Moyamoya disease

Diagnosis

To diagnose moyamoya disease, your doctor will review your symptoms and your family and medical history. Your doctor will perform a physical examination and may order several tests to diagnose moyamoya disease and any underlying conditions.

Tests may include:

• Magnetic resonance imaging (MRI). An MRI uses powerful magnets and radio waves to create detailed images of your brain. Your doctor may inject a dye into a blood vessel to view your arteries and veins and highlight blood circulation (magnetic resonance angiogram). Your doctor may recommend a perfusion MRI if available. This type of imaging can measure the amount of blood passing through the vessels.
• Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create a detailed image of your brain. Your doctor may inject a dye into a blood vessel to highlight blood flow in your arteries and veins (CT angiogram).
• Cerebral angiogram. During a cerebral angiogram, your doctor inserts a long, thin tube (catheter) into a blood vessel in your groin and guides it to your brain using X-ray imaging. Your doctor then injects dye through the catheter into the blood vessels of your brain to make them visible under X-ray imaging.
• Transcranial Doppler ultrasound. In a transcranial Doppler ultrasound, sound waves are used to obtain images of your brain. Doctors may use this test to obtain information about the blood vessels in the brain.
• Positron emission tomography (PET) scan or single-photon emission computerized tomography (SPECT). In these tests, your doctor injects you with a small amount of a safe radioactive material and places emission detectors over your brain. PET provides visual images of brain activity. SPECT measures blood flow to various regions of your brain.
• Electroencephalogram (EEG). An EEG monitors the electrical activity in your brain via a series of electrodes attached to your scalp. Children with moyamoya disease often exhibit abnormalities on EEG.

If necessary, your doctor may order other tests to rule out other conditions.

Treatment

Doctors will evaluate your condition and determine the most appropriate treatment for your condition. The goal of treatment is to reduce your symptoms, improve your blood flow, and lower your risk of serious complications such as an ischemic stroke caused by a lack of blood flow, bleeding in your brain (intracerebral hemorrhages) or death.

Your treatment may include:

Medication

Medications may be prescribed to reduce the risk of stroke or to aid in seizure control, including:

• Blood thinners. After you're diagnosed with moyamoya disease, if you have mild or no symptoms at first, then your doctor may recommend that you take aspirin or another blood thinner to prevent strokes.
• Calcium channel blockers. Also known as calcium antagonists, this type of medication may improve symptoms of headache and possibly reduce symptoms related to transient ischemic attacks.
• Anti-seizure medications. These may be prescribed if you or your child has an accompanying seizure disorder.

Revascularization surgery

If your symptoms become worse or if tests show evidence of low blood flow, your doctor may recommend revascularization surgery.

In revascularization surgery, surgeons bypass blocked arteries to help restore blood flow to your brain. Your doctor may use direct or indirect revascularization procedures, or a combination of both.

• Direct revascularization procedures. In direct revascularization surgery, surgeons stitch (suture) the scalp artery directly to a brain artery (superficial temporal artery to middle cerebral artery bypass surgery) to increase blood flow to your brain immediately.

  Direct bypass surgery may be difficult to perform in children due to the size of the blood vessels to be attached.

  Direct revascularization surgery has a risk of complications, including stroke.

• Indirect revascularization procedures. In indirect revascularization, the goal is to increase blood flow to your brain gradually over time. Indirect revascularization may be somewhat lower risk than direct revascularization.

  Types of indirect revascularization procedures include encephaloduroarteriosynangiosis (EDAS) or encephalomyosynangiosis (EMS), or a combination of both.

  In encephaloduroarteriosynangiosis (EDAS), your surgeon separates (dissects) a scalp artery over several inches.

  Your surgeon makes a small temporary opening in your skull directly beneath the artery and attaches (sutures) the intact scalp artery to the surface of your brain, which allows blood vessels from the artery to grow into your brain over time. The surgeon then replaces the bone and closes the opening in your skull.

  In encephalomyosynangiosis (EMS), your surgeon separates (dissects) a muscle in the temple region of your forehead and places it onto the surface of your brain through an opening in your skull to help restore blood flow.

  Your surgeon may perform EMS with EDAS. In this procedure, your surgeon separates (dissects) a muscle in the temple region of your forehead and places it onto the surface of your brain after attaching the scalp artery to the surface of your brain. The muscle helps to hold the artery in place as blood vessels grow into your brain over time.

  Your surgeon may remove a portion of a fatty layer of tissue from the abdominal area, place it onto the surface of your brain and attach the scalp artery to the blood vessel of the fatty layer (omental transplant). This procedure may restore blood flow to your brain.

  Your surgeon may make multiple holes (burr holes) in your skull to allow new blood vessels to grow, either as a separate procedure or in combination with other procedures.

Some people with moyamoya disease develop a bulge or ballooning of a blood vessel in the brain known as a brain aneurysm. If this occurs, surgery may be necessary to prevent or treat a ruptured brain aneurysm.

Therapy

To address the physical and mental effects of stroke on you or your child, your doctor may recommend other therapies. Physical and occupational therapy can help regain any lost physical function caused by stroke. Cognitive behavioral therapy can help address emotional issues related to having moyamoya disease, such as how to cope with fears and uncertainties about future stroke.

Preparing for your appointment

If you or your child has been diagnosed with moyamoya disease, you'll most likely be referred to a doctor who specializes in brain conditions (neurologist). You can prepare to discuss the subject with your doctor at your next appointment.

What you can do

• Write down any symptoms you or your child has experienced. Include any that may seem unrelated to the reason you scheduled the appointment.
• Make a list of all medications. Include vitamins and supplements you or your child is taking, including dosages. Write down the reasons any were discontinued, whether because of side effects or lack of effectiveness.
• Ask a family member to come with you to the doctor. Sometimes it can be difficult to remember all the information provided during an appointment. Someone who goes with you may remember something you missed or forgot.
• Write down questions. Preparing a list of questions for your doctor will help you make the most of your time together.

Some basic questions to ask include:

• What is likely causing my or my child's symptoms or condition?
• What kinds of tests are necessary? Do they require any special preparation?
• What treatments are available, and which do you recommend?
• What types of side effects can be expected from treatment?
• Is surgery a possibility?
• Are you prescribing medication? If so, is there a generic alternative?
• My child has other medical problems. How can they be managed together?
• Will I or my child have any restrictions on physical activity?
• Are there brochures or other printed materials that I can take with me? What websites do you recommend?

What to expect from your doctor

Your doctor is likely to ask you or your child a number of questions, such as:

• When did symptoms first occur?
• How often do the symptoms occur?
• Do certain activities trigger symptoms?
• Has anyone in your immediate family ever had moyamoya disease?