Optimal surgical treatment for moyamoya disease in adults: direct versus indirect bypass

Starke, Robert M.; Komotar, Ricardo J.; Connolly, E. Sander

doi:10.3171/2009.01.focus08309

Cited by 65 publications

(37 citation statements)

References 44 publications

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“…Blood-vessel anastomosis has been successfully used to develop collateral circulation after myocardial infarction and in patients with Moyamoya disease [21] . Molecular bypass using VEGF preparations has also been used to promote the development of collateral circulation after myocardial infarction and in patients with peripheral vascular ischemic diseases [2][3][4] .…”

Section: Discussionmentioning

confidence: 99%

Brain protection against ischemic stroke using choline as a new molecular bypass treatment

Jin

Wang

et al. 2015

Acta Pharmacol Sin

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Aim: To determine whether administration of choline could attenuate brain injury in a rat model of ischemic stroke and the underlying mechanisms.Methods: A rat model of ischemic stroke was established through permanent middle cerebral artery occlusion (pMCAO). After the surgery, the rats were treated with choline or choline plus the specific α7 nAChR antagonist methyllycaconitine (MLA), or with the control drug nimodipine for 10 days. The neurological deficits, brain-infarct volume, pial vessel density and the number of microvessels in the cortex were assessed. Rat brain microvascular endothelial cells (rBMECs) cultured under hypoxic conditions were used in in vitro experiments. Results: Oral administration of choline (100 or 200 mg·kg -1 ·d -1 ) or nimodipine (20 mg·kg -1 ·d -1 ) significantly improved neurological deficits, and reduced infarct volume and nerve cell loss in the ischemic cerebral cortices in pMCAO rats. Furthermore, oral administration of choline, but not nimodipine, promoted the pial arteriogenesis and cerebral-cortical capillary angiogenesis in the ischemic regions. Moreover, oral administration of choline significantly augmented pMCAO-induced increases in the expression levels of α7 nAChR, HIF-1α and VEGF in the ischemic cerebral cortices as well as in the serum levels of VEGF. Choline-induced protective effects were prevented by co-treatment with MLA (1 mg·kg -1 ·d -1, ip). Treatment of rBMECs cultured under hypoxic conditions in vitro with choline (1, 10 and 100 μmol/L) dose-dependently promoted the endothelial-cell proliferation, migration and tube formation, as well as VEGF secretion, which were prevented by co-treatment with MLA (1 μmol/L) or by transfection with HIF-1α siRNA. Conclusion: Choline effectively attenuates brain ischemic injury in pMCAO rats, possibly by facilitating pial arteriogenesis and cerebralcortical capillary angiogenesis via upregulating α7 nAChR levels and inducing the expression of HIF-1α and VEGF.

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Section: Discussionmentioning

confidence: 99%

Brain protection against ischemic stroke using choline as a new molecular bypass treatment

Jin

Wang

et al. 2015

Acta Pharmacol Sin

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“…STA-MCA bypass surgery has a high rate of patency and has been associated with good clinical outcomes, particularly in drastically improving CBF and thus diminishing the incidence of recurrent ischemic events [8,14,15,16]. Surgical approaches are divided into 3 groups: direct anastomosis, indirect anastomosis and combined anastomosis.…”

Section: Discussionmentioning

confidence: 99%

Perfusion-Weighted Magnetic Resonance Imaging Used in Assessing Hemodynamics following Superficial Temporal Artery-Middle Cerebral Artery Bypass in Patients with Moyamoya Disease

Zhou

Xiong

et al. 2013

Cerebrovasc Dis

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Background: The best strategy to assess the changes in brain hemodynamics following superficial temporal artery (STA)-middle cerebral artery (MCA) bypass in patients with Moyamoya disease remains unknown. The purpose of the present study was to assess cerebral hemodynamics using perfusion-weighted magnetic resonance imaging (PWI) before and after STA-MCA bypass surgery in patients with Moyamoya disease. Methods: STA-MCA bypass surgeries were performed on 23 symptomatic cerebral hemispheres in 21 patients (11 females/10 males, age 11-62 years) with Moyamoya disease due to cerebral ischemic attacks or intracranial hemorrhages. Brain PWI images were obtained in the frontal lobes, the temporal lobes, the occipital lobes, and the basal ganglia before and after STA-MCA bypass surgery. The relative parameters cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) derived from PWI were calculated. All patients underwent CT angiography or MR angiography after surgery in order to confirm the patency of bypass. Results: According to preoperative PWI, there was significant hypoperfusion in the symptomatic temporal and frontal lobes. According to postoperative PWI, the regional CBF had increased in both the temporal and frontal lobes on the operative side (p < 0.05, versus preoperative data). In the postoperative CBV maps, there was a significant decrease in the occipital lobe on the operative side (p < 0.05, versus preoperative data). The postoperative MTT in the temporal lobe, frontal lobe and basal ganglia area on the operative side was short, relative to the preoperative MTT (p < 0.05). The CT angiography or MR angiography imaging demonstrated patency of the bypass in all patients after surgery. During the follow-up period, all patients showed significant improvement in neurological function postoperatively. Conclusions: This study demonstrates that STA-MCA bypass is a safe and effective surgical treatment for Moyamoya disease. PWI enables an effective and objective assessment of hemodynamics before and after STA-MCA bypass surgery in patients with Moyamoya disease.

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“…2,5,7,23,31 Starke et al reviewed the literature concerning the surgical treatment and concluded that both direct and indirect bypass were effective. 30 Since there is a lack of randomized trials, it was noted that the selection of the surgical modalities depended on the preference and surgical technique mastered by the cerebrovascular neurosurgeon. 17 Furthermore, it is well known that patients with DM tend to develop stroke events in cerebrovascular and cardiovascular diseases.…”

Section: Surgical Treatmentmentioning

confidence: 99%

Surgical outcomes following encephaloduroarteriosynangiosis in adult moyamoya disease associated with Type 2 diabetes

Ren

Zhang

Liu

et al. 2016

JNS

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M oyaMoya disease (MMD), a cerebral vascular disease, is characterized by progressive stenosis and occlusion of the terminal portion of the bilateral internal carotid arteries, leading to the formation of an abnormal vascular network composed of collateral pathways at the base of the brain. MMD can cause a reduction in the blood supply to the brain, and there are 2 major etiological categories of symptoms: those due to brain ischemia (i.e., stroke, transient ischemic attack, and seizure) and those due to the deleterious consequences of the compensatory mechanisms in response to ischemia (i.e., hemorrhage from fragile collateral vessels and headache aBBreViatiONS CBF = cerebral blood flow; DM = diabetes mellitus; EDAS = encephaloduroarteriosynangiosis; MCA = middle cerebral artery; MMD = moyamoya disease; mRS = modified Rankin Scale; PCA = posterior cerebral artery; STA = superficial temporal artery; T2DM = Type 2 DM. SuBmitted January 29, 2015. OBJectiVe Debate exists regarding the merits and shortcomings of an indirect bypass procedure for treating adult patients with moyamoya disease (MMD). Considerable variation in neovascularization occurs among different organs in patients with diabetes mellitus. Here, the effect of encephaloduroarteriosynangiosis on MMD associated with Type 2 diabetes mellitus (T2DM) is evaluated. methOdS A retrospective and 1:2 matched case-control study was conducted in moyamoya patients with or without T2DM (n = 180). Postoperative collateral formations were graded according to the Modified Collateral Grading System that originated from the Matsushima Angiographic Stage Classification. Neurological function outcomes before and after the operation were evaluated according to the modified Rankin Scale. Univariate and multivariate logistic regression analyses were performed to determine the risk factors for clinical outcome. reSultS There was no statistically significant difference in the constituent ratios of initial symptom and preoperative Suzuki stage between patients with and without T2DM. Progression of angiopathy around the circle of Willis was postoperatively observed in bilateral internal carotid arteries in both groups. Patients with T2DM had a higher postoperative Suzuki stage (p < 0.01) and more frequent development of collateral angiogenesis germinating from the external carotid after indirect revascularization procedures in the surgical cerebral hemisphere (82.7% vs 72.2%; p < 0.05). The extent of postoperative collateral formation in patients with diabetes mellitus was significantly higher (p < 0.01). Postoperative clinical improvement in the diabetes group was more common after revascularization procedures (p < 0.05), and the diabetes group had lower modified Rankin Scale scores (p < 0.05) in comparison with the nondiabetes group. Late postoperative stroke and posterior cerebral artery involvement were identified as predictors of unfavorable clinical outcome in both groups, while T2DM was associated with a favorable clinical outcome. cONcluSiONS Encephaloduroarteriosynangio...

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Optimal surgical treatment for moyamoya disease in adults: direct versus indirect bypass

Cited by 65 publications

References 44 publications

Brain protection against ischemic stroke using choline as a new molecular bypass treatment

Brain protection against ischemic stroke using choline as a new molecular bypass treatment

Perfusion-Weighted Magnetic Resonance Imaging Used in Assessing Hemodynamics following Superficial Temporal Artery-Middle Cerebral Artery Bypass in Patients with Moyamoya Disease

Surgical outcomes following encephaloduroarteriosynangiosis in adult moyamoya disease associated with Type 2 diabetes

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