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Gonzalez NR, Amin-Hanjani S, Bang OY, Coffey C, Du R, Fierstra J, Fraser JF, Kuroda S, Tietjen GE, Yaghi S. Adult Moyamoya Disease and Syndrome: Current Perspectives and Future Directions: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2023; 54:e465-e479. [PMID: 37609846 DOI: 10.1161/str.0000000000000443] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Adult moyamoya disease and syndrome are rare disorders with significant morbidity and mortality. A writing group of experts was selected to conduct a literature search, summarize the current knowledge on the topic, and provide a road map for future investigation. The document presents an update in the definitions of moyamoya disease and syndrome, modern methods for diagnosis, and updated information on pathophysiology, epidemiology, and both medical and surgical treatment. Despite recent advancements, there are still many unresolved questions about moyamoya disease and syndrome, including lack of unified diagnostic criteria, reliable biomarkers, better understanding of the underlying pathophysiology, and stronger evidence for treatment guidelines. To advance progress in this area, it is crucial to acknowledge the limitations and weaknesses of current studies and explore new approaches, which are outlined in this scientific statement for future research strategies.
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Yang J, Han H, Chen Y, Lin F, Li R, Lu J, Li R, Li Z, Shi G, Wang S, Zhao Y, Chen X, Zhao J. Application of Quantitative Computed Tomographic Perfusion in the Prognostic Assessment of Patients with Aneurysmal Subarachnoid Hemorrhage Coexistent Intracranial Atherosclerotic Stenosis. Brain Sci 2023; 13:brainsci13040625. [PMID: 37190589 DOI: 10.3390/brainsci13040625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 03/26/2023] [Accepted: 04/03/2023] [Indexed: 04/09/2023] Open
Abstract
The comorbidity of aneurysmal subarachnoid hemorrhage (aSAH) with intracranial atherosclerotic stenosis (ICAS) has been suggested to increase the risk of postoperative ischemic stroke. Logistic regression models were established to explore the association between computed tomography perfusion (CTP) parameters and 3-month neurological outcomes and delayed cerebral ischemia (DCI). Prognostic-related perfusion parameters were added to the existing prognostic prediction models to evaluate model performance improvement. Tmax > 4.0 s volume > 0 mL was significantly associated with 3-month unfavorable neurological outcomes after adjusting for potential confounders (OR 3.90, 95% CI 1.11–13.73), whereas the stenosis degree of ICAS was not. Although the cross-validated area under the curve (AUC) was similar after the addition of the Tmax > 4.0 s volume > 0 mL (SAHIT: p = 0.591; TAPS: p = 0.379), the continuous net reclassification index (cNRI) and integrated discrimination index (IDI) showed that the perfusion parameters significantly improved the performance of the two models (p < 0.001 for all comparisons). Patients with coexistent aSAH and ICAS, Tmax > 4.0 s volume > 0 mL is an independent factor of 3-month neurological outcomes. A quantitative assessment of cerebral perfusion may help accurately screen patients with poor outcomes due to the coexistence of aSAH and ICAS.
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Affiliation(s)
- Jun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - JunLin Lu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610000, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Guangzhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100070, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100070, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100070, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100070, China
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Parr MS, Salehani A, Ogilvie M, Ethan Tabibian B, Rahm S, Hale AT, Tsemo GB, Aluri A, Kim J, Mathru M, Jones JGA. The effect of procedural end-tidal CO2 on infarct expansion during anterior circulation thrombectomy. Interv Neuroradiol 2022:15910199221143175. [PMID: 36464668 DOI: 10.1177/15910199221143175] [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: 02/17/2024] Open
Abstract
BACKGROUND Carbon dioxide is a potent cerebral vasodilator that may influence outcomes after ischemic stroke. The objective of this study was to investigate the effect of intraprocedural mean end-tidal CO2 (ETCO2) levels on core infarct expansion and neurologic outcome following thrombectomy for anterior circulation ischemic stroke. METHODS A retrospective review was conducted of consecutive patients from March 2020 to June 2021 who underwent mechanical thrombectomy for acute anterior circulation ischemic stroke under general anesthesia and achieved successful recanalization (Thrombolysis in Cerebral Infarction [TICI] ≥ 2b). Only patients with CT perfusion, procedural ETCO2, and postoperative MRI data were included. Segmentation software was used for multi-parametric image analysis. Normocarbia defined as mean ETCO2 of 35 mmHg was used to dichotomize subjects. Univariate and multivariate statistics were applied. RESULTS Fifty-eight patients met criteria for analysis. Of these, 44 had TICI 3 recanalization, 9 had TICI 2c, and 5 had TICI 2b. Within this combined recanalization group, patients with mean ETCO2 > 35 had significantly higher rates of functional independence at 90 days. Although patients tended to salvage more penumbra and experience smaller final infarcts when ETCO2 exceeded 35 mmHg, this did not reach statistical significance. CONCLUSIONS Stroke patients who underwent successful thrombectomy with general anesthesia achieved higher rates of functional independence when procedural ETCO2 exceeded 35 mmHg. Further studies to confirm this effect and investigate optimal ETCO2 parameters should be considered.
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Affiliation(s)
- Matthew S Parr
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Arsalaan Salehani
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark Ogilvie
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Radiology, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - B Ethan Tabibian
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sage Rahm
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew T Hale
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Georges Bouobda Tsemo
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Akshay Aluri
- Heersink School of Medicine, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jinsuh Kim
- Department of Radiology, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mali Mathru
- Department of Anesthesiology, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jesse G A Jones
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Radiology, 9968University of Alabama at Birmingham, Birmingham, AL, USA
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Chan JL, Quintero-Consuegra MD, Babadjouni RM, Chang D, Barnard ZR, Martin NA, Ziv K, Van de Wiele BM, Gonzalez NR. Encephaloduroarteriosynangiosis Operative Technique and Intraoperative Anesthesia Management: Treatment From Both Sides of the Curtain. Oper Neurosurg (Hagerstown) 2022; 22:20-27. [PMID: 34982901 PMCID: PMC10602499 DOI: 10.1227/ons.0000000000000009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 10/08/2021] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Encephaloduroarteriosynangiosis (EDAS) is a form of indirect revascularization for cerebral arterial steno-occlusive disorders. EDAS has gained growing interest as a technique applicable to pediatric and adult populations for several types of ischemic cerebral steno-occlusive conditions. OBJECTIVE To present a team-oriented, multidisciplinary update of the EDAS technique for application in challenging adult cases of cerebrovascular stenosis/occlusion, successfully implemented in more than 200 cases. METHODS We describe and demonstrate step-by-step a multidisciplinary-modified EDAS technique, adapted to maintain uninterrupted intensive medical management of patients' stroke risk factors and anesthesia protocols to maintain strict hemodynamic control. RESULTS A total of 216 EDAS surgeries were performed in 164 adult patients, including 65 surgeries for patients with intracranial atherosclerotic disease and 151 operations in 99 patients with moyamoya disease. Five patients with intracranial atherosclerotic disease had recurrent strokes (3%), and there was one perioperative death. The mean clinical follow-up was 32.9 mo with a standard deviation of 31.1. There was one deviation from the surgical protocol. There were deviations from the anesthesia protocol in 3 patients (0.01%), which were promptly corrected and did not have any clinical impact on the patients' condition. CONCLUSION The EDAS protocol described here implements a team-oriented, multidisciplinary adaptation of the EDAS technique. This adaptation resides mainly in 3 points: (1) uninterrupted administration of intensive medical management, (2) strict hemodynamic control during anesthesia, and (3) meticulous standardized surgical technique.
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Affiliation(s)
- Julie L. Chan
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Robin M. Babadjouni
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Daniel Chang
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Zachary R. Barnard
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Neil A. Martin
- Department of Neurosurgery, Pacific Neuroscience Institute, Los Angeles, California, USA
| | - Keren Ziv
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Barbara M. Van de Wiele
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Nestor R. Gonzalez
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Transnasal humidified rapid insufflation ventilatory exchange vs. facemask oxygenation in elderly patients undergoing general anaesthesia: a randomized controlled trial. Sci Rep 2020; 10:5745. [PMID: 32238855 PMCID: PMC7113239 DOI: 10.1038/s41598-020-62716-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 03/16/2020] [Indexed: 11/13/2022] Open
Abstract
Transnasal humidified rapid insufflation ventilator exchange (THRIVE) may be effective in delaying hypoxia, but the efficacy of THRIVE for oxygenation in elderly patients under general anaesthesia has not been assessed. This study assessed whether THRIVE prolonged the apnoea time in the elderly patients after induction. This was a single centre, two-group, randomized controlled trial. 60 patients (65 to 80 years of age) with American Society of Anesthesiologists (ASA) grades I ~ III who required tracheal intubation or the application of a laryngeal mask under general anaesthesia were randomly allocated to receive oxygenation using THRIVE (100% oxygen, 30~70 litres min−1) or a facemask (100% oxygen, 10 litres min−1) during the pre-oxygenation period and during apnoea. The apnoea time, which was defined as the time from the cessation of spontaneous breathing until the SpO2 decreased to 90% or the apnoea time reached 10 minutes was recorded as the primary outcome. No significant differences were found on the baseline characteristics between the groups. The apnoea time was significantly increased (P < 0.01) in the THRIVE group. The median (interquartile range) apnoea times were 600 (600–600) s in the THRIVE group and 600 (231.5–600) s in the facemask group. No significant differences were found in the PaO2, PaCO2 and vital parameters between the THRIVE and facemask groups. No increased occurrence of complications, including haemodynamic instability, resistant arrhythmia or nasal discomfort, were reported in both the THRIVE group and the facemask group. THRIVE prolongs the apnoea time in elderly patients. THRIVE may be a more effective method for pre-oxygenation than a facemask in the elderly without pulmonary dysfunction.
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Differential Expression of Vascular Endothelial Growth Factor-A 165 Isoforms Between Intracranial Atherosclerosis and Moyamoya Disease. J Stroke Cerebrovasc Dis 2018; 28:360-368. [PMID: 30392834 DOI: 10.1016/j.jstrokecerebrovasdis.2018.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 09/14/2018] [Accepted: 10/06/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Vascular endothelial growth factor-A165 (VEGF-A165) has been identified as a combination of 2 alternative splice variants: proangiogenic VEGF-A165a and antiangiogenic VEGF-A165b. Intracranial atherosclerotic disease (ICAD) and moyamoya disease (MMD) are 2 main types of intracranial arterial steno-occlusive disorders with distinct capacities for collateral formation. Recent studies indicate that VEGF-A165 regulates collateral growth in ischemia. Therefore, we investigated if there is a distinctive composition of VEGF-A165 isoforms in ICAD and MMD. METHODS Sixty-six ICAD patients, 6 MMD patients, and 5 controls were enrolled in this prospective study. ICAD and MMD patients received intensive medical management upon enrollment. Surgery was offered to 9 ICAD patients who had recurrent ischemic events, 6 MMD patients, and 5 surgical controls without ICAD. VEGF-A165a and VEGF-A165b plasma levels were measured at baseline, within 1 week after patients having surgery, and at 1, 3, and 6 months after treatment. RESULTS A significantly higher baseline VEGF-A165a/b ratio was observed in MMD compared to ICAD (P = .016). The VEGF-A165a/b ratio increased significantly and rapidly after surgical treatment in ICAD (P = .026) more so than in MMD and surgical controls. In patients with ICAD receiving intensive medical management, there was also an elevation of the VEGF-A165a/b ratio, but at a slower rate, reaching the peak at 3 months after initiation of treatment (baseline versus 3 months VEGF-A165a/b ratio, P = .028). CONCLUSIONS Our study shows an increased VEGF-A165a/b ratio in MMD compared to ICAD, and suggests that both intensive medical management and surgical revascularization elevate the VEGF-A165a/b ratio in ICAD patients.
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A Protocol for Diagnosis and Management of Aortic Atherosclerosis in Cardiac Surgery Patients. Int J Vasc Med 2017; 2017:1874395. [PMID: 28852575 PMCID: PMC5568616 DOI: 10.1155/2017/1874395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 07/02/2017] [Indexed: 11/17/2022] Open
Abstract
In patients undergoing cardiac surgery, use of perioperative screening for aortic atherosclerosis with modified TEE (A-View method) was associated with lower postoperative mortality, but not stroke, as compared to patients operated on without such screening. At the time of clinical implementation and validation, we did not yet standardize the indications for modified TEE and the changes in patient management in the presence of aortic atherosclerosis. Therefore, we designed a protocol, which combined the diagnosis of atherosclerosis of thoracic aorta and the subsequent considerations with respect to the intraoperative management and provides a systematic approach to reduce the risk of cerebral complications.
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