Moyamoya following cranial irradiation for primary brain tumors in children

Objective: To study the risk factors for the development of moyamoya syndrome after cranial irradiation for primary brain tumors in children. Methods: We reviewed neuroimaging studies and dosimetry data for 456 children who were treated with radiation for a primary brain tumor and who were prospectively evaluated with serial neuroimaging studies and neurologic evaluations. A total of 345 patients had both adequate neuroimaging and radiation dosimetry data for further analysis. We used survival analysis techniques to examine the relationship of clinically important variables as risk factors for the development of moyamoya over time. Results: Overall, 12 patients ( 3.5%) developed evidence of moyamoya. The onset of moyamoya was more rapid for patients with neurofibromatosis type 1 ( NF1) ( median of 38 vs 55 months) and for patients who received > 5,000 cGy of radiation ( median of 42 vs 67 months). In a multiple Cox proportional hazards regression analysis controlling for age at start of radiation, each 100- cGy increase in radiation dose increased the rate of moyamoya by 7% ( hazard ratio [ HR] = 1.07, 95% CI: 1.02 to 1.13, p = 0.01) and the presence of NF1 increased the rate of moyamoya threefold ( HR = 3.07, 95% CI: 0.90 to 10.46, p = 0.07). Conclusions: Moyamoya syndrome is a potentially serious complication of cranial irradiation in children, particularly for those patients with tumors in close proximity to the circle of Willis, such as optic pathway glioma. Patients who received higher doses of radiation to the circle of Willis and with neurofibromatosis type 1 have increased risk of the development of moyamoya syndrome.