Professor Beijing is an expert in the treatment of smog in China, and I would like to recommend his wonderful scientific Q&A in this area.
Smoke disease, like cerebral infarction and cerebral hemorrhage, is a kind of cerebrovascular disease, not a strange disease.
Patient: Recently the doctor said I have smog disease, but the name even sounds a bit funny, is my brain “smoke”?
Director Duan Lian: Smoke disease is a kind of cerebrovascular disease, also known as Moyamoya disease or spontaneous basilar artery ring occlusion, is a disease characterized by slow thickening of the intima of the arteries at the end of the internal carotid artery and the beginning of the anterior and middle cerebral arteries, gradual narrowing of the arterial lumen and even occlusion, and compensatory dilation of the penetrating arteries at the base of the brain, the dilation of the blood vessels in the form of angiography like the curling smoke coming out of the chimney In Japanese, the word “floating smoke” is pronounced moyamoya, so Japanese doctors Suzuki and Takaku first reported it in 1969 and called it moyamoya disease, which translates to smoke disease. In layman’s terms, the disease is caused by a blockage of the main blood vessels supplying the brain, resulting in a series of symptoms caused by ischemia in the brain.
Patient: How come I have never heard of this disease before, is it a very special kind of strange disease?
Director Duan Lian: Smog, like cerebral infarction and cerebral hemorrhage, is a kind of cerebrovascular disease, and is not a strange disease. Smoke disease is a disease that was only recognized in the 1960s, and the general public in China lacks knowledge of this disease. Even many primary care doctors do not know about smog, so most of the smog patients are not diagnosed, not to mention treated. In fact, our survey found that the incidence of smog is not low in China. It is mostly found in children and young people under 40 years old.
Patient: What causes smog?
Director Duan Lian: The cause of smog is still not very clear. The incidence of smog is 42 times higher among siblings and 37 times higher in children of patients than in normal people, and recently it was found that the occurrence of smog is related to genetic abnormalities of chromosomes. Therefore, some scholars believe that the occurrence of smog may have a genetic relationship. In the past, head and neck infections were thought to be the cause of smog, but statistical analysis of large numbers of cases showed no correlation between the occurrence of smog and these local infections. In conclusion the etiology of smog is not well understood. There is a genetic link, but also a possible link with infections, autoimmune status, and growth environment.
Patient: Is this disease hereditary? What kind of people are prone to this disease?
Director Duan Lian: According to our findings, smog has a tendency to occur in families, and many families with smog have been found. Therefore, the family members of smog patients should also be examined to rule out asymptomatic smog. Some areas have a high incidence of smog, such as Shandong, Hebei, and some areas of Heilongjiang. In particular, there are many patients concentrated in certain villages. This may be related to the environment.
Unexplained headache, limb weakness, numbness, aphasia, cerebral infarction or cerebral hemorrhage should be considered smog.
Patients: What are the symptoms that make me wonder if I have smog? What are the symptoms of smog?
Director Duan Lian: The symptoms of smog can be broadly divided into two types: cerebral ischemia caused by occlusion of the internal carotid artery and cerebral hemorrhage induced by the rupture of compensatory dilated smoke-like vessels. According to the severity of the disease, there are 6 types. The milder ones show transient transient cerebral ischemia, headache, epilepsy, limb weakness, sensory abnormalities and visual field changes, while the more severe ones start with cerebral infarction or cerebral hemorrhage and become life-threatening.
Generally speaking, children or adults with unexplained headache, limb weakness, numbness, or aphasia should consider whether it is smog and need to go to the hospital for further examination.
It is especially important to note that some children have low intelligence and slow development, also due to brain ischemia and poorly developed brain tissue caused by smog. There are also some patients with mental abnormalities and psychiatric disorders that have been found to be caused by smog.
If smog is not treated in a timely manner, cerebral infarction can occur in severe cases, which is known as stroke in Chinese medicine. After a cerebral infarction, there will be hemiplegia, inability to speak clearly or to speak, and some people may have reduced vision, difficulty seeing, or visual field defects. There are other less common symptoms, such as inability to extend the tongue and difficulty swallowing. In severe cases, disorders of consciousness may occur.
There are also a few patients who start with cerebral hemorrhage. Patients with hemorrhagic type, who usually act like normal people with no or few discomfort symptoms, have sudden onset of severe headache followed by nausea and vomiting, and soon become comatose. Upon arrival at the hospital, it is a cerebral hemorrhage, and then further examination is due to brain hemorrhage caused by smog. This part of the patient’s condition is very serious, and the serious ones are in a coma all the time, or even if they wake up, they have serious functional impairment.
Patient: I heard that eating noodles can also cause smog?
Director Duan Lian: Many parents of children with smoker’s disease would say, “My child had an attack after eating noodles, what is the reason for this? The reason is very simple, because there is a sucking action when we eat noodles, and this action will cause an increase in gas exchange, called hyperventilation. This is because after hyperventilation can cause cerebral vasospasm and cerebral ischemia. In normal people, the compensatory capacity of the cerebral blood vessels is good, even if the blood vessels are slightly spasmed, it can be corrected quickly, and the brain tissue is more tolerant to the lack of oxygen. This is not the case for smoky patients. Even a little bit of ischemia and vascular spasm can cause limb weakness, aphasia, limb numbness, and other symptoms.
Many children also have limb weakness and numbness when they play games, or after a tantrum or crying, also because the excitability of brain tissue increases after crying and oxygen consumption increases, but the blood vessels cannot increase the intracranial blood supply because of hyperventilation spasm, so the performance of cerebral ischemia, limb weakness, speech impairment, limb numbness, etc. is produced.
Patient: Since smog is a blockage of cerebral blood vessels causing cerebral ischemia, why are some patients with cerebral hemorrhage also smog?
Director Duan Lian: There are many causes of cerebral hemorrhage, the common ones are hypertensive cerebral hemorrhage, subarachnoid hemorrhage, ruptured aneurysm hemorrhage and so on. Smoky brain hemorrhage is also one of the causes. Because of intracranial vascular malformations in smog patients, the structure of the blood vessels themselves is unhealthy, and they can have poor vascular elasticity, increased brittleness, or even form tiny aneurysms. These unhealthy blood vessels often then rupture and bleed. After bleeding, the patient will exhibit severe headache, nausea, vomiting, and neck pain. In severe cases, they may become unconscious. Patients with brain hemorrhage from smog are mostly young adults in their 30s and 40s. Therefore, for unexplained cerebral hemorrhage in young adults, it is important to think if it is due to smog.
Patient: How to diagnose smog?
Director Duan Lian: In terms of clinical symptoms, if children or adults have unexplained headache, limb weakness, numbness, aphasia, or brain hemorrhage, they should consider whether it is due to smog. There are many diagnostic tools available, and CT and MRI images can show ischemic or hemorrhagic changes in the brain. Further MRA or DSA examinations can confirm the diagnosis if there is bilateral stenosis or occlusion of the internal carotid arteries with smoke-like vascular formation. If smog is suspected, cerebral angiography, which is also the gold standard for the diagnosis of smog, is advisable. For evaluation of the patient’s condition, a series of further tests such as brain Doppler ultrasound and PET are required.
It is important to emphasize that smog must be a bilateral lesion with an unknown etiology. Therefore, unilateral cerebrovascular disease or disease due to leukoaraiosis, arteritis, encephalitis, lupus erythematosus, and other clear causes cannot be diagnosed as smog.
Many of the patients I see present with symptoms such as hemiplegia and numbness of the limbs without being able to find out the cause. All that is needed is an additional angiogram during the MRI to make a clear diagnosis. However, it is sad to see that many patients have not been diagnosed in time and delayed treatment because of such a small number of tests. This leads to severe disability and serious consequences for the family and the person.
There is a way to treat smoky disease
Patient: I’ve been to many hospitals and they all say there is no cure for smog, is that right?
Director Duan Lian: Many doctors in China used to think that smog is untreatable. Many patients were diagnosed with smog, and the doctors’ helplessness caused great fear to the patients, and some of them even felt desperate and lightly died. In fact, smog is currently treatable, and early treatment can be very effective.
Because smog was first discovered by the Japanese in the 1960s, Japan has done more research in this area. They have carried out indirect vascular bypass surgery to treat smog with good results. Some of the young patients with smog had no sequelae after the treatment, participated in life normally, and even got into famous universities.
I studied with Mr. Yoshiharu Matsushima, a master of smog treatment in Japan, and after returning to China in 2003, I also carried out surgical treatment for smog. Through observation, I found that the results of patients in China were very encouraging after undergoing the surgery. There are patients who are comatose and have been able to go to school normally after treatment. There are also children who are mentally retarded and can communicate normally with people after surgery, and their intelligence has improved significantly. There are also some patients with hemiplegia who can walk normally after treatment.
Patient: Some people say that smog can heal on its own, so is it okay for smog patients to go untreated?
Director of Exercise: Some scholars believe that smog can heal spontaneously because after occlusion of the internal carotid artery in smog patients, the extracranial or other blood vessels can spontaneously grow into the ischemic area, and when the blood supply from the extracranial to the intracranial spontaneously growing vessels can meet the blood supply of the brain, it is considered spontaneous healing. However, it must be noted that during the long process of “self-healing”, the patient is likely to suffer from irreversible dysfunction of limb movement, speech impairment, mental decline, or cerebral hemorrhage, which has brought about serious consequences. Therefore, both as a doctor and as a patient, once smog is detected, it is important to actively go for treatment and promote early recovery to avoid sequelae.
Patient: How can smog be treated?
Director Duan Lian: At present, it is generally believed that for smog disease, medical treatment is ineffective. The main treatment for smog is surgery. Nowadays, many surgical methods have been developed to treat smog: direct vascular anastomosis, reconstruction of indirect intracranial and extracranial blood supply, cranial drilling, and large omental patching. Through observation, we believe that indirect intracranial and extracranial revascularization surgery is effective and less invasive, so this is the most popular surgical method.
Patient: What are the characteristics of this surgery?
Director Duan Lian: Compared with the traditional methods of treating smog, such as superficial temporal artery-middle cerebral artery anastomosis, the dural superficial temporal artery fusion is an indirect bypass surgery. It is safer than traditional treatment methods because it does not destroy the original blood supply vessels and brain tissue. In addition, depending on the patient’s condition, we choose different treatment modalities for individualized treatment, which greatly improves the safety of the procedure. In many patients, post-operative review reveals that the fused vessels are fully able to grow fully into the brain tissue and provide blood supply to the entire cerebral hemisphere.
Patients: Is it possible for patients with any condition, regardless of gender, young or old, to undergo surgery?
Director Duan Lian: Generally speaking, this is the case. The youngest patient we have treated is 2 years old, and the oldest is 74 years old. The most severe patients have fallen into coma, and the least severe have no symptoms at all. Therefore, the scope of this surgery is very wide. The timing of surgical intervention varies from patient to patient and is determined by the specialist.
Patient: Smog is a bilateral vascular abnormality, so does the surgery need to be done bilaterally?
Director of Exercise: If the diagnosis of smog is confirmed, bilateral surgery must be performed. Otherwise, if only one side is done and not the opposite side, then it is only half cured and the other half of the brain tissue may still develop.
Patient: How do I know the treatment is effective?
Director Duan Lian: First of all, in terms of clinical symptoms, since smog is a chronic disease that is constantly aggravated, we can consider the surgery effective when the clinical symptoms are relieved or no longer progress, for example, patients with transient ischemic attack no longer have symptoms such as numbness and weakness of the limbs, or the number and degree of symptom attacks are reduced. In patients who have had a cerebral infarction, the strength of the paralyzed limb is improved, or the speech function is restored in patients with speech impairment. In patients with cerebral hemorrhage, consciousness is restored with treatment and no subsequent hemorrhage occurs.
Objective examination can be done by nuclear magnetic, cerebrovascular ultrasound, cerebral angiography, cranial PET and other examinations to observe that the metabolism of brain tissue is improved and the blood vessels moved to the skull by surgery supply blood to the skull, then the operation is successful.
We summarize the law and find that if those patients with cerebral ischemia, especially children, can be detected, diagnosed and treated early, the effect is very good. For patients with cerebral hemorrhage can also prevent recurrence of cerebral hemorrhage.
Patient: What should I pay attention to in post-operative rehabilitation of patients with smog?
Director Duan Lian: First of all, there is nothing contraindicated in the diet of smog patients. However, when eating too hot food such as noodles as mentioned earlier, it can cause the onset of the disease due to constant blowing, which can easily lead to hyperventilation.
Also from life, pay attention to increase and decrease clothing according to the weather, don’t get cold and don’t get stuffy. Avoid glasses with excessively tight legs to prevent pinching of the blood vessels introduced into the skull. Pay attention to avoid trauma to the head and face, which aggravates the disease.
For patients with physical activity disorders and speech disorders, active rehabilitation should be carried out. Modern people have a new understanding of brain rehabilitation. Especially for patients with smoker’s disease, because many nerve cells are not necrotic due to ischemia, but only temporarily produce dysfunction, after surgery, due to the rich blood supply is likely to recover, then we should actively exercise, rehabilitation training. Even with hemiplegia, partial recovery can be achieved through active training. The specific ones include speech training, active limb movement training, passive training, physical therapy, etc.
Patients with smoker’s disease should also be aware that if they have a serious illness, such as surgery, special medication, or if a female patient is pregnant or has a child, they should be aware of the impact on the disease itself and ask their doctor if necessary.
What needs the family’s attention is to help the patient build up self-confidence psychologically and believe that he or she can recover. Get rid of depression, anxiety and other negative psychological effects. Encourage the patient to be more involved in social life.