A meta‐analysis of comparisons of various surgical treatments for moyamoya diseases

Abstract

Purpose: Ischemia is one of the most familiar complications in the different procedures for moyamoya disease (MMD), but the optimal surgical approaches for MMD remain unknown. We aimed to evaluate the efficiency of various surgical treatments.Methods: A literature search word was performed through four databases such as Cochrane Library, Web of Science, PubMed, and EMBASE for the literature published until May 2021. The I 2 statistic was used to assess heterogeneity. A random/fixedeffects model was used to pool.Results: There are a total of 18 studies including three surgical treatments such as including indirect, direct, and combined bypass in this study. The result revealed that indirect bypass was related to a higher incidence of recurrence stroke compared to the direct and combined bypass treatment (p = .001). Furthermore, the cases undergoing direct bypass were associated with a better angiographic change than the indirect bypass (OR = 3.254, p = .013). Conclusion:This meta-analysis demonstrated a positive effect of using the direct and combined bypass to treat MMD compared to indirect bypass due to their lower rates of recurrence stroke. K E Y W O R D Scombined bypass, direct bypass, indirect bypass, moyamoya disease INTRODUCTIONMoyamoya disease (MMD) was first reported by Japanese literature in 1957 (Suzuki & Takaku, 1969), which was characterized by progressive stenosis and eventual occlusion of the major intracranial arteries in the proximity of the distal ends of internal carotid arteries (ICA). As a result of progressive blockage of the major vessels, networks of small collateral vessels develop and show a "puff of smoke" appearance on angiography, for which the name "moyamoya" (Japanese word for "puff of smoke") was coined (Suzuki & Takaku, 1969). MMD can cause strokes including two main phenotypes in populations: the This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2021 The Authors. Brain and Behavior published by Wiley Periodicals LLC ischemic and hemorrhagic types. Severe neuropsychological disorders, including cognitive decline, depression, and anxiety that cause the quality of life decline are also the main clinical feature of MMD (Cho et al., 2015). It is reported that MMD is common in East Asian people such as Korean and Japanese, as compared to Western Hemisphere people. According to a survey performed in Japan, the prevalence of MMD was approximately 3.16/100,000 (Wakai et al., 1997). The Japanese literature has reported that the prevalence of MMD had doubled from 3900 in 1994 to 7700 in 2003 (Kainth et al., 2013). The serious complications of MMD can lead to worse clinical outcomes and an increased mortality rate in MMD patients. Despite the Brain Behav.

Outcomes after superficial temporal artery–middle cerebral artery anastomosis combined with multiple burr hole surgery and dural inversion synangiosis for moyamoya disease in adults

“…Combined bypass includes both direct and indirect bypass procedures, such as STA-MCA anastomosis combined with EDAS or STA-MCA anastomosis combined with EDAMS; combined bypass procedures are currently common in clinical use. At present, a growing number of studies suggest that combined bypass surgery is superior to direct or indirect bypass alone for the general MMD population because the surgical effect is secured by two means: an instant increase in blood flow from direct anastomosis and subsequent spontaneous ingrowth of collaterals from indirect bypass (6)(7)(8)(9). The combined bypass procedures mentioned above are always associated with various postoperative complications, such as seizures, cerebral infarction, cerebral hemorrhage, etc.…”

“…Despite some controversy, revascularization is one of the main MMD treatments used to prevent recurrent stroke and to improve the prognosis (9,10,14). There are 3 types of ECA branches that can be used in these procedures: (1) the STA or occipital artery (OP), (2) the deep temporal artery (DTA) supplying temporal muscle and periosteum, and (3) the MMA supplying the cerebral dura mater.…”

Adult Moyamoya Disease and Syndrome: Current Perspectives and Future Directions: A Scientific Statement From the American Heart Association/American Stroke Association

“…90,91 There is a lack of randomized data regarding revascularization strategy in ischemic moyamoya. Most metaanalyses 70,73,74,[92][93][94] and their source studies have several limitations, including nonrandomized allocation of treatment, heterogeneity in age and clinical presentation of cohorts, unblinded outcome assessment, variable length of follow-up, and redundancy in the included cohorts. Although some data may suggest that the direct bypass or combined approach has advantages over the indirect approach for stroke prevention 73,74,[92][93][94] and angiographic outcomes, 70,73,92,93 without differences in perioperative complications, 70,73,74 such studies have major limitations, and no strong conclusions can be made.…”

Direct, Indirect, and Combined Extracranial-to-Intracranial Bypass for Adult Moyamoya Disease: An Updated Systematic Review and Meta-Analysis

“…We hypothesize that direct or combined bypass has better favorable outcomes, angiographic revascularization, and decreased late stroke and hemorrhage rates compared with indirect bypass based on findings from prior literature. 4,[14][15][16][17][23][24][25][26][27]…”