Moyamoya disease (MMD) is a progressive cerebrovascular disease with unknown etiology, characterized by bilateral stenoocclusive changes at the terminal portion of the internal carotid artery and an abnormal vascular network formation at the base of the brain. MMD has an intrinsic nature to convert the vascular supply for the brain from internal carotid (IC) system to the external carotid (EC) system, as indicated by Suzuki’s angiographic staging. Insufficiency of this ‘IC-EC conversion system’ could result not only in cerebral ischemia, but also in intracranial hemorrhage from inadequate collateral anastomosis, both of which represent the clinical manifestation of MMD. Surgical revascularization prevents cerebral ischemic attack by improving cerebral blood flow, and recent evidence further suggests that extracranial-intracranial bypass could powerfully reduce the risk of re-bleeding in MMD patients with posterior hemorrhage, who were known to have extremely high re-bleeding risk. Although the exact mechanism underlying the hemorrhagic presentation in MMD is undetermined, most recent angiographic analysis revealed the characteristic angio-architecture related to high re-bleeding risk, such as the extension and dilatation of choroidal collaterals and posterior cerebral artery involvement. We sought to update the current management strategy for hemorrhagic MMD, including the outcome of surgical revascularization for hemorrhagic MMD in our institute. Further investigations will clarify the optimal surgical strategy to prevent hemorrhagic manifestation in patients with MMD.
Angiography ; Brain ; Brain Ischemia ; Carotid Artery, Internal ; Cerebrovascular Circulation ; Cerebrovascular Disorders ; Choroid ; Dilatation ; Hemorrhage ; Humans ; Intracranial Hemorrhages ; Moyamoya Disease ; Posterior Cerebral Artery

Moyamoya disease (MMD) is a rare and progressive cerebrovascular disorder characterized by stenosis or occlusion of the internal carotid arteries resulting in the development of fragile collateral vessels at the base of the brain. Surgical revascularization is the primary treatment option for preventing ischemic and hemorrhagic events; however, the role of medical management has become increasingly recognized, particularly in cases involving asymptomatic patients or those at a high risk for surgical complications. In this review, we aimed to investigate the current guidelines and evidence supporting various medical management strategies for MMD, including the importance of controlling risk factors and judicious use of antithrombotic therapy. Given the considerable variability in patient presentation, such as age of onset, symptomatology, and comorbid conditions, it is crucial to adopt tailored therapeutic approaches that address each patient’s unique characteristics. The existing literature on medical management is limited. However, individualized strategies may effectively mitigate the risk of ischemic events and improve the overall patient outcomes. Further research is essential to develop comprehensive and standardized treatment protocols for medical management of adult patients with MMD. In addition, ongoing trials and efforts to develop disease-modifying agents are discussed.

Moyamoya disease (MMD) is a rare and progressive cerebrovascular disorder characterized by stenosis or occlusion of the internal carotid arteries resulting in the development of fragile collateral vessels at the base of the brain. Surgical revascularization is the primary treatment option for preventing ischemic and hemorrhagic events; however, the role of medical management has become increasingly recognized, particularly in cases involving asymptomatic patients or those at a high risk for surgical complications. In this review, we aimed to investigate the current guidelines and evidence supporting various medical management strategies for MMD, including the importance of controlling risk factors and judicious use of antithrombotic therapy. Given the considerable variability in patient presentation, such as age of onset, symptomatology, and comorbid conditions, it is crucial to adopt tailored therapeutic approaches that address each patient’s unique characteristics. The existing literature on medical management is limited. However, individualized strategies may effectively mitigate the risk of ischemic events and improve the overall patient outcomes. Further research is essential to develop comprehensive and standardized treatment protocols for medical management of adult patients with MMD. In addition, ongoing trials and efforts to develop disease-modifying agents are discussed.

Moyamoya disease (MMD) is a rare and progressive cerebrovascular disorder characterized by stenosis or occlusion of the internal carotid arteries resulting in the development of fragile collateral vessels at the base of the brain. Surgical revascularization is the primary treatment option for preventing ischemic and hemorrhagic events; however, the role of medical management has become increasingly recognized, particularly in cases involving asymptomatic patients or those at a high risk for surgical complications. In this review, we aimed to investigate the current guidelines and evidence supporting various medical management strategies for MMD, including the importance of controlling risk factors and judicious use of antithrombotic therapy. Given the considerable variability in patient presentation, such as age of onset, symptomatology, and comorbid conditions, it is crucial to adopt tailored therapeutic approaches that address each patient’s unique characteristics. The existing literature on medical management is limited. However, individualized strategies may effectively mitigate the risk of ischemic events and improve the overall patient outcomes. Further research is essential to develop comprehensive and standardized treatment protocols for medical management of adult patients with MMD. In addition, ongoing trials and efforts to develop disease-modifying agents are discussed.

Moyamoya disease is characterized by a progressive stenosis at the terminal portion of the internal carotid artery and an abnormal vascular network at the base of the brain. Although its etiology is still unknown, recent genome-wide and locus-specific association studies identified RNF213 as an important susceptibility gene of moyamoya disease among East Asian population. A polymorphism in c.14576G>A in RNF213 was identified in 95% of familial patients with moyamoya disease and 79% of sporadic cases, and patients having this polymorphism were found to have significantly earlier disease onset and a more severe form of moyamoya disease, such as the presentation of cerebral infarction and posterior cerebral artery stenosis. The exact mechanism by which the RNF213 abnormality relates to moyamoya disease remains unknown, while recent reports using genetically engineered mice lacking RNF213 by homologous recombination provide new insight for the pathogenesis of this rare entity. Regarding biomarkers of moyamoya disease, moyamoya disease is characterized by an increased expression of angiogenic factors and pro-inflammatory molecules such as vascular endothelial growth factors and matrix metalloproteinase-9, which may partly explain its clinical manifestations of the pathologic angiogenesis, spontaneous hemorrhage, and higher incidence of cerebral hyperperfusion after revascularization surgery. More recently, blockade of these pro-inflammatory molecules during perioperative period is attempted to reduce the potential risk of surgical complication including cerebral hyperperfusion syndrome. In this review article, we focus on the genetics and biomarkers of moyamoya disease, and sought to discuss their clinical implication.
Angiogenesis Inducing Agents ; Animals ; Asian Continental Ancestry Group ; Biomarkers* ; Brain ; Carotid Artery, Internal ; Cerebral Infarction ; Constriction, Pathologic ; Genetics* ; Hemorrhage ; Homologous Recombination ; Humans ; Incidence ; Matrix Metalloproteinase 9 ; Mice ; Moyamoya Disease* ; Neovascularization, Pathologic ; Perioperative Period ; Posterior Cerebral Artery ; Vascular Endothelial Growth Factor A ; Vascular Endothelial Growth Factors

Moyamoya disease (MMD) is a unique cerebrovascular disease characterized by the progressive stenosis of large intracranial arteries and a hazy network of basal collaterals called moyamoya vessels. Because the etiology of MMD is unknown, its diagnosis is based on characteristic angiographic findings. Re-vascularization techniques (e.g., bypass surgery) are used to restore perfusion, and are the primary treatment for MMD. There is no specific treatment to prevent MMD progression. This review summarizes the recent advances in MMD pathophysiology, including the genetic and circulating factors related to disease development. Genetic and environmental factors may play important roles in the development of the vascular stenosis and aberrant angiogenesis in complex ways. These factors include the related changes in circulating endothelial/smooth muscle progenitor cells, cytokines related to vascular remodeling and angiogenesis, and endothelium, such as caveolin which is a plasma membrane protein. With a better understanding of MMD pathophysiology, nonsurgical approaches targeting MMD pathogenesis may be available to stop or slow the progression of this disease. The possible strategies include targeting growth factors, retinoic acid, caveolin-1, and stem cells.
Arteries ; Caveolin 1 ; Cell Membrane ; Constriction, Pathologic ; Cytokines ; Diagnosis ; Endothelium ; Intercellular Signaling Peptides and Proteins ; Moyamoya Disease* ; Perfusion ; Stem Cells ; Tretinoin

Moyamoya disease (MMD) is a unique cerebrovascular disease characterized by the progressive stenosis of large intracranial arteries and a hazy network of basal collaterals called moyamoya vessels. Because the etiology of MMD is unknown, its diagnosis is based on characteristic angiographic findings. Re-vascularization techniques (e.g., bypass surgery) are used to restore perfusion, and are the primary treatment for MMD. There is no specific treatment to prevent MMD progression. This review summarizes the recent advances in MMD pathophysiology, including the genetic and circulating factors related to disease development. Genetic and environmental factors may play important roles in the development of the vascular stenosis and aberrant angiogenesis in complex ways. These factors include the related changes in circulating endothelial/smooth muscle progenitor cells, cytokines related to vascular remodeling and angiogenesis, and endothelium, such as caveolin which is a plasma membrane protein. With a better understanding of MMD pathophysiology, nonsurgical approaches targeting MMD pathogenesis may be available to stop or slow the progression of this disease. The possible strategies include targeting growth factors, retinoic acid, caveolin-1, and stem cells.
Arteries ; Caveolin 1 ; Cell Membrane ; Constriction, Pathologic ; Cytokines ; Diagnosis ; Endothelium ; Intercellular Signaling Peptides and Proteins ; Moyamoya Disease* ; Perfusion ; Stem Cells ; Tretinoin