Combined (direct and indirect) revascularization in adult patients with moyamoya disease

2018 ◽  
Vol 20 (3) ◽  
pp. 57-66
Author(s):  
K. S. Ovsyannikov ◽  
A. V. Dubovoy ◽  
D. M. Galaktionov
Keyword(s):  
Moyamoya Disease ◽  
Perfusion Imaging ◽  
Stress Test ◽  
Adult Patients ◽  
Long Term Results ◽  
Study Objective ◽  
Indirect Revascularization ◽  
The Brain ◽  
Msct Angiography

The study objective is to analyze the results of combined (direct and indirect) brain revascularization in adult patients with moyamoya disease. Materials and methods. From February 2015 to August 2016, 12 operations were performed on 12 hemispheres in 7 patients (2 men, 5 women) with moyamoya disease. Six patients had bilateral disease, 1 – unilateral. The age of patients ranged from 25 to 60 year old, the average – 41 year old. Multislice computed tomography (MSCT) perfusion imaging of the brain with a stress test was made in every patient, MSCT angiography of the extraand intracranial arteries was perfomed. Stages of the disease were determined according to the Suzuki–Takaku classification: stage III was revealed in 5 patients, stage IV – in 2. To evaluate the clinical course of the disease the Matsushima classification was used: type VI – in 2 cases, type III – in 2, type IV – in 1, type V – in 1. In 1 case, the pathological vascular network of 1 hemisphere was detected by accident. Extracranial-intracranial (EC–IC) bypass and encephaloduromyosynangiosis (EDMS) was used in 3 cases; a double-barreled EC–IC bypass and EDMS – in 3; a double-barreled EC–IC bypass and encephaloduroperiosteomyosynangiosis – in 1; EC–IC bypass and encephaloduroarteriomyosynangiosis (EDAMS) – in 3. In 1 case was perfomed EC–IC bypass and encephaloduroperiosteosynangiosis. Only indirect revascularization was performed in 1 case – EDAMS. We assessed the neurological status in the follow-up period (5–11 months); MSCT angiography and MSCT perfusion imaging of the brain were performed. Results. All patients in follow-up period demonstrated the increase of cerebrovascular reserve according to MSCT perfusion imaging of the brain with stress tests. Stroke, epilepsy, surgical complications were not detected in the postoperative period. In 1 case, the left-hand monoparesis regressed.Conclusion. The combined (direct and indirect) revascularization may be effective in adult patients with moyamoya disease. To obtain more objective conclusions it is necessary to analyze the long-term results of interventions.

Treatment of moyamoya disease in the adult population with pial synangiosis

2014 ◽  
Vol 120 (3) ◽  
pp. 612-617 ◽  
Author(s):  
Ning Lin ◽  
Joshua P. Aronson ◽  
Sunil Manjila ◽  
Edward R. Smith ◽  
R. Michael Scott
Keyword(s):  
Moyamoya Disease ◽  
Adult Population ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Adult Patients ◽  
Cerebral Revascularization ◽  
Age At Surgery ◽  
Indirect Revascularization ◽  
Revascularization Surgery

Object Surgical treatment of moyamoya disease in the adult population commonly uses direct revascularization, the superficial temporal artery (STA) to middle cerebral artery (MCA) bypass (STA-MCA). Pial synangiosis, a method of indirect revascularization, has been used in adult patients with moyamoya when STA-MCA bypass was not technically feasible. Although the effectiveness of pial synangiosis has been well described in children, only limited reports have examined its role in adult patients with moyamoya disease. In this study the authors report on their experience with pial synangiosis revascularization for this population. Methods The authors reviewed the clinical and radiographic records of all adult patients (≥ 18 years of age) with moyamoya disease who underwent cerebral revascularization surgery using pial synangiosis at a single institution. Results From 1985 to 2010, 66 procedures (6 unilateral, 30 bilateral) were performed on 36 adult patients with moyamoya disease. The mean age at surgery was 28.3 years, and 30 patients were female. Twenty-eight patients (77.8%) presented with transient ischemic attacks (TIAs), 24 (66.7%) with stroke, and 3 (8.3%) with hemorrhage. Preoperative Suzuki stage was III or higher in 50 hemispheres (75.8%) and 3 patients had undergone prior treatments to the affected hemisphere before pial synangiosis surgery. Clinical follow-up was available for an average of 5.8 years (range 0.6–14.1 years), with 26 patients (72.2%) followed for longer than 2 years. Postoperative angiography was available for 24 patients and 46 revascularized hemispheres, and 39 (84.8%) of the 46 hemispheres demonstrated good collateral formation (Matsushima Grade A or B). Postoperative complications included 3 strokes, 5 TIAs, and 2 seizures, and there was no hemorrhage during the follow-up period. One patient required additional revascularization surgery 8 months after pial synangiosis. Conclusions Pial synangiosis is a safe and durable method of cerebral revascularization in adult patients with moyamoya and can be considered as a potential treatment option for moyamoya disease in adults.

Five-Year Outcomes of Medical Management Alone for Adult Patients with Ischemic Moyamoya Disease without Cerebral Misery Perfusion

2021 ◽  
pp. 1-7
Author(s):  
Kei Kitakami ◽  
Yoshitaka Kubo ◽  
Masahiro Yabuki ◽  
Daisuke Oomori ◽  
Tatsuhiko Takahashi ◽  
...  
Keyword(s):  
Moyamoya Disease ◽  
Medical Management ◽  
Photon Emission ◽  
Adult Patients ◽  
Antiplatelet Drug ◽  
Emission Computed Tomography ◽  
Ischemic Event ◽  
Misery Perfusion ◽  
Ischemic Events

<b><i>Introduction:</i></b> No clear guidelines for treating adult patients with ischemic moyamoya disease (MMD) without cerebral hemodynamic compromise such as misery perfusion have been established. Our previous prospective cohort study of adult patients with MMD without misery perfusion who were treated with medical management alone, including an antiplatelet drug, showed a recurrent ischemic event rate of 3% per 2 years. The present prospective study aimed to elucidate the 5-year clinical, cerebral perfusion, and cognitive outcomes of medical management alone for Japanese adult patients with ischemic MMD without cerebral misery perfusion by following the same patients for another 3 years. <b><i>Methods:</i></b> In total, 68 patients without recurrent events at a 2-year follow-up were prospectively followed up for another 3 years. Cerebral blood flow (CBF) in the symptomatic cerebral hemisphere was measured using brain perfusion single-photon emission computed tomography at inclusion and at the end of the subsequent 3-year follow-up. Neuropsychological testing was performed at inclusion and at the end of the initial 2- and subsequent 3-year follow-ups. <b><i>Results:</i></b> During the subsequent 3-year follow-up, 2 patients (3%) developed further ischemic events. In patients without further ischemic events, CBF was significantly greater at the end of the subsequent 3-year follow-up than at inclusion (<i>p</i> = 0.0037), and all neuropsychological test scores improved or remained unchanged at the end of initial 2- and subsequent 3-year follow-ups compared with that at inclusion. <b><i>Conclusion:</i></b> In adult patients receiving medical management alone for ischemic MMD without cerebral misery perfusion, the incidence of further ischemic events was 6% per 5 years and did not change between the initial 2 years after the last is­chemic event and the subsequent 3 years. In patients without further ischemic events, CBF and cognitive function had not deteriorated at 5 years after the last ischemic event.

ADDITIONAL SURGERY FOR POSTOPERATIVE ISCHEMIC SYMPTOMS IN PATIENTS WITH MOYAMOYA DISEASE

Neurosurgery ◽  
2009 ◽  
Vol 64 (1) ◽  
pp. E195-E196 ◽  
Author(s):  
Toshiaki Hayashi ◽  
Reizo Shirane ◽  
Teiji Tominaga
Keyword(s):  
Magnetic Resonance ◽  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Transient Ischemic Attack ◽  
Anterior Cerebral Artery ◽  
Additional Surgery ◽  
Indirect Revascularization ◽  
Ischemic Attack ◽  
Revascularization Surgery

Abstract OBJECTIVE In patients with moyamoya disease, surgery to revascularize the ischemic brain is a recommended treatment. However, there are a few patients who require additional revascularization surgery because of progression of the disease. Even patients who show no postoperative ischemic symptoms at first may experience late deterioration. We performed additional surgery for such lesions using occipital artery (OA)–posterior cerebral artery (PCA) bypass with indirect revascularization. The efficacy of the procedure is reported. METHODS We treated 3 patients with moyamoya disease who showed a transient ischemic attack after revascularization surgery. Three female patients, ranging in age from 6.0 to 35.2 years (mean age, 23.8 years) at the time of surgery, with ischemic symptoms (leg monoparesis in 2, visual impairment in 1) underwent the additional revascularization procedure. Preoperatively, all patients underwent indirect and/or direct revascularization surgery for initial treatment. All patients showed progression of the disease, especially in the PCA. OA–PCA bypass with encephalogaleodurosynangiosis and burr hole surgery were performed for postoperative ischemic symptoms. RESULTS All patients showed clinical and radiological improvement. The transient ischemic attack was improved in all 3 patients. They did not complain of transient ischemic attack in the recent follow-up period. Follow-up magnetic resonance imaging showed no additional cerebral infarction. Magnetic resonance angiography showed widening of the OA and development of peripheral collateral vessels. Postoperative single-photon emission computed tomographic studies showed marked increase of uptake in both anterior cerebral artery and PCA territories. Cerebral vasodilatory capacity evaluated by an acetazolamide test also showed marked improvement. One patient showed postoperative cerebral edema as a result of focal cerebral hyperperfusion. CONCLUSION OA–PCA anastomosis with indirect revascularization was effective for postoperative ischemia that showed symptoms in the anterior cerebral artery and PCA territories as a result of progression of a PCA lesion.

scholarly journals Postoperative collateral formation after indirect bypass for hemorrhagic moyamoya disease

2019 ◽  
Author(s):  
Peicong Ge ◽  
Qian Zhang ◽  
Xun Ye ◽  
Xingju Liu ◽  
Xiaofeng Deng ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Moyamoya Disease ◽  
Digital Subtraction ◽  
Regression Analyses ◽  
Multivariate Logistic Regression ◽  
Study Objective ◽  
Factors Influencing ◽  
Medical University ◽  
Collateral Formation

Abstract Background: The research on postoperative collateral formation for hemorrhagic moyamoya disease (MMD) evaluated by using digital subtraction angiography (DSA) is limited. Our study objective was to investigate the postoperative collateral formation after indirect bypass for hemorrhagic MMD. Methods: All consecutive inpatients with hemorrhagic MMD who received indirect bypass at Beijing Tiantan Hospital, Capital Medical University from January 2010 through December 2018 were screened. The site of the hemorrhage was classified as either anterior or posterior. Postoperative collateral formation was evaluated on lateral views using the Matsushima scale. Univariate and multivariate logistic regression analyses were carried out to determine the factors influencing postoperative collateral formation. Results: Six-four patients (64 hemispheres) were included in this study. After a median 8.5 months DSA follow-up, 14 (21.9%) hemispheres had grade A collateral circulation, 13 (20.3%) had grade B, and 37 (57.8%) had grade C. Twenty-seven (43.2%) hemispheres had good postoperative collateral formation and 37 (57.8%) had poor postoperative collateral formation. The univariate logistic regression analyses showed that age at operation (OR, 0.954; 95% CI, 0.908–1.003; p=0.066), hemorrhagic site (OR, 4.694; 95% CI, 1.582–13.923; p=0.005), and PCA involvement (OR, 3.474; 95% CI, 0.922–13.086; p=0.066) may effect postoperative collateral formation. The multivariate logistic regression analyses showed that only anterior hemorrhage (OR, 5.222; 95% CI, 1.605–16.987; p=0.006) was significantly related to good postoperative collateral formation. Conclusion: Anterior hemorrhage was significantly related to good postoperative collateral formation after indirect bypass.

Age-dependent revascularization patterns in the treatment of moyamoya disease in a European patient population

2009 ◽  
Vol 26 (4) ◽  
pp. E9 ◽  
Author(s):  
Marcus Czabanka ◽  
Peter Vajkoczy ◽  
Peter Schmiedek ◽  
_ _ ◽  
Peter Horn
Keyword(s):  
Moyamoya Disease ◽  
Pediatric Patients ◽  
Clinical Results ◽  
Adult Patients ◽  
Suitable Alternative ◽  
Relative Contribution ◽  
Grade Ii ◽  
Indirect Revascularization ◽  
Revascularization Procedures ◽  
Grade Iii

Object Different revascularization procedures are used in the treatment of patients with moyamoya disease (MMD). The aim of this study was to investigate the relative contribution of direct and indirect revascularization procedures to the restoration of collateral blood supply in adult and pediatric patients with MMD. Methods The authors performed 39 combined cerebral revascularization procedures (standard extraintracranial bypass [STA-MCA bypass] plus encephalomyosynangiosis [EMS]) in 10 pediatric and 10 adult patients. All patients underwent physical examination and digital subtraction angiography before and 6 months after surgery. The STA-MCA bypass and EMS function were graded as Grade I (poor), II (moderate), or III (good) on the basis of the angiograms. Results In pediatric patients, bypass function was Grade I in 12, Grade II in 8, and Grade III in 0 hemispheres; EMS function was Grade I in 0, Grade II in 12, and Grade III in 8 hemispheres. In the adult patients, bypass function was Grade I in 8, Grade II in 8, and Grade III in 3 hemispheres; EMS function was Grade I in 10 hemispheres, Grade II in 5, and Grade III in 1 hemisphere. In the pediatric patients disease was classified as improved in 14 hemispheres on the basis of clinical results and stable in 6. In the adults it was classified as improved in 12 hemispheres stable in 7 hemispheres. Conclusions Combined revascularization led to good angiographic and clinical results in both patient populations. Especially in pediatric patients, EMS represents a suitable alternative to bypass surgery.

scholarly journals Impact of posterior cerebral artery involvement on long-term clinical and social outcome of pediatric moyamoya disease

2013 ◽  
Vol 12 (6) ◽  
pp. 626-632 ◽  
Author(s):  
Takeshi Funaki ◽  
Jun C. Takahashi ◽  
Yasushi Takagi ◽  
Kazumichi Yoshida ◽  
Yoshio Araki ◽  
...  
Keyword(s):  
Risk Factors ◽  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Posterior Cerebral Artery ◽  
Univariate Analysis ◽  
Social Outcomes ◽  
Long Term Results ◽  
Social Outcome

Object In the study of pediatric moyamoya disease, information on long-term social outcomes and risk factors for unfavorable social outcomes remains insufficient. The authors analyzed the long-term results of surgical revascularization for pediatric patients with moyamoya disease to determine whether the involvement of a stenoocclusive lesion in the posterior cerebral artery (PCA), relatively common in pediatric moyamoya disease, represents an underlying predictor for unfavorable social outcomes. Methods Prospectively collected data on 61 consecutive patients with moyamoya disease who had undergone combined bypass surgery were analyzed. Neuroradiological features and other baseline clinical factors were incorporated into univariate and multivariate analyses to determine any association with an unfavorable social outcome, defined as difficulty attending regular school or obtaining regular employment. Results Posterior cerebral artery involvement detected by angiography on admission was noted in 22 (36.1%) of the 61 patients. Follow-up data were acquired in 56 patients (91.8%), and the mean follow-up period was 15.8 years. While transient ischemic attacks were eliminated in 52 (92.9%) of these 56 patients after surgery, and late-onset ischemic stroke was observed in only 1 patient during the follow-up period, 10 (17.9%) experienced an unfavorable social outcome. Although younger age at onset, longer duration between onset and surgery, infarction present on preoperative neuroradiological images, and PCA involvement had been identified as risk factors for an unfavorable social outcome in univariate analysis, only infarction present on preoperative images and PCA involvement remained statistically significant after multivariate adjustment. Conclusions Posterior cerebral artery involvement can be considered one of the underlying risk factors for unfavorable social outcome and should be studied further to improve social outcome in pediatric moyamoya disease.

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