Abstract
BackgroundAlthough the association between periventricular target collateral anastomosis and recurrent ipsilateral hemorrhage has been evaluated in adult patients with moyamoya disease (MMD), no studies have investigated the relationship between target anastomotic territory and recurrent ipsilateral hemorrhage. The goal of this study was to assess this association.MethodsConsecutive adult MMD patients who had experienced initial intracranial hemorrhage and undergone conservative treatment were included. Two readers assessed angiographic results to identify the target anastomotic territory (medial medullary artery, lateral medullary artery, multiple medullary arteries, or nonmedullary artery) responsible for the hemorrhage. Cox proportional hazard regression models were used to estimate the risk of recurrent hemorrhage.ResultsIn the 36 hemispheres with initial hemorrhage, the target anastomotic territory was in the anastomotic territory of the medial medullary artery in 10 (27.8%), lateral medullary artery in 15 (41.7%), multiple medullary arteries in 2 (5.6%), and a nonmedullary artery in 9 (25.0%) hemispheres. During 45.1 ± 40.0 months of follow-up, recurrent ipsilateral hemorrhage occurred in 44.4% (16/36) of hemispheres. The target anastomotic territories responsible for the recurrent event were in the anastomotic territory of the medial medullary artery in 9 (56.3%) hemispheres, lateral medullary artery in 6 (37.5%) hemispheres, and multiple medullary arteries in 1 (6.3%) hemisphere. The anastomotic territory of the medial medullary artery was associated with recurrent hemorrhage before (HR = 2.94; 95% CI, 1.07–8.08; p = 0.037) and after (HR = 6.65; 95% CI, 1.32–33.60; p = 0.022) adjustments were made for confounding factors.ConclusionsThe incidence of recurrent ipsilateral hemorrhage varies with the target anastomotic territory in adult patients with MMD. Medial target medullary artery anastomosis is a significant risk factor for recurrent ipsilateral hemorrhage.
Highlights
The association between periventricular target collateral anastomosis and recurrent ipsilateral hemorrhage has been evaluated in adult patients with moyamoya disease (MMD), no studies have investigated the relationship between target anastomotic territory and recurrent ipsilateral hemorrhage
From January 2008 to December 2018, a total of 457 patients with Moyamoya disease (MMD) presented with intracranial hemorrhage and were treated at a single tertiary care medical center; 68 (14.9%) of these underwent conservative treatment
The reasons for using conservative treatment in these patients were as follows: adequate external carotid artery compensation (n = 9); Modified Rankin Scale score > 3 (n = 27); presence of subarachnoid hemorrhage without target intracranial aneurysm at baseline (n = 2); patient choice based on economic reasons (n = 21); and recurrent hemorrhage occurring during the waiting period for revascularization (n = 9)
Summary
The association between periventricular target collateral anastomosis and recurrent ipsilateral hemorrhage has been evaluated in adult patients with moyamoya disease (MMD), no studies have investigated the relationship between target anastomotic territory and recurrent ipsilateral hemorrhage. The goal of revascularization surgery is to prevent recurrent hemorrhage by eliminating persistent hemodynamic stress from the anastomotic territory in the abnormally extended target collateral vessels. The risk of recurrent hemorrhage in various target territories must be evaluated. Previous studies have identified several risk factors related to recurrent hemorrhage including the hemorrhagic type [5], the hemorrhagic site [8], and the target collateral vessels involved [9, 10]. The characteristics of the target anastomotic territory responsible for hemorrhage and the relationship between this territory and recurrent ipsilateral hemorrhage are still unclear
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