Transient Neurological Events After Surgery for Pediatric Moyamoya Disease: A Retrospective Study of Postoperative Sedation Practices

Abstract

Background: Moyamoya disease is a cerebrovascular disease characterized by bilateral stenosis of the intracranial internal carotid arteries and an abnormal collateral vascular network at the base of the brain. Transient neurological events (TNEs), which are episodes of neurological dysfunction lasting <24 hours, are associated with stroke in pediatric patients with Moyamoya disease. Perioperative agitation often occurs in pediatric patients. We hypothesized that anesthetic technique and postoperative sedation would modify the association between TNE and superficial temporal artery-middle cerebral artery (STA-MCA) bypass in pediatric patients with Moyamoya disease. Methods: We retrospectively reviewed the medical records of patients with Moyamoya disease aged 15 years and below who underwent STA-MCA bypass under general anesthesia at a single cerebrovascular center in Japan between January 1999 and March 2016. The primary outcome was TNE. Mixed-effects logistic regression was used to evaluate whether postoperative sedation and anesthetic agents were associated with TNE. Results: Among 277 hemispheres in 154 pediatric patients who underwent STA-MCA bypass, 107 patients (39%) experienced TNE within 1 week after surgery. Crying (adjusted odds ratio, 3.11; 95% confidence interval, 1.01-9.59; P=0.048) was an independent risk factor for TNE. Postoperative sedation was associated with a lower incidence of TNE (adjusted odds ratio, 0.514; 95% confidence interval, 0.264-0.997; P=0.049), but premedication and anesthetic agents were not associated with TNE. Conclusion: In pediatric patients with Moyamoya disease, crying was associated with increased TNE and postoperative sedation is associated with decreased TNE.

Hemoglobin Concentration May Influence the Incidence of Postoperative Transient Neurological Events in Patients With Moyamoya After Extracranial-intracranial Arterial Bypass: A Retrospective Single Center Experience

“…The primary outcome was the occurrence of TNEs within the first 24 hours postoperatively. TNEs were defined as episodes of neurological dysfunction lasting <24 hours as previously described 11,12. The evaluation period for TNEs was limited to the first 24 hours postoperatively as all patients spent at least one 24-hour period in the ICU under the same rigorous ICU-specific nursing protocols with hourly neurological exams and Doppler graft evaluations each shift.…”

Progression in Moyamoya Disease: Clinical Features, Neuroimaging Evaluation, and Treatment

“…A previous study has confirmed that EEG is useful for evaluating transient neurological events in MMD to distinguish seizures and epileptiform changes [ 150 ]. Additionally, postoperative transient neurological dysfunction resulting from transient cortical depression often occurs in MMD [ 151 ]. This can be detected by EEG, as low amplitude arrhythmic slowing in the corresponding hemisphere [ 152 ].…”

Perioperative Management of Pediatric Patients with Moyamoya Arteriopathy

“…Pain control and sedation are optimized. 18,29,35 At our institution, we titrate analgesia based on the Face, Legs, Activity, Cry, Consolability Behavioral Pain Scale for nonverbal patients or the Wong-Baker FACES Pain Rating Scale for all others. For patients requiring sedation, a State Behavioral Scale goal is set daily, and sedatives are titrated to that goal.…”

“…13 Most published perioperative management protocols focus on the intraoperative course. [13][14][15][16][17][18][19][20][21][22] Patients are commonly admitted to the pediatric intensive care unit (PICU) after anesthesia, but little has been published to guide postoperative intensive care management, such as specifics of blood pressure management, hemodynamic and neurologic monitoring, laboratory parameters, and criteria for deescalation. Our pediatric neurocritical care team sought to create a multidisciplinary periprocedural evidence-and consensus-based care pathway for high-risk pediatric patients with moyamoya arteriopathy undergoing anesthesia for any reason to decrease the incidence of periprocedural stroke or transient ischemic attack (TIA).…”