Angioarchitectural Factors Associated with Postoperative Cerebral Infarction in Ischemic Moyamoya Disease

A nomogram to predict postoperative new-onset cerebral infarction after revascularization of moyamoya disease in adults and its validation: a retrospective study

Background

The new-onset cerebral infarction is frequent after revascularization of moyamoya disease (MMD) in adults, serving as a major public health issue worldwide. The present study aims to construct a nomogram to predict postoperative new-onset cerebral infarction (POCI) after revascularization of adult MMD.

Materials and methods

Clinical data of 653 cases of adult MMD treated with revascularization were retrospectively analyzed. They were randomly divided into a training set (n = 457) and a validation set (n = 196) at a ratio of 7:3. Based on the risk factors of POCI after revascularization of adult MMD identified by logistic regression analysis and the corresponding regression coefficients, a nomogram was constructed. Its performance to predict POCI after revascularization of adult MMD was validated by calculating the area under the curve (AUC) and the decision curve analysis.

Results

Univariate and multivariate logistic regression analyses showed that preoperative cerebral infarction (OR 2.548, 95% CI 1.357-4.787; p = 0.004), posterior cerebral artery anomalies (OR 2.106, 95% CI 1.157-3.834; p = 0.015), post-transit arterial development (OR 2.983, 95% CI 1.336-6.661; p = 0.008), pre-anesthesia mean arterial pressure > 102.830 mmHg (OR 3.329, 95% CI 1.938-5.721; p < 0.001), total operating time > 212.500 min (OR 2.256, 95% CI 1.239-4.140; p = 0.008), preoperative fibrinogen level > 2.750 g/L (OR 1.852, 95% CI 1.072-3.200; p = 0.027), and mean corpuscular hemoglobin concentration (OR 1.021, 95% CI 1.001-1.040; p = 0.038) were independent risk factors of POCI after revascularization of adult MMD. The AUC was 0.772 (95% CI 0.714-0.772) in the training set, and 0.718 (95% CI 0.603-0.833) in the validation set.

Conclusion

Collectively, the newly established nomogram effectively and intuitively predicts the POCI after revascularization of adult MMD.

Clinical trial registration

www.chictr.org, identifier ChiCTR2400087946.

Isolated anterior cerebral artery occlusion: an atypical form of moyamoya disease

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.