title: Down syndrome and moyamoya: clinical presentation and surgical management.
abstract: OBJECT Moyamoya can cause cerebral ischemia and stroke in Down syndrome (DS) patients. In this study, the authors defined a surgically treated population of patients with DS and moyamoya and compared their clinical presentation, response to surgical treatment, and long-term prognosis with those of the general population of patients with moyamoya but without DS. METHODS This study was a retrospective review of a consecutive operative series of moyamoya patients with DS treated at Boston Children's Hospital from 1985 through 2012. RESULTS Thirty-two patients, average age 9.7 years (range 1.8-29.3 years), underwent surgery for moyamoya in association with DS. The majority presented with ischemic symptoms (87% stroke, 42% transient ischemic attacks). Twenty-four patients (75%) had congenital heart disease. Nineteen patients (59%) had bilateral moyamoya on presentation, and 13 presented with unilateral disease, of which 2 progressed to surgery on the opposite side at a later date. Patients were followed for a median of 7.5 years (1-20.2 years) after surgery, with no patients lost to follow-up. Follow-up arteriography demonstrated Matsushima Grade A collaterals in 29 of 39 (74%) hemispheres, Grade B in 5 (13%), and Grade C in 5 (13%). Complications included postoperative strokes in 2 patients, which occurred within 48 hours of surgery in both; one of these patients had arm weakness and the other confusion (both had recovered completely at follow-up). Seizures occurred in 5 patients perioperatively, including one who had a new seizure disorder related to hypocalcemia. CONCLUSIONS Moyamoya disease is a cause of stroke in patients with DS. Both the incidence of preoperative stroke (87% vs 67%) and the average age at diagnosis for children under age 21 (8.4 vs 6.5 years) were greater in patients with DS and moyamoya than in the general moyamoya surgical population, suggesting a possible delay in reaching a correct diagnosis of the cause of cerebral ischemia in the DS patient population. Pial synangiosis provided long-term protection from stroke in all patients treated.
authors.affiliation: Departments of 1 Neurological Surgery and.
authors.forename: Alfred P
authors.initials: AP
authors.lastname: See
authors.affiliation: Departments of 1 Neurological Surgery and.
authors.forename: Alexander E
authors.initials: AE
authors.lastname: Ropper
authors.affiliation: Departments of 1 Neurological Surgery and.
authors.forename: Daniel L
authors.initials: DL
authors.lastname: Underberg
authors.affiliation: Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
authors.forename: Richard L
authors.initials: RL
authors.lastname: Robertson
authors.affiliation: Departments of 1 Neurological Surgery and.
authors.forename: R Michael
authors.initials: RM
authors.lastname: Scott
authors.affiliation: Departments of 1 Neurological Surgery and.
authors.forename: Edward R
authors.initials: ER
authors.lastname: Smith
mesh_terms: D000293:Adolescent; D000328:Adult; D001900:Boston; D002533:Cerebral Angiography; D002648:Child; D002675:Child, Preschool; D057210:Delayed Diagnosis; D004314:Down Syndrome / Q000150:complications*; D005260:Female; D006801:Humans; D007223:Infant; D002546:Ischemic Attack, Transient / Q000209:etiology* / Q000517:prevention & control*; D008297:Male; D008499:Medical Records; D009072:Moyamoya Disease / Q000150:complications / Q000175:diagnosis* / Q000473:pathology / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000379:methods; D010841:Pia Mater / Q000098:blood supply; D012189:Retrospective Studies; D012640:Seizures / Q000209:etiology; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods; D055815:Young Adult
keywords: DS = Down syndrome; DSA = digital subtraction angiography; Down syndrome; MRA = MR angiography; TIA = transient ischemic attack; mRS = modified Rankin Scale; moyamoya; pial synangiosis; revascularization; stroke; vascular disorders