Abstract
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.
Highlights
Moyamoya disease is a rare progressive condition with narrowing and occlusion of internal carotid artery (ICA) terminal ends [1]
We present a case of a 58-year-old man with delayed diagnosed moyamoya disease who underwent successful EDAS procedure with good neurological outcomes
Moyamoya disease is a progressive, chronic neurovascular disorder characterized by the narrowing and occlusion of the ICA terminal branches [4,5]
Summary
Moyamoya disease is a rare progressive condition with narrowing and occlusion of internal carotid artery (ICA) terminal ends [1]. A 58-year-old Hispanic man with a history of coronary artery disease and three episodes of strokes with residual left upper and lower extremity weakness presented to our facility with a new onset left-sided facial droop. He reported facial numbness, dysarthria, and blurred vision. Superficial temporal artery (STA)-MCA vascular bypass was not an option due to the lack of right MCA patency The frontal branch of the STA was bipolared and cut At this point, the STA was completely free superiorly and inferiorly with good Doppler signals superiorly and inferiorly. Followup of nine months later revealed no evidence of new stroke recurrence
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