Hemodynamic analysis of the recipient parasylvian cortical arteries for predicting postoperative hyperperfusion during STA-MCA bypass in adult patients with moyamoya disease

FOXM1 c.1205 C > A mutation is associated with unilateral Moyamoya disease and inhibits angiogenesis in human brain endothelial cells

Unilateral moyamoya disease (MMD) represents a distinct subtype characterised by occlusive changes in the circle of Willis and abnormal vascular network formation. However, the aetiology and pathogenesis of unilateral MMD remain unclear. In this study, genetic screening of a family with unilateral MMD using whole-genome sequencing helped identify the c.1205 C > A variant of FOXM1, which encodes the transcription factor FOXM1 and plays a crucial role in angiogenesis and cell proliferation, as a susceptibility gene mutation. We demonstrated that this mutation significantly attenuated the proangiogenic effects of FOXM1 in human brain endothelial cells, leading to reduced proliferation, migration, and tube formation. Furthermore, FOXM1 c.1205 C > A results in increased apoptosis of human brain endothelial cells, mediated by the downregulation of the transcription of the apoptosis-inhibiting protein BCL2. These results suggest a potential role for the FOXM1 c.1205 C > A mutation in the pathogenesis of unilateral MMD and may contribute to the understanding and treatment of this condition.

Intraoperative evaluation of local cerebral hemodynamic change by laser speckle contrast imaging for predicting postoperative cerebral hyperperfusion during STA-MCA bypass in adult patients with moyamoya disease

Cerebral hyperperfusion (CHP) occurred frequently after direct superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery for moyamoya disease (MMD). We analyzed cortical microvascular density (CMD) and the change of cerebral blood flow (LΔCBF) using intraoperative laser speckle contrast imaging (LSCI) on 130 hemispheres of 95 consecutive adult patients with MMD. The demographic characteristics, cortical hemodynamic sources, bypass methods, intraoperative blood flow data, and relative CBF changes on single-photon emission computed tomography (SPECT) examination (SΔrCBF) were compared between the groups with and without CHP. The median values for CMD, LΔCBF, and SΔrCBF were significantly higher in the CHP group than in the non-CHP group (CMD 0.240 vs 0.206, P = 0.004; LΔCBF 2.285 vs 1.870, P < 0.001; SΔCBF 1.535 vs 1.260, P < 0.001). Multivariate analysis revealed that hemodynamic sources of recipient parasylvian cortical arteries from MCA (M-PSCAs), end-to-side (E-S) bypass method, CMD ≥ 0.217, and LΔCBF ≥ 1.985 were the risk factors for CHP. Intraoperative LSCI was useful for evaluating hemodynamics and predicting CHP in patients with MMD.

Evaluation of deep learning algorithms in detecting moyamoya disease: a systematic review and single-arm meta-analysis

The diagnosis of Moyamoya disease (MMD) relies heavily on imaging, which could benefit from standardized machine learning tools. This study aims to evaluate the diagnostic efficacy of deep learning (DL) algorithms for MMD by analyzing sensitivity, specificity, and the area under the curve (AUC) compared to expert consensus. We conducted a systematic search of PubMed, Embase, and Web of Science for articles published from inception to February 2024. Eligible studies were required to report diagnostic accuracy metrics such as sensitivity, specificity, and AUC, excluding those not in English or using traditional machine learning methods. Seven studies were included, comprising a sample of 4,416 patients, of whom 1,358 had MMD. The pooled sensitivity for common and random effects models was 0.89 (95% CI: 0.85 to 0.92) and 0.92 (95% CI: 0.85 to 0.96), respectively. The pooled specificity was 0.89 (95% CI: 0.86 to 0.91) in the common effects model and 0.91 (95% CI: 0.75 to 0.97) in the random effects model. Two studies reported the AUC alongside their confidence intervals. A meta-analysis synthesizing these findings aggregated a mean AUC of 0.94 (95% CI: 0.92 to 0.96) for common effects and 0.89 (95% CI: 0.76 to 1.02) for random effects models. Deep learning models significantly enhance the diagnosis of MMD by efficiently extracting and identifying complex image patterns with high sensitivity and specificity. Trial registration: CRD42024524998 https://www.crd.york.ac.uk/prospero/displayrecord.php?RecordID=524998.

Individualised evaluation based on pathophysiology for moyamoya vasculopathy: application in surgical revascularisation

BACKGROUND

Although bypass surgery is an effective treatment for moyamoya vasculopathy (MMV), the incidence of postoperative complications is still high. This study aims to introduce a novel evaluating system based on individualised pathophysiology of MMV, and to assess its clinical significance.

METHODS

This multicentre, prospective study enrolled adult patients with MMV from Huashan Hospital, Fudan University and National Center for Neurological Disorders, China between March 2021 and February 2022. Multimodal neuroimages containing structural and functional information were used to evaluate personalised disease severity and fused to localise the surgical field, avoid invalid regions and propose alternative recipient arteries. The recipient artery was further selected intraoperatively by assessing regional haemodynamic and electrophysiological information. The preanastomosis and postanastomosis data were compared with assist with the postoperative management. Patients who received such tailored revascularisations were included in the novel group and the others were included in the traditional group. The 30-day surgical outcomes and intermediate long-term follow-up were compared.

RESULTS

Totally 375 patients (145 patients in the novel group and 230 patients in the traditional group) were included. The overall complication rate was significantly lower in the novel group (p˂0.001). In detail, both the rates of postoperative infarction (p=0.009) and hyperperfusion syndrome (p=0.010) were significantly lower. The functional outcomes trended to be more favourable in the novel group, though not significantly (p=0.260). Notably, the proportion of good functional status was higher in the novel group (p=0.009). Interestingly, the preoperative statuses of perfusion and metabolism around the bypass area were significantly correlated with the occurrence of postoperative complications (P˂0.0001).

CONCLUSIONS

This novel evaluating system helps to identify appropriate surgical field and recipient arteries during bypass surgery for MMV to achieve better haemodynamic remodelling and pathophysiological improvement, which results in more favourable clinical outcomes.

Blood-brain barrier disruption imaging in postoperative cerebral hyperperfusion syndrome using DCE-MRI

Little has been reported about the association between cerebral hyperperfusion syndrome (CHS) and blood-brain barrier (BBB) disruption in human. We aimed to investigate the changes in permeability after bypass surgery in cerebrovascular steno-occlusive diseases using dynamic contrast-enhanced MRI (DCE-MRI) and to demonstrate the association between CHS and BBB disruption. This retrospective study included 36 patients (21 hemispheres in 18 CHS patients and 20 hemispheres in 18 controls) who underwent combined bypass surgery for moyamoya and atherosclerotic steno-occlusive diseases. DCE-MRI and arterial spin labeling perfusion-weighted imaging (ASL-PWI) were obtained at the baseline, postoperative state, and discharge. Perfusion and permeability parameters were calculated at the MCA territory (CBF(territorial), Ktrans(territorial), Vp(territorial)) and focal perianastomotic area (CBF(focal), Ktrans(focal), Vp(focal)) of operated hemispheres. As compared with the baseline, both CBF(territorial) and CBF(focal) increased in the postoperative period and decreased at discharge, corresponding well to symptoms in the CHS group. Vp(focal) was lower in the postoperative period and at discharge, as compared with the baseline. In the control group, no parameters significantly differed among the three points. In conclusion, Vp at the focal perianastomotic area significantly decreased in patients with CHS during the postoperative period. BBB disruption may be implicated in the development of CHS after bypass surgery.

Combination of intraoperative indocyanine green video-angiography FLOW 800 and computed tomography perfusion to assess the risk of cerebral hyperperfusion syndrome in chronic internal carotid artery occlusion patients after revascularization surgery

Background and purpose

To study the changes of corticocerebral hemodynamics in surgical area and postoperative hyperperfusion syndrome in patients with chronic internal carotid artery occlusion (CICAO) by intraoperative indocyanine green videoangiography (ICGA)-FLOW 800 and CT perfusion after superficial temporal artery (STA)-middle cerebral artery (MCA) bypass surgery.

Methods

From October 2019 to January 2021, 77 patients diagnosed with CICAO underwent direct bypass surgery at Huadong hospital (affiliated with Fudan University) were enrolled. Regions of interest (ROIs) at STA, proximal MCA (PMCA), distal MCA (DMCA), cortical blood capillary (CBC), and cortical vein (CV) were identified after anastomosis by ICGV-FLOW 800 including peak fluorescence intensity (PFI), time to peak (TTP), and area under the time curve (AUC) of fluorescence intensity. All patients underwent perfusion-weighted CT before bypass surgery and those patients with HPS were verified by CTP after bypass.

Results

14 patients with HPS were verified by perfusion-weighted CT after bypass. In HPS group, the AUCTTP of DMCA was significantly larger (T = -3.301, p = 0.004) and TTP of CBC was shorter (T = -2.929, p = 0.005) than patients in non-HPS group. The larger AUCTTP of DMCA (OR = 3.024, 95%CI 1.390-6.578, p = 0.0050) was an independent risk factor by further multivariate logistic regression analysis.

Conclusion

The hemodynamic changes of cortical vessels during STA-MCA bypass surgery could be recorded accurately by ICGV-FLOW 800. Furthermore, the increased AUCTTP of DMCA and shorter TTP of CBC may be potential risk factors of HPS.

Adult Moyamoya Disease and Syndrome: Current Perspectives and Future Directions: A Scientific Statement From the American Heart Association/American Stroke Association

Adult moyamoya disease and syndrome are rare disorders with significant morbidity and mortality. A writing group of experts was selected to conduct a literature search, summarize the current knowledge on the topic, and provide a road map for future investigation. The document presents an update in the definitions of moyamoya disease and syndrome, modern methods for diagnosis, and updated information on pathophysiology, epidemiology, and both medical and surgical treatment. Despite recent advancements, there are still many unresolved questions about moyamoya disease and syndrome, including lack of unified diagnostic criteria, reliable biomarkers, better understanding of the underlying pathophysiology, and stronger evidence for treatment guidelines. To advance progress in this area, it is crucial to acknowledge the limitations and weaknesses of current studies and explore new approaches, which are outlined in this scientific statement for future research strategies.

Analyzing characteristics of collateral flow to parasylvian cortical arteries by three-dimensional digital subtraction angiography-magnetic resonance angiography fusion imaging in adult moyamoya disease

Objective

The hemodynamic sources of recipient parasylvian cortical arteries (PSCAs) were significantly related to postoperative cerebral hyperperfusion (CHP) after bypass surgery in patients with moyamoya disease (MMD). The present study aimed to introduce a new method to investigate the characteristics of PSCAs hemodynamic sources and their relationships with clinical presentations in adult MMD and to provide preoperative evaluation for recipient vessel selection in MMD bypass surgery.

Methods

The hemodynamic sources of the PSCAs in 171 symptomatic MMD hemispheres were analyzed by three-dimensional digital subtraction angiography (3D-DSA) combined with magnetic resonance angiography (MRA) fusion imaging. The spatial and temporal characteristics of the hemodynamic sources of the PSCAs and their associations with the patient's demographics, Suzuki stage, and initial onset type were investigated.

Results

Six major types of hemodynamic sources in the PSCAs were observed. There was a significant difference between the hemodynamic sources of the PSCAs above and below the SF (P < 0.001). With advancing Suzuki stages, collateral flow to the PSCAs above the SF from the internal carotid arteries (ICAs) significantly decreased, while the non-ICAs increased (P < 0.001). Multivariate analysis revealed that hemodynamic sources of the PSCAs above the SF were significantly associated with patients' initial onset type (P = 0.026).

Conclusion

In MMD hemispheres, the hemodynamic sources of the PSCAs above the SF are more varied than those below the SF and present a typical conversion trend from ICAs to non-ICAs with advancing Suzuki stages. Analyzing the hemodynamic sources of the PSCAs can help in understanding the conversion pattern of compensatory vascular systems, predicting episodes in MMD, and preoperatively evaluating suitable recipient vessel selection for bypass surgery to avoid postoperative CHP.

Designing a flow-controlled STA-MCA anastomosis based on the Hagen-Poiseuille law for preventing postoperative hyperperfusion in adult moyamoya disease

Background

Technical improvements for preventing postoperative symptomatic cerebral hyperperfusion (CHP) during superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis for moyamoya disease (MMD) were seldom reported.

Objectives

The aim of this study was to investigate the significance of application of a novel flow-controlled concept which voluntarily reduces the hemodynamic difference between the donor and recipient arteries based on the Hagen-Poiseuille law when performing direct anastomoses of recipient parasylvian cortical arteries (PSCAs) with anterograde hemodynamic sources from the MCA (M-PSCAs) in adult MMD.

Design

This was a retrospective observational study.

Methods

Direct anastomoses of recipient M-PSCAs were performed on 89 symptomatic hemispheres in 82 adult MMD patients in our hospital from January 2020 to June 2021. They were divided into the flow-controlled group (patients who received direct anastomosis under designed flow-controlled principles) and non-flow-controlled group (patients who received conventional direct anastomosis to obtain maximum flow). The patients' basic characteristics and incidence of postoperative CHP were compared between the two groups. Risk factors for occurrence of postoperative CHP were analyzed.

Results

Overall, 36 hemispheres were included in the non-flow-controlled group and 53 in flow-controlled group. The incidences of postoperative focal (22.6%) and symptomatic CHP (5.7%) in the flow-controlled group were significantly lower than those (focal, 52.8%; symptomatic, 25.0%) in the non-flow-controlled group (p = 0.003 and 0.009, respectively). Multivariate analysis revealed that the flow-controlled concept was significantly associated with the development of focal (p = 0.005) and symptomatic (p = 0.012) CHP.

Conclusion

The flow-controlled STA-MCA anastomosis can significantly decrease the incidence of postoperative CHP during direct anastomoses of recipient M-PSCAs in adult MMD.

Intraoperative Hemodynamics of Parasylvian Cortical Arteries for Predicting Postoperative Symptomatic Cerebral Hyperperfusion after Direct Revascularization in Patients with Moyamoya Disease: A Preliminary Study

Objective. The search for methods by which to predict the risks of cerebral hyperperfusion syn-drome (CHS) in adults with moyamoya disease (MMD), including those utilizing new biomarkers, still deserves further research. The objective of this study was to investigate the association between the hemodynamics of parasylvian cortical arteries (PSCAs) and postoperative CHS. Methods. A consecutive number of adults with MMD who had undergone direct bypass between September 2020 and December 2022 were recruited. Intraoperative microvascular doppler ultrasonography (MDU) was performed to evaluate the hemodynamics of PSCAs. The intraoperative flow direction, mean value of velocity (MVV) of recipient artery (RA) and bypass graft were recorded. According to flow direction after bypass, RA was divided into entering sylvian (RA.ES) and leaving sylvian (RA.LS) subtypes. Univariate, multivariate, and ROC analyses of the risk factors for postoperative CHS were performed. Results. A total of 16 (15.09%) cases in 106 consecutive hemispheres (101 patients) sat-isfied the postoperative CHS criteria. According to univariate analysis, advanced Suzuki stage, MVV of RA before bypass, and fold increase of MVV in RA.ES after bypass were significantly associated with postoperative CHS (p < 0.05). Multivariate analysis indicated that left-operated hemisphere (OR (95%CI), 4.58 (1.05-19.97), p = 0.043), advanced Suzuki stage (OR (95%CI), 5.47 (1.99-15.05), p = 0.017), and fold increase of MVV in RA.ES (OR (95%CI), 1.17 (1.06-1.30), p = 0.003) were statistically significantly associated with the occurrence of CHS. The cut-off value of fold increase of MVV in RA.ES was 2.7-fold (p < 0.05). Conclusions. Left-operated hemisphere, advanced Suzuki stage, and postoperative fold increase of MVV in RA.ES were potential risk factors for postoperative CHS. Intraoperative MDU was useful for evaluating hemodynamics and predicting CHS.

Physiological and pathophysiological mechanisms of the molecular and cellular biology of angiogenesis and inflammation in moyamoya angiopathy and related vascular diseases

Rationale

The etiology and pathophysiological mechanisms of moyamoya angiopathy (MMA) remain largely unknown. MMA is a progressive, occlusive cerebrovascular disorder characterized by recurrent ischemic and hemorrhagic strokes; with compensatory formation of an abnormal network of perforating blood vessels that creates a collateral circulation; and by aberrant angiogenesis at the base of the brain. Imbalance of angiogenic and vasculogenic mechanisms has been proposed as a potential cause of MMA. Moyamoya vessels suggest that aberrant angiogenic, arteriogenic, and vasculogenic processes may be involved in the pathophysiology of MMA. Circulating endothelial progenitor cells have been hypothesized to contribute to vascular remodeling in MMA. MMA is associated with increased expression of angiogenic factors and proinflammatory molecules. Systemic inflammation may be related to MMA pathogenesis.

Objective

This literature review describes the molecular mechanisms associated with cerebrovascular dysfunction, aberrant angiogenesis, and inflammation in MMA and related cerebrovascular diseases along with treatment strategies and future research perspectives.

Methods and results

References were identified through a systematic computerized search of the medical literature from January 1, 1983, through July 29, 2022, using the PubMed, EMBASE, BIOSIS Previews, CNKI, ISI web of science, and Medline databases and various combinations of the keywords "moyamoya," "angiogenesis," "anastomotic network," "molecular mechanism," "physiology," "pathophysiology," "pathogenesis," "biomarker," "genetics," "signaling pathway," "blood-brain barrier," "endothelial progenitor cells," "endothelial function," "inflammation," "intracranial hemorrhage," and "stroke." Relevant articles and supplemental basic science articles almost exclusively published in English were included. Review of the reference lists of relevant publications for additional sources resulted in 350 publications which met the study inclusion criteria. Detection of growth factors, chemokines, and cytokines in MMA patients suggests the hypothesis of aberrant angiogenesis being involved in MMA pathogenesis. It remains to be ascertained whether these findings are consequences of MMA or are etiological factors of MMA.

Conclusions

MMA is a heterogeneous disorder, comprising various genotypes and phenotypes, with a complex pathophysiology. Additional research may advance our understanding of the pathophysiology involved in aberrant angiogenesis, arterial stenosis, and the formation of moyamoya collaterals and anastomotic networks. Future research will benefit from researching molecular pathophysiologic mechanisms and the correlation of clinical and basic research results.

Classify patients with Moyamoya disease according to their cognitive performance might be helpful in clinical and practical with support vector machine based on hypergraph

Moyamoya disease (MMD) patients were now classified according to their cerebrovascular manifestations, with cognition and emotion ignored, which attenuated the therapy. The present study tried to classify them based on their cognitive and emotional performance and explored the neural basis underlying this classification using resting-state fMRI (rs-fMRI). Thirty-nine MMD patients were recruited, assessed mental function and MRI scanned. We adopted hierarchical analysis of their mental performance for new subtypes. Next, a three-step analysis, with each step consisting of 10 random cross validation, was conducted for robust brain regions in classifying the three subtypes of patients in a support vector machine (SVM) model with hypergraph of rs-fMRI. We found three new subtypes including high depression-high anxiety-low cognition (HE-LC, 50%), low depression-low anxiety-high cognition (LE-HC, 14%), and low depression-low anxiety-low cognition (LE-LC, 36%), and no hemorrhagic MMD patients fell into the LE-HC group. The temporal and the bilateral superior frontal cortex, and so forth were included in all 10 randomized SVM modeling. The classification accuracy of the final three-way classification model was 67.5% in average of 10 random cross validation. In addition, the S value between the frontal cortex and the angular cortex was positively correlated with the anxiety score and backward digit span (p < .05). Our results might provide a new perspective for MMD classification concerning patients' mental status, guide timely surgery and suggest angular cortex, and so forth should be protected in surgery for cognitive consideration.

Risk factors of postoperative cerebral hyperperfusion syndrome and its relationship with clinical prognosis in adult patients with moyamoya disease

BACKGROUND

To investigate the incidence, risk factors, and clinical prognosis of cerebral hyperperfusion syndrome (CHS) after superficial temporal artery-middle cerebral artery anastomosis combined with encephalo-duro-arterio-synangiosis (STA-MCA/EDAS) in adult patients with moyamoya disease (MMD).

METHODS

The clinical data of 160 adult patients with MMD treated by STA-MCA/EDAS from January 2016 to January 2017 were retrospectively analyzed. According to CHS diagnosis, MMD patients were divided into CHS and non-CHS group. Univariate and multivariate analysis of risk factors and Kaplan-Meier curve of stroke-free survival for CHS were performed.

RESULTS

A total of 12 patients (7.5%) developed postoperative CHS, of which 4 patients (2.5%) presented with cerebral hemorrhage. Univariate and multivariate analysis showed moyamoya vessel on the surgical hemisphere (OR = 3.04, 95% CI = 1.02-9.03, P = 0.046) and left operated hemisphere (OR = 5.16, 95% CI = 1.09-21.34, P = 0.041) were independent risk factors for CHS. The other variables, such as age, gender, presentation, hypertension, diabetes, smoking, mean mRS score on admission, modified Suzuki stage and pre-infarction stage on surgical hemisphere, and bypass patency, had no association with postoperative CHS (P > 0.05). At final follow-up with average 38 months, there were 18 out of 133 patients (13.5%, 4.91% per person year) presented with newly developed complications. There was no significant difference between newly developed complications, mean mRS scores, and Kaplan-Meier curve of stroke-free survival in patients with and without CHS (P > 0.05).

CONCLUSION

The concentration of moyamoya vessels and left operated hemisphere was independent risk factors for CHS, which could not affect the clinical prognosis if treated timely and properly. The current study offers a new perspective of moyamoya vessels and supporting data for choosing MMD candidates on cerebral revascularization.

Expression of hypoxia-inducing factor-1α and matrix metalloproteinase-9 in the recipient parasylvian cortical arteries with different hemodynamic sources in adult moyamoya disease

Objective

In our latest research, we have demonstrated that the recipient parasylvian cortical arteries (PSCAs) with hemodynamic sources from the middle cerebral artery (M-PSCAs) has a higher risk of postoperative cerebral hyperperfusion (CHP) syndrome than those from non-M-PSCAs in adult moyamoya disease (MMD) patient. However, whether there are differences between M-PSCAs and non-M-PSCAs in vascular specimens characteristics has not been studied. In this study, we further investigate the vascular specimen of recipient PSCAs by histological and immunohistochemical methods.

Methods

50 vascular specimens of recipient PSCAs were obtained from 50 adult MMD patients during the combined bypass surgeries in our departments of Zhongnan hospital. 4 recipient PSCAs samples were also obtained in the same way from the middle cerebral artery occlusion patients. The samples were received the pathological sectioning, hematoxylin and eosin staining, and immunohistochemistry, then the vascular wall thickness, matrix metalloproteinase-9 (MMP-9) and hypoxia-inducing factor-1α (HIF-1α) were analyzed.

Results

M-PSCAs adult MMD patients had a thinner intima than non-M-PSCAs in the recipient PSCAs specimens. In recipient non-M-PSCAs vascular specimens, the immunoreactivity indicating HIF-1α and matrix metalloproteinase-9 (MMP-9) was significantly higher than M-PSCAs groups. The logistic regression analyses showed that the M-PSCAs was an independent risk factor of postoperative cerebral hyperperfusion (CHP) syndrome (OR 6.235, 95% CI1.018-38.170, P = 0.048) in MMD.

Conclusion

Our results indicate that M-PSCAs adult MMD patients had thinner intima than non-MCAs adult MMD patients in the PSCAs. More importantly, HIF-1α and MMP-9 were overexpressed in non-M-PSCAs vascular specimens.

Gamma Knife radiosurgery for meningiomas of the confluence of the falx and tentorium

PURPOSE

Meningiomas arising from the confluence of the falx and tentorium (CFT) are a rare and challenging subset of meningiomas. Gamma Knife radiosurgery (GKRS) is well-established as a safe and effective management strategy for intracranial meningiomas, but its role in treating CFT meningiomas is not well-described. This paper reports the largest series focused exclusively on the outcomes of GKRS for CFT meningiomas.

METHODS

We retrospectively identified 20 CFT meningiomas out of 2031 meningioma patients who underwent GKRS at our institution between 1987 and 2021. Tumor control, overall survival (OS), and complications were recorded and analyzed. The median tumor margin dose was 13 Gy at the 50% isodose line. The median tumor volume treated was 4.4 cc (IQR 3.5-7.7). The median patient age was 58 years (range 33-83), the median MRI surveillance duration was 59 months (IQR 34-92), and the median overall follow-up duration was 92 months (IQR 42-201).

RESULTS

The local tumor control rate (PFS) at 5 and 10-years were 100% (N=10) and 83% (N=4), respectively. Eight patients had stable tumor volumes and 11 patients had regression. One patient with a twice-operated tumor had delayed progression at 7.5 years and was retreated with GKRS. No patient had adverse radiation effects during the period of MRI surveillance. The 5 and 10-year OS were 100% (N=13) and 100% (N=7), respectively.

CONCLUSIONS

GKRS is a valuable therapeutic strategy for patients with newly diagnosed CFT meningiomas or progressive residual tumors after surgical resection.

How to choose the surgical side when cerebral blood flow and cerebrovascular response are contradictory in bilateral moyamoya disease?: A case report

INTRODUCTION

Moyamoya disease (MMD) is a rare cerebrovascular disease characterized by progressive occlusion of the internal carotid artery and the secondary formation of collateral vessels. Bypass surgery is an effective treatment for MMD. Comprehensive evaluation of cerebral blood flow (CBF) and cerebrovascular response (CVR) is the common hemodynamic indication to surgery, the changes of which are usually identical.

THE PATIENTS MAIN CONCERNS AND IMPORTANT EXAMINATIONS

We reported a rare case of MMD in a 34-year-old pregnant woman with transient ischemic attacks (TIAs) for 1 month, manifesting as frequent weakness in right limbs for several minutes without obvious cause. The diagnostic digital subtraction angiography (DSA) examination revealed Suzuki Grade I in left side and Grade IV in right side under modified Suzuki scoring. No-hyperventilation test single-photon emission computed tomography (no-HVT SPECT) showed more decreased CBF in the right side of the brain, but HVT SPECT demonstrated a more impaired CVR on the left side. Comprehensively, which side should be operated on is confusing when the changes of CVR and CBF are inconsistent.

THE MAIN DIAGNOSIS, THERAPEUTICS INTERVENTIONS, AND OUTCOMES

The patient was diagnosed with bilateral MMD and underwent combined bypass surgery on the left side of the brain. The symptoms of admission were completely relieved after surgery and there were no further cerebrovascular events during the follow-up period of 4 months.

CONCLUSION

CVR is a primary surgical indication of MMD, especially when the impairment of CVR and CBF are not consistent in the ipsilateral hemisphere. Meanwhile, HVT is the vital vasoactive challenges test for measuring CVR in MMD.

A flow self-regulating superficial temporal artery–middle cerebral artery bypass based on side-to-side anastomosis for adult patients with moyamoya disease

OBJECTIVE

Side-to-side (S-S) superficial temporal artery–middle cerebral artery (STA-MCA) bypass was reportedly used to treat a special moyamoya disease (MMD) patient with collaterals arising from the donor STA. However, the S-S technique is not routinely performed to date, and its benefits are still unknown for adult MMD. The purpose of this study was to investigate the possibility of routine use of the S-S technique for adult MMD.

METHODS

The authors retrospectively analyzed the clinical data of 50 adult patients (65 hemispheres, including 30 in the end-to-side [E-S] group and 35 in the S-S group) with MMD who underwent STA-MCA bypass. The patient demographic characteristics, clinical courses, technical details, intraoperative blood flow data, postoperative and preoperative relative cerebral blood flow (rCBF) values, modified Rankin Scale (mRS) scores, and short-term revascularization results were compared between the 2 groups.

RESULTS

There were no significant differences observed in terms of the baseline characteristics, bypass patency rates, postoperative/preoperative rCBF values, incidence of cerebral hyperperfusion syndrome (CHS), mRS scores, and short-term revascularization results between the 2 groups (all p > 0.05). Intraoperative blood flow analysis showed that the increase of STA flow in the E-S group was significantly higher than that of proximal STA flow in the S-S group (p = 0.008). Although the increases of proximal and distal recipient flow in the E-S group seemed greater than those in the S-S group, the results were not statistically significant (p = 0.086 for proximal flow and p = 0.076 for distal flow). CHS symptoms in the S-S group were milder and with much shorter duration. The follow-up angiographic data of the representative case demonstrated that both frontal and parietal STA branches and the occipital artery participated in postoperative collateralization.

CONCLUSIONS

S-S anastomosis can achieve comparable clinical effects to standard E-S construction. S-S anastomosis used in adult MMD demonstrated mild CHS symptoms with short duration and had the potential to arouse all scalp arteries as donor sources for revascularization through the intact distal STA branch via flow self-regulation.

The contralateral progression in a cohort of Chinese adult patients with unilateral moyamoya disease after revascularization: a single-center long-term retrospective study

Background

Moyamoya disease (MMD) is a chronic progressive cerebrovascular disease mainly existing in the Asian population, which can be divided into unilateral and bilateral types. Contralateral progression has been reported in pediatric patients with unilateral MMD, while large series about contralateral progression in Chinese adult patients were rare. The goal of this study is to elucidate the clinical features and incidence of contralateral progression in Chinese MMD adult patients.

Methods

One hundred one Chinese adult patients with unilateral MMD who received surgery treatments between January 2015 and January 2017 in our hospital were enrolled in this study. This study contained 89 patients. Digital subtraction angiography was performed in all patients for initial diagnosis, and magnetic resonance angiography was repeated 6 months from the initial operation and then annually. Clinical characteristics, contralateral progression, and risk factors were studied. Previous related studies were also reviewed and meta-analyzed.

Results

Of these 89 patients, contralateral progression was identified in 8 patients (9.0%) within a median follow-up period of 63 months, which was lower than that in previous studies (25.9%). Single-factor analysis and multivariate analysis did not reveal significant risk factors related to the contralateral progression.

Conclusion

The progress rate in this cohort of Chinese adult patients with unilateral MMD after revascularization was 9.0%, which indicates that some of the unilateral MMD were an early form of bilateral MMD rather than a separate condition.

Trial registration.

This work was approved by the Medical Ethics Committee of Zhongnan Hospital of Wuhan University (approval number: Kelun-2017005).

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-022-05153-6.

Long term outcomes following surgery for pineal region tumors

PURPOSE

Pineal region tumors are surgically demanding tumors to resect. Long term neuro-oncologic outcomes following surgical excision of tumors from this region have been underreported. We sought to define the long term outcomes of patients undergoing resection of pineal region tumors.

METHODS

A retrospective analysis of a prospectively maintained database was performed on patients who underwent intended surgical excision of pineal region tumors. Overall survival (OS) and progression free survival (PFS) were the primary endpoints of this study. Factors associated with OS, PFS and the degree of resection were analyzed, along with 30-day complication rates and dependence on CSF diversion.

RESULTS

Sixty-eight patients with a mean age of 30.9 ± 15.3 years were analyzed. The median clinical and radiographic follow-up was 95.7 and 48.2 months, respectively. The supracerebellar infratentorial and the occipital transtentorial corridors were utilized in the majority of cases (80.9%). The gross total resection (GTR) rate was 52.9% (n=36). The 5-year OS and PFS rates were 70.2% and 58.5%, respectively. Achieving GTR was associated with improved OS (HR 0.39, p = 0.03) and PFS (HR 0.4, p = 0.006). The 30-day mortality rate was 5.9%. The need for CSF diversion was high with 77.9% of patients requiring a shunt or ETV by last follow-up.

CONCLUSIONS

This is the first modern surgical series providing long term follow-up for patients undergoing surgical resection of pineal region tumors. Obtaining a GTR of these challenging tumors is beneficial with regards to PFS/OS. Higher grade tumors have diminished PFS/OS and are treated with adjuvant chemotherapy and/or radiotherapy.

＜Editors' Choice＞ Indocyanine green emission timing of the recipient artery in revascularization surgery for moyamoya disease

In superficial temporal artery to middle cerebral artery anastomosis with indirect revascularization for patients with moyamoya disease, the optimal method for selecting the most appropriate cortical artery for the recipient in anastomosis has not been established. We investigated the relationship between the fluorescence emission timing of the recipient artery in the preanastomosis indocyanine green videoangiography and operative outcomes. This retrospective study included 51 surgical revascularization procedures for 39 moyamoya disease patients. The enrolled surgical procedures were classified into three groups based on the fluorescence emission timing of the recipient artery in preanastomosis indocyanine green videoangiography: the EARLIEST, the INTERMEDIATE, and the LATEST. Clinical characteristics and operative outcomes were also collected. The occurrence of white thrombus at the anastomosis site and symptomatic hyperperfusion showed significant differences between the groups classified by the fluorescence emission timing of the recipient artery in preanastomosis indocyanine green videoangiography (white thrombus, p = 0.001; symptomatic hyperperfusion, p = 0.026). The development of white thrombi was significantly higher in the LATEST group, and all symptomatic hyperperfusion was observed in the EARLIEST group. These results indicated that the LATEST group had a significantly higher risk for developing white thrombus, and the EARLIEST group was prone to occur symptomatic hyperperfusion. Selecting the recipient artery based on evaluating the fluorescence emission timing in preanastomosis indocyanine green videoangiography may be useful in reducing perioperative complications.

Evaluation of Revascularization in Different Suzuki Stages of Ischemic Moyamoya Disease by Whole-Brain CT Perfusion

Objective: This study compared the clinical features and hemodynamic characteristics of patients in different Suzuki stages of ischemic moyamoya disease (iMMD) before and after treatment with extracranial-intracranial (EC-IC) bypass surgery combined with encephalo-duro-myo-synangiosis and whole-brain computed tomography perfusion (WB-CTP).

Methods: A total of 126 patients in different Suzuki stages (II, III, IV, and V) of iMMD who underwent bypass surgery from April 2013 to August 2020 were included in this retrospective study. MIStar automatic analysis of Whole brain CT perfusion imaging software (WB-CTP, Apollo Medical Imaging Technology, Melbourne, Australia) was used. The patients also underwent WB-CTP 1 day before and 1 week and 3 months after the surgery. The relationships between hemodynamic parameters in WB-CTP including delay time (DT) > 3 s, relative cerebral blood flow (rCBF) < 30%, mismatch and mismatch ratio, and clinical outcomes were evaluated for different Suzuki stages, with comparisons between early (II and III) and late (IV and V) stages.

Results: Combined bypass surgery was performed in 161 hemispheres of 126 patients with iMMD. Brain volume with DT > 3 s was decreased 1 week (51.5 ± 11.8 ml, P < 0.05) and 3 months (41.5 ± 10.7 ml, P < 0.05) after bypass compared to 1 day before bypass (104.7 ± 15.1 ml) in early-stage patients. In late-stage patients, the volume was increased 1 week after bypass compared to the preoperative value (154.3 ± 14.7 vs. 118.3 ± 19.1 ml, P < 0.05). Preoperative brain volume with rCBF < 30% was lower (9.8 ± 3.9 vs. 33.5 ± 11.0 ml) whereas preoperative mismatch ratio was higher (11.2 ± 2.8 vs. 3.6 ± 1.6) in early-stage as compared to late-stage patients (both P < 0.05). A higher modified Rankin scale score (0–1) was achieved by early-stage patients than by those in the late stage (93.8 vs. 80.4%, P < 0.05) at the 3-month follow-up.

Conclusions: WB-CTP is useful for assessing the effectiveness of combined bypass/revascularization in different Suzuki stages of iMMD. Patients in the early stage of disease with higher preoperative brain volume with DT > 3 s and mismatch ratio show greater improvements in hemodynamic parameters and fewer postoperative complications associated with hemodynamic disturbance following bypass than patients in the late stage. Preoperative mismatch ratio can serve as a marker for assessing the status of collateral circulation in different Suzuki stages of iMMD.

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

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

Hyperhomocysteinemia is a risk factor for postoperative ischemia in adult patients with moyamoya disease

Growing evidence has suggested that hyperhomocysteinemia (HHcy) is a risk factor for cerebral infarction. However, the effect of HHcy on postoperative cerebral ischemia is still unclear. We aim to investigate the relationship between HHcy and postoperative ischemia of adult patients with moyamoya disease (MMD). A total of 138 adult patients with MMD were prospectively recruited from July 1 to December 31, 2019. After excluding 14 patients accepting conservative therapy, all 124 patients who underwent surgical treatment were enrolled. Patients were grouped according to postoperative ischemia and HHcy presentation, respectively. Clinical data and laboratory examinations were compared by statistical analyses. Potential risk factors were evaluated by univariate and multivariate logistic regression analysis. Comparing to the normal, patients with postoperative ischemia were higher in serum homocysteine (Hcy) level (P = 0.039) and HHcy ratio (P = 0.035). Furthermore, HHcy was more common in males (P = 0.007) than females. Logistic analysis results showed that HHcy (OR 5.234, 95% CI 1.127-24.315; P = 0.035) was an independent risk factor. HHcy was significantly associated with postoperative ischemia in MMD patients. Our study found that HHcy was correlated to the risk of postoperative ischemia. HHcy can be used as an indicator and a potential therapeutic target for postoperative ischemia in adult patients with MMD. URL: http://www.chictr.org . Unique identifier: ChiCTR2000031412.

What and why: the current situation and future prospects of "ivy sign" in moyamoya disease

“Ivy sign” is a special imaging manifestation of moyamoya disease (MMD), which shows continuous linear or punctate high intensity along the cortical sulci and subarachnoid space on magnetic resonance images. Ivy sign was reported to reflect the development of compensatory collaterals, and to be closely related to hemodynamic changes and clinical symptoms, and to indicate the postoperative prognosis, in MMD patients. It is a unique and critical marker for MMD. However, due to the lack of consistent criteria, such as definition, grading, and identification standards, ivy sign has not received much attention. We undertook a comprehensive literature search and summarized the current situation regarding ivy sign in MMD in terms of baseline characteristics, detection methods, definition, regional division and distribution patterns, grading criterions, incidence, related factors, the mechanism of ivy sign, and the effects of treatments. We also provided related concerns raised and future prospects relevant to studies about ivy sign in MMD.

Prediction of Cerebral Hyperperfusion after Superficial Temporal Artery-Middle Cerebral Artery Anastomosis by Three-Dimensional-Time-of-Flight Magnetic Resonance Angiography in Adult Patients with Moyamoya Disease

Introduction: Superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis is an effective surgical procedure for adult patients with moyamoya disease (MMD) and is known to have the potential to prevent cerebral ischemia and/or hemorrhagic stroke. Cerebral hyperperfusion (CHP) syndrome is one of the serious complications of this procedure that can result in deleterious outcomes, such as delayed intracerebral hemorrhage, but the prediction of CHP before revascularization surgery remains challenging. The present study evaluated the diagnostic value of preoperative three-dimensional (3D)-time-of-flight (TOF) magnetic resonance angiography (MRA) for predicting CHP after STA-MCA anastomosis for MMD. Materials and Methods: The signal intensity of the peripheral portion of the intracranial major arteries, such as the anterior cerebral artery (ACA), MCA, and posterior cerebral artery (PCA) ipsilateral to STA-MCA anastomosis, on preoperative MRA was graded (0–2 in each vessel) according to the ability to visualize each vessel on 97 affected hemispheres in 83 adult MMD patients. Local cerebral blood flow (CBF) at the site of anastomosis was quantitatively measured by N-isopropyl-p-[123I]-iodoamphetamine single-photon emission computed tomography 1 and 7 days after surgery, in addition to the preoperative CBF value at the corresponding area. Then, we investigated the correlation between the preoperative MRA score and the development of CHP. Results: The CHP phenomenon 1 day after STA-MCA anastomosis (local CBF increase over 150% compared with the preoperative value) was evident in 27 patients (27/97 hemispheres; 28%). Among them, 8 (8 hemispheres) developed CHP syndrome. Multivariate analysis revealed that the hemispheric MRA score (0–6), the summed ACA, MCA, and PCA scores for the affected hemisphere, was significantly associated with the development of CHP syndrome (p = 0.011). The hemispheric MRA score was also significantly correlated with the CHP phenomenon, either symptomatic or asymptomatic (p < 0.001). Conclusion: The signal intensity of the intracranial major arteries, including the ACA, MCA, and PCA, on preoperative 3D-TOF MRA may identify adult MMD patients at higher risk for CHP after direct revascularization surgery.

Matching Selection of Donor-Recipient Vessels in Revascularization Surgery Effectively Reduce the Incidence of Postoperative Hyperperfusion Syndrome in Adult Moyamoya Disease: A Retrospective Comparison Study

INTRODUCTION

Cerebral hyperperfusion syndrome (CHS) is one of the most serious complications after revascularization surgery in patients with moyamoya disease (MMD). However, there are few effective measures to prevent the occurrence of CHS.

OBJECTIVE

The present study aims to examine the effect of the method about matching selection of donor-recipient vessels during revascularization surgery on the incidence of postoperative CHS in adult MMD patients.

METHODS

216 Chinese adult patients with MMD received surgery treatment between January 2018 and December 2019 in our hospital were enrolled in this study. 191 out of 216 patients were included in this study. Matching selection method was defined as follows: (1) blood flow: the direction of blood flow and speed of the donor artery and potential receptor arteries were measured by flow 800 indocyanine green video angiography; (2) vascular diameter: the diameters of the donor artery and potential receptor arteries by a miniature ruler. Only the artery with antegrade flow and with smallest difference in flow speed and diameter with the donor artery will be selected as the receptor artery to perform anastomosis. Matching selection was performed from January 2019. Digital subtraction angiography was performed in all patients for initial MMD diagnosis. Perioperative cerebral perfusion and related clinical symptoms were monitored. Clinical characteristics, contralateral progression, and risk factors were reviewed. The incidence of CHS and the correlation of CHS with baseline characteristics or clinical conditions were analyzed.

RESULTS

Of these 191 patients, 82 patients received matching selection of donor-recipient vessels during revascularization surgery and 109 patients without. The postoperative CHS incidence in the matching group was 3.66%, which was much lower than that in the nonmatching group (15.60%). Multivariate analysis did not reveal a significant risk factor between the progression group and the nonprogression group. Correlation analysis revealed only the matching selection method was significantly associated with the reduced postoperative CHS incidence in MMD patients.

CONCLUSIONS

The matching selection of donor-recipient vessels during revascularization surgery effectively reduces the incidence of postoperative CHS in adult patients with MMD.