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Tao T, Zhu W, Yu J, Li X, Wei W, Hu M, Luo M, Wan G, Li P, Chen J, Zhang J. Intraoperative evaluation of local cerebral hemodynamic change by laser speckle contrast imaging for predicting postoperative cerebral hyperperfusion during STA-MCA bypass in adult patients with moyamoya disease. J Cereb Blood Flow Metab 2024; 44:1163-1173. [PMID: 38233750 PMCID: PMC11179619 DOI: 10.1177/0271678x241226483] [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: 07/12/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 01/19/2024]
Abstract
Cerebral hyperperfusion (CHP) occurred frequently after direct superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery for moyamoya disease (MMD). We analyzed cortical microvascular density (CMD) and the change of cerebral blood flow (LΔCBF) using intraoperative laser speckle contrast imaging (LSCI) on 130 hemispheres of 95 consecutive adult patients with MMD. The demographic characteristics, cortical hemodynamic sources, bypass methods, intraoperative blood flow data, and relative CBF changes on single-photon emission computed tomography (SPECT) examination (SΔrCBF) were compared between the groups with and without CHP. The median values for CMD, LΔCBF, and SΔrCBF were significantly higher in the CHP group than in the non-CHP group (CMD 0.240 vs 0.206, P = 0.004; LΔCBF 2.285 vs 1.870, P < 0.001; SΔCBF 1.535 vs 1.260, P < 0.001). Multivariate analysis revealed that hemodynamic sources of recipient parasylvian cortical arteries from MCA (M-PSCAs), end-to-side (E-S) bypass method, CMD ≥ 0.217, and LΔCBF ≥ 1.985 were the risk factors for CHP. Intraoperative LSCI was useful for evaluating hemodynamics and predicting CHP in patients with MMD.
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Affiliation(s)
- Tianshu Tao
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Wenting Zhu
- Britton Chance Center and MoE Key Laboratory for Biomedical Photonics, Wuhan National Laboratory for Optoelectronics, Huazhong University of Science and Technology, Wuhan, China
| | - Jin Yu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Xiang Li
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Wei Wei
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Miao Hu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Mingrui Luo
- Department of Neurosurgery, WuHan Third Hospital, Wuhan, China
| | - Guiping Wan
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Pengcheng Li
- Britton Chance Center and MoE Key Laboratory for Biomedical Photonics, Wuhan National Laboratory for Optoelectronics, Huazhong University of Science and Technology, Wuhan, China
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
| | - Jianjian Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
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Helmy M, Liao Y, Zhao Z, Li Z, He K, Xu B. Assessing donor-recipient arterial pressure dynamics in STA-MCA bypass for moyamoya disease. Chin Neurosurg J 2024; 10:15. [PMID: 38734681 PMCID: PMC11088777 DOI: 10.1186/s41016-024-00367-2] [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: 02/20/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND In bypass surgery for moyamoya disease (MMD), the superficial temporal artery's (STA) pressure needs to surpass that of the cortical M4 recipient of the middle cerebral artery (MCA), boosting cerebral blood flow into the MCA and enhancing cerebral circulation. This study investigates the STA-MCA arterial pressure parameters and gradients during bypass surgery, aiming to deepen our understanding of hemodynamic shifts pre- and post-operation. METHODS DSA imaging data were prospectively collected from patients diagnosed with bilateral MMD who underwent STA-MCA bypass surgery between 2022 and 2023 and stratified according to the Suzuki stage. The mean arterial pressure (MAP) of the donor and recipient arteries was directly measured during the STA-MCA bypass procedure, and these data were statistically analyzed and evaluated. RESULTS Among 48 MMD patients, Suzuki grading revealed that 43.8% were in early stages (II and III), while 56.2% were in advanced stages (IV, V, and VI). Predominantly, 77.1% presented with ischemic-type MMD and 22.9% with hemorrhagic type. Pre-bypass assessments showed that 62.5% exhibited antegrade blood flow direction, and 37.5% had retrograde. The mean recipient artery pressure was 35.0 ± 2.3 mmHg, with a mean donor-recipient pressure gradient (δP) of 46.4 ± 2.5 mmHg between donor and recipient arteries. Post-bypass, mean recipient artery pressure increased to 73.3 ± 1.6 mmHg. No significant correlation (r = 0.18, P = 0.21) was noted between δP and Suzuki staging. CONCLUSION Our study elucidated that cerebral blood pressure significantly decreases beyond the moyamoya network at the distal M4 segment. Furthermore, we observed bidirectional flow in MCA territories and a significant positive pressure gradient between the STA and M4 segments. The lack of correlation between Suzuki stages and M4 pressures indicates that angiographic severity may not reflect hemodynamic conditions before surgery, highlighting the need for customized surgical approaches.
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Affiliation(s)
- Mohamed Helmy
- Neurosurgery Department, Fudan University Huashan Hospital, Shanghai, 200040, People's Republic of China
- National Center for Neurological Disorders, Shanghai, 200040, People's Republic of China
| | - Yujun Liao
- Neurosurgery Department, Fudan University Huashan Hospital, Shanghai, 200040, People's Republic of China
- National Center for Neurological Disorders, Shanghai, 200040, People's Republic of China
| | - Zehao Zhao
- Neurosurgery Department, Fudan University Huashan Hospital, Shanghai, 200040, People's Republic of China
- National Center for Neurological Disorders, Shanghai, 200040, People's Republic of China
| | - Zhiqi Li
- Neurosurgery Department, Fudan University Huashan Hospital, Shanghai, 200040, People's Republic of China
- National Center for Neurological Disorders, Shanghai, 200040, People's Republic of China
| | - Kangmin He
- Neurosurgery Department, Fudan University Huashan Hospital, Shanghai, 200040, People's Republic of China
- National Center for Neurological Disorders, Shanghai, 200040, People's Republic of China
| | - Bin Xu
- Neurosurgery Department, Fudan University Huashan Hospital, Shanghai, 200040, People's Republic of China.
- National Center for Neurological Disorders, Shanghai, 200040, People's Republic of China.
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Ramirez MDJE, Chaddad-Neto F, Montemurro N, Ramirez Pena IJ, Rosario Rosario A, Catillo-Rangel C, González López G, Cardona JJ, Campero A, Baldoncini M. Decibel Decisions: The Concept of Intracranial Aneurysm Surgery With a Decibel Meter on Two Surgical Cases. Cureus 2023; 15:e48993. [PMID: 38111432 PMCID: PMC10726301 DOI: 10.7759/cureus.48993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2023] [Indexed: 12/20/2023] Open
Abstract
The present cases were used to investigate the reliability of the intraoperative decibel meter as an objective method of clipping efficiency in cerebral aneurysm surgery and to assess the impact of this method on the surgical procedure itself. Different methodologies have been developed and applied to directly or indirectly evaluate the placement of a clip, for example, intraoperative digital subtraction angiography (DSA), intraoperative micro-Doppler ultrasonography, and, more recently, indocyanine green (ICG). We included two patients with a previously non-treated unruptured brain aneurysm. In both patients, intraoperative micro-Doppler was used in combination with a decibel meter app. Here, we present the cases of two patients. In patient one, the pre-clipping average sound level/equivalent continuous sound pressure level (Avg/Leq) was 96.7 dB, while the post-clipping Avg/Leq was 94.4 dB, indicating a reduction in sound level after clipping. Similarly, the pre-clipping time-weighted average noise level (TWA) was 1.2%, while the post-clipping TWA was 0.5%, indicating a decrease in exposure dose after clipping. In patient two, the average sound level for the post-clipping measurement (94.2 dB) was higher than the pre-clipping measurement (93.5 dB), but the difference was not statistically significant. These cases indicate the potential for using sound measurements as a reliable indicator of adequate aneurysm occlusion during clipping procedures. Further research is needed to confirm these findings.
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Affiliation(s)
| | - Feres Chaddad-Neto
- Department of Neurological Surgery, Universidade Federal de São Paulo, São Paulo, BRA
| | - Nicola Montemurro
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana, Pisa, ITA
| | | | | | - Carlos Catillo-Rangel
- Neurosurgery, Servicio of the 1ro de Octubre Hospital of the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, México City, MEX
| | | | - Juan J Cardona
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, USA
| | - Alvaro Campero
- Department of Neurological Surgery, Hospital Padilla, Tucumán, ARG
| | - Matias Baldoncini
- Department of Neurosurgery, University of Buenos Aires, Buenos Aires, ARG
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Gardner Yelton SE, Williams MA, Young M, Fields J, Pearl MS, Casella JF, Lawrence CE, Felling RJ, Jackson EM, Robertson C, Scafidi S, Lee JK, Cohen AR, Sun LR. Perioperative Management of Pediatric Patients with Moyamoya Arteriopathy. J Pediatr Intensive Care 2023; 12:159-166. [PMID: 37565017 PMCID: PMC10411150 DOI: 10.1055/s-0041-1731667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022] Open
Abstract
Pediatric patients with moyamoya arteriopathy are at high risk for developing new onset transient or permanent neurologic deficits secondary to cerebral hypoperfusion, particularly in the perioperative period. It is therefore essential to carefully manage these patients in a multidisciplinary, coordinated effort to reduce the risk of new permanent neurologic deficits. However, little has been published on perioperative management of pediatric patients with moyamoya, particularly in the early postoperative period during intensive care unit admission. Our pediatric neurocritical care team sought to create a multidisciplinary periprocedural evidence- and consensus-based care pathway for high-risk pediatric patients with moyamoya arteriopathy undergoing anesthesia for any reason to decrease the incidence of periprocedural stroke or transient ischemic attack (TIA). We reviewed the literature to identify risk factors associated with perioperative stroke or TIA among patients with moyamoya and to gather data supporting specific perioperative management strategies. A multidisciplinary team from pediatric anesthesia, neurocritical care, nursing, child life, neurosurgery, interventional neuroradiology, neurology, and hematology created a care pathway for children with moyamoya undergoing anesthesia, classifying them as either high or standard risk, and applying an individualized perioperative management plan to high-risk patients. The incidence of neurologic sequelae before and after pathway implementation will be compared in future studies.
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Affiliation(s)
- Sarah E. Gardner Yelton
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Monica A. Williams
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Mollie Young
- Child Life Department, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Jennifer Fields
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Monica S. Pearl
- Department of Radiology, Children's National Hospital, Washington, District of Columbia, United States
- Departments of Radiology and Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, United States
| | - James F. Casella
- Department of Pediatrics, Division of Hematology, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Courtney E. Lawrence
- Department of Pediatrics, Division of Hematology, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Ryan J. Felling
- Department of Neurology, Division of Pediatric Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Eric M. Jackson
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Courtney Robertson
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Susanna Scafidi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Alan R. Cohen
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Lisa R. Sun
- Department of Neurology, Division of Pediatric Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
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Wang X, Liu H, Xu M, Chen C, Ma L, Dai F. Efficacy assessment of superficial temporal artery-middle cerebral artery bypass surgery in treating moyamoya disease from a hemodynamic perspective: a pilot study using computational modeling and perfusion imaging. Acta Neurochir (Wien) 2023; 165:613-623. [PMID: 36595057 DOI: 10.1007/s00701-022-05455-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 12/05/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Superficial temporal artery-middle cerebral artery (STA-MCA) bypass is a common surgery in treating moyamoya disease (MMD) with occluded MCA. Computational fluid dynamics (CFD) simulation might provide a simple, non-invasive, and low-cost tool to evaluate the efficacy of STA-MCA surgery. AIM We aim to quantitatively investigate the treatment efficacy of STA-MCA surgery in improving the blood flow of MMD patients using CFD simulation. METHODS This retrospective study included 11 MMD patients with occlusion around proximal MCA who underwent STA-MCA bypass surgery. CFD simulation was performed using patient-specific blood pressure and postoperative artery geometry. The volumetric flow rates of STA and the bypass, average flow velocity in the proximal segment of transcranial bypass, transcranial pressure drop, and transcranial flow resistance were measured and compared with a postoperative increment of cerebral blood flow (CBF) in MCA territories derived from perfusion imaging. Per-branch pressure drop from model inlet to bypass branch outlet was calculated. RESULTS The volumetric flow rates of STA and the bypass were 80.84 ± 14.54 mL/min and 46.03 ± 4.21 mL/min. Average flow velocity in proximal bypass, transcranial pressure drop, and transcranial flow resistance were 0.19 ± 0.07 m/s, 3.72 ± 3.10 mmHg, and 6.54 ± 5.65 10-8 Pa s m-3. Postoperative mean increment of CBF in MCA territories was 16.03 ± 11.72 mL·100 g-1·min-1. Per-branch pressure drop was 10.96 ± 5.59 mmHg and 7.26 ± 4.25 mmHg in branches with and without stenosis. CONCLUSIONS CFD simulation results are consistent with CBF observation in verifying the efficacy of STA-MCA bypass, where postoperative stenosis may influence the hemodynamics.
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Affiliation(s)
- Xinhong Wang
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang Province, China.
| | - Haipeng Liu
- Research Centre for Intelligent Healthcare, Coventry University, Coventry, CV1 5FB, UK.
| | - Mengxi Xu
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang Province, China
| | - Cong Chen
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang Province, China
| | - Linlin Ma
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang Province, China
| | - Fangyu Dai
- Department of Neurology, Zhoushan Hospital, Wenzhou Medical University, Zhoushan, 316000, Zhejiang Province, China
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Imaging methods for surgical revascularization in patients with moyamoya disease: an updated review. Neurosurg Rev 2021; 45:343-356. [PMID: 34417671 PMCID: PMC8827314 DOI: 10.1007/s10143-021-01596-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 06/20/2021] [Accepted: 06/24/2021] [Indexed: 02/08/2023]
Abstract
Neuroimaging is crucial in moyamoya disease (MMD) for neurosurgeons, during pre-surgical planning and intraoperative navigation not only to maximize the success rate of surgery, but also to minimize postsurgical neurological deficits in patients. This is a review of recent literatures which updates the clinical use of imaging methods in the morphological and hemodynamic assessment of surgical revascularization in patients with MMD. We aimed to assist surgeons in assessing the status of moyamoya vessels, selecting bypass arteries, and monitoring postoperative cerebral perfusion through the latest imaging technology.
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Yang D, Zhang X, Tan C, Han Z, Su Y, Duan R, Shi G, Shao J, Cao P, He S, Wang R. Intraoperative transit-time ultrasonography combined with FLOW800 predicts the occurrence of cerebral hyperperfusion syndrome after direct revascularization of Moyamoya disease: a preliminary study. Acta Neurochir (Wien) 2021; 163:563-571. [PMID: 33006072 DOI: 10.1007/s00701-020-04599-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 09/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cerebral hyperperfusion syndrome (CHS) is a common complication after direct bypass surgery in patients with Moyamoya disease (MMD). Since preventive measures may be inadequate, we assessed whether the blood flow difference between the superficial temporal artery (STA) and recipient vessels (△BF) and the direct perfusion range (DPR) are related to CHS. METHODS We measured blood flow in the STA and recipient blood vessels before bypass surgery by transit-time probe to calculate △BF. Perfusion changes around the anastomosis before and after bypass were analyzed with FLOW800 to obtain DPR. Multiple factors, such as △BF, DPR, and postoperative CHS, were analyzed using binary logistic regression. RESULTS Forty-one patients with MMD who underwent direct bypass surgery were included in the study. Postoperative CHS symptoms occurred in 13/41 patients. △BF and DPR significantly differed between the CHS and non-CHS groups. The optimal receiver operating characteristic (ROC) curve cut-off value was 31.4 ml/min for ΔBF, and the area under the ROC curve (AUC) was 0.695 (sensitivity 0.846, specificity 0.500). The optimal cut-off value was 3.5 cm for DPR, and the AUC was 0.702 (sensitivity 0.615, specificity 0.750). CONCLUSION Postoperative CHS is caused by multiple factors. △BF is a risk factor for CHS while DPR is a protective factor against CHS.
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Intraoperative local hemodynamic quantitative analysis of direct revascularization in patients with moyamoya disease. Neurosurg Rev 2020; 44:2659-2666. [PMID: 33242129 DOI: 10.1007/s10143-020-01442-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/19/2020] [Accepted: 11/13/2020] [Indexed: 10/22/2022]
Abstract
Direct bypass surgery improves blood flow in patients with moyamoya disease (MMD) as well as causes local flow relocation and disturbance. This study aimed to describe the characteristics and changes of quantitative blood flow in MMD patients. Sixty-four consecutive MMD patients (67 hemispheres) who underwent STA-MCA anastomosis between August 2013 and September 2017 were included in this study. Intraoperative blood flow of superficial temporal artery and middle cerebral artery was measured with a noninvasive, ultrasound flowprobe, before and after the bypass. All data were collected prospectively. Before the bypass, 67 hemispheres were measured and 45 hemispheres acquired post-bypass measurements. Thirty-three (49.3%) had anterograde flow and 34 (50.7%) had retrograde. Retrograde blood flow was significantly higher than anterograde blood flow in MCA-M4 section (3.71 ± 2.78 ml/min vs 2.39 ± 1.71 ml/min, P = 0.023). Thirty-eight (56.7%) patients had local cerebrovascular reactivity, whereas 29 (43.3%) lost it. After bypass, blood flow was changed into three patterns: anterograde flow (1, 2.2%), retrograde flow (3, 6.7%), and bi-direction flow (41, 91.1%). Flow of M4 was significantly improved in both proximal (13.64 ± 9.16 vs 3.28 ± 2.57, P < 0.001) and distal (7.17 ± 7.21 vs 3.28 ± 2.57, P = 0.002) sides to the bypass. Postoperative infarctions occurred in 4 (8.9%) patients. All postoperative infarctions (n = 4) happened in those patients who did not have change of flow direction in M4 section distal to the bypass (P = 0.040). Direct bypass surgery improves local blood flow after bypass surgery in both sides of the anastomosis. Flow direction was usually changed after the surgery into a bi-direction pattern: anterograde flow in M4 distal to the bypass, and retrograde flow in M4 proximal to the bypass. Proximal side acquired around 5.4 times of flow than the distal side. Patients with change of flow direction in distal M4 were related with lower risks of postoperative infarctions.
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Decreased cortical perfusion in areas with blood-brain barrier dysfunction in Moyamoya disease. Acta Neurochir (Wien) 2020; 162:2565-2572. [PMID: 32700079 DOI: 10.1007/s00701-020-04480-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/30/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Recently, several studies have focused on the relationship between blood-brain barrier (BBB) impairment and the etiology of Moyamoya disease (MMD). However, in vivo studies investigating about BBB impairment and cortical perfusion in MMD patients were really rare. METHODS This study included 16 patients diagnosed with MMD and 9 patients with atherosclerotic cerebrovascular disease (ACVD); all of who were treated with superficial temporal artery-middle cerebral artery (STA-MCA) bypass. Cortical perfusion was assessed using intraoperative indocyanine green (ICG) videoangiography by calculating the blood flow index (BFI). In addition, we used sodium fluorescein (NaFl) to evaluate the permeability of BBB in vivo during operation. RESULTS The results showed that BBB impairment in MMD patients was more significant than that in ACVD patients, whereas, the cortical perfusion was comparable between two groups. BFI was significantly improved after STA-MCA bypass both in the MMD group (post-operation vs pre-operation: 109.2 ± 67.7 vs 64.3 ± 35.0, p = 0.004) and the ACVD group (post-operation vs pre-operation: 137.6 ± 89.6 vs 90.8 ± 58.3, p = 0.015). Moreover, BFI was significantly decreased in the cortex with BBB impairment as compared with that in the cortex with intact BBB (impaired BBB vs intact BBB: 55.7 ± 26.5 vs 87.6 ± 55.1, p = 0.025). Following bypass, the cortical perfusion significantly improved in the area of BBB impairment (post-operation vs pre-operation: 93.8 ± 75.2 vs 55.7 ± 26.5, p = 0.004), which was not observed in the BBB intact area (post-operation vs pre-operation: 92.4 ± 50.4 vs 87.6 ± 55.1, p = 0.58). CONCLUSION In summary, we observed that BBB impairment in MMD patients was more significant than that in ACVD patients. This study also demonstrated for the first time that cortical perfusion was significantly decreased in the cortex with BBB impairment as compared with that in the cortex with intact BBB in MMD patients. We also observed that After STA-MCA bypass, the cortical perfusion was significantly improved in the cortex with BBB impairment. These results may provide a new insight for BBB impairment and cortical perfusion in the etiology of MMD.
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Wang G, Zhang X, Wang B, Wen Y, Chen S, Liu J, Ke B, Wu H, Zhang G, Li M, Zhang S, Ji L, Li Y, Qi S, Feng W. Flow evaluation of STA-MCA bypass using quantitative ultrasonography: An alternative to standard angiography for follow up of bypass graft. J Stroke Cerebrovasc Dis 2020; 29:105000. [PMID: 32807419 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/10/2020] [Accepted: 05/23/2020] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To date, digital subtraction angiography (DSA) has been considered as the gold imaging modality for assessing graft patency after extracranial-intracranial bypass. The utility of a noninvasive and quantitative method of assessing graft flow postoperatively was evaluated by using quantitative ultrasonography. METHOD All STA-MCA bypass surgery performed over a 5-year period at a single institution were reviewed. Measured by duplex ultrasonography, pre-operative (day1) and post-operative (day1, day7, 3month and 6 month) graft blood flow rates were recorded and analyzed. Results were correlated to Matsushima grade determined by DSA performed within 24 h when ultrasonography was conducted to confirm the graft function. RESULTS 100 patients with 131 operated hemispheres were included in this study. The mean flow rates in the STA graft on pre-operative day1, post-operative day 1 and 7, at 3- and 6-month postoperatively were 24.1, 106.7, 112.6, 97.4 and 79.7 ml/min respectively. The mean post-operative flow in the STA graft graded as A/B/C were significantly different (168.0 ± 34.8 ml/min, 91.0 ± 15.5, 42.1 ± 17.2 ml/min, respectively, p = 0.000). 124.5 ml/min and 65.5 ml/min are good cut-off value for predicting post-operative graft Matsushima grade. The analysis also showed excellent agreement between ultrasonography and DSA for assessing bypass function (κ = 0.78). CONCLUSIONS The patency of the STA grafts can be assessed noninvasively by quantitative ultrasonography, which results are comparable to those of conventional DSA. This, therefore, suggest that quantitative ultrasonography may be an alternative method to standard DSA for serial follow up of STA grafts.
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Affiliation(s)
- Gang Wang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, Guangdong, PR China
| | - Xi'an Zhang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, Guangdong, PR China
| | - Baoping Wang
- Department of Ultrasound, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, Guangdong, PR China
| | - Yunyu Wen
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, Guangdong, PR China
| | - Siyuan Chen
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, Guangdong, PR China
| | - Junjie Liu
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, Guangdong, PR China
| | - Bingbing Ke
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, Guangdong, PR China
| | - Hualan Wu
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, Guangdong, PR China
| | - Guozhong Zhang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, Guangdong, PR China
| | - Mingzhou Li
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, Guangdong, PR China
| | - Shichao Zhang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, Guangdong, PR China
| | - Lijing Ji
- Department of Ultrasound, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, Guangdong, PR China
| | - Yingjia Li
- Department of Ultrasound, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, Guangdong, PR China
| | - Songtao Qi
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, Guangdong, PR China.
| | - Wenfeng Feng
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, 510515 Guangzhou, Guangdong, PR China.
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Eguchi S, Aihara Y, Chiba K, Yamaguchi K, Kawashima A, Okada Y, Kawamata T. Do Direct Bypasses Really Resolve Capillary Vessels in Moyamoya Disease? Delayed Hemorrhage Potentially Relevant to Direct Bypasses: A Pathological Investigation. Pediatr Neurosurg 2020; 55:203-209. [PMID: 33032284 DOI: 10.1159/000509125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 06/02/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Moyamoya disease is a chronic but progressive obliterative cerebrovascular disease of bilateral internal carotid arteries (ICAs) causing hemorrhagic or ischemic cerebral strokes. Surgical revascularization has the potential for resolving the capillary vessels, but the effect on the occlusive ICA and the moyamoya vessels after a direct bypass remains unclear. PATIENT A 2-year-old girl with a history of repeated transient ischemic attacks and direct bypasses but demonstrating improvement and associated anomaly is reported. A year and a half later, after a bilateral revascularization, an intracerebral capsulized hematoma growth was identified, and it was removed surgically. Neovascularization including many microvessels similar to capillary telangiectasia were identified by pathological investigation despite the reduction of moyamoya vessels on the repeated angiograms after the revascularization surgeries. In the present case, proliferation of capillary vessels was clearly confirmed by direct bypasses. CONCLUSION There is no doubt that direct bypasses prevent further ischemic stroke by improving cerebral blood flow. However, they may result in failure in reducing the load of moyamoya vessels, albeit decreasing the potential risk of hemorrhagic strokes.
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Affiliation(s)
- Seiichiro Eguchi
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Yasuo Aihara
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan,
| | - Kentaro Chiba
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Koji Yamaguchi
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Akitsugu Kawashima
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoshikazu Okada
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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Zhang J, Li S, Fujimura M, Lau TY, Wu X, Hu M, Zheng H, Xu H, Zhao W, Li X, Chen J. Hemodynamic analysis of the recipient parasylvian cortical arteries for predicting postoperative hyperperfusion during STA-MCA bypass in adult patients with moyamoya disease. J Neurosurg 2019; 134:17-24. [PMID: 31881540 DOI: 10.3171/2019.10.jns191207] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Superficial temporal artery-middle cerebral artery (STA-MCA) bypass is a common approach for treating moyamoya disease (MMD); however, the selection of recipient vessels is still controversial, and its relationship with postoperative cerebral hyperperfusion (CHP) has not been revealed. The aim of the study was to investigate the relationship between the hemodynamic sources of the recipient parasylvian cortical arteries (PSCAs) and the occurrence of postoperative CHP. METHODS The authors retrospectively analyzed the clinical data from 68 adult patients (75 hemispheres) with MMD who underwent STA-MCA bypass. Based on their hemodynamic sources from the MCA and non-MCAs, the PSCAs were classified as M-PSCAs and non-M-PSCAs, and their distributional characteristics were studied. Moreover, the patients' demographics, incidence of postoperative CHP, and post- and preoperative relative cerebral blood flow values were examined. RESULTS The digital subtraction angiography analysis demonstrated that 40% (30/75) of the recipient PSCAs had no hemodynamic relationship with the MCA. The post- and preoperative relative cerebral blood flow values of the M-PSCA group were significantly higher than those of the non-M-PSCA group (p < 0.001). Multivariate analysis revealed that the hemodynamic source of PSCAs from the MCA was significantly associated with the development of focal (p = 0.003) and symptomatic (p = 0.021) CHP. Twelve (85.7%) of the 14 patients with symptomatic CHP and all 4 (100%) patients with postoperative hemorrhage were from the M-PSCA group. CONCLUSIONS This study revealed that direct anastomoses of PSCAs with anterograde hemodynamic sources from the MCA had a high risk of postoperative CHP during STA-MCA bypass in adult patients with MMD.
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Affiliation(s)
- Jianjian Zhang
- 1Department of Neurosurgery, Zhongnan Hospital of Wuhan University
| | - Sirui Li
- 2Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Miki Fujimura
- 3Department of Neurosurgery, Kohnan Hospital, Sendai, Japan
| | - Tsz Yeung Lau
- 4Department of Neurosurgery, Lakeland Regional Hospital, University of South Florida, Lakeland, Florida; and
| | - Xiaolin Wu
- 1Department of Neurosurgery, Zhongnan Hospital of Wuhan University
| | - Miao Hu
- 1Department of Neurosurgery, Zhongnan Hospital of Wuhan University
| | - Hanpei Zheng
- 2Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Haibo Xu
- 2Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wenyuan Zhao
- 1Department of Neurosurgery, Zhongnan Hospital of Wuhan University
| | - Xiang Li
- 5Queensland Brain Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Jincao Chen
- 1Department of Neurosurgery, Zhongnan Hospital of Wuhan University
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Lukshin VA, Usachev DY, Shulgina AA, Shevchenko EV. [Local cerebral hemodynamics following STA-MCA bypass in patients with symptomatic carotid occlusions]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2019; 83:29-41. [PMID: 31339495 DOI: 10.17116/neiro20198303129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To assess changes in local hemodynamic parameters in patients with symptomatic ICA occlusions and moyamoya disease after placement of extracranial-intracranial bypass (EC-IC bypass). MATERIAL AND METHODS The study included 112 patients who underwent surgical treatment at the National Scientific and Practical Center for Neurosurgery in the period between 1999 and 2015. Of these, 105 patients had ICA occlusions, and 7 patients had moyamoya disease. During the main stage of EC-IC bypass placement, all patients were monitored for local hemodynamic parameters using intraoperative contact Doppler ultrasonography - 89 (72%) patients (72%) and flowmetry - 56 (50%)). In 33 (29%) cases, both techniques were used. Forty two patients underwent preoperative SCT perfusion to assess the degree of perfusion deficit. Grade 1 cerebrovascular insufficiency (acute oligemia) was detected in 6 patients; grade 2 perfusion deficit (persistent oligemia) was found in 25 patients; grade 3 perfusion deficit (chronic oligemia) was present in 11 patients. Measurements were performed before bypass placement: the blood flow direction and hemodynamic parameters in the cortical arteries were evaluated; and after bypass placement: blood flow values and directions in the cortical artery, proximal and distal to the bypass area, were assessed. RESULTS A total of 112 EC-IC bypasses were placed without perioperative complications and deaths. Bypass functioning was confirmed in 108 (96.3%) cases; bypass thrombosis occurred in 4 (3.7%) cases. The distal blood flow direction was observed in patients with ICA occlusions (105 patients) in all cases before EC-IC bypass placement. Patients with moyamoya disease had more often the proximal blood flow direction - 5 (71%) out of 7 cases. The cerebral blood flow parameters obtained in this study differed significantly, depending on the baseline degree of perfusion deficit. The blood flow rate was minimal in patients with grade 1 cerebrovascular insufficiency. After revascularization, local hemodynamics in the cortical arteries was significantly dependent on the ability of EC-IC bypass to reverse blood flow in the proximal acceptor artery. A change in the blood flow direction was observed in 86 (77%) cases. The mean volumetric blood flow in EC-IC bypass was 34.2±5.7 mL/min. CONCLUSION The knowledge of baseline hemodynamic parameters and their changes after revascularization plays an important role in choosing the correct surgical technique, further bypass functioning, and, as a result, improvement of the clinical outcome after surgery.
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Affiliation(s)
- V A Lukshin
- Burdenko National Scientific and Practical Center for Neurosurgery, Moscow, Russia
| | - D Yu Usachev
- Burdenko National Scientific and Practical Center for Neurosurgery, Moscow, Russia
| | - A A Shulgina
- Burdenko National Scientific and Practical Center for Neurosurgery, Moscow, Russia
| | - E V Shevchenko
- Burdenko National Scientific and Practical Center for Neurosurgery, Moscow, Russia
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Shulgina A, Lukshin V, Usachev D, Shevchenko E. Local Cerebral Hemodynamics after Superficial Temporal Artery-Middle Cerebral Artery Bypass in Patients with Symptomatic Carotid Occlusions. Asian J Neurosurg 2019; 14:853-862. [PMID: 31497114 PMCID: PMC6703006 DOI: 10.4103/ajns.ajns_78_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context Physiological insights into blood flow alterations in cortical vessels after superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery are important for the prognosis of bypass sustainability and hemodynamic patency. Aims This study aims to assess the impact of STA-MCA bypass on local hemodynamics for patients with symptomatic carotid occlusions and Moyamoya disease. Settings and Design This article presents a prospective nonrandomized study of intraoperative blood flow measurements in cortical branches of MCA and donor vessel before and after cerebral revascularization. Materials and Methods Evaluation of local hemodynamic parameters was established for 112 patients with symptomatic carotid occlusive disease and cerebrovascular insufficiency during STA-MCA bypass surgery. We used intraoperative Doppler ultrasonography (89 patients - 72%), flowmetry (56 cases - 50%), and in 33 cases both methods. For physical justification of observed facts, we performed computational simulation with OpenFOAM CFD framework using Navier-Stokes nonstationary hemodynamic model. Statistical Analysis Used All calculations were performed with IBM SPSS Statistics version 10.0 software. We used parametric (Z-test and Student's t-test) and nonparametric models (Wilcoxon, Mann-Whitney). For categorical values, we used Fisher's exact test. Results Local cerebral hemodynamics after revascularization surgery significantly depended on initial perfusion deficit and the ability of bypass to reverse the blood flow in proximal parts of cortical artery (86 cases, 77%). Mechanism of cortical blood flow alteration was related to donor vessel cut flow value and potential consumption threshold of acceptor artery. Conclusions Knowledge of hemodynamic principles of flow redistribution after STA-MCA bypass is important to improve bypass stainability and leads to better revascularization results.
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Affiliation(s)
- Anna Shulgina
- N. N. Burdenko National Scientific and Practical Center of Neurosurgery, Moscow, Russia
| | - Vasily Lukshin
- N. N. Burdenko National Scientific and Practical Center of Neurosurgery, Moscow, Russia
| | - Dmitry Usachev
- N. N. Burdenko National Scientific and Practical Center of Neurosurgery, Moscow, Russia
| | - Elena Shevchenko
- N. N. Burdenko National Scientific and Practical Center of Neurosurgery, Moscow, Russia
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Efficacy of superficial temporal artery-middle cerebral artery double bypass in patients with hemorrhagic moyamoya disease: surgical effects for operated hemispheric sides. Neurosurg Rev 2018; 42:559-568. [PMID: 30511308 DOI: 10.1007/s10143-018-01059-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/26/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
Abstract
The effects of superficial temporal artery to middle cerebral artery (STA-MCA) double bypass on recurrent hemorrhage in the operated hemisphere in hemorrhagic moyamoya disease (HMD) have not been clearly demonstrated. This study evaluated the effectiveness of STA-MCA double bypass in the prevention of further hemorrhagic or ischemic events in the operated hemispheric sides in comparison to the conservatively treated non-operated sides. We retrospectively analyzed 52 hemispheres of 36 patients with adult-onset HMD treated with STA-MCA double bypass. Twenty and 16 patients underwent unilateral (unilateral group) and bilateral (bilateral group) surgery, respectively. In addition, the perioperative and long-term outcomes of the 52 operated sides and 20 non-operated sides in the unilateral group were compared. All bypass surgeries were successful, but 21% of the operated sides showed hyperperfusion as estimated by our methods. Perioperative mortality and morbidity rate were 0% and 5.6%, respectively. Concerning long-term follow-up, the annual rebleeding rate (ARR) in the unilateral and bilateral group was 2.7% and 2.6%/person-year, respectively (p = 0.256). The ARR in the operated and non-operated sides was 1.1% and 1.8%/side-year, respectively (p = 0.163). Two of 20 non-operated sides suffered from ischemic infarction during the follow-up period, while none of the 52 operated sides experienced ischemic events (p < 0.05). Although the long-term rebleeding rate in the operated hemisphere tended to be lower after STA-MCA double bypass compared with that in the non-operated hemisphere, the difference was not statistically significant. In conclusion, while STA-MCA double bypass could not clearly prevent rebleeding, it can prevent further ischemic attacks in patients with HMD.
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16
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Uda K, Araki Y, Muraoka S, Ota S, Wada K, Yokoyama K, Nishihori M, Izumi T, Okamoto S, Wakabayashi T. Intraoperative evaluation of local cerebral hemodynamic change by indocyanine green videoangiography: prediction of incidence and duration of postoperative transient neurological events in patients with moyamoya disease. J Neurosurg 2018:1-9. [PMID: 29676693 DOI: 10.3171/2017.10.jns171523] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 10/16/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVETransient neurological events (TNEs) occur frequently in the acute phase after direct bypass surgery for moyamoya disease (MMD), but there is currently no way to predict them. FlowInsight is a specialized software for analyzing indocyanine green (ICG) videoangiography taken with a surgical microscope. The purpose of this study was to investigate whether intraoperative evaluation of local hemodynamic changes around anastomotic sites using FlowInsight could predict the incidence and duration of TNEs.METHODSFrom patients who were diagnosed with MMD in our hospital between August 2014 and March 2017 and who underwent superficial temporal artery-middle cerebral artery bypass surgery, we investigated 25 hemispheres (in 22 patients) in which intraoperative ICG analysis was performed using FlowInsight. To evaluate the local cerebral hemodynamics before and after anastomosis, regions of interest were set at 3 locations on the brain surface around the anastomotic site, and the mean cerebral blood flow (CBF), mean gradation (Grad), mean transit time (MTT), and mean time to peak (TTP) were calculated from the 3 regions of interest. Furthermore, the change rate in CBF (ΔCBF [%]) was calculated using the formula (postanastomosis mean CBF - preanastomosis mean CBF)/preanastomosis mean CBF. ΔGrad (%), ΔMTT (%), and ΔTTP (%) were similarly calculated.RESULTSPostoperative stroke without TNE occurred in 2 of the 25 hemispheres. These 2 hemispheres (in 2 patients) were excluded from the study, and data from the remaining 23 hemispheres (in 20 patients) were analyzed. For each parameter (ΔCBF, ΔGrad, ΔMTT, and ΔTTP) calculated by FlowInsight, the difference between the groups with and without TNEs was significant. The median values for ΔCBF and ΔGrad were significantly higher in the TNE group than in the no-TNE group (ΔCBF 30.13 vs 3.54, p = 0.0106; ΔGrad 62.05 vs 10.78, p = 0.00435), whereas the median values for ΔMTT and ΔTTP were significantly lower in the TNE group (ΔMTT -16.90 vs -7.393, p = 0.023; ΔTTP -29.07 vs -7.02, p = 0.00342). Comparison of the area under the curve (AUC) for each parameter showed that ΔTTP had the highest AUC and was the parameter with the highest diagnostic accuracy (AUC 0.857). The Youden index revealed that the optimal cutoff value of ΔTTP was -11.61 (sensitivity 77.8%, specificity 71.4%) as a predictor of TNEs. In addition, Spearman's rank correlation coefficients were calculated, and ΔCBF, ΔGrad, ΔMTT, and ΔTTP each showed a strong correlation with the duration of TNEs. The larger the change in each parameter, the longer the TNEs persisted.CONCLUSIONSIntraoperative ICG videoangiography findings were correlated with the occurrence and duration of TNEs after direct bypass surgery for MMD. Screening for cases at high risk of TNEs can be achieved by ICG analysis using FlowInsight.
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Lee JK, Williams M, Reyes M, Ahn ES. Cerebrovascular blood pressure autoregulation monitoring and postoperative transient ischemic attack in pediatric moyamoya vasculopathy. Paediatr Anaesth 2018; 28:94-102. [PMID: 29205668 PMCID: PMC5960234 DOI: 10.1111/pan.13293] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Children with moyamoya vasculopathy are at high risk of perioperative cerebral ischemia or hyperperfusion. Maintaining blood pressure within the range of functional cerebrovascular blood pressure autoregulation might reduce the risk of perioperative neurologic injury. AIMS We tested whether blood pressure autoregulation is associated with postoperative transient ischemic attack in a study of patients with pediatric moyamoya vasculopathy. METHODS We conducted an observational study of 15 pediatric patients undergoing surgical revascularization with pial synangiosis. Nine patients had bilateral moyamoya and 6 had unilateral moyamoya. We measured autoregulatory vasoreactivity intraoperatively and during the first postoperative night with the hemoglobin volume index, a value derived from near-infrared spectroscopy. We also identified the optimal mean arterial blood pressure at which autoregulation was most robust in each patient. RESULTS Of the 15 children monitored, 3 with bilateral moyamoya and one with unilateral moyamoya experienced a transient ischemic attack. Poorer autoregulation during surgery was associated with postoperative transient ischemic attack among those with bilateral vasculopathy (P = .048, difference in hemoglobin volume index medians: 0.023, 95% confidence interval: 0.003-0.071). This relationship was not observed with postoperative autoregulation. The optimal mean arterial blood pressure was identifiable during surgery in all monitored patients, varied among patients, and often differed between the intraoperative and postoperative periods. CONCLUSION Dysfunctional intraoperative autoregulation may increase the risk of TIA in patients with pediatric moyamoya vasculopathy. The blood pressure range that supports autoregulation appears to vary among patients. Using autoregulation monitoring to guide individualized blood pressure goals should be studied as a potential method to reduce perioperative neurologic morbidity in pediatric patients with moyamoya.
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Affiliation(s)
- Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Monica Williams
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Reyes
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Edward S. Ahn
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
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Chen L, Xu B, Wang Y, Liao Y, Pan H, Wang Y. Preoperative evaluation of moyamoya spontaneous anastomosis of combined revascularization donor vessels in adults by duplex ultrasonography. Br J Neurosurg 2017; 32:412-417. [PMID: 29191051 DOI: 10.1080/02688697.2017.1406450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate the preoperative diagnostic value of duplex ultrasonography in moyamoya spontaneous anastomosis of combined revascularization donor vessels in adults. METHODS A total of 99 preoperative adult patients who underwent superficial temporal artery-to-middle cerebral artery (STA-MCA) anastomosis were retrospectively analyzed. Each side of the cerebral hemisphere was examined as a separate procedure. A total of 198 cerebral hemispheres were divided into three groups: a collateral, non-collateral, and control group based on digital subtraction angiography (DSA). Hemodynamic parameters, including peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) were analyzed. RESULTS There were only four of cases (5%, 4/198) of STA spontaneous anastomosis, whereas those of maxillary artery (MA) anastomosis were 44 (23.7%, 44/186). Compared with the control group, MA PSV and EDV of the collateral group increased significantly, while RI decreased significantly (p < .05). The area under the curve (AUC) of MA RI was 0.654. As a predictor of MA spontaneous anastomosis, duplex ultrasonography had high specificity but poor sensitivity. In collateral group, PSV and EDV detected two weeks post-surgery were significantly higher than those detected pre-operatively (PSV: p = .018, EDV: p = .025). By contrast, there were no significant difference of the PSV and EDV detected six months post-surgery compared with pre-operation (PSV: p = .450, EDV: p = .099). Additionally, MA RI in two weeks after the surgery was comparable with preoperative values. CONCLUSIONS Duplex ultrasonography could be applied to evaluate the adult moyamoya spontaneous anastomoses of MA preoperatively. Despite its poor sensitivity, this diagnostic modality is still reliable and specific. STA-MCA anastomosis combined with EDMS did not affect MA pre-operative spontaneous anastomosis.
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Affiliation(s)
- Li Chen
- a Department of Ultrasound , Huashan Hospital Fudan University , Shanghai , China
| | - Bin Xu
- a Department of Ultrasound , Huashan Hospital Fudan University , Shanghai , China
| | - Yong Wang
- a Department of Ultrasound , Huashan Hospital Fudan University , Shanghai , China
| | - Yujun Liao
- a Department of Ultrasound , Huashan Hospital Fudan University , Shanghai , China
| | - Huiwen Pan
- a Department of Ultrasound , Huashan Hospital Fudan University , Shanghai , China
| | - Yi Wang
- a Department of Ultrasound , Huashan Hospital Fudan University , Shanghai , China
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Choque-Velasquez J, Colasanti R, Kozyrev DA, Hernesniemi J, Kawashima A. Moyamoya Disease in an 8-Year-Old Boy: Direct Bypass Surgery in a Province of Peru. World Neurosurg 2017; 108:50-53. [PMID: 28844915 DOI: 10.1016/j.wneu.2017.08.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 08/15/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric moyamoya cases may be very arduous, even more so in a developing country, where access to specialized centers may be prevented by different factors. CASE DESCRIPTION Herein we report a challenging case, which was managed in the new Neurosurgical Center of Trujillo, regarding the direct anastomosis between the left superficial temporal artery and a cortical branch of the left middle cerebral artery in a 8-year-old Peruvian boy with moyamoya disease. Postoperatively, the patient's motor deficits and aphasia improved. To the best of our knowledge, this is the first performance of a direct revascularization for a pediatric moyamoya case in Peru. CONCLUSIONS The creation of highly specialized neurosurgical centers in the main strategic places of developing countries may allow optimal treatment of neurosurgical patients with complex diseases.
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Affiliation(s)
- Joham Choque-Velasquez
- Neurosurgical Unit, Es-Salud Trujillo Hospital, La Libertad, Peru; Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland.
| | - Roberto Colasanti
- Neurosurgical Unit, Es-Salud Trujillo Hospital, La Libertad, Peru; Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland; Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Danil A Kozyrev
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Juha Hernesniemi
- Neurosurgical Unit, Es-Salud Trujillo Hospital, La Libertad, Peru; Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Akitsugu Kawashima
- Neurosurgical Unit, Es-Salud Trujillo Hospital, La Libertad, Peru; Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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Li X, Huang Z, Wu MX, Zhang D. Effect of Adventitial Dissection of Superficial Temporal Artery on the Outcome of Superficial Temporal Artery-Middle Cerebral Artery Bypass in Moyamoya Disease. Aging Dis 2017; 8:384-391. [PMID: 28840053 PMCID: PMC5524801 DOI: 10.14336/ad.2016.1115] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 11/15/2016] [Indexed: 11/24/2022] Open
Abstract
Superficial temporal artery-middle cerebral artery (STA-MCA) has been used for the treatment of occlusive cerebrovascular disease including moyamoya disease. The effect of STA-MCA bypass depends not only on the patency of anastomosis, but also on integrity and functional capacity of the donor artery. In the present prospective study, we investigated the effect of extensive stripping STA adventitia and fasciae on hemodynamic function in STA-MCA bypass of moyamoya disease patients. Twenty patients (n=8 in control group, n=12 in stripping group) of moyamoya disease were subjected to STA-MCA end-to-side direct anastomosis. Perfusion unit (PU) values of the cortex were measured and recorded using a Laser Doppler flowmetry (LDF) for 5 days. Computed tomography perfusion was performed to determine blood flow before and after bypass. No patient experienced significant neurologic deficits associated with neurosurgical complications. LDF demonstrated that adventitial stripping group had higher cerebral blood flow increase than control group. The adventitia stripping group tends to have higher rate of increased cerebral perfusion after bypass than non-stripping group. Furthermore, the ultrasound examination at 3 days after bypass demonstrated that the adventitial stripping group has a tendency of bigger STA and higher peak systolic velocity than control group. Our result suggests that stripping adventitia of STA improves hemodynamics of STA-MCA bypass in moyamoya disease.
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Affiliation(s)
- Xin Li
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Zheng Huang
- 2Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Ming-Xing Wu
- 3Department of Neurosurgery, Beijing Puhua International Hospital, Beijing 100050, China
| | - Dong Zhang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
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Inoue A, Kohno K, Iwata S, Ohue S, Ozaki S, Ninomiya S, Tomita H, Kamogawa K, Okamoto K, Fukumoto S, Ichikawa H, Onoue S, Nakamura Y, Okuda B. Efficacy of Early Superficial Temporal Artery-Middle Cerebral Artery Double Anastomoses for Atherosclerotic Occlusion in Patients with Progressing Stroke. J Stroke Cerebrovasc Dis 2016; 26:741-748. [PMID: 27816279 DOI: 10.1016/j.jstrokecerebrovasdis.2016.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/30/2016] [Accepted: 10/10/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND We investigated the efficacy of early superficial temporal artery-middle cerebral artery (STA-MCA) double anastomoses for patients with progressing stroke due to atherosclerotic occlusion. MATERIALS AND METHODS Nine consecutive patients who underwent early STA-MCA double anastomoses were enrolled. All patients presented with progressing stroke despite maximal medical treatment. Cerebral blood flow in 7 patients was analyzed by single-photon emission tomography. Clinical outcomes were investigated postoperatively, and we evaluated the utility of early STA-MCA double anastomoses. RESULTS Nine patients in the present study included those with middle cerebral artery occlusion (n = 6) and internal carotid artery occlusion (n = 3). The mean age was 58.4 years. Subjects comprised 1 female (11.1%) and 8 males (88.9%). The cause was low perfusion ischemia due to atherosclerotic occlusion with a small infarct. The mean regional cerebral blood flow (rCBF) ratio in the middle cerebral artery territory compared to the normal side was 69.6 ± 5.3%. The duration from onset to surgery was 1-8 days (median, 3.11 days). All patients underwent early STA-MCA double anastomoses, and no reperfusion-induced hemorrhage occurred. All of them slowly achieved obvious remission compared to symptoms on admission and achieved a good functional outcome. CONCLUSIONS Early STA-MCA double anastomoses were safe and effective, and early revascularization resulted in rapid neurological improvement. We recommend this procedure for patients with progressive ischemia due to main trunk artery occlusion, when the rCBF flow ratio with the normal side was 70 ± 10%, even at the subacute stage.
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Affiliation(s)
- Akihiro Inoue
- Department of Neurosurgery, Ehime Prefectural Central Hospital, Ehime Prefecture, Japan.
| | - Kanehisa Kohno
- Department of Neurosurgery, Ehime Prefectural Central Hospital, Ehime Prefecture, Japan
| | - Shinji Iwata
- Department of Neurosurgery, Ehime Prefectural Central Hospital, Ehime Prefecture, Japan
| | - Shiro Ohue
- Department of Neurosurgery, Ehime Prefectural Central Hospital, Ehime Prefecture, Japan
| | - Saya Ozaki
- Department of Neurosurgery, Ehime Prefectural Central Hospital, Ehime Prefecture, Japan
| | - Satoko Ninomiya
- Department of Neurology, Ehime Prefectural Central Hospital, Ehime Prefecture, Japan
| | - Hitomi Tomita
- Department of Neurology, Ehime Prefectural Central Hospital, Ehime Prefecture, Japan
| | - Kenji Kamogawa
- Department of Neurology, Ehime Prefectural Central Hospital, Ehime Prefecture, Japan
| | - Kensho Okamoto
- Department of Neurology, Ehime Prefectural Central Hospital, Ehime Prefecture, Japan
| | - Shinya Fukumoto
- Department of Neurosurgery, Ehime Prefectural Central Hospital, Ehime Prefecture, Japan
| | - Haruhisa Ichikawa
- Department of Neurosurgery, Ehime Prefectural Central Hospital, Ehime Prefecture, Japan
| | - Shinji Onoue
- Department of Neurosurgery, Ehime Prefectural Central Hospital, Ehime Prefecture, Japan
| | - Yawara Nakamura
- Department of Neurosurgery, Ehime Prefectural Central Hospital, Ehime Prefecture, Japan
| | - Bungo Okuda
- Department of Neurology, Ehime Prefectural Central Hospital, Ehime Prefecture, Japan
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22
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The feasibility of detecting cerebral blood flow direction using the indocyanine green video angiography. Neurosurg Rev 2016; 39:685-90. [PMID: 27136915 DOI: 10.1007/s10143-016-0726-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/14/2016] [Accepted: 04/09/2016] [Indexed: 11/27/2022]
Abstract
The intraoperative confirmation of blood flow direction is necessary in cerebral vascular surgery. Using indocyanine green video angiography (ICG-VAG) with the FLOW 800 system, we examined the transit time of the blood vessel of interest and semiquantitatively evaluated the delay time (T1/2max) from indocyanine green (ICG) injection into the donor artery in reconstructive surgery and the middle cerebral artery (MCA) in aneurysmal surgery. The direction of cerebral blood flow (CBF), which can often be confirmed by ICG-VAG, may be more difficult to determine with faster blood flow. Here, we report our findings regarding the feasibility of detecting CBF direction using the FLOW 800 system. Twenty patients undergoing superficial temporal artery (STA) to MCA anastomosis for carotid occlusive disease and 13 patients with a small MCA aneurysm clipping were evaluated using the T1/2max, semiquantitative method with the FLOW 800 system. In STA-MCA anastomosis cases, the regions of interest (ROIs) included: the proximal donor STA and a region more than 10 mm on the distal side of the donor STA near the anastomosis site. In MCA aneurysms, the ROIs included the proximal M1 and distal M2 sides of the MCA aneurysm. T1/2max was significantly shorter for the proximal sites compared to the distal sites for all subjects (ps < 0.01). T1/2max was shorter for all subjects in the proximal sites. The direction of CBF can be determined using the FLOW 800 system.
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23
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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: 40] [Impact Index Per Article: 5.0] [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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24
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Lukshin VA, Usachev DY, Pronin IN, Akhmedov AD, Schultz EI. [Perfusion criteria of the EICMA efficacy in patients with symptomatic occlusion of the internal carotid artery]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2016; 80:67-77. [PMID: 27801401 DOI: 10.17116/neiro201680567-77] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
AIM To investigate changes in cerebral perfusion in patients with unilateral internal carotid artery occlusion before and after surgical revascularization of the brain, depending on the clinical efficacy of surgical treatment. MATERIAL AND METHODS The study included 60 patients with unilateral ICA occlusions who underwent placement of an extra-intracranial microvascular anastomosis (EICMA). All patients underwent a CT perfusion study before and after cerebral revascularization. In addition, the degree of neurological deficit was evaluated before surgery and during follow-up (3 and 8-10 months) using the NIHSS score. RESULTS All patients were divided into 3 groups, depending on the results of surgical treatment: objective improvement (43 patients), no changes (14 patients), and worsening of clinical symptoms (3 patients). In each group, the absolute and relative perfusion parameters (MTT, CBV, and CBF) were analyzed to identify the perfusion criteria for the EICMA efficacy. A significant relationship between the clinical efficacy of EICMA and a baseline perfusion deficit and its change after anastomosis placement was found. CONCLUSION Placement of EICMA is effective treatment for patients with symptomatic ICA occlusions and an increase in the blood transit time in the hemisphere ipsilateral to occlusion by more than 40% compared to that in the opposite side provided that perfusion is recovered in more than one area of the MCA territory (in accordance with the ASPECTS scale).
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Affiliation(s)
- V A Lukshin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - D Yu Usachev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - I N Pronin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A D Akhmedov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - E I Schultz
- Burdenko Neurosurgical Institute, Moscow, Russia
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25
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Moyamoya disease concurrent with Graves' disease treated by direct bypass: clinical features and treatment strategies. Acta Neurochir (Wien) 2015; 157:1095-102. [PMID: 25929211 DOI: 10.1007/s00701-015-2422-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 04/07/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Moyamoya disease (MMD) concurrent with Graves' disease (GD) is rare. There is no guideline about optimizing thyroid hormones and the appropriate timing of surgical treatment for MMD with GD. METHODS We encountered eight patients with MMD and GD presenting with cerebral ischemia who were treated by direct bypass. Thyroid hormones [free thyroxin (fT4) and free triiodothyronine (fT3)], thyroid-stimulating hormone (TSH), and TSH receptor antibody (TRAb) were measured sequentially. After thyrotoxic conditions were medically optimized, revascularization surgery was performed by superficial temporal artery-middle cerebral artery (STA-MCA) double bypass in all cases. Clinical outcomes were estimated by modified Rankin scale (mRS) at discharge and 3 months after surgery. RESULTS In six patients with thyrotoxicosis, the fT4, fT3, and TRAb (range) at the onset of cerebral ischemia were 4.81-10.30 pg/ml, 13.08-31.90 pg/ml, and 3.5-83.8 IU/l, respectively. At surgery, mean (range) fT3 and fT4 were optimized to 3.02 (1.01-4.87) pg/ml and 1.09 (0.41-1.68) ng/dl, respectively. In the thyrotoxic cases, it took 70-310 days (mean, 142 days) to optimize thyroid hormones before surgery. There was no neurological aggravation after surgery, and outcome was excellent at 3 months with mRS scores ≤2 in all cases. CONCLUSIONS For MMD concurrent with GD, optimizing thyroid hormones followed by STA-MCA double bypass was successful to prevent cerebral ischemic events.
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Fujimura M, Niizuma K, Endo H, Sato K, Inoue T, Shimizu H, Tominaga T. Quantitative analysis of early postoperative cerebral blood flow contributes to the prediction and diagnosis of cerebral hyperperfusion syndrome after revascularization surgery for moyamoya disease. Neurol Res 2014; 37:131-8. [DOI: 10.1179/1743132814y.0000000432] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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27
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Fujimura M, Niizuma K, Inoue T, Sato K, Endo H, Shimizu H, Tominaga T. Minocycline Prevents Focal Neurological Deterioration Due to Cerebral Hyperperfusion After Extracranial-Intracranial Bypass for Moyamoya Disease. Neurosurgery 2013; 74:163-70; discussion 170. [DOI: 10.1227/neu.0000000000000238] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Cerebral hyperperfusion (CHP) is a potential complication of superficial temporal artery–middle cerebral artery (STA-MCA) anastomosis for moyamoya disease (MMD), and optimal postoperative management has not yet been established. Minocycline, a neuroprotective antibiotic agent, plays a role in blocking matrix metalloproteinase 9 (MMP-9), which contributes to edema formation and hemorrhagic conversion after cerebral ischemia-reperfusion. Patients with MMD have been shown to have increased serum MMP-9 levels.
OBJECTIVE:
To examine the effect of minocycline on the prevention of postoperative CHP after STA-MCA anastomosis for MMD.
METHODS:
N-isopropyl-p-[123I]iodoamphetamine single-photon emission computed tomography was performed 1 and 7 days after STA-MCA anastomosis on 109 hemispheres in 86 consecutive patients with MMD (ages, 9-69 years; mean, 37.2 years). Postoperative systolic blood pressure was strictly maintained at lower than 130 mm Hg in all 109 surgeries. The most 60 recent hemispheres were managed by the intraoperative and postoperative intravenous administration of minocycline hydrochloride (200 mg/d). The incidence of focal neurological deterioration (FND) due to CHP was then compared with that in 36 patients undergoing 49 surgeries managed without minocycline.
RESULTS:
FND due to CHP was observed in 4 operated hemispheres in patients treated without minocycline (4/49, 8.16%), and in none in the minocycline-treated group (0/60) (P = .0241). Multivariate analysis revealed that minocycline administration (P < .001), surgery on the left hemisphere (P = .031), and a smaller recipient artery diameter (P < .001) significantly correlated with FND due to CHP.
CONCLUSION:
The administration of minocycline with strict blood pressure control may represent secure and effective postoperative management to prevent symptomatic CHP after STA-MCA anastomosis for MMD.
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Affiliation(s)
- Miki Fujimura
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Neurosurgery, National Hospital Organization, Sendai Medical Center, Sendai, Japan
| | - Kuniyasu Niizuma
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Inoue
- Department of Neurosurgery, National Hospital Organization, Sendai Medical Center, Sendai, Japan
| | - Kenichi Sato
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hidenori Endo
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Shimizu
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Lee JK, Williams M, Jennings JM, Jamrogowicz JL, Larson AC, Jordan LC, Heitmiller ES, Hogue CW, Ahn ES. Cerebrovascular autoregulation in pediatric moyamoya disease. Paediatr Anaesth 2013; 23:547-56. [PMID: 23506446 PMCID: PMC3648623 DOI: 10.1111/pan.12140] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Moyamoya syndrome carries a high risk of cerebral ischemia, and impaired cerebrovascular autoregulation may play a critical role. Autoregulation indices derived from near-infrared spectroscopy (NIRS) may clarify hemodynamic goals that conform to the limits of autoregulation. OBJECTIVES The aims of this pilot study were to determine whether the NIRS-derived indices could identify blood pressure ranges that optimize autoregulation and whether autoregulatory function differs between anatomic sides in patients with unilateral vasculopathy. METHODS Pediatric patients undergoing indirect surgical revascularization for moyamoya were enrolled sequentially. NIRS-derived autoregulation indices, the cerebral oximetry index (COx) and the hemoglobin volume index (HVx), were calculated intraoperatively and postoperatively to measure autoregulatory function. The 5-mmHg ranges of optimal mean arterial blood pressure (MAPOPT ) with best autoregulation and the lower limit of autoregulation (LLA) were identified. RESULTS Of seven enrolled patients (aged 2-16 years), six had intraoperative and postoperative autoregulation monitoring and one had only intraoperative monitoring. Intraoperative MAPOPT was identified in six (86%) of seven patients with median values of 60-80 mmHg. Intraoperative LLA was identified in three (43%) patients with median values of 55-65 mmHg. Postoperative MAPOPT was identified in six (100%) of six patients with median values of 70-90 mmHg. Patients with unilateral disease had higher intraoperative HVx (P = 0.012) on side vasculopathy. CONCLUSIONS NIRS-derived indices may identify hemodynamic goals that optimize autoregulation in pediatric moyamoya.
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Affiliation(s)
- Jennifer K. Lee
- Dept. of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesia, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Monica Williams
- Dept. of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesia, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jacky M. Jennings
- The Bloomberg School of Public Health, Baltimore, MD, and The Dept. of Pediatrics, The Johns Hopkins University School of Medicine, USA
| | - Jessica L. Jamrogowicz
- Dept. of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Abby C. Larson
- Dept. of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lori C. Jordan
- Dept. of Neurology, Vanderbilt University, Nashville, TN, USA
| | - Eugenie S. Heitmiller
- Dept. of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesia, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles W. Hogue
- Dept. of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Edward S. Ahn
- Dept. of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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