Case Reports in Neurological Medicine
Volume 2018 (2018), Article ID 7806873, 3 pages
https://doi.org/10.1155/2018/7806873

Case Report

Hyperhomocysteinemia in a Patient with Moyamoya Disease

Durga Shankar Meena, Gopal Krishana Bohra, Mahadev Meena, and Bharat Kumar Maheshwari

Department of Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Correspondence should be addressed to Durga Shankar Meena; dsmims14@gmail.com

Received 17 January 2018; Accepted 29 March 2018; Published 6 May 2018

Academic Editor: Majaz Moonis

Copyright © 2018 Durga Shankar Meena et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Moyamoya disease is a chronic progressive cerebrovascular disease characterized by bilateral occlusion or stenosis of arteries around circle of Willis. We report a case of 18-year-old female presented with recurrent episodes of headache and vertigo. On cerebral angiography, the patient was diagnosed to have moyamoya disease. On further evaluation, thrombophilia profile showed increased homocysteine level. The patient was treated conservatively with cobalamin and aspirin and advised for revascularization. According to the literature, there are few case reports of moyamoya disease with thrombotic disorders. Hence, we are reporting this interesting and rare case.

1. Introduction

Moyamoya disease is a poorly understood cerebrovascular disease with the reported incidence of 0.35 per 100,000 population [1]. Moyamoya in Japanese means “puff of smoke” which was used to describe the typical smoky angiographic appearance of collateral vessels. The etiology and pathogenesis of moyamoya disease are not well known. Familial occurrence is seen in approximately 10 percent of cases which suggests genetic etiology. There are few reports describing the classical angiographic appearance of moyamoya vessels with abnormal thrombophilia profile. Here, we present a case of 18-year-old female with moyamoya disease with hyperhomocysteinemia.

2. Case Presentation

An 18-year-old female was admitted to our hospital with chief complaints of acute onset vertigo and severe headache for the last 6 hours. Soon after hospitalization, she developed 2 episodes of generalized tonic-clonic seizures. There was past history of left hemiparesis 8 years back with recurrent episodes of vertigo and headache. There was no history of fever, head injury, ear discharge, and diplopia. There was no significant family history. On general examination, patient’s blood pressure was 150/78 mmHg at the time of admission, and rest examination was unremarkable. Her sensorium was improved after 1 hour. Higher mental functions were normal. The functions of cranial nerves were intact. Motor, sensory examination was normal and deep tendon reflexes were well preserved. The patient was further evaluated with biochemical and haematological investigations. Complete blood count, electrolytes, and blood sugar level were normal. MRI brain was done which showed infarct in right gangliocapsular region (Figure 1). We further evaluated the patient with cerebral angiography which showed occlusion of the right middle cerebral artery (M1) just distal to origin with the appearance of moyamoya collaterals (Figures 2, 3, and 4). Right internal carotid artery showed reduced calibre in comparison to left, likely due to stenosis. Since our patient has a history of stroke, we further investigated the underlying cause. On subsequent investigation for thrombophilia profile, homocysteine level was moderately increased (42 micromole/litre) (Table 1), and rest coagulation profile was unremarkable. We treated the patient conservatively with cobalamin, B-6, folic acid, and aspirin. The patient was advised for neurosurgery consultation for revascularization and further follow-up.

Table 1: Biochemical and haematological investigations.

Investigations

Homocysteine
42 μmol/L (1.0–15.39)

ANA
Negative

Anti-Ro/SSA, anti-La/SSB
Negative

Protein C
78% (normal 70–120)

Protein S
134% (normal 55–135)

Antithrombin III
110% (normal 80–120)

Lupus anticoagulant
Absent

PT
12.1 seconds (control—11.1)

APTT
28.0 seconds (control—28.8)

LDL cholesterol
60.66 mg/dl

HDL cholesterol
40.08 mg/dl

Triglycerides
122.49 mg/dl

Cholesterol
155 mg/dl

Vitamin B-12
223 pg/ml (normal 211–700)

Folate level
3.4 ng/ml (normal 2–20)

Total protein/albumin
7.0/4.0 gm/dl

Blood urea nitrogen/creatinine
33/0.94 mg/dl

Thyroid function test
T3—0.4 ng /dl FreeT4—0.9 ng/dl TSH—2.9 mIU/L

Figure 1: Axial T2-weighted MRI brain image showing infarct in right gangliocapsular region.

Figure 2: Vertebral angiogram image showing near total to complete occlusion of right M1 (MCA) just distal to origin with distal M1 reforming via perforators.

Figure 3: Cerebral angiogram (oblique view) image showing typical “puff of smoke” collaterals with right MCA stenosis (black arrow).

Figure 4: Cerebral angiogram image showing typical “puff of smoke” moyamoya collaterals (black arrow).

The patient successfully underwent surgical revascularization and at 3-month follow-up, the patient was symptomatically better.

3. Discussion

Moyamoya disease (MMD) is an uncommon chronic cerebrovascular disease characterized by the formation of collaterals near circle of Willis secondary to occlusion or stenosis of proximal, middle, or anterior cerebral artery. Moyamoya in Japanese means “puff of smoke” [2]. The etiology of moyamoya disease is unknown. 10% to 15% cases, especially in Japanese population, were reported to be familial. Patients with typical angiographic appearance without any known risk factor were considered moyamoya disease, while those with some recognized conditions (neurofibromatosis type 1, Down syndrome, cranial irradiation, and sickle cell disease) are classified as moyamoya syndrome. Abnormal thrombophilia profile in moyamoya disease is reported in the literature. There have been reports of moyamoya disease with protein c and protein s deficiency [3, 4]. One case report of homocystinuria with moyamoya was also described in the literature [5]. In our case, there was no clinical feature suggestive of homocystinuria. Cerrato et al. described a case of atherosclerotic moyamoya disease presented with ischemic stroke [6]. According to their report, atherosclerosis secondary to increased homocysteine was the likely cause of moyamoya.

Homocysteinemia mediated endothelial dysfunction, increased oxidant stress, and functional abnormalities in the release of nitric oxide are the proposed mechanism in some studies [7], leading to cerebrovascular disease. In our case, increase homocysteine could be an important trigger for the development of moyamoya vessels and stroke. The possible role of MTFHR (methylenetetrahydrofolate reductase) enzyme activity in MMD with hyperhomocysteinemia was discussed in the literature [8]. A recent study showed an association of 2 novel SNPs (single-nucleotide polymorphisms) in the gene regulating homocysteine metabolism (rs9651118 in MTHFR and rs117353193 in TCN2), causing increased homocysteine level in MMD patients [9]. However, due to financial constraints, we were not able to investigate for MTFHR gene mutation in our patient.

There is no curative treatment for moyamoya disease. Acute management is predominantly supportive with emphasis on reducing intracerebral pressure and management of seizures [10]. Secondary prevention for symptomatic moyamoya is predominantly based on surgical revascularization [11]. The goal of revascularization is to improve cerebral perfusion and prevent further risk of ischemic stroke. It is also important to look for underlying conditions such as coagulation profile.

In conclusion, our case, along with previous reports outlined above, recapitulates that homocysteinemia can be associated with moyamoya disease. The possibility of hyperhomocysteinemia should be sought in every patient presenting with moyamoya disease.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

References

K. Wakai, A. Tamakoshi, K. Ikezaki et al., “Epidemiological features of Moyamoya disease in Japan: Findings from a nationwide survey,” Clinical Neurology and Neurosurgery, vol. 99, no. 2, pp. S1–S5, 1997.

J. Suzuki and A. Takaku, “Cerebrovascular “Moyamoya" Disease. Disease Showing Abnormal Net-Like Vessels in Base of Brain,” JAMA Neurology, vol. 20, no. 3, pp. 288–299, 1969.

B. Çevik, B. Acu, D. Aksoy, and S. Kurt, “Protein S deficiency and an adult case with moyamoya syndrome that presented with primary intraventricular haemorrhage,” Balkan Medical Journal, vol. 31, no. 2, pp. 180–183, 2014.

H. Tsuda, S. Hattori, S. Tanabe et al., “Thrombophilia found in patients with Moyamoya disease,” Clinical Neurology and Neurosurgery, vol. 99, supplement 2, pp. S229–S233, 1997.

M. Erol, O. B. Gayret, O. Yigit, K. S. Cabuk, M. Toksoz, and M. Tiras, “A case of homocystinuria misdiagnosed as moyamoya disease: A case report,” Iranian Red Crescent Medical Journal, vol. 18, no. 4, Article ID e30332, 2016.

P. Cerrato, M. Grasso, A. Lentini et al., “Atherosclerotic adult Moya-Moya disease in a patient with hyperhomocysteinaemia,” Neurological Sciences, vol. 28, no. 1, pp. 45–47, 2007.

K. S. McCully, “Homocysteine and vascular disease,” Nature Medicine, vol. 2, no. 4, pp. 386–389, 1996.

Y. S. Park, Y. J. Jeon, H. S. Kim et al., “The roles of methylenetetrahydrofolate reductase 677C>T and 1298A>C polymorphisms in moyamoya disease patients,” Child’s Nervous System, vol. 30, no. 10, pp. 1687–1689, 2014.

L. Duan, L. Wei, Y. Tian et al., “Novel Susceptibility Loci for Moyamoya Disease Revealed by a Genome-Wide Association Study,” Stroke, vol. 49, no. 1, pp. 11–18, 2017.

M. Fukui, “Guidelines for the diagnosis and treatment of spontaneous occlusion of the circle of Willis (Moyamoya disease),” Clinical Neurology and Neurosurgery, vol. 99, no. 2, pp. S238–S240, 1997.

R. M. Scott and E. R. Smith, “Moyamoya disease and moyamoya syndrome,” The New England Journal of Medicine, vol. 360, no. 12, pp. 1226–1237, 2009.