Association Between Folate Metabolism Risk, Collateral Circulation, and Hemorrhagic Risk in Moyamoya Disease

Translational Stroke Research https://doi.org/10.1007/s12975-024-01324-y RESEARCH Association Between Folate Metabolism Risk, Collateral Circulation, and Hemorrhagic Risk in Moyamoya Disease Junsheng Li1,2 · Qiheng He1,2 · Chenglong Liu1,2 · Chaofan Zeng1,2 · Zhiyao Zheng1,2 · Bojian Zhang1,2 · Siqi Mou1,2 · Wei Liu1,2 · Wei Sun1,2 · Peicong Ge1,2 · Dong Zhang3 · Jizong Zhao1,2 Received: 27 August 2024 / Revised: 17 December 2024 / Accepted: 29 December 2024 © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2025 Abstract Methylenetetrahydrofolate reductase (MTHFR) and methionine synthase reductase (MTRR) polymorphisms are known risk factors for vascular diseases due to the impact on folate metabolism dysfunction and homocysteine (Hcy) accumulation. This study aimed to investigate the association between folate metabolism risk and hemorrhagic risk in moyamoya disease (MMD). In this prospective study, we enrolled 350 MMD patients with complete genotype data for MTHFR and MTRR. Patients were divided into non-hemorrhagic and hemorrhagic MMD groups. Folate metabolism risk was classified into three levels according to genotype configurations. We analyzed the association between folate metabolism risk and hemorrhagic risk in MMD. Furthermore, the association between folate metabolism risk, collateral circulation, and periventricular anastomosis (PA) was assessed. In vitro experiments were conducted on HBMECs to explore the potential mechanism. TT genotype and T allele in MTHFR C677T were significantly associated with a lower risk of hemorrhage, whereas AC genotype and C allele in MTHFR A1298C were significantly linked to a higher risk of hemorrhage. Patients with high folate metabolism risk exhibited a significantly decreased risk of hemorrhage compared to those with low folate metabolism risk. Further analyses demonstrated that high folate metabolism risk was significantly correlated with poor collateral circulation and PA dilation and elevated levels of Hcy. In vitro experiments showed that increased Hcy levels significantly inhibited the proliferation, migration, and tube formation of HBMECs. This study identified a significant negative correlation between folate metabolism risk and hemorrhagic risk in MMD. URL: http://www.chictr.org.cn. Unique identifier: ChiCTR2200061889. Keywords Moyamoya disease · Hemorrhage · Folate metabolism · Homocysteine · Collateral circulation Introduction Junsheng Li and Qiheng He contributed equally to this work. * Peicong Ge * Dong Zhang * Jizong Zhao 1 Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 Nan Si Huan Xi Road, Fengtai District, Beijing, China 2 China National Clinical Research Center for Neurological Diseases, Beijing, China 3 Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, No. 1 Da Hua Road, Dong Dan, Dongcheng District, Beijing, China Moyamoya disease (MMD) stands as a chronic, progressive cerebrovascular disorder first described in 1969 [1]. It is characterized by spontaneous progressive stenosis or occlusion of the terminal segments and major branches of the internal carotid arteries, accompanied by the development of fragile basal collateral network. These vessels exhibit a smoky appearance on cerebral angiography, which inspired the term “moyamoya” [2, 3]. MMD is a significant cause of both ischemic and hemorrhagic strokes, with a notably higher incidence in East Asian populations, particularly in China, Japan, and South Korea. While its precise etiology remains unclear, current evidence suggests a complex interplay of genetic, immune, metabolic, environmental, and other factors [4, 5]. Clinically, MMD manifests with ischemic or hemorrhagic symptoms due to reduced cerebral Vol.:(0123456789) Translational Stroke Research blood flow and the fragility of collateral vessels. Compared to the non-hemorrhagic form, hemorrhagic MMD leads to a higher rate of disability and mortality due to intracranial hemorrhage. Therefore, it has been essential to explore potential risk factors for hemorrhage in MMD patients. Emerging evidence has highlighted a significant relationship between elevated homocysteine (Hcy) levels and the risk and prognosis of MMD [6, 7]. Folate deficiency or decreased activity of critical enzymes involved in folate metabolism is the main cause of Hcy accumulation leading to hyperhomocysteinemia (HHcy). Methylenetetrahydrofolate reductase (MTHFR) and methionine synthase reductase (MTRR) play a key role. Variations in MTHFR and MTRR could lead to decreased enzyme activity. MTHFR facilitates the conversion of 5,10-methylenetetrahydrofolate (5,10-MTHF) to 5-methyltetrahydrofolate (5-MTHF), serving as a crucial donor of one-carbon units essential for the remethylation of Hcy to methionine (Met) by methionine synthase (MS). The functional activity of MS might be compromised by the oxidation of its cob(I)alamin cofactor to the cob(II)alamin form, and MTRR could restore this by reductive methylation of cob(II)alamin [8]. A genome-wide association study has identified MTHFR as a novel susceptibility gene for MMD, suggesting a potential involvement of folate metabolism impairment in the initiation and progression of MMD [9]. Additionally, previous studies have explored the link between MTHFR variants and intracranial hemorrhage, revealing significant correlations between MTHFR C677T, A1298C polymorphisms, and an increased risk of intracranial hemorrhage [10–12]. However, the specific association between folate metabolism risk and hemorrhagic risk in MMD has hardly been studied. In this study, we analyzed the prevalence of MTHFR C677T, A1298C, and MTRR A66G genotypes to assess their association with the hemorrhagic risk in MMD. We further classified these genotypes into distinct folate metabolism risk categories and investigated their correlation with hemorrhagic risk in MMD. To explore potential mechanisms, we analyzed the angiographic features across different risk levels and conducted in vitro experiments, providing further insights into the relationship between folate metabolism risk and hemorrhagic risk in MMD. Material and Methods Study Participants In this prospective study, we consecutively recruited 500 patients with MMD-type cerebrovascular disease from September 2020 to December 2021. Diagnoses were based on the 2012 Japanese guidelines for MMD using digital subtraction angiography (DSA) [13]. After excluding 82 pediatric MMD patients, 48 unilateral MMD patients, and 20 patients with incomplete genotype data, a total of 350 MMD patients were eventually included in the study. Subsequently, all patients were divided into two groups based on the presence or absence of intracranial hemorrhage, including 254 patients in the non-hemorrhagic MMD group and 96 patients in the hemorrhagic MMD group. The non-hemorrhagic MMD group included both ischemic MMD patients and asymptomatic MMD (...truncated)