Characteristic Pattern of the Cerebral Hemodynamic Changes in the Acute Stage After Combined Revascularization Surgery for Adult Moyamoya Disease: N-isopropyl-p-[123I] iodoamphetamine Single-Photon Emission Computed Tomography Study

Abstract

Objective: Surgical revascularization for moyamoya disease (MMD) prevents cerebral ischemic attack by improving cerebral blood flow (CBF) and could also reduce the risk of re-bleeding in hemorrhagic-onset patients. We sought to clarify the cerebral hemodynamic changes in the acute stage after revascularization surgery for adult MMD.Materials and methods: The present study includes 54 consecutive adult patients with MMD (21–76 years old, 43.1 average), undergoing superficial temporal artery-middle cerebral artery anastomosis with indirect pial synangiosis on 65 affected hemispheres. We prospectively performed single-photon emission computed tomography (SPECT) at postoperative day (POD) 1 and 7 of 65 surgeries. Perioperative management was conducted with strict blood pressure control (100–130 mmHg) and minocycline hydrochloride administration.Results: The outcome of 65 surgeries was favorable except for one (1.5%), which manifested as delayed intracerebral hemorrhage due to local hyperperfusion. The postoperative SPECT revealed the characteristic CBF improvement pattern with transient local hyperperfusion (POD1) and subsequent distribution of CBF in wider vascular territory (POD7) on 37 hemispheres (56.9%, 37/65).Conclusion: The revascularization surgery is a safe and effective treatment for adult MMD, while transient local hyperperfusion should be strictly managed by intensive perioperative care.

Transient Global Cerebral Hypoperfusion as a Characteristic Cerebral Hemodynamic Pattern in the Acute Stage after Combined Revascularization Surgery for Pediatric Moyamoya Disease: N-Isopropyl-P-[¹²³I] Iodoamphetamine Single-Photon Emission Computed Tomography Study

“…Moreover, the "transient hypoperfusion pattern" might be more common in 1st operation compared with 2nd operation for contralateral side of 1st operation (Table 1). On the other hand, similar postoperative hemodynamic changes are rarely observed in adult MMD patients [6,13,17]. These observations support the notion that postoperative hemodynamics can differ among pediatric and adult MMD patients.…”

“…Among adult patients, CHP is one of the major hemodynamic issues that can result in not only transient neurological deficits, severe headaches, and seizures but also delayed intracerebral hemorrhage [9][10][11][12][13][14][15][16]. Based on previous studies, the incidence of radiological and symptomatic CHP among adult MMD patients is as high as 27.8-56.9% and 0-38.2%, respectively [10][11][12][13][14][15][16][17]19]. In contrast, none of the pediatric patients had CHP, either radiological or symptomatic, in the current study.…”

“…All patients underwent combined direct-indirect revascularization surgery by superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis with encephalo-duro-myo-synangiosis (EDMS), as described previously [7,8,[10][11][12][14][15][16][17][18][19][20][21]. After craniotomy around the Sylvian fissure, the stump of the STA was anastomosed to the cortical branch (M4 segment) of the MCA, followed by EDMS.…”

“…All patients who underwent operations on 21 hemispheres were prospectively subjected to prophylactic intensive blood pressure reduction (systolic blood pressure of 100-130 mm Hg) according to a standardized postoperative management protocol to prevent CHP by continuous intravenous infusion of nicardipine hydrochloride, as reported previously [9,10,[14][15][16][17][18]20]. In brief, all patients were subjected to intraoperative and postoperative administration of minocycline hydrochloride (200 mg/day) until POD 5 to avoid the deleterious results of CHP and to reduce the potential risk of hemodynamic ischemia due to the watershed shift phenomenon.…”

“…Among adult MMD patients, cerebral hyperperfusion (CHP) syndrome is one of the most deleterious complications after STA-MCA bypass surgery [9][10][11][12][13][14][15][16]. A hemodynamics study using N-isopropyl-p-[ 123 I] iodoamphetamine single-photon emission computed tomography ( 123 I-IMP SPECT) revealed that 56.9% of adult MMD patients have a characteristic hemodynamic pattern such as a transient increase in focal cerebral blood flow (CBF) on postoperative day (POD) 1 and subsequent distribution of CBF in the entire vascular territory on POD 7 [17]. CHP is known to result in transient neurological deficits, headache, seizure, and intracerebral hemorrhage in adult MMD patients [10][11][12][13][14][15][16].…”