Abstract P568: Incidence and Progression of Posterior Circulation Involvement in Moyamoya Disease

Introduction: The incidence and natural history of posterior circulation moyamoya disease (PCMMD) is not well-characterized. Methods: Consecutive patients with moyamoya disease prospectively treated at our institution from 2015-2018 were reviewed. Results: 262 consecutive patients with moyamoya disease undergoing 370 revascularization procedures were enrolled. Concurrent PCMMD was identified in 68 (26%) patients – all of which were confined to the anterior circulation. There were no differences in age, sex, race, or rates of diabetes, hypertension, smoking, or symptoms upon presentation between patients with or without PCMMD. Patients with PCMMD were more likely to present with bilateral disease (p<0.001), higher Suzuki grade (p=0.001), more extensive collateral angiopathy (p<0.001), and pial-pial collaterals from the PCA territory (p=0.03). Patients with PCMMD were more likely to suffer from ischemic peri-operative complications in both the anterior (p=0.03) and posterior (p<0.001) circulation territories after anterior circulation revascularization. No differences were observed for hemorrhagic complications (p=1.0). Over a mean follow-up of 1.91±1.5 years, 19 (7.3%) developed new or progressive PCMMD. Patients with PCMMD progression had an Asian predilection and were less likely to present with sentinel symptoms such as headaches (p=0.05 and 0.01 respectively). Patients with bilateral disease (p=0.02), higher Suzuki (p<0.001) and collateral angiopathy grades (p=0.002), and more extensive external carotid artery supply (p=0.03) were also more likely to experience PCMMD progression. There was no association between PCMMD progression and delayed neurological events or functional outcomes, but patients with concurrent PCMMD upon presentation were associated with poor functional outcome (mRS >2) at last follow-up (p=0.02). Conclusions: Posterior circulation disease involvement often presents in the later stages of moyamoya and is associated with higher rates of ischemic peri-operative complications and poor functional outcomes likely due to reduced collateral flow. Progression of PCMMD is not uncommon. Future studies are needed to assess the impact of PCMMD progression on long-term outcomes.

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Treatment of aneurysms in patients with moyamoya disease: a 10-year single-center experience

Journal of Neurosurgery ◽

10.3171/2017.3.jns162290 ◽

2018 ◽

Vol 128 (6) ◽

pp. 1813-1822 ◽

Cited By ~ 6

Author(s):

Wei Ni ◽

Hanqiang Jiang ◽

Bin Xu ◽

Yu Lei ◽

Heng Yang ◽

...

Keyword(s):

Moyamoya Disease ◽

Posterior Circulation ◽

Cerebral Revascularization ◽

Endovascular Coiling ◽

Single Center ◽

Anterior Circulation ◽

Main Trunk ◽

Aneurysm Embolization ◽

Peripheral Aneurysms

OBJECTIVEMoyamoya disease (MMD) is occasionally accompanied by intracranial aneurysms. The purpose of this study was to delineate the efficacy of the authors’ current surgical strategy in the management of MMD-associated aneurysms of different types.METHODSBetween January 2007 and March 2016, a consecutive cohort of 34 patients with 36 MMD-associated aneurysms was enrolled in this prospective single-center cohort study. The lesions were classified as peripheral (17 aneurysms) or main trunk aneurysms (13 in the anterior circulation and 6 in the posterior circulation). For the peripheral aneurysms, revascularization with or without endovascular treatment was suggested. For the main trunk aneurysms, revascularization alone, revascularization with aneurysm clipping, or revascularization with aneurysm embolization were used, depending on the location of the aneurysms.RESULTSOf the peripheral aneurysms, 4 were treated endovascularly with staged revascularization, and 13 were treated solely with cerebral revascularization. Of the 13 main trunk aneurysms in the anterior circulation, 10 were clipped followed by revascularization, and 3 were coiled followed by staged cerebral revascularization. Of the 6 main trunk aneurysms in the posterior circulation, 4 underwent endovascular coiling and 2 were treated solely with revascularization. One patient died of contralateral intracerebral hemorrhage 6 months after the operation. No other patients suffered recurrent intracranial hemorrhage, cerebral ischemia, or aneurysm rupture. An angiographic follow-up study showed that all the bypass grafts were patent. Complete occlusion was achieved in all 21 aneurysms that were clipped or embolized. Of the remaining 15 aneurysms that were not directly treated, 12 of 13 peripheral aneurysms were obliterated during the follow-up, whereas 1 remained stable; 1 of 2 posterior main trunk aneurysms remained stable, and the other became smaller.CONCLUSIONSThe authors’ current treatment strategy may benefit patients with MMD-associated aneurysms.

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Abstract MP9: Incidence and Outcomes of Posterior Circulation Involvement in Moyamoya Disease

Stroke ◽

10.1161/str.52.suppl_1.mp9 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Seth S Tigchelaar ◽

Allan Wang ◽

Yiping Li ◽

Gary Steinberg

Keyword(s):

Moyamoya Disease ◽

Cerebral Arteries ◽

Subsequent Development ◽

Collateral Flow ◽

Bilateral Disease ◽

Operative Outcomes ◽

Ischemic Complications ◽

History Of ◽

The Impact

Moyamoya disease (MMD) is a progressive, occlusive disease of the internal carotid arteries and their proximal branches, with the subsequent development of an abnormal vascular network of small, weak blood vessels that are prone to rupture. Steno-occlusive changes in the posterior cerebral arteries (PCA) may contribute to worse outcomes in MMD patients, however, there is a paucity of information on the incidence and natural history of MMD patients with PCA disease. We retrospectively reviewed the charts of patients with MMD treated between 1987 and 2019. Demographics, peri-operative outcomes, and radiological phenotypes were recorded for 450 patients. PCA disease was scored as either 0 (no disease), 1 (mild), 2 (moderate), or 3 (severe, or occluded). Out of 450 patients, 164 (34.4%) had concurrent PCA disease. In patients with PCA disease, the extent of occlussion was mild in 56 (34%), moderate in 41 (25%), and severe in 67 (40.9%) patients. In total, there were 319 females (70.9%), with a higher proportion of female MMD patients having severe or moderate PCA disease (p=0.038). Patients with severe and moderate PCA disease had higher Suzuki grades (p<0.0001), more extensive collateral angiopathy (p<0.0001), more frequent cerebrovascular accidents on presentation (p=0.012), higher hemodynamic scores (p=0.022), and a greater frequency of post-operative ischemic complications (p=0.019). Peak modified Rankin Scale (mRS) scores were higher in patients with any severity of PCA disease (p=0.0006). Over a mean follow-up of 6.94±4.16 years, 28 patients (8.86%) developed new or progressive PCA disease. Bilateral disease was present in 66 patients (14.7%) and was associated with higher Suzuki grades (p<0.0001), more extensive collateral angiopathy (p<0.0001), and greater post-operative ischemic complications (p=0.011). Peak mRS scores were higher in patients with bilateral disease compared to patients with no PCA disease (p<0.0001). PCA disease involvement is associated with higher rates of ischemic peri-operative complications and poor functional outcomes likely due to reduced collateral flow. Progression of PCA disease is not uncommon. Future studies are needed to assess the impact of PCA disease progression on long-term outcomes.

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Automated Evaluation of Intracranial Vessel Morphology in Normal Versus Pediatric Moyamoya Disease

Neurosurgery ◽

10.1093/neuros/nyz310_655 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Jennifer L Quon ◽

Lily H Kim ◽

Pauline Mouches ◽

Rashad Jabarkheel ◽

Yi Zhang ◽

...

Keyword(s):

Moyamoya Disease ◽

Cerebral Artery ◽

Clinical Symptoms ◽

Pediatric Population ◽

Posterior Circulation ◽

Anterior Circulation ◽

Vessel Morphology ◽

Age Related ◽

The Impact ◽

Normal Artery

Abstract INTRODUCTION Evaluation of intracranial artery morphology plays an important role in diagnosing a variety of neurovascular diseases. In addition to clinical symptoms, diagnosis currently relies on qualitative rather than quantitative evaluation of vascular imaging sequences such as magnetic resonance angiography (MRA). However, previously described statistical cerebroarterial atlases have focused primarily on healthy adults and little information exists about what constitutes normal artery morphology in the pediatric population and across brain development. We aimed to quantitatively assess normal, age-related changes in artery morphology and compare normal morphology to that of children with Moyamoya disease (MMD). METHODS MRAs from 98 children (49 M/49F) aged .6 to 20 yr (median = 11.5 yr) with normal MRAs and and 18 children with radiographically confirmed MMD (10 M/8 F, median age = 7.1 yr) were retrospectively collected. All arteries were automatically segmented in both MRA datasets. Using an atlas-based approach, the radiuses of the main arteries of the anterior circulation (internal carotid artery (ICA), anterior cerebral artery (ACA), and middle cerebral artery (MCA)) and posterior circulation (PCA, BA) were measured at corresponding locations. Artery radii were compared between the 2 groups using MANCOVA with age and sex as covariates. RESULTS The artery radius was relatively consistent across age for all main arteries in normal patients. MANCOVA revealed that children with MMD exhibit significantly smaller ICA, MCA-M1, MCA-M2, and ACA radii (P < .001) compared to normal controls (mean vessel radii: ICA 1.27 vs 1.64 mm, MCA M1 0.92 vs 1.14 mm, MCA M2 0.66 vs 0.82 mm, ACA 0.72 vs 0.83 mm). There were no significant differences in the posterior circulation radii. CONCLUSION We present normal artery morphology data for children based on automatic segmentation of MRAs, and demonstrate that artery caliber is smaller in children with MMD. This resource will allow neurosurgeons to quantitatively assess MMD and the impact of bypass surgery on disease progression.

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Risk of Dependency Following Microsurgical Clipping in Good Grade Patients With Ruptured Anterior Circulation Aneurysms

Iranian Journal of Neurosurgery ◽

10.32598/irjns.7.1.6 ◽

2021 ◽

Vol 7 (1) ◽

pp. 49-56

Author(s):

Sundus Ali ◽

◽

Fauzia Sajjad ◽

Asif Shabbir ◽

Akmal Azeemi ◽

...

Keyword(s):

Surgical Techniques ◽

Neurological Deficits ◽

Anterior Circulation ◽

Microsurgical Clipping ◽

Operative Complications ◽

Good Grade ◽

Intraoperative Rupture ◽

The Impact ◽

Anterior Circulation Aneurysms

Background and Aim: Most good grade (WFNS I and II) patients who undergo microsurgical clipping achieve a favorable outcome. However, some independent patients before surgery face unfavorable outcomes after the operation, signifying the impact of microsurgical clipping. This study aimed to identify the risk of developing dependency in patients without previous neurological deficits. Methods and Materials/Patients: We reviewed 50 consecutive good grade patients with ruptured anterior circulation aneurysms who underwent microsurgical clipping between May 2017 and May 2020 in the Department of Neurosurgery, Punjab Institute of Neurosciences, Lahore, Pakistan. The clinical outcome at discharge and three months follow-up was assessed using the Glasgow Outcome Scale (GOS). Results: In this study, seven patients (14%) became dependent (GOS II and III) following clipping. Of whom, five patients (10%) suffered surgical insult in the form of intraoperative rupture (4%), post-op infarct (4%), and direct brain damage (2%). Conclusion: Patients without neurologic deficit pre-operatively still suffer unfavorable outcomes mainly due to operative complications. Vascular injuries remain the main cause of morbidity-producing dependency. Therefore, all surgical techniques must minimize the risk to vessels, both during dissection and at clip placement.

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149 Emergency Clot Retrieval and Stenting for Posterior Circulation Stroke

British Journal of Surgery ◽

10.1093/bjs/znab134.234 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

K Daga ◽

M T Ahmad ◽

M Taneja

Keyword(s):

Treatment Option ◽

Current Literature ◽

Basilar Artery ◽

Cerebral Angiography ◽

Posterior Circulation ◽

Anterior Circulation ◽

Acute Setting ◽

Post Procedure ◽

Basilar Artery Stenosis

Abstract The current literature regarding the morphology and presentations of strokes due to basilar artery stenosis/occlusion is limited. This pathology is a rare cause of stroke and its management is not clearly decided in guidelines or published literature. Moreover, posterior circulation strokes are reported to be more devastating than anterior circulation. We present a case of a 68-year-old male who presented in an acute setting with reduced consciousness, myoclonic jerks, weakness and nausea due to a stroke from an occluded mid-segment basilar artery. MRI showed evidence of left cerebellar and right occipital infarcts. Emergent cerebral angiography was performed, and he was immediately treated by thrombectomy and stenting (Stryker Wingspan stent). The patient made a full recovery within one week and remained well at follow-up 3 months post-procedure. Emergency recanalization of basilar artery strokes, by clot retrieval and stenting, should be considered as a treatment option.

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Normative distribution of posterior circulation tissue time-to-maximum: Effects of anatomic variation, tracer kinetics, and implications for patient selection in posterior circulation ischemic stroke

Journal of Cerebral Blood Flow & Metabolism ◽

10.1177/0271678x20982395 ◽

2021 ◽

pp. 0271678X2098239

Author(s):

Adam E Goldman-Yassen ◽

Matus Straka ◽

Michael Uhouse ◽

Seena Dehkharghani

Keyword(s):

Ischemic Stroke ◽

Selection Criteria ◽

Arterial Input Function ◽

Anatomic Variation ◽

Input Function ◽

Posterior Circulation ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Perfusion Time

The generalization of perfusion-based, anterior circulation large vessel occlusion selection criteria to posterior circulation stroke is not straightforward due to physiologic delay, which we posit produces physiologic prolongation of the posterior circulation perfusion time-to-maximum (Tmax). To assess normative Tmax distributions, patients undergoing CTA/CTP for suspected ischemic stroke between 1/2018-3/2019 were retrospectively identified. Subjects with any cerebrovascular stenoses, or with follow-up MRI or final clinical diagnosis of stroke were excluded. Posterior circulation anatomic variations were identified. CTP were processed in RAPID and segmented in a custom pipeline permitting manually-enforced arterial input function (AIF) and perfusion estimations constrained to pre-specified vascular territories. Seventy-one subjects (mean 64 ± 19 years) met inclusion. Median Tmax was significantly greater in the cerebellar hemispheres (right: 3.0 s, left: 2.9 s) and PCA territories (right: 2.9 s; left: 3.3 s) than in the anterior circulation (right: 2.4 s; left: 2.3 s, p < 0.001). Fetal PCA disposition eliminated ipsilateral PCA Tmax delays (p = 0.012). Median territorial Tmax was significantly lower with basilar versus any anterior circulation AIF for all vascular territories (p < 0.001). Significant baseline delays in posterior circulation Tmax are observed even without steno-occlusive disease and vary with anatomic variation and AIF selection. The potential for overestimation of at-risk volumes in the posterior circulation merits caution in future trials.

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The Impact of Smoking on Clinical Results Following the Rotator Cuff and Biceps Tendon Complex Arthroscopic Surgery

Journal of Clinical Medicine ◽

10.3390/jcm10040599 ◽

2021 ◽

Vol 10 (4) ◽

pp. 599

Author(s):

Jan Zabrzyński ◽

Gazi Huri ◽

Maciej Gagat ◽

Łukasz Łapaj ◽

Alper Yataganbaba ◽

...

Keyword(s):

Rotator Cuff ◽

Functional Outcomes ◽

Shoulder Arthroscopy ◽

Smoking Status ◽

Biceps Tendon ◽

Arthroscopic Surgery ◽

Rotator Cuff Tears ◽

Shoulder Injuries ◽

The Impact

The purpose of this study was to investigate the association of smoking and functional outcomes after arthroscopic treatment of complex shoulder injuries: rotator cuff tears (RCTs) with biceps tendon (LHBT) tears. This retrospective case-control study has been conducted on a cohort of patients who underwent shoulder arthroscopy between 2015 and 2017 due to complex injury treatment. The outcomes were assessed using the American Shoulder and Elbow Surgeons Score (ASES), the University of California at Los Angeles (UCLA) Shoulder Score, need for non-steroid anti-inflammatory drugs (NSAIDs) consumption and the visual analog scale (VAS). Complications and changes in smoking status were also noted. A cohort of 59 patients underwent shoulder arthroscopy, due to complex LHBT pathology and RCTs, and were enrolled in the final follow-up examination; with mean duration of 26.03 months. According to smoking status, 27 of patients were classified as smokers, and the remaining 32 were non-smokers. In the examined cohort, 36 patients underwent the LHBT tenotomy and 23 tenodesis. We observed a relationship between smoking status and distribution of various RCTs (p < 0.0001). The mean postoperative ASES and UCLA scores were 80.81 and 30.18 in the smoker’s group and 84.06 and 30.93 in the non-smoker’s group, respectively. There were no statistically significant differences in pre/postoperative ASES and postoperative UCLA scores between smokers and non-smokers (p > 0.05). The VAS was significantly lower in the non-smokers’ group (p = 0.0021). Multi-tendon injuries of the shoulder are a serious challenge for surgeons, and to obtain an excellent functional outcome, we need to limit the negative risk factors, including smoking. Furthermore, there is a significant association between smoking and the occurrence of massive rotator cuff tears, and the pain level measured by the VAS. Simultaneous surgical treatment of RC and LHBT lesions in the smoker population allowed us to obtain the functional outcomes approximated to non-smokers in the long-term follow-up. Of course, we cannot assert that smoking is the real cause of all complications, however, we may assume that this is a very important, negative factor in shoulder arthroscopy.

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Abstract 120: Surpass Flow Diverter for Endovascular Treatment of Intracranial Aneurysms - A Multicenter Preliminary Clinical and Angiographic Experience in 161 Patients with 186 Aneurysms

Stroke ◽

10.1161/str.45.suppl_1.120 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Ajay K Wakhloo ◽

Pedro Lylyk ◽

Joost de Vries ◽

Matthew J Gounis ◽

Alexandra Biondi ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Experimental Studies ◽

Flow Diverter ◽

Posterior Circulation ◽

Parent Artery ◽

Anterior Circulation ◽

Neck Size ◽

Wide Range ◽

New Generation

Objective: Validated through experimental studies a new generation of flow diverters (Surpass™ FD) was evaluated for treatment of intracranial aneurysms (IA). We present our multicenter preliminary clinical and angiographic experience. METHODS: To achieve the calculated flow disruption between the parent artery and aneurysm for thrombosis, single FDs were placed endovascularly in parent arteries. Implants measured 2.5-5.3mm in diameter with a length of 10-80mm. Patients were enrolled harboring a wide range large and giant wide-neck, fusiform and multiple small and blister-type aneurysm. Clinical and angiographic follow-up were performed at 1-3, 6, and 12 months. RESULTS: A total of 186 consecutive IA in 161 patients (mean age 57.1 years) were treated at 33 centers. Fifty-three aneurysms were smaller than 5 mm, 64 were 5-9.9mm in diameter, 47 were 10-20mm in diameter, and 22 were larger than 20mm (10.4±0.7mm, neck size 6.0±0.5mm [mean±SEM]) . The aneurysms originated in 63.4% from the internal carotid artery; 22% and 14.5% of the lesions were located in the anterior circulation distal to Circle of Willis and posterior circulation respectively. Technical success was achieved in 182 aneurysms (98%); average number of devices used per aneurysm was 1.05. Permanent morbidity and mortality during the follow-up period of mean 8.4months (range 1-24 months) including periprocedural complications for patients with aneurysms of the anterior circulation were encountered in 5 (3.7%) and 2 (1.5 %) patients respectively and 1 (3.7%) and 4 (14.8%) respectively for patients with aneurysms of the posterior circulation location. One-hundred-ten patients (70.5%) harboring 127 (70.2%) were available for clinical and angiographic follow-up and showed a complete or near complete aneurysm occlusion in 63 (81.8%) of the ICA. Aneurysms of the ICA≥10mm that were completely covered by FD and not previously stent-treated with a minimum of 6 months follow-up available in 16 patients showed a complete obliteration in 81.3% (n=13) and >90% occlusion in remaining 3 patients. CONCLUSION: Preliminary data demonstrate high safety and efficacy of a new generation of FD for a wide range of IA of the anterior and posterior circulation with a single implant.

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Abstract P499: The Effect of Small Vessel Disease Burden on Core/Penumbra Mismatch and Outcomes in Extended Window Thrombectomy

Stroke ◽

10.1161/str.52.suppl_1.p499 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Destiny Hooper ◽

Tariq Nisar ◽

Meryim Poursheykhi ◽

Andy Lin ◽

C. David McCane ◽

...

Keyword(s):

White Matter ◽

Perfusion Imaging ◽

Functional Outcomes ◽

Time Window ◽

Small Vessel Disease ◽

Small Vessel ◽

Collateral Flow ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Vessel Disease

Objective: Recent studies have shown the benefit of revascularization in select patients with extended window large vessel occlusion (EWLVO). We sought to assess the effect of cerebral small vessel disease (CSVD) burden on eligibility for intervention with mechanical thrombectomy (MT) and functional outcomes in patients with EWLVO. Methods: We conducted a retrospective single-center study of 135 patients with anterior circulation LVO who presented in the extended time window, 6 to 24 hours from LKW, between August 2018 and March 2020. All patients underwent perfusion imaging at initial presentation and those with target ischemic core to penumbra mismatch profiles, as defined by DAWN/DEFUSE3 criteria, were treated with MT. Included patients were evaluated for CSVD burden using T2-FLAIR MRI. The Fazekas scale (0-3) was used to quantify the amount of white matter T2 hyperintense lesions in both the periventricular (PVWM) and deep white matter (DWM). Patients’ functional outcomes were assessed at 90 days using the mRS. Multivariate ordinal logistic regression models were used and adjusted for age, gender, thrombus location and LKW to perfusion imaging time. Patient information was collected from the Houston Methodist Hospital Outcomes Based Prospective Endpoints in Stroke (HOPES) registry. Results: Of the 135 patients, 111 met imaging inclusion criteria for revascularization with MT for EWLVO. MT was deferred in 44 of these patients due to other clinical exclusions or patient refusal. Patients ineligible for MT were approximately 13 times more likely to have a higher PVWM Fazekas grade (OR =13.53, 95% CI. [2.94 - 62.39], p=0.001) and 17 times more likely to have a higher DWM Fazekas grade (OR =17.54, 95% CI. [4.20 - 73.17], p<0.001), when compared to patients who were eligible for MT. Patients who did not meet criteria for MT were nearly 7 times more likely to have poor functional outcomes at 90 days (OR =6.85, 95% CI. [2.09 - 22.44], p=0.001). Conclusion: Based on our analytical cohort of EWLVO patients, those with severe CSVD burden were more likely to be excluded from MT and had worse functional outcomes. Poor cerebrovascular reserve and diminished collateral flow leading to rapid infarct progression in patients with greater CSVD burden may be a potential explanation.

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Treatment Of Ruptured Tiny Intracranial Aneurysms By Electrocoagulation With Guidewire Manipulation:12 Cases Report

10.21203/rs.3.rs-30106/v1 ◽

2020 ◽

Author(s):

Lixia Xia ◽

Zhongfei Hao ◽

Hongjun Wang ◽

Yan Feng ◽

Yongxuan Zhan ◽

...

Keyword(s):

Intracranial Aneurysm ◽

Intracranial Aneurysms ◽

Large Scale ◽

Posterior Circulation ◽

Suitable Method ◽

Anterior Circulation ◽

Long Term Follow Up

Abstract Background: Ruptured tiny intracranial aneurysm (RTIA) is particularly rare seen. Treatment of RTIA is more difficult and not under control.Methods: We hereby present twelve rare cases of RTIA that were diagnosed based on DSA. These patients were found due to spontaneous or traumatic SAH, 11 of whom were treated only by electrocoagulation, and one of whom was treated by stent-assisted coiling and electrocoagulation.Results: There were eight patients with aneurysms located in posterior circulation and four patients with aneurysms located in anterior circulation. 11 patients were cured only by electrocoagulation merely: ten patient’ RTIA disappeared completely and immediately and another patient’s RTIA was thrombosed two months later. The twelfth patient was carried out stent-assisted coiling and electrocoagulation. The twelve patients’ average follow-up time was 12.5 months and the outcomes were all surprisingly excellent. No revascularization of aneurysm was found. Conclusions: Electrocoagulation with guidewire manipulation is a suitable method to treat RTIA. While large-scale studies with long-term follow-up are required to validate these promising results.

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