title: Natural History and Risk Factor of Recurrent Hemorrhage in Hemorrhagic Adult Moyamoya Disease.
abstract: BACKGROUND
  Recurrent hemorrhage is a serious neurosurgical problem in adult moyamoya disease (MMD) patients.
  
  
  OBJECTIVE
  To find the natural history and risk factors of recurrent hemorrhage in cases of adult hemorrhagic MMD.
  
  
  METHODS
  One hundred seventy-six adult MMD patients presenting with hemorrhage were enrolled. Patients' medical records and radiological images were retrospectively reviewed. Clinical and radiological features of recurrent hemorrhage, and related risk factors were analyzed. Poor neurological outcome was defined as a score on the modified Rankin Scale of 4 to 6. The hemisphere in which the initial hemorrhage occurred was considered as the affected one. The mean follow-up duration was 83 months.
  
  
  RESULTS
  The overall estimated rate of recurrent hemorrhage was 16.9%/person (95% confidence interval, 11.3%-24.8%) at 5 years and 26.3%/person (95% confidence interval, 18.5%-36.4%) at 10 years after the initial episode of hemorrhage. The affected hemisphere showed a higher recurrent hemorrhagic rate (11.7% vs 8.3%/hemisphere at 5 years, P = .09) after conservative treatment. As a result of recurrent hemorrhages, the number of patients with poor neurological outcome increased (first episode: 13.8%, second: 37.5%, third: 40.0%, fourth: 100%). The presence of intraventricular hemorrhage ( P = .05, hazard ratio = 3.32) and bilateral MMD ( P = .05, hazard ratio = 4.15) had a marginal significance for recurrent hemorrhage. Eight ischemic strokes (4.5%) including 4 postoperative infarctions were identified, and all ischemic strokes were minor stroke.
  
  
  CONCLUSIONS
  During the follow-up period, recurrent hemorrhagic events continued to increase and deteriorated the patients' neurological conditions. The presence of intraventricular hemorrhage was a significant risk factor of recurrent hemorrhage.
authors.affiliation: Department of Neurosurgery, Kangwon National University Hospital, Chuncheon, Republic of Korea.
authors.forename: Kang Min
authors.initials: KM
authors.lastname: Kim
authors.affiliation: Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
authors.forename: Jeong Eun
authors.initials: JE
authors.lastname: Kim
authors.affiliation: Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
authors.forename: Won-Sang
authors.initials: WS
authors.lastname: Cho
authors.affiliation: Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
authors.forename: Hyun-Seung
authors.initials: HS
authors.lastname: Kang
authors.affiliation: Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
authors.forename: Young-Je
authors.initials: YJ
authors.lastname: Son
authors.affiliation: Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea.|Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea.
authors.forename: Moon Hee
authors.initials: MH
authors.lastname: Han
authors.forename: Chang Wan
authors.initials: CW
authors.lastname: Oh
mesh_terms: D000328:Adult; D002543:Cerebral Hemorrhage / Q000453:epidemiology / Q000209:etiology; D006801:Humans; D009072:Moyamoya Disease / Q000150:complications / Q000453:epidemiology; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors
keywords: Hemorrhage; Moyamoya disease; Natural history; Risk factors