The neurosurgical management of Severe Hemophilia A and Moyamoya (SHAM): challenges, strategies, and literature review

Risheng Xu, Anita L. Kalluri, Lisa R. Sun, Courtney E. Lawrence, Jennifer K. Lee, Sujatha Kannan, Alan R. Cohen

Research output: Contribution to journalReview articlepeer-review


Introduction: Severe Hemophilia A and Moyamoya arteriopathy (SHAM syndrome) is a rare genetic disorder caused by deletion of portions of the cytogenic band Xq28. A case of SHAM syndrome requiring bilateral cerebral revascularization is described with an emphasis on perioperative management. Case report: A 5-year-old boy with severe hemophilia A complicated by factor VIII inhibition presented with right-sided weakness. Imaging revealed multiple strokes and vascular changes consistent with Moyamoya disease. The patient underwent two-staged indirect cerebral bypass revascularizations, first on the left side and several months later on the right. Perioperative management required balancing the administration of agents to prevent coagulopathy and perioperative hemorrhage while mitigating the risk of thromboembolic events associated with bypass surgery. Despite a multidisciplinary effort by the neurosurgery, hematology, critical care, and anesthesiology teams, the post-operative course after both surgeries was complicated by stroke. Fortunately, the patient recovered rapidly to his preoperative functional baseline. Conclusion: We describe a rare case of SHAM syndrome in a pediatric patient who required bilateral revascularizations and discuss strategies for managing the perioperative risk of hemorrhage and stroke. We also review existing literature on SHAM syndrome.

Original languageEnglish (US)
Pages (from-to)1077-1084
Number of pages8
JournalChild's Nervous System
Issue number6
StatePublished - Jun 2022


  • Coagulopathy
  • Hemophilia
  • Indirect bypass
  • Revascularization

ASJC Scopus subject areas

  • Clinical Neurology
  • Pediatrics, Perinatology, and Child Health


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