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NEUROIMAGING
Year : 2016  |  Volume : 11  |  Issue : 4  |  Page : 382-383
 

Moyamoya disease involving anterior and posterior circulation


Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication3-Feb-2017

Correspondence Address:
Rajesh Verma
Department of Neurology, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1817-1745.199470

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How to cite this article:
Verma R, Panwar A, Nagar K. Moyamoya disease involving anterior and posterior circulation. J Pediatr Neurosci 2016;11:382-3

How to cite this URL:
Verma R, Panwar A, Nagar K. Moyamoya disease involving anterior and posterior circulation. J Pediatr Neurosci [serial online] 2016 [cited 2017 Sep 21];11:382-3. Available from: http://www.pediatricneurosciences.com/text.asp?2016/11/4/382/199470


A 6-year-old female presented with sudden-onset right-sided hemiparesis with motor aphasia for the past 7 days. Magnetic resonance imaging of the brain [Figure 1]a revealed acute infarct in the left parietooccipital region. Magnetic resonance angiogram (MRA) [Figure 1]b and computed tomography angiogram (CTA) [Figure 2] showed narrowing of bilateral supraclinoid internal carotid arteries (ICAs), nonvisualization of bilateral middle cerebral arteries and distal part of posterior cerebral arteries (PCAs) along with extensive collateralization of vessels, creating a “puff of smoke” appearance, diagnostic of moyamoya disease.
Figure 1: Magnetic resonance imaging of the brain diff usion-weighted image (a) showed diff usion restriction in the left parietooccipital region, which was suggestive of acute infarct. Magnetic resonance angiogram of the intracranial vessels (b) revealed narrowing of bilateral supraclinoid internal carotid arteries, nonvisualization of bilateral middle cerebral arteries and distal part of posterior cerebral arteries along with extensive collateralization of vessels, creating a “puff of smoke” appearance

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Figure 2: Computed tomography angiography of the brain revealed extensive collateralization of vessels involving the arteries of anterior and posterior circulation, creating a classical “puff of smoke” appearance, diagnostic of moyamoya disease

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Moyamoya disease is characterized by progressive stenosis of the intracranial ICAs and their proximal branches. This results in the limited supply of blood flow in the major vessels of anterior circulation, which consecutively leads to the development of collateral circulation, by the small vessels. The posterior circulation involvement in moyamoya disease has not been well studied.[1] This process may rarely involve posterior circulation also, including the basilar cerebral arteries and PCAs.[2] The PCA if involved mainly affects the distal portion.[3] This is because of posterior circulation behaves as collateral pathway for maintenance of the circulation. The posterior circulation involvement is an adverse prognostic factor for outcome in moyamoya disease.[4] A study from India reported the absence of posterior circulation involvement in case series of 44 patients.[5] The ischemic episodes are rare in the posterior circulation territory till the late phase in moyamoya disease.[6] Development of extensive collateral vasculature results in the angiographic appearance of “puff of smoke” which is considered as a hallmark of the disease. The MRA and CTA images shown here depict the classical “puff of smoke” appearance and thus will serve as an excellent learning resource for medical graduates and postgraduates to understand the basic pathophysiology of the disease.

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Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Jayakumar PN, Vasudev MK, Srikanth SG. Posterior circulation abnormalities in moyamoya disease: A radiological study. Neurol India 1999;47:112-7.  Back to cited text no. 1
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2.
Scott RM, Smith ER. Moyamoya disease and moyamoya syndrome. N Engl J Med 2009;360:1226-37.  Back to cited text no. 2
    
3.
Chinchure SD, Pendharkar HS, Gupta AK, Bodhey N, Harsha KJ. Adult onset moyamoya disease: Institutional experience. Neurol India 2011;59:733-8.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Miyamoto S, Kikuchi H, Karasawa J, Nagata I, Ihara I, Yamagata S. Study of the posterior circulation in moyamoya disease. Part 2: Visual disturbances and surgical treatment. J Neurosurg 1986;65:454-60.  Back to cited text no. 4
    
5.
Garg AK, Suri A, Sharma BS. Ten-year experience of 44 patients with moyamoya disease from a single institution. J Clin Neurosci 2010;17:460-3.  Back to cited text no. 5
    
6.
Singhi P, Choudhary A, Khandelwal N. Pediatric moyamoya disease: Clinical profile, literature review and sixteen year experience from a tertiary care teaching institute. Indian J Pediatr 2013;80:1015-20.  Back to cited text no. 6
    


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