Neurosurgery
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Fragile, dilated moyamoya vessels are the main source of hemorrhagic stroke in moyamoya disease (MMD). However, the prevalence of hemorrhagic stroke largely differs between Asian and western countries, although the underlying pathophysiology has not been clarified. ⋯ The marked dilatation of PChoA and PcomA is considered a powerful predictive marker of hemorrhage in MMD. Collateral channels spontaneously shift from the anterior to posterior circulation in Japanese patients during ageing but not in European Caucasian patients. These different dilation patterns of the collateral pathway may be associated with an ethnic difference of the clinical onset type in MMD.
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While the efficacy of Intravenous tissue plasminogen activator (tPA) is well established, its impact on large vessel occlusion (LVO) is controversial. Whether IV tPA should be bypassed in favor of endovascular thrombectomy (MT) will be addressed. ⋯ A trial of MT with patients randomized for IV tPA within the 4.5-h time window should conducted at comprehensive stroke centers demonstrating equipoise between time to tPA or MT with time to treatment from ED arrival of 45 min. We may do well to consider the systems pathway taken by interventional cardiologists 15 years ago.