Encephaloduroarteriosynangiosis for adult intracranial arterial steno-occlusive disease: long-term single-center experience with 107 operations

Abstract

E ncEphaloduroartEriosynangiosis (EDAS) is a form of indirect revascularization that has been used for the treatment of pediatric moyamoya disease (MMD) since the 1970s. 20 The application of EDAS for adults with MMD has shown promising results in the early postoperative period 6 and its use has been extended to the treatment of select patients with intracranial atherosclerotic steno-occlusive disease (ICASD).7 ICASD is the most common cause of stroke worldwide. 4,10,25 It accounts for at least 10% of all strokes in the United States 21 and as much as 33%-67% of stroke in countries with predominantly Asian, Hispanic, and black populations.10 ICASD carries a worse prognosis than other stroke etiologies, with an annual rate of recurrent stroke and death of 15% despite obJect Encephaloduroarteriosynangiosis (EDAS) is a form of revascularization that has shown promising early results in the treatment of adult patients with moyamoya disease (MMD) and more recently in patients with intracranial atherosclerotic steno-occlusive disease (ICASD). Herein the authors present the long-term results of a single-center experience with EDAS for adult MMD and ICASD. methods Patients with ischemic symptoms despite intensive medical therapy were considered for EDAS. All patients undergoing EDAS were included. Clinical data, including recurrence of transient ischemic attack (TIA) and/or stroke, functional status, and death, were collected from a retrospective data set and a prospective cohort. Perren revascularization and American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) collateral grades were recorded from angiograms. results A total of 107 EDAS procedures were performed in 82 adults (36 with ICASD and 46 with MMD). During a median follow-up of 22 months, 2 (2.4%) patients had strokes; both patients were in the ICASD group. TIA-free survival and stroke-free survival analyses were performed using the product limit estimator (Kaplan-Meier) method. The probability of stroke-free survival at 2 years in the ICASD group was 94.3% (95% CI 80%-98.6%). No patient in the MMD group suffered a stroke. The probability of TIA-free survival at 2 years was 89.4% (95% CI 74.7%-96%) in ICASD and 99.7% (95% CI 87.5%-99.9%) in MMD. There were no hemorrhages or stroke-related deaths. Angiograms in 85.7% of ICASD and 92% of MMD patients demonstrated Perren Grade 3 and improvement in ASITN/SIR grade in all cases. coNclusioNs EDAS is well tolerated in adults with MMD and ICASD and improves collateral circulation to territories at risk. The rates of stroke after EDAS are lower than those reported with other treatments, including intensive medical therapy in patients with ICASD.

Evaluation of Encephaloduroarteriosynangiosis Efficacy Using Probabilistic Independent Component Analysis Applied to Dynamic Susceptibility Contrast Perfusion MRI

“…7 In a recently published report on treatment outcomes with EDAS, the rate of stroke was 2.4% (5.6% in patients with ICAS, 0% in patients with MMD) within two years after surgery. 9 These rates are lower than the previously observed rates for medical treatment (15%) or angioplasty and stenting (21%) in the SAMMPRIS trial. 10,11 …”

“…By applying probabilistic ICA, however, a significant change was observed in the surgical hemisphere that corresponded to the clinical observation of protection from stroke and reduced risk of TIA after EDAS, in agreement with prior publications reporting these beneficial clinical effects. 7,9 Specifically, the non-surgical (control) hemisphere was found to have a constant, high arterial probability and low venous and capillary probabilities, suggesting that the raw DSC signal was most consistent with a rapid arterial hemodynamic pattern. As this asymptomatic hemisphere was not affected by intracranial arterial stenosis, no perfusion deficit was expected.…”

“…Furthermore, as the clinical outcome after EDAS is likely to be superior to medical therapy alone, it will be important to assess whether such an observation may be reason enough for withholding or delaying surgery. 9–11 …”

Role of and Indications for Bypass Surgery After Carotid Occlusion Surgery Study (COSS)?

“…4,5 Indirect cerebral revascularization methods are felt to be largely ineffective for non-moyamoya vasculopathy 28,29 because of the presumed absence of the angiogenic milieu associated with MMD, although small case series have suggested some limited success with indirect strategies. 30 Currently, a RCT, the EDAS (Surgical) Revascularization in patients with Symptomatic Intracranial Arterial Stenosis (ERSIAS) is underway in the United States, which may provide some insights into the role of indirect bypass for atherosclerotic disease (ClinicalTrials.gov NCT01819597; EDAS: encephalo-duro-arterio-synangiosis). Beyond this, for atherosclerotic occlusions, the primary focus has been on examining the role of direct cerebral bypass.…”

“…Методы непрямой церебральной реваскуляризации при васкулопатиях, отличных от мойя-мойя, считают-ся неэффективными [28,29] вследствие предполагае-мого отсутствия ангиогенной среды, ассоциированной с БММ, хотя в небольших сериях случаев был продемон-стрирован некоторый ограниченный успех при приме-нении стратегий непрямого шунтирования [30]. В насто-ящее время в США проводят РКИ, EDAS (Surgical) Revascularization in patients with Symptomatic Intracranial Arterial Stenosis (ERSIAS), результаты которого позво-лят прояснить некоторые вопросы о роли непрямо-го шунтирования при атеросклеротической болезни (ClinicalTrials.gov NCT01819597; ЭДАС: энцефало-дуро-артерио-синагиоз).…”