Surgical Treatment of Adult Moyamoya Disease In Saudi Arabia: A Review Article

Moyamoya disease (MMD) is an isolated chronic, usually bilateral, vasculopathy disease of undetermined etiology. The clinical presentations of MMD include TIA, ischemic stroke, hemorrhagic stroke, seizures, headache, and cognitive impairment. Intra- and extra-cranial revascularization for the prevention of recurrence of bleeding in patients with hemorrhagic MMD is controversial. Surgical revascularization of MMD includes 3 types: Direct revascularization, indirect revascularization and combined revascularization. The surgical goal of cerebral revascularization is to prevent progression of symptomology, alleviate intracranial hemodynamic stress, and reduce the incidence of subsequent ischemic or hemorrhagic stroke. However, surgical treatments pose various complications due to the sudden increase in cerebral blood flow or hemodynamic changes caused by perioperative risk factors and anesthesia, such as HS, cerebral hemorrhage and cerebral infarction, bypass occlusion caused by distal vascular resistance, bypass occlusion caused by compression of the temporalis, and anastomotic aneurysm.

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Combined Direct and Indirect Revascularization is Associated With Low Rates of Recurrent Ischemic and Hemorrhagic Stroke in Adult Moyamoya Disease

Neurosurgery ◽

10.1227/neu.0000000000000792 ◽

2015 ◽

Vol 76 (6) ◽

pp. 789

Author(s):

&NA;

Keyword(s):

Moyamoya Disease ◽

Hemorrhagic Stroke ◽

Indirect Revascularization ◽

Adult Moyamoya Disease

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Combined Direct and Indirect Revascularization Is Associated With Low Rates of Recurrent Ischemic and Hemorrhagic Stroke in Adult Moyamoya Disease

Neurosurgery ◽

10.1227/01.neu.0000462695.46135.9a ◽

2015 ◽

Vol 76 (4) ◽

pp. N15-N16 ◽

Cited By ~ 4

Author(s):

Rami J. Aoun ◽

Samer G. Zammar ◽

Youssef Hamade ◽

Andrew Pines ◽

Catherine Casey Caughel ◽

...

Keyword(s):

Moyamoya Disease ◽

Hemorrhagic Stroke ◽

Indirect Revascularization ◽

Adult Moyamoya Disease

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Power Doppler imaging in detection of surgically induced indirect neoangiogenesis in adult moyamoya disease

Journal of Neurosurgery ◽

10.3171/jns.2005.103.5.0869 ◽

2005 ◽

Vol 103 (5) ◽

pp. 869-872 ◽

Cited By ~ 19

Author(s):

Fabienne Perren ◽

Peter Horn ◽

Peter Vajkoczy ◽

Peter Schmiedek ◽

Stephen Meairs

Keyword(s):

Moyamoya Disease ◽

Power Doppler ◽

Doppler Imaging ◽

Conventional Angiography ◽

Content Type ◽

Power Doppler Imaging ◽

Indirect Revascularization ◽

Adult Moyamoya Disease ◽

Surgically Induced ◽

Fine Print

Object. Moyamoya is a rare, chronic disease that leads to the progressive narrowing and/or occlusion of the distal internal carotid and proximal cerebral arteries. Chronic cerebral ischemia ensues due to insufficient collateral blood supply. One potential treatment consists of the restoration of regional cerebral blood flow by direct or indirect revascularization surgery. The extent of neovascularization, especially in indirect procedures such as encephalomyosynangiosis (EMS), is currently evaluated with conventional angiography. Because this method is invasive and carries some risks, the authors investigated power Doppler imaging as an alternative noninvasive bedside procedure that can be used to assess surgically induced indirect revascularization in adult patients with moyamoya disease. Methods. Twelve symptomatic patients with adult moyamoya disease (seven women and five men, mean age 38 ± 17 years) underwent combined (direct and indirect) revascularization. They were then examined using conventional angiography and power Doppler imaging to assess the extent of revascularization within 120 days postsurgery. According to the number of intracranial vessels demonstrating opacification on conventional angiography and power Doppler imaging studies, EMS was graded as follows: 1, absent (0 vessels); 2, moderate (one—four vessels); and 3, extensive (> four vessels) for both methods. Examiners were blinded to the classification results for the procedure that they did not grade. All 24 hemispheres were examined. The visual grading of EMS revealed a highly significant agreement between conventional angiography and power Doppler imaging (Spearman rank coefficient, r = 0.92; p < 0.001) and there was 100% agreement of patency of the bypass between the direct and indirect methods. Conclusions. The authors found excellent agreement between the two methods. Therefore, power Doppler imaging is a valid noninvasive alternative to carotid artery angiography in evaluating direct and indirect revascularization.

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Quantitative Angiographic Comparison With the OSIRIS Program Between the Direct and Indirect Revascularization Modalities in Adult Moyamoya Disease

Neurosurgery ◽

10.1227/neu.0b013e3182333c47 ◽

2012 ◽

Vol 70 (3) ◽

pp. 625-633 ◽

Cited By ~ 48

Author(s):

Jae Seung Bang ◽

O-Ki Kwon ◽

Jeong Eun Kim ◽

Hyun-Seung Kang ◽

Hyun Park ◽

...

Keyword(s):

Moyamoya Disease ◽

Indirect Revascularization ◽

Adult Moyamoya Disease

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Pedicled temporoparietal fascial flap for combined revascularization in adult moyamoya disease

Journal of Neurosurgery ◽

10.3171/2018.5.jns18938 ◽

2019 ◽

Vol 131 (5) ◽

pp. 1501-1507 ◽

Cited By ~ 1

Author(s):

Kristine Ravina ◽

Robert C. Rennert ◽

Ben A. Strickland ◽

Mark Chien ◽

Joseph N. Carey ◽

...

Keyword(s):

Moyamoya Disease ◽

Venous Drainage ◽

Mass Effect ◽

Occlusive Disease ◽

Large Area ◽

Fascial Flap ◽

Indirect Revascularization ◽

Direct Bypass ◽

Adult Moyamoya Disease ◽

Cerebrovascular Occlusive Disease

Moyamoya disease (MMD) is a progressive, idiopathic cerebrovascular occlusive disease. Various revascularization techniques including direct, indirect, and combined microvascular bypasses have been described. This article presents a modified revascularization technique for MMD utilizing a pedicled temporoparietal fascial flap (TPFF) for combined revascularization. This technique combines a large area of coverage for indirect revascularization with the benefits of a direct bypass. The pedicled TPFF also benefits from intact venous drainage to minimize the risk of flap swelling that could result in complications from mass effect.

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Intracranial Hemodynamic Changes During Adult Moyamoya Disease Progression

Journal of Clinical Neurology ◽

10.3988/jcn.2008.4.2.67 ◽

2008 ◽

Vol 4 (2) ◽

pp. 67 ◽

Cited By ~ 10

Author(s):

Hyun-Jeong Kwag ◽

Dong-Wook Jeong ◽

Suk Hoon Lee ◽

Dae Hyun Kim ◽

Jei Kim

Keyword(s):

Disease Progression ◽

Moyamoya Disease ◽

Hemodynamic Changes ◽

Adult Moyamoya Disease

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1165 Is hemorrhagic stroke the major clinical manifestation in adult moyamoya disease? A retrospective study since transcranial Doppler (TCD) was available to be a screen method for diagnosing the intracranial artery stenosis in Chinese

Journal of the Neurological Sciences ◽

10.1016/s0022-510x(05)81529-1 ◽

2005 ◽

Vol 238 ◽

pp. S397

Keyword(s):

Retrospective Study ◽

Clinical Manifestation ◽

Moyamoya Disease ◽

Transcranial Doppler ◽

Hemorrhagic Stroke ◽

Artery Stenosis ◽

Intracranial Artery ◽

Screen Method ◽

Intracranial Artery Stenosis ◽

Adult Moyamoya Disease

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Hemodynamic Study with Duplex Ultrasonography on Combined (Direct/Indirect) Revascularization in Adult Moyamoya Disease

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2014.05.024 ◽

2014 ◽

Vol 23 (10) ◽

pp. 2573-2579 ◽

Cited By ~ 8

Author(s):

Yong Wang ◽

Li Chen ◽

Yida Wang ◽

Huiwen Pan ◽

Yi Wang ◽

...

Keyword(s):

Moyamoya Disease ◽

Duplex Ultrasonography ◽

Indirect Revascularization ◽

Adult Moyamoya Disease ◽

Hemodynamic Study

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Can Combined Bypass Surgery at Middle Cerebral Artery Territory Save Anterior Cerebral Artery Territory in Adult Moyamoya Disease?

Neurosurgery ◽

10.1227/neu.0000000000001354 ◽

2017 ◽

Vol 80 (3) ◽

pp. 431-438 ◽

Cited By ~ 13

Author(s):

Won-Sang Cho ◽

Jeong Eun Kim ◽

Jin Chul Paeng ◽

Minseok Suh ◽

Yong-il Kim ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Moyamoya Disease ◽

Cerebral Artery ◽

Bypass Surgery ◽

Anterior Cerebral Artery ◽

Middle Cerebral Artery Territory ◽

Reservoir Capacity ◽

Hemodynamic Changes ◽

Adult Moyamoya Disease

Abstract BACKGROUND: Patients with moyamoya disease are frequently encountered with improved symptoms related to anterior cerebral artery territory (ACAt) and middle cerebral artery territory (MCAt) after bypass surgery at MCAt. OBJECTIVE: To evaluate hemodynamic changes in MCAt and ACAt after bypass surgery in adult moyamoya disease. METHODS: Combined bypass surgery was performed on 140 hemispheres in 126 patients with MCAt symptoms. Among them, 87 hemispheres (62.1%) accompanied preoperative ACAt symptoms. Clinical, hemodynamic, and angiographic states were evaluated preoperatively and approximately 6 months after surgery. RESULTS: Preoperative symptoms resolved in 127 MCAt (90.7%) and 82 ACAt (94.3%). Hemodynamic analysis of total patients showed a significant improvement in MCAt basal perfusion and reservoir capacity (P < .001 and P = .002, respectively) and ACAt basal perfusion (P = .001). In a subgroup analysis, 82 hemispheres that completely recovered from preoperative ACAt symptoms showed a significant improvement in MCAt basal perfusion and reservoir capacity (P < .001 and P = .05, respectively) and ACAt basal perfusion (P = .04). Meanwhile, 53 hemispheres that had never experienced ACAt symptoms significantly improved MCAt basal perfusion and reservoir capacity (P < .001 and P = .05, respectively); however, no ACAt changes were observed. A qualitative angiographic analysis demonstrated a higher trend of leptomeningeal formation from MCAt to ACAt in the former subgroup (P = .05). During follow-up, no ACAt infarctions were observed. CONCLUSION: Combined bypass surgery at MCAt resulted in hemodynamic improvements in ACAt and MCAt, especially in patients with preoperative ACAt symptoms.

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