Strategy and effect of repeat bypass surgery for anterior/posterior circulation in refractory moyamoya disease

2020 ◽  
Vol 132 (6) ◽  
pp. 1889-1899
Author(s):  
Haruto Uchino ◽  
Daina Kashiwazaki ◽  
Naoki Akioka ◽  
Masaki Koh ◽  
Naoya Kuwayama ◽  
...  
Keyword(s):  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Transient Ischemic Attack ◽  
Bypass Surgery ◽  
Posterior Circulation ◽  
Therapeutic Effects ◽  
Anterior Circulation ◽  
Group A ◽  
Ischemic Attack ◽  
Group B

OBJECTIVEIn this study the authors aimed to describe clinical features, surgical techniques, and long-term outcomes of repeat bypass surgery required for a certain subset of patients with moyamoya disease.METHODSThe authors retrospectively reviewed a total of 22 repeat bypass surgeries for 20 patients (age range 1–69 years) performed during the last 20 years at their institutions. The patients were classified into 2 groups. Group A included 10 patients who underwent repeat bypass surgery for anterior circulation due to insufficient revascularization on the ipsilateral side. Group B included 10 patients who underwent repeat bypass surgery for posterior circulation due to the involvement of the posterior cerebral artery (PCA) after successful initial surgery for anterior circulation.RESULTSPreoperative symptoms included headache in 3 patients, transient ischemic attack in 10, cerebral infarction in 3, and intracranial hemorrhage in 4 patients. Intervals between the initial bypass surgery and repeat bypass surgery were 0.3–30 years (median 3 years). In group A, superficial temporal artery to middle cerebral artery (MCA) anastomosis and indirect bypass were performed on 7 hemispheres. Only indirect bypass was performed on 3 hemispheres because of the lack of suitable donor or recipient arteries. In group B, occipital artery (OA) to PCA anastomosis and indirect bypass were conducted on 4 hemispheres, and OA-MCA anastomosis and indirect bypass on 1 hemisphere. Only indirect bypass was conducted on 7 hemispheres because of the lack of suitable recipient arteries. All 22 repeat bypass surgeries were successfully conducted. During follow-up periods (median 4 years), none of the patients suffered repeat stroke except 1 patient who died of recurrent intracerebral hemorrhage 3 years after repeat bypass surgery for anterior circulation.CONCLUSIONSRepeat bypass surgery was feasible and effective to reduce further incidence of headache attack, transient ischemic attack, and ischemic/hemorrhagic stroke in moyamoya disease patients. Through precise radiological analysis, surgical procedures should be planned to yield maximal therapeutic effects.

scholarly journals Posterior cerebral artery stenosis and posterior circulation revascularization surgery in pediatric patients with moyamoya disease

2018 ◽  
Vol 21 (6) ◽  
pp. 632-638 ◽  
Author(s):  
Tomomi Kimiwada ◽  
Toshiaki Hayashi ◽  
Reizo Shirane ◽  
Teiji Tominaga
Keyword(s):  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Pediatric Patients ◽  
Posterior Cerebral Artery ◽  
Posterior Circulation ◽  
Initial Diagnosis ◽  
Occipital Artery ◽  
Anterior Circulation ◽  
Before And After ◽  
Revascularization Surgery

OBJECTIVESome pediatric patients with moyamoya disease (MMD) present with posterior cerebral artery (PCA) stenosis before and after anterior circulation revascularization surgery and require posterior circulation revascularization surgery. This study evaluated the factors associated with PCA stenosis and assessed the efficacy of posterior circulation revascularization surgery, including occipital artery (OA)–PCA bypass, in pediatric patients with MMD.METHODSThe presence of PCA stenosis before and after anterior circulation revascularization surgery and its clinical characteristics were investigated in 62 pediatric patients (< 16 years of age) with MMD.RESULTSTwenty-three pediatric patients (37%) with MMD presented with PCA stenosis at the time of the initial diagnosis. A strong correlation between the presence of infarction and PCA stenosis before anterior revascularization was observed (p < 0.001). In addition, progressive PCA stenosis was observed in 12 patients (19.4%) after anterior revascularization. The presence of infarction and a younger age at the time of initial diagnosis were risk factors for progressive PCA stenosis after anterior revascularization (p < 0.001 and p = 0.002, respectively). Posterior circulation revascularization surgery, including OA-PCA bypass, was performed in 9 of the 12 patients with progressive PCA stenosis, all of whom showed symptomatic and/or radiological improvement.CONCLUSIONSPCA stenosis is an important clinical factor related to poor prognosis in pediatric MMD. One should be aware of the possibility of progressive PCA stenosis during the postoperative follow-up period and consider performing posterior circulation revascularization surgery.

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.

Combined Encephaloduroarteriosynangiosis and Bifrontal Encephalogaleo(periosteal)synangiosis in Pediatric Moyamoya Disease

Neurosurgery ◽  
2002 ◽  
Vol 50 (1) ◽  
pp. 88-96 ◽  
Author(s):  
Seung-Ki Kim ◽  
Kyu-Chang Wang ◽  
In-One Kim ◽  
Dong Soo Lee ◽  
Byung-Kyu Cho
Keyword(s):  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Single Photon ◽  
Photon Emission ◽  
Single Photon Emission ◽  
Computed Tomographic ◽  
Group A ◽  
Single Photon Emission Computed ◽  
Group B

ABSTRACT OBJECTIVE We compared the surgical results of simple encephaloduroarteriosynangiosis (EDAS) and EDAS with bifrontal encephalogaleo(periosteal)synangiosis for the treatment of pediatric moyamoya disease. METHODS Data for 159 children (up to 15 yr of age, 76 boys and 83 girls) who underwent indirect revascularization procedures for the treatment of moyamoya disease between 1987 and 1998 were retrospectively reviewed. Group A patients underwent simple EDAS (n = 67). Group B patients underwent EDAS with bifrontal encephalogaleo(periosteal)synangiosis (n = 92). The surgical results for each group were compared, in terms of clinical outcomes, neuroimaging changes, extent of revascularization evident on angiograms, and hemodynamic changes evident on single-photon emission computed tomographic scans. The average follow-up periods were 45 months for Group A and 22 months for Group B. RESULTS The overall clinical outcomes and neuroimaging changes tended to be better for Group B. In terms of single-photon emission computed tomographic changes of the whole brain after surgery, Group B patients exhibited more favorable outcomes than did Group A patients (62 versus 36%, P = 0.003). The surgical results for the anterior cerebral artery territory were significantly better for Group B than for Group A, with respect to outcomes of anterior cerebral artery symptoms (81 versus 40%, P = 0.015), revascularization on angiograms (79 versus 16%, P &lt; 0.001), and hemodynamic changes on single-photon emission computed tomographic scans (70 versus 52%, P = 0.002). The incidences of postoperative infarctions were not significantly different between the two groups. CONCLUSION EDAS with bifrontal encephalogaleo(periosteal)synangiosis is a more effective surgical modality for the treatment of pediatric moyamoya disease, compared with simple EDAS, because it covers both the middle cerebral artery and anterior cerebral artery territories of the brain.

Clinical Application of Intravenous Thrombolysis in Transient Ischemic Attack and Ischemic Stroke Guided by Multimodal MRI

2021 ◽  
Vol 11 (2) ◽  
pp. 584-589
Author(s):  
Aixia Song ◽  
Jing Chen ◽  
Yan Sun ◽  
Xiaoqin Wang ◽  
Jichao Zhang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Thrombolytic Therapy ◽  
Antiplatelet Therapy ◽  
Clinical Application ◽  
Transient Ischemic Attack ◽  
Intravenous Thrombolysis ◽  
Group A ◽  
Multimodal Mri ◽  
Ischemic Attack ◽  
Group B

Objective: To investigate the therapeutic effect of intravenous thrombolysis on TIA (Transient Ischemic Attack) under the guidance of multimodal MRI (magnetic resonance imaging), and the clinical application of intravenous thrombolysis in patients with ischemic stroke. Methods: Patients with acute ischemic stroke who underwent intravenous thrombolysis in the Department of Neurology from December 2017 to December 2018 were selected. Through CT (computed tomography) screening, 146 patients that met the diagnostic criteria were eventually included. Patients were randomly divided into group A (72 patients) and group B (74 patients). Patients in group A received antiplatelet therapy within 24 h after intravenous thrombolytic therapy for 10 days. The platelet therapy was discontinued when symptomatic intracerebral hemorrhage (SICH) occurred or NIHSS score was ≥4. In group B, after intravenous thrombolysis and antiplatelet therapy, multimodal MRI was used to detect the presence of hemorrhage and other conditions to determine whether to continue the antiplatelet therapy. The NIHSS scores before and after thrombolysis and the 90-day mRS scores after thrombolysis were collected for statistical analysis. Results: The experimental results of each group of patients showed that there was a signif- icant difference in NIHSS scores at admission and 6 h after thrombolysis (P < 0.05). The 30-day mRS score, 90-day mRS score, and prognosis were statistically significant in both groups. The differences in NIHSS scores at 6 h, 24 h, 7 d, and 14 d after thrombolysis and at admission were 1, 1.6, 1.8, and 2.8, which were statistically significant. A comparison of the prognosis of the two groups of patients with hemorrhage 24 h after thrombolysis revealed that the hemorrhage of each patient was improved. Conclusion: In the treatment of ischemic stroke diseases, the utilization of multimodal MRI in clinical intravenous thrombolytic therapy was valuable, which was very sensitive to the detection and display of blood focus. Also, in the selection of treatment methods for clinical thrombolysis in stroke patients, the targeted treatment could be better individualized for each patient.

scholarly journals Treatment for Intracranial Cerebral Artery Stenosis

2004 ◽  
Vol 10 (2_suppl) ◽  
pp. 13-16
Author(s):  
K. Kawaguchi ◽  
T. Kubo ◽  
H. Takeuchi ◽  
S. Nemoto
Keyword(s):  
Drug Treatment ◽  
Endovascular Treatment ◽  
Cerebral Artery ◽  
Therapeutic Indication ◽  
Bypass Surgery ◽  
Posterior Circulation ◽  
Artery Stenosis ◽  
Anterior Circulation ◽  
History Of ◽  
Low Incidence

Symptomatic intracranial cerebral artery stenosis is largely resistant to drug treatment. Regardless of their locations, lesions may cause cerebral infarction with a frequency of 7–10% in a year, but the natural history of asymptomatic intracranial cerebral artery stenosis remains unclear. Revascularization is indicated for symptomatic lesions which show resistance to drug treatment, while bypass surgery is the accepted therapeutic indication for haemodynamic ischemia. Endovascular treatment is effective in haemodynamic ischemia, and is also expected to be effective against embolic symptoms. Bypass surgery for anterior circulation cases is safe because of its low incidence of complications, whereas bypass surgery for posterior circulation cases is technically difficult and has a high associated complication rate. Hence, endovascular treatment is currently favored for posterior circulation cases, and has also been introduced for anterior circulation cases. Endovascular treatment has become a widespread modality for intracranial cerebral artery stenosis, but there are many unsolved problems associated with complications, technology and devices. Therefore, in practice, endovascular treatment should be used only with a strict indication, and should be performed only after considerable thought and with appropriate informed consent.

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

Neurosurgery ◽  
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.

Unilaterally Symptomatic Moyamoya Disease in Children: Long-term Follow-up of 20 Patients

Neurosurgery ◽  
2006 ◽  
Vol 59 (4) ◽  
pp. 830-837 ◽  
Author(s):  
Shinji Nagata ◽  
Toshio Matsushima ◽  
Takato Morioka ◽  
Koichiro Matsukado ◽  
Futoshi Mihara ◽  
...  
Keyword(s):  
Moyamoya Disease ◽  
Bypass Surgery ◽  
Minor Stroke ◽  
Side Group ◽  
Transient Ischemic Attacks ◽  
Perfusion Reserve ◽  
Group A ◽  
Group B ◽  
A Minor ◽  
Symptomatic Side

Abstract OBJECTIVE: In unilaterally symptomatic moyamoya disease in children, it remains controversial whether bypass surgery should be performed on the asymptomatic side along with on the symptomatic side. We aimed to verify the validity of our strategy of only performing bypass surgery on the symptomatic side. METHODS: Among 91 pediatric patients with moyamoya disease who underwent bypass surgery in our department between 1980 and 2004, 20 with unilateral ischemic symptoms who were followed for more than 60 months were analyzed in the present study. Initially, we only performed bypass surgery on the symptomatic side for all 20 patients. Among these 20 patients, five developed frequent transient ischemic attacks in the initially asymptomatic side and underwent a second bypass surgery on that side (Group A), eight developed sporadic transient ischemic attacks and were followed up without surgery (Group B), and seven did not experience any ischemic symptoms on the asymptomatic side (Group C). RESULTS: In total, 18 patients progressed well without cerebral infarctions after their last surgery, although some showed deterioration of angiographic stenosis and a transient decrease in the regional cerebral blood flow or cerebral perfusion reserve. One patient in Group A had an intraventricular hemorrhage 5 years after the second operation, and one in Group B had a minor stroke on the initially asymptomatic side. CONCLUSION: In unilaterally symptomatic moyamoya disease, bypass surgery for the asymptomatic side can be delayed until the development of ischemic symptoms, such as frequent transient ischemic attacks.

scholarly journals Outcome of endovascular treatment within and beyond 6 h without perfusion software

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Zhen Jing ◽  
Hao Li ◽  
Shengming Huang ◽  
Min Guan ◽  
Yongxin Li ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
General Anesthesia ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Symptom Onset ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Group A ◽  
Group B

AbstractEndovascular treatment (EVT) has been accepted as the standard of care for patients with acute ischemic stroke. The aim of the present study was to compare clinical outcomes of patients who received EVT within and beyond 6 h from symptom onset to groin puncture without perfusion software in Guangdong district, China. Between March 2017 and May 2018, acute ischemic stroke patients who received EVT from 6 comprehensive stroke centers, were enrolled into the registry study. In this subgroup study, we included all patients who had acute proximal large vessel occlusion in the anterior circulation. The demographic, clinical and neuroimaging data were collected from each center. A total of 192 patients were included in this subgroup study. They were divided into two groups: group A (n = 125), within 6 h; group B (n = 67), 6–24 h from symptom onset to groin puncture. There were no substantial differences between these two groups in terms of 90 days favorable outcome (modified Rankin scale [mRS] ≤ 2, P = 0.051) and mortality (P = 0.083), and the risk of symptomatic intracranial hemorrhage at 24 h (P = 0.425). The NIHSS (median 16, IQR12-20, group A; median 12, IQR8-18, group B; P = 0.009) and ASPECTS (median 10, IQR8-10, group A; median 9, IQR8-10, group B; P = 0.034) at baseline were higher in group A. The anesthesia method (general anesthesia, 21.3%, group A vs. 1.5% group B, P = 0.001) were also statistically different between the two groups. The NIHSS and ASPECTS were higher, and general anesthesia was also more widely used in group A. Clinical outcomes were not significantly different within 6 h versus 6–24 h from symptom onset to groin puncture in this real world study.

A Randomized Clinical Trial of Proton Pump Inhibitors Combined with Traditional Chinese Medicine in the Treatment of Laryngopharyngeal Reflux Disease

2021 ◽  
Author(s):  
Feng Pei ◽  
Wei Jia Hu ◽  
Yi Nan Mao ◽  
Yu Liang Zhao
Keyword(s):  
Proton Pump ◽  
Reflux Disease ◽  
Laryngopharyngeal Reflux ◽  
Short Form ◽  
Therapeutic Effects ◽  
Reflux Symptom Index ◽  
Symptom Index ◽  
Laryngopharyngeal Reflux Disease ◽  
Group A ◽  
Group B

Background:To explore whether combined with TCM based on classical proton pumpinhibitors PPIs therapy can achieve better efficacy for patients withlaryngopharyngeal reflux disease. Methods: There were 150 laryngopharyngeal refluxpatients enrolled and divided into three groups randomly, with 50 cases in each group.Patients in group A were treated with the proton pump inhibitor (PPI) lansoprazole.Patients in group B were treated with lansoprazole combined with Banxia Houpudecoction, and patients in group C were treated with acupuncture treatments and acombination of Chinese and Western medicine. The reflux symptom index (RSI), refluxfinding score (RFS), and quality of life (36 item short form health survey questionnaire)were assessed before and 4 and 8 weeks after treatment. Results: The RSI and RFSscores of the three groups were significantly reduced after treatment (P < 0.001). Ingroup B and C, they were lower than in group A at 8 weeks (P < 0.01). The SF 36 scoreof 3 groups increased after treatment. At both 4 and 8 weeks (P < 0.001), and patientsin groups B and C scored higher than patients in group A (P < 0.001). The total effectiverate of group B and group C was higher than that of group A (P < 0.05). Conclusion:All three treatments have therapeutic effects on the disease, but the efficacy of a PPIalone is not as good as the combined treatments’ efficacies. Moreover, PPI combinedwith Banxia Houpu decoction and/or acupuncture treatment substantially affects lifeimprovement.

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