Abstract
ObjectiveWe evaluated what few studies emphasized the postoperative collateral formation and cerebral hemodynamics of hemorrhagic moyamoya disease (MMD). MethodsHemorrhagic MMD patients treated surgically were retrospectively collected and dichotomized into combined bypass (CB) and indirect bypass (IB) groups. CB used superficial temporal artery-to-middle cerebral artery anastomosis combined with encephaloduroarteriomyosynangiosis (STA-MCA+EDAMS), and IB used encephaloduroarteriomyosynangiosis (EDAMS) for revascularization. Postoperative complications and clinical prognosis, as well as pre- and post-operative Modified Rankin Scale (mRS), collateral circulation status, and cerebral hemodynamics were observed and compared between the CB and IB groups. ResultsA total of 37 patients with hemorrhagic MMD were identified. Of the 68 cerebral hemispheres, 47(69.1%) were combined revascularization, and the rest were indirect. During an average follow-up of 16.5 ± 8.7 months, the recurrent stroke events were significantly lower, as well as having a postoperative mRS scores≤ 2. A satisfactory postoperative collateral formation, and an improved dilation or extension of the anterior choroidal/posterior communication artery (AchA/PcoA) were significantly higher in the CB group than in the IB group (all P < .05). Compared with preoperative cerebral hemodynamics, relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), mean transit time (MTT), and relative time to peak (rTTP) in the CB group; rCBF, rCBV, and MTT in the IB group were significantly improved (all P < .001). The CB group’s postoperative rCBF was significantly improved compared with the IB group (P < .001). ConclusionsSTA-MCA bypass combined with EDAMS can obtain better postoperative collateral formation, cerebral hemodynamics, and clinical prognosis than EDAMS alone.
Highlights
Many studies including the Japanese adult moyamoya disease trial have shown that compared with conservative treatment, surgical revascularization can significantly reduce the rehemorrhage in patients with hemorrhagic MMD, but there has been a debate on the optimal surgical procedure.[5,9−16] For example, Deng X et al have reported that in patients with hemorrhagic MMD, combined (CB), directed (DB) and indirect (IB) revascularization surgery has no significant difference in preventing rebleeding, while Park SE et al believed that CB and DB were more effective than IB.[12, 15]
Inclusion criteria included i) Adult patients (≥ 18 years old); ii) patients diagnosed with MMD according to the guidelines made by the Research Committee on MMD in Japan;[23] iii) intracranial hemorrhage occurred in the last 1ཞ12 months and iv) received CB or IB surgery; Exclusion criteria were that i) Patients diagnosed with moyamoya syndrome whose cause has been identified; ii) the patients without CT, digital subtraction angiography (DSA) or MRI examination or data loss or loss of follow-up and iii) the patients rejected revascularization surgery or had Modified Rankin Scale (mRS) score ≥ 5 points and were unsuitable for followup
According to DSA, we evaluated the preoperative collateral circulation based on the classification criteria proposed by Liu et al (Table 1, Fig. 1), the neovascularization based on Matsushima scale (Table 2), the regression of moyamoya vessels and the improvement of the AchA/Posterior communicating artery (PcoA) dilation or extension.[18, 19]
Summary
Moyamoya disease (MMD) is a chronic, progressive and irreversible cerebral vasculopathy which is characterized by progressive stenosis or occlusion of the bilateral or unilateral distal intracranial internal carotid arteries, and the proximal anterior cerebral artery and middle cerebral arteries, with abnormal moyamoya vessels formation at the skull bases.[1,2] MMD usually exhibits ischemic or hemorrhagic stroke and most occurs in 0 to 10 or 30 to 50-year-old patients.[3,4] The ischemic MMD mainly occurs in pediatric populations, while the hemorrhagic MMD usually occurs in adults and has higher mortality and disability.[4,5,6,7,8] Recently, many studies including the Japanese adult moyamoya disease trial have shown that compared with conservative treatment, surgical revascularization can significantly reduce the rehemorrhage in patients with hemorrhagic MMD, but there has been a debate on the optimal surgical procedure.[5,9−16] For example, Deng X et al have reported that in patients with hemorrhagic MMD, combined (CB), directed (DB) and indirect (IB) revascularization surgery has no significant difference in preventing rebleeding, while Park SE et al believed that CB and DB were more effective than IB.[12, 15] Even, Macyszyn et al.'s meta-analysis found that IB and CB were superior to DB. 17 Despite the controversy, most investigators believe that CB is better than IB. 17 Despite the controversy, most investigators believe that CB is better than IB. Most of the present studies focused on the analyses of postoperative clinical prognosis, rehemorrhage rate and related risk factors, while few highlighted simultaneously the neovascularization and cerebral hemodynamics, which the study conducted. Present primary focus was rebleeding and prognosis of hemorrhagic moyamoya disease (MMD), while limited researches emphasized the postoperative collateral formation and cerebral hemodynamics
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