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Moyamoya disease concurrent with Graves’ disease treated by direct bypass: clinical features and treatment strategies

  • Clinical Article - Vascular
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Abstract

Background

Moyamoya disease (MMD) concurrent with Graves’ disease (GD) is rare. There is no guideline about optimizing thyroid hormones and the appropriate timing of surgical treatment for MMD with GD.

Methods

We encountered eight patients with MMD and GD presenting with cerebral ischemia who were treated by direct bypass. Thyroid hormones [free thyroxin (fT4) and free triiodothyronine (fT3)], thyroid-stimulating hormone (TSH), and TSH receptor antibody (TRAb) were measured sequentially. After thyrotoxic conditions were medically optimized, revascularization surgery was performed by superficial temporal artery-middle cerebral artery (STA-MCA) double bypass in all cases. Clinical outcomes were estimated by modified Rankin scale (mRS) at discharge and 3 months after surgery.

Results

In six patients with thyrotoxicosis, the fT4, fT3, and TRAb (range) at the onset of cerebral ischemia were 4.81–10.30 pg/ml, 13.08–31.90 pg/ml, and 3.5–83.8 IU/l, respectively. At surgery, mean (range) fT3 and fT4 were optimized to 3.02 (1.01–4.87) pg/ml and 1.09 (0.41–1.68) ng/dl, respectively. In the thyrotoxic cases, it took 70–310 days (mean, 142 days) to optimize thyroid hormones before surgery. There was no neurological aggravation after surgery, and outcome was excellent at 3 months with mRS scores ≤2 in all cases.

Conclusions

For MMD concurrent with GD, optimizing thyroid hormones followed by STA-MCA double bypass was successful to prevent cerebral ischemic events.

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Conflict of interest

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan

    Bikei Ryu, Takakazu Kawamata, Koji Yamaguchi, Masami Ono & Yoshikazu Okada

  2. Department of Medicine II, Tokyo Women’s Medical University, Tokyo, Japan

    Akitsugu Kawashima

Authors
  1. Bikei Ryu
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  2. Takakazu Kawamata
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  3. Koji Yamaguchi
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  4. Akitsugu Kawashima
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  5. Masami Ono
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  6. Yoshikazu Okada
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Corresponding author

Correspondence to Takakazu Kawamata.

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Comment

Ryu and colleagues report about eight patients with moyamoya disease concurrent with Graves’ disease, and treated by superficial temporal artery-middle cerebral artery bypass. Even though the combination of moyamoya disease and Graves’ disease is rare, it is worth keeping it in mind, since both have similar pathogeneses and there are important risks to be considered in the perioperative period. The present paper provides important and interesting information about clinical features and treatment strategies of this exceptional group of patients.

Marcus Reinges

Giessen, Germany

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Ryu, B., Kawamata, T., Yamaguchi, K. et al. Moyamoya disease concurrent with Graves’ disease treated by direct bypass: clinical features and treatment strategies. Acta Neurochir 157, 1095–1102 (2015). https://doi.org/10.1007/s00701-015-2422-8

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  • DOI: https://doi.org/10.1007/s00701-015-2422-8

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