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Objective: Moyamoya angiopathy (MA) is a rare cerebrovascular disorder characterized by recurrent ischemic/hemorrhagic strokes due to progressive occlusion of the intracranial carotid arteries. The lack of reliable disease severity biomarkers led us to investigate molecular features of a Caucasian cohort of MA patients. Methods: The participants consisted of 30 MA patients and 40 controls. We measured cerebrospinal fluid (CSF) levels of angiogenic/inflammatory factors (ELISA). We then applied quantitative real‐time PCR on cerebral artery specimens for expression analyses of angiogenic factors. By an immunoassay based on microfluidic technology, we examined the potential correlations between plasma protein expression and MA clinical progression. A RNA interference approach toward Ring Finger Protein 213 (RNF213) and a tube formation assay were applied in cellular model. Results: We detected a statistically significant (p < 0.000001) up‐regulation of Angiopoietin‐2 (Ang‐2) in CSF and stenotic middle cerebral arteries (RQ >2) of MA patients compared to controls. A high Ang‐2 plasma concentration (p = 0.018) was associated with unfavorable outcome in a subset of MA patients. ROC curve analyses indicated Ang‐2 as diagnostic CSF biomarker (>3741 pg/mL) and prognostic plasma biomarker (>1162 pg/mL), to distinguish stable‐from‐progressive MA. Consistently, MA cellular model showed a significant up‐regulation (RQ >2) of Ang‐2 in RNF213 silenced condition. Interpretation: Our results pointed out Ang‐2 as a reliable biomarker mirroring arterial steno‐occlusion and vascular instability of MA in CSF and blood, providing a candidate factor for patient stratification. This pilot study may pave the way to the validation of a biomarker to identify progressive MA patients deserving a specific treatment path. [ABSTRACT FROM AUTHOR]

Background: Little is known about internal carotid artery (ICA) hemodynamics in patients with moyamoya angiopathy (MMA) and its role in cerebrovascular events. Purpose: To characterize ICA hemodynamics in MMA patients by 4D flow MRI and investigate its relationship with cerebrovascular events. Study Type: Prospective. Subjects: Seventy MMA patients (50 years old ± 9, 30 males). Field Strength/Sequence: Time‐resolved three‐directional velocity encoded fast field echo sequence (4D flow) MRI, T1‐weighted fast field echo sequence, T2 weighted turbo spin echo sequence, diffusion weighted echo planar imaging; T2‐weighted fluid‐attenuated inversion recovery turbo spin echo sequence, susceptibility weighted fast field echo sequence, and time‐of‐flight MR angiography fast field echo sequence at 3.0T. Assessment: ICA hemodynamics (maximum and average velocity [Vmax, Vavg], average blood flow [Flowavg], and wall shear stress) were analyzed based on 4D flow data. Cerebral infarction, defined as the occurrence of events, in 124 brain hemispheres was determined according to clinical symptoms and conventional brain MR imaging. Statistical Tests: The independent‐samples T test was used to evaluate differences in ICA hemodynamics between infarcted and non‐infarcted hemispheres. Binary logistic regression was performed to investigate the relationship between ICA hemodynamics and events. A P value < 0.05 was considered statistically significant. Results: Sixty‐one infarcted hemispheres (eight hemispheres with acute ischemic damage, 30 with chronic ischemic damage, and 23 with chronic hemorrhagic damage) had cerebrovascular events and 63 non‐infarcted hemispheres did not. The hemodynamic parameters in the infarcted hemispheres (Vmax: P < 0.001; Vavg: P = 0.003; and Flowavg: P = 0.004) were significantly lower than those in the non‐infarcted hemispheres. However, Vmax (P = 0.052), Vavg (P = 0.107), and Flowavg (P = 0.074) were not significantly different among hemispheres with acute ischemic lesions, chronic ischemic lesions and chronic hemorrhagic lesions. Vmax (odds ratio 3.033, 95% CI: 1.075–8.562) was independently associated with cerebrovascular events. Data Conclusion: Vmax maybe a higher risk factor of cerebrovascular events in MMA patients. Evidence Level: 2 Technical Efficacy Stage: 3 [ABSTRACT FROM AUTHOR]

Background and Purpose: We report the results of intra‐arterial injection of lidocaine in the middle meningeal artery in patients with intractable headache or status migrainosus. Methods: We treated four patients with intra‐arterial lidocaine (2 mg/ml) in doses up to 50 mg in each middle meningeal artery via a microcatheter bilaterally (except in one patient). In two patients with intractable headache, the daily maximum intensity of headache (graded by 11‐point numeric rating scale) was recorded for 7 days postprocedure. In two patients with status migrainosus, migraine‐related disability 3 months prior and after treatment using MIDAS (Migraine Disability Assessment) questionnaire was recorded. Results: Intra‐arterial lidocaine reduced the headache intensity from 8/10 and 10/10 to 0/10 in the two patients with intractable headaches for 2 days (day 0 and day 1) postprocedure. Despite recurrence of headache on day 2, the intensity was less than preprocedure intensity up to the last day recorded (by 3 and 2 points on day 7). In the two patients with status migrainosus, there was immediate reduction in headache intensity following intra‐arterial lidocaine. The post treatment 3‐month MIDAS score was lower in both patients compared with pretreatment 3‐month score; 3 versus 30 and 55 versus 90. Severe disability preprocedure by MIDAS was reduced to little or no disability postprocedure in one patient. Conclusions: Intra‐arterial lidocaine resulted in amelioration of headache in patients with intractable headache and those with status migrainosus with improvement lasting longer than the short half‐life of lidocaine possibly related to central desensitization. [ABSTRACT FROM AUTHOR]

Objectives: There is a lack of evidence demonstrating the utility of computed tomography (CT) to predict chronic subdural hematoma (CSDH) clinical outcomes. We aim to analyze the role of tomographic volumetric analysis in patients with CSDH., Methods: We performed a retrospective study of patients undergoing burr-hole craniostomy (BHC) for CSDH over five years at a tertiary care center. Degree of midline shift, radiographic density, subdural hematoma volume, acute blood volume, and third ventricle (3VV) and fourth ventricle (4VV) volume were estimated using semiautomatic segmentation of preoperative CT. Postoperative functional outcome was measured by two endpoints: National Institute of Health Stroke Scale (NIHSS) at discharge and short-term modified Rankin Scale (mRS) at 6-week follow-up. Univariate and multivariate analyses were performed using nonparametric tests. Discriminative capacity and optimal thresholds of independent variables were calculated by means of receiving-operative curves (ROC)., Results: A total of 79 patients were included for analysis with a median age of 78.5 years. Greater preoperative 3VV independently correlated with poor discharge NIHSS (p = .01) and short-term mRS (p = .03). A cutoff value of 0.545 mL demonstrated the highest sensitivity (77.1%) and specificity (88.8%) with an odds ratio for an mRS functional dependence of 9.29 (p = .001)., Conclusions: Greater preoperative tomographic 3VV independently prognosticates poor discharge NIHSS and 6-week mRS. A threshold 3VV of 0.545 mL can be used to identify patients at higher risk of being dependent at first protocolized follow-up., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

We read with great interest the article by Ge I et al. i [[1]] regarding the angiographic characteristics of Moyamoya disease (MMD) with the p.R4810K variant. The presence of different collateral circulation stages on digital subtraction angiography (DSA) was the result of ischaemic stimulus during the progress of MMD. Thus, the basal MMD collaterals probably do not reflect the degree of vascularization in downstream tissue and illustrate the importance of being informed on the leptomeningeal collateralization status in addition to regional hemodynamics. [Extracted from the article]