Encephalo-duro-myo-synangiosis Research Articles

Comparison of IMD and ICG videoangiography in combined bypass surgery: a single-center study.

Superficial temporal artery-middle cerebral artery (STA-MCA) bypass combined with an encephaloduromyosynangiosis (EDMS) had gained significant role in treating chronic cerebral ischemia. Invasiveness and costs of intraoperative digital subtraction angiography (DSA) limited its application in operations. To find the reliable parameters for determining bypass patency with intraoperative micro-Doppler (IMD) sonography and compare the diagnostic accuracy of indocyanine green (ICG) videoangiography with IMD in combined bypass. One hundred fifty bypass procedures were included and divided into patent and non-patent groups according to postoperative computed tomography angiography (CTA) within 72h. The surgical process was divided into four phases in the following order: preparation phase (phase 1), anastomosis phase (phase 2), the temporalis muscle closure phase (phase 3), and the bone flap closure phase (phase 4). The IMD parameters were compared between patent and non-patent groups, and then compared with the patency on CTA by statistical analyses. IMD with CTA, ICG videoangiography with CTA,IMD with ICGvideoangiography were performed to assess bypass patency. The agreement between methods was evaluated using kappa statistics. No significant differences of baseline characteristics were found between patent and non-patent group. Parameters in the STA were different between patent and non-patent groups in phases 2, 3, and 4. In patent group, Vm was apparently higher and PI was lower in phases 2, 3, and 4 compared with phase 1 (P < .001). In non-patent group, no differences of Vm and PI were found within inter-group. The best cutoff value of IMD in the STA to distinguish patent from non-patent bypasses was Vm in phase 4 > 17.5cm/s (sensitivity 94.2%, specificity 100%). In addition, the agreement for accessing bypass patency was moderate between ICGvideoangiography and CTA (kappa = 0.67), IMD and ICG videoangiography (kappa = 0.73), and good between IMD and CTA (kappa = 0.86). ICG videoangiography could directly display morphology changes of bypass. IMD could be used for providing half-quantitative parameters to assess bypass patency. Vm in phase 4 > 17.5cm/s suggesting the patency of bypass on CTA would be good. Also, compared with ICG videoangiography, IMD had more accuracy.

Safety and efficacy of aspirin after combined cerebral revascularization for ischemic moyamoya disease: A prospective study.

To analyze the safety and efficacy of regular aspirin use after combined cerebral revascularization in patients with ischemic moyamoya disease. From December 2020 to October 2021, a total of 326 patients diagnosed with ischemic moyamoya disease by global cerebral angiography and undergoing first-time combined cerebral revascularization at the Moyamoya Disease Diagnosis and Treatment Research Center of our hospital were selected. Combined cerebral revascularization: superficial temporal artery-middle cerebral artery (STA-MCA) +encephalo-duro-myo-synangiosis (EDMS).Patients were screened by 2 senior physicians according to established inclusion/exclusion criteria. Patients were divided into aspirin and non-aspirin groups based on whether they received regular oral aspirin after surgery. A total of 133 patients were enrolled in the aspirin group. A total of 71 patients (204 cases) were enrolled in the non-aspirin group. Related data were collected before and 1 year after surgery and statistically analyzed to assess the prognosis of both groups. In the two groups, the mRS Score was significantly different after one year (P = 0.023). TIA occurred in 26 patients (19.5%) in the aspirin group and 27 patients (38.0%) in the non-aspirin group within one year after surgery, and the difference between the two groups was statistically significant (P = 0.004). There was no significant difference in cerebral perfusion stage, the improvement rate of cerebral perfusion, Matsushima grading, bypass patency, and other complications within one year after the operation (P > 0.05). In patients with ischemic moyamoya disease who underwent combined cerebral revascularization, postoperative administration of aspirin can reduce the incidence of TIA without increasing the risk of bleeding, but it can not significantly improve the cerebral perfusion of the operation side, Matsushima grading, and bypass patency.

Occlusion of the Anterior Cerebral Artery Mimicking a Cerebral Aneurysm: Clinical Presentation and Literature Review

Intracranial aneurysms may be misdiagnosed with other vascular lesions such as vascular loops, infundibulum, or the stump of an occluded artery (very rare and reported compromising only the middle cerebral artery and the posterior circulation territory). Our aim was to describe a unique case of occlusion of an anterior cerebral artery mimicking a cerebral aneurysm in a probable moyamoya disease patient, and to highlight its clinical presentation, diagnosis, and management, and to perform an extensive literature review. A 67-year-old man suffering from recurrent dizziness for 3 months. Previous medical history was unremarkable. Brain magnetic resonance angiography (MRA) and digital subtraction angiography (DSA) demonstrated occlusion of the right middle cerebral artery (MCA) associated with a "probable moyamoya disease" and an aneurysm-like shadow protruding lesion at the anterior communicating artery (AcomA). Perfusion images showed ischemia along the right temporo-occipital lobe. Due to MCA occlusion with perfusion deficits and unspecific symptoms, we offered a right side encephalo-duro-myo-synangiosis (EDMS) and clipping of the AcomA aneurysm in one session. Intraoperatively, there was no evidence of the AcomA aneurysm; instead, this finding corresponded to the stump of the occluded right anterior cerebral artery (A1 segment). This segment appeared to be of yellowish color due to atherosclerosis and lacked blood flow. The patient underwent as previously planned a right side EDMS and the perioperative course was uneventful without the presence of additional ischemic attacks. Arterial branch occlusions can sometimes present atypical angiographic characteristics that can mimic a saccular intracranial aneurysm. It is relevant to consider this radiographic differential diagnosis, especially when aneurysm treatment is planned.

Pre-operative higher hematocrit and lower total protein levels are independent risk factors for cerebral hyperperfusion syndrome after superficial temporal artery-middle cerebral artery anastomosis with pial synangiosis in adult moyamoya disease patients-case-control study.

Superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis is a standard treatment for adult moyamoya disease (MMD) patients. Cerebral hyperperfusion (CHP) syndrome is one of the most serious complications of this procedure that can result in deleterious outcomes, but predicting CHP before revascularization surgery remains challenging. Furthermore, the hematological/serological factors associated with CHP syndrome are unknown. To investigate the correlation between pre-operative hematological/serological factors and the development of CHP syndrome after STA-MCA anastomosis with encephalo-duro-myo-synangiosis (EDMS) for MMD., a pre-operative peripheral blood test was performed within 5 days before surgery. Local cerebral blood flow (CBF) at the site of anastomosis was quantified by N-isopropyl-p-[123I] iodoamphetamine single-photon emission computed tomography 1 and 7 days after surgery, and the pre-operative CBF value at the corresponding area was measured. We defined CHP syndrome as a local CBF increase over 150% compared with the pre-operative value, which was responsible for delayed intracranial hemorrhage, transient focal neurological deterioration, and/or seizure. Then, we retrospectively investigated the correlation between peripheral blood test results and the development of CHP syndrome. CHP syndrome 1 day after STA-MCA anastomosis with EDMS was observed in nine patients (9/114 hemispheres; 7.9%). Multivariate analysis with multiple imputation revealed that higher hematocrit value and lower total protein level were significantly associated with the development of CHP syndrome (p value: 0.028 and 0.043, respectively). Higher pre-operative hematocrit levels and lower pre-operative total protein levels are novel risk factors for CHP syndrome after direct revascularization surgery in adult MMD patients.

Assessment of postoperative revascularization of adult patients with Moyamoya disease using MRI territory arterial spin labeling

Objective To assess postoperative revascularization of adult patients with Moyamoya disease (MMD) operated on with different surgical methods using the technology of MRI territory arterial spin labeling (T-ASL). Methods The clinical data of 84 adult MMD patients surgically treated at Department of Neurosurgery, Huashan Hospital, Fudan University from June 2018 to December 2018 were reviewed. Seventy patients received superficial temporal artery to middle cerebral artery bypass (STA-MCA bypass) combined with encephalo-duro-myo-synangiosis (EDMS) and were categorized into combined-bypass group. Fourteen patients underwent merely EDMS and categorized into indirect-bypass group. Digital subtraction angiography (DSA) and T-ASL were performed pre- and postoperatively. Matsushima staging system was applied to assess the outcome of revascularization. T-ASL scan used to investigate the revascularization area (RA) and perfusion of deep brain structures by external carotid artery (ECA) on operated side. Results The follow-up period of 84 patients ranged from 4 to 8 months (mean: 6.3±1.2 months). There was no difference in baseline data (sex, age, clinical presentations, and pre-surgical spontaneous collaterals), peri-operative complications, postoperative stroke control rate, Matsushima stage (grade A or B) between 2 groups (P>0.05). The volume of RA in combined-bypass group was larger than that in indirect-bypass group (101.5 ± 35.5 ml vs. 45.3 ± 14.2 ml, P<0.01). In the combined group, 81.4% (57/70) of operated ECA could perfuse deep structures such as basal ganglia and thalamus, compared with 2/14 in the control group (P<0.01). Conclusions The T-ASL results have suggested that RA of combined bypass seems larger and deeper than that of indirect bypass. T-ASL could an objective and sensitive method to evaluate surgical results of adult MMD in terms of RA volume and spatial distribution. Key words: Moyamoya disease; Cerebral revascularization; Territory arterial spin labeling; Treatment outcome

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.

Unilateral moyamoya disease mimicking intracranial hemorrhage in a pediatric patient: Surgical treatment with encephalo-duro-myo-synangiosis in a progressive disease

Abstract Background Moyamoya disease (MMD) is characterized by progressive bilateral internal carotid artery stenosis and its distal branches. When angiographic findings are unilateral, the diagnosis is considered to be probable MMD. Surgery is recommended treatment of patients with deterioration caused by progressive cerebral ischemic events. Different techniques have been described, and the encephalo-duro-myo-synangiosis (EDMS) procedure is highly recommended for patients with rapid deterioration. A case of unilateral MMD mimicking intracranial hemorrhage in a pediatric patient is reported. Case description A 14-year-old girl was referred to our center due to a decreased level of consciousness. Physical examination revealed right-sided hemiparesis; however, a brain CT scan showed multiple hyperdense masses mimicking a hemorrhagic lesion. A brain MRI showed a large hypointensity in the temporoparietal, suggesting a vascular lesion. In all children that exhibit encephalitis, vascular events such as MMD should be considered. An emergency surgical EDMS procedure was performed, and the patient regained consciousness and exhibited no TIAs during the follow-up period. A postoperative brain MRI showed an improvement in brain vascularity. Conclusion After EDMS, a considerable degree of neurological recovery was observed in our patient with rare unilateral MMD mimicking intracranial hemorrhage. We found that the progression of clinical improvement after indirect revascularization in our case was due to EDMS. Surgical treatment with EDMS is reasonable for MMD because it allows for flexible revascularization that adequately addresses the requirement for new blood supply in the ischemic lesion. The EDMS procedure is followed by an observation period to preclude the possibility of the patient developing definite MMD.

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.

Clinical and angiographic outcomes after combined direct and indirect bypass in adult patients with moyamoya disease: A retrospective study of 76 procedures.

The present retrospective study was performed to evaluate the clinical outcome, as well as post-operative collateral formation and revascularization patterns in combined bypass. Surgical revascularization has been the mainstay of treatment for moyamoya patients. A total of 76 hemispheres from 64 moyamoya patients undergoing combined superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and encephalo-duro-myo-synangiosis (EDMS) were retrospectively reviewed. Computed tomography perfusion and DSA were routinely performed. Modified Rankin scale (mRS) scoring and Kaplan-Meier analysis were performed, and post-operative collateral grading on digital subtraction angiography (DSA), reconstruction patterns and vessel diameter were measured to evaluate the revascularization area and vascular compensatory effect. During the follow-up period, the chief complaint was partially alleviated in 57/64 patients (89.1%). In all patients, mRS was significantly decreased after the operation. Good revascularization was established in most patients at 6 months after the surgery: 92.1% of sides were scored as 2 and 77.6% were scored as 3 by post-operative collateral grading on DSA. Dominant collateral revascularization originating from EDMS was more frequent than that from STA-MCA anastomosis (31 vs. 19 hemispheres) at 6-month follow-up. Morphologically, the calibers of the STA main trunk (2.60±0.65 mm) increased profoundly at the first 10 post-operative days (3.32±1.05 mm) and shrank back to pre-operative status at 6 months (2.20±1.01 mm) and 12 months (2.36±0.73 mm) according to DSA examination. Middle meningeal artery (MMA) and deep temporal artery (DTA) demonstrated continuous augmentation during the follow-up time (from 1.30±0.46 to 1.87±0.69 mm for MMA and 1.11±0.25 to 2.11±1.16 mm for DTA). These results strongly suggested that combined STA-MCA bypass and EDMS provided efficient revascularization and reduced acute cerebral events. The direct STA-MCA bypass provided early augmentation of cerebral perfusion, whereas the indirect EDMS provided a more durable long-term revascularization, indicating a complementary association between the two revascularization methods.

Abstract TP449: Clinical and Angiographic Outcomes From Combined Direct and Indirect Bypass in Adult Patients with Moyamoya Disease: A Retrospective Study of 76 Procedures

Objective: Surgical revascularization is the mainstay of treatment for moyamoya patients. This study was to evaluate the progonosis of combined direct and indirect procedure for moyamoya disease patients. Methods: 76 cerebral hemispheres from 64 adult moyamoya patients undergoing combined superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and encephalo-duro-myo-synangiosis (EDMS) were reviewed retrospectively. The mean follow-up period was 23±14m (6m-70m). CT or MR perfusion and Digital subtraction angiography (DSA) were performed for preoperative diagnosis and postoperative evaluation of cerebral perfusion and revascularization. mRS score, angiographic collateralization score, vessel diameter were recorded to measure neurological dysfunction, revascularization area and vascular compensatory effect respectively. Results: Among the 64 MMD patients, 69 hemispheres received combined direct and indirect operations; 7 hemispheres only received indirect operations. During our follow-up periods, neurological deficits of 57/64 patients (89.1%) were partially alleviated. mRS was significantly decreased after operations not only in all patients, but also in stroke subgroup or hemorrhage subgroup. Generally, good revascularization was established in most of the patients by combined bypass. 92.1% (70/74) sides was scored 2 and 77.6% (59/74) sides was scored 3 determined by angiographic collateralization score. Compared to the preoperative situations (2.60±0.65mm), the calibers of STA main trunk increased profoundly in at postoperative 10 days (3.32±1.05mm, p&lt;0.05 versus pre-operation), and shrinked back to preoperative status at 6 months (2.24±1.00mm, p&gt;0.05 versus pre-operation) and 12 months (2.36±0.73mm, p&gt;0.05 versus pre-operation). Conclusion: Our findings strongly suggested that combined STA-MCA bypass and EDMS provided efficient revascularization and excellent results in preventing strokes and hemorrhage in adult patients. The direct STA-MCA bypass provided early augmentation of cerebral perfusion, whereas the indirect EDMS provided a more durable long-term revascularization, indicating a complementary relationship between the two revascularization methods.

Long-term follow-up of pediatric moyamoya disease treated by combined direct-indirect revascularization surgery: single institute experience with surgical and perioperative management.

Moyamoya disease (MMD) is a rare occlusive cerebrovascular disease that mainly presents in children as cerebral ischemia. Prompt treatment with either a direct or indirect revascularization procedure is necessary for children with MMD in order to prevent repeated ischemic events. We herein present our experience with combined direct and indirect bypass surgery for the treatment of pediatric MMD as well as our uniquely designed perioperative protocol. Twenty-three patients with MMD, aged between 2 and 16years old (mean 9.36), underwent 38 combined bypass procedures between 2008 and 2015. All patients underwent single superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis combined with encephalo-duro-myo-synangiosis (EDMS). The perioperative management protocol was stratified into two unique eras: the first era with normotensive care and the second era with strict blood pressure control (systolic 100-130mmHg) and routine aspirin administration. Patients were followed after surgery for a period ranging between 3 and 131months (mean 77months) in yearly clinical and radiological follow-ups. Three postoperative complications were observed: two cases of cerebral hyperperfusion (2/38, 5.3%) and one case of perioperative minor stroke (1/38, 2.6%), two of which were in the first era. No strokes, either ischemic or hemorrhagic, were observed in the follow-up period, and the activity of daily living as shown by the modified Rankin Scale improved in 20 patients, with no deterioration being observed in any of our patients. STA-MCA bypass with EDMS is safe and effective for the management of pediatric MMD and provides long-term favorable outcomes. Perioperative care with blood pressure control combined with the administration of aspirin may reduce the potential risk of surgical complications.

Encephaloduromyosynangiosis (EDMS) on a Pediatric Patient with Cerebral Proliferative Angiopathy

Cerebral proliferative angiopathy (CPA) is a rare cerebral vascular lesion characterized by diffuse vascular abnormalities with intermingled normal brain parenchyma. Cerebral proliferative angiopathy has a complex clinical presentation, and many patients present with ischemic symptoms. We described a case of a 6 year old boy presenting with transient dizziness with weakness of left limbs. MRI showed the presence of a diffusely dilated extensive vascular lesion mainly located in the corpus callosum, right frontal and temporal lobes. Digital subtraction angiography (DSA) revealed a large hypervascular lesion with a diffuse arterial supply. 99mTc-ECD SPECT cerebral blood flow perfusion image revealed decreased perfusion in right frontal and parietal lobe. A surgical procedure of encephaloduromyosynangiosis (EDMS) was performed on the patient, and the patient exhibited disappearance of TIAs during the follow-up period. There is no consensus on treatment of cerebral proliferative angiopathy, but the hemodynamic characteristics of CPA were more similar to moyamoya disease in the PWI-MR study. Furthermore, we speculated that increased regional cerebral blood flow perfusion may relieve clinical symptoms and improve prognosis of patient with CPA. Therefore, we performed encephaloduromyosynangiosis (EDMS) on this pediatric CPA patient with ischemic symptoms. 99mTc-ECD SPECT obtained 6 months after operation showed significant improvement of right frontal and parietal blood perfusion. MR perfusion at follow-up period demonstrated the range and blood flow of vascular lesion decreased significantly compared with preoperative MR perfusion. Follow-up angiography studies showed well compensation by profound neovascularization through the superficial temporal artery, and vascular malformation disappeared around the region supplied from the ECA. EDMS procedure may be a reasonable and effective treatment for patients with ischemia associated with CPA.

Assessing surgical treatment outcome following superficial temporal artery to middle cerebral artery bypass based on computational haemodynamic analysis

To estimate haemodynamic modification of Internal Carotid Artery (ICA) after bypass surgery using computational fluid dynamic (CFD) technology and thereby aid in our understanding of the influence of hemodynamic parameters on the outcomes of bypass operations. 18 patients who underwent superficial temporal artery to middle cerebral artery bypass and encephaloduromyosynangiosis (EDMS) surgery were included. Reconstructed three-dimensional vessel geometries from MRA were segmented to create computational domains for CFD simulations. All cases were classified as three groups according to the proportion of the MCA area of distribution supplied by revascularization: A, more than two thirds; B, between two-thirds and one-third; and C, less than one-third of the MCA distribution. Pre-operative and follow-up haemodynamic parameters, especially volume flow rate and pressure drop index (PDI) in ICA were compared. For all cases, PDI and volume flow rate in the surgical-side ICA decreased significantly at follow-up (P<0.05). For the cases of group A, volume flow rate in surgical-side ICA decreased by average 24.2%, whilst for the cases of group B and C, flow rate reduced by 10.5% and 3.7%, respectively. An average PDI for cases in group A was −1.67mmHg, conversely average PDI values of group B and C were −0.53 and 0.82mmHg, respectively. The remodelling of ICA after bypass was associated with reduction in the volume flow rate and pressure drop. Good correlation with angiographic grading suggested that CFD might play a critical role as a quantitative haemodynamic technique for predicting treatment outcome during the follow-up of MMD patients.

"STA-MCA bypass with encephalo-duro-myo-synangiosis combined with bifrontal encephalo-duro-periosteal-synangiosis" as a one-staged revascularization strategy for pediatric moyamoya vasculopathy.

Moyamoya vasculopathy progressively compromises cerebral blood flow resulting in chronic hypoperfusion. The middle cerebral artery (MCA) territory and the bifrontal areas are the regions most frequently affected. Although most techniques aim to only revascularize the MCA territory, augmentation of blood flow of the bifrontal areas is of importance in the pediatric moyamoya population since these regions play an important role in cognition, intellectual development, and in lower extremity and sphincter function. We recently described a one-staged surgical procedure combining revascularization of three regions, the MCA territory unilaterally and the frontal areas bilaterally. The purpose of this article is to report our surgical experience in eight children and to emphasize the rational for bifrontal revascularization. We report a case series consisting of eight children where the following surgical strategy was applied: (1) a direct superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass with encephalo-duro-myo-synangiosis (EDMS) for unilateral MCA revascularization; in combination with (2) a bifrontal encephalo-duro-periosteal-synangiosis (EDPS) for bifrontal revascularization. Patients' characteristics and 30-day follow-up data are reported. The patient group consisted of six girls and two boys (mean age 10.0, range 4.2-17.5years): six children presented with moyamoya disease, two with moyamoya syndrome. We performed a one-staged revascularization of one MCA territory and both frontal areas in all patients. No significant complications occurred. Two patients experienced postoperative focal seizures, successfully treated with anti-epileptic medication. The single-staged STA-MCA bypass with EDMS combined with bifrontal EDPS allowed revascularization of three regions (the MCA territory unilaterally and the frontal areas bilaterally) and may serve as an alternative and safe treatment option for pediatric moyamoya patients.

Combined direct and indirect revascularization in treatment of ischemic moyamoya disease

Objective To investigate the effects of combined direct and indirect revascularization in the treatment of ischemic moyamoya disease.Methods Combined superficial temporal artery middle cerebral artery anastomosis and encephalo-duro-myo-synangiosis (EDMS) were performed in 20 adult patients with ischemic moyamoya disease,who were followedup for six months to two years.The postoperative outcomes were evaluated by CTA,DSA,MRI and PWI.Results The postoperative external carotid angiography at 6 months and 12 months revealed that the STA-MCA bypass was patent in 17 patients.12 of 17 patients were also patent at 24 months after the procedure.The extensive development of surgical collaterals from MMA and deep temporal artery through indirect bypass were observed in all patients.18 patients were free of transient ischemic attack within one year.Conclusions Combined STA MCA bypass and EDMS could provide a significant reciprocal benefit.It was a safe and effective option to improve the short-and long-term outcomes in patients with ischemic moyamoya disease. Key words: Moyamoya disease; Revascularization; Ischemic

Management of distal choroidal artery aneurysms in patients with moyamoya disease: report of three cases and review of the literature

Prevention of rebleeding plays an important role in the treatment of hemorrhagic moyamoya disease, because rebleeding results in high mortality and morbidity. We discuss possible treatment for patients with moyamoya disease accompanied with distal choroidal artery aneurysms and review the literature to summarize clinical treatment and mechanisms. The cases of three male patients who suffered from intraventricular hemorrhage are presented. Computed tomography (CT) and digital subtractive angiography (DSA) revealed that bleeding was believed to be caused by ruptured aneurysms originating from distal choroidal artery aneurysms. Two patients successfully underwent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass combined with encephalo-duro-myo-synangiosis (EDMS) and the obliteration of the aneurysm. The follow-up DSA or CT scan demonstrated that the aneurysms completely disappeared with the patency of the reconstructed artery. Neither of the patients experienced rebleeding during the follow-up period (up to 34 months). Given conservative treatment, the third patient experienced recurrent hemorrhages 4 months after the first ictus. This study describes treatment for moyamoya disease accompanied with distal choroidal artery aneurysms. Our experience suggests that cerebral revascularization combined with obliteration of the complicated distal aneurysm in the same session is a possible treatment.

Efficacy of extracranial–intracranial revascularization for non-moyamoya steno-occlusive cerebrovascular disease in a series of 66 patients

Although there is uncertainty about whether extracranial–intracranial arterial bypass is useful for the treatment of steno-occlusive cerebrovascular disease in general, there is some argument for its continued use in particular patients. In the present study, we evaluated the efficacy of superficial temporal artery–middle cerebral artery (STA–MCA) anastomosis combined with encephalo-duro-myo-synangiosis (EDMS) in the treatment of non-moyamoya steno-occlusive cerebrovascular disease by retrospectively reviewing clinical and radiological data from 66 patients treated between January 2006 and April 2011. Forty-six double STA–MCA anastomoses and 20 single anastomoses were completed, and all remained patent in the perioperative phase, as confirmed by CT angiography. Postoperative CT perfusion imaging demonstrated immediate improvement in perfusion in the revascularized hemisphere. On discharge, 50 of the 66 patients (75.8%) had an improved National Institutes of Health Stroke Scale (NIHSS) score relative to preoperative values. After at least 6months of follow-up, 54 (88.5%) patients had improved NIHSS scores relative to discharge values. CT perfusion imaging showed significant improvement compared to post-operative images. Follow-up digital subtraction angiography confirmed that 95 of 96 (99%) anastomoses remained patent. There was no significant difference between the single and double bypasses in terms of either clinical or hemodynamic outcomes on the revascularized side. STA–MCA combined with EDMS was effective for the treatment of non-moyamoya steno-occlusive cerebrovascular disease with hemodynamic impairment. Hemodynamic evaluation before and after surgery may help identify patients in need of a bypass and may be useful for predicting outcome.

Disappearance of aneurysms associated with moyamoya disease after STA–MCA anastomosis with encephaloduro myosynangiosis

Moyamoya disease is a rare cerebrovascular disease characterized by steno-occlusive vasculopathy affecting the terminal internal carotid arteries. Although the effect of direct arterial bypass on the prevention of recurrent haemorrhage or ischemic events in patients with hemorrhagic moyamoya disease has been demonstrated, disappearance of aneurysms associated with moyamoya disease has rarely been reported. In this study, we present two patients with aneurysms associated with moyamoya disease. After superficial temporal artery to middle cerebral artery anastomosis combined with encephaloduro myosynangiosis, the aneurysms on the moyamoya vessels disappeared, which was confirmed by follow-up angiography.

A new cerebral revascularization in treating moyamoya disease: superficial temporal artery-middle cerebral artery anastomosis combining with encephaloduromyosynangiosis

Objective To study the therapeutic effect of superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis combining with original in treating moyamoya disease. Methods 89 direct STA-MCA bypasses combining with were performed on 73 hemispheres in 49 cases of ischemic-type and 16 cases of hemorrlogic-type moyamoya disease during October 2005 to July 2008 in Huashan Hospital. Results The cerebral blood flow increased immediately after operation. The isehemic symptoms were relieved in all the patients. No rebleeding was found on follow up. Conclusion We named indirect revascularization using temporal muscle (the deep temporal artery) and the dura mater (the middle meningeal artery) as encephaloduromyosynangiosis (EDMS) . The combination of STA-MCA bypass with EDMS is a new rational cerebral revascularization in treating moyamoya disease. Key words: Moyamoya disease; Anastomosis, surgery; Cerebral revascularization