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Santhumayor BA, White TG, Golub D, Rivera M, Turpin J, Golombeck D, Ryu B, Shah K, Ortiz R, Black K, Katz JM, Dehdashti AR, Langer DJ. Impact of Cerebral Revascularization on Pial Collateral Flow in Patients With Unilateral Moyamoya Disease Using Quantitative Magnetic Resonance Angiography. Neurosurgery 2024; 95:596-604. [PMID: 38501815 DOI: 10.1227/neu.0000000000002905] [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: 10/17/2023] [Accepted: 01/12/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Moyamoya disease (MMD) is a chronic steno-occlusive disease of the intracranial circulation that depends on neoangiogenesis of collateral vessels to maintain cerebral perfusion and is primarily managed with cerebral revascularization surgery. A quantitative assessment of preoperative and postoperative collateral flow using quantitative magnetic resonance angiography with noninvasive optimal vessel analysis (NOVA) was used to illustrate the impact of revascularization on cerebral flow distribution. METHODS A retrospective review of patients with unilateral MMD who underwent direct, indirect, or combined direct/indirect cerebral revascularization surgery was conducted between 2011 and 2020. Using NOVA, flow was measured at the anterior cerebral artery (ACA), ACA distal to the anterior communicating artery (A2), middle cerebral artery (MCA), posterior cerebral artery (PCA), and PCA distal to the posterior communicating artery (P2). Pial flow (A2 + P2) and collateral flow (ipsilateral [A2 + P2])-(contralateral [A2 + P2]) were measured and compared before and after revascularization surgery. Total hemispheric flow (MCA + A2 + P2) with the addition of the bypass graft flow postoperatively was likewise measured. RESULTS Thirty-four patients with unilateral MMD underwent cerebral revascularization. Median collateral flow significantly decreased from 68 to 39.5 mL/min ( P = .007) after bypass. Hemispheres with maintained measurable bypass signal on postoperative NOVA demonstrated significant reduction in median collateral flow after bypass ( P = .002). Median total hemispheric flow significantly increased from 227 mL/min to 247 mL/min ( P = .007) after bypass. Only one patient suffered an ipsilateral ischemic stroke, and no patients suffered a hemorrhage during follow-up. CONCLUSION NOVA measurements demonstrate a reduction in pial collateral flow and an increase in total hemispheric flow after bypass for MMD, likely representing a decrease in leptomeningeal collateral stress on the distal ACA and PCA territories. Further studies with these measures in larger cohorts may elucidate a role for NOVA in predicting the risk of ischemic and hemorrhagic events in MMD.
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Affiliation(s)
- Brandon A Santhumayor
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Timothy G White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Danielle Golub
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Moses Rivera
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Justin Turpin
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - David Golombeck
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Brendan Ryu
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Kevin Shah
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Rafael Ortiz
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
- Current Affiliation: Department of Neurosurgery, White Plains Hospital, White Plains , New York , USA
| | - Karen Black
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Jeffrey M Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
| | - David J Langer
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead , New York , USA
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Garbani Nerini L, Bellomo J, Höbner LM, Stumpo V, Colombo E, van Niftrik CHB, Schubert T, Kulcsár Z, Wegener S, Luft A, Regli L, Fierstra J, Sebök M, Esposito G. BOLD Cerebrovascular Reactivity and NOVA Quantitative MR Angiography in Adult Patients with Moyamoya Vasculopathy Undergoing Cerebral Bypass Surgery. Brain Sci 2024; 14:762. [PMID: 39199456 PMCID: PMC11353214 DOI: 10.3390/brainsci14080762] [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: 07/08/2024] [Revised: 07/21/2024] [Accepted: 07/25/2024] [Indexed: 09/01/2024] Open
Abstract
Revascularization surgery for the symptomatic hemisphere with hemodynamic impairment is effective for Moyamoya vasculopathy patients. However, careful patient selection is crucial and ideally supported by advanced quantitative hemodynamic imaging. Recently, blood oxygenation level-dependent cerebrovascular reactivity (BOLD-CVR) and quantitative magnetic resonance angiography with non-invasive optimal vessel analysis (qMRA-NOVA) have gained prominence in assessing these patients. This study aims to present the results of BOLD-CVR and qMRA-NOVA imaging along with the changes in cerebral hemodynamics and flow status following flow augmentation with superficial temporal artery-middle cerebral artery (STA-MCA) bypass in our Moyamoya vasculopathy patient cohort. Symptomatic patients with Moyamoya vasculopathy treated at the Clinical Neuroscience Center of the University Hospital Zurich who underwent hemodynamic and flow imaging (BOLD-CVR and qMRA-NOVA) before and after bypass were included in the analysis. Reduced hemispheric volume flow rates, as well as impaired BOLD-CVR, were measured in all 12 patients with Moyamoya vasculopathy before STA-MCA bypass surgery. Following the surgical procedure, post-operative BOLD-CVR demonstrated a non-significant increase in BOLD-CVR values within the revascularized, symptomatic middle cerebral artery territory and cerebral hemisphere. The results of the statistical tests should be viewed as indicative due to the small sample size. Additionally, post-operative qMRA-NOVA revealed a significant improvement in the hemispheric volume flow rate of the affected hemisphere due to the additional bypass flow rate. Our findings affirm the presence of hemodynamic and flow impairments in the symptomatic hemisphere of the Moyamoya vasculopathy patients. Bypass surgery proves effective in improving both BOLD-CVR impairment and the hemispheric volume flow rate in our patient cohort.
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Affiliation(s)
- Loris Garbani Nerini
- Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (L.G.N.); (J.B.); (L.M.H.); (V.S.); (E.C.); (C.H.B.v.N.); (L.R.); (J.F.); (G.E.)
- Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (T.S.); (Z.K.); (S.W.); (A.L.)
- University of Zürich (UZH), Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Jacopo Bellomo
- Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (L.G.N.); (J.B.); (L.M.H.); (V.S.); (E.C.); (C.H.B.v.N.); (L.R.); (J.F.); (G.E.)
- Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (T.S.); (Z.K.); (S.W.); (A.L.)
| | - Lara Maria Höbner
- Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (L.G.N.); (J.B.); (L.M.H.); (V.S.); (E.C.); (C.H.B.v.N.); (L.R.); (J.F.); (G.E.)
- Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (T.S.); (Z.K.); (S.W.); (A.L.)
| | - Vittorio Stumpo
- Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (L.G.N.); (J.B.); (L.M.H.); (V.S.); (E.C.); (C.H.B.v.N.); (L.R.); (J.F.); (G.E.)
- Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (T.S.); (Z.K.); (S.W.); (A.L.)
| | - Elisa Colombo
- Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (L.G.N.); (J.B.); (L.M.H.); (V.S.); (E.C.); (C.H.B.v.N.); (L.R.); (J.F.); (G.E.)
- Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (T.S.); (Z.K.); (S.W.); (A.L.)
| | - Christiaan Hendrik Bas van Niftrik
- Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (L.G.N.); (J.B.); (L.M.H.); (V.S.); (E.C.); (C.H.B.v.N.); (L.R.); (J.F.); (G.E.)
- Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (T.S.); (Z.K.); (S.W.); (A.L.)
| | - Tilman Schubert
- Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (T.S.); (Z.K.); (S.W.); (A.L.)
- Department of Neuroradiology, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Zsolt Kulcsár
- Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (T.S.); (Z.K.); (S.W.); (A.L.)
- Department of Neuroradiology, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland
| | - Susanne Wegener
- Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (T.S.); (Z.K.); (S.W.); (A.L.)
- Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, 8091 Zurich, Switzerland
| | - Andreas Luft
- Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (T.S.); (Z.K.); (S.W.); (A.L.)
- Department of Neurology, University Hospital Zurich, Frauenklinikstrasse 26, 8091 Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (L.G.N.); (J.B.); (L.M.H.); (V.S.); (E.C.); (C.H.B.v.N.); (L.R.); (J.F.); (G.E.)
- Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (T.S.); (Z.K.); (S.W.); (A.L.)
| | - Jorn Fierstra
- Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (L.G.N.); (J.B.); (L.M.H.); (V.S.); (E.C.); (C.H.B.v.N.); (L.R.); (J.F.); (G.E.)
- Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (T.S.); (Z.K.); (S.W.); (A.L.)
| | - Martina Sebök
- Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (L.G.N.); (J.B.); (L.M.H.); (V.S.); (E.C.); (C.H.B.v.N.); (L.R.); (J.F.); (G.E.)
- Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (T.S.); (Z.K.); (S.W.); (A.L.)
| | - Giuseppe Esposito
- Department of Neurosurgery, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (L.G.N.); (J.B.); (L.M.H.); (V.S.); (E.C.); (C.H.B.v.N.); (L.R.); (J.F.); (G.E.)
- Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland; (T.S.); (Z.K.); (S.W.); (A.L.)
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McGuire LS, Kumar P, Ryoo JS, Alaraj A. Selective endovascular treatment of cervical arterial dissection using quantitative magnetic resonance angiography. Interv Neuroradiol 2024; 30:64-71. [PMID: 35656756 PMCID: PMC10956450 DOI: 10.1177/15910199221106040] [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: 01/31/2022] [Revised: 05/14/2022] [Accepted: 05/17/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The role of endovascular treatment in cervical artery dissection (CAD) is equivocal. This study compared cerebral blood flow in CAD between medically and endovascularly treated patients using quantitative magnetic resonance angiography (QMRA). METHODS Retrospective chart review was completed for patients with CAD. Inclusion criteria were adults (>18 years) with diagnosis of dissection of the internal carotid artery or vertebral artery who received QMRA. The cases were reviewed for clinical presentation, diagnosis, management, and imaging, and in particular, patients who underwent endovascular treatment were evaluated. RESULTS Forty-one patients were included, 46.3% female and mean age 46.0+/- 11.9 years. 21 patients (51.2%) had contralateral (ICA) dissections while 19 (46.3%) had vertebral artery (VA) dissections, and 1 had both involved. Five patients underwent stenting, angioplasty, or both. Baseline characteristics between patients who underwent medical versus endovascular treatment were similar, although patients undergoing stenting/angioplasty were more likely to have diabetes (p = 0.015) and prior anticoagulation use (p = 0.007). All endovascular patients demonstrated ischemia on MRI versus 53.1% of those undergoing medical management (p = 0.047). Comparing ipsilateral vessel flow over time in these two patient groups showed those who underwent stenting or angioplasty had lower baseline flows, albeit non-significant (p = 0.629). Patients who underwent endovascular treatment had lower distal flow compared to the medical management group. CONCLUSION This study represents the first to assess vessel flow using QMRA in patients who underwent endovascular treatment of CAD. In combination with progressive symptoms, QMRA may serve as a useful adjunct in the selection of patients for endovascular intervention in arterial dissections.
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Affiliation(s)
- Laura Stone McGuire
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Prateek Kumar
- Department of Neurology, University of Illinois at Chicago, Chicago, IL, USA
| | - James S. Ryoo
- College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
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Ballout AA, Oh SY, Libman RB, Choi Y, Black K, Sideras P, Ayoub MS, Arora R, Langer DJ, Dehdashti AR, Katz JM. Stroke mechanisms in adult moyamoya disease: The association between infarction patterns and quantitative magnetic resonance angiography flow state. J Stroke Cerebrovasc Dis 2023; 32:107447. [PMID: 38745444 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107447] [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: 05/10/2023] [Revised: 10/02/2023] [Accepted: 10/24/2023] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Flow augmentation is the mainstay treatment for moyamoya disease as hemodynamic failure is believed to be the dominant mechanism. We aimed to investigate the mechanisms of stroke in moyamoya disease by assessing the relationship between infarction patterns and quantitative magnetic resonance angiography flow state. METHODS A retrospective study of adult patients with suspected MMD who presented with MRI confirmed acute ischemic stroke predating or following QMRA by a maximum of six months between 2009 and 2021 was conducted. Of the 177 consecutive patients with MMD who received QMRA, 35 patients, consisting of 41 hemispheres, met inclusion criteria. Flow-status was dichotomized into low-flow and normal-flow state based on previously established criteria. RESULTS Mixed infarction pattern was the most frequent finding (70.7 %), followed by embolic (17.1 %), perforator (7.3 %), and internal borderzone (IBZ) (4.9 %). Infarction patterns were further dichotomized into IBZ+ (internal borderzone alone or mixed) and IBZ- (no internal borderzone constituent). Low-flow states were not significantly more frequent in the IBZ+ compared to IBZ- population (48.4 % vs. 20.0 %, p = 0.14). Ipsilateral posterior cerebral artery fractional flow was significantly higher with IBZ+ compared to IBZ- (345.0 % vs. 214.7 %, p = 0.04). CONCLUSION Mixed infarction pattern was the most common pattern of infarction in patients with moyamoya disease, implying hypoperfusion and thromboembolism are codominant stroke mechanisms. An association between ICA flow status and infarction pattern was not found, although QMRA evidence of more robust posterior cerebral artery leptomeningeal collaterals was found in patients with a hypoperfusion contribution to their stroke mechanism.
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Affiliation(s)
- Ahmad A Ballout
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra University, Hempstead, NY 11549, USA.
| | - Seok Yoon Oh
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra University, Hempstead, NY 11549, USA
| | - Richard B Libman
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra University, Hempstead, NY 11549, USA
| | - Yuna Choi
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra University, Hempstead, NY 11549, USA
| | - Karen Black
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Panagiotis Sideras
- Department of Radiology, Columbia University Irving Medical Center at New York-Presbyterian Hospital, New York, NY, USA
| | - Marc S Ayoub
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Rohan Arora
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra University, Hempstead, NY 11549, USA
| | - David J Langer
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jeffrey M Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra University, Hempstead, NY 11549, USA; Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Computational Modelling of Cerebral Blood Flow Rate at Different Stages of Moyamoya Disease in Adults and Children. BIOENGINEERING (BASEL, SWITZERLAND) 2023; 10:bioengineering10010077. [PMID: 36671650 PMCID: PMC9854682 DOI: 10.3390/bioengineering10010077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/04/2023] [Accepted: 01/04/2023] [Indexed: 01/11/2023]
Abstract
Moyamoya disease is a cerebrovascular disorder which causes a decrease in the cerebral blood flow rate. In this study, a lumped parameter model describing the pressures and flow rates in the heart chambers, circulatory system, and cerebral circulation with the main arteries in the circle of Willis, pial circulation, cerebral capillaries, and veins was used to simulate Moyamoya disease with and without coarctation of the aorta in adults and children. Cerebral blood flow rates were 724 mL/min and 1072 mL/min in the healthy adult and child cardiovascular system models. The cerebral blood flow rates in the adult and child cardiovascular system models simulating Moyamoya disease were 676 mL/min and 1007 mL/min in stage 1, 627 mL/min and 892 mL/min in stage 2, 571 mL/min and 831 in stage 3, and 444 and 537 mL/min in stage 4. The cerebral blood flow rates were 926 mL/min and 1421 mL/min in the adult and child cardiovascular system models simulating coarctation of the aorta. Furthermore, the cerebral blood flow rates in the adult and child cardiovascular system model simulating Moyamoya disease with coarctation of the aorta were 867 mL/min and 1341 mL/min in stage 1, 806 mL/min and 1197 mL/min in stage 2, 735 mL/min and 1121 in stage 3, and 576 and 741 mL/min in stage 4. The numerical model utilised in this study can simulate the advancing stages of Moyamoya disease and evaluate the associated risks with Moyamoya disease.
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Liu S, Lu M, Han C, Hao F, Sheng F, Liu Y, Zhang L, Liu D, Xie R, Zhang H, Cai J. The Value of Preoperative Phase-Contrast MRI in Predicting the Clinical Outcome of Moyamoya Disease after Encephalo-Duro-Arterial Synangiosis Surgery. AJNR Am J Neuroradiol 2022; 43:1582-1588. [PMID: 36202553 PMCID: PMC9731245 DOI: 10.3174/ajnr.a7667] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/12/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND PURPOSE In patients with Moyamoya disease, the relationship between preoperative hemodynamic status and prognosis after encephalo-duro-arterial synangiosis (EDAS) surgery was unclear. We aimed to explore the value of the preoperative hemodynamic status acquired by cine phase-contrast MR imaging in predicting collateral formation and clinical outcomes after EDAS surgery in patients with Moyamoya disease. MATERIALS AND METHODS Participants with Moyamoya disease were prospectively recruited and underwent preoperative phase-contrast MR imaging. All participants were classified into good and poor groups according to the collateral formation after EDAS surgery. On the basis of the change in the mRS system, participants were classified into the improved mRS group and the poor response group. Hemodynamic status including mean velocity, peak velocity, and blood volume flow of the superficial temporal artery was compared between groups. Logistic regression was performed to relate the phase-contrast MR imaging parameters to collateral formation and clinical outcomes. RESULTS A total of 45 patients with Moyamoya disease with unilateral EDAS surgery were finally included. Mean velocity, peak velocity, and blood volume flow of the ipsilateral superficial temporal artery were significantly greater in patients with good collateral formation compared with those with poor collateral formation (P = .011, .004, and .013, respectively). The mean velocity, peak velocity, and blood volume flow were independently associated with postoperative collateral formation after adjusting for confounding factors. Furthermore, the peak velocity of the ipsilateral superficial temporal artery was also significantly associated with improvement of the mRS score. CONCLUSIONS Good hemodynamic status of the ipsilateral superficial temporal artery as a donor artery evaluated by phase-contrast MR imaging was significantly associated with better collateral formation and improved mRS after EDAS surgery in patients with Moyamoya disease.
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Affiliation(s)
- S Liu
- From the Medical School of Chinese People's Liberation Army (S.L., L.Z.), Beijing, China
- Department of Radiology (S.L., F.S., Y.L., L.Z., D.L., R.X., H.Z., J.C.), the fifth Medical Center
| | - M Lu
- Department of Radiology (M.L.), Pingjin Hospital, Characteristic Medical Center of Chinese People's Armed Police Force, Tianjin, China
| | - C Han
- Department of Neurosurgery (C.H., F.H.), Chinese People's Liberation Army General Hospital, Beijing, China
| | - F Hao
- Department of Neurosurgery (C.H., F.H.), Chinese People's Liberation Army General Hospital, Beijing, China
| | - F Sheng
- Department of Radiology (S.L., F.S., Y.L., L.Z., D.L., R.X., H.Z., J.C.), the fifth Medical Center
| | - Y Liu
- Department of Radiology (S.L., F.S., Y.L., L.Z., D.L., R.X., H.Z., J.C.), the fifth Medical Center
| | - L Zhang
- From the Medical School of Chinese People's Liberation Army (S.L., L.Z.), Beijing, China
- Department of Radiology (S.L., F.S., Y.L., L.Z., D.L., R.X., H.Z., J.C.), the fifth Medical Center
| | - D Liu
- Department of Radiology (S.L., F.S., Y.L., L.Z., D.L., R.X., H.Z., J.C.), the fifth Medical Center
| | - R Xie
- Department of Radiology (S.L., F.S., Y.L., L.Z., D.L., R.X., H.Z., J.C.), the fifth Medical Center
| | - H Zhang
- Department of Radiology (S.L., F.S., Y.L., L.Z., D.L., R.X., H.Z., J.C.), the fifth Medical Center
| | - J Cai
- Department of Radiology (S.L., F.S., Y.L., L.Z., D.L., R.X., H.Z., J.C.), the fifth Medical Center
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Neuroimaging in Moyamoya angiopathy: Updated review. Clin Neurol Neurosurg 2022; 222:107471. [DOI: 10.1016/j.clineuro.2022.107471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/07/2022] [Accepted: 10/10/2022] [Indexed: 11/23/2022]
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Muacevic A, Adler JR. Does Advanced Imaging Aid in the Preoperative Evaluation of Patients With Moyamoya Disease? Cureus 2022; 14:e29816. [PMID: 36337792 PMCID: PMC9622031 DOI: 10.7759/cureus.29816] [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] [Accepted: 08/10/2022] [Indexed: 12/04/2022] Open
Abstract
Background Moyamoya disease is characterized by progressive nonatherosclerotic stenosis and eventual occlusion of the supraclinoid cerebral arteries with the associated development of abnormal collateral vessels. Treatment of moyamoya disease revolves around restoring cerebral blood flow (CBF) distal to the steno-occlusive disease. Numerous modalities can be used to assess hemodynamic parameters. We sought to determine the impact of preoperative imaging on surgical decision-making. Methods A retrospective review was performed of all patients seen with the diagnosis of moyamoya. Patients were grouped on presentation based on CT/MRI findings of infarction, hemorrhage, or normal. Patients who did not have all of the preoperative tests were excluded. Preoperative radiological results were dichotomized as either normal or abnormal. Results During a five-year period, 34 patients with moyamoya met the inclusion criteria. All patients had an abnormal magnetic resonance angiography (MRA) Non-invasive Optimal Vessel Analysis (NOVA; VasSol, Inc, River Forest, IL). Three patients had normal initial MRI. All symptomatic patients had abnormal preoperative workup and underwent revascularization, as all were found to have abnormal single photon emission computed tomography (SPECT). The only occasion where the decision for surgery or type of surgery was influenced by imaging findings was in patients with nonclassical or minimal symptoms. Conclusion Although hemodynamic imaging studies can aid in establishing a preoperative baseline of CBF and cerebral vascular reserve (CVR) for follow-up studies, the true implication of these tests in the preoperative evaluation of clearly symptomatic moyamoya patients is debatable. In asymptomatic/mildly symptomatic patients, hemodynamic studies are necessary to determine the need for treatment. For symptomatic patients, surgery can be performed without an exhaustive and costly preoperative hemodynamic evaluation.
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Yedavalli VS, Quon JL, Tong E, van Staalduinen EK, Mouches P, Kim LH, Steinberg GK, Grant GA, Yeom KW, Forkert ND. Intracranial Artery Morphology in Pediatric Moya Moya Disease and Moya Moya Syndrome. Neurosurgery 2022; 91:710-716. [PMID: 36084178 DOI: 10.1227/neu.0000000000002099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/05/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Moya Moya disease (MMD) and Moya Moya syndrome (MMS) are cerebrovascular disorders, which affect the internal carotid arteries (ICAs). Diagnosis and surveillance of MMD/MMS in children mostly rely on qualitative evaluation of vascular imaging, especially MR angiography (MRA). OBJECTIVE To quantitatively characterize arterial differences in pediatric patients with MMD/MMS compared with normal controls. METHODS MRA data sets from 17 presurgery MMD/MMS (10M/7F, mean age = 10.0 years) patients were retrospectively collected and compared with MRA data sets of 98 children with normal vessel morphology (49 male patients; mean age = 10.6 years). Using a level set segmentation method with anisotropic energy weights, the cerebral arteries were automatically extracted and used to compute the radius of the ICA, middle cerebral artery (MCA), anterior cerebral artery (ACA), posterior cerebral artery (PCA), and basilar artery (BA). Moreover, the density and the average radius of all arteries in the MCA, ACA, and PCA flow territories were quantified. RESULTS Statistical analysis revealed significant differences comparing children with MMD/MMS and those with normal vasculature (P < .001), whereas post hoc analyses identified significantly smaller radii of the ICA, MCA-M1, MCA-M2, and ACA (P < .001) in the MMD/MMS group. No significant differences were found for the radii of the PCA and BA or any artery density and average artery radius measurement in the flow territories (P > .05). CONCLUSION His study describes the results of an automatic approach for quantitative characterization of the cerebrovascular system in patients with MMD/MMS with promising preliminary results for quantitative surveillance in pediatric MMD/MMS management.
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Affiliation(s)
- Vivek S Yedavalli
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jennifer L Quon
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elizabeth Tong
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Eric K van Staalduinen
- Department of Radiology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Pauline Mouches
- Department of Radiology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Lily H Kim
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Gary K Steinberg
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kristen W Yeom
- Department of Radiology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Nils D Forkert
- Department of Radiology, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
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10
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Andereggen L, Amin-Hanjani S, Beck J, Luedi MM, Gralla J, Schubert GA, Tortora A, Andres RH, Arnold M, Raabe A, Reinert M. Prediction of Long-Term Restenosis After Carotid Endarterectomy Using Quantitative Magnetic Resonance Angiography. Front Neurol 2022; 13:862809. [PMID: 35847222 PMCID: PMC9279565 DOI: 10.3389/fneur.2022.862809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022] Open
Abstract
Background To detect restenosis after carotid endarterectomy (CEA), long-term monitoring is required. However, non-selective follow-up is controversial and can be limited by costs and logistical considerations. Objective To examine the value of immediate perioperative vessel flow measurements after CEA using quantitative magnetic resonance angiography (QMRA) to detect patients at risk of long-term restenosis. Methods A prospective cohort study with long-term sonographic follow-up after CEA for symptomatic internal carotid artery stenosis (ICAs) > 50%. In all patients, vessel flow has been assessed both pre- and postoperatively using QMRA within ±3 days of surgery. Data on QMRA assessment were analyzed to identify patients at risk of restenosis for up to 10 years. Results Restenosis was recorded in 4 of 24 patients (17%) at a median follow-up of 6.8 ± 2.6 years. None of them experienced an ischemic event. Perioperative flow differences were significantly greater in patients without long-term restenosis, both for the ipsilateral ICA (p < 0.001) and MCA (p = 0.03), compared to those with restenosis (p = 0.22 and p = 0.3, respectively). The ICA mean flow ratio (p = 0.05) tended to be more effective than the MCA ratio in predicting restenosis over the long term (p = 0.35). Conclusion Our preliminary findings suggest that QMRA-based mean flow increases after CEA may be predictive of restenosis over the long term. Perioperative QMRA assessment could become an operator-independent screening tool to identify a subgroup of patients at risk for restenosis, in whom long-term monitoring is advised.
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Affiliation(s)
- Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
- *Correspondence: Lukas Andereggen ; orcid.org/0000-0003-1764-688X
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, IL, United States
| | - Jürgen Beck
- Departments of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Markus M. Luedi
- Department of Anaesthesiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Angelo Tortora
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Robert H. Andres
- Faculty of Medicine, University of Bern, Bern, Switzerland
- Departments of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Raabe
- Departments of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Reinert
- Faculty of Medicine, University of Bern, Bern, Switzerland
- Clinic for Neurosurgery, Hirslanden Klinik St. Anna, Lucerne, Switzerland
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11
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Ryu B, White TG, Shah KA, Turpin J, Link T, Dehdashti AR, Katz JM, Black K, Woo HH. Utility of quantitative magnetic resonance angiography and non-invasive optimal vessel analysis for identification of complications and long-term hemodynamic changes in post-pipeline embolization patients. Interv Neuroradiol 2021; 28:396-403. [PMID: 34346801 PMCID: PMC9326859 DOI: 10.1177/15910199211034668] [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] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Quantitative magnetic resonance angiography and non-invasive optimal vessel analysis serve as powerful tools to collect and analyze hemodynamic data from pipeline embolization patients. At our institution, patients receive post-embolization quantitative magnetic resonance angiography within 24 h of treatment and within 6 months for follow-up to evaluate pipeline patency. Here, we aim to elucidate the long-term hemodynamic changes following pipeline embolization device placement and report two cases in which in-stent stenosis was detected. METHODS Medical records of patients who underwent pipeline embolization device placement for an internal carotid artery aneurysm between 2017 and 2019 were reviewed. Patients who received post-procedure NOVA and follow-up NOVA were included in the study (n = 32). Location and size of aneurysm, number of pipeline embolization device deployed, and complications were collected along with the non-invasive optimal vessel analysis report (flow volume rate (ml/min), mean, systolic, and diastolic flow velocities (cm/s), and vessel diameter (mm)). Internal carotid artery vessel flow rate was measured proximal to the pipeline embolization device. Derivations of hemodynamic parameters (pulsatility index, Lindegaard ratio, and wall shear stress) were calculated. RESULTS The middle cerebral artery mean and diastolic flow velocities were significantly lower on the follow-up NOVA compared to the post-procedure NOVA. Moreover, follow-up NOVA demonstrated lower middle cerebral artery wall shear stress on the side with flow diversion compared to the post-procedure NOVA. In-stent stenosis, requiring intervention, was detected in two patients on follow-up NOVA. One patient had a successful balloon angioplasty of the stented internal carotid artery that resolved her stenosis. However, the second patient developed progressive stenosis and expired despite intervention. CONCLUSION Long-term hemodynamic adaptations post-pipeline embolization device demonstrate decreased wall shear stress and decreased mean and diastolic flow velocities in the distal middle cerebral artery, which suggest decreasing velocity of blood flow with endothelialization of the device. Furthermore, follow-up NOVA is a useful tool for detecting potential flow-related complications such as in-stent stenosis.
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Affiliation(s)
- Brendan Ryu
- Department of Neurosurgery, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Timothy G White
- Department of Neurosurgery, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Kevin A Shah
- Department of Neurosurgery, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Justin Turpin
- Department of Neurosurgery, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Thomas Link
- Department of Neurosurgery, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Jeffrey M Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Karen Black
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Henry H Woo
- Department of Neurosurgery, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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12
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White TG, Ryu B, Shah KA, Turpin J, Black K, Link T, Dehdashti AR, Katz JM, Woo HH. Quantitative magnetic resonance angiography to assess post embolization hemodynamics following pipeline embolization. Interv Neuroradiol 2021; 28:177-182. [PMID: 34151618 DOI: 10.1177/15910199211023650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Delayed intraparenchymal hemorrhage is a known complication of the Pipeline Embolization device (PED); however, its etiology is unclear and some have suggested it is a flow related phenomenon. Quantitative magnetic resonance angiography (QMRA) serves as a powerful tool to collect and analyze hemodynamic data. We report a detailed characterization of short-term hemodynamics after PED placement. METHODS Patients who underwent PED placement for a distal internal carotid artery (ICA) aneurysm between 2017 to 2019 with post embolization QMRA were reviewed. Aneurysm characteristics, flow volume rate (ml/min), mean, systolic, and diastolic flow velocities (cm/s), vessel diameter (mm), pulsatility index, Lindegaard ratio, and wall shear stress (WSS) were collected. RESULTS A total of 67 patients were included. Post-procedure patients were found to have a significantly lower ICA flow on the side with flow diversion when compared to the side without flow diversion (218 vs. 236.3; P < 0.05). Average ICA flow after flow diversion for aneurysms >2 cm was significantly lower when compared to the untreated side (187.7 vs. 240.4; P < 0.05). There was no difference in MCA or ACA flow or velocity. WSS was significantly lower in the treated ICA (8.2 vs. 9.0; P < 0.05). Lindegaard ratio was not different in the treated vs. contralateral untreated sides. CONCLUSION PED placement for distal ICA aneurysms results in lower flow, mean velocity, and WSS when compared to the contralateral untreated ICA. This is not demonstrated distal to the Pipeline device in the ACA or MCA territories. Ultimately these findings suggest hemodynamic changes are not a cause of PED complications.
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Affiliation(s)
- Timothy G White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Brendan Ryu
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Kevin A Shah
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Justin Turpin
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Karen Black
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Thomas Link
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Jeffrey M Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Henry H Woo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
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13
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Matsuo S, Amano T, Miyamatsu Y, Yamashita S, Yasaka M, Okada Y, Nakamizo A. Carotid ultrasonography predicts collateral development following combined direct and indirect revascularization surgery in adult ischemic Moyamoya disease. Clin Neurol Neurosurg 2021; 203:106590. [PMID: 33711640 DOI: 10.1016/j.clineuro.2021.106590] [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: 12/11/2020] [Revised: 02/12/2021] [Accepted: 02/27/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The relationship between carotid ultrasonographic parameters and postoperative collateral development in adult ischemic moyamoya disease (MMD) patients who received combined direct and indirect revascularization surgery remains unclear. Herein, we investigated the postoperative changes in carotid ultrasonographic parameters in patients with adult ischemic MMD. METHODS We studied 28 adult ischemic MMD patients (31 hemispheres) who underwent combined revascularization surgery. Patients underwent preoperative and postoperative (within 14 days and 3, 12, and 24 months after surgery) magnetic resonance imaging and carotid ultrasonography. We defined the hemisphere in which all signal intensities of the superficial temporal, middle meningeal, and deep temporal arteries were increased compared with that before surgery on magnetic resonance angiography as well-developed collateral establishment. RESULTS Patients with good collateral establishment on MRA at 2-year after surgery had a lower external carotid artery (ECA) pulsatility index (PI) (P = 0.0413) and ECA/internal carotid artery (ICA) pulsatility index (PI) ratio (P = 0.0427) at 3-month post-operation. At 3-month post-operation, a cut-off ECA PI of 1.416 (sensitivity 40.0 %, specificity 92.3 %, area under the curve 0.7282, likelihood ratio 5.20, P = 0.0404) and ECA/ICA PI ratio of 0.8768 (sensitivity 50.0 %, specificity 92.31 %, area under the curve 0.7308, likelihood ratio 6.50, P = 0.0415) provided reliable values for good prediction of collateral development at 2 years after revascularization. CONCLUSION ECA/ICA PI ratio and ECA PI at 3-month after surgery can be one of the indicators for predicting future well-developed neovascularization on MRA and better outcome in patients with adult ischemic MMD who received combined direct and indirect revascularization surgery.
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Affiliation(s)
- Satoshi Matsuo
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan.
| | - Toshiyuki Amano
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Yuichiro Miyamatsu
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Sojiro Yamashita
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Akira Nakamizo
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
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14
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Quantitative Angiographic Hemodynamic Evaluation After Revascularization Surgery for Moyamoya Disease. Transl Stroke Res 2020; 11:871-881. [PMID: 32056157 PMCID: PMC7496042 DOI: 10.1007/s12975-020-00781-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 01/02/2020] [Accepted: 01/03/2020] [Indexed: 10/27/2022]
Abstract
The corresponding hemodynamic changes of the internal carotid artery (ICA) after the revascularization surgery for moyamoya disease (MMD) remain unclear. The aim of this study was to analyze the hemodynamic changes of the ipsilateral ICA after the combined direct and indirect extracranial-intracranial (EC-IC) bypass. MMD patients undergoing combined EC-IC bypass were retrospectively reviewed. The mean transit time (MTT) of ICA was evaluated by color-coding angiography before revascularization and at follow-up. The MTT defined as the blood transit time between the end of cervical portion (C1) and the C7 segment of ICA. The clinical prognosis was assessed with Matsushima grading system, moyamoya vessel reduction system, and modified Rankin Scale (mRS). The correlation between hemodynamic parameter and prognosis was analyzed. Subgroup analysis was conducted between different presentations and different ages. Fifty-one patients were identified and the mean imaging follow-up interval was 5.5 months. The ICA-MTT was increased after the combined revascularization (P < 0.001) compared with contralateral ICA. Faster preoperative ICA-MTT was significantly associated with improved mRS in the ischemic group (P = 0.05). The increased ICA-MTT was significantly associated with favorable neoangiogenesis (P = 0.04), moyamoya vessel reduction (> 50%) (P = 0.023), and improved mRS score (P = 0.008). In subgroup analysis, the correlation in the ischemic subgroup and adult subgroup remained significant. In this cohort, the ICA-MTT increased after the combined EC-IC bypass, and there was a positive correlation between the increased blood transit time and favorable outcomes. Color-coding DSA proved to be useful as a quantitative and serial method to monitor postoperative courses after revascularization in MMD.
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15
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Han Q, Huang Y. Quantitative analysis of revascularization in ischemic moyamoya disease via whole-brain computed tomography perfusion: A retrospective single-center study. Medicine (Baltimore) 2020; 99:e19168. [PMID: 32049846 PMCID: PMC7035121 DOI: 10.1097/md.0000000000019168] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Ischemic moyamoya disease (MMD) can be treated with the revascularization of superficial temporal artery to middle cerebral artery (STA-MCA) bypass combined with encephalo-duro-arterio-myo-synangiosis (EDAMS) effectively. The purpose of the present study was to quantify the revascularization of STA-MCA bypass combined with EDAMS via whole-brain computed tomography perfusion (WB-CTP).Seventy-nine consecutive patients with ischemic MMD who admitted to our hospital from August 2012 to October 2018 were carried out STA-MCA bypass combined with EDAMS. WB-CTP was performed at 24 hours prior to operation and 3 months following bypass with a follow-up WB-CTP, respectively. Both automatic analysis of WB-CTP (MIStar, Apollo Medical imaging Technology, Melbourne, Australia) for analyzing values of brain volume in delayed time (DT) >3 seconds and DT > 6 seconds, relative cerebral blood flow (γCBF) < 30% and its mismatch ratio or percentage and diffusion-weighted imaging of magnetic resonance imaging in the ischemic penumbra and the infarct core at the 2 time points were studied for verifying the effectiveness of the combined revascularization. Changes in DT values at MCA-terminal territory after revascularization had been investigated. The dynamic data were with reference to the individual cerebellar arteries.All patients with ischemic MMD underwent STA-MCA bypass combined with EDAMS successfully. The preoperative brain volume in DT > 3 seconds in MCA-terminal territory was significantly larger than that of postoperative one (P < .05) in the ischemic penumbra in ischemic MMD. The mismatch ratio in brain volume of 24 hours prior to revascularization in MCA-terminal territory was significantly lower than that of 3 months (P < .05) following combined revascularization. The percentage of mismatch in brain volume of 24 hours prior to revascularization vs that of 3 months and the value of γCBF < 30% were similar to the above mismatch ratio (P < .05). The ratio of postoperative brain volume in DT > 3 seconds vs DT > 6 seconds indicated no significant differences compared with that of preoperative one (P > .05).The WB-CTP can be regarded as a choice for quantifying the combined revascularization in the ischemic penumbra and the infarct core in ischemic MMD. As proposed methods, brain volume in DT > 3 seconds, the value of γCBF < 30% and mismatch ratio in brain volume in MCA-terminal territory should be paid more attention in assessing the validity of STA-MCA bypass combined with EDAMS in ischemic MMD.
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16
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Goto T, Shimamura K, Kuratani T, Kin K, Shijo T, Kudo T, Watanabe Y, Masada K, Sakaniwa R, Tanaka H, Sawa Y. Quantitative evaluation of blood flow in each cerebral branch associated with zone 1-2 thoracic endovascular aortic repair. Eur J Cardiothorac Surg 2019; 55:1079-1085. [PMID: 30689779 DOI: 10.1093/ejcts/ezy450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/24/2018] [Accepted: 11/27/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Optimal methods to quantitatively evaluate the blood flow in each cerebral artery after zone 1-2 thoracic endovascular aortic repair (TEVAR) remain unknown. Our objective was to evaluate the differences between preoperative and postoperative cerebral artery blood flows after zone 1-2 debranching TEVAR (dTEVAR). METHODS Between January 2016 and August 2018, a prospective analysis of the blood flow in both the internal carotid artery and the vertebral artery in 16 patients before and after zone 1-2 dTEVAR was conducted. Zone 1 dTEVAR with right axillary artery-left common carotid artery-left axillary artery (RAxA-LCCA-LAxA) bypass was performed on 7 patients. Zone 2 dTEVAR was performed on 9 patients: 4 underwent RAxA-LAxA bypass and 5 underwent LCCA-LAxA bypass. Quantitative magnetic resonance angiography was performed before and after zone 1-2 dTEVAR. RESULTS Total intracranial blood flow was preserved postoperatively [The median (interquartile range) preoperatively vs postoperatively: 621 (549-686) vs 638 (539-703) ml/min, not significant]. The anterior [469 (400-504) vs 475 (404-510) ml/min, not significant] and posterior cerebral blood flows [157 (121-199) vs 163 (123-210) ml/min, not significant] were also maintained postoperatively. In the 3 debranching procedures, the postoperative anterior and posterior cerebral blood flows were maintained at rates similar to preoperative rates, with the proportion of anterior and posterior cerebral circulations reaching almost 75% and 25%, respectively. No significant differences between preoperative and postoperative distributions of internal carotid artery blood flows were observed. Regarding vertebral artery blood flows, the distribution of blood flow through the left vertebral artery was significantly lower postoperatively than preoperatively; however, the postoperative right vertebral artery blood flow distribution significantly increased compared with the preoperative flow. CONCLUSIONS In zone 1-2 dTEVAR, total intracranial blood flow was preserved postoperatively, and the postoperative anterior and posterior cerebral circulations were maintained at rates similar to their preoperative rates.
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Affiliation(s)
- Takasumi Goto
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kazuo Shimamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Toru Kuratani
- Department of Minimally Invasive Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Keiwa Kin
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takayuki Shijo
- Department of Minimally Invasive Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tomoaki Kudo
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Watanabe
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kenta Masada
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ryoto Sakaniwa
- Department of Social Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hisashi Tanaka
- Department of Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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17
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Postoperative Intracerebral Hemorrhage After Combined Revascularization Surgery in Moyamoya Disease: Profiles and Clinical Associations. World Neurosurg 2018; 120:e593-e600. [PMID: 30165232 DOI: 10.1016/j.wneu.2018.08.132] [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: 06/26/2018] [Revised: 08/14/2018] [Accepted: 08/16/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE In combined revascularization surgery for patients with moyamoya disease, intracerebral hemorrhage (ICH) during the postoperative acute phase is a rarely observed but severe complication. Its clinical features remain unclear because of its low incidence rate. The aim of this study was to clarify the clinical characteristics of immediate postoperative ICH. METHODS The frequency, onset timing, and hematoma location of patients who demonstrated immediate postoperative ICH were investigated in 201 consecutive surgeries performed in 134 patients. Associations between immediate postoperative ICH and demographics, clinical presentation type, perioperative blood pressure (BP), and neuroimaging data were analyzed. RESULTS Postoperative ICH was observed in 6 cases (2.99%; mean age, 46.0 ± 7.6 years). The onset timing of ICH was within 24 hours after surgery in most patients (83.3%). Hematomas were located at the subcortical lesion beneath the anastomosed cortex (n = 5) and caudate head (n = 1). Three cases (50.0%) required hematoma evacuation. A higher age at surgery was associated with postoperative ICH (P = 0.046). In adult cases (132 surgeries, 65.7%), hemorrhagic presentation at onset (P = 0.0027) and an increase in BP from pre- to postoperative stage (systolic BP increase: P = 0.0058, diastolic BP increase: P = 0.0274) were significantly associated with postoperative ICH. CONCLUSIONS The results suggest that older patients, with hemorrhagic presentation and greater postoperative BP increase, should be carefully managed to avoid postoperative ICH. Immediate hematoma evacuation may be effective in preventing devastating outcomes after postoperative ICH.
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