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Alaa S. Montaser, Harishchandra Lalgudi Srinivasan, Steven J. Staffa, David Zurakowski, Anna L. Slingerland, Darren B. Orbach, Moran Hausman-Kedem, Jonathan Roth, and Edward R. Smith

, ironically, the need for less-invasive testing is most impactful), means that high-volume studies have been challenging to complete. Herein, we present the largest study (of which we are aware) to date reporting on the presence and utility of the ivy sign in the diagnosis and prognosis of pediatric moyamoya. 19 Methods This study was approved by the IRB at each respective hospital. Patient Population We retrospectively reviewed the medical records of a consecutive cohort of pediatric patients with moyamoya disease or moyamoya syndrome who underwent surgery at

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Jennifer L. Quon, Lily H. Kim, Robert M. Lober, Maryam Maleki, Gary K. Steinberg, and Kristen W. Yeom

image (B) shows increased ASL signal in the bilateral MCA territories ( arrows ) compared with the preoperative image (A). Discussion Our results show that quantitative CBF increased in the MCA territory ipsilateral to the revascularization procedure. To our knowledge, no prior study has examined ASL-based perfusion changes in pediatric moyamoya patients after revascularization. Prior studies on ASL perfusion have examined mostly the adult population and found that postsurgical CBF changes on ASL correlate with various other imaging methods, such as DSA, MRA, and DSC

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Edward R. Smith and R. Michael Scott

for pediatric moyamoya syndrome and most treated patients derive some symptomatic benefit.” 15 Indications for surgery were noted in < 15% of studies and varied between centers. General indications and timing of surgery remain controversial. The meta-analysis noted that the following statements had been used as indications for surgery: “neurological signs and symptoms likely to be related to cerebral ischemia and angiographic documentation of moyamoya disease,” “repeated ischemic attacks or progressive mental retardation,” “low cerebral blood flow in the frontal

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Kyu-Chang Wang

hyperthyroidism; and patients with postoperative headache, progressive ischemia, and different follow-up protocols. Continuous refinement of the contents of these guidelines will be necessary in the future. The work presented here represents an excellent jumping-off point for future efforts. Disclosure The author reports no conflict of interest. Reference 1 Smith ER , Scott RM : Spontaneous occlusion of the circle of Willis in children: pediatric moyamoya summary with proposed evidence-based practice guidelines. A review . J Neurosurg Pediatr 9 : 353 – 360

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Krishnan Ravindran, John C. Wellons, and Michael C. Dewan

M oyamoya is an idiopathic, progressive, stenoocclusive arteriopathy of terminal internal carotid arteries characterized by the development of abnormally dilated vessels, cerebral hypoperfusion, and secondary collateral formation. The vast majority (> 95%) of pediatric patients presenting with moyamoya have ischemic symptoms; hemorrhagic events are far less common in children (3%) than their adult counterparts (20%). 39 Goals of surgical intervention for pediatric moyamoya are thus to ameliorate cerebral blood flow, reduce cerebral ischemia, and prevent the

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Akikazu Nakamura, Akitsugu Kawashima, Hugo Andrade-Barazarte, Takayuki Funatsu, Juha Hernesniemi, and Takakazu Kawamata

patients with pediatric moyamoya disease . Stroke . 1997 ; 28 ( 6 ): 1170 – 1173 . 8 Karasawa J , Touho H , Ohnishi H , Long-term follow-up study after extracranial-intracranial bypass surgery for anterior circulation ischemia in childhood moyamoya disease . J Neurosurg . 1992 ; 77 ( 1 ): 84 – 89 . 9 Miyamoto S , Akiyama Y , Nagata I , Long-term outcome after STA-MCA anastomosis for moyamoya disease . Neurosurg Focus . 1998 ; 5 ( 5 ): e5 . 10 Funaki T

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Akikazu Nakamura, Akitsugu Kawashima, Hugo Andrade-Barazarte, Takayuki Funatsu, Juha Hernesniemi, and Takakazu Kawamata

revascularization for moyamoya disease surgical techniques and peri-operative complications . Clin Neurol Neurosurg . 1997 ; 99 ( suppl 2 ): S142 – S145 . 10.1016/S0303-8467(97)00075-9 9409425 7 Ishikawa T , Houkin K , Kamiyama H , Abe H . Effects of surgical revascularization on outcome of patients with pediatric moyamoya disease . Stroke . 1997 ; 28 ( 6 ): 1170 – 1173 . 9183345 10.1161/01.STR.28.6.1170 8 Karasawa J , Touho H , Ohnishi H , Long-term follow-up study after extracranial-intracranial bypass surgery for anterior circulation ischemia in

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Nisha Gadgil, Sandi Lam, Monika Pyarali, Michael Paldino, I-Wen Pan, and Robert C. Dauser

vascularity of dura mater with techniques such as burr holes has also been well described. 28 In 1997, Dauser et al. described the technique of dural inversion in which large dural flaps centered around the middle meningeal artery (MMA) are created. The dural flaps are then inverted, allowing an increased surface area of contact between the vascularized outer dural layer and the ischemic brain. 5 In the present study, we describe the treatment of pediatric moyamoya disease using dural inversion combined with EDAS in 169 consecutive surgeries over a 20-year period at a

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Hime Suzuki, Takeshi Mikami, Tomoyoshi Kuribara, Kazuhisa Yoshifuji, Katsuya Komatsu, Yukinori Akiyama, Hirofumi Ohnishi, Kiyohiro Houkin, and Nobuhiro Mikuni

, 38 is referred to as “medullary streaks,” and is considered to be associated with changes in vasculature. 34 The aim of this study was to investigate the characteristics of medullary streaks on FLAIR imaging in pediatric moyamoya disease and to explore the pathophysiology of the findings. Methods Patients Between April 2009 and June 2016, 14 consecutive pediatric patients with moyamoya disease were treated at Sapporo Medical University. All of the patients had been diagnosed with moyamoya disease via MRI, MRA, and digital subtraction angiography, according to

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Yong Zhang, Xiang-Yang Bao, Lian Duan, Wei-Zhong Yang, De-Sheng Li, Zheng-Shan Zhang, Cong Han, Feng Zhao, Qian Zhang, and Qian-Nan Wang

anastomosis in moyamoya disease . AJNR Am J Neuroradiol 14 : 29 – 30 , 1993 8427106 4 Baltsavias G , Khan N , Valavanis A : The collateral circulation in pediatric moyamoya disease . Childs Nerv Syst 31 : 389 – 398 , 2015 25378261 10.1007/s00381-014-2582-5 5 Bamford JM , Sandercock PA , Warlow CP , Slattery J : Interobserver agreement for the assessment of handicap in stroke patients . Stroke 20 : 828 , 1989 2728057 10.1161/01.STR.20.6.828 6 Bao XY , Duan L , Yang WZ , Li DS , Sun WJ , Zhang ZS , : Clinical features