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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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Ranjeva S, Nagebretsky A, Odozynski G, Fernandez-Bustamante A, Frendl G, Gupta RA, Sprung J, Subramaniam B, Ruiz RM, Bartels K, Giquel J, Lee JW, Houle T, Melo MFV. Effects of Intra-operative Cardiopulmonary Variability On Post-operative Pulmonary Complications in Major Non-cardiac Surgery: A Retrospective Cohort Study. J Med Syst 2024; 48:31. [PMID: 38488884 DOI: 10.1007/s10916-024-02050-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/27/2024] [Indexed: 03/17/2024]
Abstract
Intraoperative cardiopulmonary variables are well-known predictors of postoperative pulmonary complications (PPC), traditionally quantified by median values over the duration of surgery. However, it is unknown whether cardiopulmonary instability, or wider intra-operative variability of the same metrics, is distinctly associated with PPC risk and severity. We leveraged a retrospective cohort of adults (n = 1202) undergoing major non-cardiothoracic surgery. We used multivariable logistic regression to evaluate the association of two outcomes (1)moderate-or-severe PPC and (2)any PPC with two sets of exposure variables- (a)variability of cardiopulmonary metrics (inter-quartile range, IQR) and (b)median intraoperative cardiopulmonary metrics. We compared predictive ability (receiver operating curve analysis, ROC) and parsimony (information criteria) of three models evaluating different aspects of the intra-operative cardiopulmonary metrics: Median-based: Median cardiopulmonary metrics alone, Variability-based: IQR of cardiopulmonary metrics alone, and Combined: Medians and IQR. Models controlled for peri-operative/surgical factors, demographics, and comorbidities. PPC occurred in 400(33%) of patients, and 91(8%) experienced moderate-or-severe PPC. Variability in multiple intra-operative cardiopulmonary metrics was independently associated with risk of moderate-or-severe, but not any, PPC. For moderate-or-severe PPC, the best-fit predictive model was the Variability-based model by both information criteria and ROC analysis (area under the curve, AUCVariability-based = 0.74 vs AUCMedian-based = 0.65, p = 0.0015; AUCVariability-based = 0.74 vs AUCCombined = 0.68, p = 0.012). For any PPC, the Median-based model yielded the best fit by information criteria. Predictive accuracy was marginally but not significantly higher for the Combined model (AUCCombined = 0.661) than for the Median-based (AUCMedian-based = 0.657, p = 0.60) or Variability-based (AUCVariability-based = 0.649, p = 0.29) models. Variability of cardiopulmonary metrics, distinct from median intra-operative values, is an important predictor of moderate-or-severe PPC.
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Affiliation(s)
- Sylvia Ranjeva
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA.
| | - Alexander Nagebretsky
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | | | | | - Gyorgy Frendl
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - R Alok Gupta
- Department of Anesthesiology, Northwestern Medicine, Chicago, USA
| | - Juraj Sprung
- Department of Anesthesiology, Mayo Clinic, Rochester, USA
| | - Bala Subramaniam
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, USA
| | | | - Karsten Bartels
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, USA
| | - Jadelis Giquel
- Department of Anesthesiology, University of Miami Hospital and Clinics, Miami, USA
| | - Jae-Woo Lee
- Department of Anesthesiology, University of California San Francisco, San Francisco, USA
| | - Timothy Houle
- Department of Anesthesiology, Anesthesia Research Center, Massachusetts General Hospital, Boston, USA
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Qian MP, Dong MR, Han MM, Li J, Kang F. ABO blood types may affect transient neurological events after surgical revascularization in patients with moyamoya disease: a retrospective single center study. BMC Anesthesiol 2023; 23:419. [PMID: 38114904 PMCID: PMC10729420 DOI: 10.1186/s12871-023-02385-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/14/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Moyamoya disease (MMD) is a cerebrovascular disease with unknown cause. Patients with MMD disease usually experience transient neurological events (TNEs) after revascularization surgery. This retrospective single-center study was aimed to explore the risk factors of postoperative TNEs after surgical revascularization in patients with MMD. METHODS We selected 324 patients who underwent surgical revascularization between January 2017 and September 2022 in our center. The perioperative characteristics of the patients were recorded and the outcome was TNEs after surgery. An analysis of risk factors contributing to postoperative TNEs by using logistic regression model. RESULTS Three hundred twelve patients were enrolled, and the incidence of postoperative TNEs was 34% in our study. Males were more likely to suffer from postoperative TNEs (OR = 2.344, p = 0.002). Preoperative ischemic presentation (OR = 1.849, p = 0.048) and intraoperative hypotension (OR = 2.332, p = 0.002) were associated with postoperative TNEs. Compared to patients with blood type O, patients with blood type A (OR = 2.325, p = 0.028), B (OR = 2.239, p = 0.027) and AB (OR = 2.938, p = 0.019) had a significantly higher incidence of postoperative TNEs. A risk prediction model for postoperative TNEs was established, and the established risk prediction area under the receiver operating characteristic curve (ROC) of the model was 0.741. CONCLUSIONS Males, preoperative ischemic presentation and intraoperative hypotension were associated with postoperative TNEs. We also found a possible link between postoperative TNEs and ABO blood types after surgical revascularization for moyamoya patients.
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Affiliation(s)
- Mei-Ping Qian
- Department of Anesthesiology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Mei-Rong Dong
- Department of Anesthesiology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Ming-Ming Han
- Department of Anesthesiology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Juan Li
- Department of Anesthesiology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Fang Kang
- Department of Anesthesiology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China.
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Yamashina M, Inaji M, Hara S, Tanaka Y, Kaneoka A, Nariai T, Maehara T. Encephalo-Duro-Pericranio-Synangiosis for the Treatment of Moyamoya Disease with Posterior Cerebral Artery Lesions. World Neurosurg 2023; 175:e678-e685. [PMID: 37030475 DOI: 10.1016/j.wneu.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/31/2023] [Accepted: 04/01/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE We describe our experience performing encephalo-duro-pericranio synangiosis for the parieto-occipital region (EDPS-p) as a treatment for moyamoya disease (MMD) with hemodynamic disturbances caused by lesions of the posterior cerebral artery. METHODS From 2004 to 2020, 60 hemispheres of 50 patients with MMD (38/50 females, age 1-55 years) underwent EDPS-p as a treatment for hemodynamic disturbances in the parieto-occipital region. A skin incision was made on the parieto-occipital area to avoid the major skin arteries, and the pedicle flap was created by attaching the pericranium to the dura mater under the craniotomy with multiple small incisions. The surgical outcome was assessed on the basis of the following points: perioperative complications, postoperative improvement of clinical symptoms, subsequent novel ischemic events, qualitative assessment of the development of collateral vessels by magnetic resonance arteriography, quantitative assessment of postoperative perfusion improvement based on the mean transit time, and cerebral blood volume on dynamic susceptibility contrast imaging. RESULTS Perioperative infarction occurred in 7/60 hemispheres (11.7%). The transient ischemic symptoms observed preoperatively disappeared in 39/41 hemispheres (95.1%) during the follow-up period (12-187 months), and none of the patients experienced novel ischemic events. Collateral vessels supplied from the occipital arteries, middle meningeal arteries, and posterior auricular arteries developed postoperatively in 56/60 hemispheres (93.3%). Postoperative mean transit time and cerebral blood volume showed significant improvement in the occipital, parietal, and temporal areas (P < 0.001), as well as the frontal area (P = 0.01). CONCLUSIONS EDPS-p seems to be an effective surgical treatment for patients with MMD who suffer hemodynamic disturbances caused by posterior cerebral artery lesions.
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Affiliation(s)
- Motoshige Yamashina
- Department of Neurosurgery, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Motoki Inaji
- Department of Neurosurgery, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan.
| | - Shoko Hara
- Department of Neurosurgery, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Yoji Tanaka
- Department of Neurosurgery, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Azumi Kaneoka
- Department of Neurosurgery, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Tadashi Nariai
- Department of Neurosurgery, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Taketoshi Maehara
- Department of Neurosurgery, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
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Lucia K, Acker G, Rubarth K, Beyaztas D, Vajkoczy P. The Development and Effect of Systemic Hypertension on Clinical and Radiological Outcome in Adult Moyamoya Angiopathy Following Revascularization Surgery: Experience of a Single European Institution. J Clin Med 2023; 12:4219. [PMID: 37445259 DOI: 10.3390/jcm12134219] [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: 04/16/2023] [Revised: 06/10/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Patients with Moyamoya Angiopathy (MMA) display structurally altered vessels with decreased cerebral autoregulatory capacity, so aggressive lowering of systemic hypertension may aggravate ischemic symptoms, whereas uncontrolled hypertension may promote hemorrhage. This study provides an in-depth analysis of the role of hypertension in adult MMA patients including long-term analysis of clinical and radiological development. In this single-center retrospective analysis of 137 adult MMA patients with 206 surgically treated hemispheres angiographic images, clinical/operative data were reviewed and scored. Univariate Cox-regression analysis was performed to evaluate hypertension as a predictor for negative angiographic and clinical outcomes following revascularization surgery. A total of 50% of patients were being treated for hypertension prior to the first surgery. Patients with and without hypertension did not differ in terms of age, gender, diagnosis, symptom onset or disease severity (Berlin and Suzuki Grades). Although hypertension did not statistically significantly affect postoperative collaterals, moyamoya vessels or STA-MCA bypass patency, patients with hypertension showed higher rates of bypass patency and better bypass filling compared to those without hypertension. No significant differences in adverse events were found in patients with and without systemic hypertension and the presence of systemic hypertension was not found to predict negative clinical or radiological outcomes. In conclusion, the rate of systemic hypertension in MMA patients appears to be higher than the general population; however, this is not associated with an increased risk of postoperative complications or negative angiographic development following revascularization procedures. Systemic hypertension may also positively influence the rate of bypass patency and filling following revascularization procedures.
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Affiliation(s)
- Kristin Lucia
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neurosurgery, Goethe University Hospital Frankfurt Am Main, Schleusenweg 2-16, 60528 Frankfurt Am Main, Germany
| | - Güliz Acker
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Kerstin Rubarth
- Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Institute of Biometrics and Clinical Epidemiology Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Institute of Medical Informatics Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Defne Beyaztas
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
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Pettersson SD, Olofsson HKL, Ali S, Szarek D, Miękisiak G, Ogilvy CS. Risk Factors for Ischemic Stroke After Revascularization Surgery in Patients with Moyamoya Disease: An Age-Stratified Comparative Meta-Analysis. World Neurosurg 2023; 173:146-157.e14. [PMID: 36716854 DOI: 10.1016/j.wneu.2023.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/29/2023]
Abstract
BACKGROUND Patients who undergo revascularization surgery for moyamoya disease may develop postoperative ischemic stroke (pIS). Several studies have sought to identify risk factors; however, the findings remain highly inconsistent. METHODS PubMed, Scopus, and Web of Science were used to extract references. The first phase of screening required the studies to be in English, involve patients surgically treated for moyamoya disease, and report pIS. The second phase required the studies to provide ≥10 patients and include a control group. RESULTS All 22 studies were rated as high quality. Univariate analysis identified pediatrics <3 years of age as a risk factor for pIS (odds ratio [OR], 7.60; P < 0.0001). Among adult patients only, diabetes (OR, 2.10; P = 0.005), a Suzuki grade greater than 3 (OR, 1.74; P = 0.005), mean intraoperative systolic blood pressure (OR, 1.04; P < 0.0001), mean intraoperative diastolic blood pressure (OR, 1.04; P = 0.002), and revascularization in the left hemisphere (OR, 2.09; P = 0.001) were risk factors. Among both age groups, preoperative ischemic stroke (OR, 2.59; P < 0.00001) was a risk factor for pIS. Additionally, perioperative antiplatelet drug administration was a protective factor for specifically acute postoperative white thrombus among adult patients (OR, 0.35; P = 0.002). CONCLUSIONS In addition to the methods discussed that can mitigate the risk of pIS, the risk factors identified in our analysis may be of great value among surgeons for identifying high-risk patients in order to apply prophylactic measures, as well as scheduling longer and more frequent follow-up visits.
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Affiliation(s)
- Samuel D Pettersson
- Department of Neurosurgery, Medical University of Gdansk, Gdansk, Poland; Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Hanna K L Olofsson
- Department of Neurosurgery, Medical University of Gdansk, Gdansk, Poland
| | - Shan Ali
- Neurology Department, Mayo Clinic, Jacksonville, USA
| | - Dariusz Szarek
- Department of Neurosurgery, Lower Silesia Specialist Hospital of T. Marciniak, Wrocław, Poland
| | | | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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Transient ischemic attack after indirect revascularization surgery for pediatric patients with moyamoya disease: A retrospective study of intraoperative blood pressure. Anaesth Crit Care Pain Med 2023; 42:101168. [PMID: 36309164 DOI: 10.1016/j.accpm.2022.101168] [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: 11/04/2021] [Revised: 09/29/2022] [Accepted: 10/18/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study aimed to investigate the association between intraoperative blood pressure and postoperative transient ischemic attacks (TIAs) in pediatric patients with moyamoya disease after indirect revascularization surgery. METHODS We retrospectively reviewed the medical records of patients with moyamoya disease younger than 15 years who underwent indirect revascularizations under general anesthesia from 2013 to 2019. Perioperative clinical factors and intraoperative blood pressure data were collected and analyzed. Univariate and multivariable mixed-effect logistic regressions were used to identify predictors of postoperative TIA and symptom progression. RESULTS Among 444 hemispheres in 296 pediatric patients, 70 cases (16%) experienced postoperative TIAs within 2 weeks after surgery, and 34 cases (7.7%) developed postoperative symptom progression. Baseline mean blood pressure (MBP) (adjusted odds ratio, 1.261; 95% confidence interval, 1.037-1.528; P < 0.001), Average mean arterial pressure (MAP) (adjusted odds ratio, 1.137; 95% confidence interval, 1.052-1.228; P = 0.006), and Ipsilateral magnetic resonance angiography (MRA) score (adjusted odds ratio, 1.464; 95% confidence interval, 0.886-2.419; P = 0.012) were statistically significant risk factors for postoperative TIA. Average real variability of MAP (ARV-MAP), which were measures of intraoperative MAP variability (adjusted odds ratio, 4.731; 95% confidence interval, 1.419-15.257; P = 0.003) and maximum MAP declination (MaxD-MAP) (adjusted odds ratio, 1.271; 95% confidence interval, 1.013-1.520; P = 0.010) were statistically significant risk factors for postoperative symptom progression. CONCLUSION Higher pre-induction baseline blood pressure and ipsilateral MRA score were independent risk factors predicting postoperative TIA in pediatric patients with moyamoya disease after indirect revascularization. The high variability and drastic decline in intraoperative MAP showed predictive value in postoperative symptom progression.
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Wang J, Jiang H, Tang J, Lin C, Ni W, Gu Y. Postoperative cerebral infarction after revascularization in patients with moyamoya disease: Incidence and risk factors. Front Neurol 2022; 13:1053193. [PMID: 36479051 PMCID: PMC9720261 DOI: 10.3389/fneur.2022.1053193] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/07/2022] [Indexed: 11/10/2023] Open
Abstract
OBJECTIVES Cerebral infarction is the major complication of revascularization surgery in patients with moyamoya disease (MMD), and we analyzed the possible causes of cerebral infarction after revascularization surgery for MMD. METHODS MMD patients who were admitted and underwent surgical revascularization at Shanghai Huashan Hospital from January 2019 to December 2021 were retrospectively analyzed. RESULTS A total of 815 patients and 890 revascularization surgeries (677 first revascularization surgeries and 213 second revascularization surgeries) were included in this study; 453 (50.9%) were performed on the left side and 437 (49.1%) on the right side, with 779 (87.5%) combined procedures and 111 (12.5%) indirect bypasses included. The mean patient age at the time of these procedures was 44.6 ± 11.7 years (range 6-72 years). Postoperative cerebral infarctions were observed in 46 (5.17%) surgeries, among which 31 occurred after left hemisphere revascularization surgeries, with an incidence of 6.84%, and 15 occurred after right hemisphere revascularization surgeries, with an incidence of 3.43%. Of these, 30 (65.2%) occurred in the operated hemispheres, 2 (4.3%) in the contralateral hemisphere and 13 (28.3%) in the bilateral hemisphere. There were 11 cases of massive infarction (23.9%). The incidence of postoperative infarction in patients undergoing the first revascularization was 6% (41/677) and 2.3% (5/213) in the second revascularization surgeries. Initial presentation as infarction (P < 0.001), initial presentation as hemorrhage (P < 0.001), hypertension (P = 0.018), diabetes (P = 0.006), 1st or 2nd surgery and surgical side (P = 0.007) were found to be related to postoperative cerebral infarction. Initial presentation as infarction (OR = 2.934, 95% CI 1.453-5.928, P = 0.003), initial presentation as hemorrhage (OR = 0.149, 95% CI 0.035-0.641, P = 0.011), and 1st or 2nd surgery and surgical side (OR = 1.66, 95% CI 1.106-2.491, P = 0.014) were independently associated with cerebral infarction after revascularization surgeries. CONCLUSIONS In patients with MMD undergoing surgical revascularization, initial presentation as infarction and first revascularization surgery performed on the left hemisphere are independent risk factors for postoperative cerebral infarction, whereas initial presentation as hemorrhage is a protective factor.
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Affiliation(s)
- Jiaxiong Wang
- Department of Neurosurgery, South Yunnan Central Hospital of Yunnan Province (The First People's Hospital of Honghe Prefecture), Mengzi, China
| | - Hanqiang Jiang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jinwei Tang
- Department of Neurosurgery, South Yunnan Central Hospital of Yunnan Province (The First People's Hospital of Honghe Prefecture), Mengzi, China
| | - Chi Lin
- Department of Neurosurgery, South Yunnan Central Hospital of Yunnan Province (The First People's Hospital of Honghe Prefecture), Mengzi, China
| | - Wei Ni
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yuxiang Gu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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Chen JY, Tu XK. Research Progress on Postoperative Transient Neurological Dysfunction in Pediatric and Adult Patients with Moyamoya Disease after Revascularization Surgery. Clin Neurol Neurosurg 2022; 217:107254. [DOI: 10.1016/j.clineuro.2022.107254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/01/2022] [Accepted: 04/13/2022] [Indexed: 11/03/2022]
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Li F, Li C, Sun Y, Bao Y, Jiang W, Song Z, Wang Y, Liu M, Wang W, Li T, Li L. Cerebral Ischemic Complications After Surgical Revascularization for Moyamoya Disease: Risk Factors and Development of a Predictive Model Based on Preoperative Nutritional Blood Parameters. Front Nutr 2022; 9:842838. [PMID: 35360692 PMCID: PMC8960452 DOI: 10.3389/fnut.2022.842838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 02/02/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives Cerebral ischemic complications are common after revascularization in patients with moyamoya disease (MMD). Risk factors from specific laboratory variables have only been assessed by limited research. This study was to investigate the association between postoperative cerebral ischemia and nutritional blood parameters and examine predictive values of such risk factors in adults. Methods Preoperative demographics and nutritional blood parameters of patients with MMD who received revascularization at our institution from 2012 to 2021 were retrospectively reviewed. Univariate analysis and multivariable logistic regression were used to identify independent risk factors for the onset of postoperative cerebral ischemic complications. Predictive values were tested and a model incorporating these independent risk factors was created using the R program. Area under the receiver operating characteristic curve (AUC) was used for testing its discriminability. Results Postoperative cerebral ischemic complications occurred in 32 patients of 100 included procedures. Surgery on the left hemisphere, lower admission modified Rankin Scale (mRS) score, aberrant nutritional parameters including low white blood cell (WBC), and high total cholesterol (TC) were significantly associated with cerebral ischemic complications after revascularization. The intriguing role of WBC might be explained by altered immunomodulation. The AUC of this model with novel nutritional parameters yielded a value of 0.811, presenting better predictive accuracy. Additionally, the model was visualized in the form of a nomogram and translated into a user-friendly calculator to generate individual risk. Conclusions Surgical side, admission mRS score, WBC, and TC were independent risk factors for postoperative cerebral ischemic complications. The model composed of these four parameters was promising to be adopted in clinical practice.
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Affiliation(s)
- Fangbao Li
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
- School of Medicine, Dalian Medical University, Dalian, China
| | - Chuanfeng Li
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
| | - Yunwei Sun
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
| | - Yue Bao
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
| | - Wenbo Jiang
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
| | - Zuoyan Song
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, China
| | - Yongyi Wang
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
| | - Mingxing Liu
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
| | - Weimin Wang
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
| | - Tong Li
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
- *Correspondence: Tong Li
| | - Luo Li
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
- Luo Li
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Lizano-Díez I, Poteet S, Burniol-Garcia A, Cerezales M. The burden of perioperative hypertension/hypotension: A systematic review. PLoS One 2022; 17:e0263737. [PMID: 35139104 PMCID: PMC8827488 DOI: 10.1371/journal.pone.0263737] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/25/2022] [Indexed: 11/30/2022] Open
Abstract
Study objective Our goal is to review the outcomes of acute hypertensive/hypotensive episodes from articles published in the past 10 years that assessed the short- and long-term impact of acute hypertensive/hypotensive episodes in the perioperative setting. Methods We conducted a systematic peer review based upon PROSPERO and Cochrane Handbook protocols. The following study characteristics were collected: study type, author, year, population, sample size, their definition of acute hypertension, hypotension or other measures, and outcomes (probabilities, odds ratio, hazard ratio, and relative risk) and the p-values; and they were classified according to the type of surgery (cardiac and non-cardiac). Results A total of 3,680 articles were identified, and 66 articles fulfilled the criteria for data extraction. For the perioperative setting, the number of articles varies by outcome: 20 mortality, 16 renal outcomes, 6 stroke, 7 delirium and 34 other outcomes. Hypotension was reported to be associated with mortality (OR 1.02–20.826) as well as changes from the patient’s baseline blood pressure (BP) (OR 1.02–1.36); hypotension also had a role in the development of acute kidney injury (AKI) (OR 1.03–14.11). Postsurgical delirium was found in relation with BP lability (OR 1.018–1.038) and intra- and postsurgical hypotension (OR 1.05–1.22), and hypertension (OR 1.44–2.34). Increased OR (37.67) of intracranial hemorrhage was associated to postsurgical systolic BP >130 mmHg. There was a wide range of additional diverse outcomes related to hypo-, hypertension and BP lability. Conclusions The perioperative management of BP influences short- and long-term effects of surgical procedures in cardiac and non-cardiac interventions; these findings support the burden of BP fluctuations in this setting.
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Putowski Z, Czok M, Krzych ŁJ. The impact of intraoperative blood pressure variability on the risk of postoperative adverse outcomes in non-cardiac surgery: a systematic review. J Anesth 2022; 36:316-322. [PMID: 35028755 PMCID: PMC8967760 DOI: 10.1007/s00540-022-03035-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/31/2021] [Indexed: 10/26/2022]
Abstract
Hemodynamic stability during surgery seems to account for positive postoperative outcomes in patients. However, little is known about the impact of intraoperative blood pressure variability (IBPV) on the postoperative complications. The aim was to investigate whether IBPV is associated with the development of postoperative complications and what is the nature of this association. We conducted a systematic search in PubMed, Medical Subject Headings, Embase, Web of Science, SCOPUS, clinicaltrials.gov, and Cochrane Library on the 8th of April, 2021. We included studies that only focused on adults who underwent primarily elective, non-cardiac surgery in which intraoperative blood pressure variation was measured and analyzed in regard to postoperative, non-surgical complications. We identified 11 papers. The studies varied in terms of applied definitions of blood pressure variation, of which standard deviation and average real variability were the most commonly applied definitions. Among the studies, the most consistent analyzed outcome was a 30-day mortality. The studies presented highly heterogeneous results, even after taking into account only the studies of best quality. Both higher and lower IBPV were reported to be associated for postoperative complications. Based on a limited number of studies, IBPV does not seem to be a reliable indicator in predicting postoperative complications. Existing premises suggest that either higher or lower IBPV could contribute to postoperative complications. Taking into account the heterogeneity and quality of the studies, the conclusions may not be definitive.
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Affiliation(s)
- Zbigniew Putowski
- Students' Scientific Society, Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medyków 14 Street, 40752, Katowice, Poland.
| | - Marcelina Czok
- Students' Scientific Society, Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medyków 14 Street, 40752, Katowice, Poland
| | - Łukasz J Krzych
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
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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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Hara S, Nariai T, Inaji M, Tanaka Y, Maehara T. Imaging Pattern and the Mechanisms of Postoperative Infarction After Indirect Revascularization in Patients with Moyamoya Disease. World Neurosurg 2021; 155:e510-e521. [PMID: 34464770 DOI: 10.1016/j.wneu.2021.08.098] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/19/2021] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To develop preventive strategies against postoperative infarction after indirect revascularization surgery in patients with moyamoya disease (MMD), we evaluated clinical information, with a specific focus on the imaging pattern of postoperative infarction. METHODS We retrospectively evaluated 421 surgical procedures performed in 354 (262 pediatric and 159 adult) patients with MMD from April 1991 to March 2021 at our institute. In addition to clinical information, raw images of postoperative infarction were collected and categorized into subtypes by the location of the infarction. RESULTS Symptomatic and asymptomatic postoperative infarction occurred in 47 and 12 patients (11.1% and 2.6%), respectively, and more than half (51.7%) of these cases of postoperative infarction occurred immediately or the day after the surgery. Cortical infarction around the craniotomy site was the most frequent pattern observed (50/59, 84.8%), and some of these cases seemed to occur under local compression from epidural or subdural hematomas (15/50, 30.0%). Ipsilateral white matter infarctions located in the watershed area (9/59, 15.3%) and contralateral infarctions (3/59, 5.1%) were also observed. Four patients (1.0%) showed sudden occlusions of ipsilateral or contralateral large intracranial arteries immediately after surgery. Postoperative infarction caused permanent neurologic deficits in 7 patients (1.7%), and all included the cortex outside the craniotomy site. CONCLUSIONS Local cortical irritation, hemodynamic fluctuation, and thromboembolic events were suggested as possible mechanisms of postoperative infarction after indirect revascularization in patients with MMD. Minimizing cortical irritation, maintaining adequate cerebral blood flow, and perioperative antiplatelet agents might decrease the incidence of postoperative infarction.
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Affiliation(s)
- Shoko Hara
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Tadashi Nariai
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Motoki Inaji
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoji Tanaka
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Taketoshi Maehara
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
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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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Wali AR, Santiago-Dieppa DR, Srinivas S, Brandel MG, Steinberg JA, Rennert RC, Mandeville R, Murphy JD, Olson S, Pannell JS, Khalessi AA. Surgical revascularization for Moyamoya disease in the United States: A cost-effectiveness analysis. J Cerebrovasc Endovasc Neurosurg 2021; 23:6-15. [PMID: 33540961 PMCID: PMC8041505 DOI: 10.7461/jcen.2021.e2020.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/07/2020] [Indexed: 11/23/2022] Open
Abstract
Objective Moyamoya disease (MMD) is a vasculopathy of the internal carotid arteries with ischemic and hemorrhagic sequelae. Surgical revascularization confers upfront peri-procedural risk and costs in exchange for long-term protective benefit against hemorrhagic disease. The authors present a cost-effectiveness analysis (CEA) of surgical versus non-surgical management of MMD. Methods A Markov Model was used to simulate a 41-year-old suffering a transient ischemic attack (TIA) secondary to MMD and now faced with operative versus nonoperative treatment options. Health utilities, costs, and outcome probabilities were obtained from the CEA registry and the published literature. The primary outcome was incremental cost-effectiveness ratio which compared the quality adjusted life years (QALYs) and costs of surgical and nonsurgical treatments. Base-case, one-way sensitivity, two-way sensitivity, and probabilistic sensitivity analyses were performed with a willingness to pay threshold of $50,000. Results The base case model yielded 3.81 QALYs with a cost of $99,500 for surgery, and 3.76 QALYs with a cost of $106,500 for nonsurgical management. One-way sensitivity analysis demonstrated the greatest sensitivity in assumptions to cost of surgery and cost of admission for hemorrhagic stroke, and probabilities of stroke with no surgery, stroke after surgery, poor surgical outcome, and death after surgery. Probabilistic sensitivity analyses demonstrated that surgical revascularization was the cost-effective strategy in over 87.4% of simulations. Conclusions Considering both direct and indirect costs and the postoperative QALY, surgery is considerably more cost-effective than non-surgical management for adults with MMD.
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Affiliation(s)
- Arvin R Wali
- Department of Neurological Surgery, University of California, San Diego, CA, USA
| | | | - Shanmukha Srinivas
- Department of Neurological Surgery, University of California, San Diego, CA, USA
| | - Michael G Brandel
- Department of Neurological Surgery, University of California, San Diego, CA, USA
| | - Jeffrey A Steinberg
- Department of Neurological Surgery, University of California, San Diego, CA, USA
| | - Robert C Rennert
- Department of Neurological Surgery, University of California, San Diego, CA, USA
| | - Ross Mandeville
- Department of Neurology, University of California, San Diego, CA, USA
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, CA, USA
| | - Scott Olson
- Department of Neurological Surgery, University of California, San Diego, CA, USA
| | - J Scott Pannell
- Department of Neurological Surgery, University of California, San Diego, CA, USA
| | - Alexander A Khalessi
- Department of Neurological Surgery, University of California, San Diego, CA, USA
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