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Sun T, Zeng Q, Huang L, Sun J, Wu Z, Zhang B, Ling C, Chen C, Wang H. Exploration of the risk factor for infarction after revascularization in moyamoya disease. Ann Med 2024; 56:2362872. [PMID: 38913594 PMCID: PMC11198149 DOI: 10.1080/07853890.2024.2362872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 05/02/2024] [Indexed: 06/26/2024] Open
Abstract
RESULTS Eventually, 108 consecutive patients received 174 surgeries were enrolled, experienced new or expanded infarction occured in 13 (7.47%) surgeries, which showed higher Suzuki stage on the non-operative side, more posterior cerebral artery (PCA) involvement, and more intraoperative hypotension compared to those without infarction(p < .05). The Suzuki stage on the non-operative side had the highest area under the curve (AUC) of 0.737, with a sensitivity of 0.692 and specificity of 0.783. Combination of the three factors showed better efficiency, with an AUC of 0.762, a sensitivity of 0.692, and a specificity of 0.907. CONCLUSIONS Revascularization was a safe option for patients with MMD, higher Suzuki stage on the non-operative side, PCA involvement, and intraoperative hypotension might be the risk factors for new or expanded infarction after revascularization in patients with MMD.
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Affiliation(s)
- Tao Sun
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Qiuhua Zeng
- Department of Radiology, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Lixin Huang
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jun Sun
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Zhimin Wu
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Baoyu Zhang
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Cong Ling
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Chuan Chen
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Hui Wang
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
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Park JB, Kang P, Ji SH, Jang YE, Lee JH, Kim JT, Kim HS, Kim EH. Effects of goal-directed analgesia using the analgesia nociception index in children undergoing surgery for moyamoya disease: A randomised controlled trial. Eur J Anaesthesiol 2024:00003643-990000000-00193. [PMID: 38832435 DOI: 10.1097/eja.0000000000002013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND The potential benefits of Analgesia Nociception Index guided intra-operative analgesia on intra-operative opioid consumption remains to be demonstrated in paediatric anaesthesia. OBJECTIVES This study aimed to explore the effects of Analgesia Nociception Index guided analgesia on sufentanil consumption during anaesthesia and postoperative pain scores in paediatric patients with moyamoya disease. DESIGN A prospective randomised controlled study. SETTING Seoul National University Children's Hospital, Seoul, Republic of Korea. PATIENTS A total of 40 children scheduled for encephaloduroarteriosynangiosis. MAIN OUTCOME MEASURES The primary outcome was total intra-operative sufentanil consumption, and the secondary outcomes included postoperative pain scores and incidence of opioid-related adverse events. RESULTS The Analgesia Nociception Index group showed lower intra-operative sufentanil consumption (in μg kg-1 h-1) compared with the Standard group (0.30 ± 0.12 and 0.39 ± 0.17, respectively; mean difference, -0.09; 95% confidence interval, -0.19 to 0.00; P = 0.049). Postoperatively, compared with the Standard group, the Analgesia Nociception Index group reported lower median pain scores at 18 and 24 h and maximum pain within 24 h (1 [0 to 2] vs. 3 [2 to 5]; P = 0.004, 1 [0 to 2] vs. 3 [1 to 4]; P = 0.041, and 4 [3 to 5] vs. 5 [4 to 7]; P = 0.045, respectively), with fewer patients experiencing nausea (3 [15%] vs. 10 [50%], P = 0.043). CONCLUSION The Analgesia Nociception Index guided analgesic protocol can reduce intra-operative sufentanil consumption and postoperative pain within 24 h with fewer nausea symptoms in paediatric patients with moyamoya disease who undergo encephaloduroarteriosynangiosis. TRIAL REGISTRATION NUMBER NCT05672212 (registered at clinicaltrials, principal investigator: K.E.H., registration date: 2 January 2023).
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Affiliation(s)
- Jung-Bin Park
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea (J-BP, PK, S-HJ, Y-EJ, J-HL, J-TK, H-SK, E-HK)
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Kuwabara M, Okazaki T, Ishii D, Kondo H, Hosogai M, Hara T, Maeda Y, Horie N. Usefulness of combined bypass surgery for moyamoya disease in infants under 1 year of age: A technical case report. Surg Neurol Int 2024; 15:72. [PMID: 38468656 PMCID: PMC10927214 DOI: 10.25259/sni_868_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/06/2024] [Indexed: 03/13/2024] Open
Abstract
Background Among pediatric cases of moyamoya disease (MMD), cerebral ischemic symptoms often progress and worsen rapidly in infants under one year of age; therefore, it is important to treat them as early as possible. However, direct bypass surgery is often technically difficult for infants due to their small blood vessels. Here, we describe our technique to resolve the technical challenges encountered during superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass surgery in infants aged <1 year with MMD, focusing on specific procedures. Case Description We performed bilateral STA-MCA and indirect bypass in a 1-year-old girl with MMD and cerebral infarction. Before treatment, a peripherally inserted central venous catheter (PICC) was placed to avoid ischemic attacks associated with crying, dehydration, and malnutrition. All examinations and procedures that would be stressful to the patient, such as blood examinations, were performed using PICC or under sedation. The STA-MCA diameters were 0.8 and 1.2 mm, respectively. After suturing the planned anastomosis with one stitch using an 11-0 monofilament nylon thread, the thread was lifted upward, and the arterial wall was incised. Anastomosis was performed using an 11-0 monofilament nylon thread with 2-4 stitches on each side. The operation was completed without patency problems. Postoperative blood flow improved, and the patient had a good treatment course. Conclusion Direct bypass for MMD patients aged <1 year is technically challenging; however, the vessels can be connected if the procedure is carefully performed with consideration of the characteristics of the infant's vessels.
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Affiliation(s)
- Masashi Kuwabara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Qian MP, Dong MR, Han MM, Li J, Kang F. ABO blood types may affect transient neurological events after surgical revascularization in patients with moyamoya disease: a retrospective single center study. BMC Anesthesiol 2023; 23:419. [PMID: 38114904 PMCID: PMC10729420 DOI: 10.1186/s12871-023-02385-6] [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: 09/15/2023] [Accepted: 12/14/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Moyamoya disease (MMD) is a cerebrovascular disease with unknown cause. Patients with MMD disease usually experience transient neurological events (TNEs) after revascularization surgery. This retrospective single-center study was aimed to explore the risk factors of postoperative TNEs after surgical revascularization in patients with MMD. METHODS We selected 324 patients who underwent surgical revascularization between January 2017 and September 2022 in our center. The perioperative characteristics of the patients were recorded and the outcome was TNEs after surgery. An analysis of risk factors contributing to postoperative TNEs by using logistic regression model. RESULTS Three hundred twelve patients were enrolled, and the incidence of postoperative TNEs was 34% in our study. Males were more likely to suffer from postoperative TNEs (OR = 2.344, p = 0.002). Preoperative ischemic presentation (OR = 1.849, p = 0.048) and intraoperative hypotension (OR = 2.332, p = 0.002) were associated with postoperative TNEs. Compared to patients with blood type O, patients with blood type A (OR = 2.325, p = 0.028), B (OR = 2.239, p = 0.027) and AB (OR = 2.938, p = 0.019) had a significantly higher incidence of postoperative TNEs. A risk prediction model for postoperative TNEs was established, and the established risk prediction area under the receiver operating characteristic curve (ROC) of the model was 0.741. CONCLUSIONS Males, preoperative ischemic presentation and intraoperative hypotension were associated with postoperative TNEs. We also found a possible link between postoperative TNEs and ABO blood types after surgical revascularization for moyamoya patients.
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Affiliation(s)
- Mei-Ping Qian
- Department of Anesthesiology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Mei-Rong Dong
- Department of Anesthesiology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Ming-Ming Han
- Department of Anesthesiology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Juan Li
- Department of Anesthesiology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China
| | - Fang Kang
- Department of Anesthesiology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230036, Anhui, China.
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Kaku Y, Ohmori Y, Kameno K, Uchikawa H, Takemoto Y, Kawano T, Ishimura T, Uetani H, Mukasa A. Inhalational Anesthesia Reduced Transient Neurological Events After Revascularization Surgery for Moyamoya Disease. Neurosurgery 2023:00006123-990000000-01002. [PMID: 38108408 DOI: 10.1227/neu.0000000000002804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/02/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The choice between inhalational and total intravenous anesthesia (TIVA) in revascularization surgery for Moyamoya disease (MMD) remains a topic of debate. Anesthesia methods have changed with the advent of new anesthetics. This study investigated whether modern anesthesia methods affected the development of neurological symptoms after revascularization surgery for MMD. METHODS This single-center retrospective study included 63 adult patients (82 hemispheres) with MMD treated with direct and indirect bypass surgeries at our hospital between 2013 and 2022. Patients were divided into inhalational anesthesia (IA) and TIVA groups based on the anesthesia maintenance method. Baseline patient characteristics; postoperative neurological symptoms, including hyperperfusion syndrome, cerebral infarction, and transient neurological events (TNEs); and cortical hyperintensity belt (CHB) sign scores (5-point scale from 0 to 4) on postoperative magnetic resonance imaging were compared between the two groups. The operation methods, anesthetics, and intraoperative hemodynamic and ventilatory parameters were compared between patients with and without TNEs. RESULTS The IA and TIVA groups comprised 39 and 43 hemispheres, respectively. The frequency of postoperative hyperperfusion syndrome and cerebral infarction did not differ between the groups, but the number of TNEs in the IA group (5/39; 13%) was significantly lower than that in the TIVA group (16/43; 37%). Multivariate logistic regression analysis revealed that TNEs were associated with TIVA (odds ratio, 3.91; 95% CI, 1.24-12.35; P = .02). The median [IQR] postoperative CHB sign score in the IA group (2 [1-3]) was significantly lower than that in the TIVA group (4 [3-4]). CONCLUSION The IA group had fewer postoperative TNEs and lower CHB sign scores than the TIVA group. Although further studies are needed, this study provides insights into the prevention of TNEs with IA and reconsideration of the optimal anesthesia for MMD.
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Affiliation(s)
- Yasuyuki Kaku
- Department of Neurosurgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Yuki Ohmori
- Department of Neurosurgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Koki Kameno
- Department of Neurosurgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Hiroki Uchikawa
- Department of Neurosurgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Yushin Takemoto
- Department of Neurosurgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Takayuki Kawano
- Department of Neurosurgery, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | | | - Hiroyuki Uetani
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Akitake Mukasa
- Department of Neurosurgery, Kumamoto University Hospital, Kumamoto, Japan
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Guo Q, Fan YN, Wang QN, Li J, Han C, Zou Z, Liu S, Wang X, Yu D, Hao F, Gao G, Zhang Q, Pei S, Feng J, Yang R, Wang M, Fu H, Bao X, Duan L. Nomogram for Predicting Long-term Outcomes of Encephaloduroarteriosynangiosis in Toddlers with Moyamoya Disease: a Longitudinal and Cross-sectional Study. Transl Stroke Res 2023:10.1007/s12975-023-01213-w. [PMID: 37943490 DOI: 10.1007/s12975-023-01213-w] [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: 10/20/2023] [Revised: 10/29/2023] [Accepted: 10/30/2023] [Indexed: 11/10/2023]
Abstract
We investigated the long-term outcomes of encephaloduroarteriosynangiosis (EDAS) for stroke prevention in toddlers with moyamoya disease (MMD) using nomogram. Between January 2005 and December 2018, 74 toddlers with MMD underwent surgery in the Fifth Medical Centre, Chinese PLA General Hospital, 69 were < 4 years of age and included in the analysis. The modified Rankin scale (mRS) during follow-up evaluated clinical outcomes. To measure the effectiveness of EDAS, the annual risk of symptomatic infarction within the operated brain hemispheres was calculated. The event-free survival rate was determined using Kaplan-Meier curves. A nomogram generated using multivariate logistic regression analysis identified potential predictors associated with unfavorable outcomes. Additionally, discrimination, calibration, and clinical utility were assessed. A favorable clinical outcome was observed in 81.2% of the patients. The operated hemispheres showed an annual risk of 0.87% of symptomatic infarction and 0.23% of hemorrhage. Moreover, the 10-year event-free survival rates were 92.8% and 97.0% for symptomatic infarction and hemorrhage. Multivariate logistic analysis indicated that onset with infarction, initial mRS ≥ 3, and perioperative adverse events had significant and independent associations with unfavorable outcomes. However, an age at diagnosis of ≥ 2 years showed an association with favorable outcomes. Using these four factors, our model attained a concordance index of 0.912 (95% confidence interval, 0.842-0.982), well-fitted calibration curve, and cutoff value of 0.212 for predicting unfavorable outcomes. EDAS may prevent recurrent stroke and improve overall long-term clinical outcomes in toddlers with MMD. The developed nomogram accurately predicted unfavorable outcomes and assisted surgeons in patient evaluation.
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Affiliation(s)
- Qingbao Guo
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Yan-Na Fan
- Department of Radiation Oncology, Senior Department of Oncology, the Fifth Medical Center of, PLA General Hospital, Beijing, China
| | - Qian-Nan Wang
- Department of Neurosurgery, the Eighth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jingjie Li
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Cong Han
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Zhengxing Zou
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Simeng Liu
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Xiaopeng Wang
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Dan Yu
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Fangbin Hao
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Gan Gao
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Qian Zhang
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Songtao Pei
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jie Feng
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Rimiao Yang
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Minjie Wang
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Heguan Fu
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Xiangyang Bao
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China.
| | - Lian Duan
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China.
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Ishii D, Maeda Y, Kuwabara M, Hosogai M, Kume S, Hara T, Kondo H, Horie N. Pulsatility index of superficial temporal artery was associated with cerebral infarction after direct bypass surgery for moyamoya disease. J Stroke Cerebrovasc Dis 2023; 32:107346. [PMID: 37708702 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107346] [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: 08/21/2023] [Revised: 09/03/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVE Direct bypass surgery by superficial temporal artery (STA) - middle cerebral artery anastomosis is an established procedure for moyamoya disease (MMD). However, some patients may develop cerebral infarction (CI) due to the watershed shift phenomenon after the surgery. This study sought to investigate the correlation between the postoperative changes of STA flow as well as cerebral blood flow (CBF) and the incidence of CI after direct bypass surgery for MMD. METHODS We conducted a retrospective study of 62 hemispheres in 50 subjects who underwent direct bypass surgery for MMD. All subjects underwent pre- and post-operative MR imaging, ultrasound evaluation of STA, and single-photon emission computed tomography. The presence of CI was correlated with preoperative CBF, the delta difference of each value of the STA between before and after the surgery, and the postoperative increase ratio of CBF. RESULTS All bypass procedures were patent, and CI was observed in 4 cases (6.4%). There was no significant association between the incidence of CI and both pre- and post-operative CBF. However, there was a significant difference in delta pulsatility index (PI) of the STA between cases with or without CI (-0.38±0.22 and -0.87±0.63, respectively, p=0.03). Whereas, other factors did not show any significant differences between those with or without CI. CONCLUSIONS A relatively high postoperative PI of the STA was significantly associated with the incidence of CI after direct bypass surgery for MMD. A larger study is needed to confirm these findings.
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Affiliation(s)
- Daizo Ishii
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Yuyo Maeda
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masashi Kuwabara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masahiro Hosogai
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinji Kume
- Department of Clinical Laboratory, Hiroshima University Hospital, Hiroshima, Japan
| | - Takeshi Hara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroshi Kondo
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Gao F, Cong J, Duan Y, Zhao W, Zhu Z, Zheng Y, Jin L, Ji M, Li M. Screening of postoperative cerebral hyperperfusion syndrome in moyamoya disease: a three-dimensional pulsed arterial-spin labeling magnetic resonance imaging approach. Front Neurosci 2023; 17:1274038. [PMID: 37928741 PMCID: PMC10620603 DOI: 10.3389/fnins.2023.1274038] [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: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Moyamoya disease (MMD) is associated with a risk of postoperative cerebral hyperperfusion syndrome (CHS) after revascularization surgery. This study aimed to explore the feasibility of using three-dimensional pulsed arterial spin labeling (3D PASL) and phase contrast (PC) magnetic resonance imaging (MRI) for predicting CHS occurrence in patients with MMD before revascularization surgery. Methods Overall, 191 adult patients (207 hemispheres) with MMD who underwent combined revascularization surgery were included in this study. Preoperative 3D PASL-MRI and PC-MRI were performed before surgery. The PASL-MRI data were analyzed using SPM12. Patient clinical information, average flow, and preoperative cerebral blood flow (CBF) were compared between the non-CHS and CHS groups. Results Among the patients, 45 (21.74%) developed CHS after revascularization surgery. No significant differences were noted in age, sex, clinical symptoms, hypertension, diabetes, surgical side, or history of revascularization surgery between the non-CHS and CHS groups. However, the average flow in the superficial temporal artery was significantly lower in the CHS group than in the non-CHS group (p < 0.05). Furthermore, 11 clusters of preoperative CBF values were significantly greater in the CHS group than in the non-CHS group [p < 0.05, false discovery rate (FDR) corrected]. A significant correlation was also observed between the preoperative time-to-flight MR angiography (MRA) scores and CBF values in patients with MMD (p < 0.05). Conclusion Compare patients with lower preoperative CBF and higher preoperative average flow in the STA, patients with higher preoperative CBF and lower preoperative average flow in the STA are more likely to develop postoperative CHS Preoperative PASL-MRI and PC-MRI examinations may help to screen patients at high risk of developing CHS after revascularization surgery.
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Affiliation(s)
- Feng Gao
- Department of Radiology, Huadong Hospital Fudan University, Shanghai, China
| | - Jianhua Cong
- Department of Medical Centre, Huadong Hospital Fudan University, Shanghai, China
| | - Yu Duan
- Department of Neurosurgery, Huadong Hospital Fudan University, Shanghai, China
| | - Wei Zhao
- Department of Radiology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Zhenfang Zhu
- Department of Radiology, Huadong Hospital Fudan University, Shanghai, China
| | - Yu Zheng
- Department of Magnetic Resonance, Lanzhou University Second Hospital, Lanzhou, China
| | - Liang Jin
- Department of Radiology, Huadong Hospital Fudan University, Shanghai, China
| | - Ming Ji
- Department of Radiology, Huadong Hospital Fudan University, Shanghai, China
| | - Ming Li
- Department of Radiology, Huadong Hospital Fudan University, Shanghai, China
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Yomo M, Kitai R, Tada H, Isozaki M, Higashino Y, Matsuda K, Yamauchi T, Akazawa A, Kawajri S, Oiwa M, Yamada S, Tsubota T, Watanabe A, Okazawa H, Kiyono Y, Arishma H, Kikuta K. Effect of newly developed scissors-attached micro-forceps on the recipient clamp time and occurrence of anastomotic site infarction after bypass surgery for moyamoya disease. Front Neurol 2023; 14:1269400. [PMID: 37869149 PMCID: PMC10587554 DOI: 10.3389/fneur.2023.1269400] [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: 07/29/2023] [Accepted: 09/18/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction This study aimed to examine the effect of newly developed scissors-attached micro-forceps in superficial temporal artery-to-middle cerebral artery (STA-MCA) anastomosis for moyamoya disease (MMD). Materials and methods Of 179 consecutive STA-MCA anastomoses on 95 hemispheres of 71 MMD patients at the University of Fukui Hospital between 2009 and 2023, 49 anastomoses on 26 hemispheres of 21 patients were enrolled in this retrospective cohort clinical trial intraoperative indocyanine green video-angiography did not demonstrate bypass patency in three anastomoses in two patients who were excluded. Twenty-one anastomosis in 19 hemispheres of 16 patients were performed using the conventional micro-forceps (conventional group, CG), and 25 anastomoses in 22 hemispheres of 19 patients were performed using scissors-attached micro-forceps (scissors group, SG). A small infarction near the anastomotic site detected using postoperative diffusion-weighted imaging was defined as anastomotic site infarction (ASI). Factors affecting the occurrence of ASI were examined by univariate, logistic regression, and receiver operating curve (ROC) analysis. Results There were no significant differences in clinical parameters such as age, sex, number of sacrificed branches, number of sacrificed large branches, and number of sutures between the CG and SG. However, the clamp time and occurrence of ASI were significantly lower in the SG than in the CG. Logistic regression analysis revealed that the clamp time was the only significant factor predicting the occurrence of ASI. A receiver operating curve analysis also revealed that the clamp time significantly predicted the occurrence of ASI (area under the curve, 0.875; cutoff value, 33.2 min). Conclusion The newly developed scissors-attached micro-forceps could significantly reduce the clamp time and occurrence of ASI in STA-MCA anastomosis for MMD.
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Affiliation(s)
- Munetaka Yomo
- Division of Medicine, Department of Neurosurgery, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Ryuhei Kitai
- Department of Neurosurgery, Kaga Medical Center, Kaga, Japan
| | - Hiroyuki Tada
- Technology Development Section, Charmant Co., Ltd., Sabae, Japan
| | - Makoto Isozaki
- Division of Medicine, Department of Neurosurgery, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yoshifumi Higashino
- Division of Medicine, Department of Neurosurgery, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Ken Matsuda
- Division of Medicine, Department of Neurosurgery, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Takahiro Yamauchi
- Division of Medicine, Department of Neurosurgery, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Ayumi Akazawa
- Division of Medicine, Department of Neurosurgery, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Satoshi Kawajri
- Division of Medicine, Department of Neurosurgery, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Mizuki Oiwa
- Division of Medicine, Department of Neurosurgery, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Shintaro Yamada
- Division of Medicine, Department of Neurosurgery, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Tadahiro Tsubota
- Division of Medicine, Department of Neurosurgery, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Akifumi Watanabe
- Division of Medicine, Department of Neurosurgery, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Hidehiko Okazawa
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan
| | - Yasushi Kiyono
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan
| | - Hidetaka Arishma
- Division of Medicine, Department of Neurosurgery, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Kenichiro Kikuta
- Division of Medicine, Department of Neurosurgery, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
- Life Science Innovation Center, University of Fukui, Fukui, Japan
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10
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Kim JW, Hayashi T, Kim SK, Shirane R. Technical evolution of pediatric neurosurgery: moyamoya disease. Childs Nerv Syst 2023; 39:2819-2827. [PMID: 37395784 DOI: 10.1007/s00381-023-06017-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 07/04/2023]
Abstract
Moyamoya disease (MMD) is a rare steno-occlusive disease of the bilateral internal carotid arteries that predominantly occurs in East Asia. Since the first description of the MMD by Suzuki and Takaku in 1969, significant advances have been made in both basic and clinical understanding of the disease. The incidence and prevalence of pediatric MMD have increased, potentially due to improved detection rates. The advancement of neuroimaging techniques has enabled MRI-based diagnostics and detailed visualization of the vessel wall. Various methods of surgical treatments are successful in pediatric MMD patients, and recent studies emphasize the importance of reducing postoperative complications since the goal of MMD surgery is to prevent future cerebral infarction and hemorrhage. Long-term outcomes following appropriate surgical treatment in pediatric MMD patients have shown promising results, including favorable outcomes in very young patients. Further studies with a large patient cohort are needed to establish individualized risk group stratification for determining the optimal timing of surgical treatment and to conduct multidisciplinary outcome assessments.
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Affiliation(s)
- Joo Whan Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, 03080, 101 Daehak-Ro, Jongno-Gu, Seoul, Republic of Korea
| | - Toshiaki Hayashi
- Department of Pediatric Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Neurosurgery, Miyagi Children's Hospital, 4 Chome-3-17 Ochiai, Aoba Ward, Sendai, Miyagi, 989-3126, Japan
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, 03080, 101 Daehak-Ro, Jongno-Gu, Seoul, Republic of Korea.
| | - Reizo Shirane
- Department of Neurosurgery, Miyagi Children's Hospital, 4 Chome-3-17 Ochiai, Aoba Ward, Sendai, Miyagi, 989-3126, Japan.
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11
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Guo Q, Pei S, Wang QN, Li J, Han C, Liu S, Wang X, Yu D, Hao F, Gao G, Zhang Q, Zou Z, Feng J, Yang R, Wang M, Fu H, Du F, Bao X, Duan L. Risk Factors for Preoperative Cerebral Infarction in Infants with Moyamoya Disease. Transl Stroke Res 2023:10.1007/s12975-023-01167-z. [PMID: 37314678 DOI: 10.1007/s12975-023-01167-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 06/15/2023]
Abstract
There have been few reports on the risk factors for preoperative cerebral infarction in childhood moyamoya disease (MMD) in infants under 4 years. The aim of this retrospective study is to identify clinical and radiological risk factors for preoperative cerebral infarction in infants under 4 years old with MMD, and the optimal timing for EDAS was also considered. We retrospectively analyzed the risk factors for preoperative cerebral infarction, confirmed by magnetic resonance angiography (MRA), in pediatric patients aged ˂4 years who underwent encephaloduroarteriosynangiosis between April 2005 and July 2022. The clinical and radiological outcomes were determined by two independent reviewers. In addition, potential risk factors for preoperative cerebral infarction, including infarctions at diagnosis and while awaiting surgery, were analyzed using a univariate model and multivariate logistic regression to identify independent predictors of preoperative cerebral infarction. A total of 160 hemispheres from 83 patients aged <4 years with MMD were included in this study. The mean age of all surgical hemispheres at diagnosis was 2.17±0.831 years (range 0.380-3.81 years). In the multivariate logistic regression model, we included all variables with P<0.1 in the univariate analysis. The multivariate logistic regression analysis indicated that preoperative MRA grade (odds ratio [OR], 2.05 [95% confidence interval [CI], 1.3-3.25], P=0. 002), and age at diagnosis (OR, 0.61 [95% CI, 0.4-0.92], P=0. 018) were predictive factors of infarction at diagnosis. The analysis further indicated that the onset of infarction (OR, 0.01 [95% CI, 0-0.08], P<0.001), preoperative MRA grade (OR, 1.7 [95% CI, 1.03-2.8], P=0.037), and duration from diagnosis to surgery (Diag-Op) (OR, 1.25 [95% CI, 1.11-1.41], P<0.001) were predictive factors for infarction while awaiting surgery. Moreover, the regression analysis indicated that family history (OR, 8.88 [95% CI, 0.91-86.83], P=0.06), preoperative MRA grade (OR, 8.72 [95% CI, 3.44-22.07], P<0.001), age at diagnosis (OR, 0.36 [95% CI, 0.14-0.91], P=0.031), and Diag-Op (OR, 1.38 [95% CI, 1.14-1.67], P=0.001) were predictive factors for total infarction. Therefore, during the entire treatment process, careful observation, adequate risk factor management, and optimal operation time are required to prevent preoperative cerebral infarction, particularly in pediatric patients with a family history, higher preoperative MRA grade, duration from diagnosis to operation longer than 3.53 months, and aged ˂3 years at diagnosis.
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Affiliation(s)
- Qingbao Guo
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Songtao Pei
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Qian-Nan Wang
- Department of Neurosurgery, the Eighth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jingjie Li
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Cong Han
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Simeng Liu
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Xiaopeng Wang
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Dan Yu
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Fangbin Hao
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Gan Gao
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Qian Zhang
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Zhengxing Zou
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jie Feng
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Rimiao Yang
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Minjie Wang
- Medical School of Chinese PLA, Beijing, China
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Heguan Fu
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Feiyan Du
- Beijing Garrison Haidian 13th Retired Cadre Rest House, Beijing, China
| | - Xiangyang Bao
- Department of Neurosurgery, the Fifth Medical Centre, Chinese PLA General Hospital, Beijing, China.
| | - Lian Duan
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China.
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12
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Shi Z, Wu L, Wang Y, Li W, Wang J, Yang Y, Hang C. Intraoperative Hemodynamics of Parasylvian Cortical Arteries for Predicting Postoperative Symptomatic Cerebral Hyperperfusion after Direct Revascularization in Patients with Moyamoya Disease: A Preliminary Study. J Clin Med 2023; 12:jcm12113855. [PMID: 37298050 DOI: 10.3390/jcm12113855] [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: 01/18/2023] [Revised: 03/08/2023] [Accepted: 05/09/2023] [Indexed: 06/12/2023] Open
Abstract
Objective. The search for methods by which to predict the risks of cerebral hyperperfusion syn-drome (CHS) in adults with moyamoya disease (MMD), including those utilizing new biomarkers, still deserves further research. The objective of this study was to investigate the association between the hemodynamics of parasylvian cortical arteries (PSCAs) and postoperative CHS. Methods. A consecutive number of adults with MMD who had undergone direct bypass between September 2020 and December 2022 were recruited. Intraoperative microvascular doppler ultrasonography (MDU) was performed to evaluate the hemodynamics of PSCAs. The intraoperative flow direction, mean value of velocity (MVV) of recipient artery (RA) and bypass graft were recorded. According to flow direction after bypass, RA was divided into entering sylvian (RA.ES) and leaving sylvian (RA.LS) subtypes. Univariate, multivariate, and ROC analyses of the risk factors for postoperative CHS were performed. Results. A total of 16 (15.09%) cases in 106 consecutive hemispheres (101 patients) sat-isfied the postoperative CHS criteria. According to univariate analysis, advanced Suzuki stage, MVV of RA before bypass, and fold increase of MVV in RA.ES after bypass were significantly associated with postoperative CHS (p < 0.05). Multivariate analysis indicated that left-operated hemisphere (OR (95%CI), 4.58 (1.05-19.97), p = 0.043), advanced Suzuki stage (OR (95%CI), 5.47 (1.99-15.05), p = 0.017), and fold increase of MVV in RA.ES (OR (95%CI), 1.17 (1.06-1.30), p = 0.003) were statistically significantly associated with the occurrence of CHS. The cut-off value of fold increase of MVV in RA.ES was 2.7-fold (p < 0.05). Conclusions. Left-operated hemisphere, advanced Suzuki stage, and postoperative fold increase of MVV in RA.ES were potential risk factors for postoperative CHS. Intraoperative MDU was useful for evaluating hemodynamics and predicting CHS.
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Affiliation(s)
- Zhiyong Shi
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing 210008, China
| | - Lingyun Wu
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing 210008, China
| | - Yi Wang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing 210008, China
| | - Wei Li
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing 210008, China
| | - Juan Wang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing 210008, China
| | - Yongbo Yang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing 210008, China
| | - Chunhua Hang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing 210008, China
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Takasu S, Kanamori F, Hatano N, Seki Y, Saito R. Effects of superficial temporal artery to middle cerebral artery bypass on postoperative infarction rates among young children (≤ 5 years old) with moyamoya disease. Neurosurg Rev 2023; 46:87. [PMID: 37067615 DOI: 10.1007/s10143-023-01999-1] [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: 02/22/2023] [Revised: 03/23/2023] [Accepted: 04/08/2023] [Indexed: 04/18/2023]
Abstract
Revascularization surgery for young children with moyamoya disease (MMD) is challenging. Although indirect revascularization is preferred because of the technical difficulty in direct anastomosis, higher risks of postoperative infarction remain a problem. We aimed to investigate the effect of superficial temporal artery to middle cerebral artery (STA-MCA) bypass on postoperative outcomes during the acute postoperative period in young children ≤ 5 years old with MMD. This retrospective study included consecutive young children with MMD who underwent surgical revascularization of the anterior cerebral circulation. Groups were determined according to the procedures performed, namely, the combined (STA-MCA bypass with indirect revascularization) and the indirect revascularization groups. The incidences of radiological or symptomatic infarction, transient neurological events, and new neurological deficits that remained at discharge were compared between groups. Of 38 surgical procedures, there were 23 combined and 15 indirect revascularizations. The median age of the patients was 3.0 years, which was significantly different between groups (P < .01). When comparing the postoperative outcomes between groups, the incidences of radiological and symptomatic infarction and new neurological deficits that remained at discharge were significantly lower in the combined revascularization group (P < .05). Logistic regression analysis adjusted for potential confounders found that surgical modality was a statistically significant independent risk factor associated with radiological and symptomatic infarctions (indirect/combined, odds ratio: 10.2; 95% confidence interval: 1.30-79.7; P < .05). STA-MCA bypass combined with indirect revascularization can reduce the incidence of postoperative infarction in young children with MMD and might lead to better neurological outcomes.
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Affiliation(s)
- Syuntaro Takasu
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan.
- Department of Neurosurgery, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan.
| | - Fumiaki Kanamori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Norikazu Hatano
- Department of Neurosurgery, Kawashima Hospital, 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 Graduate School of Medicine, Nagoya, Japan
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Chen Y, Gong X, Yang Z, Chen F, Wang J. Risk factors and a novel cerebral infarction extent scoring system for postoperative cerebral ischemia in patients with ischemic Moyamoya disease. Sci Rep 2023; 13:5726. [PMID: 37029162 PMCID: PMC10082086 DOI: 10.1038/s41598-022-26985-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 12/22/2022] [Indexed: 04/09/2023] Open
Abstract
Postoperative cerebral ischemic complication is the most common complication of revascularization surgery for patients with moyamoya disease (MMD). This retrospective study was conducted on 63 patients with ischemic MMD. Postoperative ischemia occurred in 15 of the 70 revascularization operations performed for patients after surgical revascularization, translating to an incidence of 21.4%. Univariate analysis revealed that onset infarction (p = 0.015), posterior cerebral artery involvement (p = 0.039), strict perioperative management (p = 0.001), interval time between transient ischemic attack (TIA) or infarction presentation and operation (p = 0.002) and preoperatively cerebral infarction extent score (CIES) (p = 0.002) were significantly associated with postoperative cerebral ischemia. Multivariate analysis revealed that strict perioperative management (OR = 0.163; p = 0.047), and preoperatively CIES (OR = 1.505; p = 0.006) were independently associated with postoperative cerebral ischemia-related complications. After comprehensive improvement of perioperative management protocol, the incidence of symptomatic infarction declined to 7.4% (4 out of 54). Analysis of the area under the receiver operating characteristic curve (AUROC) indicated CIES was a predictor for both postoperative ischemia and high follow-up modified Rankin Scale scores. In summary, strict perioperative management and CIES were identified as independent risk factors for postoperative ischemic complications in ischemic MMD, demonstrating that comprehensive and individualized perioperative management improve postoperative outcomes in patients with MMD. Furthermore, application of CIES to evaluate pre-existing cerebral infarction can improve the management of patients.
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Affiliation(s)
- Yuanbing Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xuan Gong
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zeng Yang
- Department of Neurosurgery, The First People's Hospital of Changde, Changde, Hunan, China
| | - Fenghua Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China.
| | - Junyu Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China.
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15
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Shi Z, Wu L, Wang Y, Zhang H, Yang Y, Hang C. Risk factors of postoperative cerebral hyperperfusion syndrome and its relationship with clinical prognosis in adult patients with moyamoya disease. Chin Neurosurg J 2023; 9:10. [PMID: 37013602 PMCID: PMC10069070 DOI: 10.1186/s41016-023-00321-8] [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: 04/14/2022] [Accepted: 02/28/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND To investigate the incidence, risk factors, and clinical prognosis of cerebral hyperperfusion syndrome (CHS) after superficial temporal artery-middle cerebral artery anastomosis combined with encephalo-duro-arterio-synangiosis (STA-MCA/EDAS) in adult patients with moyamoya disease (MMD). METHODS The clinical data of 160 adult patients with MMD treated by STA-MCA/EDAS from January 2016 to January 2017 were retrospectively analyzed. According to CHS diagnosis, MMD patients were divided into CHS and non-CHS group. Univariate and multivariate analysis of risk factors and Kaplan-Meier curve of stroke-free survival for CHS were performed. RESULTS A total of 12 patients (7.5%) developed postoperative CHS, of which 4 patients (2.5%) presented with cerebral hemorrhage. Univariate and multivariate analysis showed moyamoya vessel on the surgical hemisphere (OR = 3.04, 95% CI = 1.02-9.03, P = 0.046) and left operated hemisphere (OR = 5.16, 95% CI = 1.09-21.34, P = 0.041) were independent risk factors for CHS. The other variables, such as age, gender, presentation, hypertension, diabetes, smoking, mean mRS score on admission, modified Suzuki stage and pre-infarction stage on surgical hemisphere, and bypass patency, had no association with postoperative CHS (P > 0.05). At final follow-up with average 38 months, there were 18 out of 133 patients (13.5%, 4.91% per person year) presented with newly developed complications. There was no significant difference between newly developed complications, mean mRS scores, and Kaplan-Meier curve of stroke-free survival in patients with and without CHS (P > 0.05). CONCLUSION The concentration of moyamoya vessels and left operated hemisphere was independent risk factors for CHS, which could not affect the clinical prognosis if treated timely and properly. The current study offers a new perspective of moyamoya vessels and supporting data for choosing MMD candidates on cerebral revascularization.
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Affiliation(s)
- Zhiyong Shi
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, Jiangsu Province, MN 210008, People's Republic of China
| | - Lingyun Wu
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, Jiangsu Province, MN 210008, People's Republic of China
| | - Yi Wang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, Jiangsu Province, MN 210008, People's Republic of China
| | - Huasheng Zhang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, Jiangsu Province, MN 210008, People's Republic of China
| | - Yongbo Yang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, Jiangsu Province, MN 210008, People's Republic of China.
| | - Chunhua Hang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, Jiangsu Province, MN 210008, People's Republic of China
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16
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Two adult patients with moyamoya disease presenting with alexia with agraphia limited to kanji: can revascularization improve characteristic symptoms? Acta Neurochir (Wien) 2023; 165:625-630. [PMID: 36562875 DOI: 10.1007/s00701-022-05460-y] [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: 05/30/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
Patients with moyamoya disease (MMD) may exhibit higher brain dysfunction due to hypoperfusion, which may be ameliorated by revascularization. However, few studies have examined the relationship between cerebral perfusion and language function or the ameliorating effect of revascularization on language dysfunction. We present two cases with MMD who presented with alexia with agraphia, specifically for Japanese kanji. The patients had impaired perfusion in the left inferior temporal and lateral occipital lobes. Following superficial temporal artery-middle cerebral artery bypass, the symptoms improved dramatically. Thus, correction of hypoperfusion may be effective even in adult patients with MMD presenting with language dysfunction.
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Liu H, Liu K, Zhang K, Zong C, Yang H, Li Y, Li S, Wang X, Zhao J, Xia Z, Song B, Xu X, Gao Y. Early neurological deterioration in patients with acute ischemic stroke: a prospective multicenter cohort study. Ther Adv Neurol Disord 2023; 16:17562864221147743. [PMID: 36710721 PMCID: PMC9880581 DOI: 10.1177/17562864221147743] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 12/08/2022] [Indexed: 01/26/2023] Open
Abstract
Background There is still no precise knowledge of the causes of progression in patients with acute ischemic stroke (AIS), and we are unable to predict patients at risk. Objective To explore the frequency, predictive factors, and the prognosis of early neurological deterioration (END) in patients with AIS. Methods In this prospective multicenter observational study, we assessed patients with AIS admitted to 18 hospitals in Henan, China. We defined END as an increase of ⩾2 points in total National Institutes of Health Stroke Scale (NIHSS) score or ⩾1 point in the motor items of the NIHSS within 7 days after admission. Risk factors were analyzed using multivariate logistic regression models. Prognosis was evaluated using the modified Rankin Scale (mRS), with poor prognosis defined as mRS 3-6. Results A total of 9114 patients with AIS within 24 h of symptom onset were enrolled in the study. END occurred in 1286 (14.1%) patients. The highest incidence (62.5%) of END occurred within 24 h after admission. After adjusting potential confounders, age, body mass index, waist-hip ratio, systolic blood pressure, baseline NIHSS, disabled at baseline, history of atrial fibrillation, diabetes mellitus, intracranial arterial stenosis, infarct location in the lenticulostriate artery area and cerebral watershed, neutrophils, lymphocytes, uric acid, and triglycerides were identified as independent predictors for END. END was significantly associated with poor prognosis at 90 days, and the adjusted OR was 1.74 (95% CI: 1.53-1.97). Conclusion One in seven hospitalized patients with AIS may experience END within 24 h of onset. The highest incidence of END occurred within 24 h of admission and decreased steeply with time. Easily identifiable risk factors predict END and could help understand the causal mechanisms and thereby prevent END.
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Affiliation(s)
- Hongbing Liu
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Kai Liu
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Ke Zhang
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Ce Zong
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongxun Yang
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Yapeng Li
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Shen Li
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin Wang
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiawei Zhao
- Department of Neurology, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, China
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18
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Yuxue S, Yan W, Bingqian X, Hao L, Chaoyue L. Arterial spin labeling for moyamoya angiopathy: A preoperative and postoperative evaluation method. Transl Neurosci 2023; 14:20220288. [PMID: 37303475 PMCID: PMC10251162 DOI: 10.1515/tnsci-2022-0288] [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: 02/10/2023] [Revised: 04/25/2023] [Accepted: 05/08/2023] [Indexed: 06/13/2023] Open
Abstract
Objectives Studies have shown that arterial spin labeling (ASL) effectively replaces traditional MRI perfusion imaging for detecting cerebral blood flow (CBF) in patients with Moyamoya angiopathy (MMA). However, there are few reports on the relationship between neovascularization and cerebral perfusion in patients with MMA. The aim of this study is to investigate the effects of neovascularization on cerebral perfusion with MMA after bypass surgery. Methods We selected patients with MMA in the Department of Neurosurgery between September 2019 and August 2021 and enrolled them based on the inclusion and exclusion criteria. ASL imaging was used to monitor the baseline CBF level before surgery and determine the changes in cerebral vessels at postoperative 1 week and 6 months, respectively. The Alberta stroke grade, modified Rankin Scale (mRS), and digital subtraction angiography images were used to evaluate the effect of postoperative CBF status and prognosis. Ninety hemispheres from 51 patients were included in this study. There were no significant differences in the baseline data of the enrolled patients. At 1 week and 6 months post-surgery, the CBF state in the operation area was significantly changed compared with that at baseline (P < 0.05). The preoperative Alberta score (t = 2.714, P = 0.013) and preoperative mRS score (t = 6.678, P < 0.001) correlated with postoperative neovascularization. Conclusion ASL is an effective method for detecting CBF and plays an important role in the long-term follow-up of patients with MMA. Combined cerebral revascularization significantly improves CBF in the operation area both in the short and long terms. Patients with lower preoperative Alberta scores and higher mRS scores were more likely to benefit from combined cerebral revascularization surgery. However, regardless of the type of patient, CBF reconstruction can effectively improve prognosis.
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Affiliation(s)
- Sun Yuxue
- Department of Neurosurgery, Henan Provincial People’s Hospital (Zhengzhou University People’s Hospital, Henan University People’s Hospital), Zhengzhou, China
| | - Wang Yan
- Department of Radiology, Henan Provincial People’s Hospital (Zhengzhou University People’s Hospital, Henan University People’s Hospital), Zhengzhou, China
| | - Xue Bingqian
- Department of Neurosurgery, Henan University People’s Hospital (Henan Provincial People’s Hospital), Zhengzhou, China
| | - Liang Hao
- Department of Neurosurgery, Henan Provincial People’s Hospital (Zhengzhou University People’s Hospital, Henan University People’s Hospital), Zhengzhou, China
| | - Li Chaoyue
- Department of Neurosurgery, Henan Provincial People’s Hospital (Zhengzhou University People’s Hospital, Henan University People’s Hospital), Zhengzhou, China
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19
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Chiba K, Aihara Y, Fukui A, Yamaguchi K, Kawashima A, Okada Y, Kawamata T. Transient neurological events in childhood moyamoya disease. J Neurosurg Pediatr 2023; 31:78-86. [PMID: 36334284 DOI: 10.3171/2022.9.peds22166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 09/14/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients sometimes experience transient neurological events (TNEs) during the early postoperative period after revascularization surgery for childhood moyamoya disease. The clinical background and pathophysiology of TNEs remain unclear. This study aimed to evaluate the incidence rate of TNEs and discuss the factors associated with pediatric moyamoya disease. METHODS The authors retrospectively reviewed 110 cerebral hemispheres of 61 pediatric patients younger than 15 years who were treated from 2011 to 2020. All children underwent either simple double-direct or combined revascularization surgery. Of these 61 patients, 52 underwent bilateral surgery and 9 underwent unilateral surgery. The authors calculated the incidence of TNEs in accordance with a previously reported TNE definition. Cerebral blood flow (CBF) was evaluated in all eligible cases with xenon CT immediately after revascularization surgery. RESULTS The incidence rate of TNEs in patients with childhood moyamoya disease was 26.4%. TNEs occurred after an average (range) of 6.26 (2-12) days postoperatively without triggers, and all identified TNEs spontaneously resolved within 2 weeks. The most common symptoms were dysarthria, facial palsy, and numbness around the mouth, followed by sensory disturbance of the upper extremities. The presence of focal hyperperfusion on xenon CT performed immediately after revascularization surgery was strongly correlated with the incidence of TNEs (p = 0.0001). Focal hyperperfusion was observed in 43 of 110 operative sides (39.1%). Notably, only 25.6% of patients with focal hyperperfusion showed numerical global hyperperfusion. In addition, a decrease in CBF compared with the thalamic region in the contralateral side was observed in TNE-affected cases (p = 0.0443). CONCLUSIONS TNEs occurred more frequently in childhood moyamoya disease patients than expected. The clinical background, including symptoms, timing, and duration, was almost identical to TNEs in adults. Focal hyperperfusion, rather than numerical global hyperperfusion, was strongly correlated with the incidence of TNEs. Furthermore, the authors advocate the notion that a clinical course where symptoms occur without triggers may be a unique characteristic of TNEs, especially in childhood moyamoya disease.
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Affiliation(s)
- Kentaro Chiba
- 1Department of Neurosurgery, Tokyo Women's Medical University, Tokyo
| | - Yasuo Aihara
- 1Department of Neurosurgery, Tokyo Women's Medical University, Tokyo
| | - Atsushi Fukui
- 1Department of Neurosurgery, Tokyo Women's Medical University, Tokyo
| | - Koji Yamaguchi
- 1Department of Neurosurgery, Tokyo Women's Medical University, Tokyo
| | - Akitsugu Kawashima
- 2Department of Neurosurgery, Tokyo Women's Medical University, Yachiyo Medical Center, Chiba; and
| | - Yoshikazu Okada
- 3Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan
| | - Takakazu Kawamata
- 1Department of Neurosurgery, Tokyo Women's Medical University, Tokyo
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Kanamori F, Araki Y, Yokoyama K, Uda K, Kurimoto M, Shiba Y, Mamiya T, Takayanagi K, Ishii K, Nishihori M, Izumi T, Okamoto S, Saito R. The usefulness and safety of dexmedetomidine for postoperative sedation in pediatric patients with moyamoya disease. J Neurosurg Pediatr 2022; 30:301-307. [PMID: 35901711 DOI: 10.3171/2022.6.peds2241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE After revascularization surgery in pediatric patients with moyamoya disease (MMD), resting and avoiding crying is important. However, this inaction is often difficult because of pain or anxiety. Dexmedetomidine (DEX), which has sedative and analgesic properties, may be useful in reducing those uncomfortable conditions; however, its common side effects include bradycardia and hypotension, which have a risk of decreasing the cerebral blood flow. The aim of this study was to investigate the efficacy and safety of using DEX for pediatric patients with MMD in the acute period after revascularization surgery. METHODS This retrospective study included pediatric patients with MMD who underwent revascularization surgery. Based on whether DEX was used for light sedation during postoperative days (PODs) 0-1 after extubation, the patients were divided into DEX or control groups. For neurological outcomes, the incidence of symptomatic cerebral infarction and transient neurological events (TNEs) during PODs 0-1 and the entire hospitalization were investigated. In addition, the Richmond Agitation-Sedation Scale (RASS) was used to assess the effect of DEX, and bradycardia and hypotension were evaluated as side effects. RESULTS A total of 84 surgical procedures were included in this study (27 in the DEX group and 57 in the control group). During PODs 0-1, symptomatic infarction was not observed in either group. The incidence of TNEs was almost the same in both groups: 2 (7.4%) of the 27 procedures in the DEX group and 4 (7.0%) of the 57 procedures in the control group (p > 0.99). Moreover, the incidences of symptomatic infarction and TNEs during the entire hospitalization did not differ significantly (symptomatic infarction, p > 0.99; TNEs, p = 0.20). Regarding the DEX effect, the median RASS scores during PODs 0-1 were -1.0 (drowsy) in the DEX group and +1.0 (restless) in the control group, showing a significant difference (p < 0.01). Regarding side effects, bradycardia was observed only in 3 (11.1%) of the 27 procedures in the DEX group (p = 0.03), and hypotension was not observed in any of the cases. CONCLUSIONS In pediatric patients with MMD who are extubated after revascularization surgery, DEX produced appropriate light sedation and analgesia. The risk for symptomatic infarction is almost the same in cases in which DEX is used and those in which it is not; however, neurosurgeons should be cautious of bradycardia and TNEs as potential side effects.
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Okuyama T, Kawabori M, Ito M, Sugiyama T, Kazumata K, Fujimura M. Outcomes of Combined Revascularization Surgery for Moyamoya Disease without Preoperative Cerebral Angiography. World Neurosurg 2022; 165:e446-e451. [PMID: 35750140 DOI: 10.1016/j.wneu.2022.06.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Cerebral angiography is the gold standard for diagnosing moyamoya disease (MMD), whereas magnetic resonance (MR) imaging/angiography is becoming more popular in the field of cerebrovascular disease due to its low invasiveness. Although there are concerns about using only MR imaging/angiography for preoperative analysis of MMD, considering the underestimation of pre-existing transdural collateral circulations and dangerous collaterals related to the risk of hemorrhage, we retrospectively reviewed our 10-year experience of MR imaging-first diagnosis and analyzed the perioperative outcomes. METHODS We analyzed 160 consecutive direct/indirect combined revascularization procedures for MMD preoperatively assessed using MR imaging/angiography alone. Perioperative complications were assessed for up to 2 weeks after surgery. Locations of the lesions responsible for complications were further classified into the surgical field, the ipsilateral hemisphere outside the surgical field, and the contralateral hemisphere. RESULTS Sixty-four revascularization procedures were performed in 38 children, and 96 procedures were performed in 68 adults. There was no difference in the incidence of perioperative ischemic complications between adults (6.3%) and pediatric patients (4.7%), but hemorrhagic complications were more frequently observed in adults (7.3%) than in children (0%) (P < 0.05). There was no specific lesion deviation for ischemic complications; however, hemorrhagic complications predominantly occurred in the surgical field. CONCLUSIONS Direct/indirect combined revascularization surgery based on our preoperative diagnostic protocol with the MR-first strategy resulted in favorable outcomes in pediatric MMD patients with relatively low complication rates. However, the validity of the MR-first diagnostic protocol should be further evaluated in adult patients with MMD.
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Affiliation(s)
- Tomohiro Okuyama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masahito Kawabori
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | - Masaki Ito
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Taku Sugiyama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Ken Kazumata
- Department of Neurosurgery, Hokkaido Medical Center, Sapporo, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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22
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Xu L, Li Y, Tong Y, Hu JW, He XC, Fu XJ, Zhou GY, Cao Y, Yu XB, Zhou H, Xu CR, Wang L. The Recipient Vessel Hemodynamic Features Affect the Occurrence of Cerebral Edema in Moyamoya Disease After Surgical Revascularization: A Single-Center Retrospective Study. Front Neurol 2022; 13:890126. [PMID: 35651348 PMCID: PMC9149593 DOI: 10.3389/fneur.2022.890126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 04/01/2022] [Indexed: 11/13/2022] Open
Abstract
Objective In moyamoya disease (MMD) with direct or combined revascularization, the initially hemodynamic recipient features are likely one of the main causes of acute hemodynamic disruption. Previous studies have explored the relationship between recipient diameter or flow velocity and postoperative complications, but there are still no optimal selection criteria with multiple potential recipient vessels. Cerebral edema is one of the most common radiological manifestations in the acute postoperative period. This study assessed the hemodynamic characteristics of cortex vessels related to postoperative cerebral edema. Methods All patients who had undergone direct or combined revascularization with preoperative digital subtraction angiography (DSA) between 2019 and 2021 were eligible for inclusion in this study. The application of DSA was performed and regular radiological examinations were employed after surgery. DSA was analyzed with the hemodynamic features within chosen recipient vessels. Cerebral edema was identified as a low-density image on CT or high signaling in the MRI T2 phase. The recipient hemodynamic characteristics and demographic presentation, as well as clinical data, were retrospectively analyzed in this study. Results A total of 103 patients underwent direct or combined revascularization with preoperative DSA. The mean age of this enrolled cohort was 44.31 ± 10.386 years, in which bilaterally involved MMD accounted for the main part. The preliminary correlation analysis found preoperative disease period (p = 0.078), recipients observed in angiography (p = 0.002), and surgery on the left (p = 0.097) may be associated with cerebral edema. The following regression analysis confirmed low occurrence of cerebral edema was accompanied by recipients observed in angiography (p = 0.003). After subdividing by flow direction and hemodynamic sources, the incidence rate of anterograde direction, anterior sources, and posterior sources were significantly lower than undetected recipients. Conclusions Cerebral edema is a common radiological manifestation in MMDs after surgery. In this study, the observation in angiography reliably identifies a variety of physiological or pathological recipient detection, flow direction, and hemodynamic sources in patients with MMD after revascularization, which indicates the selection strategy of potential recipients and highlights the importance of recipient observability in DSA. Meanwhile, vascular conditions determined by recipient hemodynamics meditate the occurrence of postoperative cerebral edema.
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Affiliation(s)
- Liang Xu
- Department of Neurosurgery, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Yin Li
- Department of Neurosurgery, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Yun Tong
- Department of Neurosurgery, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jun-Wen Hu
- Department of Neurosurgery, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xu-Chao He
- Department of Neurosurgery, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xiong-Jie Fu
- Department of Neurosurgery, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Guo-Yang Zhou
- Department of Neurosurgery, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Yang Cao
- Department of Neurosurgery, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xiao-Bo Yu
- Department of Neurosurgery, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Hang Zhou
- Department of Neurosurgery, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Chao-Ran Xu
- Department of Neurosurgery, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Lin Wang
- Department of Neurosurgery, School of Medicine, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
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Araki Y, Mamiya T, Fujita N, Yokoyama K, Uda K, Kanamori F, Takayanagi K, Ishii K, Nishihori M, Takeuchi K, Tanahashi K, Nagata Y, Nishimura Y, Tanei T, Muraoka S, Izumi T, Kato K, Saito R. Symptomatic hyperperfusion after combined revascularization surgery in patients with pediatric moyamoya disease: patient series. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022. [PMCID: PMC9379730 DOI: 10.3171/case2274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Symptomatic hyperperfusion after cerebral revascularization for pediatric moyamoya disease (MMD) is a rare phenomenon. The authors report a series of patients with this condition. OBSERVATIONS In all three patients in this case series, the combined revascularization was on the left side, the patency of bypass grafts was confirmed after surgery, and focal hyperemia around the anastomotic site was observed on single photon emission computed tomography (SPECT). On the first to eighth days after surgery, all of the patients developed neurological manifestations, including motor aphasia, cheiro-oral syndrome, motor weakness of their right upper limbs, and severe headaches. These symptoms disappeared completely approximately 2 weeks after surgery, and all patients were discharged from the hospital. Quantitative SPECT was performed to determine the proportional change in cerebral blood flow (ΔRCBF) (to ipsilateral cerebellar ratio (denoted ΔRCBF) in the region of interest around the anastomoses, and the mean value was 1.34 (range, 1.29–1.41). LESSONS This rare condition, which develops soon after surgery, requires an accurate diagnosis by SPECT. One indicator is that the ΔRCBF has risen to 1.3 or higher. Subsequently, strategic blood pressure treatment and fluid management could prevent the development of hemorrhagic stroke.
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Affiliation(s)
- Yoshio Araki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takashi Mamiya
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Naotoshi Fujita
- Department of Radiological Technology, Nagoya University Hospital, Aichi, Japan
| | - Kinya Yokoyama
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kenji Uda
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Fumiaki Kanamori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kai Takayanagi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kazuki Ishii
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masahiro Nishihori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kazuhito Takeuchi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kuniaki Tanahashi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yuichi Nagata
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yusuke Nishimura
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takafumi Tanei
- Department of Neurosurgery, Komaki City Hospital, Komaki, Aichi, Japan
| | - Shinsuke Muraoka
- Department of Neurosurgery, Tosei General Hospital, Seto, Aichi, Japan; and
| | - Takashi Izumi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Katsuhiko Kato
- Functional Medical Imaging, Biomedical Imaging Sciences, Division of Advanced Information Health Sciences, Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
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Kanamori F, Araki Y, Yokoyama K, Uda K, Mamiya T, Nohira S, Takayanagi K, Ishii K, Nishihori M, Izumi T, Saito R. Angiographic characteristics of improper watershed shift after STA-MCA bypass in a patient with moyamoya disease: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE22104. [PMID: 36303494 PMCID: PMC9379717 DOI: 10.3171/case22104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/08/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND In patients with moyamoya disease (MMD) who receive superficial temporal artery (STA) to middle cerebral artery (MCA) bypass, hypoperfusion remote from the anastomosis site rarely occurs. Watershed shift due to direct bypass has been proposed as the mechanism; however, no report has confirmed this phenomenon using angiography. OBSERVATIONS A 48-year-old man presented with transient weakness in his left arm. Angiography revealed severe bilateral stenosis of the MCAs and moyamoya vessels. The right anterior cerebral artery (ACA) had short stenosis at A2 but ample blood supply to the cortical area of the right ACA and MCA regions. The patient was diagnosed with MMD and received a single STA-MCA bypass. The next day, he had difficulty communicating, and a cerebral infarction away from the anastomosis site was identified. Perfusion examination revealed hyperperfusion around the direct bypass and hypoperfusion away from the anastomosis site. Angiography revealed bypass patency; however, the original anterograde flow of the right ACA decreased significantly at the stenosed point, indicating an improper watershed shift. LESSONS STA-MCA bypass for patients with MMD can cause an improper watershed shift decreasing cerebral flow. Donor flow should be prepared based on each angiographic characteristic, and the risk of the improper watershed shift should be considered.
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Affiliation(s)
- Fumiaki Kanamori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yoshio Araki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kinya Yokoyama
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kenji Uda
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takashi Mamiya
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Shota Nohira
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kai Takayanagi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kazuki Ishii
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masahiro Nishihori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takashi Izumi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
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Chen JY, Tu XK. Research Progress on Postoperative Transient Neurological Dysfunction in Pediatric and Adult Patients with Moyamoya Disease after Revascularization Surgery. Clin Neurol Neurosurg 2022; 217:107254. [DOI: 10.1016/j.clineuro.2022.107254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/01/2022] [Accepted: 04/13/2022] [Indexed: 11/03/2022]
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Araki Y, Yokoyama K, Uda K, Kanamori F, Mamiya T, Takayanagi K, Ishii K, Nishihori M, Takeuchi K, Tanahashi K, Nagata Y, Tanei T, Nishimura Y, Izumi T, Saito R. Spatially separate cerebral infarction in the posterior cerebral artery territory after combined revascularization of the middle cerebral artery territory in an adult patient with moyamoya disease and fetal-type posterior communicating artery: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21704. [PMID: 36273866 PMCID: PMC9379675 DOI: 10.3171/case21704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 02/02/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Remote cerebral infarction after combined revascularization of the middle cerebral artery (MCA) territory is rare in patients with moyamoya disease (MMD) with a fetal-type posterior communicating artery (PCoA). OBSERVATIONS A 57-year-old woman developed numbness in her right upper limb and transient motor weakness and was diagnosed with MMD. She also had a headache attack and a scintillating scotoma in the right visual field. Preoperative magnetic resonance angiography (MRA) showed stenosis of the left posterior cerebral artery (PCA). Combined revascularization was performed for the left MCA territory. No new neurological deficits were observed for 2 days after the operation, but right hemianopia, alexia, and agraphia appeared on postoperative day (POD) 4. Magnetic resonance imaging showed a new left occipitoparietal lobe infarction, and MRA showed occlusion of the distal left PCA. After that point, the alexia and agraphia gradually improved, but right hemianopia remained at the time of discharge on POD 18. LESSONS Cerebral ischemia in the PCA territory may occur after combined revascularization of the MCA territory in patients with fetal-type PCoA. For these cases, a double-barrel bypass or indirect revascularization to induce a slow conversion could be considered on its own as a treatment option.
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Affiliation(s)
- Yoshio Araki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan; and
| | - Kinya Yokoyama
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan; and
| | - Kenji Uda
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan; and
| | - Fumiaki Kanamori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan; and
| | - Takashi Mamiya
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan; and
| | - Kai Takayanagi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan; and
| | - Kazuki Ishii
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan; and
| | - Masahiro Nishihori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan; and
| | - Kazuhito Takeuchi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan; and
| | - Kuniaki Tanahashi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan; and
| | - Yuichi Nagata
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan; and
| | - Takafumi Tanei
- Department of Neurosurgery, Komaki City Hospital, Aichi, Japan
| | - Yusuke Nishimura
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan; and
| | - Takashi Izumi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan; and
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan; and
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Gao F, Zhao W, Zheng Y, Duan Y, Ji M, Lin G, Zhu Z. Intravoxel Incoherent Motion Magnetic Resonance Imaging Used in Preoperative Screening of High-Risk Patients With Moyamoya Disease Who May Develop Postoperative Cerebral Hyperperfusion Syndrome. Front Neurosci 2022; 16:826021. [PMID: 35310102 PMCID: PMC8924456 DOI: 10.3389/fnins.2022.826021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/26/2022] [Indexed: 11/16/2022] Open
Abstract
Objective This study aimed to investigate the feasibility of preoperative intravoxel incoherent motion (IVIM) MRI for the screening of high-risk patients with moyamoya disease (MMD) who may develop postoperative cerebral hyperperfusion syndrome (CHS). Methods This study composed of two parts. In the first part 24 MMD patients and 24 control volunteers were enrolled. IVIM-MRI was performed. The relative pseudo-diffusion coefficient, perfusion fraction, apparent diffusion coefficient, and diffusion coefficient (rD*, rf, rADC, and rD) values of the IVIM sequence were compared according to hemispheres between MMD patient and healthy control groups. In the second part, 98 adult patients (124 operated hemispheres) with MMD who underwent surgery were included. Preoperative IVIM-MRI was performed. The rD*, rf, rADC, rD, and rfD* values of the IVIM sequence were calculated and analyzed. Operated hemispheres were divided into CHS and non-CHS groups. Patients’ age, sex, Matsushima type, Suzuki stage, and IVIM-MRI examination results were compared between CHS and non-CHS groups. Results Only the rf value was significantly higher in the healthy control group than in the MMD group (P < 0.05). Out of 124 operated hemispheres, 27 were assigned to the CHS group. Patients with clinical presentation of Matsushima types I–V were more likely to develop CHS after surgery (P < 0.05). The rf values of the ipsilateral hemisphere were significantly higher in the CHS group than in the non-CHS group (P < 0.05). The rfD* values of the ACA and MCA supply areas of the ipsilateral hemisphere were significantly higher in the CHS group than in the non-CHS group (P < 0.05). Only the rf value of the anterior cerebral artery supply area in the contralateral hemisphere was higher in the CHS group than in the non-CHS group (P < 0.05). The rf values of the middle and posterior cerebral artery supply areas and the rD, rD*, and rADC values of the both hemispheres were not significantly different between the CHS and non-CHS groups (P > 0.05). Conclusion Preoperative non-invasive IVIM-MRI analysis, particularly the f-value of the ipsilateral hemisphere, may be helpful in predicting CHS in adult patients with MMD after surgery. MMD patients with ischemic onset symptoms are more likely to develop CHS after surgery.
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Affiliation(s)
- Feng Gao
- Department of Radiology, Huadong Hospital Fudan University, Shanghai, China
- *Correspondence: Feng Gao,
| | - Wei Zhao
- Department of Radiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Yu Zheng
- Department of Radiology, Chengdu Second People’s Hospital, Chengdu, China
| | - Yu Duan
- Department of Neurosurgery, Huadong Hospital Fudan University, Shanghai, China
| | - Ming Ji
- Department of Radiology, Huadong Hospital Fudan University, Shanghai, China
| | - Guangwu Lin
- Department of Radiology, Huadong Hospital Fudan University, Shanghai, China
| | - Zhenfang Zhu
- Department of Radiology, Huadong Hospital Fudan University, Shanghai, China
- Zhenfang Zhu,
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Fujimura M. Moyamoya Disease-Standards and Advances in Revascularization Procedure and Peri-operative Management. Adv Tech Stand Neurosurg 2022; 44:175-186. [PMID: 35107679 DOI: 10.1007/978-3-030-87649-4_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Moyamoya disease (MMD) is a chronic, occlusive cerebrovascular disease with unknown etiology characterized by progressive stenosis at the terminal portion of the internal carotid artery and the abnormal vascular network formation at the base of the brain. Superficial temporal artery-middle cerebral artery (STA-MCA) bypass is a preferred surgical procedure for ischemic-onset MMD patients by improving cerebral blood flow. Recent evidence further indicates that flow-augmentation bypass has a potential role for preventing re-bleeding in hemorrhagic-onset MMD patients. Based on such cumulative evidence, there is a worldwide increase in the number of MMD patients undergoing bypass surgery, thus thorough understanding of the basic pathology of MMD including peri-operative hemodynamics is critical for avoiding surgical complications. The author sought to demonstrate the standard surgical procedure of STA-MCA bypass with indirect pial synangiosis for adult MMD patients and its pitfall in the early postoperative period, introducing the characteristic peri-operative hemodynamic condition of adult MMD after surgery, such as local cerebral hyperperfusion and intrinsic hemodynamic ischemia caused by watershed shift phenomenon.
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Affiliation(s)
- Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan.
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Tokairin K, Sugiyama T, Ito M, Fujimura M. Intraoperative Early Venous Filling Phenomenon as an Intrinsic Sign of the Local Hemodynamic Change after Revascularization Surgery in a Patient with Adult Moyamoya Disease: Implications of a Potential Arteriovenous Shunt. NMC Case Rep J 2022; 8:755-760. [PMID: 35079544 PMCID: PMC8769467 DOI: 10.2176/nmccrj.cr.2021-0181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/23/2021] [Indexed: 11/27/2022] Open
Abstract
After revascularization surgery for patients with moyamoya disease (MMD), local and global hemodynamic changes occur intraoperatively and in the early postoperative period. Local cerebral hyperperfusion and watershed shift ischemia are well-known perioperative pathologies after revascularization for MMD, but early venous filling phenomenon is markedly rare. We report the case of a 19-year-old woman with hemorrhagic-onset MMD who presented with grand mal seizure and subarachnoid hemorrhage. She underwent superficial temporal artery (STA)–middle cerebral artery (MCA) anastomosis combined with indirect pial synangiosis on the affected hemisphere. Intraoperatively, notable early arterial blood filling in the fine cortical vein was observed around the site of anastomosis right after the STA–MCA anastomosis under the surgical microscope and fluorescence indocyanine green video angiography. Recovery of consciousness after general anesthesia was normal, although she exhibited a focal seizure 1 hour later. Postoperative magnetic resonance imaging was not remarkable, and cerebral hemodynamics significantly improved in the acute stage after surgical revascularization. Considering the intrinsic vulnerability of the microvascular anatomy of MMD, the present case is notable because early venous filling was observed intraoperatively. This phenomenon suggests the existence of a potential arteriovenous shunt as an underlying pathology of MMD, but its implications in the early postoperative course should be further verified in a larger number of MMD patients undergoing surgical revascularization.
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Affiliation(s)
- Kikutaro Tokairin
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Taku Sugiyama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Masaki Ito
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
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Araki Y, Yokoyama K, Uda K, Kanamori F, Kurimoto M, Shiba Y, Mamiya T, Takayanagi K, Ishii K, Nishihori M, Takeuchi K, Tanahashi K, Nagata Y, Nishimura Y, Okamoto S, Sumitomo M, Izumi T, Saito R. Paradoxical symptomatic cerebral blood flow decreases after combined revascularization surgery for patients with pediatric moyamoya disease: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21628. [PMID: 36130575 PMCID: PMC9379648 DOI: 10.3171/case21628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/29/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Transient neurological deficits (TNDs) develop after cerebral revascularization in patients with moyamoya disease (MMD). The authors report a rare pediatric MMD case with extensive decreased cerebral blood flow (CBF) and prolonged TNDs after combined revascularization. OBSERVATIONS A 9-year-old boy presented with transient left upper limb weakness, and MMD was diagnosed. A right-sided combined surgery was performed. Two years after the surgery, frequent but transient facial (right-sided) and upper limb weakness appeared. The left internal carotid artery terminal stenosis had progressed. Therefore, a left combined revascularization was performed. The patient’s motor aphasia and right upper limb weakness persisted for approximately 10 days after surgery. Magnetic resonance angiography showed that the direct bypass was patent, but extensive decreases in left CBF were observed using single photon emission tomography. With adequate fluid therapy and blood pressure control, the neurological symptoms eventually disappeared, and CBF improved. LESSONS The environment of cerebral hemodynamics is heterogeneous after cerebral revascularization for MMD, and the exact mechanism of CBF decreases was not identified. TNDs are significantly associated with the onset of stroke during the early postoperative period. Therefore, appropriate treatment is desired after determining complex cerebral hemodynamics using CBF studies.
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Affiliation(s)
- Yoshio Araki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kinya Yokoyama
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kenji Uda
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Fumiaki Kanamori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Michihiro Kurimoto
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yoshiki Shiba
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takashi Mamiya
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kai Takayanagi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kazuki Ishii
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masahiro Nishihori
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kazuhito Takeuchi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Kuniaki Tanahashi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yuichi Nagata
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yusuke Nishimura
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Sho Okamoto
- Department of Neurosurgery, Aichi Rehabilitation Hospital, Aichi, Japan; and
| | - Masaki Sumitomo
- Department of Neurosurgery, Toyota Kosei Hospital, Aichi, Japan
| | - Takashi Izumi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
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Kanoke A, Fujimura M, Tashiro R, Ozaki D, Tominaga T. Transient Global Cerebral Hypoperfusion as a Characteristic Cerebral Hemodynamic Pattern in the Acute Stage after Combined Revascularization Surgery for Pediatric Moyamoya Disease: N-Isopropyl-P-[123I] Iodoamphetamine Single-Photon Emission Computed Tomography Study. Cerebrovasc Dis 2021; 51:453-460. [PMID: 34933301 DOI: 10.1159/000520801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/09/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Surgical revascularization prevents cerebral ischemic attack by improving cerebral blood flow (CBF) in both adult and pediatric patients with moyamoya disease (MMD). Uneven hemodynamic changes, including local cerebral hyperperfusion and remote ischemia, can cause delayed intracerebral hemorrhage and perioperative infarctions in adult MMD patients, but the characteristic hemodynamic pattern among pediatric MMD patients after revascularization surgery is poorly understood. METHODS This study included 16 consecutive pediatric MMD patients (age, 6-16 years; mean age, 11.3) undergoing superficial temporal artery-middle cerebral artery anastomosis combined with encephalo-duro-myo-synangiosis on 21 affected hemispheres. Perioperative management was conducted by aspirin administration and strict blood pressure control (110-130 mm Hg). We prospectively performed N-isopropyl-p-[123I] iodoamphetamine single-photon emission computed tomography on postoperative days (POD) 1 and 7 and analyzed the temporal changes in perioperative hemodynamics. RESULTS Four patients (19.0%, 4/21) exhibited immediate CBF improvement from POD 1, which was classified as "immediate redistribution pattern." In contrast, 9 (42.9%, 9/21) demonstrated transient hemispheric global hypoperfusion at POD 1 and subsequent CBF improvement at POD 7, which was defined as "transient hypoperfusion pattern." Although 8 patients, including 4 with "transient hypoperfusion pattern" (44.4, 4/9), developed mild transient neurological deterioration in the acute stage, it resolved in all 21 patients, and there were no permanent neurological deficits. DISCUSSION/CONCLUSIONS This study revealed that the "transient hypoperfusion pattern" after revascularization surgery is relatively common among pediatric MMD patients, and its outcome is favorable under strict perioperative management.
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Affiliation(s)
- Atsushi Kanoke
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan.,Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan.,Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Division of Advanced Cerebrovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ryosuke Tashiro
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Dan Ozaki
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Demura M, Oishi M, Uchiyama N, Mohri M, Miyashita K, Nakada M. Limb-shaking syndrome derived from the contralateral hemisphere following unilateral revascularisation for moyamoya disease. Surg Neurol Int 2021; 12:579. [PMID: 34877065 PMCID: PMC8645482 DOI: 10.25259/sni_937_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/04/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Moyamoya disease is a rare chronic steno-occlusive cerebrovascular disease. It may have variable clinical symptoms associated with cerebral stroke, including motor paralysis, sensory disturbances, seizures, or headaches. However, patients with moyamoya disease rarely present with involuntary movement disorders, including limb-shaking syndrome, with no previous reports of limb-shaking syndrome occurring after revascularization procedures for this disease. Although watershed shifts can elicit transient neurological deterioration after revascularisation, symptoms originating from the contralateral hemisphere following the revascularization procedure are rare. Here, we report the case of moyamoya disease wherein the patient developed limb-shaking syndrome derived from the contralateral hemisphere after unilateral revascularisation. Case Description: A 16-year-old girl presented with transient left upper and lower limb numbness and headache. Based on digital subtraction angiography, she was diagnosed with symptomatic moyamoya disease. Single-photon emission computed tomography (SPECT) showed decreased cerebral blood flow (CBF) on the right side, and she underwent direct and indirect bypasses on this side. Involuntary movements appeared in her right upper limb immediately postoperatively. SPECT showed decreased CBF to the bilateral frontal lobes. Subsequently, the patient was diagnosed with limb-shaking syndrome. After performing left-hemispheric revascularisation, the patient’s symptoms resolved, and SPECT imaging confirmed improvements in CBF to the bilateral frontal lobes. Conclusion: Revascularization for moyamoya disease can lead to watershed shifts, which can induce limb-shaking syndrome derived from abnormalities in the contralateral hemisphere of the revascularized side. For patients with new-onset limb-shaking syndrome after moyamoya revascularisation procedures, additional revascularization may be warranted for treatment of low perfusion areas.
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Affiliation(s)
- Munehiro Demura
- Department of Neurosurgery, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Masahiro Oishi
- Department of Neurosurgery, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Naoyuki Uchiyama
- Department of Neurosurgery, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Masanao Mohri
- Department of Neurosurgery, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Katsuyoshi Miyashita
- Department of Neurosurgery, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Mitsutoshi Nakada
- Department of Neurosurgery, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
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Kawanami K, Kokubo Y, Sato S, Itagaki H, Sonoda Y. A case report: An increased oxygen extraction fraction in remote ischemic lesions after revascularization for moyamoya disease with a progression of posterior cerebral artery stenosis. Acta Radiol Open 2021; 10:20584601211047241. [PMID: 34603748 PMCID: PMC8485292 DOI: 10.1177/20584601211047241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/30/2021] [Indexed: 11/16/2022] Open
Abstract
The cerebral metabolism, such as the oxygen extraction fraction (OEF), in remote ischemic lesions following revascularization for moyamoya disease (MMD) has not yet been fully elucidated. We herein report a patient with an increased OEF in a remote ischemic lesion after revascularization in a case of adult-onset MMD. A 21-year-old woman suffered from a left parietal lobe infarction due to MMD. At 2 months after onset, left superficial temporal artery (STA)–middle cerebral artery (MCA) bypass and encephalo-myo-synangiosis (EMS) were performed. The postoperative course was uneventful. 15O-positron emission tomography (PET) performed at 2 months after the first operation revealed an increased OEF in the contralateral (right) frontal lobe that was suspected of being possible remote ischemia. The patient underwent right STA-MCA bypass and EMS. 15O-PET at 14 days after the second operation revealed an increased OEF in the contralateral (left) occipital lobe that was suspected of potentially being remote ischemia caused by a watershed shift. Two years after the second surgery, left occipital artery (OA)–posterior cerebral artery (PCA) anastomosis and EMS were performed due to transient right hemianopsia. Neither rebleeding nor ischemic complications occurred 2 years after the third surgery. We need to be alert for the possible progression of PCA stenosis in MMD after revascularization. It might induce remote ischemia after revascularization. OA–PCA bypass is therefore considered to be an effective treatment option in such cases.
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Affiliation(s)
- Kanako Kawanami
- Department of Neurosurgery, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Yasuaki Kokubo
- Department of Neurosurgery, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Shinji Sato
- Department of Neurosurgery, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Hiroshi Itagaki
- Department of Neurosurgery, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Yukihiko Sonoda
- Department of Neurosurgery, Faculty of Medicine, Yamagata University, Yamagata, Japan
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Gupta SK, Narayanan R, Aggarwal A, Mohanty M, Ahuja C, Verma N, Praneeth K, Agarwal V. Outcome Following Surgical Revascularization in Patients of Moyamoya Disease with Focus on Graft Patency and Angiographic Changes. Neurol India 2021; 69:620-627. [PMID: 34169855 DOI: 10.4103/0028-3886.319228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Surgical revascularization is the mainstay of treatment in symptomatic patients of moyamoya disease (MMD). Objective The present study analyzed the postoperative angio-architecture in pediatric and adult patients of moyamoya disease. Material and Methods Patients with MMD, both ischemic and hemorrhagic, were subjected to surgery. A superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis was attempted in all. It was augmented by an encephalo-duro-myo-synangiosis), this was labelled as the combined surgical group. In patients where a direct bypass was not possible encephalo-duro-arterio-myo-synangiosis (EDAMS) was performed and these patients were put in the indirect surgery group. In the postoperative period, MRA was performed in all patients to look for (a) graft patency, (b) regression of moyamoya vessels, and (c) degree of surgical neovascularization (as quantified on adapted Matsushima and Inaba grading system). Results Eighty-two patients underwent 131 surgical revascularization procedures. A combined surgery (STA-MCA bypass and EDAMS) was performed in 100 hemispheres and indirect surgery (EDAMS) on 31 sides. In children less than 5 years of age, STA-MCA anastomosis was possible in more than 50% of patients. Clinical improvement was seen in 85.4% of patients. Postoperative MRA demonstrated a patent bypass graft in 97% of cases. Regression of moyamoya vessels was seen in half of the cases and good surgical revascularization (type A and B) was seen in more than 80% of hemispheres in the combined surgery and indirect surgery group. Conclusions Revascularization procedures led to a regression of moyamoya collaterals, appearance of surgical neo angiogenesis, and a graft patency rate of 97%. Surgical group with combined revascularization had a trend towards better collateral development.
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Affiliation(s)
- Sunil K Gupta
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajashekhar Narayanan
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Aggarwal
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manju Mohanty
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Chirag Ahuja
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Verma
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kokkula Praneeth
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivek Agarwal
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Raper DMS, Rutledge WC, Winkler EA, Meisel K, Callen AL, Cooke DL, Abla AA. Controversies and Advances in Adult Intracranial Bypass Surgery in 2020. Oper Neurosurg (Hagerstown) 2021; 20:1-7. [PMID: 32895706 DOI: 10.1093/ons/opaa276] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/11/2020] [Indexed: 02/02/2023] Open
Abstract
Cerebral revascularization utilizing a variety of bypass techniques can provide either flow augmentation or flow replacement in the treatment of a range of intracranial pathologies, including moyamoya disease, intracranial atherosclerotic disease, and complex aneurysms that are not amenable to endovascular or simple surgical techniques. Though once routine, the publication of high-quality prospective evidence, along with the development of flow-diverting stents, has limited the indications for extracranial-to-intracranial (EC-IC) bypass. Nevertheless, advances in imaging, assessment of cerebral hemodynamics, and surgical technique have changed the risk-benefit calculus for EC-IC bypass. New variations of revascularization surgery involving multiple anastomoses, flow preserving solutions, IC-IC constructs, and posterior circulation bypasses have been pioneered for otherwise difficult to treat pathology including giant aneurysms, dolichoectasia, and medically refractory intracranial atherosclerosis. This review provides a practical update on recent advances in adult intracranial bypass surgery.
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Affiliation(s)
- Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, California
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Karl Meisel
- Department of Neurology, University of California, San Francisco, California
| | - Andrew L Callen
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California
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Hayashi T, Kimiwada T, Karibe H, Shirane R, Sasaki T, Metoki H, Tominaga T. Preoperative Risks of Cerebral Infarction in Pediatric Moyamoya Disease. Stroke 2021; 52:2302-2310. [PMID: 33971740 DOI: 10.1161/strokeaha.120.032699] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Toshiaki Hayashi
- Department of Neurosurgery, Miyagi Children's Hospital, Sendai, Japan (T.H., T.K., R.S.)
| | - Tomomi Kimiwada
- Department of Neurosurgery, Miyagi Children's Hospital, Sendai, Japan (T.H., T.K., R.S.)
| | - Hiroshi Karibe
- Department of Neurosurgery, Sendai City Hospital, Japan (H.K.)
| | - Reizo Shirane
- Department of Neurosurgery, Miyagi Children's Hospital, Sendai, Japan (T.H., T.K., R.S.)
| | - Tatsuya Sasaki
- Department of Neurosurgery (T.S.), Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Hirohito Metoki
- Division of Public Health, Hygiene and Epidemiology (H.M.), Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan (T.T.)
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Postoperative stroke and neurological outcomes in the early phase after revascularization surgeries for moyamoya disease: an age-stratified comparative analysis. Neurosurg Rev 2021; 44:2785-2795. [PMID: 33415521 DOI: 10.1007/s10143-020-01459-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 11/16/2020] [Accepted: 12/09/2020] [Indexed: 01/09/2023]
Abstract
Stroke and neurological outcomes in the early phase following revascularization for moyamoya disease (MMD) may depend on the patient's age. In this study, an age-stratified comparative analysis was performed to clarify this issue. We reviewed 105 MMD patients who underwent 179 revascularization surgeries. The demographic characteristics were collected in four age groups (≤ 5 and 6-17 years for pediatric patients and 18-49 and ≥ 50 years for adults). Additionally, we assessed the incidence of subsequent stroke and deterioration of modified Rankin Scale (mRS) score. Then, we evaluated predictors of postoperative stroke and mRS deterioration using logistic regression. The mean patient age was 26.2 ± 18.5 years. No significant difference in the incidence of postoperative stroke was observed between age groups; however, the incidence tended to be increased among patients aged ≤ 5 years (17.9%) and patients aged ≥ 50 years (16.7%). Deterioration of mRS scores was significantly associated with ages ≤ 5 years (17.9%) and ≥ 50 years (11.1%). Logistic regression showed that posterior cerebral artery involvement (odds ratio [OR], 4.6) and postoperative transient neurological events (TNEs) (OR, 5.93) were risk factors for postoperative stroke. Age ≤ 5 years (OR, 9.73), postoperative TNEs (OR, 7.38), and postoperative stroke (OR, 49) were identified as predictors of unfavorable neurological outcomes. The novel feature of this comparative analysis by age group is that membership in the early-childhood MMD patient group (under 5 years old) was an independent risk factor for unfavorable short-term neurological outcomes and was mainly associated with the incidence of postoperative severe cerebral infarction.
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Fujimura M, Tominaga T. Characteristic Pattern of the Cerebral Hemodynamic Changes in the Acute Stage After Combined Revascularization Surgery for Adult Moyamoya Disease: N-isopropyl-p-[ 123I] iodoamphetamine Single-Photon Emission Computed Tomography Study. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 132:57-61. [PMID: 33973029 DOI: 10.1007/978-3-030-63453-7_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Surgical revascularization for moyamoya disease (MMD) prevents cerebral ischemic attack by improving cerebral blood flow (CBF) and could also reduce the risk of re-bleeding in hemorrhagic-onset patients. We sought to clarify the cerebral hemodynamic changes in the acute stage after revascularization surgery for adult MMD. MATERIALS AND METHODS The present study includes 54 consecutive adult patients with MMD (21-76 years old, 43.1 average), undergoing superficial temporal artery-middle cerebral artery anastomosis with indirect pial synangiosis on 65 affected hemispheres. We prospectively performed single-photon emission computed tomography (SPECT) at postoperative day (POD) 1 and 7 of 65 surgeries. Perioperative management was conducted with strict blood pressure control (100-130 mmHg) and minocycline hydrochloride administration. RESULTS The outcome of 65 surgeries was favorable except for one (1.5%), which manifested as delayed intracerebral hemorrhage due to local hyperperfusion. The postoperative SPECT revealed the characteristic CBF improvement pattern with transient local hyperperfusion (POD1) and subsequent distribution of CBF in wider vascular territory (POD7) on 37 hemispheres (56.9%, 37/65). CONCLUSION The revascularization surgery is a safe and effective treatment for adult MMD, while transient local hyperperfusion should be strictly managed by intensive perioperative care.
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Affiliation(s)
- Miki Fujimura
- Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan.
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University, Sendai, Japan
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TASHIRO R, FUJIMURA M, NISHIZAWA T, SAITO A, TOMINAGA T. Cerebral Hyperperfusion and Concomitant Reversible Lesion at the Splenium after Direct Revascularization Surgery for Adult Moyamoya Disease: Possible Involvement of MERS and Watershed Shift Phenomenon. NMC Case Rep J 2021; 8:451-456. [PMID: 35079503 PMCID: PMC8769435 DOI: 10.2176/nmccrj.cr.2020-0337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/13/2021] [Indexed: 11/20/2022] Open
Abstract
Superficial temporal artery (STA)–middle cerebral artery (MCA) bypass is the standard surgical treatment for moyamoya disease (MMD). Local cerebral hyperperfusion (CHP) is one of the potential complications, which could enhance intrinsic inflammation and oxidative stress in MMD patients and accompany concomitant watershed shift (WS) phenomenon, defined as the paradoxical decrease in the cerebral blood flow (CBF) near the site of CHP. However, CHP and simultaneous remote reversible lesion at the splenium have never been reported. A 22-year-old man with ischemic-onset MMD underwent left STA–MCA bypass. Although asymptomatic, local CHP and a paradoxical CBF decrease at the splenium were evident on N-isopropyl-p-[123I] iodoamphetamine single-photon emission computed tomography 1 day after surgery. The patient was maintained under strict blood pressure control, but he subsequently developed transient delirium 4 days after surgery. MRI revealed a high-signal-intensity lesion with a low apparent diffusion coefficient at the splenium. After continued intensive management, the splenial lesion disappeared 14 days after surgery. The patient was discharged without neurological deficits. Catheter angiography 2 months later confirmed marked regression of posterior-to-anterior collaterals via the posterior pericallosal artery, suggesting dynamic watershed shift between blood flow supplies from the posterior and anterior circulation. Mild encephalitis/encephalopathy with a reversible splenial lesion could explain the pathophysiology of the postoperative splenial lesion in this case, which is associated with generation of oxidative stress, enhanced inflammation, and metabolic abnormalities. Rapid postoperative hemodynamic changes, including local CHP and concomitant WS phenomenon, might participate in the formation of the splenial lesion.
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Affiliation(s)
- Ryosuke TASHIRO
- Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan
| | - Miki FUJIMURA
- Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan
| | - Taketo NISHIZAWA
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Atsushi SAITO
- Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan
| | - Teiji TOMINAGA
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Abstract
Moyamoya disease (MMD) is a chronic, occlusive cerebrovascular disease with unknown etiology, which is characterized by progressive steno-occlusive changes at the terminal portion of the internal carotid artery and an abnormal vascular network formation at the base of the brain. MMD has an intrinsic temporal nature to attempt a gradual conversion of the vascular supply for the brain from intracranial/internal carotid (IC) system to extracranial/external carotid (EC) system, so called "IC-EC conversion." Compatible cerebrovascular angio-architecture could be found in association with a variety of conditions such as neuro-fibromatosis type-1, Down's syndrome and cranial irradiation, which is called as moyamoya syndrome, akin/quasi MMD, or secondary MMD. Diagnosis of moyamoya vasculopathy, either idiopathic or secondary, is clinically important because flow-augmentation bypass is markedly beneficial for this entity to prevent cerebral ischemic attack by improving cerebral blood flow. Moreover, recent evidence indicated that flow-augmentation bypass could prevent re-bleeding in hemorrhagic MMD patients. Based on these backgrounds, there is a worldwide increase in the number of MMD patients undergoing bypass surgery. We sought to demonstrate our standard surgical procedure of superficial temporal artery-middle cerebral artery bypass with indirect pial synangiosis for MMD and its technical pitfall. We also discuss the intrinsic peri-operative hemodynamics of MMD after bypass surgery, including local cerebral hyper-perfusion and characteristic hemodynamic ischemia caused by watershed shift phenomenon. The aim of this review article is to understand the basic pathology of MMD, which is essential for complication avoidance while conducting flow-augmentation bypass for MMD.
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Affiliation(s)
- Miki Fujimura
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan - .,Division of Advanced Cerebrovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan -
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Tashiro R, Fujimura M, Katsuki M, Nishizawa T, Tomata Y, Niizuma K, Tominaga T. Prolonged/delayed cerebral hyperperfusion in adult patients with moyamoya disease with RNF213 gene polymorphism c.14576G>A (rs112735431) after superficial temporal artery-middle cerebral artery anastomosis. J Neurosurg 2020; 135:417-424. [PMID: 33096527 DOI: 10.3171/2020.6.jns201037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/08/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is the standard surgical management for moyamoya disease (MMD), whereas cerebral hyperperfusion (CHP) is one of the potential complications of this procedure that can result in delayed intracerebral hemorrhage and/or neurological deterioration. Recent advances in perioperative management in the early postoperative period have significantly reduced the risk of CHP syndrome, but delayed intracerebral hemorrhage and prolonged/delayed CHP are still major clinical issues. The clinical implication of RNF213 gene polymorphism c.14576G>A (rs112735431), a susceptibility variant for MMD, includes early disease onset and a more severe form of MMD, but its significance in perioperative pathology is unknown. Thus, the authors investigated the role of RNF213 polymorphism in perioperative hemodynamics after STA-MCA anastomosis for MMD. METHODS Among 96 consecutive adult patients with MMD comprising 105 hemispheres who underwent serial quantitative cerebral blood flow (CBF) analysis by N-isopropyl-p-[123I]iodoamphetamine SPECT after STA-MCA anastomosis, 66 patients consented to genetic analysis of RNF213. Patients were routinely maintained under strict blood pressure control during and after surgery. The local CBF values were quantified at the vascular territory supplied by the bypass on postoperative days (PODs) 1 and 7. The authors defined the radiological CHP phenomenon as a local CBF increase of more than 150% compared with the preoperative values, and then they investigated the correlation between RNF213 polymorphism and the development of CHP. RESULTS CHP at POD 1 was observed in 23 hemispheres (23/73 hemispheres [31.5%]), and its incidence was not statistically different between groups (15/41 [36.6%] in RNF213-mutant group vs 8/32 [25.0%] in RNF213-wild type (WT) group; p = 0.321). CHP on POD 7, which is a relatively late period of the CHP phenomenon in MMD, was evident in 9 patients (9/73 hemispheres [12.3%]) after STA-MCA anastomosis. This prolonged/delayed CHP was exclusively observed in the RNF213-mutant group (9/41 [22.0%] in the RNF213-mutant group vs 0/32 [0.0%] in the RNF213-WT group; p = 0.004). Multivariate analysis revealed that RNF213 polymorphism was significantly associated with CBF increase on POD 7 (OR 5.47, 95% CI 1.06-28.35; p = 0.043). CONCLUSIONS Prolonged/delayed CHP after revascularization surgery was exclusively found in the RNF213-mutant group. Although the exact mechanism underlying the contribution of RNF213 polymorphism to the prolonged/delayed CBF increase in patients with MMD is unclear, the current study suggests that genetic analysis of RNF213 is useful for predicting the perioperative pathology of patients with MMD.
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Affiliation(s)
- Ryosuke Tashiro
- 1Department of Neurosurgery, Kohnan Hospital, Sendai
- 2Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai; and
| | - Miki Fujimura
- 1Department of Neurosurgery, Kohnan Hospital, Sendai
| | - Masahito Katsuki
- 1Department of Neurosurgery, Kohnan Hospital, Sendai
- 2Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai; and
| | | | - Yasutake Tomata
- 3Division of Epidemiology, Department of Health Informatics and Public Health, Tohoku University School of Public Health, Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Kuniyasu Niizuma
- 2Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai; and
| | - Teiji Tominaga
- 2Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai; and
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Assessment of Transient Cerebral Hemodynamic Disturbance via Whole-Brain Computed Tomography Perfusion After Extracranial-Intracranial Bypass in Ischemic Moyamoya Disease. World Neurosurg 2020; 146:e112-e121. [PMID: 33069937 DOI: 10.1016/j.wneu.2020.10.046] [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: 07/25/2020] [Revised: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To assess the cerebral hemodynamic data associated with transient cerebral hemodynamic disturbance (TCHD), including cerebral hyperperfusion syndrome (CHS) and watershed shift ischemia (WSI), by whole-brain (WB) computed tomography perfusion (CTP) before and after revascularization for ischemic moyamoya disease. METHODS A total of 115 consecutive patients with ischemic moyamoya disease underwent revascularization. All patients underwent WB-CTP 24 hours before operation and on the day of onset of TCHD and 6 months after revascularization. The volumes of delay time (DT) >3 seconds and mismatch and relative cerebral blood flow <30% were calculated in 3 time points. RESULTS Of the 115 patients, 18 115 had TCHD, comprising 10 with CHS and 8 with WSI. Compared with the brain volume of DT >3 seconds before revascularization, the volume decreased significantly (P < 0.05) on the day of CHS. The volume of mismatch in 3 time points indicated no significant differences (P > 0.05). The volume of relative cerebral blood flow <30% showed obvious differences of significance among 10 patients with CHS (P < 0.05) at 3 time points. In the WSI group, the volume of DT >3 seconds, mismatch, and DT >3 seconds showed significant differences, relatively (P < 0.05), at 3 time points. At the time of onset of TCHD, DT >3 seconds and mismatch in the CHS group were dramatically lower than those in the WSI group (P < 0.05). DT >3 seconds in the no-TCHD group showed significant differences (P < 0.05) at 3 time points. CONCLUSIONS WB-CTP could be used to assess the cerebral hemodynamic characteristics before and after revascularization. DT >3 seconds and mismatch played important roles in evaluating distinct features of TCHD.
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Takahashi S, Horiguchi T. Relationship between ischaemic symptoms during the early postoperative period in patients with moyamoya disease and changes in the cerebellar asymmetry index. Clin Neurol Neurosurg 2020; 197:106090. [PMID: 32693340 DOI: 10.1016/j.clineuro.2020.106090] [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: 06/08/2020] [Revised: 07/11/2020] [Accepted: 07/13/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of this study was to clarify the relationship between ischaemic symptoms during the early postoperative period in patients with moyamoya disease and changes in the cerebellar asymmetry index (AI), a parameter used to quantitatively identify crossed cerebellar diaschisis (CCD). PATIENTS AND METHODS We analysed the data of 18 patients with moyamoya disease who underwent quantitative IMP-cerebral blood flow SPECT at least once during the follow-up period. Cerebellar AI scores were calculated using the CBF of the cerebellum calculated automatically from multiple slices of SPECT images with automated ROI setup software and categorized and statistically examined according to the presence or absence of ischaemic symptoms. RESULTS The cerebellar AI calculated from SPECT performed in the patients who presented with ischaemic symptoms was 0.094 ± 0.023 (mean ± SD), which was significantly elevated compared to the value of 0.013 ± 0.025 (mean ± SD) calculated from SPECT performed when the patients did not present with ischaemic symptoms (p < 0.0001). Limiting the time of SPECT to calculate the cerebellar AI to be compared to the acute phase within 2 weeks after surgery did not change this trend, and again, the cerebellar AI was statistically significantly elevated in the presence of ischaemic symptoms (0.094 ± 0.023 (mean ± SD)) compared to the AI in the absence of ischaemic symptoms (0.000081 ± 0.026 (mean ± SD)) (p = 0.0003). In patients who underwent quantitative SPECT in the acute phase during the first postoperative week, the cerebellar AI values calculated from the results of SPECT performed during the preoperative period as well as multiple times during postoperative period were followed over time in each case. The cerebellar AI increased in patients who presented with symptoms of ischaemia postoperatively but then tended to decrease reversibly and approach zero with the disappearance of symptoms of ischaemia. CONCLUSIONS Since the cerebellar AI reflects the symptom of ischaemia in patients with moyamoya disease, especially in the early stage after revascularization surgery, and is a parameter that improves with symptom improvement, it seems to be useful for understanding the state of cerebral blood flow after bypass surgery in patients with moyamoya disease.
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Affiliation(s)
- Satoshi Takahashi
- Department of Neurosurgery, Keio University, School of Medicine, Tokyo, Japan.
| | - Takashi Horiguchi
- Department of Neurosurgery, Keio University, School of Medicine, Tokyo, Japan
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Nielsen TH, Abhinav K, Sussman ES, Han SS, Weng Y, Bell-Stephens T, Heit JJ, Steinberg GK. Direct versus indirect bypass procedure for the treatment of ischemic moyamoya disease: results of an individualized selection strategy. J Neurosurg 2020; 134:1578-1589. [PMID: 32534489 DOI: 10.3171/2020.3.jns192847] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The only effective treatment for ischemic moyamoya disease (iMMD) is cerebral revascularization by an extracranial to intracranial bypass. The preferred revascularization method remains controversial: direct versus indirect bypass. The purpose of this study was to test the hypothesis that method choice should be personalized based on angiographic, hemodynamic, and clinical characteristics to balance the risk of perioperative major stroke against treatment efficacy. METHODS Patients with iMMD were identified retrospectively from a prospectively maintained database. Those with mild to moderate internal carotid artery or M1 segment stenosis, preserved cerebrovascular reserve, intraoperative M4 segment anterograde flow ≥ 8 ml/min, or the absence of frequent and severe transient ischemic attacks (TIAs) or stroke had been assigned to indirect bypass. The criteria for direct bypass were severe ICA or M1 segment stenosis or occlusion, impaired cerebrovascular reserve or steal phenomenon, intraoperative M4 segment retrograde flow or anterograde flow < 8 ml/min, and the presence of frequent and severe TIAs or clinical strokes. The primary study endpoint was MRI-confirmed symptomatic stroke ≤ 7 days postoperatively resulting in a decline in the modified Rankin Scale (mRS) score from preoperatively to 6 months postoperatively. As a secondary endpoint, the authors assessed 6-month postoperative DSA-demonstrated revascularization, which was classified as < 1/3, 1/3-2/3, or > 2/3 of the middle cerebral artery territory. RESULTS One hundred thirty-eight patients with iMMD affecting 195 hemispheres revascularized in the period from March 2016 to June 2018 were included in this analysis. One hundred thirty-three hemispheres were revascularized with direct bypass and 62 with indirect bypass. The perioperative stroke rate was 4.7% and 6.8% in the direct and indirect groups, respectively (p = 0.36). Degree of revascularization was higher in the direct bypass group (p = 0.03). The proportion of patients improving to an mRS score 0-1 (from preoperatively to 6 months postoperatively) tended to be higher in the direct bypass group, although the difference between the two bypass groups was not statistically significant (p = 0.27). CONCLUSIONS The selective use of an indirect bypass procedure for iMMD did not decrease the perioperative stroke rate. Direct bypass provided a significantly higher degree of revascularization. The authors conclude that direct bypass is the treatment of choice for iMMD.
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Affiliation(s)
- Troels H Nielsen
- 1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine
| | - Kumar Abhinav
- 1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine
| | - Eric S Sussman
- 1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine
| | - Summer S Han
- 1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine.,2Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine; and
| | - Yingjie Weng
- 2Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine; and
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- 1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine
| | - Jeremy J Heit
- 3Department of Radiology, NeuroInterventional Radiology Section, and Stanford Stroke Center, Stanford University School of Medicine, Stanford, California
| | - Gary K Steinberg
- 1Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine
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Zhang M, Tang J, Liu N, Xue Y, Ren X, Fu J. Postoperative Functional Outcomes and Prognostic Factors in Two Types of Adult Moyamoya Diseases. J Stroke Cerebrovasc Dis 2020; 29:104846. [PMID: 32439351 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104846] [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: 02/19/2020] [Accepted: 03/24/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND To determine the functional outcomes in each period for adult ischemic and hemorrhagic Moyamoya disease (MMD) patients and identify prognostic factors. METHODS The current retrospective study reviewed consecutive adult MMD patients surgically treated from January 2012 to June 2017. Perioperative clinical data were collected and follow-up was conducted via telephone interviews. Functional outcomes and prognostic factors were analyzed. RESULTS A total of 219 ischemic MMD patients (268 hemispheres) and 157 hemorrhagic patients (193 hemispheres) were included. The median follow-up time was 18 months (3-69 months). MMD type had no significant effect on the modified Rankin Scale(mRS) score at discharge. Perioperative complications (P = 0.004) and the mRS score at baseline (P < 0.001) were risk factors correlated with the short-term functional outcomes in both groups, while diabetes mellitus (DM, P = 0.022) also played a role in the ischemic group. During the follow-up period, functional outcomes obviously improved in both groups, but two groups showed nonproportional cumulative curves for favorable functional outcomes (log-rank test, P = 0.483). Stroke recurrence (P < 0.001) and mRS at discharge (P < 0.001) were common factors related with long-term functional outcomes in two types of MMD patients. Particularly, female patients with ischemic MMD were more likely to have higher mRS scores (P = 0.028) and Suzuki stage was positively associated with long-term functional outcomes in hemorrhagic group (P = 0.044). CONCLUSIONS MMD type had no significant effect on prognosis while both types of MMD patients showed overall significant improvements in functional outcomes after surgery. Different types of MMD patients have distinct prognostic factors for short-term and long-term functional outcomes.
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Affiliation(s)
- Miaoyi Zhang
- Department of Neurology, North Huashan hospital, Fudan University, No.108 Lu Xiang Road, Shanghai 201900, China
| | - Jie Tang
- Department of Neurology, Huashan Hospital, Fudan University, No.12 Wulumuqi Zhong Road, Jing an District, Shanghai 200040, China
| | - Na Liu
- Department of Neurology, Huashan Hospital, Fudan University, No.12 Wulumuqi Zhong Road, Jing an District, Shanghai 200040, China
| | - Yang Xue
- Department of Neurology, Huashan Hospital, Fudan University, No.12 Wulumuqi Zhong Road, Jing an District, Shanghai 200040, China
| | - Xue Ren
- Department of Neurology, Huashan Hospital, Fudan University, No.12 Wulumuqi Zhong Road, Jing an District, Shanghai 200040, China
| | - Jianhui Fu
- Department of Neurology, North Huashan hospital, Fudan University, No.108 Lu Xiang Road, Shanghai 201900, China; Department of Neurology, Huashan Hospital, Fudan University, No.12 Wulumuqi Zhong Road, Jing an District, Shanghai 200040, China.
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Li Z, Lu J, Ma L, Wu C, Xu Z, Chen X, Ye X, Wang R, Zhao Y. dl-3-n-butylphthalide for alleviation of neurological deficit after combined extracranial-intracranial revascularization for moyamoya disease: a propensity score-matched analysis. J Neurosurg 2020; 132:421-433. [PMID: 30771781 DOI: 10.3171/2018.10.jns182152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 10/15/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Postoperative neurological deficits impair the overall outcome of revascularization surgery for patients with moyamoya disease (MMD). dl-3-n-butylphthalide (NBP) is approved for the treatment of ischemic stroke in China. This pilot study evaluated the effect of NBP on perioperative stroke and neurological deficits in patients with MMD. METHODS The authors studied cases in which patients underwent combined revascularization surgery for MMD at their institution, with or without NBP administration. The overall study group included 164 patients (213 surgically treated hemispheres), including 49 patients who received NBP (25 mg twice daily) for 7 postoperative days. The incidence of perioperative stroke and transient neurological deficit (TND) and the severity of neurological deficits were compared between 49 propensity score-matched case pairs with or without NBP treatment. Subgroup analyses by type of onset and preoperative neurological status were also performed to determine specific characteristics of patients who might benefit from NBP administration. RESULTS In the overall cohort, baseline characteristics differed with respect to preoperative stroke and modified Rankin Scale (mRS) score between patients who received NBP and those who did not receive it. In the 49 propensity score-matched pairs, postoperative stroke was observed in 11 patients and TND occurred in 21 patients, with no significant difference in incidence between the 2 groups. However, the TND was less severe in the NBP-treated group (p = 0.01). At 1 month after surgery, the neurological outcome was more favorable (p = 0.001) and the disability-free recovery rate was higher in patients with NBP treatment (p < 0.001). The number of patients who experienced an improved neurological function, compared to preoperative function, as measured by mRS, was greater in the NBP group than in the no-NBP group (p < 0.001). Multivariable analysis revealed that NBP administration was associated with decreased severity of TND (OR 0.28, p = 0.02), improved neurological function (OR 65.29, p = 0.04), and lower postoperative mRS score (OR 0.06, p < 0.001). These beneficial effects of NBP remained significant in ischemic type MMD and patients with preoperative mRS scores of 2 or greater. CONCLUSIONS Postoperative administration of NBP may alleviate perioperative neurological deficits after revascularization surgery for MMD, especially in patients with ischemic MMD and unfavorable preoperative status. The results of this study suggest that randomized controlled trials to assess the potential benefit of NBP in patients with MMD may be warranted.
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Affiliation(s)
- Zongze Li
- 1Department of Neurosurgery, Peking University International Hospital
| | - Junlin Lu
- 1Department of Neurosurgery, Peking University International Hospital.,Departments of2Neurosurgery and
| | - Li Ma
- 1Department of Neurosurgery, Peking University International Hospital.,Departments of2Neurosurgery and.,3China National Clinical Research Center for Neurological Diseases
| | - Chunxue Wu
- 4Neuroradiology, Beijing Tiantan Hospital, Capital Medical University
| | - Zongsheng Xu
- 1Department of Neurosurgery, Peking University International Hospital
| | - Xiaolin Chen
- 1Department of Neurosurgery, Peking University International Hospital.,Departments of2Neurosurgery and.,3China National Clinical Research Center for Neurological Diseases
| | - Xun Ye
- 1Department of Neurosurgery, Peking University International Hospital.,Departments of2Neurosurgery and.,3China National Clinical Research Center for Neurological Diseases
| | - Rong Wang
- 1Department of Neurosurgery, Peking University International Hospital.,Departments of2Neurosurgery and.,3China National Clinical Research Center for Neurological Diseases
| | - Yuanli Zhao
- 1Department of Neurosurgery, Peking University International Hospital.,Departments of2Neurosurgery and.,3China National Clinical Research Center for Neurological Diseases.,5Center of Stroke, Beijing Institute for Brain Disorders; and.,6Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, P. R. China
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Transient neurological deterioration due to watershed shift after STA-MCA bypass surgery in acute atherosclerotic occlusion. J Clin Neurosci 2020; 73:111-117. [DOI: 10.1016/j.jocn.2020.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/02/2019] [Accepted: 01/04/2020] [Indexed: 11/21/2022]
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Uchino H, Kazumata K, Ito M, Nakayama N, Kuroda S, Houkin K. Crossed cerebellar diaschisis as an indicator of severe cerebral hyperperfusion after direct bypass for moyamoya disease. Neurosurg Rev 2020; 44:599-605. [PMID: 32076897 DOI: 10.1007/s10143-020-01265-8] [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: 12/11/2019] [Revised: 01/21/2020] [Accepted: 02/10/2020] [Indexed: 10/25/2022]
Abstract
Cerebral hyperperfusion (HP) complicates the postoperative course of patients with moyamoya disease (MMD) after direct revascularization surgery. Crossed cerebellar diaschisis (CCD) has been considered to be rarely associated with HP after revascularization surgery. This study aimed to describe the clinical features and factors associated with CCD secondary to cerebral HP after revascularization surgery for MMD. We analyzed 150 consecutive hemispheres including 101 in adults and 49 in pediatric patients who underwent combined direct and indirect bypass for MMD. Using single-photon emission computed tomography (SPECT), serial cerebral blood flow (CBF) was measured immediately after the surgery and on postoperative days 2 and 7. Pre- and postoperative voxel-based analysis of SPECT findings was performed to compare the changes in regional CBF. Multivariate logistic regression analysis was performed to test the effect of multiple variables on CCD. Asymptomatic and symptomatic HP was observed in 41.3% (62/150) and 16.7% (25/150) of the operated hemispheres, respectively. CCD was observed in 18.4% (16/87) of these hemispheres with radiological HP. Multivariate analysis revealed that the occurrence of CCD was significantly associated with symptomatic HP (p = 0.0015). Voxel-based analysis showed that the CBF increase in the operated frontal cortex, and the CBF reduction in the contralateral cerebellar hemisphere on day 7 were significantly larger in symptomatic HP than in asymptomatic HP (median 11.3% vs 7.5%; - 6.0% vs - 1.7%, respectively). CCD secondary to postoperative HP is more common than anticipated in MMD. CCD could potentially be used as an indicator of severe postoperative HP in patients with MMD.
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Affiliation(s)
- Haruto Uchino
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | - Ken Kazumata
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Masaki Ito
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Naoki Nakayama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Satoshi Kuroda
- Department of Neurosurgery, University of Toyama, Toyama, Japan
| | - Kiyohiro Houkin
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Zhang J, Li S, Fujimura M, Lau TY, Wu X, Hu M, Zheng H, Xu H, Zhao W, Li X, Chen J. Hemodynamic analysis of the recipient parasylvian cortical arteries for predicting postoperative hyperperfusion during STA-MCA bypass in adult patients with moyamoya disease. J Neurosurg 2019; 134:17-24. [PMID: 31881540 DOI: 10.3171/2019.10.jns191207] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Superficial temporal artery-middle cerebral artery (STA-MCA) bypass is a common approach for treating moyamoya disease (MMD); however, the selection of recipient vessels is still controversial, and its relationship with postoperative cerebral hyperperfusion (CHP) has not been revealed. The aim of the study was to investigate the relationship between the hemodynamic sources of the recipient parasylvian cortical arteries (PSCAs) and the occurrence of postoperative CHP. METHODS The authors retrospectively analyzed the clinical data from 68 adult patients (75 hemispheres) with MMD who underwent STA-MCA bypass. Based on their hemodynamic sources from the MCA and non-MCAs, the PSCAs were classified as M-PSCAs and non-M-PSCAs, and their distributional characteristics were studied. Moreover, the patients' demographics, incidence of postoperative CHP, and post- and preoperative relative cerebral blood flow values were examined. RESULTS The digital subtraction angiography analysis demonstrated that 40% (30/75) of the recipient PSCAs had no hemodynamic relationship with the MCA. The post- and preoperative relative cerebral blood flow values of the M-PSCA group were significantly higher than those of the non-M-PSCA group (p < 0.001). Multivariate analysis revealed that the hemodynamic source of PSCAs from the MCA was significantly associated with the development of focal (p = 0.003) and symptomatic (p = 0.021) CHP. Twelve (85.7%) of the 14 patients with symptomatic CHP and all 4 (100%) patients with postoperative hemorrhage were from the M-PSCA group. CONCLUSIONS This study revealed that direct anastomoses of PSCAs with anterograde hemodynamic sources from the MCA had a high risk of postoperative CHP during STA-MCA bypass in adult patients with MMD.
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Affiliation(s)
- Jianjian Zhang
- 1Department of Neurosurgery, Zhongnan Hospital of Wuhan University
| | - Sirui Li
- 2Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Miki Fujimura
- 3Department of Neurosurgery, Kohnan Hospital, Sendai, Japan
| | - Tsz Yeung Lau
- 4Department of Neurosurgery, Lakeland Regional Hospital, University of South Florida, Lakeland, Florida; and
| | - Xiaolin Wu
- 1Department of Neurosurgery, Zhongnan Hospital of Wuhan University
| | - Miao Hu
- 1Department of Neurosurgery, Zhongnan Hospital of Wuhan University
| | - Hanpei Zheng
- 2Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Haibo Xu
- 2Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wenyuan Zhao
- 1Department of Neurosurgery, Zhongnan Hospital of Wuhan University
| | - Xiang Li
- 5Queensland Brain Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Jincao Chen
- 1Department of Neurosurgery, Zhongnan Hospital of Wuhan University
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Choi JW, Chong S, Phi JH, Lee JY, Kim HS, Chae JH, Lee J, Kim SK. Postoperative Symptomatic Cerebral Infarction in Pediatric Moyamoya Disease: Risk Factors and Clinical Outcome. World Neurosurg 2019; 136:e158-e164. [PMID: 31870818 DOI: 10.1016/j.wneu.2019.12.072] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 12/11/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Indirect bypass surgery is used to improve the hemodynamic status of pediatric patients with moyamoya disease (MMD). Symptomatic cerebral infarction during the early postoperative period may be the most frustrating complication. This study was conducted to investigate the factors associated with early postoperative symptomatic cerebral infarction. METHODS Between January 2000 and February 2014, we performed 1241 indirect bypass surgeries in 659 pediatric MMD patients. Symptomatic infarction during the early postoperative period was diagnosed in 63 operations in 61 patients. RESULTS The overall incidence of symptomatic cerebral infarction after indirect bypass surgery was 5.1%. The median age of the patients with postoperative infarction was 6 years (mean, 6.4 years; range, 1-15 years). The performance of 2 craniotomies in single operation was associated with a higher rate of cerebral infarction. Moreover, the incidence was higher in young patients (age <6 years) compared with older patients. In a matched analysis, an immediate postoperative hemoglobin level >13 g/dL was associated with decreased risk of infarction (odds ratio, 0.144; P = 0.003). Mutation of the methylenetetrahydrofolate reductase (MTHFR) gene occurred in a relatively high proportion of our infarction cohort. CONCLUSIONS Postoperative symptomatic infarctions can occur despite a unified surgical method and formulaic perioperative management protocol. Patient-centered factors, such as young age, genetic background of MTHFR, and certain medical conditions, including hyperthyroidism, renovascular hypertension, and hemolytic uremic syndrome, as well as management-related factors, including 2 craniotomies and low immediate postoperative hemoglobin level, could be risk factors for early postoperative symptomatic cerebral infarction.
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Affiliation(s)
- Jung Won Choi
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sangjoon Chong
- Department of Neurosurgery, Asan Medical Center, Seoul, Republic of Korea
| | - Ji Hoon Phi
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Yeoun Lee
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Division of Pediatric Anesthesiology and Pain Medicine, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jong Hee Chae
- Division of Pediatric Neurology, Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Joongyub Lee
- Division of Clinical Epidemiology, Medical Research Collaborating Center, Biomedical Research Institution, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
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