Postoperative cerebral infarction after revascularization in patients with moyamoya disease: Incidence and risk factors

Abstract

ObjectivesCerebral infarction is the major complication of revascularization surgery in patients with moyamoya disease (MMD), and we analyzed the possible causes of cerebral infarction after revascularization surgery for MMD.MethodsMMD patients who were admitted and underwent surgical revascularization at Shanghai Huashan Hospital from January 2019 to December 2021 were retrospectively analyzed.ResultsA total of 815 patients and 890 revascularization surgeries (677 first revascularization surgeries and 213 second revascularization surgeries) were included in this study; 453 (50.9%) were performed on the left side and 437 (49.1%) on the right side, with 779 (87.5%) combined procedures and 111 (12.5%) indirect bypasses included. The mean patient age at the time of these procedures was 44.6 ± 11.7 years (range 6–72 years). Postoperative cerebral infarctions were observed in 46 (5.17%) surgeries, among which 31 occurred after left hemisphere revascularization surgeries, with an incidence of 6.84%, and 15 occurred after right hemisphere revascularization surgeries, with an incidence of 3.43%. Of these, 30 (65.2%) occurred in the operated hemispheres, 2 (4.3%) in the contralateral hemisphere and 13 (28.3%) in the bilateral hemisphere. There were 11 cases of massive infarction (23.9%). The incidence of postoperative infarction in patients undergoing the first revascularization was 6% (41/677) and 2.3% (5/213) in the second revascularization surgeries. Initial presentation as infarction (P < 0.001), initial presentation as hemorrhage (P < 0.001), hypertension (P = 0.018), diabetes (P = 0.006), 1st or 2nd surgery and surgical side (P = 0.007) were found to be related to postoperative cerebral infarction. Initial presentation as infarction (OR = 2.934, 95% CI 1.453–5.928, P = 0.003), initial presentation as hemorrhage (OR = 0.149, 95% CI 0.035–0.641, P = 0.011), and 1st or 2nd surgery and surgical side (OR = 1.66, 95% CI 1.106–2.491, P = 0.014) were independently associated with cerebral infarction after revascularization surgeries.ConclusionsIn patients with MMD undergoing surgical revascularization, initial presentation as infarction and first revascularization surgery performed on the left hemisphere are independent risk factors for postoperative cerebral infarction, whereas initial presentation as hemorrhage is a protective factor.

Clinical Features and Risk Factors of Postoperative Stroke in Adult Moyamoya Disease

“…Overall, the findings from this comparative study provide valuable insights into potential predictors for postoperative stroke in patients with MMD. While risk factors for postoperative stroke have been explored in multiple retrospective studies [12,13,18,19], the precise underlying cause of postoperative hemorrhage and ischemia remains elusive. In the current study, MMD patients with preoperative hemorrhage were found to be more likely to have PHS than patients from the control group.…”

“…However, the incidences of postoperative ischemic/hemorrhagic stroke still reached 5.4-5.5% [12]. To date, general risk factors for stroke in adults with MMD who have had surgical revascularization have not been sufficiently investigated [13,14].…”

Natural course of hemodynamically stable hemispheres contralateral to operated hemispheres in adult patients with ischemic moyamoya diseases

“…Although only one hemisphere presents with severe symptoms indicating bypass surgery, both hemispheres undergo bypass surgery due to the bilateral nature of moyamoya vasculopathy, regardless of the asymptomatic and stable presentation in the other hemisphere. Bypass surgery is considered only for symptomatic and hemodynamically unstable hemispheres in some institutions, including our institution 5 , 7 , 10 ; however, bilateral bypass surgery is adopted in other institutions 11 , 12 . There is no detailed recommendation on the necessity of bilateral bypass surgery in ischemic MMD, even in some guidelines 9 , 13 – 15 .…”

Clinical effect of a modified superficial temporal artery-middle cerebral artery bypass surgery in Moyamoya disease treatment

“…However, due to the mismatch in thickness and blood flow between intracranial recipient vessels (middle cerebral artery M3 and M4) and extracranial donor vessels (superficial temporal artery frontal or parietal branches), the success rate of direct vascular anastomosis and surgical outcome are often affected ( 4 ). Especially when the superficial temporal artery branch is significantly thicker or the blood flow is too large, the direct single-vessel end-side anastomosis may lead to over-perfusion of blood flow in the recipient vessel, which may cause brain tissue edema and neurological damage, or even hemorrhage and infarction, endangering the patient’s life and safety ( 5 , 6 ). To address this situation, clinicians often use a variety of means to reduce donor blood flow and flow rate by narrowing the lumen of the donor vessel or increasing the degree of vessel turning ( 7 ).…”