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

Abstract

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...

Increased prevalence of autoimmune disease in patients with unilateral compared with bilateral moyamoya disease

“…These findings suggest that unilateral MMD patients tend to be more symptomatic, which is consistent with previous reports. 6,10,12 The higher prevalence of concurrent disease in the unilateral MMD patients than in the bilateral MMD patients may suggest symptomatic differences between these 2 subgroups.…”

Perioperative Complications and Long-Term Outcomes After Bypasses in Adults with Moyamoya Disease: A Systematic Review and Meta-Analysis

“…Rates by procedure type were 3.2% (n=11) of 341 patients undergoing direct bypass (13 studies 6,7,15,16,[18][19][20][21][22][23][24][25][26] [35][36][37][38][39][40]43 ).…”

The Efficacy of Single Barrel Superficial Temporal Artery-middle Cerebral Artery Bypass in Treatment of Adult Patients with Ischemic-type Moyamoya Disease

“…Indirect revascularization surgeries, such as encephaloduroarteriosynangiosis and other variants, are generally accepted as standard for pediatric MMD 12)13)19). However, there is no study answering the question of which type of surgical technique is practically the most useful in the treatment of adult patients with ischemic type MMD, 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 1)3)4)11)14)15)21)24). In this study, we evaluated the efficacy of single barrel superficial temporal artery (STA)-middle cerebral artery (MCA) bypass for adult patients with ischemic type MMD by reviewing clinical and radiological data.…”