revascularization of the middle cerebral artery territory in an adult patient with moyamoya disease and fetal-type posterior communicating artery: illustrative case

“…23 However, a large-scale study has confirmed the effectiveness of aspirin in preventing further ischemic attacks after adult ischemic MMD. 24 There have also been a few reports testing the outcomes of perioperative aspirin administration. [25][26][27] Rashad et al 26 reported that strict blood pressure control and aspirin administration can reduce the potential risk of surgical complications in combined revascularization for pediatric patients with MMD.…”

Case report: Moyamoya disease, the culprit in an adult female presenting with left sided numbness

“…Surgical intervention was superior as it had the longest interval period between further strokes and it reduced the rate of further cerebral ischemic events (1.9%) compared to the antiplatelet therapy group (5.7%) and the conservative management group (15.1%). [13] A large Korean national retrospective cohort study observed patients with MMD from 2002 to 2016 and it showed strong evidence that the use of antiplatelet therapy decreased mortality by two thirds in those patients compared to non-antiplatelet use. [14] In this case, the radiographic imaging combined with the clinical presentation of the patient supports the diagnosis of Moyamoya disease.…”

Development and Validation of a Nomogram to Predict the Individual Future Stroke Risk for Adult Patients With Moyamoya Disease: A Multicenter Retrospective Cohort Study in China

“…With regard to hemorrhagictype MMD, surgical revascularization is employed to prevent recurrent stroke and improve neurological dysfunctions (10)(11)(12)(13). For ischemic-type MMD, antiplatelet therapy is inferior to surgical revascularization while superior to conservative management for changing the blood supply and preventing future stroke events (37). Revascularization surgery is capable of reducing the recurrence of future stroke for patient with hemorrhagic MMD, but it has not shown an advantage over conservative treatment for patients with ischemic MMD (14,38).…”