Mohammadi Oranus, Krieger David, Butt Ifrah, Danckers Mauricio
Internal Medicine, Aventura Hospital and Medical Center, Aventura, USA.
Neurosurgery, Aventura Hospital and Medical Center, Aventura, USA.
Cureus. 2019 Dec 22;11(12):e6446. doi: 10.7759/cureus.6446.
We present a case of a 58-year-old man with delayed diagnosed moyamoya disease who underwent encephaloduroarteriosynangiosis (EDAS) procedure. This patient with a history of three strokes presented to our facility with new left facial droop. Neurological examination revealed left facial droop and hemiparesis. Brain magnetic resonance imaging (MRI) described right frontal lobe acute ischemia. Head computed tomography (CT) angiography revealed bilateral supraclinoid internal carotid artery (ICA) occlusions. Cerebral angiography demonstrated diffuse intracranial vascular irregularity with stenosis, more above the bilateral supraclinoid ICAs and the right middle cerebral artery (MCA) suggestive of moyamoya disease. Due to the lack of MCA patency, he underwent EDAS. Superficial temporal artery (STA) was dissected inferiorly and the posterior branch was bipolared, then STA was movable. A bur hole made at the superior and inferior portion along the STA. Dura was opened, and STA was brought on top of the pia. His facial droop gradually improved after that. Nine months later, no new strokes reported. Moyamoya disease is a rare neurovascular disorder characterized by narrowing and occlusion of the ICA branches. Its symptoms include recurrent ischemic/hemorrhagic strokes. Incidence in Hispanics has not been studied. The gap between the first manifestations and disease progression is one to eight years. Its diagnosis is often delayed. Our patient had recurrent strokes for five years. Despite therapy with antiplatelets, new ischemic stroke brought him to our institution. Rate of recurrent strokes despite antiplatelets was reported 10.3% per year. Brain CTs and MRIs had failed to detect strokes' etiology. Catheter-directed angiography is the gold standard test for diagnosis of moyamoya disease. Antiplatelet alone is ineffective and surgery is the effective method to prevent further strokes, although there are no studies in adults regarding the efficacy of indirect revascularization. In direct revascularization, usually STA anastomoses to MCA. Indirect method works through the development of leptomeningeal collaterals. Postoperative complications are infarction and hyperperfusion syndrome. Seong-eun et al. proposed that modified EDAS is simpler with less complications in comparison with direct revascularization. Some other studies showed higher chance of stroke in indirect method versus direct technique. In conclusion, it is important to consider moyamoya disease as a differential diagnosis in patients with recurrent strokes.
我们报告一例58岁男性迟发性烟雾病患者，该患者接受了脑-硬脑膜-动脉血管融通术（EDAS）。该患者有三次中风病史，因新发左侧面部下垂前来我院就诊。神经系统检查发现左侧面部下垂和偏瘫。脑部磁共振成像（MRI）显示右额叶急性缺血。头部计算机断层扫描（CT）血管造影显示双侧床突上段颈内动脉（ICA）闭塞。脑血管造影显示颅内血管弥漫性不规则并伴有狭窄，更多见于双侧床突上段ICA和右侧大脑中动脉（MCA），提示烟雾病。由于MCA无通畅性，他接受了EDAS。颞浅动脉（STA）向下解剖，后支进行双极电凝，然后STA可移动。沿STA在上下部制作骨孔。打开硬脑膜，将STA置于软脑膜上方。此后他的面部下垂逐渐改善。九个月后，未报告新的中风。烟雾病是一种罕见的神经血管疾病，其特征是ICA分支狭窄和闭塞。其症状包括反复缺血性/出血性中风。西班牙裔人群中的发病率尚未研究。首次出现症状与疾病进展之间的间隔为1至8年。其诊断往往延迟。我们的患者反复中风五年。尽管接受了抗血小板治疗，但新发缺血性中风仍使他前来我院。据报道，尽管使用抗血小板药物，每年复发性中风的发生率为10.3%。脑部CT和MRI未能检测到中风的病因。导管导向血管造影是诊断烟雾病的金标准检查。单独使用抗血小板药物无效，手术是预防进一步中风的有效方法，尽管尚无关于成人间接血运重建疗效的研究。在直接血运重建中，通常将STA与MCA吻合。间接方法通过软脑膜侧支循环的形成起作用。术后并发症为梗死和高灌注综合征。Seong-eun等人提出，与直接血运重建相比，改良EDAS更简单，并发症更少。其他一些研究表明，间接方法与直接技术相比中风几率更高。总之，对于反复中风的患者，将烟雾病作为鉴别诊断很重要。
