Combined Revascularization Research Articles

Lessons Learned from the Initial Experience with Pedicled Temporoparietal Fascial Flap for Combined Revascularization In Moyamoya Angiopathy: A Case Series

The pedicled temporoparietal fascial flap (TPFF) with a direct superficial temporal (STA) artery to middle cerebral artery (MCA) bypass is a novel combined revascularization approach for moyamoya angiopathy (MMA). With this case series, we aim to report the initial experience with pedicled TPFF combined revascularization for MMA treatment. Data from 14 consecutive patients undergoing pedicled TPFF combined revascularization for MMA between May 2016 and December 2018 were retrospectively reviewed. Patients admitted with acute ischemia or a modified Rankin Scale (mRS) score >3 were considered high risk. Mean ± standard deviation age on surgery was 41.9 ± 15.4 years. Three of 14 patients (21.4%) presented with an mRS score >3. Nine of 14 patients (64.3%) presented with ischemic stroke, 4 of whom (44.4%) had acute ischemia. Direct anastomosis patency was confirmed in all cases postoperatively. Mean hospitalization time was 13 ± 9.3 days and mean follow-up time was 14.1 ± 9.3 months. From admission to follow-up, neurologic status improved in 8 patients (57.1%) and stabilized in 6 patients (42.9%). Overall, 11/14 patients (78.6%) achieved good functional outcome (mRS score ≤2). All patients achieved some radiographic collateral development, with 5 (71.5%) graded as Matsushima A and B. Three patients developed new radiographic ischemia and 3 experienced wound complications, all in the high-risk group. The TPFF combined approach is a viable strategy for revascularization in MMA. This technique may be suboptimal in patients presenting with acute ischemia and/or mRS score >3.

Lessons Learned From the Initial Experience With Pedicled Temporoparietal Fascial Flap for Combined Revascularization in Moyamoya Angiopathy: A Case Series

Abstract INTRODUCTION The pedicled temporoparietal fascial flap (TPFF) with a direct superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass is a novel combined revascularization approach for moyamoya angiopathy (MMA). We aim to report the initial experience with pedicled TPFF combined revascularization for MMA treatment. METHODS Data from fourteen consecutive patients undergoing pedicled TPFF combined revascularization for MMA between May 2016 and December 2018 were retrospectively reviewed. Patients admitted with acute ischemia or a modified Rankin Scale (mRS) score >3 were considered high-risk. RESULTS The median (interquartile range) age was 45.5 (29-56.5) yr. Median mRS score upon admission was 2 (0.8-3.3). Direct anastomosis patency was confirmed in all cases postoperatively. Asymptomatic direct anastomosis occlusion upon follow-up occurred in one case. Median hospitalization time was 12.5 (3.8-18.5) days and median follow-up time was 11.5 (7.8-20) mo. Median mRS upon discharge and at follow-up was 1 (0-4) and 0.5 (0-1.5), respectively. From admission to follow-up, neurologic status improved in 8 (57.1%) and stabilized in 6 (42.9%) patients. Overall, 11/14 (78.6%) patients achieved a good functional outcome (mRS equal or greater than 2). Postoperative Matsushima grades were able to be assigned in 7/14 (50%) patients at a median time of 7.7 (5.3-10.9) mo. All patients achieved some degree of collateral development with 5 (71.5%) of the patients graded as Matsushima A and B. New radiographic ischemia was identified in three patients, all of which were in the high-risk group. Moderate to severe wound complications (3/14) were also limited to the high-risk group. Mild peri-incisional alopecia was found in three (21.4%) patients. CONCLUSION The TPFF combined approach is a viable strategy for revascularization in MMA. This technique may be suboptimal in patients presenting with acute ischemia or those with mRS greater than 3.

Selection strategy of neoadjuvant therapy for pancreatic cancer

Pancreatic cancer is a common malignancy with the worst prognosis. Radical surgery has been the only curative treatment for pancreatic cancer. With the advancement of surgical techniques and the implementation of the concept of comprehensive treatment for cancer in recent years, neoadjuvant therapy for pancreatic cancer has received more attention. There are continuing controversies in the hotspots and difficulties, with opportunities and challenges coexisting. Four famous experts and their teams in pancreatic surgery discussed selection strategy of neoadjuvant therapy for pancreatic cancer based on clinical experiences. Professor Wang Chunyou proposed that surgery was prior for patients with a higher likelihood of achieving R0 resection for pancreatic cancer to avoid the possibility of tumor progression and loss the opportanity of radical resection during neoadjuvant therapy. For patients with less chance of radical resection for pancreatic cancer and unresectable pancreatic cancer, neoadjuvant therapy is worthy of a positive attempt. Professor Jin Gang and his team believed that neoadjuvant therapy played an important role in improving the survival time of patients with pancreatic head cancer, especially with borderline resectable pancreatic head cancer. After neoadjuvant therapy, pancreatic surgeons should pay attention to improvement of surgery safety and R0 resection rate. Professor Dai Menghua and his team suggested that patients with resectable pancreatic cancer and borderline resectable pancreatic cancer could benefit from neoadjuvant therapy, which required proof from clinical trials. Surgeons should choose the appropriate treatment strategy based on guidelines and individual conditions for patients with pancreatic cancer. Professor Shao Cheghao and his team suggested that surgical treatment after neoadjuvant therapy or translational therapy for locally advanced pancreatic head cancer is safe, effective and feasible, especially for pancreaticoduodenectomy with combined revascularization. For the treatment of patients with pancreatic head cancer after neoadjuvant chemotherapy, the choice of next treatment options, evaluation indicators, timing of surgery and surgical methods need to be further studied. Key words: Pancreatic neoplasms; Pancreatic cancer; Pancreatic head neoplasms; Pancreatic head cancer; Neoadjuvant therapy; Surgical procedures, operative

Dl-3-n-butylphthalide for alleviation of neurological deficit after combined extracranial-intracranial revascularization for moyamoya disease: a propensity score-matched analysis.

Postoperative neurological deficits impair the overall outcome of revascularization surgery for patients with moyamoya disease (MMD). dl-3-n-butylphthalide (NBP) is approved for the treatment of ischemic stroke in China. This pilot study evaluated the effect of NBP on perioperative stroke and neurological deficits in patients with MMD. The authors studied cases in which patients underwent combined revascularization surgery for MMD at their institution, with or without NBP administration. The overall study group included 164 patients (213 surgically treated hemispheres), including 49 patients who received NBP (25 mg twice daily) for 7 postoperative days. The incidence of perioperative stroke and transient neurological deficit (TND) and the severity of neurological deficits were compared between 49 propensity score-matched case pairs with or without NBP treatment. Subgroup analyses by type of onset and preoperative neurological status were also performed to determine specific characteristics of patients who might benefit from NBP administration. In the overall cohort, baseline characteristics differed with respect to preoperative stroke and modified Rankin Scale (mRS) score between patients who received NBP and those who did not receive it. In the 49 propensity score-matched pairs, postoperative stroke was observed in 11 patients and TND occurred in 21 patients, with no significant difference in incidence between the 2 groups. However, the TND was less severe in the NBP-treated group (p = 0.01). At 1 month after surgery, the neurological outcome was more favorable (p = 0.001) and the disability-free recovery rate was higher in patients with NBP treatment (p < 0.001). The number of patients who experienced an improved neurological function, compared to preoperative function, as measured by mRS, was greater in the NBP group than in the no-NBP group (p < 0.001). Multivariable analysis revealed that NBP administration was associated with decreased severity of TND (OR 0.28, p = 0.02), improved neurological function (OR 65.29, p = 0.04), and lower postoperative mRS score (OR 0.06, p < 0.001). These beneficial effects of NBP remained significant in ischemic type MMD and patients with preoperative mRS scores of 2 or greater. Postoperative administration of NBP may alleviate perioperative neurological deficits after revascularization surgery for MMD, especially in patients with ischemic MMD and unfavorable preoperative status. The results of this study suggest that randomized controlled trials to assess the potential benefit of NBP in patients with MMD may be warranted.

Endovascular and two-stage combined revascularization of the penis at arteriogenic erectile dysfunction

The possibility of application of endovascular and two-stage combined revascularization of the penis in the arteriogenic ED treatment is shown. Twenty male patients with multifocal atherosclerotic lesions of the aorto-iliac-femoral segments underwent the analysis of the branching patterns of the IPA according to the classifcation by Adachi and Yamaki followed by the interventional endovascular intervention (angioplasty, stenting) of the iliac arteries. Seventeen patients underwent the unilateral and three patients – bilateral stenting of the common and external iliac arteries. Three patients out of the total number of the operated ones additionally underwent an open revascularization of the penis by epigastric-penic anastomosis. A complex preoperative examination of patients – candidates for revascularization of the penis for arteriogenic erectile dysfunction was performed and included ultrasound, МCT-angiography of the pelvic arteries, and electroneuromyographic examination of atherosclerotic lesions of the pool vessels of the inner pudental artery. Subsequently, endovascular and combined open revascularization operations were performed on the iliac and penis vessels. The erectile function improvement according to the IIEF-5 scale (8–12 scores before the operation vs 16–19 points after the operation) was noted in 1, 3, 6, 12 months (p&lt; 0.05). Combined revascularization operations on the iliac and penis arteries (endovascular and open “bypass”) allow an adequate arterial blood perfusion to the penis in the steno-occlusive lesions of the pool vessels of the IPA affected by atherosclerosis.

Wound healing complications after revascularization for moyamoya vasculopathy with reference to different skin incisions

OBJECTIVEMoyamoya vasculopathy (MMV) is a steno-occlusive cerebrovascular disease that can be treated by a surgical revascularization. All the revascularization techniques influence the blood supply of the scalp, with a risk for wound healing disorders. The authors' aim was to analyze the wound healing process in the patients who underwent a direct or combined bypass surgery with a focus on different skin incisions.METHODSThe authors retrospectively identified all the patients with MMV who were treated surgically in their institution. Subsequently, they analyzed demographic data, clinical symptoms, surgical treatment, and detailed history of complications. Based on the evolution of their surgical techniques and the revascularization strategy to be used, the authors applied the following skin incisions: linear incision, curved incision, incomplete Y incision, and complete Y incision. Group comparisons regarding wound healing disorders were performed with significance testing using Fisher's exact test.RESULTSThe authors identified 172 patients with MMV (61.6% moyamoya disease, 7% unilateral moyamoya disease, 29.7% moyamoya syndrome, and 1.7% unilateral moyamoya syndrome), of whom 124 underwent bilateral operations. One-quarter of the patients were juveniles. A total of 236 hemispheres were included in the analysis, of which 27.9% were treated by a combined procedure with encephalomyosynangiosis. Overall, 5.1% major and 1.7% minor wound complications occurred. The overall wound complication rate was lower in direct revascularization compared to combined revascularization (3% vs 15.2%). The lowest incidence of wound healing disorders was found in the linear incision group for the parietal superficial temporal artery branch (1.6%), followed by the incomplete Y incision group for the frontal branch of the superficial temporal artery (3.8%) in the direct bypass group. In the combined revascularization cohort, major or minor wound disorders appeared in 14.3% and 4.8%, respectively, in the complete Y incision group and in 4.2% (for both major and minor) in the curved incision group. The complete Y incision caused significantly more wound healing disorders compared to the remaining incision types (17.1% vs 3.1%, p = 0.007).CONCLUSIONSWound healing disorders are one of the major complications of revascularization surgery. Their incidence depends on the revascularization strategy and skin incision applied, with a complete Y incision giving the worst results.

A Method of Mobilization of the Lower Epigastric Artery for Bypass Penile Revascularization Surgery

The effectiveness of microsurgical revascularization performed according to indications ranges from 85.3% within the first three years of observation and up to 65.5 % during a five-year follow-up. These data are significant evidence of the necessity to rationalize both the indications for this kind of surgery and the surgical techniques. Five revascularization operations were performed using the Virag II and Michal II technique in the Sharlip modification with a satisfactory result. Two-stage combined revascularization, including angioplasty and stent placement in the common iliac artery as the first stage and open penile revascularization surgery as the second stage was performed in one patient. In all the cases, the lower epigastric artery (epigastrica inferior) was used as a donor artery for bypass epigastric-penile anastomosis. The article discusses issues of the mobilization of the above artery for its use as a donor shunt, as well as methods of prevention and diagnosis of arterial thrombosis in it in the postoperative period with the use of duplex ultrasound and angiography.

Pedicled temporoparietal fascial flap for combined revascularization in adult moyamoya disease.

Moyamoya disease (MMD) is a progressive, idiopathic cerebrovascular occlusive disease. Various revascularization techniques including direct, indirect, and combined microvascular bypasses have been described. This article presents a modified revascularization technique for MMD utilizing a pedicled temporoparietal fascial flap (TPFF) for combined revascularization. This technique combines a large area of coverage for indirect revascularization with the benefits of a direct bypass. The pedicled TPFF also benefits from intact venous drainage to minimize the risk of flap swelling that could result in complications from mass effect.

Combined (direct and indirect) revascularization in adult patients with moyamoya disease

The study objective is to analyze the results of combined (direct and indirect) brain revascularization in adult patients with moyamoya disease. Materials and methods. From February 2015 to August 2016, 12 operations were performed on 12 hemispheres in 7 patients (2 men, 5 women) with moyamoya disease. Six patients had bilateral disease, 1 – unilateral. The age of patients ranged from 25 to 60 year old, the average – 41 year old. Multislice computed tomography (MSCT) perfusion imaging of the brain with a stress test was made in every patient, MSCT angiography of the extraand intracranial arteries was perfomed. Stages of the disease were determined according to the Suzuki–Takaku classification: stage III was revealed in 5 patients, stage IV – in 2. To evaluate the clinical course of the disease the Matsushima classification was used: type VI – in 2 cases, type III – in 2, type IV – in 1, type V – in 1. In 1 case, the pathological vascular network of 1 hemisphere was detected by accident. Extracranial-intracranial (EC–IC) bypass and encephaloduromyosynangiosis (EDMS) was used in 3 cases; a double-barreled EC–IC bypass and EDMS – in 3; a double-barreled EC–IC bypass and encephaloduroperiosteomyosynangiosis – in 1; EC–IC bypass and encephaloduroarteriomyosynangiosis (EDAMS) – in 3. In 1 case was perfomed EC–IC bypass and encephaloduroperiosteosynangiosis. Only indirect revascularization was performed in 1 case – EDAMS. We assessed the neurological status in the follow-up period (5–11 months); MSCT angiography and MSCT perfusion imaging of the brain were performed. Results. All patients in follow-up period demonstrated the increase of cerebrovascular reserve according to MSCT perfusion imaging of the brain with stress tests. Stroke, epilepsy, surgical complications were not detected in the postoperative period. In 1 case, the left-hand monoparesis regressed.Conclusion. The combined (direct and indirect) revascularization may be effective in adult patients with moyamoya disease. To obtain more objective conclusions it is necessary to analyze the long-term results of interventions.

Postoperative Intracerebral Hemorrhage After Combined Revascularization Surgery in Moyamoya Disease: Profiles and Clinical Associations

In combined revascularization surgery for patients with moyamoya disease, intracerebral hemorrhage (ICH) during the postoperative acute phase is a rarely observed but severe complication. Its clinical features remain unclear because of its low incidence rate. The aim of this study was to clarify the clinical characteristics of immediate postoperative ICH. The frequency, onset timing, and hematoma location of patients who demonstrated immediate postoperative ICH were investigated in 201 consecutive surgeries performed in 134 patients. Associations between immediate postoperative ICH and demographics, clinical presentation type, perioperative blood pressure (BP), and neuroimaging data were analyzed. Postoperative ICH was observed in 6 cases (2.99%; mean age, 46.0 ± 7.6 years). The onset timing of ICH was within 24 hours after surgery in most patients (83.3%). Hematomas were located at the subcortical lesion beneath the anastomosed cortex (n= 5) and caudate head (n= 1). Three cases (50.0%) required hematoma evacuation. A higher age at surgery was associated with postoperative ICH (P= 0.046). In adult cases (132 surgeries, 65.7%), hemorrhagic presentation at onset (P= 0.0027) and an increase in BP from pre- to postoperative stage (systolic BP increase: P= 0.0058, diastolic BP increase: P= 0.0274) were significantly associated with postoperative ICH. The results suggest that older patients, with hemorrhagic presentation and greater postoperative BP increase, should be carefully managed to avoid postoperative ICH. Immediate hematoma evacuation may be effective in preventing devastating outcomes after postoperative ICH.

Long-Term Outcomes After Combined Revascularization Surgery in Adult Hemorrhagic Moyamoya Disease

Risk factors for rebleeding after revascularization surgery are unclear. We aimed to evaluate long-term outcomes after combined revascularization surgery for adult hemorrhagic moyamoya disease (MMD) and identify risk factors for initial and recurrent hemorrhage. A total of 105 adult patients with hemorrhagic MMD from January 2007 to May 2011 were prospectively enrolled in this study. All patients underwent combined revascularization surgery on unilateral hemorrhagic hemispheres and were observed for at least 5 years. After a median follow-up time of 77 months, 12 patients were lost to follow-up. Twelve of the remaining 93 patients developed rebleeding, and 6 patients died. According to rebleeding sites, ipsilateral and contralateral rebleeding occurred in 6 and 6 patients, respectively. There was no significant difference between the 2 groups (P > 0.05). The annual risks of overall, ipsilateral, and contralateral rebleeding were 1.1%, 0.62%, and 0.51%, respectively. A significant correlation was observed between improvement of anterior choroidal artery-posterior communicating artery dilation or extension in the operated hemispheres and low risk of ipsilateral rebleeding (P < 0.05). Progression of Suzuki stage in the nonhemorrhagic hemispheres was significantly associated with contralateral rebleeding (P < 0.05). Combined revascularization surgery may help prevent ipsilateral rebleeding in adult patients with hemorrhagic MMD by improvement of anterior choroidal artery-posterior communicating artery dilation and extension in the operated hemisphere. Progression of Suzuki stage in the nonhemorrhagic hemispheres was a strong predictor of subsequent contralateral rebleeding.

The Optimum Operative Time of Revascularization for Patients with Moyamoya Disease Following Acute Onset.

Whether surgery should be performed in patients with acute onset of moyamoya disease (MMD) is controversial. This study aimed to determine optimum operative time for patients with MMD. We retrospectively analyzed 57 patients with MMD admitted between January 2016 and June 2017. All patients consented to combined revascularization. Considering the time interval between acute onset of MMD and surgery, we divided all patients into an early group and later group (>90 days between MMD onset and surgery). We compared postoperative complications, neurologic improvement, and favorable outcome between groups to estimate optimum operative time of revascularization. More patients in the early group presented with ischemic events compared with the later group (18/28 vs. 11/29, P= 0.047). The difference in worst preoperative mRS score (≥3) between groups was not statistically significant (3/28 vs. 3/29, P= 0.964). Rate of postoperative complications in the early group was significantly higher than in the later group (39.2% vs. 13.7%, P= 0.029). There was neurologic improvement in 50.0% of patients in the early group and 75.9% of patients in the later group (P= 0.043). The rate of favorable outcome after revascularization in the later group (89.7%) was higher than in the early group (78.6%), but there was no significant difference (P= 0.251). It seems more reasonable to opt for delayed revascularization for patients with acute-onset MMD, but the decision must take into account the morbidity of ongoing ischemic or hemorrhagic events.

Moya-Moya syndrome after cranial radiation for optic glioma with NF1. Case report and literature review of syndromic cases

IntroductionMoya-Moya angiopathy is a neurovascular disease that predisposes to ischemic or hemorrhagic strokes. It is generated by a steno-occlusion of the terminal portion of the internal carotid arteries, which induces the development of abnormal neovessels in the deep regions of the brain. Some pathologies such as sickle cell disease, Down syndrome or Graves’ disease may be associated with Moya-Moya angiopathy. These syndromic forms harbor several differences compared with idiopathic Moya-Moya disease. Case reportWe report the case of a young patient who presented with a syndromic form of Moya-Moya angiopathy after cranial radiation therapy for an optic glioma associated with type 1 neurofibromatosis treated by combined revascularization. We discuss the particularities of syndromic forms, in their presentation and management based on a review of the literature. ConclusionMany diseases can be associated with Moya-Moya syndrome. Symptomatic patients should undergo surgery, but the risk of postoperative complications appears to be greater than that encountered in patients with non-syndromic Moya-Moya angiopathy.

Clinical analysis of combined revascularization in treating ischemic Moyamoya disease in adults

ObjectiveThe aim of this study was to investigate the clinical efficacy of superficial temporal artery-middle cerebral artery anastomosis (STA-MCA)+encephalo-duro-myo-synangiosis (EDMS) in treating ischemic Moyamoya disease (IMD) in adults. MethodsA total of 30 adult patients with IMD were selected to be included in the study; they underwent STA-MCA+EDMS and were followed up for 3 months to 2 years. The digital subtraction angiography findings, modified Rankin scale (mRs) score, and complications of all the patients were compared. ResultsThirty patients successfully completed the surgery. Three patients had postoperative complications (two patients with cerebral infarction on the surgical side and one patient with poor scalp healing). The postoperative morbidity rate was 10%. Angiography conducted at 3 to 6 months postoperatively showed 28 cases of anastomotic patency; the anastomotic patency rate was 93.3%. The mRs scores of the patients’ neurological function 3 months after surgery were lower than those before surgery. ConclusionSTA-MCA+EDMS is effective in treating Moyamoya disease.

Transmiocardial laser revascularization in combination with bone marrow cells implantation in the ischemic heart disease surgery: long-term results

Transmiocardial laser revascularization in combination with bone marrow cells implantation in the ischemic heart disease surgery: long-term results

Preoperative evaluation of moyamoya spontaneous anastomosis of combined revascularization donor vessels in adults by duplex ultrasonography

Objective: To evaluate the preoperative diagnostic value of duplex ultrasonography in moyamoya spontaneous anastomosis of combined revascularization donor vessels in adults.Methods: A total of 99 preoperative adult patients who underwent superficial temporal artery-to-middle cerebral artery (STA-MCA) anastomosis were retrospectively analyzed. Each side of the cerebral hemisphere was examined as a separate procedure. A total of 198 cerebral hemispheres were divided into three groups: a collateral, non-collateral, and control group based on digital subtraction angiography (DSA). Hemodynamic parameters, including peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) were analyzed.Results: There were only four of cases (5%, 4/198) of STA spontaneous anastomosis, whereas those of maxillary artery (MA) anastomosis were 44 (23.7%, 44/186). Compared with the control group, MA PSV and EDV of the collateral group increased significantly, while RI decreased significantly (p < .05). The area under the curve (AUC) of MA RI was 0.654. As a predictor of MA spontaneous anastomosis, duplex ultrasonography had high specificity but poor sensitivity. In collateral group, PSV and EDV detected two weeks post-surgery were significantly higher than those detected pre-operatively (PSV: p = .018, EDV: p = .025). By contrast, there were no significant difference of the PSV and EDV detected six months post-surgery compared with pre-operation (PSV: p = .450, EDV: p = .099). Additionally, MA RI in two weeks after the surgery was comparable with preoperative values.Conclusions: Duplex ultrasonography could be applied to evaluate the adult moyamoya spontaneous anastomoses of MA preoperatively. Despite its poor sensitivity, this diagnostic modality is still reliable and specific. STA-MCA anastomosis combined with EDMS did not affect MA pre-operative spontaneous anastomosis.

Combined Direct and Indirect Cerebral Revascularization Using Local and Flow-Through Flaps.

Extracranial-intracranial bypass is indicated in ischemic disease such as moyamoya, certain intracranial aneurysms, and other complex neurovascular diseases. In this article, we present our series of local and flow-through flaps for cerebral revascularization as an additional tool to provide direct and indirect revascularization and/or soft tissue coverage. A retrospective review of a prospectively maintained database was performed identifying nine patients. Ten direct arterial bypass procedures with nine indirect revascularization and/or soft tissue reconstruction were performed. Indications for arterial bypass included intracranial aneurysm (n = 2) and moyamoya disease (n = 8). Indications for soft tissue transfer included infected cranioplasty (one) and indirect cerebral revascularization (eight). Four flow-through flaps and five pedicled flaps were used including a flow-through radial forearm fasciocutaneous flap (one), flow-through radial forearm fascial flaps (three), and pedicled temporoparietal fascial (TPF) flaps with distal end anastomosis (five). The superficial temporal vessels (seven) and facial vessels (two) were used as the vascular inflow. Arterial bypass was established into the middle cerebral artery (six) and anterior communicating artery (three). There were no intraoperative complications. All flaps survived with no donor-site complications. In one case of flow-through TPF flap, the direct graft failed, but the indirect flap remained vascularized. Local and flow-through flaps can improve combined direct and indirect revascularization and provide soft tissue reconstruction. Minimal morbidity has been encountered in early outcomes though long-term results remain under investigation for these combined neurosurgery and plastic surgery procedures. The level of evidence is IV.

Curative effect of surgery on moyamoya disease: an analysis of 47 patients

To evaluate the effect of surgery on 47 patients with moyamoya disease by retrospective analysis. Methods: A total of 47 patients with moyamoya disease were enrolled from August, 2010 to According to the improved treatment in August, 2013, all cases were divided into two groups: a pre-improved group and a post-improved group. According to different surgical methods, they were divided into two subgroups: an indirect revascularization subgroup and a combined revascularization subgroup. Results: The cerebral ischemia in 77.4% of patients was relieved after the surgery. There was significant difference in outcomes of patients between the pre-improved group and the post-improved group (P<0.05), while there was no significant difference between the pre-improved indirect revascularization subgroup and the pre-improved combined revascularization subgroup. There was also no significant difference between the post-improved indirect revascularization subgroup and the post-improved combined revascularization subgroups (P>0.05). Conclusion: Surgical treatment can improve the outcomes of patients with moyamoya disease, but there is no significant difference in surgical effects between indirect and combined revascularization.

Effect of Aspirin in Postoperative Management of Adult Ischemic Moyamoya Disease.

Aspirin has been implicated in the postoperative management of moyamoya disease (MMD) in order to avoid bypass failure and decrease the incidence of subsequent stroke. However, its effect has not been completely determined yet. In this study, we retrospectively reviewed data of 184 adult patients (197 hemispheres) presented with ischemic-onset MMD who had undergone direct or combined revascularization in our hospital, to clarify the effect of postoperative aspirin therapy in the management of moyamoya disease. Fifty-nine hemispheres that had been administered with aspirin (100 mg/day) after bypass surgery were defined as the "aspirin group," whereas 138 that hadn't been given aspirin postoperatively were defined as the "control group". Among 197 hemispheres, the mortality rate was 0. The incidence of postoperative newly developed infarction, transient ischemic attack, and hemorrhage were not significantly different between the aspirin and control groups. The patency rate of bypass graft was not significantly different between the groups, either. Notably, more patients experienced major stroke in the control group (9/138) than the aspirin group (1/59), but no statistical difference was found (P > 0.05). In the aspirin group, more patients had improved outcome than the control group (P=0.04). Our findings showed that aspirin might not decrease the incidence of postoperative ischemic stroke or increase patency rate of bypass graft, but it does not increase the risk of hemorrhages, either. Also, postoperative aspirin therapy might improve outcome. More studies are needed to provide evidence for postoperative antiplatelet therapy in MMD management.

Abstract TP133: Interactive Development of Direct and Indirect Bypass After Combined Revascularization for Moyamoya Disease: The Significance of Indirect Bypass

Background &amp; Purpose: The additional effects of indirect bypass on combined revascularization surgery in moyamoya disease (MMD) remain unclear. Our purpose in this study is to evaluate how direct and indirect bypass in combined revascularization change through long term follow up and to analyze the clinical factors or hemodynamic parameters involved in these changes. Methods: A retrospective survey was conducted with a sample size of 97 hemispheres from 69 consecutive patients (43 adults and 26 children) with MMD treated by combined revascularization. We used magnetic resonance angiography (MRA) to evaluate bypass development with the diameters of superior temporal artery (STA) for the direct bypass and middle meningeal artery (MMA) and deep temporal artery (DTA) for the indirect bypass. A multivariate logistic regression analysis was used to study the related multiple variables on bypass development. Results: Good indirect bypass indicated by MMA development was seen 78% of the adult hemispheres and 95% of the pediatric ones. Dual development of direct and indirect bypasses was most frequently observed (47% and 56% of the adult and pediatric hemispheres, respectively). When indirect bypasses developed, 28% of the STAs reduced in diameter reciprocally from the acute to the chronic phases after surgery. The development of indirect bypass was significantly better in the adult hemispheres at Suzuki stage 4 or greater ( P =0.02; odds ratio 7.4, 95% confidence interval, 1.4-39.4). The disease onset type and the hemodynamic parameters were not associated with the development of surgical revascularization. Conclusions: Indirect bypass developed effectively in both adult and pediatric patients, even in the presence of direct bypass. The universal application of indirect bypass is considered an optimal surgical strategy to maximize revascularization in MMD.