Intraoperative transit-time ultrasonography combined with FLOW800 predicts the occurrence of cerebral hyperperfusion syndrome after direct revascularization of Moyamoya disease: a preliminary study.

BACKGROUND: Cerebral hyperperfusion syndrome (CHS) is a common complication after direct bypass surgery in patients with Moyamoya disease (MMD). Since preventive measures may be inadequate, we assessed whether the blood flow difference between the superficial temporal artery (STA) and recipient vessels (△BF) and the direct perfusion range (DPR) are related to CHS. METHODS: We measured blood flow in the STA and recipient blood vessels before bypass surgery by transit-time probe to calculate △BF. Perfusion changes around the anastomosis before and after bypass were analyzed with FLOW800 to obtain DPR. Multiple factors, such as △BF, DPR, and postoperative CHS, were analyzed using binary logistic regression. RESULTS: Forty-one patients with MMD who underwent direct bypass surgery were included in the study. Postoperative CHS symptoms occurred in 13/41 patients. △BF and DPR significantly differed between the CHS and non-CHS groups. The optimal receiver operating characteristic (ROC) curve cut-off value was 31.4 ml/min for ΔBF, and the area under the ROC curve (AUC) was 0.695 (sensitivity 0.846, specificity 0.500). The optimal cut-off value was 3.5 cm for DPR, and the AUC was 0.702 (sensitivity 0.615, specificity 0.750). CONCLUSION: Postoperative CHS is caused by multiple factors. △BF is a risk factor for CHS while DPR is a protective factor against CHS.

Characteristics of cognitive impairment in adult asymptomatic moyamoya disease.

BACKGROUND: Cognitive impairment in adult moyamoya disease (MMD) is thought to be the result of ischemic stroke; however, the presence and extent of cognitive decline in asymptomatic patients is unclear. METHODS: After classification using T2-weighted fluid attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI), a total of 19 MMD patients with a history of cerebral infarction, 21 asymptomatic MMD patients, and 20 healthy controls matched for age, sex, and years of education were prospectively included in this study. A detailed neuropsychological evaluation of two moyamoya subgroups and normal controls was conducted. RESULTS: Asymptomatic patients showed varying degrees of decline in intelligence (Raven's Standard Progressive Matrices, P = 0.001), spatial imagination (mental rotation, P = 0.014), working memory (verbal working memory-backward digit span, P = 0.011), and computational ability (simple subtraction, P = 0.014; complex subtraction, P < 0.001) compared with normal controls. MMD patients with cerebral infarction had more severe impairment in complex arithmetic (P = 0.027) and word short-term memory (P = 0.01) than those without symptoms. CONCLUSION: In asymptomatic MMD patients, a variety of cognitive impairment precedes the onset of clinical symptoms such as cerebral infarction, which may be a long-term complication of conservative treatment.

Supraorbital keyhole versus pterional craniotomies for ruptured anterior communicating artery aneurysms: a propensity score-matched analysis.

The safety and efficacy of the supraorbital keyhole approach for aneurysm surgery have not been well researched through a high-quality controlled study. The objective of the study was to compare the safety and efficacy of the supraorbital and pterional approaches for ruptured anterior communicating aneurysm (AComAn). A total of 140 patients, with 70 patients in each group, were enrolled after 1:1 propensity score matching. Clinical variables, postoperative complications, and long-term outcomes were retrospectively compared. Baseline characteristics were equivalent between the two groups. Significantly shorter operative time and less intraoperative blood loss were observed in the supraorbital group compared to the pterional group (141.9 min vs. 184.5 min, P < 0.001; 160.4 ml vs. 250.7 ml, P = 0.008). The incidence of intraoperative aneurysm rupture was similar between the groups (20% vs. 18.6%, P = 0.830). The rate of procedural complications involving subdural hematoma and intracranial infection was lower in patients treated through the supraorbital (10.0%) vs. the pterional approach (32.9%, P < 0.001), but no significant difference was observed for the incidence of ischemic events (15.7% vs. 18.6%, P = 0.654). Within a median 33.4-month (range, 11-67 months) follow-up, a similar proportion of patients achieved a favorable outcome (Glasgow Outcome Scale IV or V) across the two groups (83.6% vs. 80.0%, P = 0.285), while better cosmetic results were observed in the supraorbital group (94.0%) vs. the pterional group (86.2%, P = 0.129). According to our results, we recommend the keyhole approach for AComAn surgery for neurosurgeons who have gained sufficient experience with this technique due to its advantages over the pterional approach.

Carotid endarterectomy for treatment of carotid in-stent restenosis: long-term follow-up results and surgery experiences from one single centre.

OBJECTIVE: Few studies have reported the surgical treatment of carotid in-stent restenosis (ISR), more data and longer follow-up are needed. We describe the surgical treatment of ISR by standard carotid endarterectomy (CEA) with stent removal, including long-term follow-up in 10 patients from our centre. METHODS: Ten patients from our centre who underwent CEA with stent removal for ISR were retrospectively analysed, including nine symptomatic and one asymptomatic ISR of at least 70% with mean age 67.3, the median time between carotid artery stenting and CEA was 17 months (range, 2-54 months). RESULTS: Standard CEA with stent removal was performed in all 10 patients without much technical difficulty (9 male and 1 female, mean age 67.3). Two cases were performed in hybrid operation room. There were a total of three complications that happened in three patients (30%) respectively. An asymptomatic dissecting aneurysm was formed on the petrous internal carotid artery in one patient who was followed up without intervention. In the second case, dissection occurred in the arterial wall distal to the site of the stent after stent removal revealed by intraoperative angiography, and another stent was implanted. The patient sustained temporary hypoglossal nerve dysfunction postoperatively. The third patient suffered cerebral hyperperfusion with complete recovery when discharged. No neurological complications occurred in other seven patients. After follow-up of 25 months (range, 11-54 months), one patient died of rectal cancer without ischaemic attack and restenosis 4 years postoperation; in one patient occurred recurrent symptomatic restenosis (90%) 1 year later; all other patients remained asymptomatic and without recurrent restenosis (>50%) by follow-up carotid ultrasound or CT angiography. CONCLUSION: It seems that CEA with stent removal is a reasonable choice, by experienced hand, for symptomatic ISR with higher but acceptable complications. The indication of stent removal for asymptomatic ISR needs further observation.

More Precise Imaging Analysis and Diagnosis of Moyamoya Disease and Moyamoya Syndrome Using High-Resolution Magnetic Resonance Imaging.

BACKGROUND: The diagnosis of moyamoya disease (MMD) is often uncertain. Moyamoya syndrome (MMS) is often misdiagnosed as MMD. High-resolution magnetic resonance imaging (HR-MRI) enables vessel wall assessment to obtain more precise diagnoses. The aim of this study was to determine the true etiologies of arterial steno-occlusion in patients with an angiographic diagnosis of MMD or MMS using HR-MRI. METHODS: HR-MRI was performed in 21 adult patients with angiographically proven MMD or MMS. A definite diagnosis was based on the HR-MRI findings. The diagnoses made via the 2 different imaging technologies were compared, and significant findings were analyzed. RESULTS: A total of 21 patients were enrolled, including 7 patients with angiographically proven MMD and 14 patients with angiographically proven MMS. Among the 7 patients with MMD, HR-MRI confirmed the diagnosis of MMD in 6; the remaining patient was considered to have atherosclerosis in the bilateral distal internal carotid arteries (ICAs) and the left middle cerebral artery. Among the 14 patients with MMS, HR-MRI confirmed MMD in 6 patients (including 2 patients with unilateral MMD), atherosclerosis in 5 patients (including 3 patients with bilateral atherosclerosis and 2 with unilateral atherosclerosis), arterial dissection of the left ICA in 1 patient, and MMD in the left cerebral hemisphere with atherosclerosis in the right hemisphere in 2 patients. CONCLUSIONS: Differentiating MMD from MMS is difficult in certain situations, and HR-MRI may help provide a more in-depth understanding of MMD and MMS, thereby achieving a more reliable diagnosis.