Characterization of Direct and Indirect Cerebral Revascularization for the Treatment of European Patients with Moyamoya Disease

Czabanka, Marcus; Peña-Tapia, Pablo; Scharf, Johann; Schubert, Gerrit Alexander; Münch, Elke; Horn, Peter A.; Schmiedek, Peter; Vajkoczy, Peter

doi:10.1159/000330351

Cited by 89 publications

(75 citation statements)

References 32 publications

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“…However, because revascularization using the indirect procedure often results in insufficient revascularization in adults, the direct/combined procedure has been increasingly used. 1,2,6,9,14,15,26,39,44 A limitation of this study was its retrospective nature. Because our surgical procedure also includes several steps of the indirect procedure (inverting dura matter, suturing temporalis muscle to the dura, and the placement of the pericranial flap), the result cannot be simply interpreted as a direct comparison between the direct STA-MCA bypass and indirect procedure alone.…”

Section: Discussionmentioning

confidence: 99%

“…At institutions that mainly performed the direct/combined bypass, the procedure was completed in 50%-67.2% of the pediatric patients. 6,15 Thirty-two studies (4161 patients) provided data on postoperative complications (Tables 2 and 3). The rates of postoperative stroke related to direct/combined and indirect revascularization were 5.4% (95% CI 3.4%-7.5%) and 5.5% (95% CI 3.7%-7.3%) per surgery, respectively (nonsignificant difference; Tables 2 and 3).…”

Section: Systematic Reviewmentioning

confidence: 99%

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The frequency of postoperative stroke in moyamoya disease following combined revascularization: a single-university series and systematic review

Kazumata

Ito

Tokairin

et al. 2014

JNS

156

111

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M oyaMoya disease (MMD) is a progressive stenoocclusive cerebrovascular disease characterized by collateral vascular networks that look like "a puff of smoke" (moyamoya vessels) at the base of the brain. 35,58 Various revascularization procedures have been shown to improve cerebral hemodynamics and decrease the risk of ischemic attack; however, hemodynamic compromises and bleeding-prone vasculopathy lead to postoperative neurological morbidity. In anesthesia management, hypocapnia during surgery induces critical decreases in cerebral blood flow. It is also well known that crying induces hyperventilation and stroke during the perioperative period in children. 45,51 Hemodynamic compromise is also aggravated by blood loss, decreased circulating volume, and low blood pressure. 38,53 Furthermore, recent studies have shown that postoperative hyperperfusion develops frequently after surgery. 11,60 A previous review suggested that direct and combined bypass for MMD provide better collateral circula- Object. Although combined direct and indirect anastomosis in patients with moyamoya disease immediately increases cerebral blood flow, the surgical procedure is more complex. Data pertinent to the postoperative complications associated with combined bypass are relatively scarce compared with those associated with indirect bypass. This study investigated the incidence and characteristics of postoperative stroke in combined bypass and compared them with those determined from a literature review to obtain data from a large population.Methods. A total of 358 revascularization procedures in 236 patients were retrospectively assessed by reviewing clinical charts and radiological data. PubMed was searched for published studies on surgical treatment to determine the incidence of postoperative complications in a larger population.Results. Seventeen instances of postoperative stroke were observed in 16 patients (4.7% per surgery, 95% CI 2.8%-7.5%). Postoperative stroke was more frequent (7.9% per surgery) in adults than in pediatric patients (1.7% per surgery, OR 4.07, 95% CI 1.12-14.7; p < 0.05). Acute progression of stenoocclusive changes were identified in the major cerebral arteries (anterior cerebral artery, n = 3; middle cerebral artery, n = 1; posterior cerebral artery, n = 2). The postoperative stroke rate was comparable with that (5.4%) determined from a literature search that included studies reporting more than 2000 direct/combined procedures. No differences in the stroke rates between the direct/combined and indirect procedures were found. In the literature review, direct/combined bypass was more often associated with excellent revascularization (angiographic opacification greater than two-thirds) than indirect bypass (p < 0.05).Conclusions. This experience of 358 consecutive procedures is one of the largest series for which the postoperative stoke rate for direct/combined bypass performed with a unified strategy has been reported. A systematic review confirmed that the postoperative stroke rate for the direct/combined pro...

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Section: Discussionmentioning

confidence: 99%

Section: Systematic Reviewmentioning

confidence: 99%

The frequency of postoperative stroke in moyamoya disease following combined revascularization: a single-university series and systematic review

Kazumata

Ito

Tokairin

et al. 2014

JNS

156

111

View full text Add to dashboard Cite

show abstract

“…1 Although the pathogenesis is not yet known, revascularization surgery has shown satisfactory results in pediatric and adult MMD. [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] Indirect revascularization surgeries, such as encephaloduroarteriosynangiosis and other variants, are generally accepted as standard for pediatric MMD. 3,4,7,9,12 In adult MMD, however, there is still controversy about the effectiveness of some types of revascularization surgeries because there have been no randomized studies to compare the efficacy of surgical techniques, and several retrospective studies have been conducted with various age ranges, small numbers of patients, short-term follow-up, and no standardization of surgical techniques.…”

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confidence: 99%

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

Cho

Kim

et al. 2014

Stroke

144

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Background and Purpose-The surgical outcomes of adult moyamoya disease are rarely reported. We aimed to evaluate the long-term outcomes of combined revascularization surgery in patients with adult moyamoya disease. Methods-Combined revascularization surgery consisting of superficial temporal artery-middle cerebral artery anastomosis with encephalodurogaleosynangiosis was performed on 77 hemispheres in 60 patients. Clinical, angiographic, and hemodynamic states were evaluated retrospectively using quantitative methods preoperatively and postoperatively in the short-term (≈6 months) and long-term (≈5 years) periods. The mean clinical follow-up duration was 71.0±10.1 months (range, 60-104 months). Results-Clinical status improved until 6 months after surgery and remained stable thereafter, as assessed by the Karnofsky Performance Scale and modified Rankin Scale. The revascularization area relative to supratentorial area significantly increased in the long-term period compared with that in the short-term period (54.8% versus 44.2%; P<0.001). Cerebral blood flow in the territory of the middle cerebral artery improved in the short-term period compared with that in the preoperative period (68.7 versus 59.1; considering blood flow of the pons as 50; P<0.001) and thereafter became stable (65.5 in the long term; P=0.219). The annual risks of symptomatic hemorrhage and infarction were 0.4% and 0.2%, respectively, in the operated hemispheres. Conclusions-Combined

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“…12,13 This was, to the best of our knowledge, the longest follow-up study among the previous reports on direct or combined bypass for pediatric moyamoya disease. 3,6,11,13,16 …”

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confidence: 99%

Impact of posterior cerebral artery involvement on long-term clinical and social outcome of pediatric moyamoya disease

Funaki

Takahashi

Takagi

et al. 2013

PED

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Object In the study of pediatric moyamoya disease, information on long-term social outcomes and risk factors for unfavorable social outcomes remains insufficient. The authors analyzed the long-term results of surgical revascularization for pediatric patients with moyamoya disease to determine whether the involvement of a stenoocclusive lesion in the posterior cerebral artery (PCA), relatively common in pediatric moyamoya disease, represents an underlying predictor for unfavorable social outcomes. Methods Prospectively collected data on 61 consecutive patients with moyamoya disease who had undergone combined bypass surgery were analyzed. Neuroradiological features and other baseline clinical factors were incorporated into univariate and multivariate analyses to determine any association with an unfavorable social outcome, defined as difficulty attending regular school or obtaining regular employment. Results Posterior cerebral artery involvement detected by angiography on admission was noted in 22 (36.1%) of the 61 patients. Follow-up data were acquired in 56 patients (91.8%), and the mean follow-up period was 15.8 years. While transient ischemic attacks were eliminated in 52 (92.9%) of these 56 patients after surgery, and late-onset ischemic stroke was observed in only 1 patient during the follow-up period, 10 (17.9%) experienced an unfavorable social outcome. Although younger age at onset, longer duration between onset and surgery, infarction present on preoperative neuroradiological images, and PCA involvement had been identified as risk factors for an unfavorable social outcome in univariate analysis, only infarction present on preoperative images and PCA involvement remained statistically significant after multivariate adjustment. Conclusions Posterior cerebral artery involvement can be considered one of the underlying risk factors for unfavorable social outcome and should be studied further to improve social outcome in pediatric moyamoya disease.

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Characterization of Direct and Indirect Cerebral Revascularization for the Treatment of European Patients with Moyamoya Disease

Cited by 89 publications

References 32 publications

The frequency of postoperative stroke in moyamoya disease following combined revascularization: a single-university series and systematic review

The frequency of postoperative stroke in moyamoya disease following combined revascularization: a single-university series and systematic review

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

Impact of posterior cerebral artery involvement on long-term clinical and social outcome of pediatric moyamoya disease

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