Socioeconomic and demographic disparities of moyamoya disease in the United States.

OBJECTIVES: Although stroke incidence is inversely associated with socioeconomic status, whether similar disparities exist with moyamoya disease (MMD) is unknown. Determining the socioeconomic and demographic factors involved in MMD will provide better direction in elucidating the etiology or addressing healthcare inequalities. PATIENTS AND METHODS: To investigate MMD incidence with respect to sex, age, income, residence, and race/ethnicity, we examined the largest American administrative dataset, the National (Nationwide) Inpatient Sample (NIS), which surveys 20 % of United States discharges irrespective of payor. We then determined median annual incidence per 100,000 people and trends between 2008-2015. RESULTS: Overall MMD incidence (with 25th and 75th quartiles) was 0.293 (0.283, 0.324) and annually increasing (τ = 0.857, p = 0.004). Females had an incidence of 0.398 (0.371, 0.464), larger (p = 0.008) than the male incidence of 0.185 (0.165, 0.195). Amongst age groups incidence varied (χ2 = 8.857, p = 0.012) as follows: 1-17 years old group, 0.298 (0.259, 0.346); 18-44 group, 0.380 (0.346, 0.412); 45-64 group, 0.308 (0.280, 0.328). Those 18-44 ha d a significantly larger incidence relative to the 1-17 (p = 0.039) and 45-64 (p = 0.008) groups. Individuals with low income had an incidence of 0.514, larger (p = 0.008) than the 0.239 of middle/high income patients. Depending on whether the patients lived in an urban, suburban, or rural community, incidence differed (χ2 = 7.6, p = 0.022) as follows, respectively: 0.344 (0.293, 0.371); 0.269 (0.258, 0.294); 0.283 (0.273, 0.293). Living in an urban community resulted in a significantly greater incidence, relative to suburban (p = 0.016) or rural (p = 0.032). Amongst race/ethnicity (χ2 = 7.6, p = 0.022), incidence for Asian/Pacific Islanders, Blacks, Whites, and Hispanics between 2008-2013 was as follows, respectively: 0.509 (0.429, 0.595); 0.292 (0.219, 0.356); 0.148 (0.137, 0.157); 0.121 (0.075, 0.153). Other than comparisons between Whites and Blacks/Hispanics, incidence significantly varied between all groups. Annually incidence was significantly increasing for females (τ = 0.929, p = 0.002), ages 18-44 (τ = 0.786, p = 0.009), ages 45-64 (τ = 0.714, p = 0.019), middle/high income (τ = 0.786, p = 0.009), and urban (τ = 0.714, p = 0.019) or suburban (τ = 0.714, p = 0.035) dwelling patients. CONCLUSION: MMD diagnoses between 2008-2015 have been significantly increasing in the United States, with disparities growing between socioeconomic and demographic strata. Disproportionately, incidence was greatest for patients who were low income, urban living, female, aged 18-44, and Asian/Pacific Islanders. This data highlights a growing healthcare inequality amongst MMD and provides direction in etiology elucidation.

Adult moyamoya angiopathy in Bourgogne-Franche-Comté: Epidemiology, diagnosis and management.

INTRODUCTION: Moyamoya angiopathy (MMA) is a progressive steno-occlusive disease of the distal internal carotid arteries mainly described in Asia. It induces the development of collateral vascular networks to reduce chronic cerebral hypoperfusion. Symptoms depend on the patient's age in Asia: children are at greater risk of transient or constituted ischemic events, whereas adults are more exposed to hemorrhagic stroke. Data from the literature seem to show that the pattern of MMA in western countries differs from that in Asia. MATERIAL AND METHODS: A retrospective study of patients with MMA was conducted in Bourgogne-Franche-Comté (mid-eastern France). Clinical data (symptoms, risk factors, age at diagnosis, number and timing of recurrences, type of treatment) as well as radiological data (angiographic findings, Suzuki's grade) were analyzed. RESULTS: Seventeen adult patients (9 men, 53%) were followed at the university hospitals of Besançon and Dijon from 2009 to 2016. Fourteen patients (83%) had bilateral disease. The mean age at diagnosis was 49 years (±16), 83% of the patients were Caucasian and 17% originated from Maghreb. Only 17% of the hemispheres had a hemorrhagic form. Ischemic form was more frequent before diagnosis with transient ischemic attack (24% of patients) and stroke (83% of patients). With medical treatment, 9 patients suffered from stroke recurrence (53% of patients) with an average delay of 22.7±34 months. Three patients (18%) had combined surgical management by encephelo-synangiosis and superficial temporal artery-to-middle cerebral artery (STA-MCA) anastomosis, without symptom recurrence after treatment with an average follow up of 14 months. CONCLUSION: MMA remains a rare cerebrovascular disease in Europe and requires multidisciplinary care. Epidemiological analysis showed differences with the Asian population, especially the predominance of ischemic forms in adults.

Predictors of Surgical Site Infection After Nonemergent Craniotomy: A Nationwide Readmission Database Analysis.

OBJECTIVE: Surgical site infections (SSIs) carry significant patient morbidity and mortality and are a major source of readmissions after craniotomy. Because of their deleterious effects on health care outcomes and costs, identifying modifiable risk factors holds tremendous value. However, because SSIs after craniotomy are rare and most existing data comprise single-institution studies with small sample sizes, many are likely underpowered to discern for such factors. The objective of this study was to use a large hetereogenous patient sample to determine SSI incidence after nonemergent craniotomy and identify factors associated with readmission and subsequent need for wound washout. METHODS: We used the 2010-2014 Nationwide Readmissions Database cohorts to discern for factors predictive of SSI and washout. RESULTS: We identified 93,920 nonemergent craniotomies. There were 2079 cases of SSI (2.2%) and 835 reoperations for washout (0.89%) within 30 days of index admission and there were 2761 cases of SSI (3.6%) and 1220 reoperations for washout (1.58%) within 90 days. Several factors were predictive of SSI in multivariate analysis, including tumor operations, external ventricular drain (EVD), age, length of stay, diabetes, discharge to an intermediate-care facility, insurance type, and hospital bed size. Many of these factors were similarly implicated in reoperation for washout. CONCLUSIONS: SSI incidence in neurosurgery is low and most readmissions occur within 30 days. Several factors predicted SSI after craniotomy, including operations for tumor, younger age, hospitalization length, diabetes, discharge to institutional care, larger hospital bed size, Medicaid insurance, and presence of an EVD. Diabetes and EVD placement may represent modifiable factors that could be explored in subsequent prospective studies for their associations with cranial SSIs.

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.

OBJECTIVE: The purposes of this study were to review the cerebrovascular events (CVE) during pregnancy and puerperium in adults with moyamoya disease (MMD) and to evaluate its risk factors. METHODS: We reviewed electronic medical records on 141 pregnancies in 71 women diagnosed with MMD and this study included only 27 pregnancies (23 patients) diagnosed with MMD before pregnancy. Basal and acetazolamide-stress brain perfusion single-photon emission computed tomography (SPECT) was conducted for 40 hemispheres in 21 pregnancies within 1 year of the gestational period, ranging from 22 months before delivery to 12 months after delivery for evaluation of the hemodynamic status of the patients to devise the MMD treatment strategy. RESULTS: Twelve pregnancies (44.4%) showed CVE during pregnancy or puerperium in the group diagnosed with MMD before pregnancy. All the 12 CVE were ischemic, without any hemorrhagic events. A decreased cerebral vascular reserve capacity (CVRC) on stress SPECT was observed in 25 (62.5%) of the 40 hemispheres, and 18 of these 25 hemispheres showed TIA. In contrast, only 2 of 15 hemispheres which revealed normal CVRC on stress SPECT showed TIA. Overall, a decreased CVRC on stress SPECT imaging was statistically associated with development of CVE (P < 0.001). Furthermore, the clinical type of MMD was also regarded as predictive factor for CVE in this study. Especially, ischemic type MMD revealed a statistical association with the development of CVE (P = 0.014, odds ratio = 16.50). CONCLUSIONS: Assessment of cerebral hemodynamic status with stress SPECT may predict CVE during pregnancy and puerperium.

Moyamoya disease: review of the literature and estimation of excess morbidity and mortality.

As a result of greater screening with brain imaging tests, the incidence of Moyamoya Disease (MMD) is increasing. In the past, comparative mortality experience has been based on small patient numbers and relatively short follow-up periods. The objective of this article is to estimate the degree of excess morbidity and mortality associated with this rare impairment. In addition we will provide a concise review of the literature, including pathophysiology, clinical manifestation, diagnostic criteria and surgical treatment.