title: Encephaloduroarteriosynangiosis and encephalomyoarteriosynangiosis for treatment of moyamoya syndrome in pediatric patients with sickle cell disease.
abstract: OBJECT Pediatric patients with sickle cell disease (SCD) and moyamoya syndrome (MMS) are at significant risk for cerebrovascular accidents despite chronic transfusion therapy. Encephaloduroarteriosynangiosis (EDAS) and encephalomyoarteriosynangiosis (EMAS) are additional therapeutic options for these patients. To date, the incidence of complications after and efficacy of EDAS and EMAS in stroke prevention in this population have been described in several institutional case series reports, but no randomized prospective trials have been reported. METHODS The authors retrospectively reviewed the cases of all pediatric patients at the University of Alabama at Birmingham with a history of homozygous hemoglobin S (HbS) and sickle cell/β-thalassemia (SB0 thalassemia) and on chronic transfusion therapy, including 14 patients with MMS who underwent EDAS or EMAS. RESULTS Sixty-two patients with SCD and on chronic transfusion therapy were identified. After exclusion of patients on chronic transfusion therapy for indications other than stroke prevention, 48 patients (77.4%) remained. Of those patients, 14 (29.1%) underwent EDAS or EMAS. Nine (18.8%) and 25 (52.1%) patients were on chronic transfusion therapy for primary or secondary stroke prevention, respectively, but did not undergo EDAS or EMAS. The 14 patients with SCD and radiological evidence of MMS and on chronic transfusion therapy for primary or secondary stroke prevention underwent 21 EDAS or EMAS procedures for progressive vascular disease (92.9% of patients), stroke (71.4%), and/or seizure (7.1%). The mean (± SD) time from initiation of chronic transfusion therapy to EDAS or EMAS was 76.8 ± 58.8 months. Complications included 1 perioperative stroke, 1 symptomatic subdural hygroma, 1 postoperative seizure, and 1 case of intraoperative cerebral edema that required subsequent cranioplasty. Before EDAS or EMAS, the stroke rate was calculated to be 1 stroke per 7.8 patient-years. One additional stroke occurred during the follow-up period (mean follow-up time 33.7 ± 19.6 months), resulting in a post-EDAS/EMAS stroke rate of 1 stroke per 39.3 patient-years, a 5-fold reduction compared with that in the pre-EDAS/EMAS period. The patients' mean pre-EDAS/EMAS HbS level of 29.5% ± 6.4% was comparable to the mean post-EDAS/EMAS HbS level of 25.5% ± 6.1% (p = 0.104). CONCLUSIONS The results of this retrospective case series in a large cohort of pediatric patients with SCD and MMS suggest that EDAS/EMAS provides a stroke-prevention benefit with an acceptably low morbidity rate. Given the combined experience with EDAS and EMAS for this indication at this and other institutions, a prospective clinical trial to assess their efficacy compared with that of chronic transfusion therapy alone is warranted.
authors.affiliation: Departments of 1 Neurosurgery and.
authors.forename: Christoph J
authors.initials: CJ
authors.lastname: Griessenauer
authors.affiliation: Pediatric Hematology Oncology, University of Alabama at Birmingham, Alabama; and.
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Lebensburger
authors.affiliation: Harvard Medical School, Boston, Massachusetts.
authors.forename: Michelle H
authors.initials: MH
authors.lastname: Chua
authors.affiliation: Departments of 1 Neurosurgery and.
authors.forename: Winfield S
authors.initials: WS
authors.lastname: Fisher
authors.affiliation: Pediatric Hematology Oncology, University of Alabama at Birmingham, Alabama; and.
authors.forename: Lee
authors.initials: L
authors.lastname: Hilliard
authors.affiliation: Pediatric Hematology Oncology, University of Alabama at Birmingham, Alabama; and.
authors.forename: Christina J
authors.initials: CJ
authors.lastname: Bemrich-Stolz
authors.affiliation: Pediatric Hematology Oncology, University of Alabama at Birmingham, Alabama; and.
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Howard
authors.affiliation: Departments of 1 Neurosurgery and.
authors.forename: James M
authors.initials: JM
authors.lastname: Johnston
mesh_terms: D000293:Adolescent; D000407:Alabama; D000755:Anemia, Sickle Cell / Q000150:complications*; D001803:Blood Transfusion; D002545:Brain Ischemia / Q000209:etiology / Q000517:prevention & control; D002533:Cerebral Angiography; D002548:Cerebral Revascularization / Q000379:methods*; D002560:Cerebrovascular Circulation; D002648:Child; D002675:Child, Preschool; D005260:Female; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008499:Medical Records; D009072:Moyamoya Disease / Q000150:complications / Q000175:diagnosis* / Q000601:surgery*; D055502:Secondary Prevention; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D065227:Transfusion Reaction; D016896:Treatment Outcome; D055815:Young Adult; D017086:beta-Thalassemia / Q000150:complications*
keywords: DSA = digital subtraction angiography; EDAS = encephaloduroarteriosynangiosis; EMAS = encephalomyoarteriosynangiosis; Hb = hemoglobin; HbS = hemoglobin S; ICA = internal carotid artery; MCA = middle cerebral artery; MMS = moyamoya syndrome; MRA = MR angiography; SCD = sickle cell disease; TCD = transcranial Doppler; moyamoya syndrome; sickle cell disease; vascular disorders