Moya-Moya Syndrome: 1) Risk of bleeding during medical therapy 2) Risk and benefit of Medical vs. Surgical therapy
Objective: To determine the risk and benefit of medical vs. surgical treatment in Moya-Moya disease. Background: The optimal management of Moya-Moya disease is unknown. Many investigators favor surgical therapy on the belief that the risk of intracranial bleeding on medical therapy is high (appx.25%). This practice is based on retrospective review of small series. Method: We reviewed retrospectively charts of 30 patients, with Moya-Moya disease treated either medically or surgically in our institution from 1986 to 2000. Risk of hemorrhage and risk of recurrent stroke were analyzed in both groups using Fisher’s exact test. Results: 20/30 patients received only medical therapy. Of these, 13 were treated with warfarin, and 15 with antiplatelet agents (8 received both warfarin and antiplatelet). 10/30 patients were treated surgically (either extracranial-intracranial bypass (ECIC), encephalodural synangiosis (EDS), or omental grafting). 7 of the surgical patients were also treated with either warfarin or antiplatelet agents. There was no hemorrhage in either the medical or surgical groups. Recurrent infarction or TIA risk was similar between the two groups. 6 medically treated patients had recurrent infarction, vs. 4 surgically treated patients (R.R 0.78, 95% C.I.0.45- 1.35, p=0.413). Conclusion: Our data does not support the belief that medical therapy (either anticoagulation or antiplatelet therapy) is associated with a high risk of intracranial hemorrhage. The risk of recurrent infarction was similar in the two groups, although our numbers are too small to detect a modest difference between the two therapeutic modalities. Given the rarity of Moya-Moya disease, a multi-institutional trial will be necessary to settle this important issue.