Abstract
Objectives: This study aimed to compare the postoperative risks and long-term effects between direct bypass surgery (DB) and indirect bypass (IB) surgery for pediatric patients with ischemic-type moyamoya disease (MMD).Method: Pediatric patients (under or equal to 18 years old) who were diagnosed as MMD and given surgical treatments at our center between 2009 and 2015 were retrospectively reviewed from a prospective database. Pediatric hemorrhagic-type MMD patients and those who did not undergo digital subtraction angiography (DSA) were excluded. Patients who underwent DB were matched with patients who underwent IB using 1:1 propensity score matching. Postoperative complications, recurrent ischemic stroke events and modified Rankin Scale (mRS) scores at the last follow-up were compared between the matched pairs.Results: A total of 223 pediatric patients were screened, and 138 patients (DB:34, IB:104) were considered for the propensity score match. Thirty four pairs were obtained. Nine patients had postoperative complications, including 6 (17.6%) in the DB group and 3 (8.8%) in the IB group (P = 0.476). The mean follow-up period was 71.9 ± 22.2 months for the DB group and 60.2 ± 24.3 months for the IB group (P = 0.041). Kaplan-Meier analysis showed a longer stroke-free time in the DB group than in the IB group (P = 0.025). At last follow-up, good neurological status (mRS ≤ 1) was achieved in 32 (94.1%) of the DB group and 34 (100.0%) of the IB group. MRS score at last follow-up were significantly lower than at time of admission (all pts: 1.09 ± 0.45 vs. 0.28 ± 0.51, P < 0.001; DB group: 1.12 ± 0.48 vs. 0.32 ± 0.59, P < 0.001; IB group: 1.06 ± 0.42 vs. 0.24 ± 0.43, P < 0.001).Conclusion: Both techniques were effective in improving the neurological status of pediatric ischemic-type MMD patients, and direct bypass surgery might be more superior in preventing recurrent ischemic strokes in the short-term.
Highlights
Moyamoya disease (MMD) is characterized by progressive stenosis and occlusion of the terminal internal carotid artery (ICA) and its branches, leading to severely compromised cerebral blood flow and subsequent ischemic or hemorrhagic strokes [1,2,3]
We retrospectively reviewed pediatric patients who underwent direct bypass (DB) and indirect bypass (IB) at our center, using propensity score matching to reduce the heterogeneity between groups, and comparing surgical complications and long-term outcomes between pediatric MMD patients received different surgical modalities
Our results showed the procedure of DB requires a longer time than IB (203.0 ± 50.9 vs. 138.2 ± 40.6 min, P < 0.001), the overall incidences of postoperative complications were not significantly different between the two groups [17.6 vs. 8.8%, P = 0.476, power (1-β): 28.2%]
Summary
Moyamoya disease (MMD) is characterized by progressive stenosis and occlusion of the terminal internal carotid artery (ICA) and its branches, leading to severely compromised cerebral blood flow and subsequent ischemic or hemorrhagic strokes [1,2,3]. A Japanese epidemiologic study reported a two-peak feature of onset age in MMD patients, affecting both children (5–9 years old) and middle-aged adults (around 40 years old) [4]. Surgical revascularization has been recognized as the most effective treatment for MMD as it significantly reduces the risk of future strokes comparing to conservative management [2, 5, 6]. Previous studies showed that in adult ischemic-type MMD patients, the direct bypass was more effective in preventing recurrent ischemic strokes than indirect bypass, despite the fact that similar longterm neurological outcomes were achieved by different surgical modalities [9, 18]. We conducted the current study to investigate the effect of DB and IB for ischemic-type pediatric MMD patients. To increase the comparability between patients who underwent different surgical modalities, we performed propensity score matching between patients who underwent DB and IB, surgical outcomes were compared between the matched groups
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