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Sakai R, Hara S, Inaji M, Tanaka Y, Nariai T, Maehara T. Stroke and Disease Progression During Long-Term Follow-Up of Patients with Moyamoya Disease Older Than 50 Years. World Neurosurg 2024; 187:e898-e907. [PMID: 38734172 DOI: 10.1016/j.wneu.2024.05.008] [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: 04/29/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024]
Abstract
OBJECTIVE The long-term prognosis of elderly patients with moyamoya disease (MMD) is not fully understood and needs to be elucidated. METHODS MMD patients who first visited our institute between 1999 and 2019, were ≥ 50 years of age, and were followed for ≥1 year were retrospectively included. Follow-up data such as stroke and disease progression on magnetic resonance angiography (MRA) were collected from medical records. The surgical outcomes of ischemic patients treated with indirect revascularization were assessed. RESULTS Of the 60 patients included (mean (standard deviation) = 57.0 (5.5) years, 38 females), 9 patients initially received indirect revascularization, 3 patients received direct revascularization, and 49 patients were treated conservatively. During the 57.4 (53.7) month follow-up, the symptomatic stroke rate (person-year %) was 2.79%, and MRA progression was 3.14%. Symptomatic patients had a greater rate of symptomatic stroke than asymptomatic patients did (1.46%-5.74% vs. 0.94%, P = 0.15), while MRA progression was more common in asymptomatic patients (0%-3.83% vs. 5.64%, P = 0.22). Among the 14 hemispheres of 11 patients who underwent indirect revascularization, 13/14 (92.9%) demonstrated good neovascularization and no ischemic stroke occurred after surgery. CONCLUSIONS In elderly patients with MMD, MRA progression was not uncommon, especially in asymptomatic patients. Symptomatic patients exhibited a high symptomatic stroke rate, and indirect revascularization seems to be effective at reducing future ischemic stroke in ischemic patients with misery perfusion. Because follow-up events were not uncommon, lifelong follow-up seems necessary for elderly MMD patients, as well as for younger patients.
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Affiliation(s)
- Ryosuke Sakai
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shoko Hara
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Motoki Inaji
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoji Tanaka
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tadashi Nariai
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Taketoshi Maehara
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
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Uchino H, Ito M, Fujima N, Tokairin K, Tatezawa R, Sugiyama T, Fujimura M. Predictive value of the hemispheric magnetic resonance angiography score on the development of indirect pial synangiosis after combined revascularization surgery for adult moyamoya disease. Acta Neurochir (Wien) 2024; 166:181. [PMID: 38630203 DOI: 10.1007/s00701-024-06079-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/10/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE It is difficult to precisely predict indirect bypass development in the context of combined bypass procedures in moyamoya disease (MMD). We aimed to investigate the predictive value of magnetic resonance angiography (MRA) signal intensity in the peripheral portion of the major cerebral arteries for indirect bypass development in adult patients with MMD. METHODS We studied 93 hemispheres from 62 adult patients who underwent combined direct and indirect revascularization between 2005 and 2019 and genetic analysis for RNF213 p.R4810K. The signal intensity of the peripheral portion of the major intracranial arteries during preoperative MRA was graded as a hemispheric MRA score (0-3 in the middle cerebral artery and 0-2 in the anterior cerebral and posterior cerebral arteries, with a high score representing low visibility) according to each vessel's visibility. Postoperative bypass development was qualitatively evaluated using MRA, and we evaluated the correlation between preoperative factors, including the hemispheric MRA score and bypass development, using univariate and multivariate analyses. RESULTS A good indirect bypass was observed in 70% of the hemispheres. Hemispheric MRA scores were significantly higher in hemispheres with good indirect bypass development than in those with poor indirect bypass development (median: 3 vs. 1; p < 0.0001). Multiple logistic regression analysis revealed hemispheric MRA score as an independent predictor of good indirect bypass development (odds ratio, 2.1; 95% confidence interval, 1.3-3.6; p < 0.01). The low hemispheric MRA score (< 2) and wild-type RNF213 predicted poor indirect bypass development with a specificity of 0.92. CONCLUSION Hemispheric MRA score was a predictive factor for indirect bypass development in adult patients who underwent a combined bypass procedure for MMD. Predicting poor indirect bypass development may lead to future tailored bypass surgeries for MMD.
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Affiliation(s)
- Haruto Uchino
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-Ku, Sapporo, 060-8638, Japan.
| | - Masaki Ito
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Noriyuki Fujima
- Department of Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kikutaro Tokairin
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Ryota Tatezawa
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Taku Sugiyama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita-Ku, Sapporo, 060-8638, Japan
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Torazawa S, Miyawaki S, Imai H, Hongo H, Ono H, Ogawa S, Sakai Y, Kiyofuji S, Koizumi S, Komura D, Katoh H, Ishikawa S, Saito N. Association of Genetic Variants with Postoperative Donor Artery Development in Moyamoya Disease: RNF213 and Other Moyamoya Angiopathy-Related Gene Analysis. Transl Stroke Res 2024:10.1007/s12975-024-01248-7. [PMID: 38592555 DOI: 10.1007/s12975-024-01248-7] [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: 01/31/2024] [Revised: 03/21/2024] [Accepted: 03/31/2024] [Indexed: 04/10/2024]
Abstract
Robust postoperative bypass development is a characteristic of moyamoya disease (MMD); however, genetic factors mediating this phenomenon remain incompletely understood. Therefore, we aimed to elucidate the relationship between postoperative donor artery development and genetic variants. We retrospectively enrolled 63 patients (79 hemispheres) who underwent combined revascularization surgery. Postoperative development of the superficial temporal artery (STA), middle meningeal artery, and deep temporal artery (DTA) was assessed using the caliber-change ratio determined from magnetic resonance angiography measurements. We analyzed RNF213 and 36 other moyamoya angiopathy-related genes by whole-exome sequencing and extracted rare or damaging variants. Thirty-five participants carried RNF213 p.Arg4810Lys (all heterozygotes), whereas 5 had RNF213 rare variants (RVs). p.Arg4810Lys was significantly associated with postoperative DTA development, while age at surgery, hypertension, and hyperlipidemia were inversely associated. Multiple regression analysis revealed that age and p.Arg4810Lys held statistical significance (P = 0.044, coefficient - 0.015, 95% confidence interval (CI) - 0.029 to 0.000 and P = 0.001, coefficient 0.670, 95% CI 0.269 to 1.072, respectively). Those with RNF213 RV without p.Arg4810Lys exhibited a significant trend toward poor DTA development (P = 0.001). Hypertension demonstrated a significant positive association with STA development, which remained significant even after multiple regression analysis (P = 0.001, coefficient 0.303, 95% CI 0.123 to 0.482). Following Bonferroni correction for multiple comparisons, targeted analyses of RNF213 and 36 moyamoya angiopathy-related genes showed a significant association of only RNF213 p.Arg4810Lys with favorable DTA development (P = 0.001). A comprehensive analysis of RNF213, considering both p.Arg4810Lys and RVs, may provide a clearer prediction of postoperative DTA development.
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Affiliation(s)
- Seiei Torazawa
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan.
| | - Hideaki Imai
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
- Department of Neurosurgery, Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Hiroki Hongo
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Hideaki Ono
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Shizuoka, Japan
| | - Shotaro Ogawa
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Yu Sakai
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Satoshi Kiyofuji
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Satoshi Koizumi
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Daisuke Komura
- Department of Preventive Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroto Katoh
- Department of Preventive Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shumpei Ishikawa
- Department of Preventive Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
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Guo Y, Dou W, Wang X, Wang X, Mao H, Chen K. Can combined high-resolution vessel wall imaging and multiple post-labeling delay 3D pseudo-continuous arterial spin labeling differentiate moyamoya disease from atherosclerotic moyamoya syndrome? Eur J Radiol 2023; 169:111184. [PMID: 37931375 DOI: 10.1016/j.ejrad.2023.111184] [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: 08/17/2022] [Revised: 03/02/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023]
Abstract
PURPOSE To investigate whether moyamoya disease (MMD) and atherosclerotic moyamoya syndrome (AS-MMS) differ in vascular morphology and perfusion characteristics using T1w-CUBE imaging and multiple post-labeling delay 3D pseudo-continuous arterial spin labeling imaging (MP 3D-PcASL), and to explore the potential of the combined techniques for accurate diagnosis of both diseases. METHOD This prospective study enrolled 51 patients with moyamoya vasculopathy, including 26 with MMD and 25 with AS-MMS. All patients underwent digital subtraction angiography (DSA)/magnetic resonance angiography (MRA), T1w-CUBE imaging, and MP 3D-PCASL examinations. Morphological parameters, including the outer diameter, maximum wall thickness, luminal stenosis morphology, degree of wall enhancement, number of collateral vessels, and perfusion parameters, such as cerebral blood flow (CBF) and arterial transit time (ATT), were measured. After univariate analysis between the two groups, logistic regression models based on the derived parameters of T1w-CUBE imaging, MP 3D-PCASL, and combined imaging were implemented, and receiver operating characteristic (ROC) curves were generated to compare the discriminatory power of the different imaging methods for the diagnosis of MMD. RESULTS With T1w-CUBE imaging, MMD showed a smaller outer diameter (2.76 ± 0.39 vs. 3.07 ± 0.49 mm) and maximum wall thickness (1.27 ± 0.19 vs. 1.49 ± 0.24 mm) than AS-MMS (both P < 0.05). Using MP 3D-pcASL, the resultant CBF (36.64 ± 14.28 vs. 28.77 ± 8.63 mL/100 g/min) was higher in MMD relative to AS-MMS, while an opposite pattern was shown for ATT (1.61 ± 0.09 vs. 1.72 ± 0.13 s; both P < 0.05). Robust diagnostic efficacies for disease differentiation, confirmed by high areas under the ROC curve (AUCs) (>0.808), were separately shown with T1w-CUBE and MP 3D-pcASL derived parameters. However, the combined multivariate logistic regression model showed optimaldiagnostic efficacy(AUC: 0.938; P < 0.05). CONCLUSIONS Combined T1w-CUBE imaging and MP 3D-PCASL provides distinctive morphological and functional features to evaluate vessel walls and cerebral perfusion, and might help distinguish MMD from AS-MMS.
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Affiliation(s)
- Yu Guo
- Department of Radiology, The First Affiliated Hospital of Shandong First Medical University&Shandong Provincial Qianfoshan Hospital, No.16766, Jingshi Rd, Jinan 250014, Shandong Province, China; Shandong First Medical University, Jinan 250000, Shandong Province, China
| | - Weiqiang Dou
- MR Research, GE Healthcare, Beijing 10076, China
| | - Xinyu Wang
- Department of Radiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Xinyi Wang
- Department of Radiology, The First Affiliated Hospital of Shandong First Medical University&Shandong Provincial Qianfoshan Hospital, No.16766, Jingshi Rd, Jinan 250014, Shandong Province, China.
| | - Huimin Mao
- Shandong First Medical University, Jinan 250000, Shandong Province, China
| | - Kunjian Chen
- Shandong First Medical University, Jinan 250000, Shandong Province, China
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Lu L, Huang Y, Han Y, Li Y, Wan X, Chen J, Zhang X, Shu K, Lei T, Wang S, Gan C, Zhang H. Clinical effect of a modified superficial temporal artery-middle cerebral artery bypass surgery in Moyamoya disease treatment. Front Neurol 2023; 14:1273822. [PMID: 37941571 PMCID: PMC10628485 DOI: 10.3389/fneur.2023.1273822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/03/2023] [Indexed: 11/10/2023] Open
Abstract
Background Cerebral extracranial-intracranial (EC-IC) revascularization technique (superficial temporal artery-middle cerebral artery (STA-MCA) bypass grafting) has become the preferred surgical method for the treatment of Moyamoya disease (MMD). We attempted to completely free the two branches of the superficial temporal artery without disconnection. Extracranial and intracranial blood flow reconstruction were then modified by selectively performing a direct bypass technique on one branch and a patch fusion technique on the other of the STA based on the blood flow and the vascular diameter of the intracranial surface blood vessels. Methods A series of modified STA-MCA bypass surgeries performed consecutively between March 2022 and March 2023 were reviewed and compared to conventional combined bypass surgeries performed during the same period. The following information was collected from all enrolled patients: demographic characteristics, clinical symptoms, and preoperative and postoperative imaging, including Suzuki stage and Matsushima grade. The modified Rankin scale (mRS) was used to assess the changes in neurological status before and after surgery. Results A total of 41 patients with Moyamoya disease (MMD) who underwent cerebral revascularization were included in this study, of which 30 were conventional revascularization and 11 were modified revascularization. The mean age was 49.91 years, and 18 (43.9%) of the patients were women. The modified group had a lower incidence of cerebral hyperperfusion syndrome (18.2%) than the conventional group (23.3%). After at least 3 months of follow-up, the bypass patency rate remained 100% in the modified group and 93.3% in the conventional group. All patients in the modified group achieved a better Matsushima grade (A + B), with six (54.5%) having an A and five (45.5%) having a B. In contrast, four patients (13.3%) in the conventional group had a Matsushima grade of C. In all, 72.8% of the modified group had postoperative mRS scores of 0 and 1, which was higher than that of the traditional group (63.3%). Conclusion The improved STA-MCA bypass could provide blood flow to multiple cerebral ischemic areas, reduce excessive blood perfusion, and ensure blood supply to the scalp, with lower complications and better clinical benefits than the traditional combined bypass.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Chao Gan
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huaqiu Zhang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Zhang XH, He JH, Zhang XS, Zhang J, Wang CJ, Dong YP, Tao W. Comparison of revascularization and conservative treatment for hemorrhagic moyamoya disease in East Asian Countries: a single-center case series and a systematic review with meta-analysis. Front Neurol 2023; 14:1169440. [PMID: 37332987 PMCID: PMC10272728 DOI: 10.3389/fneur.2023.1169440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 04/28/2023] [Indexed: 06/20/2023] Open
Abstract
Objective The optimal treatment approach for hemorrhagic moyamoya disease (HMMD) remains a topic of debate, particularly regarding the comparative efficacy of revascularization versus conservative treatment. Our study, which included a single-center case series and a systematic review with meta-analysis, aimed to determine whether surgical revascularization is associated with a significant reduction in postoperative rebleeding, ischemic events, and mortality compared to conservative treatment among East Asian HMMD patients. Methods We conducted a systematic literature review by searching PubMed, Google Scholar, Wanfang Med Online (WMO), and the China National Knowledge Infrastructure (CNKI). The outcomes of surgical revascularization and conservative treatment, including rebleeding, ischemic events and mortality, were compared. The authors' institutional series of 24 patients were also included and reviewed in the analysis. Results A total of 19 East Asian studies involving 1,571 patients as well as our institution's retrospective study of 24 patients were included in the study. In the adult patients-only studies, those who underwent revascularization had significantly lower rates of rebleeding, ischemic events, and mortality compared to those who received conservative treatment (13.1% (46/352) vs. 32.4% (82/253), P < 0.00001; 4.0% (5/124) vs. 14.9% (18/121), P = 0.007; and 3.3% (5/153) vs. 12.6% (12/95), P = 0.01, respectively). In the adult/pediatric patients' studies, similar statistical results of rebleeding, ischemic events, and mortality have been obtained (70/588 (11.9%) vs. 103/402 (25.6%), P = 0.003 or <0.0001 in a random or fixed-effects model, respectively; 14/296 (4.7%) vs. 26/183 (14.2%), P = 0.001; and 4.6% (15/328) vs. 18.7% (23/123), P = 0.0001, respectively). Conclusion The current single-center case series and systematic review with meta-analysis of studies demonstrated that surgical revascularization, including direct, indirect, and a combination of both, significantly reduces rebleeding, ischemic events, and mortality in HMMD patients in the East Asia region. More well-designed studies are warranted to further confirm these findings.
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Affiliation(s)
- Xiang-Hua Zhang
- Department of Neurosurgery, Beijing Friendship Hospital Affiliated With Capital Medical University, Beijing, China
| | - Jun-Hua He
- Department of Neurosurgery, Zhejiang Provincial Tongde Hospital, Hangzhou, China
| | - Xiang-Sheng Zhang
- Department of Neurosurgery, Beijing Friendship Hospital Affiliated With Capital Medical University, Beijing, China
| | - Jing Zhang
- Department of Neurosurgery, Beijing Friendship Hospital Affiliated With Capital Medical University, Beijing, China
| | - Cheng-jun Wang
- Department of Neurosurgery, Beijing Friendship Hospital Affiliated With Capital Medical University, Beijing, China
| | - Yi-Peng Dong
- Department of Neurosurgery, Beijing Friendship Hospital Affiliated With Capital Medical University, Beijing, China
| | - Wu Tao
- Department of Neurosurgery, Beijing Friendship Hospital Affiliated With Capital Medical University, Beijing, China
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Gao P, Chen D, Yuan S, Kong T, Zhang D, Zhu X, Li X, Zhen Y, Yan D. Follow-up outcomes of different bypass surgical modalities for adults with ischaemic-type moyamoya disease. Br J Neurosurg 2023; 37:148-157. [PMID: 34553657 DOI: 10.1080/02688697.2021.1981239] [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: 10/20/2022]
Abstract
PURPOSE The preferred surgical method for treating adults with moyamoya disease (MMD) remains controversial. The purpose of this study was to compare the efficacy of different surgical methods in the treatment of adults with ischaemic-type MMD. METHODS We retrospectively analyzed the data of patients with ischaemic-type MMD who underwent indirect bypass (IB), direct bypass (DB), or combined bypass (CB) at the First Affiliated Hospital of Zhengzhou University from January 2013 to December 2019. Postoperative complications, improvements in neurological function, haemodynamics, recurrent stroke and neovascularization were compared. RESULTS A total of 310 adults (371 hemispheres) with ischaemic-type MMD were included in our study. Ninety, 127, and 154 hemispheres underwent IB, DB and CB, respectively. A total of 24 (6.5%) ischaemic events and 8 (2.8%) symptomatic hyperperfusion events occurred after the operations. There was no significant difference in postoperative complications among the three types of surgery (p = 0.300). During the follow-up period, there were 21 cases (5.7%) of recurrent ischaemia and 12 cases (3.2%) of recurrent haemorrhage. Kaplan-Meier survival analysis showed that the ischaemia-free survival of the CB group was significantly longer than that of the IB group (p = 0.047), but there was no significant difference in haemorrhage-free survival among the three groups (p = 0.660). Six months after the operation, DB and CB were superior to IB in improving cerebral blood flow and neovascularization (p = 0.002), but there was no significant difference in the improvement of neurological function among the three groups at the last follow-up (p = 0.784). CONCLUSION The three surgical methods achieved satisfactory results in the treatment of ischaemic-type MMD. DB and CB can significantly improve haemodynamics and reduce recurrent stroke. In terms of improving neurological function, the curative effect of the three surgical methods remains to be further explored.
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Affiliation(s)
- Peng Gao
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Di Chen
- Department of Neurosurgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shanpeng Yuan
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Tengxiao Kong
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Dongtao Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Xuqiang Zhu
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Xueyuan Li
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yingwei Zhen
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Dongming Yan
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Henan, China
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Chen S, Wang B, Wen Y, Wang Z, Long T, Chen J, Zhang G, Li M, Zhang S, Pan J, Feng W, Qi S, Wang G. Ultrasonic hemodynamic changes of superficial temporal artery graft in different angiogenesis outcomes of Moyamoya disease patients treated with combined revascularization surgery. Front Neurol 2023; 14:1115343. [PMID: 36873438 PMCID: PMC9978192 DOI: 10.3389/fneur.2023.1115343] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/25/2023] [Indexed: 02/18/2023] Open
Abstract
Objective Combined bypass is commonly used in adult Moyamoya disease (MMD) for revascularization purposes. The blood flow from the external carotid artery system supplied by the superficial temporal artery (STA), middle meningeal artery (MMA), and deep temporal artery (DTA) can restore the impaired hemodynamics of the ischemic brain. In this study we attempted to evaluate the hemodynamic changes of the STA graft and predict the angiogenesis outcomes in MMD patients after combined bypass surgery by using quantitative ultrasonography. Methods We retrospectively studied Moyamoya patients who were treated by combined bypass between September 2017 and June 2021 in our hospital. We quantitatively measured the STA with ultrasound and recorded the blood flow, diameter, pulsatility index (PI) and resistance index (RI) to assess graft development preoperatively and at 1 day, 7 days, 3 months, and 6 months after surgery. All patients received both pre- and post- operative angiography evaluation. Patients were divided into either well- or poorly-angiogenesis groups according to the transdural collateral formation status on angiography at 6 months after surgery (W group or P group). Patients with matshushima grade A or B were divided into W group. Patients with matshushima grade C were divided into P group, indicating a poor angiogenesis development. Results A total of 52 patients with 54 operated hemispheres were enrolled, including 25 men and 27 women with an average age of 39 ± 14.3 years. Compared to preoperative values, the average blood flow of an STA graft at day 1 postoperation increased from 16.06 ± 12.47 to 117.47± 73.77 (mL/min), diameter increased from 1.14 ± 0.33 to 1.81 ± 0.30 (mm), PI dropped from 1.77 ± 0.42 to 0.76 ± 0.37, and RI dropped from 1.77 ± 0.42 to 0.50 ± 0.12. According to the Matsushima grade at 6 months after surgery, 30 hemispheres qualified as W group and 24 hemispheres as P group. Statistically significant differences were found between the two groups in diameter (p = 0.010) as well as flow (p = 0.017) at 3 months post-surgery. Flow also remained significantly different at 6 months after surgery (p = 0.014). Based on GEE logistic regression evaluation, the patients with higher levels of flow post-operation were more likely to have poorly-compensated collateral. ROC analysis showed that increased flow of ≥69.5 ml/min (p = 0.003; AUC = 0.74) or a 604% (p = 0.012; AUC = 0.70) increase at 3 months post-surgery compared with the pre-operative value is the cut-off point which had the highest Youden's index for predicting P group. Furthermore, a diameter at 3 months post-surgery that is ≥0.75 mm (p = 0.008; AUC = 0.71) or 52% (p =0.021; AUC = 0.68) wider than pre-operation also indicates a high risk of poor indirect collateral formation. Conclusions The hemodynamic of the STA graft changed significantly after combined bypass surgery. An increased flow of more than 69.5 ml/min at 3 months was a good predictive factor for poor neoangiogenesis in MMD patients treated with combined bypass surgery.
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Affiliation(s)
- Siyuan Chen
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Baoping Wang
- Department of Ultrasonography, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yunyu Wen
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhibin Wang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tinghan Long
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junda Chen
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Guozhong Zhang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Mingzhou Li
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shichao Zhang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jun Pan
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wenfeng Feng
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Songtao Qi
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Gang Wang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Luo M, Yu J, Xin C, Wan L, Zhang J. How to choose the surgical side when cerebral blood flow and cerebrovascular response are contradictory in bilateral moyamoya disease?: A case report. Medicine (Baltimore) 2022; 101:e31679. [PMID: 36397453 PMCID: PMC9666088 DOI: 10.1097/md.0000000000031679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Moyamoya disease (MMD) is a rare cerebrovascular disease characterized by progressive occlusion of the internal carotid artery and the secondary formation of collateral vessels. Bypass surgery is an effective treatment for MMD. Comprehensive evaluation of cerebral blood flow (CBF) and cerebrovascular response (CVR) is the common hemodynamic indication to surgery, the changes of which are usually identical. THE PATIENTS MAIN CONCERNS AND IMPORTANT EXAMINATIONS We reported a rare case of MMD in a 34-year-old pregnant woman with transient ischemic attacks (TIAs) for 1 month, manifesting as frequent weakness in right limbs for several minutes without obvious cause. The diagnostic digital subtraction angiography (DSA) examination revealed Suzuki Grade I in left side and Grade IV in right side under modified Suzuki scoring. No-hyperventilation test single-photon emission computed tomography (no-HVT SPECT) showed more decreased CBF in the right side of the brain, but HVT SPECT demonstrated a more impaired CVR on the left side. Comprehensively, which side should be operated on is confusing when the changes of CVR and CBF are inconsistent. THE MAIN DIAGNOSIS, THERAPEUTICS INTERVENTIONS, AND OUTCOMES The patient was diagnosed with bilateral MMD and underwent combined bypass surgery on the left side of the brain. The symptoms of admission were completely relieved after surgery and there were no further cerebrovascular events during the follow-up period of 4 months. CONCLUSION CVR is a primary surgical indication of MMD, especially when the impairment of CVR and CBF are not consistent in the ipsilateral hemisphere. Meanwhile, HVT is the vital vasoactive challenges test for measuring CVR in MMD.
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Affiliation(s)
- Mingrui Luo
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Jin Yu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Can Xin
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Lei Wan
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Jianjian Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
- *Correspondence: Jianjian Zhang, Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Donghu Road 169, Wuhan 430071, China (e-mail: )
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10
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Araki Y, Yokoyama K, Uda K, Kanamori F, Mamiya T, Takayanagi K, Ishii K, Shintai K, Nishihori M, Tsukada T, Takeuchi K, Tanahashi K, Nagata Y, Nishimura Y, Tanei T, Nagashima Y, Muraoka S, Izumi T, Seki Y, Saito R. The preoperative focal cerebral blood flow status may be associated with slow flow in the bypass graft after combined surgery for moyamoya disease. Surg Neurol Int 2022; 13:511. [DOI: 10.25259/sni_772_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
Abstract
Background:
The aim of this study was to investigate the association between early postoperative slow flow in bypass grafts and preoperative focal cerebral blood flow (CBF) in patients who underwent combined surgery for moyamoya disease (MMD).
Methods:
The subjects were 18 patients (22 surgeries) who underwent single photon emission computed tomography (SPECT) before surgery. The CBF value of the middle cerebral artery territory was extracted from the SPECT data, and the value relative to the ipsilateral cerebellar CBF (relative CBF, or RCBF) was calculated. The association between RCBF and early postoperative slow flow in the bypass graft was investigated. In addition, the correlation between the revascularization effect and preoperative RCBF was analyzed.
Results:
In four of 22 surgeries (18.2%), slow flow in the bypass graft was identified in the early postoperative period. Preoperative RCBF in the slow flow and patent groups was 0.86 ± 0.15 and 0.87 ± 0.15, respectively, with no significant difference (P = 0.72). The signal intensity of four slow-flowed bypasses was improved in all cases on magnetic resonance angiography images captured during the chronic phase (mean of 3.3 months postoperatively). The revascularization scores were 2 ± 0.82 and 2.1 ± 0.68 in the slow flow and patent groups, respectively, and did not differ significantly (P = 0.78). A significant correlation was not observed between preoperative RCBF and the revascularization effect.
Conclusion:
No significant association was observed between preoperative RCBF and early postoperative slow flow in bypass grafts in patients with MMD undergoing combined surgery. Given the high rate of improved depiction of slow-flowed bypass in the chronic postoperative phase, the conceptual significance of an opportune surgical intervention is to maintain CBF by supporting the patient’s own intracranial-extracranial conversion function.
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Affiliation(s)
- Yoshio Araki
- Department of Neurosurgery, Nagoya University, Nagoya, Japan
| | - Kinya Yokoyama
- Department of Neurosurgery, Nagoya University, Nagoya, Japan
| | - Kenji Uda
- Department of Neurosurgery, Nagoya University, Nagoya, Japan
| | | | - Takashi Mamiya
- Department of Neurosurgery, Nagoya University, Nagoya, Japan
| | - Kai Takayanagi
- Department of Neurosurgery, Nagoya University, Nagoya, Japan
| | - Kazuki Ishii
- Department of Neurosurgery, Nagoya University, Nagoya, Japan
| | - Kazunori Shintai
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | | | - Tetsuya Tsukada
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | | | | | - Yuichi Nagata
- Department of Neurosurgery, Nagoya University, Nagoya, Japan
| | | | - Takafumi Tanei
- Department of Neurosurgery, Nagoya University, Nagoya, Japan
| | | | - Shinsuke Muraoka
- Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Japan
| | - Takashi Izumi
- Department of Neurosurgery, Nagoya University, Nagoya, Japan
| | - Yukio Seki
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University, Nagoya, Japan
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11
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Hirayama A, Yonemochi T, Yokota K, Shigematsu H, Srivatanakul K, Sorimachi T. Cerebrovascular Reserve Impairment in the Anterior Cerebral Artery Territory Predicts Deep Temporal Artery Enlargement After Combined Revascularization Surgery in Moyamoya Disease. World Neurosurg 2022; 167:e344-e349. [PMID: 35963608 DOI: 10.1016/j.wneu.2022.08.013] [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: 04/07/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE A combined surgery of direct and indirect revascularization has been frequently performed in patients with moyamoya disease, though the efficacy of indirect revascularization surgery in adult patients with moyamoya disease has not been established. This study aimed to evaluate superficial temporal artery (STA) and deep temporal artery (DTA) diameters 1 day and 3 months after combined revascularization surgery in patients with moyamoya disease. We also investigated clinical factors related to DTA enlargement after surgery. METHODS We examined 78 cerebral hemispheres in 57 adult and pediatric patients with moyamoya disease who underwent combined revascularization surgery [STA-MCA bypass and encephalo-duro-myo-synangiosis] in our institution. STA and DTA diameters were measured on axial magnetic resonance angiography images at 1 day and 3 months after surgery. RESULTS DTA diameter increased in 64 hemispheres (82.1%). DTA diameter increase in association with STA diameter decrease was found in 39 hemispheres (50%). The proportion of hemispheres with a reduction in STA diameter was significantly higher in hemispheres with DTA enlargement than in hemispheres with DTA reduction (P = 0.0088). Among the 64 hemispheres with DTA enlargement, 51 (79.7%) showed cerebrovascular reserve (CVR) impairment in the anterior cerebral artery (ACA) territory before surgery. CVR impairment in the ACA territory was the only clinical factor related to DTA enlargement (P < 0.001). CONCLUSION The DTA frequently enlarges after combined revascularization surgery, even in adult patients with moyamoya disease. In patients with impaired CVR in the ACA territory, blood supply from the DTA to the ACA territory can be expected after combined revascularization surgery.
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Affiliation(s)
- Akihiro Hirayama
- Department of Neurosurgery, Tokai University School of Medicine, Kanagawa, Japan.
| | - Takuya Yonemochi
- Department of Neurosurgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Kazuma Yokota
- Department of Neurosurgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Hideaki Shigematsu
- Department of Neurosurgery, Tokai University School of Medicine, Kanagawa, Japan
| | | | - Takatoshi Sorimachi
- Department of Neurosurgery, Tokai University School of Medicine, Kanagawa, Japan
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12
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Li Y, Hu JW, He XC, Cao Y, Yu XB, Fu XJ, Zhou H, Hu LB, Xu L, Xu CR, Wang YJ, Wang L. Bloody fluids located between the temporal muscle and targeted cerebral cortex affect the establishment of indirect collaterals in Moyamoya disease with surgical bypass: A case-control study. Front Neurol 2022; 13:960199. [PMID: 36388183 PMCID: PMC9644190 DOI: 10.3389/fneur.2022.960199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/12/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Bypass yields favorable outcomes in the treatment of Moyamoya disease (MMD). Bloody fluids accumulate between the targeted cortex and the temporal muscle after surgical bypass. These fluids are handled empirically via subcutaneous tubes or conservative treatments. However, substances located in certain positions may adversely affect the establishment of indirect collaterals (ICs) from muscular grafts. Methods Patients in our hospital from January 2014 to December 2019 were eligible for inclusion. Digital subtraction angiography (DSA) and radiological examinations were used during the perioperative and follow-up periods. Bloody fluid volumes were calculated using computed tomography- (CT-) based 3D Slicer software. The characteristics of bloody fluids, patient demographics, and clinical data were retrospectively analyzed. Results In total, 110 patients underwent indirect or combined bypass with follow-up DSA. The mean age of the enrolled patients was 42.4 ± 11.8 years. Previous ischemia (p = 0.001), previous hemorrhage (p = 0.013), bloody fluid volume (p = 0.049), and the time of imaging (p = 0.081) were associated with indirect outcomes. Ordinal regression analysis confirmed that good indirect outcomes were associated with previous ischemia (p < 0.001) and a large bloody fluid volume (p = 0.013). Further subgroups based on fluid volume were significantly correlated with IC establishment (p = 0.030). Conclusions A large bloody fluid volume and previous ischemic history were associated with good indirect outcomes. The presence of bloody fluids may reflect impaired degrees of muscular donors due to bipolar electrocoagulation, thus highlighting the importance of appropriate application of bipolar forceps.
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Affiliation(s)
- Yin Li
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Jun-wen Hu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Xu-chao He
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Yang Cao
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Xiao-bo Yu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Xiong-jie Fu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Hang Zhou
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Li-bin Hu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Liang Xu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Chao-ran Xu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Yong-jie Wang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Lin Wang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
- *Correspondence: Lin Wang
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13
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Lucia K, Acker G, Mrosk F, Beyaztas D, Vajkoczy P. Longitudinal angiographic characterization of the efficacy of combined cerebral revascularization using minimally invasive encephalodurosynangiosis in patients with moyamoya angiopathy. Neurosurg Rev 2022; 45:3689-3698. [PMID: 36163319 DOI: 10.1007/s10143-022-01862-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/23/2022] [Accepted: 09/11/2022] [Indexed: 11/30/2022]
Abstract
Moyamoya angiopathy (MMA) can be treated using direct, indirect, or combined revascularization procedures. We perform combined revascularization using the STA-MCA bypass and minimally invasive encephalodurosynangiosis (MIS-EDS). Due to lack of systematic analyses to date it remains unclear whether and to which extent this limited EDS serves as a growth source for extracerebral blood vessels into the brain. The objective of the current study is to characterize the extent of angiographic filling of MIS-EDS and STA-MCA bypass development over time and to determine possible predictors of EDS development in adult MMA patients. Single-center retrospective analysis of 81 MMA patients (139 hemispheres) treated with a MIS-EDS and STA-MCA bypass was performed. Angiographic images and clinical/operative data were reviewed and scored. Uni-/ and multivariate Cox regression analyses identified preoperative predictors of good EDS vascularization. At 3-6 months after surgery EDS showed moderate and high angiographic filling in 40% and 5% of hemispheres, respectively. After 12 months moderate and high filling was found in 57% and 4% of hemispheres, respectively. STA-MCA bypass filling was moderate in 47% and high in 7% of hemispheres at 3-6 months and 45% moderate and 9% high after 12 months. High STA-MCA bypass filling on angiography was a negative predictor of EDS development. MIS-EDS is a simple technique and serves as a source of vessel growth into the brain. EDS development lags behind that of STA-MCA bypass and can be recommended as an additive revascularization source when combined with a direct bypass.
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Affiliation(s)
- K Lucia
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - G Acker
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Clinician Scientist Program, Charitéplatz 1, 10117, Berlin, Germany
| | - F Mrosk
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - D Beyaztas
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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14
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Kawabori M, Ito M, Kazumata K, Tokairin K, Hatanaka KC, Ishikawa S, Houkin K, Fujimura M. Impact of RNF213 c.14576G>A Variant on the Development of Direct and Indirect Revascularization in Pediatric Moyamoya Disease. Cerebrovasc Dis 2022; 52:171-176. [PMID: 36063804 PMCID: PMC10906473 DOI: 10.1159/000526089] [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: 04/21/2022] [Accepted: 06/27/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Superficial temporal artery (direct) and encephalomyosynangiosis (indirect) revascularization may develop after combined bypass surgery in pediatric patients with moyamoya disease (MMD). However, arterial development varies widely among patients, and the underlying mechanisms remain unknown. OBJECTIVES We evaluated the relationship between the development of donor arteries after bypass surgery in pediatric patients with MMD and the MMD-susceptibility gene variant c.14576G>A of ring finger protein (RNF) 213. METHODS The data of pediatric patients with MMD (age <16 years at the time of surgery) treated with combined bypass surgery between September 2013 and April 2019 were consecutively analyzed. Quantitative measurements of the superficial temporal artery (STA), deep temporal artery (DTA), and middle meningeal artery (MMA) diameters with magnetic resonance angiography (MRA) source imaging were performed preoperatively and at 6-12 months postoperatively. The postoperative caliber change ratios (CCRs) were calculated. The relationship between CCRs and RNF213 c.14576G>A status was examined. RESULTS Forty-eight hemispheres from 28 pediatric patients with MMD were examined. Three hemispheres belonged to patients with the AA genotype; 33 to patients with the AG genotype (AA/AG group); and 12 to patients with the GG genotype (GG group; wild type). The CCRs for the DTA were significantly higher in patients with RNF213 variant (AA/AG group; 2.5 ± 0.1) than in the GG group (2.0 ± 0.2) (p = 0.03), whereas the CCRs for the STA were significantly higher in the GG (1.6 ± 0.1) than in the AA/AG group (1.3 ± 0.6) (p = 0.02). There was no significant difference in the CCRs for the MMA and basilar artery between the groups. Other factors, including sex, age, and MRA grading, were not associated with the development of specific bypass development. CONCLUSIONS The extent of collateral development associated with direct or indirect bypass was found to differ between the genotypes of the RNF213 c.14576G>A associated with pediatric MMD. This genetic variant correlates with the development of the disease and affects revascularization after bypass surgery in pediatric patients with MMD.
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Affiliation(s)
- Masahito Kawabori
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaki Ito
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ken Kazumata
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kikutaro Tokairin
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kanako C. Hatanaka
- Clinical Biobank, Clinical Research and Medical Innovation Center, Hokkaido University Hospital, Sapporo, Japan
| | - Susumu Ishikawa
- Institute for Genetic Medicine, Hokkaido University, Sapporo, Japan
| | - Kiyohiro Houkin
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Nguyen VN, Parikh KA, Motiwala M, Erin Miller L, Barats M, Milton C, Khan NR. Surgical techniques and indications for treatment of adult moyamoya disease. Front Surg 2022; 9:966430. [PMID: 36061058 PMCID: PMC9437590 DOI: 10.3389/fsurg.2022.966430] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/29/2022] [Indexed: 11/17/2022] Open
Abstract
Moyamoya disease (MMD) is a chronic, progressive cerebrovascular disease involving the occlusion or stenosis of the terminal portion of the internal carotid artery (ICA) and the proximal anterior and middle cerebral arteries. Adults with MMD have been shown to progressively accumulate neurological and cognitive deficits without treatment, with a mortality rate double that of pediatric patients with MMD. Surgical intervention is the mainstay of treatment to prevent disease progression and improve clinical outcomes. Several different types of bypasses can be utilized for revascularization in MMD, including indirect, direct, and combined forms of extracranial-to-intracranial (EC-IC) bypass. Overall, the choice of appropriate technique requires consideration of the age of the patient, preoperative hemodynamics, neurologic status, and territories most at risk and in need of revascularization. Here, we will review the indications and surgical techniques for the treatment of adult MMD. Step-by-step instructions for performing several bypass variants with technical pearls are discussed.
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Affiliation(s)
- Vincent N. Nguyen
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, United States
| | - Kara A. Parikh
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, United States
| | - Mustafa Motiwala
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, United States
| | - L. Erin Miller
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, United States
| | - Michael Barats
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, United States
| | - Camille Milton
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, United States
| | - Nickalus R. Khan
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, United States
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, United States
- Correspondence: Nickalus Khan
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Kimura K, Kubo Y, Dobashi K, Katakura Y, Chida K, Kobayashi M, Yoshida K, Fujiwara S, Terasaki K, Kawamura T, Ogasawara K. Angiographic, Cerebral Hemodynamic, and Cognitive Outcomes of Indirect Revascularization Surgery Alone for Adult Patients With Misery Perfusion due to Ischemic Moyamoya Disease. Neurosurgery 2022; 90:676-683. [PMID: 35311740 DOI: 10.1227/neu.0000000000001907] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Revascularization surgery for adult patients with ischemic moyamoya disease (MMD) may improve both cognitive function and cerebral perfusion. OBJECTIVE To determine angiographic, cerebral hemodynamic, and cognitive outcomes of indirect revascularization surgery alone for adult patients with misery perfusion due to ischemic MMD (IDR group) and to test the superiority of indirect revascularization surgery for cognitive improvement by conducting comparisons with historical control patients who had undergone direct revascularization surgery (DR group) through prospective cohort study with historical controls. METHODS Twenty adult patients with cerebral misery perfusion underwent encephalo-duro-myo-arterio-pericranial-synangiosis alone. Cerebral angiography through arterial catheterization, brain perfusion single-photon emission computed tomography, and neuropsychological testing were performed preoperatively and at 6 months postoperatively. RESULTS In 17 patients of the IDR group, collateral flows that were newly formed after surgery on angiograms fed more than one-third of the middle cerebral artery (MCA) cortical territory. In the IDR group, perfusion in the MCA territory was significantly increased after surgery (P < .0001), and the difference in MCA perfusion between before and after surgery was significantly greater (P = .0493) compared with the DR group. Improved cognition was significantly more frequent in the IDR group (65%) than in the DR group (31%, P = .0233). CONCLUSION Indirect revascularization surgery alone forms sufficient collateral circulation, improves cerebral hemodynamics, and recovers cognitive function in adult patients with misery perfusion due to ischemic MMD. The latter 2 beneficial effects may be higher when compared with patients undergoing direct revascularization surgery.
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Affiliation(s)
- Kazuto Kimura
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
| | - Yoshitaka Kubo
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
| | - Kazumasa Dobashi
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
| | - Yasukazu Katakura
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
| | - Kohei Chida
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
- Institute for Biomedical Sciences, School of Medicine, Iwate Medical University, Japan
| | - Masakazu Kobayashi
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
- Institute for Biomedical Sciences, School of Medicine, Iwate Medical University, Japan
| | - Kenji Yoshida
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
| | - Shunrou Fujiwara
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
| | - Kazunori Terasaki
- Institute for Biomedical Sciences, School of Medicine, Iwate Medical University, Japan
| | | | - Kuniaki Ogasawara
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Japan
- Institute for Biomedical Sciences, School of Medicine, Iwate Medical University, Japan
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17
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Kuroda S, Fujimura M, Takahashi J, Kataoka H, Ogasawara K, Iwama T, Tominaga T, Miyamoto S. Diagnostic Criteria for Moyamoya Disease - 2021 Revised Version. Neurol Med Chir (Tokyo) 2022; 62:307-312. [PMID: 35613882 PMCID: PMC9357455 DOI: 10.2176/jns-nmc.2022-0072] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
In this report, we, the Research Committee on Moyamoya Disease (Spontaneous Occlusion of the circle of Willis), describe in detail the changes in the new “Diagnostic Criteria 2021” for moyamoya disease and its scientific basis to make it widely known to the world. The revised criteria cover all aspects of the disease, including a definition of the disease concept, diagnostic imaging, and the concept of quasi-moyamoya disease (moyamoya syndrome).
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Affiliation(s)
- Satoshi Kuroda
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Jun Takahashi
- Department of Neurosurgery, Kindai University Faculty of Medicine
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center
| | | | - Toru Iwama
- Department of Neurosurgery, Gifu University School of Medicine
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
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18
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Changes in cerebral blood flow in the postoperative chronic phase after combined cerebral revascularization for moyamoya disease with ischaemic onset. Neurosurg Rev 2022; 45:2471-2480. [PMID: 35319072 DOI: 10.1007/s10143-022-01774-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/09/2022] [Accepted: 03/16/2022] [Indexed: 10/18/2022]
Abstract
The purpose of this study was to examine the effects of combined revascularization for ischaemic-onset moyamoya disease (MMD) on cerebral haemodynamics by comparing cerebral blood flow (CBF) during the postoperative chronic phase with preoperative CBF. A retrospective cohort of 24 MMD patients (representing 31 surgeries) who received single photon emission computed tomography (SPECT) before and more than 6 months after surgery was investigated. The CBF value of each vascular territory was extracted from SPECT data, and the value relative to the ipsilateral cerebellar value (relative CBF, or RCBF) was calculated. The correlation between the revascularization effect and the proportional change in RCBF before and after surgery (calculated as post-RCBF/pre-RCBF ("post/pre-RCBF")) was analysed. Furthermore, the relationships between changes in neurological symptoms and post/pre-RCBF were investigated. Preoperative and postoperative mean RCBF values were 0.92 ± 0.15 and 0.96 ± 0.13 (p = 0.619) in the anterior cerebral artery territory, 0.99 ± 0.17 and 1.01 ± 0.17 (p = 0.598) in the middle cerebral artery territory and 1.15 ± 0.22 and 1.14 ± 0.19 (p = 0.062) in the posterior cerebral artery territory, respectively. No significant correlation was found between the revascularization score and post/pre-RCBF. The revascularization score and post/pre-RCBF were not significant predictors of worsening neurological symptoms postoperatively. No significant change in RCBF was observed in any vascular territory in the chronic phase after revascularization. Combined revascularization may assist in the redirection of blood flow from the internal to the external carotid system and contribute to CBF maintenance.
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Impact of RNF213 founder polymorphism (p.R4810K) on the postoperative development of indirect pial synangiosis after direct/indirect combined revascularization surgery for adult Moyamoya disease. Neurosurg Rev 2022; 45:2305-2313. [DOI: 10.1007/s10143-022-01749-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/07/2021] [Accepted: 01/30/2022] [Indexed: 10/19/2022]
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Iodice A, Signa S, Severino M, Tortora D, Zanetti A, Amico G, Piatelli G, Bertamino M, Pavanello M. Combined medical therapy and neurosurgical revascularization preventing stroke in post-varicella angiopathy: Case report and review of literature. Brain Dev 2021; 43:1051-1056. [PMID: 34332825 DOI: 10.1016/j.braindev.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/12/2021] [Accepted: 07/16/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Post varicella angiopathy (PVA) is an underdiagnosed but potentially severe disease in both pediatric and adult settings. No guidelines are available for the medical and neurosurgical management of this condition. We report the first pediatric case with headache and PVA who was treated with surgical revascularization before the onset of ischemic events. METHODS This case report was conducted via retrospective chart review. A literature review was also completed, in order to identify previously described PVA undergone to revascularization. RESULTS We report on a 9-year-old boy presenting with a long history of headache and PVA involving the distal left middle cerebral artery. The arterial lesion rapidly worsened over a 10 months' period with formation of focal moyamoya-like collaterals, despite an adequate intravenous antiviral treatment. The pattern of headaches significantly changed with a clear left-side lateralization and a "re-build-up" phenomenon on EEG. The patient was treated with left superficial temporal artery - middle cerebral artery (STA-MCA) bypass and encephalo-duro-arterio-myo-pericranial-synangiosis. This combined treatment resulted in an immediate and persistent improvement of brain perfusion, accompanied by prompt resolution of neurological symptoms. Two cases who presented with Suzuki stage III (unilateral or bilateral) moyamoya PVA and recurrent strokes or transient ischemic attacks despite adequate pharmacological prophylaxis have been surgically treated using both indirect and direct revascularization technique. The outcome was good in both cases. CONCLUSION Surgical revascularization may have a role in the treatment of PVA and may prevent stroke. Given the lack of standardized treatment algorithms, individualized regimens should be formulated on a case-specific basis.
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Affiliation(s)
| | - Sara Signa
- Dipartimento di Neuroscienze, riabilitazione, oftalmologia, genetica e scienze materno-infantili (DINOGMI) Università di Genova, Genoa, Italy; Autoinflammatory Diseases and Immunodeficiencies Center, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Domenico Tortora
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Alice Zanetti
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giulia Amico
- Dipartimento di Neuroscienze, riabilitazione, oftalmologia, genetica e scienze materno-infantili (DINOGMI) Università di Genova, Genoa, Italy; Medical Genetic Unit,IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Marta Bertamino
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Marco Pavanello
- Neurosurgery Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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July J. A case report of moyamoya disease in children treated with encephalo-duro-myo-arterio-pericranial synangiosis. MEDICAL JOURNAL OF INDONESIA 2021. [DOI: 10.13181/mji.cr.204452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Moyamoya disease that manifests during childhood may pose a special challenge for surgeons. We report a case of a 10-year-old girl who suffered from moyamoya disease and was successfully treated with encephalo-duro-myo-arterio-pericranial synangiosis (EDMAPS). She presented with a recurrent transient ischemic attack that worsened for 1 year. She was aphasic globally (sensory and motor) and had slightly weak right extremities. Her magnetic resonance angiography and computed tomography angiography showed the typical features of moyamoya disease with bilateral stenosis at the terminal internal carotid artery, bilaterally abnormal vascular networks, and a left ischemic event involving the temporoparietal region. She was recovered well after underwent bilateral EDMAPS, fully regained her language function after 3 months, and gathered her strength back. Therefore, EDMAPS could be a good, safe, and effective treatment for moyamoya disease in children.
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Uchino H, Yamamoto S, Kashiwazaki D, Akioka N, Kuwayama N, Noguchi K, Kuroda S. Using postoperative remodeling of donor arteries on MR angiography to predict the development of surgical collaterals in moyamoya disease. J Neurosurg 2021; 134:1-9. [PMID: 31703196 DOI: 10.3171/2019.8.jns191846] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 08/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The calibers of donor arteries can change dynamically after bypass surgery in patients with moyamoya disease (MMD). The present study aimed to evaluate the cutoffs of caliber changes in donor arteries associated with good surgical revascularization and to assess the impact of clinical factors potentially related to bypass development. METHODS The authors studied 71 hemispheres of 30 adults and 16 children with MMD who underwent combined direct and indirect revascularization. They quantitatively measured the calibers of the superficial temporal artery (STA), deep temporal artery (DTA), and middle meningeal artery (MMA) with MR angiography (MRA) source images and calculated the postoperative caliber change ratios (CCRs) to assess direct and indirect bypass development. These values were compared with the findings of digital subtraction angiography, in which revascularization areas were categorized into 3 groups (poor, good, and excellent). RESULTS In both adult and pediatric hemispheres, the median STA and DTA CCRs were higher in better-revascularization groups (p < 0.05), while MMA CCRs were not significantly different among the groups. Receiver operating characteristic analysis revealed that the cutoff STA CCRs of > 1.1 and > 1.3 were associated with good direct revascularization in adult and pediatric hemispheres, respectively. Cutoff DTA CCRs of > 1.6 and > 1.2 were associated with good indirect revascularization in adult and pediatric hemispheres, respectively. Considering these cutoff values, STA and DTA CCRs showed high median values, irrespective of age, severity of cerebrovascular reserve, disease stage, and disease-onset type. CONCLUSIONS Caliber changes in STAs and DTAs can be easily measured using MRA, and they could be indicators of direct and indirect bypass development. The dual development of a direct and indirect bypass was most frequently observed in the context of a combined bypass procedure in both adults and children with MMD.
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Affiliation(s)
- Haruto Uchino
- Departments of1Neurosurgery and
- 3Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | | | | | | | | | - Kyo Noguchi
- 2Radiology, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
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Clinical outcomes after revascularization for pediatric moyamoya disease and syndrome: A single-center series. J Clin Neurosci 2020; 79:137-143. [PMID: 33070883 DOI: 10.1016/j.jocn.2020.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 06/25/2020] [Accepted: 07/06/2020] [Indexed: 11/22/2022]
Abstract
Moyamoya is a progressive cerebrovascular arteriopathy that affects children of any age. The goal of this study was to determine imaging and clinical outcomes as well as complication rates in a pediatric cohort undergoing either a combined direct/indirect or indirect-only revascularization approach. Patients with moyamoya disease or syndrome ≤ 18 years of age at the time of initial surgery were identified, and clinical data were collected retrospectively. Over a 12-year period, 26 patients underwent revascularization procedures on 49 hemispheres with a median follow-up of 2.6 years from surgery. Median age at surgery was 7.3 years (range 1.4-18.0 years). Thirty-three hemispheres (67.3%) underwent combined revascularization with a direct bypass and encephalomyosynangiosis, and sixteen hemispheres (32.7%) underwent indirect-only revascularization. The rate of 30-day perioperative complication was 10.2%, and the rate of postoperative clinical stroke by end of follow-up was 10.2% by hemisphere. There was a 5.7% rate of intraoperative bypass failure requiring conversion to an indirect revascularization approach. On follow-up imaging, 96.9% of direct bypasses remained patent. On multivariate analysis, higher preoperative Pediatric Stroke Outcome Measure (PSOM) scores were associated with lower rates of good clinical outcome on follow-up (unit OR 0.03; p = 0.03). Patients with age < 5.4 years had lower rates of good clinical outcome on follow-up. In this North American cohort, both combined direct/indirect and indirect only revascularization techniques were feasible. However, younger children < 5.4 years of age have worse outcomes than older children, similar to east Asian cohorts.
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Nakamura A, Kawashima A, Nomura S, Kawamata T. Measurement of Intraoperative Graft Flow Predicts Radiological Hyperperfusion during Bypass Surgery in Patients with Moyamoya Disease. Cerebrovasc Dis Extra 2020; 10:66-75. [PMID: 32726777 PMCID: PMC7443641 DOI: 10.1159/000508827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 05/20/2020] [Indexed: 12/04/2022] Open
Abstract
Introduction Moyamoya disease (MMD) is a rare cerebrovascular disease associated with cerebral infarction or hemorrhage. Hyperperfusion is the most significant complication of direct bypass surgery. Previous research has shown that an increase in cerebral blood flow (CBF) is strongly related to symptomatic hyperperfusion and highlighted the importance of postoperative assessment of CBF. Objective The principal aims of this study were to quantitatively analyze the relationship between intraoperative graft flow and increase in CBF and to evaluate the effectiveness of intraoperative graft flow measurement during bypass surgery for patients with MMD. Methods This study included 91 surgeries in 67 consecutive adult patients with MMD who underwent direct revascularization surgery at our institution between November 2013 and September 2018. Intraoperative graft flow of the branches and main trunk was measured in all patients, after anastomosis had been established. Postoperative CBF measurements were performed under sedation, immediately after surgery. Radiological hyperperfusion was defined as focal high uptake, as determined by CBF imaging immediately after surgery. Patients were divided into two groups (radiological hyperperfusion and nonradiological hyperperfusion groups), and the relationship between intraoperative graft flow and radiological hyperperfusion was analyzed. Results Significant differences were observed between the radiological hyperperfusion and nonradiological hyperperfusion groups in terms of intraoperative graft flow of both the branch (median 72 vs. 42 mL/min, respectively; p < 0.01) and main trunk (median 113 vs. 68 mL/min, respectively; p < 0.01). A receiver-operating characteristic analysis was performed to test the utility of intraoperative flow as a quantitative measure. We set the cutoff values for the intraoperative branch and main trunk flow at 57 mL/min (sensitivity: 0.707, specificity: 0.702; area under the curve [AUC]: 0.773; 95% confidence interval [CI]: 0.675–0.871) and 84 mL/min (sensitivity: 0.667, specificity: 0.771; AUC: 0.78; 95% CI: 0.685–0.875), respectively. Conclusions Measuring intraoperative graft flow during bypass surgery may be an effective means of predicting hyperperfusion and could serve to facilitate early therapeutic intervention such as strict blood pressure control.
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Affiliation(s)
- Akikazu Nakamura
- Department of Neurosurgery, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan
| | - Akitsugu Kawashima
- Department of Neurosurgery, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan,
| | - Shunsuke Nomura
- Department of Neurosurgery, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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Yamamoto S, Kashiwazaki D, Uchino H, Saito H, Akioka N, Kuwayama N, Kuroda S. Clinical and Radiological Features of Childhood Onset Adult Moyamoya Disease: Implication for Hemorrhagic Stroke. Neurol Med Chir (Tokyo) 2020; 60:360-367. [PMID: 32536657 PMCID: PMC7358781 DOI: 10.2176/nmc.oa.2020-0001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Some of the pediatric moyamoya patients spend their childhood without diagnosed as moyamoya disease (MMD) because of their mild ischemic attacks and emerge again with ischemic or hemorrhagic stroke in their adulthood. This study was aimed to clarify the clinical characteristics of adult moyamoya patients with childhood onset and elucidate the impact of long disease period on their clinical features. Present study included 116 untreated hemispheres of 69 adult patients with MMD. They were divided into two groups: childhood onset group (26 hemispheres of 14 patients) and adult onset group (90 hemispheres of 55 patients). Clinical features were compared between the two groups. The incidence of hemorrhagic stroke was significantly higher in childhood onset group (P = 0.0091). Lenticulostriate and choroidal channels were more developed in childhood onset group (P = 0.044 and P <0.001, respectively). Vault moyamoya was more frequently observed in childhood onset group (P <0.001). The development of surgical collaterals through indirect bypass was more marked in childhood onset group (P = 0.0019). Multivariate analysis revealed that childhood onset and developed choroidal channels were significantly associated with the occurrence of hemorrhagic stroke (OR 4.31 [95% CI 1.21-15.4], P = 0.025 and OR 6.78 [95% CI 1.78-25.8], P = 0.0050, respectively). This study clearly shows that adult moyamoya patients with childhood onset have more developed spontaneous collaterals, which may, in turn, highly causes hemorrhagic stroke. Adult moyamoya patients with "childhood onset" should be recognized as a novel and important concept when elucidating the underlying mechanisms of hemorrhagic stroke in MMD.
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Affiliation(s)
- Shusuke Yamamoto
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama
| | - Daina Kashiwazaki
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama
| | - Haruto Uchino
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama
| | - Hisayasu Saito
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama
| | - Naoki Akioka
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama
| | - Naoya Kuwayama
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama
| | - Satoshi Kuroda
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama
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Miyoshi K, Chida K, Kobayashi M, Kubo Y, Yoshida K, Terasaki K, Ogasawara K. Two-Year Clinical, Cerebral Hemodynamic, and Cognitive Outcomes of Adult Patients Undergoing Medication Alone for Symptomatically Ischemic Moyamoya Disease Without Cerebral Misery Perfusion: A Prospective Cohort Study. Neurosurgery 2020; 84:1233-1241. [PMID: 29850833 DOI: 10.1093/neuros/nyy234] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/03/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In nonsurgical adult moyamoya disease (MMD) patients with ischemic onset and stable hemodynamics, the cerebral hemodynamic and cognitive course remains unclear. OBJECTIVE To clarify, through a prospective cohort study, 2-yr clinical, cerebral hemodynamic, and cognitive outcomes of adult patients receiving medication alone for symptomatically ischemic MMD without cerebral misery perfusion. METHODS Seventy patients without cerebral misery perfusion on the first 15O gas positron emission tomography (PET) were clinically followed up for 2 yr. The second PET was performed at the end of the 2-yr follow-up. Neuropsychological tests were also performed at the study entry and the end of the 2-yr follow-up. RESULTS During the 2-yr follow-up period, 2 patients (3%) developed further cerebral ischemic symptoms and showed new cerebral misery perfusion on PET performed at recurrence. None of the 68 patients without further ischemic symptoms showed cerebral misery perfusion on second PET. All 66 patients who underwent the first and second neuropsychological tests displayed unchanged interval cognition at the 2-yr follow-up. CONCLUSION Among adult patients receiving medication alone for symptomatically ischemic MMD without cerebral misery perfusion, the incidence of recurrent ischemic events was 3% per 2 yr. In patients without recurrent ischemic events, cerebral hemodynamics and cognitive function had not deteriorated by 2 yr after the last event.
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Affiliation(s)
- Kenya Miyoshi
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kohei Chida
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Masakazu Kobayashi
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Yoshitaka Kubo
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kenji Yoshida
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kazunori Terasaki
- Cyclotron Research Center, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, School of Medicine, Iwate Medical University, Morioka, Japan
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Uchino H, Kashiwazaki D, Akioka N, Koh M, Kuwayama N, Houkin K, Kuroda S. Strategy and effect of repeat bypass surgery for anterior/posterior circulation in refractory moyamoya disease. J Neurosurg 2020; 132:1889-1899. [PMID: 31151103 DOI: 10.3171/2019.3.jns181979] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 03/05/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In this study the authors aimed to describe clinical features, surgical techniques, and long-term outcomes of repeat bypass surgery required for a certain subset of patients with moyamoya disease. METHODS The authors retrospectively reviewed a total of 22 repeat bypass surgeries for 20 patients (age range 1-69 years) performed during the last 20 years at their institutions. The patients were classified into 2 groups. Group A included 10 patients who underwent repeat bypass surgery for anterior circulation due to insufficient revascularization on the ipsilateral side. Group B included 10 patients who underwent repeat bypass surgery for posterior circulation due to the involvement of the posterior cerebral artery (PCA) after successful initial surgery for anterior circulation. RESULTS Preoperative symptoms included headache in 3 patients, transient ischemic attack in 10, cerebral infarction in 3, and intracranial hemorrhage in 4 patients. Intervals between the initial bypass surgery and repeat bypass surgery were 0.3-30 years (median 3 years). In group A, superficial temporal artery to middle cerebral artery (MCA) anastomosis and indirect bypass were performed on 7 hemispheres. Only indirect bypass was performed on 3 hemispheres because of the lack of suitable donor or recipient arteries. In group B, occipital artery (OA) to PCA anastomosis and indirect bypass were conducted on 4 hemispheres, and OA-MCA anastomosis and indirect bypass on 1 hemisphere. Only indirect bypass was conducted on 7 hemispheres because of the lack of suitable recipient arteries. All 22 repeat bypass surgeries were successfully conducted. During follow-up periods (median 4 years), none of the patients suffered repeat stroke except 1 patient who died of recurrent intracerebral hemorrhage 3 years after repeat bypass surgery for anterior circulation. CONCLUSIONS Repeat bypass surgery was feasible and effective to reduce further incidence of headache attack, transient ischemic attack, and ischemic/hemorrhagic stroke in moyamoya disease patients. Through precise radiological analysis, surgical procedures should be planned to yield maximal therapeutic effects.
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Affiliation(s)
- Haruto Uchino
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
- 2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Daina Kashiwazaki
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
| | - Naoki Akioka
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
| | - Masaki Koh
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
| | - Naoya Kuwayama
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
| | - Kiyohiro Houkin
- 2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Satoshi Kuroda
- 1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and
- 2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Yu J, Hu M, Yi L, Zhou K, Zhang J, Chen J. Paradoxical association of symptomatic cerebral edema with local hypoperfusion caused by the 'watershed shift' after revascularization surgery for adult moyamoya disease: a case report. Ther Adv Neurol Disord 2019; 12:1756286419878343. [PMID: 31598140 PMCID: PMC6764047 DOI: 10.1177/1756286419878343] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 08/28/2019] [Indexed: 11/26/2022] Open
Abstract
Superficial temporal artery–middle cerebral artery anastomosis is generally
considered as an effective method in improving damage associated with
intracerebral occlusions in moyamoya disease. Hemodynamic changes caused by
revascularization are the cause of many postoperative complications. Of the 186
consecutive surgeries for moyamoya disease at our hospital from 2015, we herein
presented one case of adult-onset moyamoya disease that manifested symptomatic
local cerebral edema and local hypoperfusion caused by the ‘watershed shift’. A
67-year-old woman presented with limb numbness on the right side and underwent
superficial temporal artery–middle cerebral artery anastomosis, resulting in
neurological dysfunction and the formation of a reversible high-signal lesion at
left frontotemporal lobes on T2-weighted images along with a decrease in
perfusion values on 123I N-isopropyl-p-iodoamphetamine single-photon
emission computed tomography, while the anastomotic vessel was patent on
magnetic resonance angiography. This phenomenon of hypoperfusion area (left
frontotemporal lobe) remote to anastomotic site (left temporal lobe area) led to
the diagnosis of the ‘watershed shift’ phenomenon. In light of the hypoperfusion
induced by ‘watershed shift’, the patient was treated with fluid replacement.
With the gradual recovery of perfusion, the patient presented significantly
improvement both on the magnetic resonance imaging findings and neurological
symptoms. In conclusion, regional cerebral edema with hypoperfusion, possibly
due to cerebral ischemia and the ‘watershed shift’ phenomenon, may be another
novel entity that needs to be considered as a potential complication after
extracranial–intracranial bypass for moyamoya disease.
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Affiliation(s)
- Jin Yu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Miao Hu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Lei Yi
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Keyao Zhou
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jianjian Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Donghu Road 169, Wuhan 430071, China
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Donghu Road 169, Wuhan 430071, China
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Ravina K, Kim PE, Rennert RC, Wolfswinkel EM, Strickland BA, Carey JN, Russin JJ. Lessons Learned from the Initial Experience with Pedicled Temporoparietal Fascial Flap for Combined Revascularization In Moyamoya Angiopathy: A Case Series. World Neurosurg 2019; 132:e259-e273. [PMID: 31491577 DOI: 10.1016/j.wneu.2019.08.182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/18/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The pedicled temporoparietal fascial flap (TPFF) with a direct superficial temporal (STA) artery to middle cerebral artery (MCA) bypass is a novel combined revascularization approach for moyamoya angiopathy (MMA). With this case series, we aim to report the initial experience with pedicled TPFF combined revascularization for MMA treatment. METHODS Data from 14 consecutive patients undergoing pedicled TPFF combined revascularization for MMA between May 2016 and December 2018 were retrospectively reviewed. Patients admitted with acute ischemia or a modified Rankin Scale (mRS) score >3 were considered high risk. RESULTS Mean ± standard deviation age on surgery was 41.9 ± 15.4 years. Three of 14 patients (21.4%) presented with an mRS score >3. Nine of 14 patients (64.3%) presented with ischemic stroke, 4 of whom (44.4%) had acute ischemia. Direct anastomosis patency was confirmed in all cases postoperatively. Mean hospitalization time was 13 ± 9.3 days and mean follow-up time was 14.1 ± 9.3 months. From admission to follow-up, neurologic status improved in 8 patients (57.1%) and stabilized in 6 patients (42.9%). Overall, 11/14 patients (78.6%) achieved good functional outcome (mRS score ≤2). All patients achieved some radiographic collateral development, with 5 (71.5%) graded as Matsushima A and B. Three patients developed new radiographic ischemia and 3 experienced wound complications, all in the high-risk group. CONCLUSIONS The TPFF combined approach is a viable strategy for revascularization in MMA. This technique may be suboptimal in patients presenting with acute ischemia and/or mRS score >3.
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Affiliation(s)
- Kristine Ravina
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Paul E Kim
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of California at San Diego, San Diego, California, USA
| | - Erik M Wolfswinkel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ben A Strickland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Joseph N Carey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jonathan J Russin
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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Zhao Y, Lu J, Yu S, Li J, Deng X, Zhang Y, Zhang D, Wang R, Wang H, Zhao Y. Comparison of Long-Term Effect Between Direct and Indirect Bypass for Pediatric Ischemic-Type Moyamoya Disease: A Propensity Score-Matched Study. Front Neurol 2019; 10:795. [PMID: 31417483 PMCID: PMC6684789 DOI: 10.3389/fneur.2019.00795] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 07/10/2019] [Indexed: 11/13/2022] Open
Abstract
Objectives: This study aimed to compare the postoperative risks and long-term effects between direct bypass surgery (DB) and indirect bypass (IB) surgery for pediatric patients with ischemic-type moyamoya disease (MMD). Method: Pediatric patients (under or equal to 18 years old) who were diagnosed as MMD and given surgical treatments at our center between 2009 and 2015 were retrospectively reviewed from a prospective database. Pediatric hemorrhagic-type MMD patients and those who did not undergo digital subtraction angiography (DSA) were excluded. Patients who underwent DB were matched with patients who underwent IB using 1:1 propensity score matching. Postoperative complications, recurrent ischemic stroke events and modified Rankin Scale (mRS) scores at the last follow-up were compared between the matched pairs. Results: A total of 223 pediatric patients were screened, and 138 patients (DB:34, IB:104) were considered for the propensity score match. Thirty four pairs were obtained. Nine patients had postoperative complications, including 6 (17.6%) in the DB group and 3 (8.8%) in the IB group (P = 0.476). The mean follow-up period was 71.9 ± 22.2 months for the DB group and 60.2 ± 24.3 months for the IB group (P = 0.041). Kaplan-Meier analysis showed a longer stroke-free time in the DB group than in the IB group (P = 0.025). At last follow-up, good neurological status (mRS ≤ 1) was achieved in 32 (94.1%) of the DB group and 34 (100.0%) of the IB group. MRS score at last follow-up were significantly lower than at time of admission (all pts: 1.09 ± 0.45 vs. 0.28 ± 0.51, P < 0.001; DB group: 1.12 ± 0.48 vs. 0.32 ± 0.59, P < 0.001; IB group: 1.06 ± 0.42 vs. 0.24 ± 0.43, P < 0.001). Conclusion: Both techniques were effective in improving the neurological status of pediatric ischemic-type MMD patients, and direct bypass surgery might be more superior in preventing recurrent ischemic strokes in the short-term.
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Affiliation(s)
- Yahui Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Junlin Lu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shaochen Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiaxi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaofeng Deng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Rong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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Kazumata K, Tha KK, Tokairin K, Ito M, Uchino H, Kawabori M, Sugiyama T. Brain Structure, Connectivity, and Cognitive Changes Following Revascularization Surgery in Adult Moyamoya Disease. Neurosurgery 2019; 85:E943-E952. [DOI: 10.1093/neuros/nyz176] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/23/2019] [Indexed: 11/13/2022] Open
Abstract
AbstractBACKGROUNDThe effect of the combined direct/indirect revascularization surgery in Moyamoya disease has not been evaluated sufficiently with regard to cognitive function, brain microstructure, and connectivity.OBJECTIVETo investigate structural and functional changes following revascularization surgery in patients with moyamoya disease (MMD) through a combined analysis of brain morphology, microstructure, connectivity, and neurobehavioral data.METHODSNeurobehavioral and neuroimaging examinations were performed in 25 adults with MMD prior to and >12 mo after revascularization surgery. Cognitive function was investigated using the Wechsler Adult Intelligence Scale-III, Trail-Making Test, Wisconsin Card Sorting Test, Continuous Performance Test, Stroop test, and Wechsler Memory Scale. We assessed white matter integrity using diffusion tensor imaging, brain morphometry using magnetization-prepared rapid gradient-echo sequences, and brain connectivity using resting-state functional magnetic resonance imaging (MRI).RESULTSCognitive examinations revealed significant changes in the full-scale intelligence quotient (IQ), performance IQ (PIQ), perceptual organization (PO), processing speed, and Stroop test scores after surgery (P < .05). Enlargement of the lateral ventricle, volume reductions in the corpus callosum and subcortical nuclei, and cortical thinning in the prefrontal cortex were also observed (P < .05). Fractional anisotropy in the white matter tracts, including the superior longitudinal fasciculus, increased 2 to 4 yr after surgery, relative to that observed in the presurgical state (P < .05). Resting-state brain connectivity was increased predominantly in the fronto-cerebellar circuit and was positively correlated with improvements in PIQ and PO (P < .05).CONCLUSIONRevascularization surgery may improve processing speed and attention in adult patients with MMD. Further, multimodal MRI may be useful for detecting subtle postsurgical brain structural changes, reorganization of white matter tracts, and brain connectivity alterations.
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Affiliation(s)
- Ken Kazumata
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Japan
| | - Khin Khin Tha
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Japan
| | - Kikutaro Tokairin
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Japan
| | - Masaki Ito
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Japan
| | - Haruto Uchino
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Japan
| | - Masahito Kawabori
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Japan
| | - Taku Sugiyama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Japan
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Machida T, Higuchi Y, Nakano S, Izumi M, Ishige S, Fujikawa A, Akaogi Y, Shimada J, Ono J. Sagittal splitting of the temporalis muscle for encephalo-myo-synangiosis to prevent ischemic complications due to a swollen temporalis muscle without inhibiting collateral developments in patients with moyamoya disease. J Neurosurg 2019; 130:1957-1964. [PMID: 29932376 DOI: 10.3171/2018.1.jns172244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 01/04/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Encephalo-myo-synangiosis (EMS) is an effective revascularization procedure for the treatment of moyamoya disease (MMD). However, the temporalis muscle used for EMS sometimes swells and causes ischemic complications by compressing the underlying brain. This study aimed to elucidate the effect of sagittal splitting (SS) of the muscle for prevention of ischemic complications and its impact on the postoperative development of collateral vessels. METHODS In this historical case-control study, we analyzed 60 hemispheres in adult patients with MMD who underwent EMS using the temporalis muscle from December 1998 to November 2017. The muscle was divided anteroposteriorly by coronal splitting, and the anterior, posterior, or both parts of the muscle were used for EMS in 17, 4, and 39 hemispheres, respectively. In cases performed after 2006, the muscle was halved by SS, and the medial half was used for EMS to reduce the muscle volume (n = 47). The degree of postoperative muscle swelling was evaluated by measuring the maximum thickness of the muscle on CT scans obtained 3 to 7 days after surgery. The collateral developments of the anterior deep temporal artery (aDTA), posterior deep temporal artery (pDTA), and middle temporal artery (MTA) were assessed using digital subtraction angiography and MR angiography performed 6 months or more after surgery. RESULTS SS significantly reduced the temporalis muscle thickness from 12.1 ± 5.0 mm to 7.1 ± 3.0 mm (p < 0.01). Neurological deterioration due to the swollen temporalis muscle developed in 4 of the 13 hemispheres without SS (cerebral infarction in 1, reversible neurological deficit in 2, and convulsion in 1) but in none with SS. There were no significant differences in the postoperative collateral developments of the aDTA, pDTA, and MTA between hemispheres with and without SS. The MTA more frequently developed in hemispheres with EMS in which the posterior part of the muscle was used (30/37) than those in which this part was not used (4/16) (p < 0.01). CONCLUSIONS SS of the temporalis muscle might prevent neurological deterioration caused by the swollen temporalis muscle by reducing its volume without inhibiting the development of the collateral vessels.
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Affiliation(s)
- Toshio Machida
- 1Department of Neurosurgery, Chiba Cerebral and Cardiovascular Center
- 2Department of Neurosurgery, Eastern Chiba Medical Center
| | - Yoshinori Higuchi
- 3Department of Neurological Surgery, Chiba University Graduate School of Medicine
| | - Shigeki Nakano
- 1Department of Neurosurgery, Chiba Cerebral and Cardiovascular Center
- 2Department of Neurosurgery, Eastern Chiba Medical Center
| | - Masaki Izumi
- 1Department of Neurosurgery, Chiba Cerebral and Cardiovascular Center
| | - Satoshi Ishige
- 1Department of Neurosurgery, Chiba Cerebral and Cardiovascular Center
| | - Atsushi Fujikawa
- 4Department of Neurosurgery, Chibaken Saiseikai Narashino Hospital; and
| | - Yuichi Akaogi
- 5Department of Neurology, Chiba Cerebral and Cardiovascular Center, Chiba, Japan
| | - Junichiro Shimada
- 5Department of Neurology, Chiba Cerebral and Cardiovascular Center, Chiba, Japan
| | - Junichi Ono
- 1Department of Neurosurgery, Chiba Cerebral and Cardiovascular Center
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Lin YH, Kuo MF, Lu CJ, Lee CW, Yang SH, Huang YC, Liu HM, Chen YF. Standardized MR Perfusion Scoring System for Evaluation of Sequential Perfusion Changes and Surgical Outcome of Moyamoya Disease. AJNR Am J Neuroradiol 2019; 40:260-266. [PMID: 30655253 DOI: 10.3174/ajnr.a5945] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 12/01/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Simple-but-precise evaluation of cerebral perfusion is crucial for the treatment of Moyamoya disease. We aimed to develop a standardized scoring system for MR perfusion suitable for Moyamoya disease evaluation and investigate the postoperative serial changes and outcome predictors. MATERIALS AND METHODS From January 2013 to December 2016, patients diagnosed with Moyamoya disease and receiving indirect revascularization were recruited prospectively. Clinical data and serial imaging studies were analyzed. The TTP maps were standardized using cerebellar reference values. We developed a scoring system of standardized TTP maps: 14 points for each hemisphere with higher points indicating better perfusion. RESULTS In total, 24 children (4-17 years of age, 41 hemispheres) and 20 adults (18-51 years of age, 34 hemispheres) were included. The mean preoperative TTP scores were higher in children (7.34 ± 3.90) than in adults (4.88 ± 3.24). The standardized TTP maps revealed dynamic improvement with an increase in the corresponding scores at the 1-, 3-, and 6-month postoperative follow-ups; the scores stabilized after 6 months. The mean improvement in the 6-month scores of the pediatric and adult groups was 4.15 ± 3.55 and 6.03 ± 3.04, respectively. The 6-month TTP score improvements were associated with Matsushima grades. If we took score improvement as the outcome, the preoperative TTP score was the only significant predictor in multivariable analysis. CONCLUSIONS The standardized TTP maps and scoring system facilitated the quantification of the sequential perfusion changes during Moyamoya disease treatment. The preoperative perfusion status was the only predictor of indirect revascularization outcome.
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Affiliation(s)
- Y-H Lin
- From the Department of Medical Imaging (Y.-H.L., C.-J.L., C.-W.L., Y.-F.C.)
| | - M-F Kuo
- Division of Neurosurgery (M.-F.K., S.-H.Y.), Department of Surgery, National Taiwan University Hospital, Taiwan
| | - C-J Lu
- From the Department of Medical Imaging (Y.-H.L., C.-J.L., C.-W.L., Y.-F.C.)
| | - C-W Lee
- From the Department of Medical Imaging (Y.-H.L., C.-J.L., C.-W.L., Y.-F.C.)
| | - S-H Yang
- Division of Neurosurgery (M.-F.K., S.-H.Y.), Department of Surgery, National Taiwan University Hospital, Taiwan
| | - Y-C Huang
- Department of Medical Imaging (Y.-C.H.), Min-Sheng General Hospital, Taoyuan, Taiwan
| | - H-M Liu
- Department of Radiology (H.-M.L.), Fu Jen Catholic University Hospital, New Taipei City, Taiwan
| | - Y-F Chen
- From the Department of Medical Imaging (Y.-H.L., C.-J.L., C.-W.L., Y.-F.C.)
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Arnone GD, Hage ZA, Charbel FT. Single Vessel Double Anastomosis for Flow Augmentation – A Novel Technique for Direct Extracranial to Intracranial Bypass Surgery. Oper Neurosurg (Hagerstown) 2019; 17:365-375. [DOI: 10.1093/ons/opy396] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 01/03/2019] [Indexed: 11/12/2022] Open
Abstract
AbstractBACKGROUNDA double anastomosis using a single superficial temporal artery (STA) donor branch for both a proximal side-to-side (S2S) and a distal end-to-side anastomosis is a novel direct bypass technique for use in selected patients necessitating flow augmentation.OBJECTIVETo describe the single-vessel double anastomosis (SVDA) technique, including its indications, advantages, and limitations, in addition to reporting our cases series of patients who underwent a SVDA bypass surgery.METHODSPatients undergoing a SVDA bypass at a single institution between January 2010 and February 2016 were retrospectively reviewed. Intraoperative flow data was collected, including STA cut-flow, bypass flows, and cut flow index (CFI). Bypass patency was assessed by cerebral angiography and quantitative magnetic resonance angiography with noninvasive optimal vessel analysis. Adverse events occurring during the hospital stay and clinical status at last follow up was recorded.RESULTSSeven patients underwent SVDA bypass. Mean follow-up was 14.5 mo. Initial CFI for the S2S bypasses averaged 0.56 ± 0.25 and CFI after the SVDA averaged 1.15 ± 0.24. There was a statistically significant average difference in CFI before and after the SVDA bypass (p < .013). Thirteen bypasses (93%) were patent postoperatively, and remained patent at last follow up. Four patients experienced various postoperative complications. None of the patients had a new stroke since hospital discharge.CONCLUSIONSVDA is a novel technique that can be advantageous for selected cases of extracranial-to-intracranial bypass. Expertise in bypass procedures is a necessary prerequisite. Graft patency rates and complications appear comparable to other bypass techniques.
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Affiliation(s)
- Gregory D Arnone
- University of Illinois at Chicago, Department of Neurosurgery, Chicago, Illinois
| | - Ziad A Hage
- Novant Health Neurosurgery Specialists, Charlotte, North Carolina
| | - Fady T Charbel
- University of Illinois at Chicago, Department of Neurosurgery, Chicago, Illinois
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Yeh SJ, Tang SC, Tsai LK, Lee CW, Chen YF, Liu HM, Yang SH, Hsieh YL, Kuo MF, Jeng JS. Greater ultrasonographic changes in pediatric moyamoya patients compared with adults after indirect revascularization surgeries. J Neurosurg Pediatr 2018; 22:663-671. [PMID: 30168733 DOI: 10.3171/2018.6.peds18151] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 06/05/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEPediatric and adult patients with moyamoya disease experience similar clinical benefits from indirect revascularization surgeries, but there are still debates about age-related angiographic differences of the collaterals established after surgery. The goal of this study was to assess age-related differences on ultrasonography before and after indirect revascularization surgeries in moyamoya patients, focusing on some ultrasonographic parameters known to be correlated with the collaterals supplied by the external carotid artery (ECA).METHODSThe authors prospectively included moyamoya patients (50 and 26 hemispheres in pediatric and adult patients, respectively) who would undergo indirect revascularization surgery. Before surgery and at 1, 3, and 6 months after surgery, the patients underwent ultrasonographic examinations. The ultrasonographic parameters included peak-systolic velocity (PSV), end-diastolic velocity (EDV), resistance index (RI), and flow volume (FV) measured in the ECA, superficial temporal artery (STA), and internal carotid artery on the operated side. The mean values, absolute changes, and percentage changes of these parameters were compared between the pediatric and adult patients. Logistic regression analysis was used to clarify the determinants affecting postoperative EDV changes in the STA.RESULTSBefore surgery, the adult patients had mean higher EDV and lower RI in the STA and ECA than the pediatric group (all p < 0.05). After surgery, the pediatric patients had greater changes (absolute and percentage changes) in the PSV, EDV, RI, and FV in the STA and ECA (all p < 0.05). The factors affecting postoperative EDV changes in the STA at 6 months were age (p = 0.006) and size of the revascularization area (i.e., revascularization in more than the temporal region vs within the temporal region; p = 0.009). Pediatric patients who received revascularization procedures in more than the temporal region had higher velocities (PSV and EDV) in the STA than those who received revascularization within the temporal region (p < 0.05 at 1-6 months), but such differences were not observed in the adult group.CONCLUSIONSThe greater changes of these parameters in the STA and ECA in pediatric patients than in adults after indirect revascularization surgeries indicated that pediatric patients might have a greater increase of collaterals postoperatively than adults. Pediatric patients who undergo revascularization in more than the temporal region might have more collaterals than those who undergo revascularization within the temporal region.
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Affiliation(s)
| | | | - Li-Kai Tsai
- 1Stroke Center and Department of Neurology, and
| | | | | | - Hon-Man Liu
- 3Department of Radiology, Fu Jen Catholic University Hospital; and
- 4School of Medicine, Fu Jen University, New Taipei City, Taiwan
| | - Shih-Hung Yang
- 5Neurosurgery, National Taiwan University Hospital, Taipei
| | | | - Meng-Fai Kuo
- 5Neurosurgery, National Taiwan University Hospital, Taipei
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Ishii D, Okazaki T, Matsushige T, Shinagawa K, Sakamoto S, Oshita J, Kurisu K. Chronic Dilatation of Superficial Temporal Artery and Middle Meningeal Artery Associated with Development of Collateral Circulation After Bypass Surgery for Moyamoya Angiopathy. World Neurosurg 2018; 119:e864-e873. [DOI: 10.1016/j.wneu.2018.07.287] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/30/2018] [Accepted: 07/31/2018] [Indexed: 11/28/2022]
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Park W, Park ES, Lee S, Park JC, Chung J, Lee JM, Ahn JS. Intracranial Hemorrhage After Superficial Temporal Artery-Middle Cerebral Artery Direct Anastomosis for Adults with Moyamoya Disease. World Neurosurg 2018; 119:e774-e782. [PMID: 30096496 DOI: 10.1016/j.wneu.2018.07.266] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/29/2018] [Accepted: 07/30/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Intracranial hemorrhage, such as intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and intraventricular hemorrhage (IVH), is an extremely rare complication after surgical revascularization for moyamoya disease (MMD). However, the incidence, timing, prognosis, possible mechanism, and prevention are not well known. METHODS Adult patients with MMD who underwent direct bypass or combined bypass and experienced ICH, SAH, or IVH within 7 days postoperatively were enrolled in this study. The medical records and radiologic findings of these patients, together with their intraoperative video recordings, were reviewed retrospectively. RESULTS Direct superficial temporal artery (STA)-middle cerebral artery (MCA) bypass or combined bypass was performed for 222 hemispheres in 193 adult patients with MMD between January 2001 and December 2016. Intracranial hemorrhage occurred perioperatively in 8 hemispheres (3.6%) in 8 patients. The hemorrhages developed immediately after STA-MCA direct anastomosis during surgery in 3 patients. Hemorrhage on computed tomography and neurologic deterioration were also observed immediately postoperatively in 2 patients and during the postoperative period in 3 patients. Although 4 patients received medical management, neurosurgical treatment was needed in the other 4 patients. One patient died, and 6 patients were left with moderate or severe disabilities. CONCLUSIONS Intracranial hemorrhage (ICH, IVH, or SAH) after direct bypass for adult patients with MMD is an extremely rare but fatal complication. Although these hemorrhages can be associated with hyperperfusion syndrome, no effective prevention has been established.
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Affiliation(s)
- Wonhyoung Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eun Suk Park
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Seungjoo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jaewoo Chung
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung Min Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Deng X, Gao F, Zhang D, Zhang Y, Wang R, Wang S, Cao Y, Zhao Y, Pan Y, Liu X, Zhang Q, Zhao J. Direct versus indirect bypasses for adult ischemic-type moyamoya disease: a propensity score–matched analysis. J Neurosurg 2018; 128:1785-1791. [DOI: 10.3171/2017.2.jns162405] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVEThe optimal surgical modality for moyamoya disease (MMD) remains unclear. The aim of this study was to compare the surgical effects of direct bypass (DB) and indirect bypass (IB) in the treatment of adult ischemic-type MMD.METHODSAdult patients with ischemic-type MMD who underwent either DB or IB from 2009 to 2015 were identified retrospectively from a prospective database. Patients lost to follow-up or with a follow-up period less than 12 months were excluded. Recurrent stroke events and modified Rankin Scale (mRS) scores at the last follow-up were compared between the 2 surgical groups after 1:1 propensity score matching.RESULTSA total of 220 patients were considered, including 143 patients who underwent DB and 77 patients who underwent IB. After propensity score matching, 70 pairs were obtained. The median follow-up period was 40.5 months (range 14–75 months) in the DB group and 31.5 months (range 14–71 months) in the IB group (p = 0.004). Kaplan-Meier analysis showed that patients who received DB had a longer stroke-free time (mean 72.1 months) compared with patients who received IB (mean 61.0 months) (p = 0.045). Good neurological status (mRS score ≤ 2) was achieved in 64 patients in the DB group (91.4%) and 66 patients in the IB group (94.3%), but there was no significant difference (p = 0.512).CONCLUSIONSAlthough neurological function outcome was not determined by the surgical modality, DB is more effective in preventing recurrent ischemic strokes than IB for adult ischemic-type MMD.
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Affiliation(s)
- Xiaofeng Deng
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- 4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease; and
| | - Faliang Gao
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- 4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease; and
| | - Dong Zhang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- 4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease; and
| | - Yan Zhang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- 4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease; and
| | - Rong Wang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- 4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease; and
| | - Shuo Wang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- 4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease; and
| | - Yong Cao
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- 4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease; and
| | - Yuanli Zhao
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- 4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease; and
| | - Yuesong Pan
- 2China National Clinical Research Center for Neurological Diseases (NCRC-ND)
- 5Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingju Liu
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- 4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease; and
| | - Qian Zhang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- 4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease; and
| | - Jizong Zhao
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University
- 4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease; and
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Jiang H, Yang H, Ni W, Lei Y, Su J, Gu Y, Xu B, Mao Y. Long-Term Outcomes After Combined Revascularization Surgery in Adult Hemorrhagic Moyamoya Disease. World Neurosurg 2018; 116:e1032-e1041. [PMID: 29859362 DOI: 10.1016/j.wneu.2018.05.153] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/20/2018] [Accepted: 05/22/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Risk factors for rebleeding after revascularization surgery are unclear. We aimed to evaluate long-term outcomes after combined revascularization surgery for adult hemorrhagic moyamoya disease (MMD) and identify risk factors for initial and recurrent hemorrhage. METHODS A total of 105 adult patients with hemorrhagic MMD from January 2007 to May 2011 were prospectively enrolled in this study. All patients underwent combined revascularization surgery on unilateral hemorrhagic hemispheres and were observed for at least 5 years. RESULTS After a median follow-up time of 77 months, 12 patients were lost to follow-up. Twelve of the remaining 93 patients developed rebleeding, and 6 patients died. According to rebleeding sites, ipsilateral and contralateral rebleeding occurred in 6 and 6 patients, respectively. There was no significant difference between the 2 groups (P > 0.05). The annual risks of overall, ipsilateral, and contralateral rebleeding were 1.1%, 0.62%, and 0.51%, respectively. A significant correlation was observed between improvement of anterior choroidal artery-posterior communicating artery dilation or extension in the operated hemispheres and low risk of ipsilateral rebleeding (P < 0.05). Progression of Suzuki stage in the nonhemorrhagic hemispheres was significantly associated with contralateral rebleeding (P < 0.05). CONCLUSIONS Combined revascularization surgery may help prevent ipsilateral rebleeding in adult patients with hemorrhagic MMD by improvement of anterior choroidal artery-posterior communicating artery dilation and extension in the operated hemisphere. Progression of Suzuki stage in the nonhemorrhagic hemispheres was a strong predictor of subsequent contralateral rebleeding.
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Affiliation(s)
- Hanqiang Jiang
- Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Heng Yang
- Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Wei Ni
- Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Yu Lei
- Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Jiabin Su
- Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Yuxiang Gu
- Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China.
| | - Bin Xu
- Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Ying Mao
- Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
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Khachatryan VA, Samochernykh KA, Mamatkhanov MR, Potemkina EG, Goroshchenko SA, Tadevosyan AR, Litvinenko PV. [Methods to assess competence of indirect cerebral revascularization in children]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 82:30-38. [PMID: 29795084 DOI: 10.17116/oftalma201882230-38] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The use of catheterization cerebral angiography (CCA) to assess collateral blood flow through an indirect anastomosis is traumatic for children, uses a high radiation dose, and requires anesthetic care in most cases. AIM we aimed to compare the capabilities of triplex ultrasound (TU) of vessels, magnetic resonance angiography (MRA), computed tomography angiography (CTA), and CCA in assessing the competence of indirect cerebral revascularization (ICR) in children. MATERIAL AND METHODS ICR was performed in 18 children in 24 hemispheres (24 operations). The results were evaluated by Matsushima classification-based comparison of the data of preoperative and postoperative clinical examinations, TU of the superficial temporal artery, magnetic resonance imaging (MRI) and computed tomography (CT) of vessels, and selective cerebral angiography. RESULTS After surgery, improvements in the neurological and neuropsychological status were assessed. Matsushima grade A collaterals were found in 12 (50%) cases, grade B collaterals were present in 3 (13%) cases, grade C collaterals were present in 7 (29%) cases, and grade D collaterals were detected in 1 (4%) case; in 1 (4%) case, the superficial temporal artery was not enhanced. MR angiography visualized 18 (75%) indirect anastomoses, CT angiography revealed 4 indirect anastomoses, and TU visualized 4 indirect anastomoses. Comparison of preoperative and postoperative TU data for the superficial temporal artery revealed significant changes in blood flow in the form of increased rate indices and a decreased resistance index; mean values of indices for each angiographic class of revascularization and significant differences in pre- and postoperative observations were calculated. CONCLUSION Examination of ICR competence using CCA is necessary in the presence of persistent clinical signs of chronic cerebral circulatory insufficiency, absence of increased blood flow and decreased peripheral resistance in the superficial temporal artery, and lack of anastomosis according to MRA. The most optimal techniques for postoperative examination are MRA with perfusion and diffusion maps and TU.
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Affiliation(s)
- V A Khachatryan
- Almazov National Medical Research Center, Akkuratova Str., 2, Saint-Petersburg, Russia, 197341
| | - K A Samochernykh
- Almazov National Medical Research Center, Akkuratova Str., 2, Saint-Petersburg, Russia, 197341
| | - M R Mamatkhanov
- Almazov National Medical Research Center, Akkuratova Str., 2, Saint-Petersburg, Russia, 197341
| | - E G Potemkina
- Polenov Russian Research Institute of Neurosurgery, a Branch of the Almazov National Medical Research Center, Mayakovskogo Str., 12, Saint-Petersburg, Russia, 191014
| | - S A Goroshchenko
- Polenov Russian Research Institute of Neurosurgery, a Branch of the Almazov National Medical Research Center, Mayakovskogo Str., 12, Saint-Petersburg, Russia, 191014
| | - A R Tadevosyan
- Research Center of Traumatology and Orthopedics, 9-ya Street, 123, Nork-Marash, Yerevan, Armenia, 0047
| | - P V Litvinenko
- Almazov National Medical Research Center, Akkuratova Str., 2, Saint-Petersburg, Russia, 197341
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Zhao J, Liu H, Zou Y, Zhang W, He S. Clinical and angiographic outcomes after combined direct and indirect bypass in adult patients with moyamoya disease: A retrospective study of 76 procedures. Exp Ther Med 2018; 15:3570-3576. [PMID: 29545885 DOI: 10.3892/etm.2018.5850] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 01/02/2018] [Indexed: 11/05/2022] Open
Abstract
The present retrospective study was performed to evaluate the clinical outcome, as well as post-operative collateral formation and revascularization patterns in combined bypass. Surgical revascularization has been the mainstay of treatment for moyamoya patients. A total of 76 hemispheres from 64 moyamoya patients undergoing combined superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and encephalo-duro-myo-synangiosis (EDMS) were retrospectively reviewed. Computed tomography perfusion and DSA were routinely performed. Modified Rankin scale (mRS) scoring and Kaplan-Meier analysis were performed, and post-operative collateral grading on digital subtraction angiography (DSA), reconstruction patterns and vessel diameter were measured to evaluate the revascularization area and vascular compensatory effect. During the follow-up period, the chief complaint was partially alleviated in 57/64 patients (89.1%). In all patients, mRS was significantly decreased after the operation. Good revascularization was established in most patients at 6 months after the surgery: 92.1% of sides were scored as 2 and 77.6% were scored as 3 by post-operative collateral grading on DSA. Dominant collateral revascularization originating from EDMS was more frequent than that from STA-MCA anastomosis (31 vs. 19 hemispheres) at 6-month follow-up. Morphologically, the calibers of the STA main trunk (2.60±0.65 mm) increased profoundly at the first 10 post-operative days (3.32±1.05 mm) and shrank back to pre-operative status at 6 months (2.20±1.01 mm) and 12 months (2.36±0.73 mm) according to DSA examination. Middle meningeal artery (MMA) and deep temporal artery (DTA) demonstrated continuous augmentation during the follow-up time (from 1.30±0.46 to 1.87±0.69 mm for MMA and 1.11±0.25 to 2.11±1.16 mm for DTA). These results strongly suggested that combined STA-MCA bypass and EDMS provided efficient revascularization and reduced acute cerebral events. The direct STA-MCA bypass provided early augmentation of cerebral perfusion, whereas the indirect EDMS provided a more durable long-term revascularization, indicating a complementary association between the two revascularization methods.
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Affiliation(s)
- Jinbing Zhao
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Hongyi Liu
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Yuanjie Zou
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Wenbin Zhang
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Shengxue He
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
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Acker G, Fekonja L, Vajkoczy P. Surgical Management of Moyamoya Disease. Stroke 2018; 49:476-482. [PMID: 29343587 DOI: 10.1161/strokeaha.117.018563] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 11/18/2017] [Accepted: 12/08/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Güliz Acker
- From the Department of Neurosurgery (G.A., L.F., P.V.) and Center for Stroke Research Berlin (G.A., L.F., P.V.), Charité-Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany (G.A.); and Cluster of Excellence: Image Knowledge Gestaltung: An Interdisciplinary Laboratory, Humboldt University, Berlin, Germany (L.F.)
| | - Lucius Fekonja
- From the Department of Neurosurgery (G.A., L.F., P.V.) and Center for Stroke Research Berlin (G.A., L.F., P.V.), Charité-Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany (G.A.); and Cluster of Excellence: Image Knowledge Gestaltung: An Interdisciplinary Laboratory, Humboldt University, Berlin, Germany (L.F.)
| | - Peter Vajkoczy
- From the Department of Neurosurgery (G.A., L.F., P.V.) and Center for Stroke Research Berlin (G.A., L.F., P.V.), Charité-Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany (G.A.); and Cluster of Excellence: Image Knowledge Gestaltung: An Interdisciplinary Laboratory, Humboldt University, Berlin, Germany (L.F.).
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TOMINAGA T, SUZUKI N, MIYAMOTO S, KOIZUMI A, KURODA S, TAKAHASHI JC, FUJIMURA M, HOUKIN K. Recommendations for the Management of Moyamoya Disease: A Statement from Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) [2nd Edition]. ACTA ACUST UNITED AC 2018. [DOI: 10.2335/scs.46.1] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Teiji TOMINAGA
- On behalf of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) Research on Intractable Diseases of the Ministry of Health, Labour and Welfare
| | - Norihiro SUZUKI
- On behalf of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) Research on Intractable Diseases of the Ministry of Health, Labour and Welfare
| | - Susumu MIYAMOTO
- On behalf of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) Research on Intractable Diseases of the Ministry of Health, Labour and Welfare
| | - Akio KOIZUMI
- On behalf of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) Research on Intractable Diseases of the Ministry of Health, Labour and Welfare
| | - Satoshi KURODA
- On behalf of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) Research on Intractable Diseases of the Ministry of Health, Labour and Welfare
| | - Jun C. TAKAHASHI
- On behalf of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) Research on Intractable Diseases of the Ministry of Health, Labour and Welfare
| | - Miki FUJIMURA
- On behalf of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) Research on Intractable Diseases of the Ministry of Health, Labour and Welfare
| | - Kiyohiro HOUKIN
- On behalf of the Research Committee on Spontaneous Occlusion of the Circle of Willis (Moyamoya Disease) Research on Intractable Diseases of the Ministry of Health, Labour and Welfare
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Komura S, Mikami T, Sugino T, Suzuki Y, Komatsu K, Wanibuchi M, Mikuni N. Complementary Relation Between Direct and Indirect Bypass in Progress of Collateral Circulation in Moyamoya Disease. World Neurosurg 2017; 104:197-204. [PMID: 28478244 DOI: 10.1016/j.wneu.2017.04.122] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/17/2017] [Accepted: 04/18/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND One of the important aims of surgery for moyamoya disease is to establish indirect revascularization. The purpose of this study was to assess the progress of the middle meningeal artery (MMA) after our novel preservation method and to evaluate the relation between direct and indirect bypass in the chronic stage. METHODS A total of 24 hemispheric sides of 19 patients with moyamoya disease were included in this study. Craniotomy was performed with preservation of the MMA during the procedure, then direct bypass was carried out. The relationship between anatomic variations of the MMA and success rate of preserving the MMA during craniotomy was noted. The alteration of the MMA and superficial temporal artery (STA) diameters was then evaluated using magnetic resonance imaging, and the correlation between the MMA and the STA in the chronic stage was examined. RESULTS In total, the MMA was preserved during craniotomy in 20 hemispheric sides (83.3%). During the 3-year follow-up period, the MMA and STA diameters were significantly increased. At 3 years after surgery, the alteration of the MMA diameter was significantly more marked in pediatric cases than in adult cases, and MMA diameter was moderately but significantly negatively correlated with STA diameter. CONCLUSIONS In moyamoya disease, the MMA could be developed as a pathway for indirect revascularization even after simple preservation, especially in pediatric patients. The progress of the MMA and the STA occurs through their synergistic interaction, and the balance might be decided based on their complementary relations in the chronic stage.
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Affiliation(s)
- Shoichi Komura
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Takeshi Mikami
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan.
| | - Toshiya Sugino
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Yuto Suzuki
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Katsuya Komatsu
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | | | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
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