Individualized Perioperative Blood Pressure Management for Adult Moyamoya Disease: Experience from 186 Consecutive Procedures

Clinical Characteristics of Immediate Contralateral Ischemia Subsequent to Revascularization for Moyamoya Disease

BACKGROUND

Moyamoya disease is a bilateral steno-occlusive disease involving the cerebral vasculature. While some patients are affected by procedure-related ipsilateral ischemia, ischemic complications contralateral to the revascularization are rarely observed.

METHODS

We retrospectively investigated 135 hemispheres (103 patients) that underwent revascularization in our institution between April 2006 and September 2022. Revascularization surgery comprised single superficial temporal artery-middle cerebral artery anastomosis and encephalo-myo-synangiosis. Certain patients aged under 10 years underwent indirect revascularization. Bilateral revascularization was performed with an interval of >3 months. Medical records and neuroimages were reviewed, and patients with contralateral ischemic complications were identified. Some cases underwent genetic analysis.

RESULTS

The mean age was 34.5 (range: 5-71) years, and 95 cases (70.4%) were in women. Of the 102 cases examined for the RNF213 c.14429 G > A (p.Arg4810Lys) variant, 33 (32.4%) and 69 (67.6%) showed the GG and GA genotype, respectively. Three cases (2.2%, all female, age range 44-71 years) were complicated with contralateral infarction. The infarcted area distributions of the 2 cases with RNF213 c.14429 G > A variant were patchy and peripheral. The other case showed on magnetic resonance imaging (MRI) angiography total occlusion of the internal carotid artery where patency had been confirmed preoperatively.

CONCLUSIONS

Contralateral ischemia after revascularization occurred in 2.2% of cases. We classified them into peripheral and central types: peripheral type, an infarction owing to hemodynamic insufficiency or intracranial blood flow redistribution; central type, total occlusion of the contralateral internal carotid artery. Intensive preoperative management can minimize the risk of peripheral types, and neurosurgeons should beware of severe central types.

Clinical Features and Risk Factors of Postoperative Stroke in Adult Moyamoya Disease

BACKGROUND AND PURPOSE

The clinical features of and risk factors for postoperative stroke after surgical revascularization in adult moyamoya disease (MMD) have not been fully elucidated. To this end, the baseline clinical features were hereby described, and the risk factors for postoperative stroke were determined.

METHODS

Data of 4078 MMD inpatients were collected retrospectively across all secondary- and higher-level hospitals of Hubei Province from January 2019 to December 2020. In accordance with inclusion and exclusion criteria, 559 adult MMD inpatients were finally enrolled. The associated characteristics and potential risk factors were analyzed, and the Kaplan-Meier risk of stroke was also calculated.

RESULTS

The patients consisted of 286 females and 273 males, with a mean age of 49.1 ± 10.0 years, all of whom had at least 1 year of follow-up (median 25.1 months). There were 356 cases of preoperative ischemic symptoms and 203 cases of preoperative hemorrhage symptoms. Indirect, direct, and combined revascularization were conducted on 97, 105 and 357 patients, respectively. Among these patients, 17 had postoperative hemorrhagic stroke (PHS), and 43 had postoperative ischemic stroke (PIS). A comparison between PHS/PIS group and control group (patients without postoperative stroke events) showed that preoperative hemorrhage was significantly associated with PHS (p = 0.003), while hypertension (p = 0.003), diabetes mellitus (p = 0.003) and modified Rankin scale (mRS) (p = 0.034) at admission were associated with a higher rate of PIS. Furthermore, preoperative hemorrhagic stroke was identified as a risk factor for PHS (odds ratio [OR], 4.229 [95% CI, 1.244-14.376]; p = 0.021), while hypertension (odds ratio [OR], 0.424 [95% CI, 0.210-0.855]; p = 0.017), diabetes mellitus (odds ratio [OR], 0.368 [95% CI, 0.163-0.827]; p = 0.016) and admission mRS (odds ratio [OR], 2.301 [95% CI, 1.157-4.575]; p = 0.017) were found to be risk factors for PIS.

CONCLUSIONS

The age distribution of adult MMD patients with revascularization was predominantly concentrated within the range from 46 to 55 years. Preoperative hemorrhage events were considered the risk factor for PHS. Hypertension, diabetes and admission mRS were correlated with PIS, and were also the risk factors for PIS. These results indicated the possible contribution of enhancing systematic disease management to the prevention of postoperative cerebrovascular accidents.

Post-Surgical Cognitive Outcomes of Moyamoya Disease: A Systematic Review

BACKGROUND

Moyamoya disease (MMD) is an occlusive arteriopathy leading to stroke. Progressive if left untreated, revascularization surgery has become the mainstay of treatment. Although clinical and radiographic outcomes of MMD after intervention are well-characterized, cognitive outcomes in pediatric patients remain unclear. We aimed to examine postoperative cognitive outcomes in children with MMD, examine factors associated with cognitive changes after intervention, and define the effect of revascularization surgery on cognitive outcomes.

METHODS

A systematic review was conducted following PRISMA guidelines searching PubMed, Embase, and Scopus databases. Articles met inclusion criteria if they studied pediatric patients undergoing revascularization surgery for MMD and examined cognitive outcomes either qualitatively or quantitatively. All data extracted from included articles was examined descriptively.

RESULTS

Of 1091 resultant articles, 12 articles containing 446 patients were included. Surgery was associated with maintained or improved full scale intellectual quotient (IQ), performance IQ, perceptual IQ, memory quotient and verbal memory. However, 70% of patients had impaired cognitive function, with associated poor school performance. Improvements in cognition were associated with increased cerebral blood flow, particularly to the middle cerebral artery, due to the development of collaterals. Female sex, shorter duration from symptom onset to surgery, and surgery after age 7 were predictive of cognitive improvement. Completed ischemic stroke prior to surgery was associated with poorer cognitive outcomes.

CONCLUSIONS

Although children with MMD have improved cognitive outcomes following revascularization overall, a distinct subset experience cognitive impairment. Consideration of patient-specific and treatment-related factors is important to enable proper risk stratification and inform management approaches.

Effect of cerebral oxygen saturation monitoring in patients undergoing superficial temporal anterior-middle cerebral artery anastomosis for ischemic Moyamoya disease: a prospective cohort study

Objective

Regional cerebral oxygen saturation (rSO2) is linked with blood pressure. This study evaluated the influence of perioperative rSO2 monitoring on the prognosis of ischemic Moyamoya disease (MMD) patients undergoing anastomosis surgery.

Methods

In this prospective cohort, patients with unilateral ischemic MMD of Suzuki stage ≥3 were included. The decision of rSO2 was made by the clinician and the patient. The rSO2 group maintained intraoperative rSO2 levels through the modulation of blood pressure, inhaled oxygen concentration, carbon dioxide in arterial blood, and red blood cell transfusion. The non-rSO2 group used conventional anesthesia practices. Perioperative mean arterial pressure (MAP), rSO2 values, neurological complications, and postoperative results were assessed.

Results

A total of 75 eligible patients were categorized into a rSO2 monitoring group (n = 30) and a non-rSO2 monitoring group (n = 45). For the rSO2 group, the preoperative rSO2 was significantly lower on the affected side (P < 0.05). After anastomosis, this value notably increased (P = 0.01). A moderate relationship was observed between perioperative rSO2 and MAP before, during, and after surgery, with correlation coefficients (r) of 0.536, 0.502, and 0.592 (P < 0.05). Post-surgery MAP levels differed between the groups, with the rSO2 group showing decreased levels compared to pre-surgery and the non-rOS2 group displaying elevated levels. Notably, the rSO2 group reported shorter hospitalizations and decreased neurological complications. Patients with a hypertension history found postoperative MAP influencing hospital stay duration.

Conclusion

Perioperative rSO2 surveillance enhanced cerebral perfusion and minimized postoperative complications in ischemic MMD patients. Thus, rSO2 monitoring is advocated for MMD patients undergoing vascular anastomosis.

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

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.

Effects of superficial temporal artery to middle cerebral artery bypass on postoperative infarction rates among young children (≤ 5 years old) with moyamoya disease

Revascularization surgery for young children with moyamoya disease (MMD) is challenging. Although indirect revascularization is preferred because of the technical difficulty in direct anastomosis, higher risks of postoperative infarction remain a problem. We aimed to investigate the effect of superficial temporal artery to middle cerebral artery (STA-MCA) bypass on postoperative outcomes during the acute postoperative period in young children ≤ 5 years old with MMD. This retrospective study included consecutive young children with MMD who underwent surgical revascularization of the anterior cerebral circulation. Groups were determined according to the procedures performed, namely, the combined (STA-MCA bypass with indirect revascularization) and the indirect revascularization groups. The incidences of radiological or symptomatic infarction, transient neurological events, and new neurological deficits that remained at discharge were compared between groups. Of 38 surgical procedures, there were 23 combined and 15 indirect revascularizations. The median age of the patients was 3.0 years, which was significantly different between groups (P < .01). When comparing the postoperative outcomes between groups, the incidences of radiological and symptomatic infarction and new neurological deficits that remained at discharge were significantly lower in the combined revascularization group (P < .05). Logistic regression analysis adjusted for potential confounders found that surgical modality was a statistically significant independent risk factor associated with radiological and symptomatic infarctions (indirect/combined, odds ratio: 10.2; 95% confidence interval: 1.30-79.7; P < .05). STA-MCA bypass combined with indirect revascularization can reduce the incidence of postoperative infarction in young children with MMD and might lead to better neurological outcomes.

Prediction of hemorrhagic cerebral hyperperfusion syndrome after direct bypass surgery in adult nonhemorrhagic moyamoya disease: combining quantitative parameters on RAPID perfusion CT with clinically related factors

OBJECTIVE

The aim of this study was to identify predictive factors for hemorrhagic cerebral hyperperfusion syndrome (hCHS) after direct bypass surgery in adult nonhemorrhagic moyamoya disease (non-hMMD) using quantitative parameters on rapid processing of perfusion and diffusion (RAPID) perfusion CT software.

METHODS

A total of 277 hemispheres in 223 patients with non-hMMD who underwent combined bypass were retrospectively reviewed. Preoperative volumes of time to maximum (Tmax) > 4 seconds and > 6 seconds were obtained from RAPID analysis of perfusion CT. These quantitative parameters, along with other clinical and angiographic factors, were statistically analyzed to determine the significant predictors for hCHS after bypass surgery.

RESULTS

Intra- or postoperative hCHS occurred in 13 hemispheres (4.7%). In 7 hemispheres, subarachnoid hemorrhage occurred intraoperatively, and in 6 hemispheres, intracerebral hemorrhage was detected postoperatively. All hCHS occurred within the 4 days after bypass. Advanced age (OR 1.096, 95% CI 1.039-1.163, p = 0.001) and a large volume of Tmax > 6 seconds (OR 1.011, 95% CI 1.004-1.018, p = 0.002) were statistically significant factors in predicting the risk of hCHS after surgery. The cutoff values of patient age and volume of Tmax > 6 seconds were 43.5 years old (area under the curve [AUC] 0.761) and 80.5 ml (AUC 0.762), respectively.

CONCLUSIONS

In adult patients with non-hMMD older than 43.5 years or with a large volume of Tmax > 6 seconds over 80.5 ml, more prudence is required in the decision to undergo bypass surgery and in postoperative management.

The usefulness and safety of dexmedetomidine for postoperative sedation in pediatric patients with moyamoya disease

OBJECTIVE

After revascularization surgery in pediatric patients with moyamoya disease (MMD), resting and avoiding crying is important. However, this inaction is often difficult because of pain or anxiety. Dexmedetomidine (DEX), which has sedative and analgesic properties, may be useful in reducing those uncomfortable conditions; however, its common side effects include bradycardia and hypotension, which have a risk of decreasing the cerebral blood flow. The aim of this study was to investigate the efficacy and safety of using DEX for pediatric patients with MMD in the acute period after revascularization surgery.

METHODS

This retrospective study included pediatric patients with MMD who underwent revascularization surgery. Based on whether DEX was used for light sedation during postoperative days (PODs) 0-1 after extubation, the patients were divided into DEX or control groups. For neurological outcomes, the incidence of symptomatic cerebral infarction and transient neurological events (TNEs) during PODs 0-1 and the entire hospitalization were investigated. In addition, the Richmond Agitation-Sedation Scale (RASS) was used to assess the effect of DEX, and bradycardia and hypotension were evaluated as side effects.

RESULTS

A total of 84 surgical procedures were included in this study (27 in the DEX group and 57 in the control group). During PODs 0-1, symptomatic infarction was not observed in either group. The incidence of TNEs was almost the same in both groups: 2 (7.4%) of the 27 procedures in the DEX group and 4 (7.0%) of the 57 procedures in the control group (p > 0.99). Moreover, the incidences of symptomatic infarction and TNEs during the entire hospitalization did not differ significantly (symptomatic infarction, p > 0.99; TNEs, p = 0.20). Regarding the DEX effect, the median RASS scores during PODs 0-1 were -1.0 (drowsy) in the DEX group and +1.0 (restless) in the control group, showing a significant difference (p < 0.01). Regarding side effects, bradycardia was observed only in 3 (11.1%) of the 27 procedures in the DEX group (p = 0.03), and hypotension was not observed in any of the cases.

CONCLUSIONS

In pediatric patients with MMD who are extubated after revascularization surgery, DEX produced appropriate light sedation and analgesia. The risk for symptomatic infarction is almost the same in cases in which DEX is used and those in which it is not; however, neurosurgeons should be cautious of bradycardia and TNEs as potential side effects.

Spatially separate cerebral infarction in the posterior cerebral artery territory after combined revascularization of the middle cerebral artery territory in an adult patient with moyamoya disease and fetal-type posterior communicating artery: illustrative case

BACKGROUND

Remote cerebral infarction after combined revascularization of the middle cerebral artery (MCA) territory is rare in patients with moyamoya disease (MMD) with a fetal-type posterior communicating artery (PCoA).

OBSERVATIONS

A 57-year-old woman developed numbness in her right upper limb and transient motor weakness and was diagnosed with MMD. She also had a headache attack and a scintillating scotoma in the right visual field. Preoperative magnetic resonance angiography (MRA) showed stenosis of the left posterior cerebral artery (PCA). Combined revascularization was performed for the left MCA territory. No new neurological deficits were observed for 2 days after the operation, but right hemianopia, alexia, and agraphia appeared on postoperative day (POD) 4. Magnetic resonance imaging showed a new left occipitoparietal lobe infarction, and MRA showed occlusion of the distal left PCA. After that point, the alexia and agraphia gradually improved, but right hemianopia remained at the time of discharge on POD 18.

LESSONS

Cerebral ischemia in the PCA territory may occur after combined revascularization of the MCA territory in patients with fetal-type PCoA. For these cases, a double-barrel bypass or indirect revascularization to induce a slow conversion could be considered on its own as a treatment option.

Spinal Versus General Anesthesia for Cesarean Delivery in Pregnant Women With Moyamoya Disease: A Retrospective Observational Study

BACKGROUND

Moyamoya disease, a rare chronic cerebrovascular disease with a fragile vascular network at the base of the brain, can cause ischemic or hemorrhagic strokes or seizures. Precise blood pressure control and adequate analgesia are important for patients with moyamoya disease to prevent neurological events such as ischemia and hemorrhage. This study aimed to compare the intraoperative mean arterial pressure of pregnant women with moyamoya disease according to the mode of anesthesia (general anesthesia versus spinal anesthesia) used during cesarean delivery.

METHODS

We retrospectively reviewed the medical records of 87 cesarean deliveries in 74 patients who had been diagnosed with moyamoya disease before cesarean delivery. The primary outcome, intraoperative maximum mean arterial pressure during anesthesia, was compared according to the type of anesthesia administered (general versus spinal anesthesia). Other perioperative hemodynamic data (lowest mean arterial pressure, incidence of hypotension, vasopressor use, and antihypertensive agent use), maternal neurologic symptoms, neonatal outcomes (Apgar scores <7, ventilatory support, and intensive care unit admission), maternal and neonatal length of stay, postoperative pain scores, and rescue analgesic use were assessed as secondary outcomes.

RESULTS

While the lowest blood pressure during anesthesia and incidence of hypotension did not differ between the 2 groups, the maximum mean arterial pressure during anesthesia was lower in the spinal anesthesia group than that in the general anesthesia group (104.8 ± 2.5 vs 122.0 ± 4.6; P = .002). Study data did not support the claim that maternal neurologic symptoms differ according to the type of anesthesia used (5.6% vs 9.3%; P = .628); all patients recovered without any sequelae. The postoperative pain scores were lower, and fewer rescue analgesics were used in the spinal anesthesia group than in the general anesthesia group. Other maternal and neonatal outcomes were not different between the 2 groups.

CONCLUSIONS

Compared with general anesthesia, spinal anesthesia mitigated the maximum arterial blood pressure during cesarean delivery and improved postoperative pain in patients with moyamoya disease.

Paradoxical symptomatic cerebral blood flow decreases after combined revascularization surgery for patients with pediatric moyamoya disease: illustrative case

BACKGROUND

Transient neurological deficits (TNDs) develop after cerebral revascularization in patients with moyamoya disease (MMD). The authors report a rare pediatric MMD case with extensive decreased cerebral blood flow (CBF) and prolonged TNDs after combined revascularization.

OBSERVATIONS

A 9-year-old boy presented with transient left upper limb weakness, and MMD was diagnosed. A right-sided combined surgery was performed. Two years after the surgery, frequent but transient facial (right-sided) and upper limb weakness appeared. The left internal carotid artery terminal stenosis had progressed. Therefore, a left combined revascularization was performed. The patient’s motor aphasia and right upper limb weakness persisted for approximately 10 days after surgery. Magnetic resonance angiography showed that the direct bypass was patent, but extensive decreases in left CBF were observed using single photon emission tomography. With adequate fluid therapy and blood pressure control, the neurological symptoms eventually disappeared, and CBF improved.

LESSONS

The environment of cerebral hemodynamics is heterogeneous after cerebral revascularization for MMD, and the exact mechanism of CBF decreases was not identified. TNDs are significantly associated with the onset of stroke during the early postoperative period. Therefore, appropriate treatment is desired after determining complex cerebral hemodynamics using CBF studies.

The First 24 h Hemodynamic Management in NICU after Revascularization Surgery in Moyamoya Disease

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.