Ischaemic stroke after acute intracranial haemorrhage in patients with moyamoya disease: six new cases and a short literature review

Abstract

We report six new cases of ischaemic stroke after cerebral haemorrhage in patients with moyamoya disease (MMD) and analyse their clinical and radiological characteristics, together with cases reported in the literature, to deduce the mechanism of cerebral infarct. Six (2%) of 246 patients with MMD who were admitted to our hospitals between 1993 and 2009 suffered cerebral infarct after intracranial haemorrhage. Ten patients identified in the literature with the PubMed search engine were also included in this study. All the ischaemic lesions in these 16 patients were analysed according to their location, size, and number and were compared according to the spatial relationship between the haemorrhage and infarct, as follows: (1) anterior vs posterior involvement, (2) cortical vs subcortical involvement, (3) watershed vs non-watershed infarct, (4) small vs large infarct, (5) single vs multiple infarct, and (6) adjacent vs distant involvement. Acute synchronous multiple brain infarcts occurred in six (38%) patients and recurrent infarcts in three patients (19%). Cerebral infarcts had mainly cortical (72%), anterior (66%), and distant involvement (75%) and were large (69%) and non-watershed (66%). Adjacent infarct had significantly anterior involvement (P < 0.05), and distant infarcts tended to have cortical involvement. Non-watershed infarcts had significantly cortical involvement (P < 0.05). Watershed infarcts tended to be large. Vasospasm was confirmed either pathologically or angiographically in two patients with large cerebral infarcts. We suggest that thromboembolism or vasospasm plays a crucial role in the pathogenesis of cerebral infarction after acute intracranial haemorrhage in patients with MMD.