scholarly journals Direct versus indirect revascularization procedures for moyamoya disease: a comparative effectiveness study

2017 ◽  
Vol 126 (5) ◽  
pp. 1523-1529 ◽  
Author(s):  
Luke Macyszyn ◽  
Mark Attiah ◽  
Tracy S. Ma ◽  
Zarina Ali ◽  
Ryan Faught ◽  
...  
Keyword(s):  
Decision Analysis ◽  
Moyamoya Disease ◽  
Literature Search ◽  
Definitive Treatment ◽  
Decision Analysis Model ◽  
Life Years ◽  
Significant Difference ◽  
Indirect Revascularization ◽  
Revascularization Procedures

OBJECTIVEMoyamoya disease (MMD) is a chronic cerebrovascular disease that can lead to devastating neurological outcomes. Surgical intervention is the definitive treatment, with direct, indirect, and combined revascularization procedures currently employed by surgeons. The optimal surgical approach, however, remains unclear. In this decision analysis, the authors compared the effectiveness of revascularization procedures in both adult and pediatric patients with MMD.METHODSA comprehensive literature search was performed for studies of MMD. Using complication and success rates from the literature, the authors constructed a decision analysis model for treatment using a direct and indirect revascularization technique. Utility values for the various outcomes and complications were extracted from the literature examining preferences in similar clinical conditions. Sensitivity analysis was performed.RESULTSA structured literature search yielded 33 studies involving 4197 cases. Cases were divided into adult and pediatric populations. These were further subdivided into 3 different treatment groups: indirect, direct, and combined revascularization procedures. In the pediatric population at 5- and 10-year follow-up, there was no significant difference between indirect and combination procedures, but both were superior to direct revascularization. In adults at 4-year follow-up, indirect was superior to direct revascularization.CONCLUSIONSIn the absence of factors that dictate a specific approach, the present decision analysis suggests that direct revascularization procedures are inferior in terms of quality-adjusted life years in both adults at 4 years and children at 5 and 10 years postoperatively, respectively. These findings were statistically significant (p < 0.001 in all cases), suggesting that indirect and combination procedures may offer optimal results at long-term follow-up.

scholarly journals Clinical and Imaging Outcomes After Combined Direct and Indirect Bypass for Pediatric Moyamoya Disease: A Single Center Retrospective Series

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Ramin A Morshed ◽  
Daniel Murph ◽  
Jasmin Dao ◽  
Kathleen Colao ◽  
Lauro Avalos ◽  
...  
Keyword(s):  
Moyamoya Disease ◽  
Pediatric Patients ◽  
Age Groups ◽  
Unknown Etiology ◽  
Vascular Bypass ◽  
Indirect Revascularization ◽  
Direct Bypass ◽  
Stage 1 ◽  
Revascularization Procedures

Abstract INTRODUCTION Moyamoya disease is a progressive cerebrovascular arteriopathy of unknown etiology, causing narrowing and eventual occlusion of the internal carotid arteries and their branches. Surgical revascularization is a key component of the overall treatment strategy. The goal of this study was to determine outcomes and complications related to direct vascular bypass in a pediatric cohort with Moyamoya disease. METHODS All pediatric patients (<18 yr of age) treated with direct bypass combined with encephalomyosynangiosis between 2006 and 2017 at the authors’ institution were included in the cohort. Demographic features, treatment, and outcomes were determined retrospectively from clinical reports available through the electronic medical record. RESULTS A total of 18 patients (11 females and 7 males) underwent 32 bypass procedures with a median follow-up of 2.2 yr (range 22 d 8.6 yr). Mean age at operation was 8.3 yr (range 1.4-16.9 yr). Preoperative Suzuki stage 1, 2, 3, 4, and 5 were seen in 2, 7, 7, 12, and 4 hemispheres, respectively. By last follow-up, 3 patients had evidence of new clinical ischemic stroke, all occurring within 30 d of surgery. Favorable outcomes (pediatric modified Rankin scores 0-2) at last follow-up were seen in 15 patients (83.3%). There was 1 death in the cohort due to gastrointestinal bleeding related to underlying medical comorbidities. On review of imaging at last follow-up for surviving patients, 29 of 30 direct arterial bypasses were patent; 12 and 5 patients had stable and worse imaging findings, respectively, when compared to immediate postoperative scans. CONCLUSION Combined direct and indirect revascularization procedures may be successfully applied to pediatric patients with Moyamoya disease of all age groups. The direct bypass component provides immediate revascularization and is associated with high rates of patency on follow-up imaging.

Outcome of repeat revascularization surgery for moyamoya disease after an unsuccessful indirect revascularization

2011 ◽  
Vol 115 (2) ◽  
pp. 328-336 ◽  
Author(s):  
Paritosh Pandey ◽  
Gary K. Steinberg
Keyword(s):  
Mr Imaging ◽  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Repeat Revascularization ◽  
Recipient Vessel ◽  
Indirect Revascularization ◽  
Collateral Vessels ◽  
Revascularization Surgery ◽  
Revascularization Procedures

Object Revascularization for moyamoya disease, either by direct anastomosis or indirect procedures, is an accepted and effective form of treatment for prevention of future ischemic events. Indirect procedures do not provide sufficient collateral vessels in a subset of patients, who then have persistent or new symptoms. Repeat revascularization procedures may be recommended for these patients. Methods Sixteen patients underwent repeat revascularization after undergoing an indirect procedure in the same hemisphere. These patients were included in the study, and a retrospective review of their clinical details, neuroimaging results, surgical details, and outcome was performed. Direct revascularization was the procedure of choice; however, in patients with no acceptable recipient vessel (> 0.6 mm) the authors added a second indirect procedure for further revascularization. Results Over the last 19 years, 16 patients (8 male and 8 female patients, age range 5–48 years, mean 16.7 years, 10 pediatric and 6 adult patients) underwent repeat revascularization for moyamoya disease. Initially all patients presented with ischemic symptoms (4 transient ischemic attacks [TIAs] and 12 strokes; 2 patients had bilateral symptoms). Angiography revealed that 13 patients had bilateral disease, and 3 had unilateral disease. Initial surgery was bilateral encephaloduroarteriosynangiosis (EDAS) in 9, unilateral EDAS alone in 3, unilateral EDAS with contralateral superficial temporal artery–middle cerebral artery (STA-MCA) bypass in 2, bilateral encephalomyosynangiosis (EMS) in 1, and unilateral EMS in 1. Thirteen of the 16 patients continued to have TIAs in the hemisphere ipsilateral to surgery, whereas 1 patient had seizures and cognitive deficit, 1 had asymptomatic infarct on MR imaging, and 1 had visual symptoms. Poor revascularization was seen on angiography studies in all patients. The median duration between the surgeries was 24 months (3 months–10 years). Repeat revascularization was performed in 23 hemispheres (16 patients). Direct revascularization was performed in 14 hemispheres (60.9%): STA-MCA bypass in 10, external carotid artery–MCA vein bypass in 2, occipital artery (OA)–MCA in 1, and OA–posterior cerebral artery in 1 hemisphere. Indirect revascularization was performed for patients without an acceptable recipient vessel, and was done in 9 hemispheres. The procedures included EMS (4 hemispheres), repeat EDAS (2), and omental transposition (3). There was 1 postoperative death in a patient undergoing a high-flow vein graft implantation. None of the other patients experienced any neurological worsening after surgery. Follow-up was available in all patients, ranging from 3 to 144 months (mean 34 months, median 12 months). Of the 15 patients who survived repeat revascularization surgery, 12 (80%) were free from any TIA, stroke, or any other neurological symptoms. Two patients had occasional TIAs, less frequent than before, whereas 1 patient had frequent TIAs and underwent revision of the revascularization. Angiographic studies were available in 11 patients, and showed improved flow in the hemispheres in 10 patients. Follow-up MR imaging performed at 6 months did not reveal a new infarct in any patient. Conclusions Repeat revascularization procedures are effective for patients who are clinically symptomatic and have inadequate collateral vessels following indirect procedures. Although direct procedures are preferred, the choice of procedure depends on the operative findings and the status of donor and recipient vessels.

scholarly journals Surgical Treatments for Lumbar Spine Diseases: A Systematic Review and Meta-Analysis

2021 ◽  
Author(s):  
Kanthika Wasinpongwanich ◽  
Tanawin Nopsopon ◽  
Krit Pongpirul
Keyword(s):  
Lumbar Spine ◽  
Clinical Outcomes ◽  
Risk Ratio ◽  
Literature Search ◽  
Operative Time ◽  
Meta Analysis ◽  
Fusion Rate ◽  
Significant Difference ◽  
Spine Diseases

Purpose Surgical treatment is mandatory in some patients with lumbar spine diseases. To obtain spine fusion, many operative techniques were developed with different fusion rates and clinical results. This study aimed to collect randomized controlled trial (RCT) data to compare fusion rate, clinical outcomes, complications among Transforaminal Lumbar Interbody Fusion (TLIF), and other techniques for lumbar spine diseases. Methods A systematic literature search of PubMed, Embase, Scopus, Web of Science, and CENTRAL databases was searched for studies up to 13 February 2020. The meta-analysis was done using a random-effects model. Pooled risk ratio (RR) or mean difference (MD) with a 95% confidence interval of fusion rate, clinical outcomes, and complication in TLIF and other techniques for lumbar diseases. Results The literature search identified 3,682 potential studies, 15 RCTs (915 patients) were met our inclusion criteria and were included in the meta-analysis. Compared to other techniques, TLIF had slightly lower fusion rate (RR=0.84 [95% CI 0.72, 0.97], p=0.02, I2=0.0%) at 1-year follow-up while there was no difference on fusion rate at 2-year follow up (RR=1.06 [95% CI 0.96, 1.18], p=0.27, I2=69.0%). The estimated risk ratio of total adverse events (RR=0.90 [95% CI 0.59, 1.38], p=0.63, I2=0.0%) and revision rate (RR=0.78 [95%CI 0.34, 1.79], p=0.56, I2=39.0%) showed no difference. TLIF had approximately half an hour more operative time than other techniques (MD=31.88 [95% CI 5.33, 58.44], p=0.02, I2=92.0%). There was no significant difference between TLIF and other techniques in terms of the blood loss, and clinical outcomes. Conclusions Besides fusion rate at 1-year follow-up and operative time, our study demonstrated similar outcomes of TLIF with other techniques for lumbar diseases in regard to fusion rate, clinical outcomes, and complications.

scholarly journals Clinical features and long-term outcomes of moyamoya disease: a single-center experience with 528 cases in China

2015 ◽  
Vol 122 (2) ◽  
pp. 392-399 ◽  
Author(s):  
Xing-ju Liu ◽  
Dong Zhang ◽  
Shuo Wang ◽  
Yuan-li Zhao ◽  
Mario Teo ◽  
...  
Keyword(s):  
Clinical Features ◽  
Moyamoya Disease ◽  
Positive Impact ◽  
Chinese Patients ◽  
Single Center ◽  
Long Term Outcomes ◽  
Kaplan Meier ◽  
Significant Difference ◽  
Revascularization Procedures

OBJECT The aim of this study was to describe the baseline clinical features and long-term outcomes of patients with moyamoya disease (MMD) based on a 25-year period at a single center in China. METHODS  Data obtained in 528 consecutive patients with MMD treated at the authors' hospital from 1984 to 2010 were reviewed retrospectively. Events of transient ischemic attack, new infarction, and hemorrhage were included. The Kaplan-Meier risk of stroke was calculated. RESULTS  The mean (± SD) patient age was 26 ± 13 years (range 2–67 years), and the female/male ratio was 0.9:1. There were 332 cases of ischemia and 196 hemorrhages. Adults had a higher rate of bleeding than children (50.7% vs 14.0%, respectively; p < 0.001). One hundred twenty-two patients were treated conservatively, and 406 patients underwent revascularization procedures. Of 528 patients, 331 (62.7%) had at least 1 year of follow-up (median 39.5 months) and data from these patients were analyzed. Rebleeding and mortality rates in patients with hemorrhagic MMD (n = 104) were higher than in those with ischemic MMD (n = 227) (26.9% vs 2.2% [p < 0.001] and 4.8% vs 0.4% [p < 0.05], respectively). Twenty-five of 60 (41.7%) conservatively treated patients and 8 of 271 (2.9%) surgically treated patients experienced rebleeding events, a difference that was significant in the Kaplan-Meier curve of rebleeding (p < 0.01). An improvement in perfusion was found in 164 of 224 (73.2%) surgically treated patients 1 month after discharge. However, there was no significant difference in the rate of ischemic events in the surgical and conservative groups (18.8% and 28.3%, respectively; p = 0.09). Among the 104 hemorrhagic cases, rebleeding attacks were observed in 25 patients in the nonsurgical group (n = 60) and 3 patients in the surgical group (n = 44) (41.7% and 6.8%, respectively; OR 9.7 [95% CI 2.7–35.0]; p < 0.01). CONCLUSIONS  There was no difference in the sex distribution of Chinese patients with MMD. Patients with hemorrhagic MMD had a much higher rate of rebleeding and poorer prognosis than those with the ischemic type. Surgical revascularization procedures can improve cerebral perfusion and have a positive impact in preventing rebleeding in patients with hemorrhagic MMD.

Comparison of conventionally fractionated and hypofractionated schedule for post-prostatectomy salvage radiotherapy: Early results from non-randomized observational study.

2017 ◽  
Vol 35 (6_suppl) ◽  
pp. e551-e551
Author(s):  
Jure Murgic ◽  
Blanka Jaksic ◽  
Ivan Kruljac ◽  
Marin Prpic ◽  
Mirjana Budanec ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Side Effects ◽  
Hormonal Therapy ◽  
Cox Proportional Hazards Model ◽  
Hypofractionated Radiotherapy ◽  
Definitive Treatment ◽  
Early Results ◽  
Significant Difference ◽  
Conventionally Fractionated

e551 Background: Data on hypofractionated radiotherapy in definitive treatment of prostate cancer are maturing; however, limited information is available for hypofractionated radiotherapy after prostatectomy. We aimed to compare hypofractionated and conventionally fractionated radiotherapy in salvage setting for biochemically recurrent prostate cancer. Methods: A retrospective analysis was performed in 106 patients with proven PSA recurrence treated to the prostate bed. Patients were non-randomly, in a alternating fashion, subjected to either 52.5 Gy in 20 fractions of 2.625 Gy over 4 weeks (N = 57, hypofractionated group) or 66 Gy in 33 fractions of 2 Gy over 6.5 weeks (N = 49, conventionally fractionated group). There was no statistically significant difference in pathologic T-stage and Gleason score distribution between the groups. In the conventionally fractionated group there were more patients with positive margins (p = 0.01), more prevalent concomitant hormonal therapy (50.9% vs 61.2%, p = 0.001), but less long-term hormonal therapy (21.4% vs 81%, p < 0.001), compared to hypofractionated group. Median follow-up was 20 months (range 6-36 months). Failure (PSA nadir+0.2) rates between the groups were compared using Cox proportional hazards model. Radiation-related side-effects were assessed using RTOG scoring scale. Results: At this early point, 13 patients (22.8%), and 6 patients (12.2%) experienced treatment failure in the hypofractionated group and conventionally fractionated group, respectively (HR 3.1, 95%CI (1.5-6.3)). More late grade 2 gastrointestinal and genitourinary side-effects were observed in conventionally fractionated group (4.1% vs 1.8%, and 2% vs 0%, p = 0.01, respectively). No grade 3 toxicities were observed. Conclusions: More initial biochemical failures were observed in hypofractionated group compared to conventionally fractionated group. However, baseline heterogeneity between the groups and short follow-up preclude any causal observation of differential efficacy between these two schedules. Randomized phase II trial is planned to prospectively compare these two regimens.

Cost-utility analysis of surveillance strategies for soft tissue sarcoma recurrence.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. 11565-11565
Author(s):  
Bonny Chau ◽  
Marita Zimmermann ◽  
Michael Wagner ◽  
Lee D. Cranmer
Keyword(s):  
Cost Effectiveness ◽  
Soft Tissue ◽  
Imaging Modality ◽  
Soft Tissue Sarcomas ◽  
Definitive Treatment ◽  
Published Data ◽  
X Rays ◽  
Life Years ◽  
Screening Intervals

11565 Background: Soft tissue sarcomas (STS) are uncommon malignancies with significant biological and clinical variation. After primary curative therapy, patients enter a program of surveillance for recurrence with periodic chest x-rays (CXR) or computed tomography (CT). We compared costs and health outcomes of CXR and CT at a range of frequencies and durations of follow-up. Methods: We used a Markov model to simulate a cohort of 10,000 STS patients through their surveillance experience for lung metastasis after completion of definitive treatment for stage II or III primary disease. Health states in the model were no evidence of disease, recurrence, and death. We assessed the method of chest imaging, duration of follow-up, and interval (every 3 months or 6 months) of surveillance in the first 3 years. Cost effectiveness was assessed for each screening modality and screening frequency. Recurrence probabilities, utilities, treatment costs, and other parameters were from previously published data. Outcomes were costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICER). Results: The initial evaluation comparing screening every 3 months for 3 years, every 6 months for years 4 and 5, and annually from years 6 to 10 resulted in 632,264 QALYs and $1,038,351,481 costs for CT, compared to 631,834 QALYs and $746,019,937 for CXR, resulting in an ICER of $679,322/QALY. In comparing screening intervals, less frequent screening intervals of every 6 months compared to every 3 months for the first three years using CT resulted in an ICER of $690,527/QALY and for CXR, the ICER was $271,423/QALY. In comparing screening duration between 6 years and 10 years of follow-up, strategies with longer follow-up resulted in slightly higher QALYs in each of the comparison scenarios, at a much higher cost. Conclusions: In our evaluation, more frequent screening the first 3 years and longer duration of surveillance resulted in higher QALYs in both screening modalities. However, in the comparisons the ICERs exceed common willingness to pay thresholds of $150,000/QALY gained; CXR is the more cost-effective imaging modality. Limitation of this model includes the simplification of disease progression and heterogeneity in STS.

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.

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.

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