The use of nitroglycerin for treatment of progressive moyamoya disease: A prospective pilot study of safety and efficacy

Abstract

No proven medical therapy exists for the treatment of moyamoya disease. Case reports have suggested that calcium channel blockers may be beneficial, potentially improving cerebral blood flow through a vasodilatory effect. The first objective of this pilot study was to prospectively evaluate whether intraarterial nitroglycerin, a potent vasodilator, could improve angiographic cerebral circulation in moyamoya patients. The second objective was to monitor the safety profile of transdermal nitroglycerin in our cohort of patients. Intraarterial nitroglycerin was infused in five patients with moyamoya disease at escalating doses. Angiography was performed before and after the nitroglycerin infusion. Pre- and post-infusion angiograms were compared for angiographic improvement. The contralateral side was used as an internal control in patients with unilateral moyamoya disease. The patients were then placed on a transdermal nitroglycerin patch and followed with serial neurological exams, blood pressure measurements, and either follow-up angiography or single photon emission computed tomography scans. All five patients had evidence of angiographic improvement after nitroglycerin infusion in the affected arteries, but no change was identified in the control arteries of patients with unilateral disease. No patient had adverse effects from either intraarterial or transdermal nitroglycerin. This small pilot study demonstrates angiographic improvement after intraarterial nitroglycerin in affected moyamoya arteries, but not in control arteries in the same patients, if present. There were no complications associated with transdermal nitroglycerin in these patients.