UofL Health’s Louisville Brain Bypass and Revascularization Center (LBBRC) aims to identify and treat patients with Moyamoya disease (MMD), Moyamoya syndrome (MMS), related intracranial steno-occlusive disorders (SOD) and extracranial vascular stenosis (carotid and vertebral) with medical and surgical treatment options. Our team evaluates each patient through a comprehensive, interdisciplinary program of UofL Health providers spanning multiple neuro-specific subspecialties.
- Moyamoya Disease (MMD): This is a progressive narrowing of the intracranial carotid arteries, usually with one side first followed by the other, and progressive strokes, transient ischemic attacks (TIAs, or “mini-strokes”) and/or bleeds in the brain.
- Moyamoya syndrome (MMS): MMS is like MMD but more often affects one side of the brain only. It can be associated with a number of conditions like lupus, prior radiation, sickle cell anemia, Down syndrome, neurofibromatosis or thyroid disease, or it can present due to unknown reasons (i.e. “idiopathic”). Similar to MMD, MMS can present with progressive strokes, transient ischemic attacks (TIAs, or “mini-strokes”) and/or bleeds in the brain.
- Steno-occlusive disorders (SOD): SOD includes any narrowing or closed arteries in the brain, which can happen for various reasons including dissections, tears in the artery or a build-up of plaque (i.e. intracranial atherosclerotic disease (ICAD)). Most of the time, medical management is best for first-line treatment.
- Carotid or vertebral artery stenosis: Narrowing in the blood vessels of the head and neck, and can present with strokes or TIAs. A combination of medical and/or surgical treatment is used for these patients.
Treatments and Procedures
We have experts in vascular neurology that will evaluate each patient for any and all risk factors associated with disease progression and – when appropriate – develop a personalized regimen of medication with close appointment follow-up. This includes anti-platelet medication, anti-coagulation (blood thinners), cholesterol and hypertension-modifying medications, along with lifestyle modification.
Most patients will undergo a diagnostic angiogram using wires and catheters, through either the wrist or groin artery, to evaluate the blood vessels of the brain, head, and neck. This procedure is performed generally as an outpatient appointment and takes about an hour, with 1-4 hours of recovery before discharge. Since this procedure involves entering the arteries of the head and neck, it is classified as invasive and therefore has a small risk of causing a stroke. We take every precaution possible to prevent this and the risk of stroke is less than 1%. This procedure is generally required for a thorough evaluation of the blood vessels.
In some cases of SOD or carotid or vertebral stenosis, endovascular stenting may be an option to enhance blood flow to the brain. Any stenting requires that the patient take 2 separate antiplatelet medications (usually aspirin and Plavix) for 6 months, and a single antiplatelet agent thereafter.
One way to restore blood flow to the brain is to use an artery that normally goes to the scalp and connect it to a brain blood vessel after performing a craniotomy. This procedure is called a “direct bypass”. UofL Health offers one of the only centers in the state and region to provide direct bypasses to patients.
If the recipient or donor blood vessels are not viable or large enough to perform a direct bypass, we can perform an indirect revascularization procedure where a piece of scalp tissue or meninges is laid on top of the brain after performing craniotomy for blood vessels to grow over time and help flow to the brain. This procedure also has excellent results in preventing strokes and TIAs in patients with MMS and MMD.
For carotid stenosis in the neck, oftentimes we can offer surgery to open the carotid artery in the neck and remove the plaque to reduce the risk of having a stroke or TIA. For patients with carotid stenosis, each case is different, and we will discuss the benefits and risks of both using a stent and surgical removal of the plaque.