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Sun T, Zeng Q, Huang L, Sun J, Wu Z, Zhang B, Ling C, Chen C, Wang H. Exploration of the risk factor for infarction after revascularization in moyamoya disease. Ann Med 2024; 56:2362872. [PMID: 38913594 PMCID: PMC11198149 DOI: 10.1080/07853890.2024.2362872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 05/02/2024] [Indexed: 06/26/2024] Open
Abstract
RESULTS Eventually, 108 consecutive patients received 174 surgeries were enrolled, experienced new or expanded infarction occured in 13 (7.47%) surgeries, which showed higher Suzuki stage on the non-operative side, more posterior cerebral artery (PCA) involvement, and more intraoperative hypotension compared to those without infarction(p < .05). The Suzuki stage on the non-operative side had the highest area under the curve (AUC) of 0.737, with a sensitivity of 0.692 and specificity of 0.783. Combination of the three factors showed better efficiency, with an AUC of 0.762, a sensitivity of 0.692, and a specificity of 0.907. CONCLUSIONS Revascularization was a safe option for patients with MMD, higher Suzuki stage on the non-operative side, PCA involvement, and intraoperative hypotension might be the risk factors for new or expanded infarction after revascularization in patients with MMD.
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Affiliation(s)
- Tao Sun
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Qiuhua Zeng
- Department of Radiology, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Lixin Huang
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jun Sun
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Zhimin Wu
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Baoyu Zhang
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Cong Ling
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Chuan Chen
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Hui Wang
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
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Hu B, Gao J, Lu Y, Wang Y. Applications of Degradable Hydrogels in Novel Approaches to Disease Treatment and New Modes of Drug Delivery. Pharmaceutics 2023; 15:2370. [PMID: 37896132 PMCID: PMC10610366 DOI: 10.3390/pharmaceutics15102370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/03/2023] [Accepted: 09/07/2023] [Indexed: 10/29/2023] Open
Abstract
Hydrogels are particularly suitable materials for loading drug delivery agents; their high water content provides a biocompatible environment for most biomolecules, and their cross-linked nature protects the loaded agents from damage. During delivery, the delivered substance usually needs to be released gradually over time, which can be achieved by degradable cross-linked chains. In recent years, biodegradable hydrogels have become a promising technology in new methods of disease treatment and drug delivery methods due to their many advantageous properties. This review briefly discusses the degradation mechanisms of different types of biodegradable hydrogel systems and introduces the specific applications of degradable hydrogels in several new methods of disease treatment and drug delivery methods.
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Affiliation(s)
- Bo Hu
- Department of Medicinal Chemistry, College of Pharmaceutical Sciences, Capital Medical University, Beijing 100069, China; (B.H.); (J.G.)
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs, Engineering Research Center of Endogenous Prophylactic, Ministry of Education of China, Beijing Laboratory of Biomedical Materials, Beijing 100069, China
| | - Jinyuan Gao
- Department of Medicinal Chemistry, College of Pharmaceutical Sciences, Capital Medical University, Beijing 100069, China; (B.H.); (J.G.)
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs, Engineering Research Center of Endogenous Prophylactic, Ministry of Education of China, Beijing Laboratory of Biomedical Materials, Beijing 100069, China
| | - Yu Lu
- Department of Medicinal Chemistry, College of Pharmaceutical Sciences, Capital Medical University, Beijing 100069, China; (B.H.); (J.G.)
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs, Engineering Research Center of Endogenous Prophylactic, Ministry of Education of China, Beijing Laboratory of Biomedical Materials, Beijing 100069, China
- Laboratory for Clinical Medicine, Capital Medical University, Beijing 100069, China
| | - Yuji Wang
- Department of Medicinal Chemistry, College of Pharmaceutical Sciences, Capital Medical University, Beijing 100069, China; (B.H.); (J.G.)
- Beijing Area Major Laboratory of Peptide and Small Molecular Drugs, Engineering Research Center of Endogenous Prophylactic, Ministry of Education of China, Beijing Laboratory of Biomedical Materials, Beijing 100069, China
- Laboratory for Clinical Medicine, Capital Medical University, Beijing 100069, China
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Chen Y, Gong X, Yang Z, Chen F, Wang J. Risk factors and a novel cerebral infarction extent scoring system for postoperative cerebral ischemia in patients with ischemic Moyamoya disease. Sci Rep 2023; 13:5726. [PMID: 37029162 PMCID: PMC10082086 DOI: 10.1038/s41598-022-26985-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 12/22/2022] [Indexed: 04/09/2023] Open
Abstract
Postoperative cerebral ischemic complication is the most common complication of revascularization surgery for patients with moyamoya disease (MMD). This retrospective study was conducted on 63 patients with ischemic MMD. Postoperative ischemia occurred in 15 of the 70 revascularization operations performed for patients after surgical revascularization, translating to an incidence of 21.4%. Univariate analysis revealed that onset infarction (p = 0.015), posterior cerebral artery involvement (p = 0.039), strict perioperative management (p = 0.001), interval time between transient ischemic attack (TIA) or infarction presentation and operation (p = 0.002) and preoperatively cerebral infarction extent score (CIES) (p = 0.002) were significantly associated with postoperative cerebral ischemia. Multivariate analysis revealed that strict perioperative management (OR = 0.163; p = 0.047), and preoperatively CIES (OR = 1.505; p = 0.006) were independently associated with postoperative cerebral ischemia-related complications. After comprehensive improvement of perioperative management protocol, the incidence of symptomatic infarction declined to 7.4% (4 out of 54). Analysis of the area under the receiver operating characteristic curve (AUROC) indicated CIES was a predictor for both postoperative ischemia and high follow-up modified Rankin Scale scores. In summary, strict perioperative management and CIES were identified as independent risk factors for postoperative ischemic complications in ischemic MMD, demonstrating that comprehensive and individualized perioperative management improve postoperative outcomes in patients with MMD. Furthermore, application of CIES to evaluate pre-existing cerebral infarction can improve the management of patients.
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Affiliation(s)
- Yuanbing Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xuan Gong
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zeng Yang
- Department of Neurosurgery, The First People's Hospital of Changde, Changde, Hunan, China
| | - Fenghua Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China.
| | - Junyu Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China.
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The First 24 h Hemodynamic Management in NICU after Revascularization Surgery in Moyamoya Disease. Behav Neurol 2021; 2021:5061173. [PMID: 34691282 PMCID: PMC8536456 DOI: 10.1155/2021/5061173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/25/2021] [Indexed: 11/18/2022] Open
Abstract
Objective To evaluate whether hemodynamic factors are risk factors for prognosis in moyamoya disease (MMD). Materials and Methods The retrospective study reviewed a single-center MMD cohort in Huashan Hospital from August 2017 to January 2020. Stroke events in 30 days and follow-up modified Rankin Scale (mRS) grade were recorded. Systematic assessments with perioperative mean arterial pressure (MAP), red blood cell (RBC) parameters, and fluid management were also conducted. Logistic regressions were applied to evaluate the predictors of worse outcomes. Data was analyzed using SPSS 24.0. Results Admission to neurological intensive care unit (NICU) totalled about 347 after revascularization surgery. The result showed that the higher the postoperative MAP level (favorable group 95.7 ± 11.4 mmHg vs. unfavorable group 103.6 ± 10.4 mmHg, p < 0.001) and the greater the MAP variability (favorable group 0.26 ± 13.2 vs. unfavorable group 7.2 ± 13.5, p = 0.006) were, the higher the patient's follow-up mRS grade was. What is more, a higher early postoperative Hb level also seemed to predict a worse long-term clinical outcome (favorable group 116.9 ± 17.1 g/L vs. unfavorable group 123.7 ± 13.0 g/L, p = 0.03), but the difference disappeared after adjusting sex and age. Logistic regression analyses showed that a higher level of postoperative MAP (β = 0.024, 95% CI (0.004, 0.044), and p = 0.02) within the first 24 h in NICU might be the short-term risk factor. For long-term outcome, a higher level (β = 1.058, 95% CI (1.022, 1.096), and p = 0.001) and a greater variability (β = 30.982, 95% CI (2.112, 454.414), and p = 0.01) of postoperative MAP might be the negative predictors of mRS grade. Conclusions The early postoperative hemodynamic management might be extremely critical for patients with MMD. Both high postoperative MAP levels and large MAP variability might affect the prognosis. What is more, we also found that a higher postoperative Hb level might be related with a worse outcome.
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Ahmed SU, Lee H, Steinberg GK. Commentary: Direct vs Indirect Revascularization in a North American Cohort of Moyamoya Disease. Neurosurgery 2021; 89:E114-E115. [PMID: 33957669 DOI: 10.1093/neuros/nyab165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 12/20/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Syed Uzair Ahmed
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine and Stanford Health Care, Stanford, California, USA
| | - Hubert Lee
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine and Stanford Health Care, Stanford, California, USA
| | - Gary K Steinberg
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine and Stanford Health Care, Stanford, California, USA
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Blood Pressure and Transient Postoperative Neurologic Deterioration, Following Superficial Temporal-to-Middle Cerebral Artery Anastomosis in Adult Patients with Moyamoya Disease: A Retrospective Cohort Study. J Clin Med 2021; 10:jcm10122567. [PMID: 34200622 PMCID: PMC8227225 DOI: 10.3390/jcm10122567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/28/2021] [Accepted: 06/07/2021] [Indexed: 11/17/2022] Open
Abstract
We investigated whether intraoperative systolic blood pressure (ISBP) is associated with the risk of transient neurologic deficits (TND) following superficial temporal-to-middle cerebral artery (STA-MCA) anastomosis in adult patients with moyamoya disease (MMD). In this retrospective observational study, data from adult patients with MMD who had undergone STA-MCA anastomosis at a single tertiary academic hospital during May 2003–April 2014 were examined. Data on patient characteristics were obtained from electronic medical records, including the details of comorbidities and laboratory findings. TND was the primary outcome of interest. Out of 192 patients (228 hemispheres), 66 (29%) hemispheres had TND after surgery. There were significant differences in ISBP between patients with and without TND. The lowest ISBP quartile was independently associated with TND (odds ratio: 5.50; 95% confidence interval: 1.96–15.46). Low ISBP might lead to TND after STA-MCA anastomosis in adult patients with MMD. In patients with poor perfusion status, low ISBP was associated with an increased risk of TND. Our findings suggest that strict ISBP control might be required to prevent TND after anastomosis in patients with MMD, in particular, in patients with poor perfusion status. Given limitations due to the retrospective design, further studies are needed to clarify these findings.
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Characteristics of Moyamoya Disease in the Older Population: Is It Possible to Define a Typical Presentation and Optimal Therapeutical Management? J Clin Med 2021; 10:jcm10112287. [PMID: 34070336 PMCID: PMC8197522 DOI: 10.3390/jcm10112287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 12/17/2022] Open
Abstract
Whereas several studies have been so far presented about the surgical outcomes in terms of mortality and perioperative complications for elderly patients submitted to neurosurgical treatments, the management of elderly moyamoya patients is unclear. This review aims to explore the available data about the clinical manifestation, characteristics, and outcome after surgery of older patients with moyamoya arteriopathy (MA). We found only two articles strictly concerning elderly patients with MA. We have also evaluated other reported adult series of moyamoya patients, including elderly cases in their analysis. Patients with MA above 50 years old may be considered a peculiar subset in which patients are often presenting with ischemic symptoms and a higher Suzuki grade. Conservative treatment may be proposed in asymptomatic or stable cases due to their fragility and possible increase of post-operative complications, while the best surgical options in symptomatic cases are still under investigation, although we believe that a minimal invasive superficial temporal artery—middle cerebral artery bypass could be considered the treatment of choice for the immediate effect on brain perfusion with a limited rate of post-operative complications.
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Nielsen TH, Abhinav K, Sussman ES, Han SS, Weng Y, Bell-Stephens T, Heit JJ, Steinberg GK. Direct versus indirect bypass procedure for the treatment of ischemic moyamoya disease: results of an individualized selection strategy. J Neurosurg 2021; 134:1578-1589. [PMID: 32534489 DOI: 10.3171/2020.3.jns192847] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The only effective treatment for ischemic moyamoya disease (iMMD) is cerebral revascularization by an extracranial to intracranial bypass. The preferred revascularization method remains controversial: direct versus indirect bypass. The purpose of this study was to test the hypothesis that method choice should be personalized based on angiographic, hemodynamic, and clinical characteristics to balance the risk of perioperative major stroke against treatment efficacy. METHODS Patients with iMMD were identified retrospectively from a prospectively maintained database. Those with mild to moderate internal carotid artery or M1 segment stenosis, preserved cerebrovascular reserve, intraoperative M4 segment anterograde flow ≥ 8 ml/min, or the absence of frequent and severe transient ischemic attacks (TIAs) or stroke had been assigned to indirect bypass. The criteria for direct bypass were severe ICA or M1 segment stenosis or occlusion, impaired cerebrovascular reserve or steal phenomenon, intraoperative M4 segment retrograde flow or anterograde flow < 8 ml/min, and the presence of frequent and severe TIAs or clinical strokes. The primary study endpoint was MRI-confirmed symptomatic stroke ≤ 7 days postoperatively resulting in a decline in the modified Rankin Scale (mRS) score from preoperatively to 6 months postoperatively. As a secondary endpoint, the authors assessed 6-month postoperative DSA-demonstrated revascularization, which was classified as < 1/3, 1/3-2/3, or > 2/3 of the middle cerebral artery territory. RESULTS One hundred thirty-eight patients with iMMD affecting 195 hemispheres revascularized in the period from March 2016 to June 2018 were included in this analysis. One hundred thirty-three hemispheres were revascularized with direct bypass and 62 with indirect bypass. The perioperative stroke rate was 4.7% and 6.8% in the direct and indirect groups, respectively (p = 0.36). Degree of revascularization was higher in the direct bypass group (p = 0.03). The proportion of patients improving to an mRS score 0-1 (from preoperatively to 6 months postoperatively) tended to be higher in the direct bypass group, although the difference between the two bypass groups was not statistically significant (p = 0.27). CONCLUSIONS The selective use of an indirect bypass procedure for iMMD did not decrease the perioperative stroke rate. Direct bypass provided a significantly higher degree of revascularization. The authors conclude that direct bypass is the treatment of choice for iMMD.
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Affiliation(s)
- Troels H Nielsen
- 1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine
| | - Kumar Abhinav
- 1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine
| | - Eric S Sussman
- 1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine
| | - Summer S Han
- 1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine
- 2Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine; and
| | - Yingjie Weng
- 2Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine; and
| | | | - Jeremy J Heit
- 3Department of Radiology, NeuroInterventional Radiology Section, and Stanford Stroke Center, Stanford University School of Medicine, Stanford, California
| | - Gary K Steinberg
- 1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine
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Song T, Liu X, Han R, Huang L, Zhang J, Xu H. Effects of end-tidal carbon dioxide levels in patients undergoing direct revascularization for Moyamoya disease and risk factors associated with postoperative complications. Medicine (Baltimore) 2021; 100:e24527. [PMID: 33607783 PMCID: PMC7899818 DOI: 10.1097/md.0000000000024527] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 01/05/2021] [Indexed: 01/05/2023] Open
Abstract
A history of transient ischemic attack, severity of disease, urinary output, hematocrit, hypocapnia, and hypotension during direct revascularization (superficial temporal artery to middle cerebral artery [STA-MCA]) in patients with Moyamoya disease (MMD) may lead to a poor prognosis, however, to our knowledge evidence for end-tidal carbon dioxide (ETCO2) targets is lacking. Within the ranges of standardized treatment, the article was primarily designed to study the risk factors associated with the neurologic outcomes during STA-MCA for MMD especially including ETCO2 ranges and the duration in different groups. The primary goals of this study were to investigate the risk factors for neurologic deterioration and explore the association between ETCO2 ranges and neurologic outcome during general anesthesia for STA-MCA.This retrospective observational study included 56 consecutively adult Moyamoya patients who underwent STA-MCA under general anesthesia between January 2015 and August 2019. ETCO2 was summarized per patient every 5 minutes. Clinical outcome was assessed with clinical presentation, computed tomography findings, magnetic resonance imaging findings, cerebral angiography, and the modified Rankin Scale scores at discharge as main outcome measure. The outcomes were also compared for the duration of surgery, anesthesia, and the length of stay.A total of 56 patients were studied, all patients had comprehensive ETCO2 measurements. The incidence of postoperative complications was 44.6% (25/56). There was no association between age, sex, hypertension, diabetes, smoking history, drinking history, sevoflurane use, invasive arterial blood pressure monitoring, combined encephalomyosynangiosis and postoperative complications. Duration of surgery (P = .04), anesthesia (P = .036), hospital stay (P = .023) were significant correlates of postoperative complications. In the multiple logistic regression model, they were not the significant predictors. The ETCO2 ranges and the length of time in different groups within the current clinical setting was not associated with postoperative complications (P > .05).Within a standardized intraoperative treatment strategy, we found that postoperative complications had no significant correlation with sex, age, hypertension, diabetes, smoking history, drinking history, invasive arterial blood pressure monitoring, combined encephalomyosynangiosis, or sevoflurane use. Further, hypocapnia and hypercapnia during STA-MCA were not found to be associated with postoperative complications in patients with MMD.
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Affiliation(s)
- Tingting Song
- The First Hospital of Jilin University, Changchun, Jilin
| | - Xiancun Liu
- Linyi people's hospital, Linyi, Shandong, China
| | - Rui Han
- The First Hospital of Jilin University, Changchun, Jilin
| | - Lihua Huang
- The First Hospital of Jilin University, Changchun, Jilin
| | - Jingjing Zhang
- The First Hospital of Jilin University, Changchun, Jilin
| | - Haiyang Xu
- The First Hospital of Jilin University, Changchun, Jilin
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Ong JA, Low SY, Seow WT, Goh CP, Yeo TT, Chou N, Low DC, Nga V. Revascularisation surgery for paediatric moyamoya disease: The Singapore experience. J Clin Neurosci 2020; 82:207-213. [PMID: 33246909 DOI: 10.1016/j.jocn.2020.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/20/2020] [Accepted: 11/01/2020] [Indexed: 11/26/2022]
Abstract
Moyamoya disease (MMD) is characterized by the spontaneous occlusion of the distal internal carotid arteries and resultant neo-angiogenesis of fragile collateral blood vessels. Direct and indirect revascularization surgeries have shown to effectively reduce stroke risks in paediatric MMD, whereby the latter is a more utilised technique in children. This study was undertaken to determine the outcomes of revascularization in Singapore's multi-ethnic, Southeast Asian paediatric population. This is an ethics-approved study conducted in Singapore's 2 tertiary children hospital units: KK Women's and Children's Hospital and National University Hospital. Sixteen patients with a diagnosis of ischaemic-type MMD are recruited between 01 January 2002 to 31 January 2019; and a total of 24 surgeries are undertaken (24 cerebral hemispheres). There are 2 cases of stroke within 30 days post-surgery. However, no stroke recurrence is observed beyond 30 days after surgery in all patients. Four patients reported recurrent transient ischaemic attack symptoms in the follow-up period ranging from 3 months to 12 years. Data analyses show a statistically significant improvement in modified Rankin's Scale (mMRS) in post-operative patients from baseline to discharge, and at 3 months after surgery. Our study also observes that predictors of recurrent ischaemic events include higher pre-operative MRS, Suzuki stage and perioperative infarction. To the authors' knowledge, this is the first study to date reporting the outcomes of revascularisation in a paediatric Southeast Asian cohort.
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Affiliation(s)
- Jamie Ah Ong
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road Level 11, 119228, Singapore
| | - Sharon Yy Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, 11 Jalan Tan Tock Seng, 308433, Singapore.
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, 11 Jalan Tan Tock Seng, 308433, Singapore
| | - Chun Peng Goh
- Division of Neurosurgery, Department of Surgery, National University Hospital, 5 Lower Kent Ridge Rd, 119074, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Hospital, 5 Lower Kent Ridge Rd, 119074, Singapore
| | - Ning Chou
- Division of Neurosurgery, Department of Surgery, National University Hospital, 5 Lower Kent Ridge Rd, 119074, Singapore
| | - David Cy Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, 11 Jalan Tan Tock Seng, 308433, Singapore
| | - Vincent Nga
- Division of Neurosurgery, Department of Surgery, National University Hospital, 5 Lower Kent Ridge Rd, 119074, Singapore
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Li C, Zhang N, Yu S, Xu Y, Yao Y, Zeng M, Li D, Xia C. Individualized Perioperative Blood Pressure Management for Adult Moyamoya Disease: Experience from 186 Consecutive Procedures. J Stroke Cerebrovasc Dis 2020; 30:105413. [PMID: 33160127 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105413] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/11/2020] [Accepted: 10/14/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND In adult patients with moyamoya disease (MMD) underwent combined revascularization, cerebral infarction during the acute postoperative phase is common and can lead to neurological dysfunction after revascularization in MMD patients. The aim of this study was to share the experience of individualized perioperative blood pressure (BP) management for adult MMD patients in one single center. METHODS We retrospectively reviewed 144 adult patients with MMD who underwent 186 procedures of combined revascularization at our institution from March 2013 to July 2019. Clinical features and outcomes were analyzed, in particular regarding cerebral infarction and hyperperfusion syndrome (HPS). All of the patients received individualized management perioperatively, especially about the blood pressure management according to the characteristics of moyamoya disease. RESULTS Postoperative cerebral infarction and HPS within 14 days after revascularization were recorded. Cerebral infarction occurred in four (2.1%) procedures among four patients. No patients suffered from a malignant cerebral infarction and only one patient had permanent neurological deficits. The incidence of HPS was 10.8% and no one presented with intracranial hemorrhage. All of the symptoms were reversible without any brain parenchymal injury. CONCLUSIONS Our findings suggest that we can decrease the incidence and extent of cerebral infarction in adult MMD patients following combined revascularization by individualized perioperative BP management.
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Affiliation(s)
- Changwen Li
- Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui, 230036, China; Department of Neurosurgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, 230036, China
| | - Nan Zhang
- Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui, 230036, China; Department of Neurosurgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, 230036, China
| | - Shaojie Yu
- Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui, 230036, China; Department of Neurosurgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, 230036, China
| | - Yong Xu
- Department of Neurosurgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, 230036, China
| | - Yang Yao
- Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui, 230036, China; Department of Neurosurgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, 230036, China
| | - Minghui Zeng
- Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui, 230036, China; Department of Neurosurgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, 230036, China
| | - Dongxue Li
- Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui, 230036, China; Department of Neurosurgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, 230036, China
| | - Chengyu Xia
- Department of Neurosurgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui, 230036, China; Department of Neurosurgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, 230036, China.
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Sussman ES, Madhugiri V, Teo M, Nielsen TH, Furtado SV, Pendharkar AV, Ho AL, Esparza R, Azad TD, Zhang M, Steinberg GK. Contralateral acute vascular occlusion following revascularization surgery for moyamoya disease. J Neurosurg 2019; 131:1702-1708. [PMID: 30554188 DOI: 10.3171/2018.8.jns18951] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 08/03/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Revascularization surgery is a safe and effective surgical treatment for symptomatic moyamoya disease (MMD) and has been shown to reduce the frequency of future ischemic events and improve quality of life in affected patients. The authors sought to investigate the occurrence of acute perioperative occlusion of the contralateral internal carotid artery (ICA) with contralateral stroke following revascularization surgery, a rare complication that has not been previously reported. METHODS This study is a retrospective review of a prospective database of a single surgeon's series of revascularization operations in patients with MMD. From 1991 to 2016, 1446 bypasses were performed in 905 patients, 89.6% of which involved direct anastomosis of the superficial temporal artery (STA) to a distal branch of the middle cerebral artery (MCA). Demographic, surgical, and radiographic data were collected prospectively in all treated patients. RESULTS Symptomatic contralateral hemispheric infarcts occurred during the postoperative period in 34 cases (2.4%). Digital subtraction angiography (DSA) was performed in each of these patients. In 8 cases (0.6%), DSA during the immediate postoperative period revealed associated new occlusion of the contralateral ICA. In each of these cases, revascularization surgery involved direct anastomosis of the STA to an M4 branch of the MCA. Preoperative DSA revealed moderate (n = 1) or severe (n = 3) stenosis or occlusion (n = 4) of the ipsilateral ICA and mild (n = 2), moderate (n = 4), or severe (n = 2) stenosis of the contralateral ICA. The baseline Suzuki stage was 4 (n = 7) or 5 (n = 1). The collateral supply originated exclusively from the intracranial circulation in 4/8 patients (50%), and from both the intracranial and extracranial circulation in the remaining 50% of patients. Seven (88%) of 8 patients improved symptomatically during the acute postoperative period with induced hypertension. The modified Rankin Scale (mRS) score at discharge was worse than baseline in 7/8 patients (88%), whereas 1 patient had only minor deficits that did not affect the mRS score. At the 3-year follow-up, 3/8 patients (38%) were at their baseline mRS score or better, 1 patient had significant disability compared with preoperatively, 2 patients had died, and 1 patient was lost to follow-up. Three-year follow-up is not yet available in 1 patient. CONCLUSIONS Acute occlusion of the ICA on the contralateral side from an STA-MCA bypass is a rare, but potentially serious, complication of revascularization surgery for MMD. It highlights the importance of the hemodynamic interrelationships that exist between the two hemispheres, a concept that has been previously underappreciated. Induced hypertension during the acute period may provide adequate cerebral blood flow via developing collateral vessels, and good outcomes may be achieved with aggressive supportive management and expedited contralateral revascularization.
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13
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Ravina K, Kim PE, Rennert RC, Wolfswinkel EM, Strickland BA, Carey JN, Russin JJ. Lessons Learned from the Initial Experience with Pedicled Temporoparietal Fascial Flap for Combined Revascularization In Moyamoya Angiopathy: A Case Series. World Neurosurg 2019; 132:e259-e273. [PMID: 31491577 DOI: 10.1016/j.wneu.2019.08.182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/18/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The pedicled temporoparietal fascial flap (TPFF) with a direct superficial temporal (STA) artery to middle cerebral artery (MCA) bypass is a novel combined revascularization approach for moyamoya angiopathy (MMA). With this case series, we aim to report the initial experience with pedicled TPFF combined revascularization for MMA treatment. METHODS Data from 14 consecutive patients undergoing pedicled TPFF combined revascularization for MMA between May 2016 and December 2018 were retrospectively reviewed. Patients admitted with acute ischemia or a modified Rankin Scale (mRS) score >3 were considered high risk. RESULTS Mean ± standard deviation age on surgery was 41.9 ± 15.4 years. Three of 14 patients (21.4%) presented with an mRS score >3. Nine of 14 patients (64.3%) presented with ischemic stroke, 4 of whom (44.4%) had acute ischemia. Direct anastomosis patency was confirmed in all cases postoperatively. Mean hospitalization time was 13 ± 9.3 days and mean follow-up time was 14.1 ± 9.3 months. From admission to follow-up, neurologic status improved in 8 patients (57.1%) and stabilized in 6 patients (42.9%). Overall, 11/14 patients (78.6%) achieved good functional outcome (mRS score ≤2). All patients achieved some radiographic collateral development, with 5 (71.5%) graded as Matsushima A and B. Three patients developed new radiographic ischemia and 3 experienced wound complications, all in the high-risk group. CONCLUSIONS The TPFF combined approach is a viable strategy for revascularization in MMA. This technique may be suboptimal in patients presenting with acute ischemia and/or mRS score >3.
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Affiliation(s)
- Kristine Ravina
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Paul E Kim
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of California at San Diego, San Diego, California, USA
| | - Erik M Wolfswinkel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ben A Strickland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jonathan J Russin
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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14
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Chiarelli PA, Patel AP, Lee A, Chandra SR, Sekhar LN. Sternocleidomastoid Encephalomyosynangiosis for Treatment-Resistant Moyamoya Disease. Oper Neurosurg (Hagerstown) 2019; 17:E23-E28. [PMID: 30169838 DOI: 10.1093/ons/opy234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 07/31/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Refractory ischemic symptoms in moyamoya disease are a challenging problem, particularly in situations in which multiple direct and indirect revascularization techniques have already been employed. In addition, revascularization of the parietal lobes is difficult, as this area is a watershed between the middle cerebral artery and posterior cerebral artery distributions. CLINICAL PRESENTATION This is the case of a 50-yr-old woman with hemibody sensorimotor deficits, who had previously undergone bilateral arterial bypass and temporalis myosynangiosis. A method for indirect surgical cerebral revascularization is described, utilizing a rotated and tunneled sternocleidomastoid flap. The perfused muscle is approximated to the cortical surface, with adjacent sulci dissected to expose the underlying vasculature. After sternocleidomastoid encephalomyosynangiosis, the patient experienced symptomatic improvement, along with the appearance of new pial collateral vasculature on diagnostic cerebral angiography. Pre- and postoperative dynamic perfusion computed tomography with acetazolamide challenge demonstrate an increase in cerebral blood flow and decrease in mean transit time, as well as improved cerebrovascular reserve. CONCLUSION Sternocleidomastoid encephalomyosynangiosis using a tunneled muscle flap is a useful method for revascularization of the parietal and occipital lobes, particularly for refractory moyamoya in cases where a variety of other options have been exhausted.
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Affiliation(s)
- Peter A Chiarelli
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Anoop P Patel
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Amy Lee
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Srinivasa R Chandra
- Division of OMF - Head and Neck Surgery, University of Nebraska, Omaha, Nebraska
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington, Seattle, Washington
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15
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Wei W, Chen X, Yu J, Li XQ. Risk factors for postoperative stroke in adults patients with moyamoya disease: a systematic review with meta-analysis. BMC Neurol 2019; 19:98. [PMID: 31092214 PMCID: PMC6518622 DOI: 10.1186/s12883-019-1327-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 05/06/2019] [Indexed: 01/11/2023] Open
Abstract
Background This systematic review and meta-analysis aimed to clarify the risk factors for postoperative stroke in adult patients with moyamoya disease (MMD). Methods We comprehensively searched MEDLINE/PubMed, Web of Science, and Cochrane Library for eligible published literature with regard to the risk factors and postoperative complications in adult patients with MMD. Statistical analysis was conducted using Stata version 12.0. Pooled odds ratio (OR) with 95% confidence interval (CI) were assessed for each risk factor. Results There were 8 studies encompassing 1649 patients who underwent surgery with MMD were selected for analysis. Preoperative ischemic event significantly increase the risk of postoperative stroke events (OR = 1.40; 95%CI = 1.02–1.92; P = 0.039). PCA involvement correlate with an increased risk of post-infarction (OR = 4.60; 95%CI = 2.61–8.11; P = 0.000). Compared to direct bypass, patients who underwent indirect bypass or combined bypass could significantly increase the risk of postoperative stroke events. (OR = 1.17; 95%CI = 1.03–1.33; p = 0.017). MMD patients with diabetes were associated with an increased risk of postoperative stroke events (OR = 4.02, 95% CI = 1.59–10.16; p = 0.003). MMD patients with hypertension, age at onset and male sex were not associated with an increased risk of postoperative stroke events (P > 0.05). Conclusions This systematic review and meta-analysis indicated that preoperative ischemic events, PCA involvement and diabetes were independent risk factors for postoperative stroke in MMD patients. Therefore, in order to ensure the curative effect of patients with MMD, it is very necessary to detect these risk factors and prevent postoperative complications in time.
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Affiliation(s)
- Wei Wei
- Department of Neurosurgery, Affiliated Dalian Municipal Central Hospital, Dalian Medical University, Dalian, 116033, China
| | - Xin Chen
- Department of Epidemiology, School of Public Health, Dalian Medical University, Dalian, 116044, China.
| | - Jun Yu
- Department of Neurosurgery, Affiliated Dalian Municipal Central Hospital, Dalian Medical University, Dalian, 116033, China
| | - Xu-Qin Li
- Department of Neurosurgery, Affiliated Dalian Municipal Central Hospital, Dalian Medical University, Dalian, 116033, China.
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16
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Zheng J, Yu LB, Dai KF, Zhang Y, Wang R, Zhang D. Clinical Features, Surgical Treatment, and Long-Term Outcome of a Multicenter Cohort of Pediatric Moyamoya. Front Neurol 2019; 10:14. [PMID: 30723451 PMCID: PMC6349739 DOI: 10.3389/fneur.2019.00014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 01/07/2019] [Indexed: 11/22/2022] Open
Abstract
Objective: This study aims to investigate the clinical features, long-term outcomes, and prognostic predictors of a multicenter cohort of children with moyamoya disease. Methods: A series of 303 consecutive pediatric moyamoya disease (MMD) patients were screened in the present study. The clinical characteristics were retrospectively collected, and long-term outcomes was evaluated. Furthermore, logistic regression analyses were performed to determine the prognostic predictors for the clinical outcome. Results: The mean onset age at diagnosis was 9.4 years old. The gender ratio (girl-to-boy ratio) was 1.1:1.0. Among these 303 patients, 13 patients underwent different surgical modalities in bilateral hemispheres, while eight patients failed to follow-up, and were excluded. Therefore, a total of 282 patients were analyzed. Among these patients, 17 patients underwent combined bypass (CB), 47 patients underwent direct bypass (DB), 150 patients underwent indirect bypass (IB), and 68 patients underwent conservative treatment. Furthermore, recurrent stroke events were observed in 35 patients (12.4%). The Kaplan-Meier analysis demonstrated that there was no significant difference in either ischemia or hemorrhage-free time among the different surgical modalities (P = 0.67 and 0.79, respectively). Furthermore, longer ischemia-free time was observed in the surgical group, when compared to the conservative group (P < 0.01). In addition, 82.7% (177/214) of patients who underwent surgical treatment obtained good outcomes (mRS 0-1), which were significantly higher than the rate of patients who underwent conservative treatment (52.9%, 36/68; P < 0.01). The rate of patients with improved symptoms was also significantly different (93.0 vs. 16.2%, P < 0.01). However, no significant difference was observed in the rate of good outcomes, disability, and improved symptoms among the different surgical modalities. The logistic regression analyses revealed that postoperative ischemic events were the only risk factor associated with unfavorable clinical outcome (OR:3.463; 95% CI:1.436–8.351; P < 0.01). Conclusion: CB, DB, and IB might have similar effects on long-term clinical outcome in pediatric MMD. However, surgical revascularization is superior, when compared to conservative treatment. Furthermore, postoperative ischemic events were confirmed as potential prognostic factors associated with unfavorable clinical outcome.
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Affiliation(s)
- Jun Zheng
- Department of Neurosurgery, Beijing Tiantan Hospital, China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of Neurosurgery, The Second Hospital of Hebei Medical University, Hebei, China
| | - Le-Bao Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Ke-Fang Dai
- Department of Neurosurgery, Xingtai Third Hospital, Shandong, China
| | - Yan Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Rong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
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17
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Yan Y, Li Y, Huang L, Zhang S. A Comprehensive Meta-Analysis for Bypass Surgery in Adult Moyamoya. World Neurosurg 2019; 124:161-170. [PMID: 30654155 DOI: 10.1016/j.wneu.2018.12.183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 12/19/2018] [Accepted: 12/20/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the outcomes of bypass surgery for adult moyamoya and compare different surgical modalities by performing a comprehensive meta-analysis of relevant studies. METHODS A systematic literature search was performed and articles regarding different treatments for adult patients with moyamoya were included. Odds ratios (ORs) were calculated to evaluate stroke recurrence, mortality, perioperative complications, and angiographic revascularization among different surgical methods and conservative treatment (CT). RESULTS A total of 17 studies with 2224 adult patients with moyamoya were included in the meta-analysis. Compared with CT, surgical revascularization significantly decreased the future stroke events in the total population ([OR] 0.404; 95% confidence interval [CI] 0.279-0.585; P < 0.001) and in the hemorrhagic-onset patients as well (OR 0.259; 95% CI 0.138-0.486; P < 0.001). However, for those patients with moyamoya and ischemia, there was no significant difference for future stroke events between the bypass and CT groups (OR 0.470; 95% CI 0.140-1.579; P = 0.222). Bypass also showed no mortality reduction compared with CT (OR 0.372; 95% CI 0.120-1.154; P = 0.087). For different surgical techniques, no differences for future stroke events, mortality, and perioperative complications were found between direct bypass and indirect bypass, whereas the degree of angiographic revascularization was better in the direct bypass group than in the indirect group (OR 4.720; 95% CI 1.222-18.230; P = 0.024). CONCLUSIONS The bypass treatment was superior to conservative treatment in preventing recurrent stroke in adult patients with moyamoya, especially in those with a hemorrhagic onset. Direct bypass is associated with better revascularization results compared with indirect bypass.
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Affiliation(s)
- Yawei Yan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Yunjie Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Liangjiang Huang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Suming Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China.
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18
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Chou SC, Chen YF, Lee CW, Hsu HC, Wang KC, Yang SH, Liu HM, Kuo MF. Improving Indirect Revascularization for Effective Treatment of Adult Moyamoya Disease: A Prospective Clinical, Cerebral Angiographic, and Perfusion Study. World Neurosurg 2018; 119:e180-e191. [PMID: 30031192 DOI: 10.1016/j.wneu.2018.07.088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/09/2018] [Accepted: 07/10/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Indirect revascularization is simple and safe, but it is not commonly used in adult moyamoya disease owing to its unreliable effect. This prospective study aimed to evaluate the effectiveness of indirect revascularization in treating adult moyamoya disease after refinement of the surgical technique and perioperative care. METHODS Adult patients who underwent indirect revascularization as the primary treatment for moyamoya disease between November 2013 and January 2017 were studied. The indirect revascularization procedures included encephalo-duro-arterio-synangiosis and encephalo-myo-synangiosis in the temporal region and encephalo-pericranio-synangiosis in other hypoperfusion areas. The preoperative and postoperative clinical conditions, cerebral angiography findings, and time-to-peak prolongation areas on magnetic resonance perfusion studies were assessed to evaluate the revascularization effect. Refinements of the surgical technique included the selection of surgical area based on perfusion imaging, craniotomy size, and number of affected hemispheres, along with the inclusion of a dural flap in every procedure. RESULTS Nineteen patients (17 females and 2 males), and a total of 31 cerebral hemispheres, were included. The mean patient age was 32.7 ± 11.4 years. After a mean follow-up of 38.6 ± 11.5 months, all patients showed clinical improvement or stabilization. Available postoperative angiography demonstrated Matsushima grade A or B in 19 of 21 hemispheres. The mean time-to-peak prolongation index of all 31 hemispheres improved from 24.09 ± 9.83% preoperatively to 12.82 ± 6.75% at 3-6 months after surgery (P < 0.001). The complication rate was 12.9%, and all complications were transient. CONCLUSIONS With refinements of surgical techniques and perioperative care, indirect revascularization is more reliable and can be a viable alternative treatment for adult moyamoya disease. In our cohort, outcomes were satisfactory, with mean 38.6-month follow-up.
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Affiliation(s)
- Sheng-Che Chou
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan; Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, National Taiwan University College of Medicine, Douliou City, Taiwan
| | - Ya-Fang Chen
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Hao-Chun Hsu
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan; Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, National Taiwan University College of Medicine, Douliou City, Taiwan
| | - Kuo-Chuan Wang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Shih-Hung Yang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Hon-Man Liu
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan; Department of Medical Imaging, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Meng-Fai Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan.
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19
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Zhai X, Mao L, Wang H, Zhang X, Hang C, Wu W, Jia Y, Liu L. Risk Factors Associated with Neurologic Deterioration After Combined Direct and Indirect Revascularization in Patients with Moyamoya Disease on the East Coast of China. World Neurosurg 2018; 118:e92-e98. [PMID: 29945005 DOI: 10.1016/j.wneu.2018.06.125] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 06/14/2018] [Accepted: 06/15/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Neurologic deterioration is the primary distinctive complication after revascularization surgery in patients with moyamoya disease (MMD). The present study investigated the risk factors for neurologic deterioration after combined direct and indirect revascularization in patients with MMD. METHODS A retrospective review of 123 patients with MMD undergoing 138 combined direct and indirect revascularization procedures was performed. Demographics, clinical manifestation, medical history, neurologic deterioration complications, and relevant information of the operation were recorded. RESULTS There were 25 (18.12%) postoperative neurologic deterioration complications (13 reversible neurologic deficits, 9 infarctions with neurologic sequelae, and 3 hemorrhages). Preoperative multiple symptom episodes and one-staged bilateral revascularization were significantly correlated with postoperative neurologic deterioration complications (P < 0.05 and P < 0.01, respectively). The incidence rate (26.39%) of postoperative neurologic deterioration in ischemic MMDs was significantly greater than hemorrhagic MMDs (7.69%; P < 0.01) In total, 34.78% of patients with transient ischemic attack onset and 22.45% of patients with infarction onset suffered from postoperative neurologic deterioration, and there was no significant difference between them (P > 0.05). Postoperative neurologic deterioration complications had no significant correlation with sex, age at the time of surgery, type of surgical procedure, unilateral MMD or not, interval between the last attack and operation, and history of thyroid disease, hypertension, and autoimmune disease. CONCLUSIONS Preoperative multiple symptom episodes and one-staged bilateral revascularization are risk factors associated with postoperative neurologic deterioration in patients with MMD. Therefore, 2 unilateral revascularization procedures performed successively rather than one-staged bilateral revascularization procedures should be performed in patients with bilateral MMD.
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Affiliation(s)
- Xiaolei Zhai
- Department of Neurosurgery, Shuyang Hospital, Xuzhou Medical University, Shuyang, Jiangsu, China
| | - Lei Mao
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China.
| | - Handong Wang
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Xin Zhang
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Chunhua Hang
- Department of Neurosurgery, Drum Tower Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Wei Wu
- Department of Neurosurgery, The First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yue Jia
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Liansong Liu
- Department of Neurosurgery, Shuyang Hospital, Xuzhou Medical University, Shuyang, Jiangsu, China
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20
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Kashiwazaki D, Akioka N, Kuwayama N, Houkin K, Czabanka M, Vajkoczy P, Kuroda S. Berlin Grading System Can Stratify the Onset and Predict Perioperative Complications in Adult Moyamoya Disease. Neurosurgery 2018; 81:986-991. [PMID: 28605471 DOI: 10.1093/neuros/nyx140] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 05/24/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The grading system for moyamoya disease is not established. OBJECTIVE To assess the usefulness of a recently proposed grading system for stratifying the clinical severity and predicting postoperative morbidity in adult moyamoya disease. METHODS We investigated 176 hemispheres from 89 adult patients who were diagnosed with moyamoya disease in Japan. Their data were analyzed using the Berlin grading system with minor modifications. After summarizing the numerical values for digital subtraction angiography (1-3 points), magnetic resonance imaging (0-1 points), and single-photon emission computed tomography (0-2 points), 3 grades of moyamoya disease were defined: mild (grade I) = 1 to 2 points, moderate (grade II) = 3 to 4 points, and severe (grade III) = 5 to 6 points. In total, 82 of 161 hemispheres underwent superficial temporal artery to middle cerebral artery anastomosis and indirect synangiosis. Postoperative neurological morbidity was included within 30 d after surgery. RESULTS Preoperative examinations categorized 87 hemispheres as grade I, 39 as grade II, and 50 as grade III. There was a significant correlation between the Berlin grading system and clinical severity (P < .001). Perioperative complications occurred in 12 of 82 (14.6%) hemispheres, including transient ischemic attack in 3 hemispheres, ischemic stroke in 4 hemispheres, symptomatic hyperperfusion in 4 hemispheres, and intracerebral hemorrhage in 1 hemisphere. The Berlin grading system was related to their occurrence (P < .001). CONCLUSION The Berlin grading system facilitates the stratification of clinical severity and predicting postoperative neurological morbidity in adult moyamoya disease, thereby suggesting its general usage in clinical practice.
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Affiliation(s)
- Daina Kashiwazaki
- Department of Neurosurgery, Graduate School of Medicine and Pharmacological Science, University of Toyama, To-yama, Japan
| | - Naoki Akioka
- Department of Neurosurgery, Graduate School of Medicine and Pharmacological Science, University of Toyama, To-yama, Japan
| | - Naoya Kuwayama
- Department of Neurosurgery, Graduate School of Medicine and Pharmacological Science, University of Toyama, To-yama, Japan
| | - Kiyohiro Houkin
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Marcus Czabanka
- Department of Neurosurgery, Charité-Universitätsmedizin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin, Berlin, Germany
| | - Satoshi Kuroda
- Department of Neurosurgery, Graduate School of Medicine and Pharmacological Science, University of Toyama, To-yama, Japan
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21
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Lee SU, Oh CW, Kwon OK, Bang JS, Ban SP, Byoun HS, Kim T. Surgical Treatment of Adult Moyamoya Disease. Curr Treat Options Neurol 2018; 20:22. [PMID: 29808372 DOI: 10.1007/s11940-018-0511-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Moyamoya disease (MMD) is being increasingly diagnosed with the development of radiological surveillance technology and increased accessibility to medical care. Accordingly, there have been several recent reports on treatment outcomes in MMD. In this review, we summarize recent advances in surgical treatment and outcomes of adult MMD, while addressing related controversies. RECENT FINDINGS Recent studies suggest that revascularization surgery leads to significantly more favorable outcomes for stroke prevention, angiographic and hemodynamic changes, and clinical outcomes than does conservative treatment for adult patients with ischemic MMD. Moreover, direct revascularization methods should be considered as the first-line treatment over indirect methods, although the latter may be considered if a direct method is not possible. In cases of hemorrhagic MMD, several studies have demonstrated that surgical treatment is more effective than conservative treatment in preventing further hemorrhage. In addition to revascularization surgery, endovascular treatment is emerging as a breakthrough therapy for hemorrhagic MMD. Accumulating evidence regarding the surgical treatment of adult MMD suggests the benefit of revascularization over conservative management for both ischemic and hemorrhagic patients. However, the benefit of revascularization in asymptomatic adult MMD remains unclear.
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Affiliation(s)
- Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro Jongno-Gu, Seoul, 03080, Republic of Korea
| | - O-Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Seung Pil Ban
- Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Hyoung Soo Byoun
- Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea. .,Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-Ro Jongno-Gu, Seoul, 03080, Republic of Korea.
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22
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Muraoka S, Araki Y, Kondo G, Kurimoto M, Shiba Y, Uda K, Ota S, Okamoto S, Wakabayashi T. Postoperative Cerebral Infarction Risk Factors and Postoperative Management of Pediatric Patients with Moyamoya Disease. World Neurosurg 2018; 113:e190-e199. [DOI: 10.1016/j.wneu.2018.01.212] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 01/30/2018] [Accepted: 01/31/2018] [Indexed: 11/28/2022]
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23
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Hervé D, Kossorotoff M, Bresson D, Blauwblomme T, Carneiro M, Touze E, Proust F, Desguerre I, Alamowitch S, Bleton JP, Borsali A, Brissaud E, Brunelle F, Calviere L, Chevignard M, Geffroy-Greco G, Faesch S, Habert MO, De Larocque H, Meyer P, Reyes S, Thines L, Tournier-Lasserve E, Chabriat H. French clinical practice guidelines for Moyamoya angiopathy. Rev Neurol (Paris) 2018. [PMID: 29519672 DOI: 10.1016/j.neurol.2017.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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24
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Park SE, Kim JS, Park EK, Shim KW, Kim DS. Direct versus indirect revascularization in the treatment of moyamoya disease. J Neurosurg 2017; 129:480-489. [PMID: 29076784 DOI: 10.3171/2017.5.jns17353] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE For patients with moyamoya disease (MMD), surgical intervention is usually required because of progressive occlusion of the internal carotid artery. The indirect bypass method has been widely accepted as the treatment of choice in pediatric patients. However, in adult patients with MMD, the most effective treatment method remains a matter of debate. Here, the authors compared the clinical outcomes from MMD patients treated with either extracranial-intracranial arterial bypass (EIAB; 43 hemispheres) or modified encephaloduroarteriosynangiosis (mEDAS; 75 hemispheres) to investigate whether mEDAS is an effective surgical method for treating adults with symptomatic MMD. METHODS A comparative analysis was performed in patients treated using either mEDAS or EIAB. Collateral grading, collateral vein counting, and symptom analysis were used to assess the outcome of surgery. RESULTS Seventy-seven percent (58/75) of mEDAS cases and 83.7% (36/43) of EIAB cases in the analysis experienced improvement in their symptoms after surgery. Furthermore, patients in 98.7% (74/75) of mEDAS cases and those in 95.3% (41/43) of EIAB cases exhibited improved collateral grades. Increases in regions of perfusion were seen after both procedures. CONCLUSIONS Modified EDAS and EIAB both result in positive outcomes for symptomatic adults with MMD. However, when considering the benefit of both surgeries, the authors propose mEDAS, a simpler and less strenuous surgery with a lower risk of complications, as a sufficient and safe treatment option for symptomatic adults with MMD.
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25
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Jang DK, Lee KS, Rha HK, Huh PW, Yang JH, Park IS, Ahn JG, Sung JH, Han YM. Bypass surgery versus medical treatment for symptomatic moyamoya disease in adults. J Neurosurg 2017; 127:492-502. [DOI: 10.3171/2016.8.jns152875] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEIn this study the authors evaluated whether extracranial-intracranial bypass surgery can prevent stroke occurrence and decrease mortality in adult patients with symptomatic moyamoya disease (MMD).METHODSThe medical records of 249 consecutive adult patients with symptomatic MMD that was confirmed by digital subtraction angiography between 2002 and 2011 at 8 institutions were retrospectively reviewed. The study outcomes of stroke recurrence as a primary event and death during the 6-year follow-up and perioperative complications within 30 days as secondary events were compared between the bypass and medical treatment groups.RESULTSThe bypass group comprised 158 (63.5%) patients, and the medical treatment group comprised 91 (36.5%) patients. For 249 adult patients with MMD, bypass surgery showed an HR of 0.48 (95% CI 0.27–0.86, p = 0.014) for stroke recurrence calculated by Cox regression analysis. However, for the 153 patients with ischemic MMD, the HR of bypass surgery for stroke recurrence was 1.07 (95% CI 0.43–2.66, p = 0.887). For the 96 patients with hemorrhagic MMD, the multivariable adjusted HR of bypass surgery for stroke recurrence was 0.18 (95% CI 0.06–0.49, p = 0.001). For the treatment modality, indirect bypass and direct bypass (or combined bypass) did not show any significant difference for stroke recurrence, perioperative stroke, or mortality (log rank; p = 0.524, p = 0.828, and p = 0.616, respectively).CONCLUSIONSDuring the treatment of symptomatic MMD in adults, bypass surgery reduces stroke recurrence for the hemorrhagic type, but it does not do so for the ischemic type. The best choice of bypass methods in adult patients with MMD is uncertain. In adult ischemic MMD, a prospective randomized study to evaluate the effectiveness and safety of bypass surgery to prevent recurrent stroke is necessary.
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Affiliation(s)
- Dong-Kyu Jang
- 1Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon
| | - Kwan-Sung Lee
- 2Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul
| | - Hyoung Kyun Rha
- 3Department of Neurosurgery, Youido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul
| | - Pil-Woo Huh
- 4Department of Neurosurgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu
| | - Ji-Ho Yang
- 5Department of Neurosurgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon
| | - Ik Seong Park
- 6Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon
| | - Jae-Geun Ahn
- 7Department of Neurosurgery, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul; and
| | - Jae Hoon Sung
- 8Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Young-Min Han
- 1Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon
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26
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Machida T, Nakano S, Ishige S, Ono J, Fujikawa A. Subcortical Low-Intensity Lesions on Fluid-Attenuated Inversion Recovery Images After Revascularization Surgery for Moyamoya Disease. World Neurosurg 2016; 98:512-519. [PMID: 27888077 DOI: 10.1016/j.wneu.2016.11.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 11/09/2016] [Accepted: 11/12/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Although uncommon, subcortical low-intensity (SCLI) changes on fluid-attenuated inversion recovery images are observed in various diseases, including cerebral ischemia. Here, we aimed to clarify the incidence and clinical implications of SCLI changes after revascularization surgery for moyamoya disease, focusing on the correlation with postoperative transient neurologic events (TNEs). METHODS In this retrospective case series analysis, we included 10 hemispheres from 9 adults with moyamoya disease who underwent revascularization surgery. Subcortical signal intensity at the 5 gyri around the anastomosis point was quantitatively measured at 1 week and 3 months postoperatively. Changes in cerebral blood flow (CBF) were assessed using single-photon emission computed tomography. RESULTS Images taken 1 week after surgery showed widespread SCLI changes below the operative fields in all 10 cases, but these changes normalized by 3 months. In addition, the changes in signal intensity at anastomoses negatively correlated with the changes in CBF (R2 = 0.36; P = 0.039). Postoperative TNEs occurred in 6 cases (60%) but were resolved within 17 days after surgery. Postoperative CBF increased in 9 of the 10 cases, with a median of 23%; however, these increases were not associated with the development of TNEs. The SCLI changes at the anastomosis points did not differ by the experience of TNEs. CONCLUSIONS Early after surgery, SCLI changes are common findings below the operative fields but negatively correlate with increases in CBF. Although no significant association was found between TNEs and the SCLI changes, the synchronized development of these phenomena may suggest a common underlying pathogenesis.
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Affiliation(s)
- Toshio Machida
- Department of Neurosurgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan.
| | - Shigeki Nakano
- Department of Neurosurgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan
| | - Satoshi Ishige
- Department of Neurosurgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan
| | - Junichi Ono
- Department of Neurosurgery, Chiba Cerebral and Cardiovascular Center, Ichihara, Chiba, Japan
| | - Atsushi Fujikawa
- Department of Neurosurgery, Chibaken Saiseikai Narashino Hospital, Narashino, Chiba, Japan
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Direct Bypass Versus Indirect Bypass in Adult Moyamoya Angiopathy with Symptoms or Hemodynamic Instability: A Meta-analysis of Comparative Studies. World Neurosurg 2016; 94:273-284. [DOI: 10.1016/j.wneu.2016.07.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 07/01/2016] [Accepted: 07/01/2016] [Indexed: 11/19/2022]
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Macyszyn L, Attiah M, Ma TS, Ali Z, Faught R, Hossain A, Man K, Patel H, Sobota R, Zager EL, Stein SC. Direct versus indirect revascularization procedures for moyamoya disease: a comparative effectiveness study. J Neurosurg 2016; 126:1523-1529. [PMID: 27471892 DOI: 10.3171/2015.8.jns15504] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Moyamoya disease (MMD) is a chronic cerebrovascular disease that can lead to devastating neurological outcomes. Surgical intervention is the definitive treatment, with direct, indirect, and combined revascularization procedures currently employed by surgeons. The optimal surgical approach, however, remains unclear. In this decision analysis, the authors compared the effectiveness of revascularization procedures in both adult and pediatric patients with MMD. METHODS A comprehensive literature search was performed for studies of MMD. Using complication and success rates from the literature, the authors constructed a decision analysis model for treatment using a direct and indirect revascularization technique. Utility values for the various outcomes and complications were extracted from the literature examining preferences in similar clinical conditions. Sensitivity analysis was performed. RESULTS A structured literature search yielded 33 studies involving 4197 cases. Cases were divided into adult and pediatric populations. These were further subdivided into 3 different treatment groups: indirect, direct, and combined revascularization procedures. In the pediatric population at 5- and 10-year follow-up, there was no significant difference between indirect and combination procedures, but both were superior to direct revascularization. In adults at 4-year follow-up, indirect was superior to direct revascularization. CONCLUSIONS In the absence of factors that dictate a specific approach, the present decision analysis suggests that direct revascularization procedures are inferior in terms of quality-adjusted life years in both adults at 4 years and children at 5 and 10 years postoperatively, respectively. These findings were statistically significant (p < 0.001 in all cases), suggesting that indirect and combination procedures may offer optimal results at long-term follow-up.
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Affiliation(s)
- Luke Macyszyn
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark Attiah
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tracy S Ma
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zarina Ali
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ryan Faught
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alisha Hossain
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karen Man
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hiren Patel
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rosanna Sobota
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric L Zager
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sherman C Stein
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Cho H, Jo KI, Yu J, Yeon JY, Hong SC, Kim JS. Low flow velocity in the middle cerebral artery predicting infarction after bypass surgery in adult moyamoya disease. J Neurosurg 2016; 126:1573-1577. [PMID: 27257840 DOI: 10.3171/2016.3.jns152256] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Direct and indirect bypass surgeries are recognized as the most effective treatments for preventing further stroke in adults with moyamoya disease (MMD). However, the risk factors for postoperative infarction after bypass surgery for MMD are not well established. Therefore, the objective of this study was to investigate the risk factors for postoperative infarction. In particular, the authors sought to determine whether transcranial Doppler (TCD) ultrasonography measurements of mean flow velocity (MFV) in the middle cerebral artery (MCA) could predict postrevascularization infarction. METHODS The medical records of patients with MMD who underwent direct bypass surgery at the authors' institution between July 2012 and April 2015 were reviewed. The MFV in the MCA was measured with TCD ultrasonography and categorized as high (> 80 cm/sec), medium (40-80 cm/sec), and low (< 40 cm/sec). Postoperative MRI, including diffusion-weighted imaging, was performed for all patients within a week of their surgery. Angiographic findings were classified according to the Suzuki scale. Postrevascularization infarction was defined as any diffusion restriction on postoperative MRI scans. Postoperative neurological status was assessed through a clinical chart review, and the modified Rankin Scale was used to evaluate clinical outcomes. RESULTS Of 43 hemispheres in which bypass surgery for MMD was performed, 11 showed postrevascularization infarction. Ten of these hemispheres had low MFV and 1 had medium MFV in the ipsilateral MCA. In both univariate and multivariate analyses, a low MFV was associated with postrevascularization infarction (adjusted OR 109.2, 95% CI 1.9-6245.3). A low MFV was also statistically significantly associated with more advanced MMD stage (p = 0.02). CONCLUSIONS A low MFV in the ipsilateral MCA may predict postrevascularization infarction. Bypass surgery for MMD appears to be safe in early-stage MMD. Results of TCD ultrasonography provide clinical data on the hemodynamics in MMD patients before and after revascularization.
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Affiliation(s)
- Hoyeon Cho
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; and
| | - Kyung Il Jo
- Department of Neurosurgery, Hana General Hospital, Cheongju, Korea
| | - Jua Yu
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; and
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; and
| | - Seung-Chyul Hong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; and
| | - Jong Soo Kim
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul; and
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30
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Park W, Ahn JS, Lee HS, Park JC, Kwun BD. Risk Factors for Newly Developed Cerebral Infarction After Surgical Revascularization for Adults with Moyamoya Disease. World Neurosurg 2016; 92:65-73. [PMID: 27020972 DOI: 10.1016/j.wneu.2016.03.053] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 03/17/2016] [Accepted: 03/17/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE It is important to recognize the incidence and risk factors for ischemic complications after surgical revascularization for moyamoya disease (MMD). However, most studies focus on pediatric MMD or pediatric and adult MMD. Our study identified the incidence and risk factors of newly developed cerebral infarction after surgical revascularization for adult MMD. METHODS Ischemic complications were defined as newly developed cerebral infarction within 15 days after surgery, as identified by imaging studies. To identify the incidence and these risk factors for adult patients ≥18 years, we retrospectively reviewed our experience with 194 adult MMD patients with 241 surgical revascularizations. RESULTS The incidence of symptomatic infarction after surgical revascularization was 5.8% (14 cases); 30 cases (12.4%) experienced a silent infarction. In univariate analysis, initial presentation as infarction, initial presentation as hemorrhage, transient ischemic attacks (TIAs) >3 times/month, involvement of the posterior cerebral artery (PCA), combined bypass, and using muscle for revascularization were variables related to the newly developed cerebral infarction. Multivariate analysis revealed that the following factors were independently associated with newly developed cerebral infarction after surgery: cerebral infarction as initial presentation (odds ratio [OR] 1.150; 95% confidence interval [CI] 1.038-1.273; P = 0.0073), TIAs >3times/month (OR 1.188; 95% CI 1.058-1.335; P = 0.0035), and PCA involvement (OR 1.095; 95% CI 1.005-1.194; P = 0.039). CONCLUSIONS Our findings demonstrate that newly developed, silent cerebral infarction developed more frequently than symptomatic cerebral infarction in adult patients. Cerebral infarction as initial presentation, frequent TIA before surgery, and PCA involvement were also independent risk factors for newly developed cerebral infarction after surgical revascularization for adult MMD.
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Affiliation(s)
- Wonhyoung Park
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, South Korea
| | - Jung Cheol Park
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Byung Duk Kwun
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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31
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Antonucci MU, Burns TC, Pulling TM, Rosenberg J, Marks MP, Steinberg GK, Zaharchuk G. Acute Preoperative Infarcts and Poor Cerebrovascular Reserve Are Independent Risk Factors for Severe Ischemic Complications following Direct Extracranial-Intracranial Bypass for Moyamoya Disease. AJNR Am J Neuroradiol 2016; 37:228-235. [PMID: 26564435 DOI: 10.3174/ajnr.a4535] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 07/03/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Severe ischemic changes are a rare but devastating complication following direct superficial temporal artery to MCA bypass in patients with Moyamoya disease. This study was undertaken to determine whether preoperative MR imaging and/or cerebrovascular reserve assessment by using reference standard stable xenon-enhanced CT could predict such complications. MATERIALS AND METHODS Among all adult patients undergoing direct bypass at our institution between 2005 and 2010 who received a clinically interpretable xenon-enhanced CT examination, we identified index cases (patients with >15-mL postoperative infarcts) and control cases (patients without postoperative infarcts and without transient or permanent ischemic symptoms). Differences between groups were evaluated by using the Mann-Whitney U test. Univariate and multivariate generalized linear model regression was used to test predictors of postoperative infarct. RESULTS Six index cases were identified and compared with 25 controls. Infarct size in the index cases was 95 ± 55 mL. Four of 6 index cases (67%), but no control patients, had preoperative acute infarcts. Baseline CBF was similar, but cerebrovascular reserve was significantly lower in the index cases compared with control cases. For example, in the anterior circulation, median cerebrovascular reserve was -0.4% (range, -38.0%-16.6%) in index versus 26.3% (range, -8.2%-60.5%) in control patients (P = .003). Multivariate analysis demonstrated that the presence of a small preoperative infarct (regardless of location) and impaired cerebrovascular reserve were independent, significant predictors of severe postoperative ischemic injury. CONCLUSIONS Acute infarcts and impaired cerebrovascular reserve on preoperative imaging are independent risk factors for severe ischemic complications following superficial temporal artery to MCA bypass in Moyamoya disease.
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Affiliation(s)
- Michael U Antonucci
- Department of Radiology, Medical University of South Carolina, Charleston, SC
| | - Terrence C Burns
- Department of Neurosurgery, Stanford University and Stanford University Medical Center, Stanford, CA
| | - T Michael Pulling
- Department of Radiology, Stanford University and Stanford University Medical Center, Stanford, CA
| | - Jarrett Rosenberg
- Department of Radiology, Stanford University and Stanford University Medical Center, Stanford, CA
| | - Michael P Marks
- Department of Radiology, Stanford University and Stanford University Medical Center, Stanford, CA
| | - Gary K Steinberg
- Department of Neurosurgery, Stanford University and Stanford University Medical Center, Stanford, CA
| | - Greg Zaharchuk
- Department of Radiology, Stanford University and Stanford University Medical Center, Stanford, CA
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Yu J, Shi L, Guo Y, Xu B, Xu K. Progress on Complications of Direct Bypass for Moyamoya Disease. Int J Med Sci 2016; 13:578-87. [PMID: 27499690 PMCID: PMC4974906 DOI: 10.7150/ijms.15390] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 06/20/2016] [Indexed: 11/05/2022] Open
Abstract
Moyamoya disease (MMD) involves progressive occlusion of the intracranial internal carotid artery resulting in formation of moyamoya-like vessels at the base of the brain. It can be characterized by hemorrhage or ischemia. Direct vascular bypass is the main and most effective treatment of MMD. However, patients with MMD differ from those with normal cerebral vessels. MMD patients have unstable intracranial artery hemodynamics and a poor blood flow reserve; therefore, during the direct bypass of superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis, perioperative risk factors and anesthesia can affect the hemodynamics of these patients. When brain tissue cannot tolerate a high blood flow rate, it becomes prone to hyperperfusion syndrome, which leads to neurological function defects and can even cause intracranial hemorrhage in severe cases. The brain tissue is prone to infarction when hemodynamic equilibrium is affected. In addition, bypass vessels become susceptible to occlusion or atrophy when blood resistance increases. Even compression of the temporalis affects bypass vessels. Because the STA is used in MMD surgery, the scalp becomes ischemic and is likely to develop necrosis and infection. These complications of MMD surgery are difficult to manage and are not well understood. To date, no systematic studies of the complications that occur after direct bypass in MMD have been performed, and reported complications are hidden among various case studies; therefore, this paper presents a review and summary of the literature in PubMed on the complications of direct bypass in MMD.
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Affiliation(s)
- Jinlu Yu
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, 130021, P.R. China
| | - Lei Shi
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, 130021, P.R. China
| | - Yunbao Guo
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, 130021, P.R. China
| | - Baofeng Xu
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, 130021, P.R. China
| | - Kan Xu
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, 130021, P.R. China
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Funaki T, Takahashi JC, Takagi Y, Kikuchi T, Yoshida K, Mitsuhara T, Kataoka H, Okada T, Fushimi Y, Miyamoto S. Unstable moyamoya disease: clinical features and impact on perioperative ischemic complications. J Neurosurg 2015; 122:400-7. [DOI: 10.3171/2014.10.jns14231] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Unstable moyamoya disease, reasonably defined as cases exhibiting either rapid disease progression or repeated ischemic stroke, represents a challenge in the treatment of moyamoya disease. Despite its overall efficacy, direct bypass for such unstable disease remains controversial in terms of safety. This study aims to reveal factors associated with unstable disease and to assess its impact on postoperative silent or symptomatic ischemic lesions.
METHODS
This retrospective cohort study included both pediatric and adult patients with moyamoya disease who had undergone 140 consecutive direct bypass procedures at Kyoto University Hospital. “Unstable moyamoya disease” was defined as either the rapid progression of a steno-occlusive lesion or repeat ischemic stroke, either occurring within 6 months of surgery. The extent of progression was determined through a comparison of the findings between 2 different MR angiography sessions performed before surgery. The clinical variables of the stable and unstable disease groups were compared, and the association between unstable disease and postoperative diffusion-weighted imaging (DWI)–detected lesion was assessed through univariate and multivariate analyses with generalized estimating equations.
RESULTS
Of 134 direct bypass procedures performed after patients had undergone at least 2 sessions of MR angiography, 24 (17.9%) were classified as cases of unstable disease. Age younger than 3 years (p = 0.029), underlying disease causing moyamoya syndrome (p = 0.049), and radiographic evidence of infarction (p = 0.030) were identified as factors associated with unstable disease. Postoperative DWI-defined lesions were detected after 13 of 140 procedures (9.3%), although only 4 lesions (2.9%) could be classified as a permanent complication. The incidence of postoperative DWI-detected lesions in the unstable group was notable at 33.3% (8 of 24). Univariate analysis revealed that unstable disease (p < 0.001), underlying disease (p = 0.028), and recent stroke (p = 0.012) were factors associated with DWI-detected lesions. Unstable disease remained statistically significant after adjustment for covariates in both the primary and sensitivity analyses (primary analysis: OR 6.62 [95% CI 1.79–24.5]; sensitivity analysis: OR 5.36 [95% CI 1.47–19.6]).
CONCLUSIONS
Unstable moyamoya disease, more prevalent in younger patients and those with underlying disease, is a possible risk factor for perioperative ischemic complications. Recognition of unstable moyamoya disease may contribute to an improved surgical result through focused perioperative management based on appropriate surgical risk stratification.
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Affiliation(s)
| | | | | | | | | | | | - Hiroharu Kataoka
- 2Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tomohisa Okada
- 3Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto; and
| | - Yasutaka Fushimi
- 3Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto; and
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Bao XY, Duan L, Yang WZ, Li DS, Sun WJ, Zhang ZS, Zong R, Han C. Clinical Features, Surgical Treatment, and Long-Term Outcome in Pediatric Patients with Moyamoya Disease in China. Cerebrovasc Dis 2015; 39:75-81. [DOI: 10.1159/000369524] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 11/03/2014] [Indexed: 11/19/2022] Open
Abstract
Background: There was few detailed demographic and clinical data about Chinese patients with moyamoya disease. Here we describe the clinical features, surgical treatment, and long-term outcome of pediatric patients with moyamoya disease at a single institution in China. Methods: Our cohort included 288 pediatric patients with moyamoya disease. The demographic and clinical characteristics were obtained by retrospective chart review and long-term outcome was evaluated using the stroke status. Univariate and multivariate logistic regression analyses were performed to determine the risk factors for clinical outcome. The risk of subsequent stroke was determined using the Kaplan-Meier method. Results: The median age for the onset of symptoms was 8.0 years. The ratio of female to male patients was 1:1. Familial occurrence of moyamoya disease was 9.4%. The incidence of postoperative complications was 4.2%. Postoperative ischemic events were identified as predictors of unfavorable clinical outcome, while older age of symptom onset was associated with a favorable clinical outcome. The Kaplan-Meier estimate stroke risk was 5% in the first 2 years, and the 5-year-Kaplan-Meier risk of stroke was 9% after surgery for all patients treated with surgical revascularization. Overall, 86% of patients had an independent life with no significant disability. Conclusion: This long-term survey demonstrated that most surgically treated pediatric patients with MMD maintain good outcomes. Our results indicate that an early diagnosis and active intervention before the establishment of irreversible hemodynamic change are essential to achieve a favorable clinical outcome.
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Surgical management of Moyamoya disease and syndrome: Current concepts and personal experience. Rev Neurol (Paris) 2015; 171:31-44. [DOI: 10.1016/j.neurol.2014.08.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 06/05/2014] [Accepted: 08/29/2014] [Indexed: 11/18/2022]
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Kazumata K, Ito M, Tokairin K, Ito Y, Houkin K, Nakayama N, Kuroda S, Ishikawa T, Kamiyama H. The frequency of postoperative stroke in moyamoya disease following combined revascularization: a single-university series and systematic review. J Neurosurg 2014; 121:432-40. [DOI: 10.3171/2014.1.jns13946] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Object
Although combined direct and indirect anastomosis in patients with moyamoya disease immediately increases cerebral blood flow, the surgical procedure is more complex. Data pertinent to the postoperative complications associated with combined bypass are relatively scarce compared with those associated with indirect bypass. This study investigated the incidence and characteristics of postoperative stroke in combined bypass and compared them with those determined from a literature review to obtain data from a large population.
Methods
A total of 358 revascularization procedures in 236 patients were retrospectively assessed by reviewing clinical charts and radiological data. PubMed was searched for published studies on surgical treatment to determine the incidence of postoperative complications in a larger population.
Results
Seventeen instances of postoperative stroke were observed in 16 patients (4.7% per surgery, 95% CI 2.8%–7.5%). Postoperative stroke was more frequent (7.9% per surgery) in adults than in pediatric patients (1.7% per surgery, OR 4.07, 95% CI 1.12–14.7; p < 0.05). Acute progression of stenoocclusive changes were identified in the major cerebral arteries (anterior cerebral artery, n = 3; middle cerebral artery, n = 1; posterior cerebral artery, n = 2). The postoperative stroke rate was comparable with that (5.4%) determined from a literature search that included studies reporting more than 2000 direct/combined procedures. No differences in the stroke rates between the direct/combined and indirect procedures were found. In the literature review, direct/combined bypass was more often associated with excellent revascularization (angiographic opacification greater than two-thirds) than indirect bypass (p < 0.05).
Conclusions
This experience of 358 consecutive procedures is one of the largest series for which the postoperative stoke rate for direct/combined bypass performed with a unified strategy has been reported. A systematic review confirmed that the postoperative stroke rate for the direct/combined procedure was comparable to that for the indirect procedure.
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Affiliation(s)
- Ken Kazumata
- 1Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo
| | - Masaki Ito
- 1Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo
| | - Kikutaro Tokairin
- 1Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo
| | - Yasuhiro Ito
- 1Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo
| | - Kiyohiro Houkin
- 1Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo
| | - Naoki Nakayama
- 1Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo
| | - Satoshi Kuroda
- 2Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama
| | - Tatsuya Ishikawa
- 3Department of Surgical Neurology, Akita Research Institute for Brain and Blood Vessels, Akita; and
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Kim JE, Jeon JS. An update on the diagnosis and treatment of adult Moyamoya disease taking into consideration controversial issues. Neurol Res 2014; 36:407-16. [DOI: 10.1179/1743132814y.0000000351] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Hervé D, Philippi A, Belbouab R, Zerah M, Chabrier S, Collardeau-Frachon S, Bergametti F, Essongue A, Berrou E, Krivosic V, Sainte-Rose C, Houdart E, Adam F, Billiemaz K, Lebret M, Roman S, Passemard S, Boulday G, Delaforge A, Guey S, Dray X, Chabriat H, Brouckaert P, Bryckaert M, Tournier-Lasserve E. Loss of α1β1 soluble guanylate cyclase, the major nitric oxide receptor, leads to moyamoya and achalasia. Am J Hum Genet 2014; 94:385-94. [PMID: 24581742 DOI: 10.1016/j.ajhg.2014.01.018] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 01/31/2014] [Indexed: 12/09/2022] Open
Abstract
Moyamoya is a cerebrovascular condition characterized by a progressive stenosis of the terminal part of the internal carotid arteries (ICAs) and the compensatory development of abnormal "moyamoya" vessels. The pathophysiological mechanisms of this condition, which leads to ischemic and hemorrhagic stroke, remain unknown. It can occur as an isolated cerebral angiopathy (so-called moyamoya disease) or in association with various conditions (moyamoya syndromes). Here, we describe an autosomal-recessive disease leading to severe moyamoya and early-onset achalasia in three unrelated families. This syndrome is associated in all three families with homozygous mutations in GUCY1A3, which encodes the α1 subunit of soluble guanylate cyclase (sGC), the major receptor for nitric oxide (NO). Platelet analysis showed a complete loss of the soluble α1β1 guanylate cyclase and showed an unexpected stimulatory role of sGC within platelets. The NO-sGC-cGMP pathway is a major pathway controlling vascular smooth-muscle relaxation, vascular tone, and vascular remodeling. Our data suggest that alterations of this pathway might lead to an abnormal vascular-remodeling process in sensitive vascular areas such as ICA bifurcations. These data provide treatment options for affected individuals and strongly suggest that investigation of GUCY1A3 and other members of the NO-sGC-cGMP pathway is warranted in both isolated early-onset achalasia and nonsyndromic moyamoya.
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Hwang JW, Yang HM, Lee H, Lee HK, Jeon YT, Kim JE, Lim YJ, Park HP. Predictive factors of symptomatic cerebral hyperperfusion after superficial temporal artery-middle cerebral artery anastomosis in adult patients with moyamoya disease. Br J Anaesth 2012; 110:773-9. [PMID: 23274781 DOI: 10.1093/bja/aes470] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Symptomatic cerebral hyperperfusion (SCH) is a potential complication after superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis in patients with moyamoya disease. This retrospective study was designed to determine factors associated with SCH after STA-MCA anastomosis in adult moyamoya patients. METHODS Eighty-two adult moyamoya patients undergoing STA-MCA anastomosis between July 2005 and December 2010 were enrolled. Laboratory data such as haemoglobin and white blood cell (WBC) count, preoperative (patient characteristic data, initial clinical manifestation, the angiographic staging), intraoperative (surgical time, the operative side, anaesthetic technique, fluid balance, arterial pressure, arterial partial pressure of carbon dioxide, the lowest haematocrit, and intraoperative transfusion), and postoperative (arterial pressure, Acute Physiology and Chronic Health Evaluation II score) data were collected and used as predictable factors for postoperative SCH, in which a focal intense increase in cerebral blood flow at the anastomosis site was shown in postoperative single-photon emission computed tomography. RESULTS Among 82 patients with 99 surgeries, 39 patients (47 sides, 47%) suffered from transient neurological deterioration due to SCH from 1 to 9 days after operation (median: 2 days), which was sustained for 1-14 days (median: 7 days). The operation on the dominant hemisphere [odds ratio (OR), 5.09; 95% confidence interval (CI), 2.07-12.54, P<0.001] was an independent risk factor for SCH. Also, WBC count on postoperative day 1 was significantly correlated with SCH (OR 1.19; 95%CI, 1.02-1.38, P=0.029). CONCLUSIONS The operation on the dominant hemisphere and increased postoperative WBC count may be associated with SCH after STA-MCA anastomosis in adult-onset moyamoya patients.
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Affiliation(s)
- J W Hwang
- Department of Anaesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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Bao XY, Duan L, Li DS, Yang WZ, Sun WJ, Zhang ZS, Zong R, Han C. Clinical features, surgical treatment and long-term outcome in adult patients with Moyamoya disease in China. Cerebrovasc Dis 2012; 34:305-13. [PMID: 23146868 DOI: 10.1159/000343225] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 09/05/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Moyamoya disease (MMD) develops mostly in Asian countries including Japan, Korea, mainland China and Taiwan. However, there are few detailed demographic and clinical data about Chinese patients with MMD. Currently, the most effective treatment in adult patients with MMD is unknown. There have only been a few small case series reporting on encephaloduroarteriosynangiosis (EDAS) in an adult population. Here we describe the clinical features, surgical treatment and long-term outcome of adults with MMD treated at a single institution in China. METHODS Our cohort included 470 adult patients with MMD. The demographic and clinical characteristics were obtained by retrospective chart review and long-term outcome was evaluated using the stroke status. The modified Rankin Scale (mRS) was used to determine the neurological functional outcome. Univariate and multivariate logistic regression analyses were performed to determine risk factors for postoperative morbidity and functional outcome. The risk of subsequent stroke was determined using the Kaplan-Meier method and Cox regression was used to determine risk factors for postoperative or subsequent strokes. RESULTS The median age for the onset of symptoms was 36.8 (range, 18-59) years. The ratio of female to male patients was 1:1 (231/239). Familial occurrence of MMD was 2.3%. The most common initial symptom was a cerebral ischemic event. The incidence of postoperative ischemic events or hemorrhage was 5.9% (9.8% of patients). Older age at symptom onset, posterior cerebral artery (PCA) involvement and the presence of transient ischemic attack (TIA) were identified as predictors of adverse postoperative events. The Kaplan-Meier estimate stroke risk was 10.1% in the first 2 years, and the 5-year Kaplan-Meier risk of stroke was 13% after surgery for all patients treated with surgical revascularization. Older age at symptom onset, PCA involvement and the presence of TIA were identified as predictors of postoperative or subsequent strokes. Overall, 73.2% of patients had an independent life with no significant disability, with the strongest predictor being the preoperative mRS score. CONCLUSION Clinical characteristics of adult MMD in China are different from those in other Asian countries. EDAS in adult patients with MMD carries a low risk, is effective at preventing future ischemic events and improves quality of life.
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Affiliation(s)
- Xiang-Yang Bao
- Department of Neurosurgery, 307 Hospital, PLA Center for Cerebral Vascular Disease, Beijing, PR China
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Abstract
Background and Purpose—
Moyamoya disease is characterized by chronic stenoocclusive vasculopathy involving the distal supraclinoid internal carotid arteries and presents with ischemic or hemorrhagic symptoms. We review advances in the understanding and management of moyamoya disease.
Summary of Review—
Cerebral revascularization, either direct or indirect, is the cornerstone of treatment for moyamoya disease. Recent advances have been made in understanding the molecular biology and pathophysiology of moyamoya disease, and new genetic mutations and deletions have been identified. Imaging for moyamoya disease is also rapidly improving with new sequences of MRI and better methods of assessing ischemia and cerebrovascular reserve. Positron emission tomography has emerged as an important tool to measure cerebrovascular reserve. Novel surgical techniques assess patency and ischemia during superficial temporal to middle cerebral artery bypass, including indocyanine green videoangiography to evaluate anastomosis patency, and various methods to monitor intraoperative blood flow. Newer methods of indirect revascularization have been described with placement of more tissues supplied by the external carotid artery on the brain surface. Postoperative hyperperfusion to the chronically ischemic brain tissue is a recently identified causative factor of complications. Interestingly, complications from hyperperfusion mimic those caused by ischemia, although they have different treatments, making the role of postoperative blood flow assessment important in distinguishing between the two. Awareness has also increased that even asymptomatic patients can experience significant cognitive decline attributable to chronic ischemia. Whether this reverts after successful revascularization requires investigation.
Conclusions—
Surgical revascularization with direct, indirect, and combined methods remains the preferred procedure for patients with moyamoya disease.
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Affiliation(s)
- Paritosh Pandey
- From the Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, CA
| | - Gary K. Steinberg
- From the Department of Neurosurgery, Stanford Stroke Center and Stanford Institute for Neuro-Innovation and Translational Neurosciences, Stanford University School of Medicine, Stanford, CA
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Yeon JY, Kim JS, Hong SC. Incidental major artery aneurysms in patients with non-hemorrhagic moyamoya disease. Acta Neurochir (Wien) 2011; 153:1263-70. [PMID: 21279660 DOI: 10.1007/s00701-011-0948-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Accepted: 01/13/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Major artery aneurysms may be found incidentally while evaluating moyamoya disease (MMD). The purpose of this study was to delineate the prevalence and characteristics of these uncommon aneurysms with a brief mention of their management and outcomes. METHODS We conducted a retrospective review of 249 adult patients who were diagnosed with non-hemorrhagic MMD. Cerebral angiograms obtained at the time of initial diagnosis were carefully reviewed to identify incidental aneurysms located on a major intracranial artery or near its tributaries. Aneurysms originating from distal peripheral arteries or moyamoya vessels were ineligible for this study. RESULTS Nine patients (3.6%) were found to have 13 major artery aneurysms, 7 (54%) of which were located in the posterior circulation, especially in older patients with bilateral MMD. The sizes of all aneurysms were less than 10 mm. Surgical clipping was performed on two aneurysms, and endovascular coiling on six (five posterior circulation aneurysms). Ischemic complications occurred in two patients after clipping of an anterior communicating artery aneurysm and in one patient after the second coiling of a recanalized basilar tip aneurysm. CONCLUSIONS Incidental major artery aneurysms can be found in 3.6% of adult patients with non-hemorrhagic MMD, an observed frequency that increases with age. About half of these aneurysms are located in the posterior circulation, particularly in older patients with bilateral MMD. Considering the risks of treatment-related complications, more information about the natural course of these aneurysms is needed to design proper management strategies both for the aneurysms and MMD.
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Affiliation(s)
- Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 IL-Won Dong, Kang-Nam Ku, Seoul, Republic of Korea, 135-710
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