Digital subtraction angiographic characteristics of progression of moyamoya disease 6 months prior to surgical revascularisation

Potential of unilateral combined bypass surgery to accelerate contralateral radiological progression in pediatric moyamoya disease

Background

Surgical cerebral revascularization is recommended for treating pediatric moyamoya disease (MMD). However, whether unilateral combined bypass surgery can cause disease progression on the contralateral side is uncertain. The study aimed to investigate the vascular architecture and regional cerebral blood flow (rCBF) status of patients with pediatric MMD after successful unilateral combined bypass surgery and to identify the possible risk factors.

Methods

Pediatric patients diagnosed with MMD and admitted to Xuanwu Hospital who underwent combined bypass surgery between 2019 and 2021 were enrolled. Digital subtraction angiography (DSA) and magnetic resonance imaging (MRI) with arterial spin labeling (ASL) were performed to investigate the vascular architecture and rCBF during surgery and at short-term follow-up. Suzuki's angiographic staging and moyamoya vessel grading system were both used. Progression was defined as an increase in either Suzuki stage or moyamoya vessel grade detected after unilateral surgery. All analyses were performed with conventional statistic methods.

Results

A total of 27 successive patients with a median age of 8 [interquartile range (IQR), 5-14] years old were identified. On the non-operated (non-OP) side, 11 (40.7%) patients demonstrated progression, all of whom showed an increase in the moyamoya vessel grade, and 5 also displayed Suzuki stage progression during the median 4.7 (IQR, 3.7-5.7) months follow-up. However, rCBF barely changed on the non-OP side compared to preoperation [preoperation: median, 49.6, (IQR, 42.9-61.1) mL/100 g/min; postoperation: median, 50.2, (IQR, 43.5-59.3) mL/100 g/min; P=0.445].

Conclusions

Combined bypass surgery might accelerate the radiological progression on the contralateral side, which occurs before the decline of rCBF. Those with earlier Suzuki stage MMD of the non-OP side are prone to rapid progression after unilateral combined revascularization.

Transradial Access Failures During Neuroangiography for Patients With Moyamoya

BACKGROUND

Despite studies continuing to demonstrate the utility of transradial access (TRA) in neuroangiography, minimal data exist regarding predictors of TRA failure. Furthermore, although many patients with moyamoya disease/syndrome will require life-long angiographic evaluation, even less has been reported on the usage of TRA in this population.

OBJECTIVE

To perform a matched analysis at our high-volume moyamoya center to determine predictors of TRA failure in these patients.

METHODS

A total of 636 patients undergoing TRA for neuroangiography were identified from 2018 to 2020. Demographic and angiographic characteristics including radial artery spasm (RAS), radial anomalies, and access site conversion were compared between patients with moyamoya and the rest of the cohort. A 4:1 matched analysis, based on age and sex, was also performed to eliminate confounding variables.

RESULTS

Patients with moyamoya were younger (40 vs 57 years, P < .0001), had smaller radial diameters (1.9 vs 2.6 mm, P < .0001), more commonly had a high brachial bifurcation (25.9% vs 8.5%, P = .008), more frequently experienced clinically significant RAS (40% vs 8.4%, P < .0001), and more often required access site conversion (26.7% vs 7.8%, P = .002). Increasing age was associated with less TRA failures in patients with moyamoya (odds ratio = 0.918) but more failures in the rest of the cohort (odds ratio = 1.034). In the matched analysis, patients with moyamoya continued to experience more radial anomalies, RAS, and access site conversions.

CONCLUSION

Patients with moyamoya, when controlling for age and sex, have higher rates of TRA failure during neuroangiography. Increasing age in Moyamoya is inversely correlated with TRA failures suggesting that younger patients with moyamoya are at higher risk of extracranial arteriopathy.

Indirect revascularization vs. non-surgical treatment for Moyamoya disease and Moyamoya syndrome: A comparative effectiveness study

Background

The efficacy of indirect revascularization vs. non-surgical treatment in adults with Moyamoya disease (MMD) and Moyamoya syndrome (MMS) remains controversial.

Objective

To compare the clinical outcomes of indirect revascularization and non-surgical treatments in adult patients with MMD and MMS.

Methods

We collected medical records and follow-up results of adult patients with MMD and MMS who received treatment in the China-Japan Union Hospital of Jilin University between January 2019 and December 2021. A Shapiro-Wilk test, independent sample t-test or Mann-Whitney U-test, and Pearson chi-square test were used to compare baseline variables. The propensity-score analysis was used to compare clinical outcomes of patients with MMD and MMS who underwent indirect revascularization and non-surgical treatments. The color-coded digital subtraction angiography (CC-DSA) was used to quantitatively analyzed the preoperative and postoperative (at 6-month follow-up) images of patients in the surgical group.

Results

A total of 144 patients were included in this study, of whom 37 received indirect revascularization treatment and 107 received non-surgical treatment. The average age of the patients was 58.3 ± 13.4 years. Perioperative complications were observed in eight of the operations. During the follow-up period, a total of 35 stroke events occurred, including two cases (5.4%) in the surgery group and 33 cases (30.8%) in the non-surgery group (p < 0.05). The preoperative mean transit time (MTT) of bypass vessel (superficial temporal artery, STA) was 0.26 ± 0.07, and the postoperative MTT of bypass vessel was 3.0 ± 0.25, and there was no statistical difference between the subgroups.

Conclusion

Indirect revascularization surgery can significantly reduce the recurrent stroke incidence of MMD and MMS patients.

Imaging methods for surgical revascularization in patients with moyamoya disease: an updated review

Neuroimaging is crucial in moyamoya disease (MMD) for neurosurgeons, during pre-surgical planning and intraoperative navigation not only to maximize the success rate of surgery, but also to minimize postsurgical neurological deficits in patients. This is a review of recent literatures which updates the clinical use of imaging methods in the morphological and hemodynamic assessment of surgical revascularization in patients with MMD. We aimed to assist surgeons in assessing the status of moyamoya vessels, selecting bypass arteries, and monitoring postoperative cerebral perfusion through the latest imaging technology.

Progression in Moyamoya Disease: Clinical Feature, Neuroimaging Evaluation and Treatment

Moyamoya disease (MMD) is a chronic cerebrovascular disease characterized by progressive stenosis of the arteries of the circle of Willis, with the formation of collateral vascular network at the base of the brain. Its clinical manifestations are complicated. Numerous studies have attempted to clarify the clinical features of MMD, including its epidemiology, genetic characteristics, and pathophysiology. With the development of neuroimaging techniques, various neuroimaging modalities with different advantages have deepened the understanding of MMD in terms of structural, functional, spatial, and temporal dimensions. At present, the main treatment for MMD focuses on neurological protection, cerebral blood flow reconstruction, and neurological rehabilitation, such as pharmacological treatment, surgical revascularization, and cognitive rehabilitation. In this review, we discuss recent progress in understanding the clinical features, in the neuroimaging evaluation and treatment of MMD.