Challenging direct bypass surgery for very young children with moyamoya disease: technical notes

OBJECTIVEThe purpose of this study was to evaluate treatment outcomes of future stroke prevention, perioperative complications, and angiographic revascularization in adults with symptomatic moyamoya disease (MMD) according to treatment modalities and surgical techniques.METHODSA systemic literature review was performed based on searches of the PubMed, Embase, and Cochrane Central databases. A fixed-effects model was used in cases of heterogeneity less than 50%. Publication bias was determined by Begg’s funnel plot, Egger’s test of the intercept, and the Begg and Mazumdar rank correlation test.RESULTSEleven articles were included in the meta-analysis. Bypass surgery significantly decreased the future stroke events compared with conservative treatments in adult MMD (odds ratio [OR] 0.301, p < 0.001). Direct bypass showed better future stroke prevention than indirect bypass (OR 0.494, p = 0.028). There was no meaningful difference in perioperative complications between direct and indirect bypass (OR 0.665, p = 0.176). Direct bypass was associated with better angiographic outcomes than indirect bypass (OR 6.832, p < 0.001).CONCLUSIONSBypass surgery can be effective in preventing future stoke events in adults with MMD. Direct bypass seems to provide better risk reduction with respect to stroke than indirect bypass in these patients.

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Hemodynamic study about cortical hyperintensity belt sign after direct bypass surgery for moyamoya disease

Journal of Clinical Neuroscience ◽

10.1016/j.jocn.2020.02.022 ◽

2020 ◽

Vol 74 ◽

pp. 124-129 ◽

Cited By ~ 2

Author(s):

Yushin Takemoto ◽

Takayuki Kawano ◽

Yuki Ohmori ◽

Yasuyuki Kaku ◽

Ken Uekawa ◽

...

Keyword(s):

Moyamoya Disease ◽

Bypass Surgery ◽

Direct Bypass ◽

Hemodynamic Study

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Direct Bypass Surgery Vs. Combined Bypass Surgery for Hemorrhagic Moyamoya Disease: A Comparison of Angiographic Outcomes

Frontiers in Neurology ◽

10.3389/fneur.2018.01121 ◽

2018 ◽

Vol 9 ◽

Cited By ~ 7

Author(s):

Yahui Zhao ◽

Shaochen Yu ◽

Junlin Lu ◽

Lebao Yu ◽

Jiaxi Li ◽

...

Keyword(s):

Moyamoya Disease ◽

Bypass Surgery ◽

Direct Bypass

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Analysis of Factors Related to Cerebral Infarction after Direct Bypass Surgery in Adults with Moyamoya Disease

Cerebrovascular Diseases ◽

10.1159/000504743 ◽

2020 ◽

Vol 49 (1) ◽

pp. 55-61

Author(s):

Yun Qian ◽

Bin Huang ◽

Zongmin Hu ◽

Jian Wang ◽

Peng Zhao ◽

...

Keyword(s):

Risk Factors ◽

Cerebral Infarction ◽

Clinical Data ◽

Moyamoya Disease ◽

Bypass Surgery ◽

Clinical Manifestations ◽

History Of ◽

Direct Bypass ◽

Nonoperative Side

Objective: High-risk factors of the patients with moyamoya disease (MMD) were analyzed to provide the basis for prediction and management of cerebral infarction after direct bypass surgery in adult MMD. Methods: 1. Retrospective analysis of clinical data was collected from adult MMD patients (n = 250) following superficial temporal artery-middle cerebral artery bypass surgery performed in our hospital from July 2013 to December 2017. Of the 250 patients, all underwent hemispherical bypass surgery, and bilateral surgery was performed on 14 patients. 2. Clinical data were analyzed based on sex, age, hypertension, diabetes, smoking history, history of alcohol use, presurgery cerebral infarction, transient ischemic attack, classification of clinical manifestations, clinical typing, Suzuki stage of surgical side, Suzuki stage of nonoperative side, preoperative Modified Rankin Scale (MRS), and lesions of the postoperative cycle or not. Results: 1. There were significant differences in classification of clinical manifestations, preoperative infarction, clinical typing, and Suzuki stage of nonoperative side (p < 0.05). 2. Logistic regression analysis showed that the independent factors affecting postoperative cerebral infarction were preoperative infarction and the Suzuki stage of nonoperative side (p < 0.05). The preoperative infarction (B 1.431, OR 4.184, 95% CI 1.217–14.382) and the Suzuki stage of nonoperative side (B 0.495, OR 1.640, 95% CI 1.207–2.227) were both risk factors. Conclusion: The possibility of a new cerebral infarction in postoperative patients with a history of cerebral infarction was greater. The Suzuki stages (I–VI) of the nonoperative side was higher and associated with an increased probability of cerebral infarction after surgery.

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Moyamoya Disease in an 8-Year-Old Boy: Direct Bypass Surgery in a Province of Peru

World Neurosurgery ◽

10.1016/j.wneu.2017.08.112 ◽

2017 ◽

Vol 108 ◽

pp. 50-53 ◽

Cited By ~ 1

Author(s):

Joham Choque-Velasquez ◽

Roberto Colasanti ◽

Danil A. Kozyrev ◽

Juha Hernesniemi ◽

Akitsugu Kawashima

Keyword(s):

Moyamoya Disease ◽

Bypass Surgery ◽

Direct Bypass

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Disruption of Cortical Arterial Network is Associated with the Severity of Transient Neurologic Events After Direct Bypass Surgery in Adult Moyamoya Disease

World Neurosurgery ◽

10.1016/j.wneu.2017.01.039 ◽

2017 ◽

Vol 100 ◽

pp. 311-315 ◽

Cited By ~ 6

Author(s):

Yusuke Egashira ◽

Keita Yamauchi ◽

Yukiko Enomoto ◽

Noriyuki Nakayama ◽

Shinichi Yoshimura ◽

...

Keyword(s):

Moyamoya Disease ◽

Bypass Surgery ◽

Arterial Network ◽

Direct Bypass ◽

Adult Moyamoya Disease

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Clinical implications of the cortical hyperintensity belt sign in fluid-attenuated inversion recovery images after bypass surgery for moyamoya disease

Journal of Neurosurgery ◽

10.3171/2015.10.jns151022 ◽

2017 ◽

Vol 126 (1) ◽

pp. 1-7 ◽

Cited By ~ 24

Author(s):

Eika Hamano ◽

Hiroharu Kataoka ◽

Naomi Morita ◽

Daisuke Maruyama ◽

Tetsu Satow ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Moyamoya Disease ◽

Cerebral Artery ◽

Bypass Surgery ◽

Vasogenic Edema ◽

Posterior Part ◽

The Other ◽

Neurological Deficits ◽

Other Hand ◽

Direct Bypass

OBJECTIVE Transient neurological symptoms are frequently observed during the early postoperative period after direct bypass surgery for moyamoya disease. Abnormal signal changes in the cerebral cortex can be seen in postoperative MR images. The purpose of this study was to reveal the radiological features of the “cortical hyperintensity belt (CHB) sign” in postoperative FLAIR images and to verify its relationship to transient neurological events (TNEs) and regional cerebral blood flow (rCBF). METHODS A total of 141 hemispheres in 107 consecutive patients with moyamoya disease who had undergone direct bypass surgery were analyzed. In all cases, FLAIR images were obtained during postoperative days (PODs) 1–3 and during the chronic period (3.2 ± 1.13 months after surgery). The CHB sign was defined as an intraparenchymal high-intensity signal within the cortex of the surgically treated hemisphere with no infarction or hemorrhage present. The territory of the middle cerebral artery was divided into anterior and posterior parts, with the extent of the CHB sign in each part scored as 0 for none; 1 for presence in less than half of the part; and 2 for presence in more than half of the part. The sum of these scores provided the CHB score (0–4). TNEs were defined as reversible neurological deficits detected both objectively and subjectively. The rCBF was measured with SPECT using N-isopropyl-p-[123I]iodoamphetamine before surgery and during PODs 1–3. The rCBF increase ratio was calculated by comparing the pre- and postoperative count activity. RESULTS Cortical hyperintensity belt signs were detected in 112 cases (79.4%) and all disappeared during the chronic period. Although all bypass grafts were anastomosed to the anterior part of the middle cerebral artery territory, CHB signs were much more pronounced in the posterior part (p < 0.0001). TNEs were observed in 86 cases (61.0%). Patients with TNEs showed significantly higher CHB scores than those without (2.31 ± 0.13 vs 1.24 ± 0.16, p < 0.0001). The CHB score, on the other hand, showed no relationship with the rCBF increase ratio (p = 0.775). In addition, the rCBF increase ratio did not differ between those patients with TNEs and those without (1.15 ± 0.033 vs 1.16 ± 0.037, p = 0.978). CONCLUSIONS The findings strongly suggest that the presence of the CHB sign during PODs 1–3 can be a predictor of TNEs after bypass surgery for moyamoya disease. On the other hand, presence of this sign appears to have no direct relationship with the postoperative local hyperperfusion phenomenon. Vasogenic edema can be hypothesized as the pathophysiology of the CHB sign, because the sign was transient and never accompanied by infarction in the present series.

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Intraoperative evaluation of local cerebral hemodynamic change by indocyanine green videoangiography: prediction of incidence and duration of postoperative transient neurological events in patients with moyamoya disease

Journal of Neurosurgery ◽

10.3171/2017.10.jns171523 ◽

2019 ◽

Vol 130 (4) ◽

pp. 1367-1375 ◽

Cited By ~ 5

Author(s):

Kenji Uda ◽

Yoshio Araki ◽

Shinsuke Muraoka ◽

Shinji Ota ◽

Kentaro Wada ◽

...

Keyword(s):

Indocyanine Green ◽

Moyamoya Disease ◽

Bypass Surgery ◽

Mean Transit Time ◽

Superficial Temporal Artery ◽

Regions Of Interest ◽

Youden Index ◽

Anastomotic Site ◽

Intraoperative Evaluation ◽

Direct Bypass

OBJECTIVETransient neurological events (TNEs) occur frequently in the acute phase after direct bypass surgery for moyamoya disease (MMD), but there is currently no way to predict them. FlowInsight is a specialized software for analyzing indocyanine green (ICG) videoangiography taken with a surgical microscope. The purpose of this study was to investigate whether intraoperative evaluation of local hemodynamic changes around anastomotic sites using FlowInsight could predict the incidence and duration of TNEs.METHODSFrom patients who were diagnosed with MMD in our hospital between August 2014 and March 2017 and who underwent superficial temporal artery–middle cerebral artery bypass surgery, we investigated 25 hemispheres (in 22 patients) in which intraoperative ICG analysis was performed using FlowInsight. To evaluate the local cerebral hemodynamics before and after anastomosis, regions of interest were set at 3 locations on the brain surface around the anastomotic site, and the mean cerebral blood flow (CBF), mean gradation (Grad), mean transit time (MTT), and mean time to peak (TTP) were calculated from the 3 regions of interest. Furthermore, the change rate in CBF (ΔCBF [%]) was calculated using the formula (postanastomosis mean CBF − preanastomosis mean CBF)/preanastomosis mean CBF. ΔGrad (%), ΔMTT (%), and ΔTTP (%) were similarly calculated.RESULTSPostoperative stroke without TNE occurred in 2 of the 25 hemispheres. These 2 hemispheres (in 2 patients) were excluded from the study, and data from the remaining 23 hemispheres (in 20 patients) were analyzed. For each parameter (ΔCBF, ΔGrad, ΔMTT, and ΔTTP) calculated by FlowInsight, the difference between the groups with and without TNEs was significant. The median values for ΔCBF and ΔGrad were significantly higher in the TNE group than in the no-TNE group (ΔCBF 30.13 vs 3.54, p = 0.0106; ΔGrad 62.05 vs 10.78, p = 0.00435), whereas the median values for ΔMTT and ΔTTP were significantly lower in the TNE group (ΔMTT −16.90 vs −7.393, p = 0.023; ΔTTP −29.07 vs −7.02, p = 0.00342). Comparison of the area under the curve (AUC) for each parameter showed that ΔTTP had the highest AUC and was the parameter with the highest diagnostic accuracy (AUC 0.857). The Youden index revealed that the optimal cutoff value of ΔTTP was −11.61 (sensitivity 77.8%, specificity 71.4%) as a predictor of TNEs. In addition, Spearman’s rank correlation coefficients were calculated, and ΔCBF, ΔGrad, ΔMTT, and ΔTTP each showed a strong correlation with the duration of TNEs. The larger the change in each parameter, the longer the TNEs persisted.CONCLUSIONSIntraoperative ICG videoangiography findings were correlated with the occurrence and duration of TNEs after direct bypass surgery for MMD. Screening for cases at high risk of TNEs can be achieved by ICG analysis using FlowInsight.

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