Safety and Efficacy of RIC in Pediatric Moyamoya Disease Patients Treated With Revascularization Therapy

Capital Medical University42 enrolled

Overview

Revascularization surgery has been the standard treatment to prevent ischemic stroke in pediatric Moyamoya disease (MMD) patients with ischemic symptoms. However, perioperative complications, such as hyperperfusion syndrome, new infarct on imaging, or ischemic stroke, are inevitable. Remote ischemic conditioning (RIC) is a noninvasive and easy-to-use neuroprotective strategy, and it has potential effects on preventing hyperperfusion syndrome and ischemic infarction.

This study will provide insights into the preliminary proof of principle, safety, and efficacy of RIC in pediatric MMD patients undergoing revascularization surgery therapy, and this data will provide parameters for future larger scale clinical trials if efficacious.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

PREVENTION

Masking

SINGLE

Enrollment

Conditions

Moyamoya Disease Pediatric

Interventions

Eligibility

Sex: ALLMax age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: * Age: ≥0 and ≤18 * All of the patients underwent digital subtraction angiography and met the current diagnostic criteria recommended by the Research Committee on MMD (Spontaneous Occlusion of the Circle of Willis) of the Ministry of Health and Welfare of Japan in 2012 * Suzuki stages concentrated in Stage III and IV * Presentation with ischemic symptoms, such as transient ischemic attack (TIA), headache, seizure, hemorrhagic stroke, and ischemic stroke confirmed by MRI * Informed consent obtained from patient or acceptable patient's surrogate Exclusion Criteria: * Severe hepatic or renal dysfunction * Severe hemostatic disorder or severe coagulation dysfunction * Patients with unilateral MMD or the presence of secondary moyamoya phenomenon caused by autoimmune disease, Down syndrome, neurofibromatosis, leptospiral infection, or previous skull-base radiation therapy * Any of the following cardiac disease - rheumatic mitral and or aortic stenosis, prosthetic heart valves, atrial fibrillation, atrial flutter, sick sinus syndrome, left atrial myxoma, patent foramen ovale, left ventricular mural thrombus or valvular vegetation, congestive heart failure, bacterial endocarditis, or any other cardiovascular condition interfering with participation * Serious, advanced, or terminal illnesses with anticipated life expectancy of less than one year * Patient participating in a study involving other drug or device trial study * Patients with existing neurological or psychiatric disease that would confound the neurological or functional evaluations * Unlikely to be available for follow-up for 3 months * Contraindication for RIC - severe soft-tissue injury, fracture, or peripheral vascular disease in the upper limbs.

Outcomes

Primary Outcomes

the incidence of major neurologic complications

Including transient ischemic attack, cerebral infarction, intracranial hemorrhage, and seizures.

Time frame: during the perioperative period

Secondary Outcomes

The score of National Institute of Health stroke scale score

National Institute of Health Stroke Scale (NIHSS) is considered as a standardized assessment of neurological functions in the acute phase of stroke, and it is generally used to quantify patient's neurological impairments on 15 items in 11 fields of different neurological status.The score of the scale ranges from 0 to 42.And higher score indicates worse neurological function.

Time frame: change from baseline (preoperation) at 24 hours, 48 hours, 72 hours, and at 5-7 days or if discharged earlier

The score of Modified Rankin scale score

The Modified Rankin Scale Score (mRS) is the most comprehensive and most widely used primary outcome measurement to assess the neurological functional disability in contemporary acute stroke trials. The mRS is an ordinal, graded interval scale that assigns patients among 7 global disability levels, which ranges from 0 (no symptom) to 5 (severe disability) and 6 (death). We will use mRS to evaluate the degree of disability or dependence during daily activities. The mRS will be assessed by certified study investigator, who is blinded to the treatment assignment, at 90 days postoperation. The distribution of mRS will be compared between groups

Time frame: change from baseline (pre-RIC treatment) at 180 days after revascularization therapy

Symptomatic intracerebral hemorrhage

Symptomatic intracranial hemorrhage, including any subarachnoid hemorrhage associated with clinical symptoms and symptomatic intracerebral hemorrhage. Head computed tomography or magnetic reasoning imaging (MRI) scan will be performed to confirm intracerebral hemorrhage, and the imaging will be evaluated by two independent neuroradiologists who are blinded to the study assignment.

Time frame: during the first 180 days after revascularization therapy

Incidence of new infarct in brain

Head MRI is a precise method which is commonly used to evaluate weather there's new infarct in brain.

Time frame: during 72 hours and 180 days after revascularization therapy

Angiographic outcome

Angiographic outcome will be assessed following Matsushima's criteria (proportion of the middle cerebral artery territory with revascularization from collaterals from the external carotid artery through the burr holes): Grade A: \>2/3; Grade B: between 1/3 and 2/3; Grade C: \<1/3.

Time frame: 180 days after revascularization therapy

Death and adverse event

All causes of death will be included to compute mortality at 180 days postoperation, and mortality will be compared between groups. Any adverse event will be reported and its relationship with the RIC intervention will be evaluated.

Time frame: 180 days after revascularization therapy

Infarct volume in brain

Head MRI is a precise method which is commonly used to evaluate infarct size.

Time frame: during 72 hours and 180 days after revascularization therapy

Distal radial pulses

professional doctors will check the distal radial pulses

Time frame: within 7 days after RIC treatment

Visual inspection for local edema

Professional oculists will check the fundus oculi to evaluate whether there is local edema.

Time frame: within 7days after RIC treatment

The number of patients with erythema,and/or skin lesions related to RIC

Professional doctors will check it and the investigator will record the number.

Time frame: within 7days after RIC treatment

Palpation for tenderness

Professional doctors will check it.

Time frame: within 7days after RIC treatment

The number of patients not tolerating RIC procedure,and refuse to continue the RIC procedure

The investigator will record the number.

Time frame: within 7days after RIC treatment

The number of patients with any other adverse events related to RIC intervention

The investigator will record the number.

Time frame: within 7days after RIC treatment

The score of ABCD2

We use this scale to evaluate the patients' risk of stroke who with TIA .The score of the scale ranges from 0 to 7, and the higher score indicates higher risk of stroke in the patients who with TIA.The scale will be assessed by qualified investigator who are blinded to the treatment assignment

Time frame: change from baseline (pre-RIC treatment) at 180 days after revascularization therapy

The level of S-100A4