Pregnancy after direct cerebral bypass for moyamoya disease

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  • 1 Department of Neurosurgery and Stanford Stroke Center,
  • 2 Quantitative Sciences Unit, and
  • 3 Department of Obstetrics and Gynecology, Maternal Fetal Medicine, Stanford University School of Medicine, Stanford, California
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OBJECTIVE

Moyamoya disease (MMD) disproportionately affects young to middle-aged women. The main treatment for this challenging disease is cerebral bypass surgery. Vascular neurosurgeons often need to counsel women regarding pregnancy following bypass for MMD, but there is a paucity of data. The authors set out to examine neurological and obstetric outcomes in an extensive cohort of MMD patients who had pregnancies following cerebral revascularization at the Stanford Medical Center.

METHODS

The authors identified all patients at their institution who underwent cerebral bypass for MMD from 1990 through 2018 and who later became pregnant. Some of these patients also had pregnancies prior to undergoing bypass surgery, and the authors examined these pregnancies as well. They performed a chart review and brief telephone survey to identify obstetric complications, transient ischemic attacks (TIAs), and strokes. Neurological and obstetric outcomes were compared to published rates. They also compared pre- and post-bypass pregnancy complication rates using logistic regression techniques.

RESULTS

There were 71 pregnancies among 56 women whose mean age was 30.5 years. Among 59 post-bypass pregnancies, there were 5 (8%) perinatal TIAs. There were no MRI-confirmed strokes or strokes with residual deficits. Among 12 pre-bypass pregnancies, there were 3 (25%) TIAs and 2 (17%) MRI-confirmed strokes. There were no hemorrhagic complications in either group. In the generalized estimating equations analysis, performing cerebral revascularization prior to pregnancy versus after pregnancy was associated with lower odds of perinatal stroke or TIA (OR 0.15, p = 0.0061). Nine pregnancies (13%) were complicated by preeclampsia, and there was one (1%) instance of eclampsia. The overall rate of cesarean delivery was 39%. There were 2 miscarriages, both occurring in the first trimester. There were no maternal deaths.

CONCLUSIONS

The authors present neurological and obstetric outcomes data in a large cohort of MMD patients. These data indicate that post-bypass pregnancy is accompanied by low complication rates. There were no ischemic or hemorrhagic strokes among post-bypass pregnant MMD patients. The rate of obstetric complications was low overall. The authors recommend close collaboration between the vascular neurosurgeon and the obstetrician regarding medical management, including blood pressure goals and continuation of low-dose aspirin.

ABBREVIATIONS CVR = cerebrovascular reserve; MCA = middle cerebral artery; MMD = moyamoya disease; STA = superficial temporal artery; TIA = transient ischemic attack.

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Contributor Notes

Correspondence Gary K. Steinberg: Stanford University School of Medicine, Stanford, CA. gsteinberg@stanford.edu.

INCLUDE WHEN CITING Published online November 15, 2019; DOI: 10.3171/2019.8.JNS191372.

Disclosures Dr. Steinberg reports being a consultant for Qool Therapeutics, Peter Lazic US, Inc., NeuroSave, SanBio, and Zeiss.

  • 1

    Acker G, Czabanka M, Schmiedek P, Vajkoczy P: Pregnancy and delivery in moyamoya vasculopathy: experience of a single European institution. Neurosurg Rev 41:615619, 2018

    • Search Google Scholar
    • Export Citation
  • 2

    Arias EJ, Derdeyn CP, Dacey RG Jr, Zipfel GJ: Advances and surgical considerations in the treatment of moyamoya disease. Neurosurgery 74 (Suppl 1):S116S125, 2014

    • Search Google Scholar
    • Export Citation
  • 3

    Barrett HL, Lust K, Fagermo N, Callaway LK, Minuzzo L: Moyamoya disease in pregnancy: maintenance of maternal blood pressure. Obstet Med 5:3234, 2012

    • Search Google Scholar
    • Export Citation
  • 4

    Burke GM, Burke AM, Sherma AK, Hurley MC, Batjer HH, Bendok BR: Moyamoya disease: a summary. Neurosurg Focus 26(4):E11, 2009

  • 5

    Fukushima K, Yumoto Y, Kondo Y, Fujita Y, Morokuma S, Tsukimori K, : A retrospective chart review of the perinatal period in 22 pregnancies of 16 women with Moyamoya disease. J Clin Neurosci 19:13581362, 2012

    • Search Google Scholar
    • Export Citation
  • 6

    Guzman R, Lee M, Achrol A, Bell-Stephens T, Kelly M, Do HM, : Clinical outcome after 450 revascularization procedures for moyamoya disease. Clinical article. J Neurosurg 111:927935, 2009

    • Search Google Scholar
    • Export Citation
  • 7

    Hardin JW, Hilbe JM: Generalized Estimating Equations. Boca Raton: Chapman and Hall/CRC, 2012

  • 8

    Huang S, Guo ZN, Shi M, Yang Y, Rao M: Etiology and pathogenesis of moyamoya disease: an update on disease prevalence. Int J Stroke 12:246253, 2017

    • Search Google Scholar
    • Export Citation
  • 9

    Hutcheon JA, Lisonkova S, Joseph KS: Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy. Best Pract Res Clin Obstet Gynaecol 25:391403, 2011

    • Search Google Scholar
    • Export Citation
  • 10

    Inayama Y, Kondoh E, Chigusa Y, Io S, Funaki T, Matsumura N, : Moyamoya disease in pregnancy: a 20-year single-center experience and literature review. World Neurosurg 122:684691.e2, 2019

    • Search Google Scholar
    • Export Citation
  • 11

    Komiyama M, Yasui T, Kitano S, Sakamoto H, Fujitani K, Matsuo S: Moyamoya disease and pregnancy: case report and review of the literature. Neurosurgery 43:360369, 1998

    • Search Google Scholar
    • Export Citation
  • 12

    Kuriyama S, Kusaka Y, Fujimura M, Wakai K, Tamakoshi A, Hashimoto S, : Prevalence and clinicoepidemiological features of moyamoya disease in Japan: findings from a nationwide epidemiological survey. Stroke 39:4247, 2008

    • Search Google Scholar
    • Export Citation
  • 13

    Lee SU, Chung YS, Oh CW, Kwon OK, Bang JS, Hwang G, : Cerebrovascular events during pregnancy and puerperium resulting from preexisting moyamoya disease: determining the risk of ischemic events based on hemodynamic status assessment using brain perfusion single-photon emission computed tomography. World Neurosurg 90:6675, 2016

    • Search Google Scholar
    • Export Citation
  • 14

    Maragkos GA, Ascanio LC, Chida K, Boone MD, Ogilvy CS, Thomas AJ, : Moyamoya disease in pregnancy: a systematic review. Acta Neurochir (Wien) 160:17111719, 2018

    • Search Google Scholar
    • Export Citation
  • 15

    Martin JA, Hamilton BE, Osterman MJK: Births in the United States, 2018. NCHS Data Brief, no 346. Hyattsville, MD: National Center for Health Statistics, 2019 (https://www.cdc.gov/nchs/products/databriefs/db346.htm) [Accessed September 18, 2019]

    • Search Google Scholar
    • Export Citation
  • 16

    Peerless SJ: Risk factors of moyamoya disease in Canada and the USA. Clin Neurol Neurosurg 99 (Suppl 2):S45S48, 1997

  • 17

    Santoro JD, Lee S, Mlynash M, Nguyen T, Lazzareschi DV, Kraler LD, : Blood pressure elevation and risk of moyamoya syndrome in patients with trisomy 21. Pediatrics 142: e20180840, 2018

    • Search Google Scholar
    • Export Citation
  • 18

    Suzuki J, Kodama N: Moyamoya disease—a review. Stroke 14:104109, 1983

  • 19

    Takahashi JC, Ikeda T, Iihara K, Miyamoto S: Pregnancy and delivery in moyamoya disease: results of a nationwide survey in Japan. Neurol Med Chir (Tokyo) 52:304310, 2012

    • Search Google Scholar
    • Export Citation
  • 20

    Teo MK, Madhugiri V, Steinberg GK: Surgical aspects of moyamoya disease, in Caplan LR, Biller J, Leary MC, (eds): Primer on Cerebrovascular Diseases, ed 2. London: Academic Press/Elsevier, 2017, pp 859864

    • Search Google Scholar
    • Export Citation

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