Microembolic signals and antiplatelet therapy in Moyamoya angiopathy

Pompsch, Mosche; Veltkamp, Roland; Diehl, Rolf R.; Kraemer, Markus

doi:10.1007/s00415-022-11323-4

Cited by 6 publications

(5 citation statements)

References 33 publications

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“…119 One retrospective study in a small population of MMA observed a reduction of MES after antiplatelet administration or regimen change. 120 Direct embolism has been even also visualised during surgery in a MMA patient. 121 Evaluating the type of antiplatelet drugs, the most commonly used agents in the studies included in this analysis were aspirin, clopidogrel or cilostazol as monotherapy, with only a minority of patients receiving dual antiplatelet therapy.…”

Section: Resultsmentioning

confidence: 96%

European Stroke Organisation (ESO) Guidelines on Moyamoya angiopathy Endorsed by Vascular European Reference Network (VASCERN)

Bersano

Khan²,

Gimeno

et al. 2023

European Stroke Journal

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The European Stroke Organisation (ESO) guidelines on Moyamoya Angiopathy (MMA), developed according to ESO standard operating procedure and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, were compiled to assist clinicians in managing patients with MMA in their decision making. A working group involving neurologists, neurosurgeons, a geneticist and methodologists identified nine relevant clinical questions, performed systematic literature reviews and, whenever possible, meta-analyses. Quality assessment of the available evidence was made with specific recommendations. In the absence of sufficient evidence to provide recommendations, Expert Consensus Statements were formulated. Based on low quality evidence from one RCT, we recommend direct bypass surgery in adult patients with haemorrhagic presentation. For ischaemic adult patients and children, we suggest revascularization surgery using direct or combined technique rather than indirect, in the presence of haemodynamic impairment and with an interval of 6–12 weeks between the last cerebrovascular event and surgery. In the absence of robust trial, an Expert Consensus was reached recommending long-term antiplatelet therapy in non-haemorrhagic MMA, as it may reduce risk of embolic stroke. We also agreed on the utility of performing pre- and post- operative haemodynamic and posterior cerebral artery assessment. There were insufficient data to recommend systematic variant screening of RNF213 p.R4810K. Additionally, we suggest that long-term MMA neuroimaging follow up may guide therapeutic decision making by assessing the disease progression. We believe that this guideline, which is the first comprehensive European guideline on MMA management using GRADE methods will assist clinicians to choose the most effective management strategy for MMA.

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Section: Resultsmentioning

confidence: 96%

European Stroke Organisation (ESO) Guidelines on Moyamoya angiopathy Endorsed by Vascular European Reference Network (VASCERN)

Bersano

Khan²,

Gimeno

et al. 2023

European Stroke Journal

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“…Future prospective studies on larger patient populations with longer follow-up periods are warranted and will be undertaken by our group on the role of CVR together with the cerebral hemodynamic and energy metabolic radiological variables on the risks of future brain infarctions as well as deterioration in neurological, cognitive, and health-related quality of life. However, it must also be mentioned that mechanisms other than hemodynamic insufficiency contribute to stroke and neurological decline in MMD, including microthrombi and intracerebral hemorrhage ( 1 , 27 ).…”

Section: Discussionmentioning

confidence: 99%

“…When the CVR becomes negative and OEF is exhausted, CMRO 2 deteriorates and infarction takes place (stage III). However, it is important to emphasize that other mechanisms such as microthrombi and hemorrhage also contribute to stroke in MMD in addition to hemodynamic compromise due to vessel stenosis ( 1 , 27 ). ACA, anterior cerebral artery; CBF, cerebral blood flow;

, cerebral metabolic rate of oxygen; CTTH, capillary transit time heterogeneity; CVR, cerebrovascular reserve; ICA, internal carotid artery; MMD, moyamoya disease.…”

Section: Discussionmentioning

confidence: 99%

Cerebrovascular reserve in moyamoya disease: relation to cerebral blood flow, capillary dysfunction, oxygenation, and energy metabolism

et al. 2023

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BackgroundCerebral hemodynamics in moyamoya disease (MMD) is complex and needs further elucidation. The primary aim of the study was to determine the association of the cerebrovascular reserve (CVR) with cerebral blood flow (CBF) disturbances, oxygen extraction fraction (OEFmax), and energy metabolism (CMRO2max) in MMD, using arterial spin label magnetic resonance imaging (ASL-MRI) before and after acetazolamide administration.MethodsThirty-nine ASL-MRI scans with a concurrent acetazolamide challenge from 16 MMD patients at the Uppsala University Hospital, Sweden, 2016–2021, were retrospectively analyzed. CBF was assessed before and 5, 15, and 25 min after acetazolamide administration, and the maximal response CVRmax was used for further analyses. Dynamic susceptibility contrast (DSC) MRI was performed 30 min after acetazolamide injection, and the data were analyzed using the Cercare Medical Neurosuite to assess capillary transit time heterogeneity (CTTH; indicating microvascular function), OEFmax, and CMRO2max.ResultsIn the ACA territory, a lower CVRmax was associated with lower baseline CBF, higher CTTH, and higher OEFmax but not with CMRO2max in generalized estimating equation models. In the MCA territory, lower CVRmax was associated with lower baseline CBF and higher CMRO2max but not with CTTH and OEFmax..ConclusionAltogether, a compromised CVR in MMD patients reflected disturbances in macro-/microvascular blood flow, oxygenation, and CMRO2. ASL-MRI with acetazolamide challenge is a feasible and radiation-free alternative to positron emission tomography (PET) imaging in MMD.

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“…Furthermore, Jeon et al [ 20 ] identified that emboli, detected as high-intensity transient signals and distal to high-grade stenotic arteries, were etiological in recent cerebral infarctions. These revelations underscore that both hemodynamic impairment and thromboembolism are instrumental in cerebral infarction within MMD[ 21 ].…”

Section: Antithrombotic Management In MMDmentioning

confidence: 99%

Is medical management useful in Moyamoya disease?

Muengtaweepongsa,

Panpattanakul

2024

World J Clin Cases

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Moyamoya disease (MMD), characterized by progressive internal carotid artery stenosis and collateral vessel formation, prompts cerebral perfusion complications and is stratified into idiopathic and Moyamoya syndrome subtypes. A multifaceted approach toward MMD management addresses cerebral infarctions through revascularization surgery and adjunctive medical therapy, while also navigating risks such as intracranial hemorrhage and cerebral infarction resulting from arterial stenosis and fragile collateral vessels. Addressing antithrombotic management reveals a potential role for treatments like antiplatelet agents and anticoagulants, despite the ambiguous contribution of thrombosis to MMD-related infarctions and the critical balance between preventing ischemic events and averting hemorrhagic complications. Transcranial doppler has proven useful in thromboembolic detection, despite persisting challenges concerning the efficacy and safety of antithrombotic treatments. Furthermore, antihypertensive interventions aim to manage blood pressure meticulously, especially during intracerebral hemorrhage, with recommendations and protocols varying based on the patient’s hypertension status. Additionally, lipid-lowering therapeutic strategies, particularly employing statins, are appraised for their possible beneficial role in MMD management, even as comprehensive data from disease-specific clinical trials remains elusive. Comprehensive guidelines and protocols to navigate the multifaceted therapeutic avenues for MMD, while maintaining a delicate balance between efficacy and safety, warrant further meticulous research and development. This protocol manuscript seeks to elucidate the various aspects and challenges imbued in managing and navigating through the complex landscape of MMD treatment.

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Microembolic signals and antiplatelet therapy in Moyamoya angiopathy

Cited by 6 publications

References 33 publications

European Stroke Organisation (ESO) Guidelines on Moyamoya angiopathy Endorsed by Vascular European Reference Network (VASCERN)

European Stroke Organisation (ESO) Guidelines on Moyamoya angiopathy Endorsed by Vascular European Reference Network (VASCERN)

Cerebrovascular reserve in moyamoya disease: relation to cerebral blood flow, capillary dysfunction, oxygenation, and energy metabolism

Is medical management useful in Moyamoya disease?

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