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Northam WT, Slingerland AL, Orbach DB, Smith ER. Magnetic Resonance Imaging/Angiography Versus Catheter Angiography for Annual Follow-up of Pediatric Moyamoya Patients: A Cost Outcomes Analysis. Neurosurgery 2023; 92:1243-1248. [PMID: 36744923 DOI: 10.1227/neu.0000000000002357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/08/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Digital subtraction angiography (DSA) assesses revascularization in pediatric moyamoya patients after surgery, but MRI and angiography (MRI/A) may provide comparable data. OBJECTIVE To evaluate DSA and MRI/A with respect to clinical utility in postoperative follow-up, complication profile, and relative cost at 1 year. METHODS All pediatric moyamoya patients who received bilateral indirect revascularization between 2011 and 2020 were retrospectively reviewed at 1 institution. Patients who underwent MRI/A-only, DSA-only, or both after 1 year were compared. RESULTS Eighty-two patients were included. At 1 year, patients who underwent either MRI/A (n = 29) or DSA (n = 40) had no significant differences in detection rate of new at-risk hypovascular territories (6.9% vs 2.5%, P = .568) or need for subsequent revascularization beyond the mean 40 ± 24-month follow-up period (3.4% vs 5.0%, P > .9). Among patients who underwent both MRI/A and DSA (n = 13), both studies identified the same at-risk territories. No patients experienced MRI/A-related complications, compared with 3 minor DSA-related complications. The use of MRI/A yielded a 6.5-fold reduction in cost per study vs DSA at 1 year. CONCLUSION Using DSA to follow moyamoya patients after indirect revascularization is generally safe but associated with a low rate of minor complications and a 6.5-fold greater financial cost relative to MRI/A. These data support changing practice to eliminate the use of DSA when following routine bilateral moyamoya cases in the absence of clinical symptoms or specific concerns. Using MRI/A as the primary postoperative follow-up modality in this select population provides noninferior care and greater patient access, while reducing cost and potentially decreasing risk.
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Affiliation(s)
- Weston T Northam
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Anna L Slingerland
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Darren B Orbach
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
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Lee KS, Zhang JJY, Bhate S, Ganesan V, Thompson D, James G, Silva AHD. Surgical revascularizations for pediatric moyamoya: a systematic review, meta-analysis, and meta-regression analysis. Childs Nerv Syst 2023; 39:1225-1243. [PMID: 36752913 PMCID: PMC10167165 DOI: 10.1007/s00381-023-05868-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/28/2023] [Indexed: 02/09/2023]
Abstract
INTRODUCTION There is no clear consensus regarding the technique of surgical revascularization for moyamoya disease and syndrome (MMD/MMS) in the pediatric population. Previous meta-analyses have attempted to address this gap in literature but with methodological limitations that affect the reliability of their pooled estimates. This meta-analysis aimed to report an accurate and transparent comparison between studies of indirect (IB), direct (DB), and combined bypasses (CB) in pediatric patients with MMD/MMS. METHODS In accordance with PRISMA guidelines, systematic searches of Medline, Embase, and Cochrane Central were undertaken from database inception to 7 October 2022. Perioperative adverse events were the primary outcome measure. Secondary outcomes were rates of long-term revascularization, stroke recurrence, morbidity, and mortality. RESULTS Thirty-seven studies reporting 2460 patients and 4432 hemispheres were included in the meta-analysis. The overall pooled mean age was 8.6 years (95% CI: 7.7; 9.5), and 45.0% were male. Pooled proportions of perioperative adverse events were similar between the DB/CB and IB groups except for wound complication which was higher in the former group (RR = 2.54 (95% CI: 1.82; 3.55)). Proportions of post-surgical Matsushima Grade A/B revascularization favored DB/CB over IB (RR = 1.12 (95% CI 1.02; 1.24)). There was no significant difference in stroke recurrence, morbidity, and mortality. After meta-regression analysis, year of publication and age were significant predictors of outcomes. CONCLUSIONS IB, DB/CB are relatively effective and safe revascularization options for pediatric MMD/MMS. Low-quality GRADE evidence suggests that DB/CB was associated with better long-term angiographic revascularization outcomes when compared with IB, although this did not translate to long-term stroke and mortality benefits.
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Affiliation(s)
- Keng Siang Lee
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK.
- Great Ormond Street Institute of Child Health, University College London, London, UK.
- Department of Neurosurgery, King's College Hospital, London, UK.
- Department of Basic and Clinical Neurosciences, Maurice, Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
- Bristol Medical School, University of Bristol, Bristol, UK.
| | - John J Y Zhang
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Sanjay Bhate
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Vijeya Ganesan
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Dominic Thompson
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Greg James
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Adikarige Haritha Dulanka Silva
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Institute of Child Health, University College London, London, UK
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Sum CHF, Tsang ACO, Cheng KKF, Ho WWS, Leung GKK, Lui WM. Surgical revascularization for moyamoya angiopathy: Clinical and radiological outcomes of direct and indirect bypasses in 86 affected hemispheres. J Clin Neurosci 2022; 99:66-72. [PMID: 35255359 DOI: 10.1016/j.jocn.2022.02.036] [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: 12/07/2021] [Revised: 02/05/2022] [Accepted: 02/23/2022] [Indexed: 11/17/2022]
Abstract
Moyamoya is a progressive cerebral angiopathy that entails a formidable natural history of repeated ischemic or haemorrhagic insults if not intervened. The potential advantages of direct/combined bypass can be harvested only if they are not outweighed by perioperative morbidity. Direct bypasses for the paediatric group have been less utilized because of small vessel calibres and an inherently more robust angioplasticity. This study was undertaken to examine the clinical and perfusion imaging outcomes of operated moyamoya disease or syndrome patients in Hong Kong's Southeast Asian population. Comparison was made between direct/combined and indirect bypass cohorts. Subgroup analysis of the paediatric cohort was conducted to determine outcomes of a direct-bypass-first strategy. From November 2000 to September 2020, 86 hemispheres underwent revascularization at a tertiary neurosurgical unit with a mean clinical follow-up time of 70.0 months. 70.9% of the procedures involved direct bypasses. Direct/combined revascularization demonstrated superiority in restoring adequate cerebrovascular reserve capacity (CVRC) (63.2% vs 27.3%, p = 0.015), and freedom from transient ischemic attacks in the first 5 years post-operation by Kaplan-Meier plot with log-rank test (p = 0.038). Follow-up imaging revealed 96.5% of the bypass grafts remained patent. Direct/combined procedures significantly predicted restoration of adequate CVRC on follow-up perfusions scans by binary logistic regression (OR 4.57, p = 0.009). Compared to the adult cohort, direct bypasses in children carried no excessive perioperative morbidity. These results support a liberal bypass-first paradigm in both adult and paediatric cohorts.
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Affiliation(s)
- Christopher Hiu-Fung Sum
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Anderson Chun On Tsang
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
| | - Kevin King-Fai Cheng
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Wilson Wai-Shing Ho
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Gilberto Ka Kit Leung
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Wai Man Lui
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
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Bernson-Leung ME, Rapalino O, Walker MA, Butler WE. Case 40-2021: A 9-Year-Old Boy with Transient Weakness, Facial Droop, and Slurred Speech. N Engl J Med 2021; 385:2563-2572. [PMID: 34965341 DOI: 10.1056/nejmcpc2107358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Miya E Bernson-Leung
- From the Department of Neurology, Boston Children's Hospital (M.E.B.-L.), the Departments of Neurology (M.E.B.-L., M.A.W.), Radiology (O.R.), and Neurosurgery (W.E.B.), Harvard Medical School, and the Departments of Radiology (O.R.), Neurology (M.A.W.), and Neurosurgery (W.E.B.), Massachusetts General Hospital - all in Boston
| | - Otto Rapalino
- From the Department of Neurology, Boston Children's Hospital (M.E.B.-L.), the Departments of Neurology (M.E.B.-L., M.A.W.), Radiology (O.R.), and Neurosurgery (W.E.B.), Harvard Medical School, and the Departments of Radiology (O.R.), Neurology (M.A.W.), and Neurosurgery (W.E.B.), Massachusetts General Hospital - all in Boston
| | - Melissa A Walker
- From the Department of Neurology, Boston Children's Hospital (M.E.B.-L.), the Departments of Neurology (M.E.B.-L., M.A.W.), Radiology (O.R.), and Neurosurgery (W.E.B.), Harvard Medical School, and the Departments of Radiology (O.R.), Neurology (M.A.W.), and Neurosurgery (W.E.B.), Massachusetts General Hospital - all in Boston
| | - William E Butler
- From the Department of Neurology, Boston Children's Hospital (M.E.B.-L.), the Departments of Neurology (M.E.B.-L., M.A.W.), Radiology (O.R.), and Neurosurgery (W.E.B.), Harvard Medical School, and the Departments of Radiology (O.R.), Neurology (M.A.W.), and Neurosurgery (W.E.B.), Massachusetts General Hospital - all in Boston
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Zhang X, Xiao W, Zhang Q, Xia D, Gao P, Su J, Yang H, Gao X, Ni W, Lei Y, Gu Y. Progression in Moyamoya Disease: Clinical Feature, Neuroimaging Evaluation and Treatment. Curr Neuropharmacol 2021; 20:292-308. [PMID: 34279201 PMCID: PMC9413783 DOI: 10.2174/1570159x19666210716114016] [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: 01/28/2021] [Revised: 05/08/2021] [Accepted: 07/09/2021] [Indexed: 11/22/2022] Open
Abstract
Moyamoya disease (MMD) is a chronic cerebrovascular disease characterized by progressive stenosis of the arteries of the circle of Willis, with the formation of collateral vascular network at the base of the brain. Its clinical manifestations are complicated. Numerous studies have attempted to clarify the clinical features of MMD, including its epidemiology, genetic characteristics, and pathophysiology. With the development of neuroimaging techniques, various neuroimaging modalities with different advantages have deepened the understanding of MMD in terms of structural, functional, spatial, and temporal dimensions. At present, the main treatment for MMD focuses on neurological protection, cerebral blood flow reconstruction, and neurological rehabilitation, such as pharmacological treatment, surgical revascularization, and cognitive rehabilitation. In this review, we discuss recent progress in understanding the clinical features, in the neuroimaging evaluation and treatment of MMD.
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Affiliation(s)
- Xin Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Weiping Xiao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Qing Zhang
- Department of Nursing, Huashan Hospital North, Fudan University, China
| | - Ding Xia
- Department of Radiology, Huashan Hospital North, Fudan University, China
| | - Peng Gao
- Department of Radiology, Huashan Hospital North, Fudan University, China
| | - Jiabin Su
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Heng Yang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Xinjie Gao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Wei Ni
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Yu Lei
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Yuxiang Gu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
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Characteristics of Moyamoya Disease in the Older Population: Is It Possible to Define a Typical Presentation and Optimal Therapeutical Management? J Clin Med 2021; 10:jcm10112287. [PMID: 34070336 PMCID: PMC8197522 DOI: 10.3390/jcm10112287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 12/17/2022] Open
Abstract
Whereas several studies have been so far presented about the surgical outcomes in terms of mortality and perioperative complications for elderly patients submitted to neurosurgical treatments, the management of elderly moyamoya patients is unclear. This review aims to explore the available data about the clinical manifestation, characteristics, and outcome after surgery of older patients with moyamoya arteriopathy (MA). We found only two articles strictly concerning elderly patients with MA. We have also evaluated other reported adult series of moyamoya patients, including elderly cases in their analysis. Patients with MA above 50 years old may be considered a peculiar subset in which patients are often presenting with ischemic symptoms and a higher Suzuki grade. Conservative treatment may be proposed in asymptomatic or stable cases due to their fragility and possible increase of post-operative complications, while the best surgical options in symptomatic cases are still under investigation, although we believe that a minimal invasive superficial temporal artery—middle cerebral artery bypass could be considered the treatment of choice for the immediate effect on brain perfusion with a limited rate of post-operative complications.
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