Recurrent hemodynamic ischemic strokes as the presenting feature of moyamoya disease

Moyamoya disease (MMD) is a progressive and occlusive cerebrovascular disorder affecting the circle of Willis and surrounding arteries, characterized by a “puff of smoke” appearance on angiography. Recurrent transient ischemic attacks (TIAs) and strokes are common manifestations, frequently attributed to impaired cerebral hemodynamics due to poor collateral blood flow. This hemodynamic compromise A 34-year-old woman presented with four episodes of right-sided hemiparesis, slurred speech, and intermittent headaches over eight months, each resolving spontaneously within several days. Neuroimaging, including a non-contrast head computed tomography scan, revealed hypodensity at the border region between the territories of the left anterior cerebral artery and middle cerebral artery. Cerebral digital subtraction angiography revealed the characteristic “puff of smoke” appearance in the right internal carotid artery (ICA), along with severe stenosis of the left ICA. The primary clinical manifestations of MMD include ischemic events such as TIAs, ischemic strokes, and seizures. Recurrent strokes in young patients warrant prompt evaluation for underlying vascular disorders, including MMD. Hemodynamic compromise, a key contributor to recurrent ischemia in this condition, underscores the importance of optimizing collateral circulation to mitigate future stroke risk. Managing hemodynamic stroke in MMD involves adopting a healthy lifestyle and carefully regulating blood pressure to prevent inadequate blood flow and reduce the risk of recurrent strokes.