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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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Xu H, Ni H, Zhou C, Wang X, Wei J, Qian T, Dai Z, Lan W, Wu X, Yu J, Li X, Gao X, Xu B, Lin J. Analysis of rescue strategies for acute thrombosis during STA-MCA bypass surgery and the literature review. Acta Neurochir (Wien) 2024; 166:303. [PMID: 39042271 PMCID: PMC11266200 DOI: 10.1007/s00701-024-06194-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 07/10/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND AND OBJECTIVES STA-MCA bypass surgery is mainly used for Moyamoya disease, giant intracranial aneurysms, and resection of intracranial tumors requiring sacrifice of blood vessels. The intraoperative patency of the reconstructive vessels is critical to the efficacy of the procedure. This study aimed to evaluate the efficacy of intra-arterially infused tirofiban for the treatment of acute thrombosis during STA-MCA bypass surgery and countermeasures for acute thrombosis. METHODS This study involved 209 patients (272 hemispheres) who underwent STA-MCA surgery between November 2020 and December 2023. Intraoperative acute thrombosis occurred in eight patients (3.83%,8 hemispheres). We retrospectively reviewed the clinical and imaging data, surgical procedure, and follow-up outcomes of eight patients. We implemented the different thrombolytic methods to evaluate the optimal thrombosis management during the bypass surgery. After three months, we assessed neurological functions using the modified Rankin Scale (mRS) and conducted a literature review using PubMed. RESULTS Eight patients (four male patients and four female patients) developed acute thrombosis during the bypass surgery. Of the eight patients, two underwent re-anastomosis after thrombus removal, three received local injections of tirofiban into the anastomosis or the branches of the superficial temporal artery, and three underwent superselective intra-arterial tirofiban infusion using a microcatheter. Thrombosis were resolved, and arteries were recanalized in all patients. The mRS score was 0 in all patients. No major ischemic or hemorrhagic complications occurred. CONCLUSION Our treatment methods were efficacious in the management of acute thrombosis. Intra-arterial tirofiban administration seems to be a simple and effective treatment option for acute thrombosis during STA-MCA bypass surgery.
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Affiliation(s)
- Haitao Xu
- The First Affiliated Hospital, Health Science Center, Ningbo University, Ningbo, China
| | - Haojin Ni
- The First Affiliated Hospital, Health Science Center, Ningbo University, Ningbo, China
| | - Chenhui Zhou
- Department of Neurosurgery, Ningbo Key Laboratory of Nervous System and Brain Function, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, 315010, China
| | - Xinwen Wang
- Department of Neurology, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Jie Wei
- Department of Neurosurgery, Ningbo Key Laboratory of Nervous System and Brain Function, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, 315010, China
| | - Tiansheng Qian
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Zifeng Dai
- Department of Neurosurgery, Ningbo Key Laboratory of Nervous System and Brain Function, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, 315010, China
| | - Wenting Lan
- Department of Radiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Xin Wu
- Department of Radiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Jiacheng Yu
- Department of Radiology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Xianru Li
- Department of Neurosurgery, Ningbo Key Laboratory of Nervous System and Brain Function, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, 315010, China
| | - Xiang Gao
- Department of Neurosurgery, Ningbo Key Laboratory of Nervous System and Brain Function, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, 315010, China.
| | - Bin Xu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China.
| | - Jinghui Lin
- Department of Neurosurgery, Ningbo Key Laboratory of Nervous System and Brain Function, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, 315010, China.
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Ding J, Chang X, Ma P, Yang G, Zhang R, Li Y, Lei T, Mu L, Zhang X, Li Z, Tang J, Tang Z. Prediction of cerebral infarction after bypass surgery in adult moyamoya disease: using pulsatility index on TCD. BMC Neurol 2024; 24:198. [PMID: 38867178 PMCID: PMC11167940 DOI: 10.1186/s12883-024-03707-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 06/03/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND At present, the most effective treatment for symptomatic moyamoya disease (MMD) is surgery. However, the high incidence of postoperative complications is a serious problem plaguing the surgical treatment of MMD, especially the acute cerebral infarction. Decreased cerebrovascular reserve is an independent risk factor for ischemic infarction, and the pulsatility index (PI) of transcranial Doppler (TCD) is a common intuitive index for evaluating intracranial vascular compliance. However, the relationship between PI and the occurrence of ischemic stroke after operation is unclear. OBJECTIVE To explore whether the PI in the middle cerebral artery (MCA) could serve as a potential predictor for the occurrence of ischemic infarction after bypass surgery in MMD. METHODS We performed a retrospective analysis of data from 71 patients who underwent combined revascularization surgery, including superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and encephalo-duro-myo-synangiosis (EDMS). The patients were divided into two groups according to the median of ipsilateral MCA-PI before operation, low PI group (MCA-PI < 0.614) and high PI group (MCA-PI ≥ 0.614). Univariate and multivariate regression analysis were used to explore risk factors affecting the occurrence of postoperative cerebral infarction. RESULTS Among the 71 patients with moyamoya disease, 11 patients had cerebral infarction within one week after revascularization. Among them, 10 patients' ipsilateral MCA-PI were less than 0.614, and another one's MCA- PI is higher than 0.614. Univariate analysis showed that the lower ipsilateral MCA-PI (0.448 ± 0.109 vs. 0.637 ± 0.124; P = 0.001) and higher Suzuki stage (P = 0.025) were linked to postoperative cerebral infarction. Multivariate analysis revealed that lower ipsilateral MCA-PI was an independent risk factor for predicting postoperative cerebral infarction (adjusted OR = 14.063; 95% CI = 6.265 ~ 37.308; P = 0.009). CONCLUSIONS A lower PI in the ipsilateral MCA may predict the cerebral infarction after combined revascularization surgery with high specificity. And combined revascularization appears to be safer for the moyamoya patients in early stages.
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Affiliation(s)
- Jiangbo Ding
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, 650032, Yunnan Province, China
- Department of Neurosurgery, South Yunnan Central Hospital of Yunnan Province (The First People's Hospital of Honghe Prefecture), Mengzi, 661199, Yunnan Province, China
| | - Xuying Chang
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, 650032, Yunnan Province, China
| | - Peiyu Ma
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, 650032, Yunnan Province, China
| | - Guangwu Yang
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, 650032, Yunnan Province, China
| | - Ruoyu Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, 650032, Yunnan Province, China
| | - Yuanyuan Li
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, 650032, Yunnan Province, China
| | - Ting Lei
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, 100093, China
| | - Linjie Mu
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, 650032, Yunnan Province, China
| | - Xingkui Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, 650032, Yunnan Province, China
| | - Zhigao Li
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, 650032, Yunnan Province, China
| | - Jinwei Tang
- Department of Neurosurgery, South Yunnan Central Hospital of Yunnan Province (The First People's Hospital of Honghe Prefecture), Mengzi, 661199, Yunnan Province, China
| | - Zhiwei Tang
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, 650032, Yunnan Province, China.
- First Affiliated Hospital of Kunming Medical University, No. 295 Xichang Road, Wuhua District, Kunming City, Yunnan Province, China.
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Ran KR, Nair SK, Srinivas T, Xie ME, Kilgore CB, Ye X, Yedavalli VS, Sun LR, Jackson CM, Caplan JM, Gonzalez LF, Tamargo RJ, Huang J, Xu R. Hemoglobin Drop is Associated with Early Post-operative Stroke Following Revascularization Surgery for Moyamoya Disease. J Neurosurg Anesthesiol 2024:00008506-990000000-00109. [PMID: 38686811 DOI: 10.1097/ana.0000000000000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 03/25/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Postoperative stroke is a potentially devastating neurological complication following surgical revascularization for Moyamoya disease. We sought to evaluate whether peri-operative hemoglobin levels were associated with the risk of early post-operative stroke following revascularization surgery in adult Moyamoya patients. METHODS Adult patients having revascularization surgeries for Moyamoya disease between 1999-2022 were identified through single institutional retrospective review. Logistic regression analysis was used to test for the association between hemoglobin drop and early postoperative stroke. RESULTS In all, 106 revascularization surgeries were included in the study. A stroke occurred within 7 days after surgery in 9.4% of cases. There were no significant associations between the occurrence of an early postoperative stroke and patient age, gender, or race. Mean postoperative hemoglobin drop was greater in patients who suffered an early postoperative stroke compared with patients who did not (2.3±1.1 g/dL vs. 1.3±1.1 g/dL, respectively; P=0.034). Patients who experienced a hemoglobin drop post-operatively had 2.03 times greater odds (95% confidence interval, 1.06-4.23; P=0.040) of having a stroke than those whose hemoglobin levels were stable. Early postoperative stroke was also associated with an increase in length of hospital stay (P<0.001), discharge to a rehabilitation facility (P=0.014), and worse modified Rankin scale at 1 month (P=0.001). CONCLUSION This study found a significant association between hemoglobin drop and early postoperative stroke following revascularization surgery in adult patients with Moyamoya disease. Based on our findings, it may be prudent to avoid hemoglobin drops in Moyamoya patients undergoing surgical revascularization.
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Affiliation(s)
| | | | | | | | | | | | | | - Lisa R Sun
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
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Zhang H, Lu M, Liu S, Liu D, Liu X, Shen X, Han C, Sheng F, Cai J. Predictors of Stroke Outcomes in Conservatively Treated Patients With Moyamoya Disease: A Follow-up MRI Study. J Magn Reson Imaging 2024; 59:1456-1463. [PMID: 37357525 DOI: 10.1002/jmri.28880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 06/11/2023] [Accepted: 06/13/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND Little is known about the association between stroke and imaging and clinical features in conservatively treated patients with moyamoya disease (MMD). PURPOSE To investigate independent risk factors for stroke in conservatively treated patients with MMD during a long-term follow-up. STUDY TYPE Prospective study. SUBJECTS One hundred sixty conservatively managed patients with MMD (median age 46 years, 89 male). FIELD STRENGTH/SEQUENCE Time of flight, turbo inversion recovery magnitude T1WI, turbo spin echo (TSE) T2WI, echo-planar imaging DWI, T2-fluid attenuated inversion recovery, dynamic susceptibility contrast-magnetic resonance imaging, and pre- and post-contrast 3D TSE T1WI sequences at 3.0 Tesla. ASSESSMENT Patients were assessed at baseline and followed yearly. Ischemic and hemorrhagic stroke incidence rates were determined. Multiple demographic, clinical (modified Rankin score [mRS]), and cerebral imaging (cerebral blood volume [CBV] and concentric enhancement of arterial wall) factors at baseline were considered as potential predictors of stroke during the follow-up period. STATISTICAL TESTS Univariable and multivariable Cox proportional hazards models to calculate the hazard ratios (HRs) and corresponding 95% confidence interval (CI) for stroke. Cumulative risk of stroke was estimated by the Kaplan-Meier product-limit method. A P value <0.05 was considered statistically significant. RESULTS The median follow-up duration was 47 months. During the follow-up period, 18 (11.25%) patients experienced stroke events (13 [8.13%] ischemic, 5 [3.12%] hemorrhagic). Univariable analysis showed that 11 factors were significantly associated with stroke. After adjustment for clinical characteristics, multivariable analysis showed that mRS score ≥3 (HR, 1.99; 95% CI, 1.26-3.14), decreased CBV (HR, 5.31; 95% CI, 2.32-12.13), and concentric enhancement of the arterial wall (HR, 4.16; 95% CI, 1.55-11.15) were significantly associated with stroke. DATA CONCLUSION Decreased CBV, mRS score ≥ 3, and concentric enhancement of the arterial wall were significantly associated with increased incidence of stroke in conservatively treated MMD. EVIDENCE LEVEL 2 TECHNICAL EFFICACY: Stage 4.
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Affiliation(s)
- Hongtao Zhang
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Mingming Lu
- Department of Radiology, Pingjin Hospital, Characteristic Medical Center of Chinese People's Armed Police Force, Tianjin, China
| | - Shitong Liu
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Dongqing Liu
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xu Liu
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xuxuan Shen
- Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Cong Han
- Department of Neurosurgery, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Fugeng Sheng
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jianming Cai
- Department of Radiology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
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Onodera K, Ooigawa H, Tabata S, Kimura T, Lepic M, Suzuki K, Kurita H. Effect of revascularization surgery on cerebral hemodynamics in adult moyamoya disease. Clin Neurol Neurosurg 2024; 239:108180. [PMID: 38452713 DOI: 10.1016/j.clineuro.2024.108180] [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: 12/15/2023] [Revised: 01/31/2024] [Accepted: 02/14/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVE Few studies have reported local hemodynamic changes after revascularization surgery. This study aimed to identify regional hemodynamic changes after combined revascularization surgery for moyamoya disease using single-photon emission computed tomography with N-isopropyl-p-123I-iodoamphetamine. METHODS A total of 46 adults with moyamoya disease who underwent combined revascularization surgery from August 2009 to July 2021 at our facility were enrolled. The combined bypass procedure comprised a single direct bypass to the motor area and encephalo-duro-arterio-myo-synangiosis. The preoperative and postoperative cerebral blood flow (CBF) and cerebral vascular reserve (CVR) in the genu; precentral, central, parietal, angular, temporal, and posterior regions; splenium; hippocampus; and cerebellum were measured. To modify the examination variability, the cerebral-to-cerebellar activity ratio (CCR) was calculated by dividing the counts in the region by those in the cerebellum (CBF-CCR and CVR-CCR). RESULTS Postoperatively, asymptomatic cerebral infarction occurred in three (6.5%) patients. The CBF-CCR and CVR-CCR improved in the precentral, parietal, and temporal regions and in the overall middle cerebral artery (MCA) territory. Sub-analysis of anterior cerebral artery (ACA) and posterior cerebral artery (PCA) territory hemodynamics revealed that patients with normal preoperative hemodynamics showed no changes in the CBF-CCR and CVR-CCR postoperatively, whereas patients with preoperative perfusion impairment exhibited improved CVR-CCR in the ACA territory (0.13-0.3, p=0.019) and CBF-CCR in the PCA territory (0.93-0.96, p=0.0039). CONCLUSION Combined revascularization surgery with single bypass to the motor area improved hemodynamics in the primary targeted MCA territory and in the ACA and PCA territories among patients with preoperative hemodynamic impairment.
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Affiliation(s)
- Koki Onodera
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Japan.
| | - Hidetoshi Ooigawa
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Shinya Tabata
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Tatsuki Kimura
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Milan Lepic
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Japan; Clinic for Neurosurgery, Faculty of Medicine of the Military Medical Academy, University of Defense, Belgrade, Serbia
| | - Kaima Suzuki
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Japan
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Kurisu K, Ito M, Uchino H, Sugiyama T, Fujimura M. Long-term Outcomes of Combined Revascularization Surgery for Moyamoya Disease in the Elderly: A Single Institute Experience. Neurol Med Chir (Tokyo) 2024; 64:108-115. [PMID: 38267055 PMCID: PMC10992987 DOI: 10.2176/jns-nmc.2023-0219] [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: 09/19/2023] [Accepted: 11/18/2023] [Indexed: 01/26/2024] Open
Abstract
The opportunity to treat older patients with Moyamoya disease (MMD) is increasing. However, the surgical outcomes after combined direct and indirect revascularization for elderly patients with MMD are not fully understood, especially for those ≥60 years old. This retrospective study examined 232 consecutive hemispheres of 165 adults with MMD who underwent combined revascularization. Clinical features and surgical outcomes were compared between the elderly (≥60 years) and nonelderly group (<60 years). Thirteen (5.6%, 64.4 ± 4.0 years old) and 219 hemispheres (94.4%, 40.2 ± 10.8 years old) were included in the elderly and nonelderly group, respectively. The proportion of clinical presentations before surgery did not differ. However, the prevalence of hypertension and hyperlipidemia was significantly higher in the elderly group than in the nonelderly group. Meanwhile, hyperthyroidism was observed only in the nonelderly group. No significant intergroup differences were observed in the incidence of perioperative complications occurring within four weeks postsurgery. Notably, the elderly group was more prone to develop perioperative intracerebral hemorrhage (odds ratio (OR) 3.14, 95% confidence interval (CI) 0.45-13.5) than the nonelderly group. During a median follow-up period of 7.8 years, the incidence of stroke recurrence occurring later than four weeks postsurgery was not significantly different between the groups (hazard ratio, 1.19; 95% CI 0.133-10.6). The prevalence of independent outcomes (76.9% vs. 90.4%, P = 0.14) and mortality (7.7% vs. 1.4%, P = 0.21) did not differ significantly between the elderly and nonelderly groups, respectively. Perioperative intracerebral hemorrhage may be common in the elderly and should be considered to achieve a favorable surgical outcome.
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Affiliation(s)
- Kota Kurisu
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Masaki Ito
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Haruto Uchino
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Taku Sugiyama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
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Liu SM, Gao G, Hao FB, Liu ST, Yang RM, Zhang HD, Wang MJ, Zou ZX, Yu D, Zhang Q, Guo QB, Wang XP, Fu HG, Li JJ, Han C, Duan L. Isolated anterior cerebral artery occlusion: an atypical form of moyamoya disease. Stroke Vasc Neurol 2024:svn-2023-002992. [PMID: 38460971 DOI: 10.1136/svn-2023-002992] [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: 11/21/2023] [Accepted: 02/07/2024] [Indexed: 03/11/2024] Open
Abstract
BACKGROUND The relationship between anterior cerebral artery (ACA) occlusion and moyamoya disease (MMD) has rarely been studied. In this study, we focused on a special type of MMD: isolated ACA-occlusive MMD. We investigated clinical attributes, genotypes and progression risk factors in patients with ACA-occlusive MMD, providing initial insights into the relationship between ACA occlusion and MMD. METHODS We retrospectively analysed digital subtraction angiography (DSA) from 2486 patients and diagnosed 139 patients with ACA-occlusive MMD. RNF213 p.R4810K (rs112735431) mutation analysis was performed. Patients were categorised into progression and non-progression groups based on whether they progressed to typical MMD. Differences in clinical characteristics, neuropsychological assessment, radiological findings and genotypes were evaluated. Logistic regression analyses identified risk factors for ACA-occlusive MMD progression. RESULTS The median age of patients with ACA-occlusive MMD was 36 years, and the primary symptom was transient ischaemic attack (TIA). 72.3% of ACA-occlusive MMD patients had cognitive decline. Of 116 patients who underwent RNF213 gene mutation analysis, 90 patients (77.6%) carried the RNF213 p.R4810K GG allele and 26 (22.4%) carried the GA allele. Of 102 patients with follow-up DSA data, 40 patients (39.2%) progressed. Kaplan-Meier curve estimates indicated a higher incidence of ischaemic stroke in the progression group during follow-up (p=0.035). Younger age (p=0.041), RNF213 p.R4810K GA genotype (p=0.037) and poor collateral compensation from the middle cerebral artery (MCA) to ACA (p<0.001) were risk factors of ACA-occlusive MMD progression to typical MMD. CONCLUSIONS Cognitive decline and TIA might be the main manifestations of ACA-occlusive MMD. Isolated ACA occlusion may be an early signal of MMD. The initial lesion site of MMD is not strictly confined to the terminal portion of the internal carotid artery. Younger patients, patients with RNF213 p.R4810K GA genotype or those with inadequate MCA-to-ACA compensation are more likely to develop typical MMD.
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Affiliation(s)
- Si-Meng Liu
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Gan Gao
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Fang-Bin Hao
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Shi-Tong Liu
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Ri-Miao Yang
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Hou-di Zhang
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Min-Jie Wang
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Zheng-Xing Zou
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Dan Yu
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Qian Zhang
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Qing-Bao Guo
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Xiao-Peng Wang
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - He-Guan Fu
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jing-Jie Li
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese PLA, Beijing, China
| | - Cong Han
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Lian Duan
- Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
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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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10
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Guo L, Yang L, Li C, Zeng Y, Xu R, Wang Z, Jiang C. The clinical outcome of emergency superficial temporal artery-to-middle cerebral artery bypass in acute ischemic stroke with large vessel occlusion. Neurosurg Rev 2024; 47:25. [PMID: 38163848 PMCID: PMC10758367 DOI: 10.1007/s10143-023-02257-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/27/2023] [Accepted: 12/18/2023] [Indexed: 01/03/2024]
Abstract
The role of superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass in acute ischemic stroke (AIS) is contentious, with no evidence in patients with AIS and large vessel occlusion (AIS-LVO). We conducted a cohort study to assess emergency STA-MCA outcomes in AIS-LVO and a meta-analysis to evaluate STA-MCA outcomes in early AIS treatment. From January 2018 to March 2021, we consecutively recruited newly diagnosed AIS-LVO patients, dividing them into STA-MCA and non-STA-MCA groups. To evaluate the neurological status and outcomes, we employed the National Institutes of Health Stroke Scale (NIHSS) during the acute phase and the modified Rankin Scale (mRS) during the follow-up period. Additionally, we conducted a meta-analysis encompassing all available clinical studies to assess the impact of STA-MCA on patients with AIS. In the cohort study (56 patients), we observed more significant neurological improvement in the STA-MCA group at two weeks (p = 0.030). However, there was no difference in the clinical outcomes between the two groups. Multivariable logistic regression identified the NIHSS at two weeks (OR: 0.840; 95% CI: 0.754-0.936, p = 0.002) as the most critical predictor of a good outcome. Our meta-analysis of seven studies indicated a 67% rate for achieving a good outcome (mRS < 3) at follow-up points (95% CI: 57%-77%, I2 = 44.1%). In summary, while the meta-analysis suggested the potential role of STA-MCA bypass in mild to moderate AIS, our single-center cohort study indicated that STA-MCA bypass does not seem to improve the prognosis of patients who suffer from AIS-LVO.
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Affiliation(s)
- Lei Guo
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Li Yang
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Chunling Li
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Yi Zeng
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Ruxiang Xu
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Zhengyu Wang
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
| | - Chonggui Jiang
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
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11
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Krylov VV, Senko IV, Amiralieva MS, Staroverov MS, Grigoryev IV, Kordonskaya OO, Glotova NA. [Moyamoya disease in adults: treatment methods in modern era]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:75-82. [PMID: 38512098 DOI: 10.17116/jnevro202412403275] [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] [Indexed: 03/22/2024]
Abstract
Moyamoya angiopathy is a chronic progressive cerebrovascular disease characterized by stenosis and occlusion of the distal segments of the internal carotid arteries and/or proximal segments of the middle and anterior cerebral arteries, with a gradual compensatory restructuring of the cerebral circulation to the system of the external carotid arteries. Today, the main treatment method for Moyamoya angiopathy is surgical revascularization of the brain. A search and analysis of publications on the treatment of adult patients with Moyamoya angiopathy was carried out in the PubMed and Medscape databases over the past 10 years. We present a case of an adult female patient with a hemorrhagic form of Moyamoya angiopathy stage IV according to J. Suzuki, who underwent staged combined revascularization of both cerebral hemispheres. Surgical revascularization included the creation of a low-flow extra-intracranial shunt combined with a combination of indirect synangiosis. The combination of direct and indirect methods of surgical revascularization enables to achieve the development of an extensive network of collaterals and fully compensate for cerebral circulatory disorders both in the early and late postoperative periods, which is confirmed by instrumental diagnostic data. Combined revascularization is the most effective modern method of treating patients with Moyamoya angiopathy due to the complementary influence of direct and indirect components of revascularization.
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Affiliation(s)
- V V Krylov
- Federal Center of Brain Research and Neurotechnology, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
- Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - I V Senko
- Federal Center of Brain Research and Neurotechnology, Moscow, Russia
| | - M Sh Amiralieva
- Federal Center of Brain Research and Neurotechnology, Moscow, Russia
| | - M S Staroverov
- Federal Center of Brain Research and Neurotechnology, Moscow, Russia
- Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
- Clinical City Hospital No. 4, Perm, Russia
| | - I V Grigoryev
- Federal Center of Brain Research and Neurotechnology, Moscow, Russia
| | - O O Kordonskaya
- Federal Center of Brain Research and Neurotechnology, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - N A Glotova
- Federal Center of Brain Research and Neurotechnology, Moscow, Russia
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12
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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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13
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Liu W, Huang K, Zhang J, Zhou D, Chen J. Clinical Features and Risk Factors of Postoperative Stroke in Adult Moyamoya Disease. Brain Sci 2023; 13:1696. [PMID: 38137144 PMCID: PMC10741386 DOI: 10.3390/brainsci13121696] [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: 10/14/2023] [Revised: 11/21/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND AND PURPOSE The clinical features of and risk factors for postoperative stroke after surgical revascularization in adult moyamoya disease (MMD) have not been fully elucidated. To this end, the baseline clinical features were hereby described, and the risk factors for postoperative stroke were determined. METHODS Data of 4078 MMD inpatients were collected retrospectively across all secondary- and higher-level hospitals of Hubei Province from January 2019 to December 2020. In accordance with inclusion and exclusion criteria, 559 adult MMD inpatients were finally enrolled. The associated characteristics and potential risk factors were analyzed, and the Kaplan-Meier risk of stroke was also calculated. RESULTS The patients consisted of 286 females and 273 males, with a mean age of 49.1 ± 10.0 years, all of whom had at least 1 year of follow-up (median 25.1 months). There were 356 cases of preoperative ischemic symptoms and 203 cases of preoperative hemorrhage symptoms. Indirect, direct, and combined revascularization were conducted on 97, 105 and 357 patients, respectively. Among these patients, 17 had postoperative hemorrhagic stroke (PHS), and 43 had postoperative ischemic stroke (PIS). A comparison between PHS/PIS group and control group (patients without postoperative stroke events) showed that preoperative hemorrhage was significantly associated with PHS (p = 0.003), while hypertension (p = 0.003), diabetes mellitus (p = 0.003) and modified Rankin scale (mRS) (p = 0.034) at admission were associated with a higher rate of PIS. Furthermore, preoperative hemorrhagic stroke was identified as a risk factor for PHS (odds ratio [OR], 4.229 [95% CI, 1.244-14.376]; p = 0.021), while hypertension (odds ratio [OR], 0.424 [95% CI, 0.210-0.855]; p = 0.017), diabetes mellitus (odds ratio [OR], 0.368 [95% CI, 0.163-0.827]; p = 0.016) and admission mRS (odds ratio [OR], 2.301 [95% CI, 1.157-4.575]; p = 0.017) were found to be risk factors for PIS. CONCLUSIONS The age distribution of adult MMD patients with revascularization was predominantly concentrated within the range from 46 to 55 years. Preoperative hemorrhage events were considered the risk factor for PHS. Hypertension, diabetes and admission mRS were correlated with PIS, and were also the risk factors for PIS. These results indicated the possible contribution of enhancing systematic disease management to the prevention of postoperative cerebrovascular accidents.
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Affiliation(s)
- Wen Liu
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Donghu Road 169, Wuhan 430071, China; (W.L.); (K.H.); (J.Z.)
- Neuroepigenetic Research Lab, Medical Research Institute, Wuhan University, Donghu Road 115, Wuhan 430071, China
| | - Kaixin Huang
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Donghu Road 169, Wuhan 430071, China; (W.L.); (K.H.); (J.Z.)
- Neuroepigenetic Research Lab, Medical Research Institute, Wuhan University, Donghu Road 115, Wuhan 430071, China
| | - Jianjian Zhang
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Donghu Road 169, Wuhan 430071, China; (W.L.); (K.H.); (J.Z.)
- Neuroepigenetic Research Lab, Medical Research Institute, Wuhan University, Donghu Road 115, Wuhan 430071, China
| | - Da Zhou
- Center for Health Information and Statistics of Hubei, Wuhan 430071, China;
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital, Wuhan University, Donghu Road 169, Wuhan 430071, China; (W.L.); (K.H.); (J.Z.)
- Neuroepigenetic Research Lab, Medical Research Institute, Wuhan University, Donghu Road 115, Wuhan 430071, China
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14
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Chen P, Wang Y, Li S, Tang D, Yang S, Zeng F, Yu L, Zhang D, Ding W, Wu S, Chen F, Huang Z. Development and External Validation of Nomogram for Cerebral Infarction in Moyamoya Diseases. Transl Stroke Res 2023; 14:890-898. [PMID: 36656462 DOI: 10.1007/s12975-023-01127-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 12/31/2022] [Accepted: 01/04/2023] [Indexed: 01/20/2023]
Abstract
More than 60% of moyamoya disease (MMD) patients suffers cerebral ischemia and preoperative cerebral infarction (CI) increases the risk of postoperative stroke and unfavorable outcome. We established a nomogram system for risk stratification of CI to help tailoring individualized management. We enrolled 380 patients including 680 hemispheres for the training cohort from our hospital and 183 patients including 348 hemispheres for the validation cohort from multicenter. A nomogram for CI was formulated based on the multivariable logistic regression analysis. The predictive accuracy and discriminative ability of nomogram were determined with concordance index (C-index) and calibration curve. For the training cohort, 246 hemispheres (36.2%) were found with CI. In multivariable logistic regression used generalized estimating equations approach, anterior choroidal artery (AchA) grade (grade 1, OR 0.214, 95%CI 0.124-0.372, P < 0.001; grade 2, OR 0.132, 95%CI 0.066-0.265, P < 0.001), cerebral perfusion (OR 4.796, 95%CI 2.922-7.872; P < 0.001), white matter hyperintensity (OR 3.652, 95%CI 1.933-6.902; P < 0.001), brush sign (OR 3.555, 95%CI 2.282-5.538; P < 0.001), and ivy sign (equivocal, OR 4.752, 95%CI 2.788-8.099, P < 0.001; present, OR 8.940, 95%CI 4.942-16.173, P < 0.001) were significant factors for CI. The C-index of the nomogram for predicting cerebral infarction was 0.890 (95%CI 0.866-0.915) in the training cohort and 0.847 (95%CI 0.805-0.889) in the validation cohort. The nomogram composed of AchA grade, cerebral perfusion, white matter hyperintensity, brush sign, and ivy sign could provide risk stratification of CI before surgery in patients with MMD. Active treatment might be recommended before CI, which could reduce the risk of stroke after surgery.
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Affiliation(s)
- Pan Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Ying Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Shifu Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Dong Tang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Shuai Yang
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Feiyue Zeng
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Lebao Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Wei Ding
- Department of Neurosurgery, Hunan Children's Hospital, Changsha, 410007, China
| | - Shuihua Wu
- Department of Neurosurgery, Hunan Children's Hospital, Changsha, 410007, China
| | - Fenghua Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Zheng Huang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, 410008, China.
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15
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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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16
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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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17
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Zhang XH, He JH, Zhang XS, Zhang J, Wang CJ, Dong YP, Tao W. Comparison of revascularization and conservative treatment for hemorrhagic moyamoya disease in East Asian Countries: a single-center case series and a systematic review with meta-analysis. Front Neurol 2023; 14:1169440. [PMID: 37332987 PMCID: PMC10272728 DOI: 10.3389/fneur.2023.1169440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 04/28/2023] [Indexed: 06/20/2023] Open
Abstract
Objective The optimal treatment approach for hemorrhagic moyamoya disease (HMMD) remains a topic of debate, particularly regarding the comparative efficacy of revascularization versus conservative treatment. Our study, which included a single-center case series and a systematic review with meta-analysis, aimed to determine whether surgical revascularization is associated with a significant reduction in postoperative rebleeding, ischemic events, and mortality compared to conservative treatment among East Asian HMMD patients. Methods We conducted a systematic literature review by searching PubMed, Google Scholar, Wanfang Med Online (WMO), and the China National Knowledge Infrastructure (CNKI). The outcomes of surgical revascularization and conservative treatment, including rebleeding, ischemic events and mortality, were compared. The authors' institutional series of 24 patients were also included and reviewed in the analysis. Results A total of 19 East Asian studies involving 1,571 patients as well as our institution's retrospective study of 24 patients were included in the study. In the adult patients-only studies, those who underwent revascularization had significantly lower rates of rebleeding, ischemic events, and mortality compared to those who received conservative treatment (13.1% (46/352) vs. 32.4% (82/253), P < 0.00001; 4.0% (5/124) vs. 14.9% (18/121), P = 0.007; and 3.3% (5/153) vs. 12.6% (12/95), P = 0.01, respectively). In the adult/pediatric patients' studies, similar statistical results of rebleeding, ischemic events, and mortality have been obtained (70/588 (11.9%) vs. 103/402 (25.6%), P = 0.003 or <0.0001 in a random or fixed-effects model, respectively; 14/296 (4.7%) vs. 26/183 (14.2%), P = 0.001; and 4.6% (15/328) vs. 18.7% (23/123), P = 0.0001, respectively). Conclusion The current single-center case series and systematic review with meta-analysis of studies demonstrated that surgical revascularization, including direct, indirect, and a combination of both, significantly reduces rebleeding, ischemic events, and mortality in HMMD patients in the East Asia region. More well-designed studies are warranted to further confirm these findings.
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Affiliation(s)
- Xiang-Hua Zhang
- Department of Neurosurgery, Beijing Friendship Hospital Affiliated With Capital Medical University, Beijing, China
| | - Jun-Hua He
- Department of Neurosurgery, Zhejiang Provincial Tongde Hospital, Hangzhou, China
| | - Xiang-Sheng Zhang
- Department of Neurosurgery, Beijing Friendship Hospital Affiliated With Capital Medical University, Beijing, China
| | - Jing Zhang
- Department of Neurosurgery, Beijing Friendship Hospital Affiliated With Capital Medical University, Beijing, China
| | - Cheng-jun Wang
- Department of Neurosurgery, Beijing Friendship Hospital Affiliated With Capital Medical University, Beijing, China
| | - Yi-Peng Dong
- Department of Neurosurgery, Beijing Friendship Hospital Affiliated With Capital Medical University, Beijing, China
| | - Wu Tao
- Department of Neurosurgery, Beijing Friendship Hospital Affiliated With Capital Medical University, Beijing, China
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18
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Northam WT, Slingerland AL, Orbach DB, Smith ER. Magnetic Resonance Imaging/Angiography Versus Catheter Angiography for Annual Follow-up of Pediatric Moyamoya Patients: A Cost Outcomes Analysis. Neurosurgery 2023; 92:1243-1248. [PMID: 36744923 DOI: 10.1227/neu.0000000000002357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/08/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Digital subtraction angiography (DSA) assesses revascularization in pediatric moyamoya patients after surgery, but MRI and angiography (MRI/A) may provide comparable data. OBJECTIVE To evaluate DSA and MRI/A with respect to clinical utility in postoperative follow-up, complication profile, and relative cost at 1 year. METHODS All pediatric moyamoya patients who received bilateral indirect revascularization between 2011 and 2020 were retrospectively reviewed at 1 institution. Patients who underwent MRI/A-only, DSA-only, or both after 1 year were compared. RESULTS Eighty-two patients were included. At 1 year, patients who underwent either MRI/A (n = 29) or DSA (n = 40) had no significant differences in detection rate of new at-risk hypovascular territories (6.9% vs 2.5%, P = .568) or need for subsequent revascularization beyond the mean 40 ± 24-month follow-up period (3.4% vs 5.0%, P > .9). Among patients who underwent both MRI/A and DSA (n = 13), both studies identified the same at-risk territories. No patients experienced MRI/A-related complications, compared with 3 minor DSA-related complications. The use of MRI/A yielded a 6.5-fold reduction in cost per study vs DSA at 1 year. CONCLUSION Using DSA to follow moyamoya patients after indirect revascularization is generally safe but associated with a low rate of minor complications and a 6.5-fold greater financial cost relative to MRI/A. These data support changing practice to eliminate the use of DSA when following routine bilateral moyamoya cases in the absence of clinical symptoms or specific concerns. Using MRI/A as the primary postoperative follow-up modality in this select population provides noninferior care and greater patient access, while reducing cost and potentially decreasing risk.
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Affiliation(s)
- Weston T Northam
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Anna L Slingerland
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Darren B Orbach
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA
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19
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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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20
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Pang CH, Lee SU, Lee Y, Kim WB, Kwon MY, Sunwoo L, Kim T, Bang JS, Kwon OK, Oh CW. Prediction of hemorrhagic cerebral hyperperfusion syndrome after direct bypass surgery in adult nonhemorrhagic moyamoya disease: combining quantitative parameters on RAPID perfusion CT with clinically related factors. J Neurosurg 2023; 138:683-692. [PMID: 35901742 DOI: 10.3171/2022.5.jns212838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/04/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to identify predictive factors for hemorrhagic cerebral hyperperfusion syndrome (hCHS) after direct bypass surgery in adult nonhemorrhagic moyamoya disease (non-hMMD) using quantitative parameters on rapid processing of perfusion and diffusion (RAPID) perfusion CT software. METHODS A total of 277 hemispheres in 223 patients with non-hMMD who underwent combined bypass were retrospectively reviewed. Preoperative volumes of time to maximum (Tmax) > 4 seconds and > 6 seconds were obtained from RAPID analysis of perfusion CT. These quantitative parameters, along with other clinical and angiographic factors, were statistically analyzed to determine the significant predictors for hCHS after bypass surgery. RESULTS Intra- or postoperative hCHS occurred in 13 hemispheres (4.7%). In 7 hemispheres, subarachnoid hemorrhage occurred intraoperatively, and in 6 hemispheres, intracerebral hemorrhage was detected postoperatively. All hCHS occurred within the 4 days after bypass. Advanced age (OR 1.096, 95% CI 1.039-1.163, p = 0.001) and a large volume of Tmax > 6 seconds (OR 1.011, 95% CI 1.004-1.018, p = 0.002) were statistically significant factors in predicting the risk of hCHS after surgery. The cutoff values of patient age and volume of Tmax > 6 seconds were 43.5 years old (area under the curve [AUC] 0.761) and 80.5 ml (AUC 0.762), respectively. CONCLUSIONS In adult patients with non-hMMD older than 43.5 years or with a large volume of Tmax > 6 seconds over 80.5 ml, more prudence is required in the decision to undergo bypass surgery and in postoperative management.
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Affiliation(s)
| | | | | | | | | | - Leonard Sunwoo
- 2Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
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21
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Bao XY, Duan L. Chinese expert consensus on the treatment of MMD. Chin Neurosurg J 2023; 9:5. [PMID: 36823677 PMCID: PMC9948401 DOI: 10.1186/s41016-023-00318-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/16/2023] [Indexed: 02/25/2023] Open
Abstract
Moyamoya disease (MMD), also known as spontaneous occlusion of the circle of Willis, is defined by progressive stenosis or occlusion of the internal carotid arteries, and it can progress to the anterior, middle, and posterior cerebral arteries. As these arteries are gradually stenosed, a collateral network of capillaries develops at the base of the brain, producing the characteristic reticulate appearance ("puff of smoke") on angiography. Therefore, it was named by Suzuki and Takaku in 1969 after the Japanese term "moyamoya" (Suzuki and Takaku, Arch Neurol 20:288-299, 1969). MMD is most common in East Asian countries such as Japan and Korea, and it shows a slight female predominance. MMD is mainly characterized by ischemia and hemorrhage. Hemorrhagic MMD is very rare in children, and most cases occur in adults due to the rupture of the compensatory blood vessels, which often leads to hemorrhagic symptoms (Scott and Smith, N Engl J Med 360:1226-1237, 2009). In recent years, the diagnosis rate has increased with the popularization of imaging techniques. However, the pathogenesis of MMD is still not completely understood, and there is currently no evidence to suggest that drug treatment can delay or even reverse the progression of MMD. The current drug treatment for in MMD only targets its clinical symptoms, including ischemia and hemorrhage. The main choice of treatment for MMD is surgical revascularization. As an increasing number of hospitals have developed surgical treatment for MMD, our compiling group has jointly discussed the formulation of a consensus among Chinese experts on the treatment of MMD.
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Affiliation(s)
- Xiang-Yang Bao
- grid.414252.40000 0004 1761 8894Department of Neurosurgery, the First Medical Centre, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, Beijing, 100071 China
| | - Lian Duan
- Department of Neurosurgery, the First Medical Centre, Chinese PLA General Hospital, 8 Dong-Da Street, Fengtai District, Beijing, 100071, China.
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22
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Transient ischemic attack after indirect revascularization surgery for pediatric patients with moyamoya disease: A retrospective study of intraoperative blood pressure. Anaesth Crit Care Pain Med 2023; 42:101168. [PMID: 36309164 DOI: 10.1016/j.accpm.2022.101168] [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: 11/04/2021] [Revised: 09/29/2022] [Accepted: 10/18/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study aimed to investigate the association between intraoperative blood pressure and postoperative transient ischemic attacks (TIAs) in pediatric patients with moyamoya disease after indirect revascularization surgery. METHODS We retrospectively reviewed the medical records of patients with moyamoya disease younger than 15 years who underwent indirect revascularizations under general anesthesia from 2013 to 2019. Perioperative clinical factors and intraoperative blood pressure data were collected and analyzed. Univariate and multivariable mixed-effect logistic regressions were used to identify predictors of postoperative TIA and symptom progression. RESULTS Among 444 hemispheres in 296 pediatric patients, 70 cases (16%) experienced postoperative TIAs within 2 weeks after surgery, and 34 cases (7.7%) developed postoperative symptom progression. Baseline mean blood pressure (MBP) (adjusted odds ratio, 1.261; 95% confidence interval, 1.037-1.528; P < 0.001), Average mean arterial pressure (MAP) (adjusted odds ratio, 1.137; 95% confidence interval, 1.052-1.228; P = 0.006), and Ipsilateral magnetic resonance angiography (MRA) score (adjusted odds ratio, 1.464; 95% confidence interval, 0.886-2.419; P = 0.012) were statistically significant risk factors for postoperative TIA. Average real variability of MAP (ARV-MAP), which were measures of intraoperative MAP variability (adjusted odds ratio, 4.731; 95% confidence interval, 1.419-15.257; P = 0.003) and maximum MAP declination (MaxD-MAP) (adjusted odds ratio, 1.271; 95% confidence interval, 1.013-1.520; P = 0.010) were statistically significant risk factors for postoperative symptom progression. CONCLUSION Higher pre-induction baseline blood pressure and ipsilateral MRA score were independent risk factors predicting postoperative TIA in pediatric patients with moyamoya disease after indirect revascularization. The high variability and drastic decline in intraoperative MAP showed predictive value in postoperative symptom progression.
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23
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Chen S, Wang B, Wen Y, Wang Z, Long T, Chen J, Zhang G, Li M, Zhang S, Pan J, Feng W, Qi S, Wang G. Ultrasonic hemodynamic changes of superficial temporal artery graft in different angiogenesis outcomes of Moyamoya disease patients treated with combined revascularization surgery. Front Neurol 2023; 14:1115343. [PMID: 36873438 PMCID: PMC9978192 DOI: 10.3389/fneur.2023.1115343] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/25/2023] [Indexed: 02/18/2023] Open
Abstract
Objective Combined bypass is commonly used in adult Moyamoya disease (MMD) for revascularization purposes. The blood flow from the external carotid artery system supplied by the superficial temporal artery (STA), middle meningeal artery (MMA), and deep temporal artery (DTA) can restore the impaired hemodynamics of the ischemic brain. In this study we attempted to evaluate the hemodynamic changes of the STA graft and predict the angiogenesis outcomes in MMD patients after combined bypass surgery by using quantitative ultrasonography. Methods We retrospectively studied Moyamoya patients who were treated by combined bypass between September 2017 and June 2021 in our hospital. We quantitatively measured the STA with ultrasound and recorded the blood flow, diameter, pulsatility index (PI) and resistance index (RI) to assess graft development preoperatively and at 1 day, 7 days, 3 months, and 6 months after surgery. All patients received both pre- and post- operative angiography evaluation. Patients were divided into either well- or poorly-angiogenesis groups according to the transdural collateral formation status on angiography at 6 months after surgery (W group or P group). Patients with matshushima grade A or B were divided into W group. Patients with matshushima grade C were divided into P group, indicating a poor angiogenesis development. Results A total of 52 patients with 54 operated hemispheres were enrolled, including 25 men and 27 women with an average age of 39 ± 14.3 years. Compared to preoperative values, the average blood flow of an STA graft at day 1 postoperation increased from 16.06 ± 12.47 to 117.47± 73.77 (mL/min), diameter increased from 1.14 ± 0.33 to 1.81 ± 0.30 (mm), PI dropped from 1.77 ± 0.42 to 0.76 ± 0.37, and RI dropped from 1.77 ± 0.42 to 0.50 ± 0.12. According to the Matsushima grade at 6 months after surgery, 30 hemispheres qualified as W group and 24 hemispheres as P group. Statistically significant differences were found between the two groups in diameter (p = 0.010) as well as flow (p = 0.017) at 3 months post-surgery. Flow also remained significantly different at 6 months after surgery (p = 0.014). Based on GEE logistic regression evaluation, the patients with higher levels of flow post-operation were more likely to have poorly-compensated collateral. ROC analysis showed that increased flow of ≥69.5 ml/min (p = 0.003; AUC = 0.74) or a 604% (p = 0.012; AUC = 0.70) increase at 3 months post-surgery compared with the pre-operative value is the cut-off point which had the highest Youden's index for predicting P group. Furthermore, a diameter at 3 months post-surgery that is ≥0.75 mm (p = 0.008; AUC = 0.71) or 52% (p =0.021; AUC = 0.68) wider than pre-operation also indicates a high risk of poor indirect collateral formation. Conclusions The hemodynamic of the STA graft changed significantly after combined bypass surgery. An increased flow of more than 69.5 ml/min at 3 months was a good predictive factor for poor neoangiogenesis in MMD patients treated with combined bypass surgery.
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Affiliation(s)
- Siyuan Chen
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Baoping Wang
- Department of Ultrasonography, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yunyu Wen
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhibin Wang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tinghan Long
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junda Chen
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Guozhong Zhang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Mingzhou Li
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shichao Zhang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jun Pan
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wenfeng Feng
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Songtao Qi
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Gang Wang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Teo M, Abhinav K, Bell-Stephens TE, Madhugiri VS, Sussman ES, Azad TD, Ali R, Esparza R, Zhang M, Steinberg GK. Short- and long-term outcomes of moyamoya patients post-revascularization. J Neurosurg 2022; 138:1374-1384. [PMID: 36272120 DOI: 10.3171/2022.8.jns22336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 08/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The post-bypass stroke risk factors and long-term outcomes of moyamoya patients are not well documented. Therefore, the authors studied 30-day stroke risks and patients’ long-term physical, functional, and social well-being.
METHODS
This was a single-institution combined moyamoya disease (MMD) database interrogation and questionnaire study. From 1991 to 2014, 1250 revascularization procedures (1118 direct bypasses, 132 indirect bypasses) were performed in 769 patients. Completed questionnaires were received from and available for analysis on 391 patients, and 6-month follow-up data were available for 96.4% (741/769) of the patients.
RESULTS
The patients consisted of 548 females and 221 males, with a mean age of 32 years (range 1–69 years). Three hundred fifty-eight bypasses were performed in 205 pediatric patients (73% direct bypasses), and 892 revascularizations were performed in 564 adults (96% direct bypasses). Fifty-two patients (6.8%) developed major strokes with a worsening modified Rankin Scale (mRS) score within 30 days postoperatively. The 30-day major stroke risk was 5.3% (41/769) and 2.6% (12/467) after the first and second bypasses, respectively. Logistic regression analysis revealed that older age, modified MRI (mMRI) score, and hemodynamic reserve (HDR) score are clearly associated with higher postoperative stroke risks. Over a mean follow-up of 7.3 years (range 0.5–26 years), the long-term stroke risk among 741 patients was 0.6% per patient-year; 75% of these patients had excellent outcomes (mRS score 0–1). The long-term outcome questionnaire study showed that 84% (234/277) of patients reported resolution or improvement in their preoperative headache, 83% (325/391) remained employed or in school, and 87% (303/348) were self-caring.
CONCLUSIONS
In this large, single-center surgical series, most of the adult and pediatric patients had direct revascularization, with a 4.2% per-bypass-procedure (6.8% per patient) 30-day major stroke risk and a 0.6% per-patient-year long-term stroke risk. The authors identified various risk factors that are highly correlated with postoperative morbidity (age, mMRI score, and HDR score) and are involved in ongoing work to develop the predictive modeling for future patient selection and treatment.
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Affiliation(s)
- Mario Teo
- Department of Neurosurgery, Stanford University School of Medicine and Stanford Stroke Center, Stanford, California
| | - Kumar Abhinav
- Department of Neurosurgery, Stanford University School of Medicine and Stanford Stroke Center, Stanford, California
| | - Teresa E. Bell-Stephens
- Department of Neurosurgery, Stanford University School of Medicine and Stanford Stroke Center, Stanford, California
| | - Venkatesh S. Madhugiri
- Department of Neurosurgery, Stanford University School of Medicine and Stanford Stroke Center, Stanford, California
| | - Eric S. Sussman
- Department of Neurosurgery, Stanford University School of Medicine and Stanford Stroke Center, Stanford, California
| | - Tej Deepak Azad
- Department of Neurosurgery, Stanford University School of Medicine and Stanford Stroke Center, Stanford, California
| | - Rohaid Ali
- Department of Neurosurgery, Stanford University School of Medicine and Stanford Stroke Center, Stanford, California
| | - Rogelio Esparza
- Department of Neurosurgery, Stanford University School of Medicine and Stanford Stroke Center, Stanford, California
| | - Michael Zhang
- Department of Neurosurgery, Stanford University School of Medicine and Stanford Stroke Center, Stanford, California
| | - Gary K. Steinberg
- Department of Neurosurgery, Stanford University School of Medicine and Stanford Stroke Center, Stanford, California
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25
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Tsukinaga A, Yoshitani K, Ozaki T, Takahashi JC, Ogata S, Ohnishi Y. Quantitative regional cerebral blood flow measurement using near-infrared spectroscopy and indocyanine green in patients undergoing superficial temporal to middle cerebral artery bypass for moyamoya disease: a novel method using a frequency filter. J Clin Monit Comput 2022; 37:421-429. [PMID: 36167879 DOI: 10.1007/s10877-022-00916-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/07/2022] [Indexed: 11/30/2022]
Abstract
Measuring regional cerebral blood flow (rCBF) after revascularization for moyamoya disease, as a type of ischemic cerebrovascular disease, is crucial. This study aims to validate our novel technology that combines near-infrared spectroscopy (NIRS) with a frequency filter to extract the arterial component. We measured rCBF before and after revascularization for moyamoya disease and at the end of the surgery using NIRO-200NX (Hamamatsu Photonics, Japan) and indocyanine green (ICG). rCBF was calculated using Fick's principle, change in arterial ICG concentrations, and maximum arterial ICG concentration. rCBF measured with NIRS (rCBF_N) was compared with pre- and postoperative rCBF measured with SPECT (rCBF_S). Thirty-four procedures were analyzed. rCBF_N increased from baseline to end of the surgery (mean difference (MD), 2.99 ml/min/100 g; 95% confidence interval (CI), 0.40-5.57 ml/min/100 g on the diseased side; MD, 4.94 ml/min/100 g; 95% CI, 2.35-7.52 ml/min/100 g on the non-diseased side). Similar trends were observed for rCBF_S (MD, 3.98 ml/min/100 g; 95% CI, 2.30-5.67 ml/min/100 g on the diseased side; MD, 2.77 ml/min/100 g; 95% CI, 1.09-4.45 ml/min/100 g on the non-diseased side). Intraclass correlations 3 (ICC3s) between rCBF_N and rCBF_S were weak on the diseased side (ICC3, 0.25; 95% CI, -0.03-0.5; p = 0.07) and the non-diseased side (ICC3, 0.24; 95% CI, -0.05-0.5; p = 0.08). rCBF measurements based on this novel method were weakly correlated with rCBF measurements with SPECT.
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Affiliation(s)
- Akito Tsukinaga
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 6-1 Kishibeshimmachi, SuitaOsaka, 564-8565, Japan
| | - Kenji Yoshitani
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 6-1 Kishibeshimmachi, SuitaOsaka, 564-8565, Japan.
| | - Takeo Ozaki
- Systems Division, Hamamatsu Photonics K.K, Hamamatsu, Japan
| | - Jun C Takahashi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Soshiro Ogata
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshihiko Ohnishi
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, 6-1 Kishibeshimmachi, SuitaOsaka, 564-8565, Japan
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26
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Angioarchitectural Factors Associated with Postoperative Cerebral Infarction in Ischemic Moyamoya Disease. Brain Sci 2022; 12:brainsci12101270. [PMID: 36291204 PMCID: PMC9599360 DOI: 10.3390/brainsci12101270] [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: 08/20/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 11/17/2022] Open
Abstract
Objective: To investigate the angioarchitectural factors associated with postoperative cerebral infarction in ischemic moyamoya disease. Methods: Data on patients who underwent surgery for ischemic MMD from 1 October 2015 to 31 October 2020, at Peking University International Hospital were collected and retrospectively analyzed. General conditions such as patient sex, age, site of surgery, preoperative manifestations such as TIA attack and old cerebral infarction, and seven angioarchitectural factors of the MMD based on DSA were selected and measured. Statistical analysis was performed by the Pearson chi-square statistic, analysis of variance (ANOVA), and multifactor logistic regression analysis. Results: Age (OR, 0.969; 95%CI, 0.939–1.000; p = 0.049), A1stenosis (OR, 5.843; 95%CI, 1.730–19.732; p = 0.004), M1stenosis (OR, 6.206; 95%CI, 2.079–18.526; p = 0.001), PCA anomalies (OR, 4.367; 95%CI, 1.452–13.129; p = 0.049), Unstable compensation (OR, 5.335; 95%CI, 1.427–19.948; p = 0.013), TIA (OR, 4.264; 95%CI, 1.844–9.863; p = 0.001), Old cerebral infarction (OR, 2.972; 95%CI, 1.194–7.397; p = 0.019). The above seven factors can be used in the regression equation to predict the probability of postoperative cerebral infarction. The prediction accuracy is 90.2%. Conclusions: Age, TIA attack, old cerebral infarction, and five angioarchitectural factors of MMD are strongly associated with postoperative cerebral infarction. Seven factors, including age, TIA attack, old infarction, and four angioarchitectural factors, can be taken to quantify the probability of surgical cerebral infarction in MMD.
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Nguyen VN, Parikh KA, Motiwala M, Erin Miller L, Barats M, Milton C, Khan NR. Surgical techniques and indications for treatment of adult moyamoya disease. Front Surg 2022; 9:966430. [PMID: 36061058 PMCID: PMC9437590 DOI: 10.3389/fsurg.2022.966430] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/29/2022] [Indexed: 11/17/2022] Open
Abstract
Moyamoya disease (MMD) is a chronic, progressive cerebrovascular disease involving the occlusion or stenosis of the terminal portion of the internal carotid artery (ICA) and the proximal anterior and middle cerebral arteries. Adults with MMD have been shown to progressively accumulate neurological and cognitive deficits without treatment, with a mortality rate double that of pediatric patients with MMD. Surgical intervention is the mainstay of treatment to prevent disease progression and improve clinical outcomes. Several different types of bypasses can be utilized for revascularization in MMD, including indirect, direct, and combined forms of extracranial-to-intracranial (EC-IC) bypass. Overall, the choice of appropriate technique requires consideration of the age of the patient, preoperative hemodynamics, neurologic status, and territories most at risk and in need of revascularization. Here, we will review the indications and surgical techniques for the treatment of adult MMD. Step-by-step instructions for performing several bypass variants with technical pearls are discussed.
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Affiliation(s)
- Vincent N. Nguyen
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, United States
| | - Kara A. Parikh
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, United States
| | - Mustafa Motiwala
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, United States
| | - L. Erin Miller
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, United States
| | - Michael Barats
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, United States
| | - Camille Milton
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, United States
| | - Nickalus R. Khan
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, United States
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, United States
- Correspondence: Nickalus Khan
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Association of Contrast Enhancement of Proximal Internal Carotid Artery Wall and Champagne Bottle Neck Sign with Ipsilateral Stroke in Moyamoya Disease Patients. Eur J Radiol 2022; 155:110501. [DOI: 10.1016/j.ejrad.2022.110501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 08/10/2022] [Accepted: 08/22/2022] [Indexed: 11/18/2022]
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Hirano Y, Ono H, Inoue T, Ohara K, Tanishima T, Tamura A, Saito I. STA-A3 Bypass Using Radial Artery Graft for Progressive Cerebral Infarction of Bilateral ACA Region after STA-MCA Bypass Surgery for Moyamoya Disease. Asian J Neurosurg 2022; 17:352-356. [PMID: 36120622 PMCID: PMC9473830 DOI: 10.1055/s-0042-1750305] [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] [Indexed: 11/28/2022] Open
Abstract
Direct revascularization surgery, such as superficial temporal artery (STA)-middle cerebral artery (MCA) bypass, is effective in preventing ischemia and hemorrhage for moyamoya disease. On the other hand, when ischemia of the anterior cerebral artery (ACA) region progresses after ipsilateral STA-MCA bypass, it is difficult to perform revascularization from the viewpoint of the donor artery. A 55-year-old woman with right hemiparesis was diagnosed with cerebral infarction due to moyamoya disease. Left STA-MCA bypass was performed with no postoperative complications, but memory impairment and decreased motivation were observed 2 months after the operation. Magnetic resonance imaging and angiography revealed new infarction in the bilateral ACA area and deterioration in the signal intensity of bilateral ACAs. Revascularization of the bilateral ACA regions was considered necessary, but the left STA was already used in the previous surgery. Therefore, STA-radial artery (RA)-A3 bypass using RA graft combined with right STA-MCA bypass was performed. STA-A3 bypass using an RA graft may be the optimal treatment for ischemia of the ACA region that progresses after STA-MCA bypass.
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Affiliation(s)
- Yudai Hirano
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya-shi, Shizuoka, Japan
| | - Hideaki Ono
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya-shi, Shizuoka, Japan
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
| | - Kenta Ohara
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Takeo Tanishima
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya-shi, Shizuoka, Japan
| | - Akira Tamura
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya-shi, Shizuoka, Japan
| | - Isamu Saito
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya-shi, Shizuoka, Japan
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Xu R, Kalluri AL, Sun LR, Lawrence CE, Lee JK, Kannan S, Cohen AR. The neurosurgical management of Severe Hemophilia A and Moyamoya (SHAM): challenges, strategies, and literature review. Childs Nerv Syst 2022; 38:1077-1084. [PMID: 35262754 DOI: 10.1007/s00381-022-05489-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/03/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Severe Hemophilia A and Moyamoya arteriopathy (SHAM syndrome) is a rare genetic disorder caused by deletion of portions of the cytogenic band Xq28. A case of SHAM syndrome requiring bilateral cerebral revascularization is described with an emphasis on perioperative management. CASE REPORT A 5-year-old boy with severe hemophilia A complicated by factor VIII inhibition presented with right-sided weakness. Imaging revealed multiple strokes and vascular changes consistent with Moyamoya disease. The patient underwent two-staged indirect cerebral bypass revascularizations, first on the left side and several months later on the right. Perioperative management required balancing the administration of agents to prevent coagulopathy and perioperative hemorrhage while mitigating the risk of thromboembolic events associated with bypass surgery. Despite a multidisciplinary effort by the neurosurgery, hematology, critical care, and anesthesiology teams, the post-operative course after both surgeries was complicated by stroke. Fortunately, the patient recovered rapidly to his preoperative functional baseline. CONCLUSION We describe a rare case of SHAM syndrome in a pediatric patient who required bilateral revascularizations and discuss strategies for managing the perioperative risk of hemorrhage and stroke. We also review existing literature on SHAM syndrome.
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Affiliation(s)
- Risheng Xu
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Anita L Kalluri
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Lisa R Sun
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Courtney E Lawrence
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Jennifer K Lee
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Sujatha Kannan
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Alan R Cohen
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA.
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Farooq J, Heller RS, Noureldine MHA, Wang ZJ, Wei G, Mhaskar R, Ren Z, van Loveren H, Lau T, Agazzi S. Modern Appraisal of Patency and Complications in Cerebral Bypass Surgery: A Single Institution Experience. Oper Neurosurg (Hagerstown) 2022; 22:355-363. [DOI: 10.1227/ons.0000000000000177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 09/29/2021] [Indexed: 11/19/2022] Open
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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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Li F, Li C, Sun Y, Bao Y, Jiang W, Song Z, Wang Y, Liu M, Wang W, Li T, Li L. Cerebral Ischemic Complications After Surgical Revascularization for Moyamoya Disease: Risk Factors and Development of a Predictive Model Based on Preoperative Nutritional Blood Parameters. Front Nutr 2022; 9:842838. [PMID: 35360692 PMCID: PMC8960452 DOI: 10.3389/fnut.2022.842838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 02/02/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives Cerebral ischemic complications are common after revascularization in patients with moyamoya disease (MMD). Risk factors from specific laboratory variables have only been assessed by limited research. This study was to investigate the association between postoperative cerebral ischemia and nutritional blood parameters and examine predictive values of such risk factors in adults. Methods Preoperative demographics and nutritional blood parameters of patients with MMD who received revascularization at our institution from 2012 to 2021 were retrospectively reviewed. Univariate analysis and multivariable logistic regression were used to identify independent risk factors for the onset of postoperative cerebral ischemic complications. Predictive values were tested and a model incorporating these independent risk factors was created using the R program. Area under the receiver operating characteristic curve (AUC) was used for testing its discriminability. Results Postoperative cerebral ischemic complications occurred in 32 patients of 100 included procedures. Surgery on the left hemisphere, lower admission modified Rankin Scale (mRS) score, aberrant nutritional parameters including low white blood cell (WBC), and high total cholesterol (TC) were significantly associated with cerebral ischemic complications after revascularization. The intriguing role of WBC might be explained by altered immunomodulation. The AUC of this model with novel nutritional parameters yielded a value of 0.811, presenting better predictive accuracy. Additionally, the model was visualized in the form of a nomogram and translated into a user-friendly calculator to generate individual risk. Conclusions Surgical side, admission mRS score, WBC, and TC were independent risk factors for postoperative cerebral ischemic complications. The model composed of these four parameters was promising to be adopted in clinical practice.
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Affiliation(s)
- Fangbao Li
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
- School of Medicine, Dalian Medical University, Dalian, China
| | - Chuanfeng Li
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
| | - Yunwei Sun
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
| | - Yue Bao
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
| | - Wenbo Jiang
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
| | - Zuoyan Song
- Department of Anesthesiology, Qingdao Municipal Hospital, Qingdao, China
| | - Yongyi Wang
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
| | - Mingxing Liu
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
| | - Weimin Wang
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
| | - Tong Li
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
- *Correspondence: Tong Li
| | - Luo Li
- Department of Neurosurgery, Qingdao Municipal Hospital, Qingdao, China
- Luo Li
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Sum CHF, Tsang ACO, Cheng KKF, Ho WWS, Leung GKK, Lui WM. Surgical revascularization for moyamoya angiopathy: Clinical and radiological outcomes of direct and indirect bypasses in 86 affected hemispheres. J Clin Neurosci 2022; 99:66-72. [PMID: 35255359 DOI: 10.1016/j.jocn.2022.02.036] [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: 12/07/2021] [Revised: 02/05/2022] [Accepted: 02/23/2022] [Indexed: 11/17/2022]
Abstract
Moyamoya is a progressive cerebral angiopathy that entails a formidable natural history of repeated ischemic or haemorrhagic insults if not intervened. The potential advantages of direct/combined bypass can be harvested only if they are not outweighed by perioperative morbidity. Direct bypasses for the paediatric group have been less utilized because of small vessel calibres and an inherently more robust angioplasticity. This study was undertaken to examine the clinical and perfusion imaging outcomes of operated moyamoya disease or syndrome patients in Hong Kong's Southeast Asian population. Comparison was made between direct/combined and indirect bypass cohorts. Subgroup analysis of the paediatric cohort was conducted to determine outcomes of a direct-bypass-first strategy. From November 2000 to September 2020, 86 hemispheres underwent revascularization at a tertiary neurosurgical unit with a mean clinical follow-up time of 70.0 months. 70.9% of the procedures involved direct bypasses. Direct/combined revascularization demonstrated superiority in restoring adequate cerebrovascular reserve capacity (CVRC) (63.2% vs 27.3%, p = 0.015), and freedom from transient ischemic attacks in the first 5 years post-operation by Kaplan-Meier plot with log-rank test (p = 0.038). Follow-up imaging revealed 96.5% of the bypass grafts remained patent. Direct/combined procedures significantly predicted restoration of adequate CVRC on follow-up perfusions scans by binary logistic regression (OR 4.57, p = 0.009). Compared to the adult cohort, direct bypasses in children carried no excessive perioperative morbidity. These results support a liberal bypass-first paradigm in both adult and paediatric cohorts.
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Affiliation(s)
- Christopher Hiu-Fung Sum
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Anderson Chun On Tsang
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
| | - Kevin King-Fai Cheng
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Wilson Wai-Shing Ho
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Gilberto Ka Kit Leung
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Wai Man Lui
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
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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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Impact of RNF213 founder polymorphism (p.R4810K) on the postoperative development of indirect pial synangiosis after direct/indirect combined revascularization surgery for adult Moyamoya disease. Neurosurg Rev 2022; 45:2305-2313. [DOI: 10.1007/s10143-022-01749-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/07/2021] [Accepted: 01/30/2022] [Indexed: 10/19/2022]
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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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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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40
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The First 24 h Hemodynamic Management in NICU after Revascularization Surgery in Moyamoya Disease. Behav Neurol 2021; 2021:5061173. [PMID: 34691282 PMCID: PMC8536456 DOI: 10.1155/2021/5061173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/25/2021] [Indexed: 11/18/2022] Open
Abstract
Objective To evaluate whether hemodynamic factors are risk factors for prognosis in moyamoya disease (MMD). Materials and Methods The retrospective study reviewed a single-center MMD cohort in Huashan Hospital from August 2017 to January 2020. Stroke events in 30 days and follow-up modified Rankin Scale (mRS) grade were recorded. Systematic assessments with perioperative mean arterial pressure (MAP), red blood cell (RBC) parameters, and fluid management were also conducted. Logistic regressions were applied to evaluate the predictors of worse outcomes. Data was analyzed using SPSS 24.0. Results Admission to neurological intensive care unit (NICU) totalled about 347 after revascularization surgery. The result showed that the higher the postoperative MAP level (favorable group 95.7 ± 11.4 mmHg vs. unfavorable group 103.6 ± 10.4 mmHg, p < 0.001) and the greater the MAP variability (favorable group 0.26 ± 13.2 vs. unfavorable group 7.2 ± 13.5, p = 0.006) were, the higher the patient's follow-up mRS grade was. What is more, a higher early postoperative Hb level also seemed to predict a worse long-term clinical outcome (favorable group 116.9 ± 17.1 g/L vs. unfavorable group 123.7 ± 13.0 g/L, p = 0.03), but the difference disappeared after adjusting sex and age. Logistic regression analyses showed that a higher level of postoperative MAP (β = 0.024, 95% CI (0.004, 0.044), and p = 0.02) within the first 24 h in NICU might be the short-term risk factor. For long-term outcome, a higher level (β = 1.058, 95% CI (1.022, 1.096), and p = 0.001) and a greater variability (β = 30.982, 95% CI (2.112, 454.414), and p = 0.01) of postoperative MAP might be the negative predictors of mRS grade. Conclusions The early postoperative hemodynamic management might be extremely critical for patients with MMD. Both high postoperative MAP levels and large MAP variability might affect the prognosis. What is more, we also found that a higher postoperative Hb level might be related with a worse outcome.
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Ogawa S, Sato D, Torazawa S, Ota T. Acute Thrombectomy for Contralateral Internal Carotid Artery Occlusion after Revascularization Surgery for Quasi-moyamoya Disease: A Case Report. NMC Case Rep J 2021; 8:673-679. [PMID: 35079533 PMCID: PMC8769482 DOI: 10.2176/nmccrj.cr.2021-0089] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/29/2021] [Indexed: 11/27/2022] Open
Abstract
Ischemic complications can occur after revascularization surgery for moyamoya disease, but acute contralateral internal carotid artery (ICA) occlusion is an extremely rare complication. The patient was a 51-year-old woman with no medical history. Left frontal lobe infarction and bilateral ICA terminal stenosis were identified by repeated transient right paresis and aphasia. We diagnosed her with quasi-moyamoya disease associated with hyperthyroidism and performed revascularization surgery for the symptomatic left side. Although neurological symptoms did not worsen immediately after the surgery, disturbance of consciousness, right conjugate deviation, and left paresis appeared 4 hr after the surgery. New infarction appeared in the right frontal lobe, and the blood signal beyond the right middle cerebral artery (MCA) disappeared on MRI and MRA. Mechanical thrombectomy (MT) using a suction catheter improved antegrade blood flow in the MCA. The left paresis remained at discharge (modified Rankin Scale score = 4), but she was able to walk independently 3 months after the operation and was independent at home. Acute contralateral ICA occlusion after revascularization for moyamoya disease is an extremely rare complication, but the symptoms can be severe and treatment should be considered. To the best of our knowledge, there have been no reports of MT for postoperative acute contralateral ICA occlusion. Since the results of endovascular treatment such as percutaneous transluminal angioplasty and stent placement for patients with moyamoya disease are poor, MT using an aspiration catheter could be a good treatment option.
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Affiliation(s)
- Shotaro Ogawa
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan
| | - Daisuke Sato
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan
| | - Seiei Torazawa
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan
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Ahmed SU, Lee H, Steinberg GK. Commentary: Direct vs Indirect Revascularization in a North American Cohort of Moyamoya Disease. Neurosurgery 2021; 89:E114-E115. [PMID: 33957669 DOI: 10.1093/neuros/nyab165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 12/20/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Syed Uzair Ahmed
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine and Stanford Health Care, Stanford, California, USA
| | - Hubert Lee
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine and Stanford Health Care, Stanford, California, USA
| | - Gary K Steinberg
- Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine and Stanford Health Care, Stanford, California, USA
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Clinical and Genetic Risk Factors of Long-Term Outcomes after Encephaloduroarteriosynangiosis in Moyamoya Disease in China. J Stroke Cerebrovasc Dis 2021; 30:105847. [PMID: 33992965 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES This retrospective study was conducted to analyze the associations between ring finger protein 213 p.R4810K variant, clinical features and long-term outcomes in patients with moyamoya disease (MMD) after encephaloduroarteriosynangiosis treatment. MATERIALS AND METHODS A total of 2,545 patients with MMD in China were included in this study (median of follow-up duration: 32.00 months). Multiple Cox regression models were used to assess the associations between p.R4810K variant, clinical features and long-term outcomes. RESULTS For all patients, in multivariate Cox analysis, no association was observed between p.R4810K and long-term outcomes. Pediatric onset (HR, 0.38; 95%CI, 0.25-0.59) and headache (HR, 0.26; 95%CI, 0.08-0.83) were inversely and hypertension (HR, 1.43 95%CI, 1.06-1.94), diabetes (HR, 1.55; 95%CI, 1.00-2.40), bilateral lesions (HR, 2.73; 95%CI, 1.12-6.65) and posterior cerebral artery involvement (HR, 1.44; 95%CI, 1.08-1.90) were positively associated with follow-up stroke (all P < 0.05). Pediatric onset (HR, 0.46; 95%CI, 0.26-0.82) was inversely and hyperlipidemia (HR, 1.83; 95%CI, 1.23-2.73), smoking (HR, 1.86; 95%CI, 1.13-3.07), high Suzuki angiographic stage (HR, 1.71, 95%CI, 1.09-2.70), poor admission neurologic status (HR, 8.93; 95%CI, 6.49-12.29) and follow-up stroke (HR, 8.31; 95%CI, 6.01-11.49) were positively associated with poor neurologic outcome at the last follow-up visit (all P < 0.05). The factors were not consistent in the different groups of age at onset. CONCLUSIONS In our study, p.R4810K may play no role in long-term outcomes in Chinese MMD. Clinical features including age at onset, initial symptoms, risk factors of stroke, imaging, poor admission neurologic status were associated with poor outcomes in MMD after EDAS.
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Alkhaibary A, Almutairi OT, Elarjani T, Alnefaie N, Alhussinan MA, Bafaquh M, Alturki AY. The Top-100 most cited articles on Moyamoya disease: A bibliometric analysis. J Cerebrovasc Endovasc Neurosurg 2021; 23:85-98. [PMID: 33975427 PMCID: PMC8256026 DOI: 10.7461/jcen.2021.e2020.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 12/17/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Moyamoya disease (MMD) is a progressive steno-occlusive cerebrovascular phenomenon with unknown pathogenesis. Considering the abundance of articles addressing Moyamoya disease, a detailed analysis concerning the publication trends is of paramount importance. The aim of the study is to report the current knowledge of the top-100 most cited articles on Moyamoya disease in the literature. METHODS A non-time restricted keyword-based search was performed in June 2020 using the Scopus database. The search keywords included the following: "Moyamoya", "Moyamoya disease", and "Moyamoya syndrome". The search result was used to rank the articles based on their citation count. The top-100 most-cited articles were obtained and classified into seven categories. RESULTS A total of 3,543 articles on Moyamoya disease were published between 1955 and 2020. The Top-100 articles were published between 1977 and 2016 with a total of 16,119 citations, per year, and 7.23% rate of self-citation. The 1990s was the most productive decade (N=42). The most contributing country to the list was Japan (N=60). Stroke was the most active journal (N=23). Houkin, K., a Japanese neurosurgeon, was the most prolific author (N=15). CONCLUSIONS Moyamoya disease has been extensively investigated in the literature throughout the years. The majority of articles published in the literature were addressing the surgical management and clinical outcome. Authors from neurosurgical backgrounds were the most active contributors to the field of Moyamoya disease.
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Affiliation(s)
- Ali Alkhaibary
- Division of Neurosurgery, Department of Surgery, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Othman T Almutairi
- Department of Adult Neurosurgery, National Neurosciences Institute, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Turki Elarjani
- Department of Neurological Surgery, University of Miami, Miami, FL, USA
| | - Nada Alnefaie
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Mohammed Bafaquh
- Neurocritical Care Division, Critical Care Administration, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Abdulrahman Y Alturki
- Department of Adult Neurosurgery, National Neurosciences Institute, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia.,Neurocritical Care Division, Critical Care Administration, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
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45
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Connolly F, Alsolivany J, Czabanka M, Vajkoczy P, Valdueza JM, Röhl JE, Siebert E, Danyel LA. Blood volume flow in the superficial temporal artery assessed by duplex sonography: predicting extracranial-intracranial bypass patency in moyamoya disease. J Neurosurg 2021; 135:1666-1673. [PMID: 33836503 DOI: 10.3171/2020.9.jns202709] [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: 07/21/2020] [Accepted: 09/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery is an important therapy for symptomatic moyamoya disease. Its success depends on bypass function, which may be impaired by primary or secondary bypass insufficiency. Catheter angiography is the current gold standard to assess bypass function, whereas the diagnostic value of ultrasonography (US) has not been systematically analyzed so far. METHODS The authors analyzed 50 STA-MCA bypasses in 39 patients (age 45 ± 14 years [mean ± SD]; 26 female, 13 male). Bypass patency was evaluated by catheter angiography, which was performed within 24 hours after US. The collateral circulation through the bypass was classified into 4 types as follows: the bypass supplies more than two-thirds (type A); between one-third and two-thirds (type B); or less than one-third (type C) of the MCA territory; or there is bypass occlusion (type D). The authors assessed the mean blood flow velocity (BFV), the blood volume flow (BVF), and the pulsatility index (PI) in the external carotid artery and STA by duplex sonography. Additionally, they analyzed the flow direction of the MCA by transcranial color-coded sonography. US findings were compared between bypasses with higher (types A and B) and lower (types C and D) capacity. RESULTS Catheter angiography revealed high STA-MCA bypass capacity in 35 cases (type A: n = 22, type B: n = 13), whereas low bypass capacity was noted in the remaining 15 cases (type C: n = 12, type D: n = 3). The BVF values in the STA were 60 ± 28 ml/min (range 4-121 ml/min) in the former and 12 ± 4 ml/min (range 6-18 ml/min) in the latter group (p < 0.0001). Corresponding values of mean BFV and PI were 57 ± 21 cm/sec (range 16-100 cm/sec) versus 22 ± 8 cm/sec (range 10-38 cm/sec) (p < 0.0001) and 0.8 ± 0.2 (range 0.4-1.3) versus 1.4 ± 0.5 (range 0.5-2.4) (p < 0.0001), respectively. Differences in the external carotid artery were less distinct: BVF 217 ± 71 ml/min (range 110-425 ml/min) versus 151 ± 41 ml/min (range 87-229 ml/min) (p = 0.001); mean BFV 47 ± 17 cm/sec (range 24-108 cm/sec) versus 40 ± 7 cm/sec (range 26-50 cm/sec) (p = 0.15); PI 1.5 ± 0.4 (range 1.0-2.5) versus 1.9 ± 0.4 (range 1.2-2.6) (p = 0.009). A retrograde blood flow in the MCA was found in 14 cases (9 in the M1 and M2 segment; 5 in the M2 segment alone), and all of them showed a good bypass function (type A, n = 10; type B, n = 4). The best parameter (cutoff value) to distinguish bypasses with higher capacity from bypasses with lower capacity was a BVF in the STA ≥ 21 ml/min (sensitivity 100%, negative predictive value 100%, specificity 91%, positive predictive value 83%). CONCLUSIONS Duplex sonography is a suitable diagnostic tool to assess STA-MCA bypass function in moyamoya disease. Hemodynamic monitoring of the STA by US provides an excellent predictor of bypass patency.
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Affiliation(s)
| | | | | | | | - Jose M Valdueza
- 3Neurological Center, Segeberger Kliniken, Schleswig-Holstein, Bad Segeberg; and
| | | | - Eberhard Siebert
- 4Institute of Neuroradiology, University Hospital Charité, Berlin, Germany
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Zhang A, Brown N, Cheaney B, Campos JK, Chase Ransom R, Hsu FP. Updates in the management of moyamoya disease. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.100976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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47
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Lu J, Zhao Y, Li M, Ma L, Chen Y, Wang R, Ye X, Wang H, Chen X, Zhao Y. Clinical Implications of the "Brush Sign" in Susceptibility-Weighted Imaging for Moyamoya Disease. Cerebrovasc Dis 2021; 50:147-155. [PMID: 33556948 DOI: 10.1159/000511936] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 09/23/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Infarction is one of the most common postoperative complications after surgical revascularization for moyamoya disease (MMD). Increased conspicuity of deep medullary veins (DMVs) on susceptibility-weighted imaging (SWI), known as "brush sign," could predict the severity of MMD. This study aimed to reveal the features of the "brush sign" in preoperative SWI and to verify its relationship to postoperative infarction. METHODS Consecutive patients with MMD who had undergone cerebral revascularization surgery were included. Routine preoperative SWI was performed. The "brush sign" was defined according to the number of the conspicuous DMVs > 5 detected on SWI. Postoperative infarctions were defined as the high-intensity signal on postoperative DWI images, with or without neurologic deficits. The modified Rankin scale (mRS) was applied to evaluate the prognosis of patients. RESULTS In the enrolled 100 hemispheres, 35 were presented with the "brush sign." Patients with ischemic onset manifestation and previous infarction history tended to present with the "brush sign." Multivariate analysis showed that the "brush sign" (OR 13.669; 95% CI, 1.747-106.967, p = 0.013) and decreased rCBF (OR 6.050; 95% CI, 1.052-34.799, p = 0.044) were independent risk factors of postoperative infarction. Besides, the "brush sign" showed a significant correlation with a higher mRS score at discharge (p = 0.047). CONCLUSION The findings strongly suggest that the presence of the "brush sign" preoperatively can be a predictor of infarction after surgical revascularization for ischemic MMD. It may contribute to an improved surgical result through focused perioperative management based on appropriate surgical risk stratification.
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Affiliation(s)
- Junlin Lu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yahui Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mingtao Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Rong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Department of Neurosurgery, Peking University International Hospital, Beijing, China.,Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing, China
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Liu J, Xu Q, Niu H, Wang R, Ye X, Liu X. Postoperative incidence of seizure and cerebral infarction in pediatric patients with epileptic type moyamoya disease: a meta-analysis of single rate. Chin Neurosurg J 2021; 7:11. [PMID: 33526093 PMCID: PMC7852094 DOI: 10.1186/s41016-020-00224-y] [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: 05/29/2020] [Accepted: 12/14/2020] [Indexed: 11/10/2022] Open
Abstract
Background Surgery is a conventional mature treatment for moyamoya disease (MMD). However, whether surgery is also an effective therapy for epileptic type MMD has seldom been investigated systematically. The study aims to summarize the pooled postoperative incidence of seizure and cerebral infarction in pediatric patients with epileptic type moyamoya disease. Method The study was a systematic review and critical appraisal with a meta-analysis of cohort studies, both prospective and retrospective. Studies were identified by a computerized search of PubMed, Embase, Web of Science, Wanfang, and CNKI databases. In a literature search, a total of 7 cohort studies were identified. The I2statistic was used to quantify heterogeneity. A fixed-effect model was used to synthesize the results. The linear regression test of funnel plot asymmetry was used to estimate the potential publication bias. Results The pooled estimated postoperative incidence of seizure in pediatric patients with epileptic type moyamoya disease was 23.44%. The pooled estimated postoperative incidence of cerebral infarction in pediatric patients with epileptic type moyamoya disease was 9.12%. Low substantial heterogeneity and potential publication bias were present. Conclusions Evidence from this study suggests that the postoperative incidence of seizure and cerebral infarction is relatively low. Surgery is an effective and secure therapy for pediatric patients with epileptic type moyamoya disease.
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Affiliation(s)
- Jingjing Liu
- Peking University International Hospital, Department of Neurology, Peking University, Beijing, China.,Boston Children's Hospital, Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Harvard Medical School, Boston, USA
| | - Qinlan Xu
- Peking University International Hospital, Department of Neurology, Peking University, Beijing, China
| | - Hongchuan Niu
- Peking University International Hospital, Department of Neurosurgery, Peking University, Beijing, China
| | - Rong Wang
- Peking University International Hospital, Department of Neurosurgery, Peking University, Beijing, China.,Beijing Tiantan Hospital, Department of Neurosurgery, Capital Medical University, Beijing, China
| | - Xun Ye
- Peking University International Hospital, Department of Neurosurgery, Peking University, Beijing, China. .,Beijing Tiantan Hospital, Department of Neurosurgery, Capital Medical University, Beijing, China.
| | - Xianzeng Liu
- Peking University International Hospital, Department of Neurology, Peking University, Beijing, China.
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Neuroanesthesiology Update. J Neurosurg Anesthesiol 2021; 33:107-136. [PMID: 33480638 DOI: 10.1097/ana.0000000000000757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 12/18/2020] [Indexed: 11/27/2022]
Abstract
This review summarizes the literature published in 2020 that is relevant to the perioperative care of neurosurgical patients and patients with neurological diseases as well as critically ill patients with neurological diseases. Broad topics include general perioperative neuroscientific considerations, stroke, traumatic brain injury, monitoring, anesthetic neurotoxicity, and perioperative disorders of cognitive function.
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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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