Moyamoya syndrome in cocaine-dependent patients.

I enjoyed Storen et al’s article regarding two cocaine-dependent patients who manifested angiographic changes that suggested moyamoya syndrome (1). We published a similar case in the on-line journal, Neurosurgical Focus, the internet journal of the Journal of Neurosurgery (2). Our patient was a 30-year-old, right-handed, Caucasian woman who had heavy dependency on intranasal cocaine from the ages of 16–27. She presented with a long history of headache, which was worsening in frequency and intensity, and with dysphasia and right-sided weakness. CT and MR studies showed multiple, small cerebral infarctions of different ages, and cerebral anteriography revealed evidence of advanced-stage moyamoya changes, with virtual occlusion of supraclinoid carotid arteries bilaterally. Despite aspirin treatment, the patient continued to have symptoms, and she underwent eventual bilateral pial synangioses to enhance collateralization to each hemisphere. The postoperative arteriograms indicated excellent collateralization bilaterally, and the patient has remained neurologically stable without further events for the past 9 years. Preand postoperative arteriograms are available on the on-line publication (www.neurosurgery. org/focus/november98/5-5-7.html). We also thought that the network of collateral vessels beyond the bilateral carotid occlusive process implied an insidious progressive process rather than an acute event, and felt that chronic vasoconstriction was the most likely explanation for the development of the angiographic and clinical phenomena.