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1.
Acta Neurochir (Wien) ; 166(1): 303, 2024 07 23.
Artículo en Inglés | MEDLINE | ID: mdl-39042271

RESUMEN

BACKGROUND AND OBJECTIVES: STA-MCA bypass surgery is mainly used for Moyamoya disease, giant intracranial aneurysms, and resection of intracranial tumors requiring sacrifice of blood vessels. The intraoperative patency of the reconstructive vessels is critical to the efficacy of the procedure. This study aimed to evaluate the efficacy of intra-arterially infused tirofiban for the treatment of acute thrombosis during STA-MCA bypass surgery and countermeasures for acute thrombosis. METHODS: This study involved 209 patients (272 hemispheres) who underwent STA-MCA surgery between November 2020 and December 2023. Intraoperative acute thrombosis occurred in eight patients (3.83%,8 hemispheres). We retrospectively reviewed the clinical and imaging data, surgical procedure, and follow-up outcomes of eight patients. We implemented the different thrombolytic methods to evaluate the optimal thrombosis management during the bypass surgery. After three months, we assessed neurological functions using the modified Rankin Scale (mRS) and conducted a literature review using PubMed. RESULTS: Eight patients (four male patients and four female patients) developed acute thrombosis during the bypass surgery. Of the eight patients, two underwent re-anastomosis after thrombus removal, three received local injections of tirofiban into the anastomosis or the branches of the superficial temporal artery, and three underwent superselective intra-arterial tirofiban infusion using a microcatheter. Thrombosis were resolved, and arteries were recanalized in all patients. The mRS score was 0 in all patients. No major ischemic or hemorrhagic complications occurred. CONCLUSION: Our treatment methods were efficacious in the management of acute thrombosis. Intra-arterial tirofiban administration seems to be a simple and effective treatment option for acute thrombosis during STA-MCA bypass surgery.


Asunto(s)
Revascularización Cerebral , Tirofibán , Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Revascularización Cerebral/métodos , Revascularización Cerebral/efectos adversos , Tirofibán/uso terapéutico , Tirofibán/administración & dosificación , Estudios Retrospectivos , Arterias Temporales/cirugía , Arteria Cerebral Media/cirugía , Trombosis/etiología , Fibrinolíticos/uso terapéutico , Complicaciones Intraoperatorias/etiología , Resultado del Tratamiento , Terapia Trombolítica/métodos
2.
BMC Neurol ; 24(1): 198, 2024 Jun 12.
Artículo en Inglés | MEDLINE | ID: mdl-38867178

RESUMEN

BACKGROUND: At present, the most effective treatment for symptomatic moyamoya disease (MMD) is surgery. However, the high incidence of postoperative complications is a serious problem plaguing the surgical treatment of MMD, especially the acute cerebral infarction. Decreased cerebrovascular reserve is an independent risk factor for ischemic infarction, and the pulsatility index (PI) of transcranial Doppler (TCD) is a common intuitive index for evaluating intracranial vascular compliance. However, the relationship between PI and the occurrence of ischemic stroke after operation is unclear. OBJECTIVE: To explore whether the PI in the middle cerebral artery (MCA) could serve as a potential predictor for the occurrence of ischemic infarction after bypass surgery in MMD. METHODS: We performed a retrospective analysis of data from 71 patients who underwent combined revascularization surgery, including superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and encephalo-duro-myo-synangiosis (EDMS). The patients were divided into two groups according to the median of ipsilateral MCA-PI before operation, low PI group (MCA-PI < 0.614) and high PI group (MCA-PI ≥ 0.614). Univariate and multivariate regression analysis were used to explore risk factors affecting the occurrence of postoperative cerebral infarction. RESULTS: Among the 71 patients with moyamoya disease, 11 patients had cerebral infarction within one week after revascularization. Among them, 10 patients' ipsilateral MCA-PI were less than 0.614, and another one's MCA- PI is higher than 0.614. Univariate analysis showed that the lower ipsilateral MCA-PI (0.448 ± 0.109 vs. 0.637 ± 0.124; P = 0.001) and higher Suzuki stage (P = 0.025) were linked to postoperative cerebral infarction. Multivariate analysis revealed that lower ipsilateral MCA-PI was an independent risk factor for predicting postoperative cerebral infarction (adjusted OR = 14.063; 95% CI = 6.265 ~ 37.308; P = 0.009). CONCLUSIONS: A lower PI in the ipsilateral MCA may predict the cerebral infarction after combined revascularization surgery with high specificity. And combined revascularization appears to be safer for the moyamoya patients in early stages.


Asunto(s)
Infarto Cerebral , Revascularización Cerebral , Enfermedad de Moyamoya , Complicaciones Posoperatorias , Ultrasonografía Doppler Transcraneal , Humanos , Enfermedad de Moyamoya/cirugía , Enfermedad de Moyamoya/diagnóstico por imagen , Masculino , Femenino , Adulto , Infarto Cerebral/etiología , Infarto Cerebral/diagnóstico por imagen , Infarto Cerebral/epidemiología , Estudios Retrospectivos , Revascularización Cerebral/efectos adversos , Revascularización Cerebral/métodos , Ultrasonografía Doppler Transcraneal/métodos , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/diagnóstico por imagen , Arteria Cerebral Media/diagnóstico por imagen , Arteria Cerebral Media/cirugía , Flujo Pulsátil/fisiología , Adulto Joven , Factores de Riesgo
3.
J Neurosurg ; 141(4): 927-935, 2024 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-38579355

RESUMEN

OBJECTIVE: Cerebral infarction is a common complication in patients undergoing revascularization surgery for moyamoya disease (MMD). Although previous statistical evaluations have identified several risk factors for postoperative brain ischemia, the ability to predict its occurrence based on these limited predictors remains inadequately explored. This study aimed to assess the feasibility of machine learning algorithms for predicting cerebral infarction after revascularization surgery in patients with MMD. METHODS: This retrospective study was conducted across two centers and harnessed data from 512 patients with MMD who had undergone revascularization surgery. The patient cohort was partitioned into internal and external datasets. Using perioperative clinical data from the internal cohort, three distinct machine learning algorithms-namely the support vector machine, random forest, and light gradient-boosting machine models-were trained and cross-validated to predict the occurrence of postoperative cerebral infarction. Predictive performance validity was subsequently assessed using an external dataset. Shapley additive explanations (SHAP) analysis was conducted to augment the prediction model's transparency and to quantify the impact of each input variable on shaping both the aggregate and individual patient predictions. RESULTS: In the cohort of 512 patients, 33 (6.4%) experienced postrevascularization cerebral infarction. The cross-validation outcomes revealed that, among the three models, the support vector machine model achieved the largest area under the receiver operating characteristic curve (ROC-AUC) at mean ± SD 0.785 ± 0.052. Notably, during external validation, the light gradient-boosting machine model exhibited the highest accuracy at 0.903 and the largest ROC-AUC at 0.710. The top-performing prediction model utilized five input variables: postoperative serum gamma-glutamyl transpeptidase value, positive posterior cerebral artery (PCA) involvement on preoperative MRA, infarction as the rationale for surgery, presence of an infarction scar on preoperative MRI, and preoperative modified Rankin Scale score. Furthermore, the SHAP analysis identified presence of PCA involvement, infarction as the rationale for surgery, and presence of an infarction scar on preoperative MRI as positive influences on postoperative cerebral infarction. CONCLUSIONS: This study indicates the usefulness of employing machine learning techniques with routine perioperative data to predict the occurrence of cerebral infarction after revascularization procedures in patients with MMD.


Asunto(s)
Infarto Cerebral , Aprendizaje Automático , Enfermedad de Moyamoya , Complicaciones Posoperatorias , Humanos , Enfermedad de Moyamoya/cirugía , Enfermedad de Moyamoya/diagnóstico por imagen , Femenino , Masculino , Estudios Retrospectivos , Infarto Cerebral/etiología , Infarto Cerebral/diagnóstico por imagen , Adulto , Complicaciones Posoperatorias/etiología , Persona de Mediana Edad , Revascularización Cerebral/efectos adversos , Revascularización Cerebral/métodos , Adulto Joven , Máquina de Vectores de Soporte , Valor Predictivo de las Pruebas
4.
World Neurosurg ; 187: e610-e619, 2024 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-38677649

RESUMEN

OBJECTIVE: Transient neurological deficits (TNDs) are known to develop after direct bypass for Moyamoya disease and may be risk factors for subsequent stroke. However, the factors involved in the development of TNDs and stroke after indirect revascularization alone, including their association with subsequent stroke, remain unclear. The purpose of this study was to investigate this issue. METHODS: The subjects of the study were 30 patients with Moyamoya disease who underwent a total of 40 indirect revascularization procedures at our institution. Clinical and radiological data were collected retrospectively. To examine factors associated with the development of postoperative TND/stroke/asymptomatic disease, the clinical characteristics of each group were statistically compared. RESULTS: The mean age at surgery was 7 years (range 1-63). TNDs developed after surgery in 9 out of 40 patients (22.5%). Stroke in the acute postoperative period occurred in 3 patients (7.5%), all of whom experienced cerebral infarctions. Demographic data and preoperative clinical information were not different between the groups. However, posterior cerebral artery involvement on preoperative imaging was significantly associated with the development of TNDs and stroke (P = 0.006). Furthermore, postoperative stroke was associated with unfavorable outcomes (P = 0.025). CONCLUSIONS: Posterior cerebral artery involvement is significantly associated with the occurrence of TNDs. In contrast, TNDs after indirect revascularization have little relationship with the subsequent development of stroke. TNDs usually resolve without new strokes, and a better understanding of this particular pathology could help establish an optimal treatment regimen.


Asunto(s)
Revascularización Cerebral , Accidente Cerebrovascular Isquémico , Enfermedad de Moyamoya , Arteria Cerebral Posterior , Complicaciones Posoperatorias , Humanos , Enfermedad de Moyamoya/cirugía , Enfermedad de Moyamoya/diagnóstico por imagen , Enfermedad de Moyamoya/complicaciones , Femenino , Masculino , Revascularización Cerebral/efectos adversos , Revascularización Cerebral/métodos , Adulto , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Adolescente , Estudios Retrospectivos , Niño , Adulto Joven , Arteria Cerebral Posterior/diagnóstico por imagen , Arteria Cerebral Posterior/cirugía , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/etiología , Accidente Cerebrovascular Isquémico/cirugía , Preescolar , Lactante , Enfermedades del Sistema Nervioso/etiología , Enfermedades del Sistema Nervioso/epidemiología , Enfermedades del Sistema Nervioso/diagnóstico por imagen
5.
Zhonghua Yi Xue Za Zhi ; 104(15): 1310-1315, 2024 Apr 16.
Artículo en Chino | MEDLINE | ID: mdl-38637167

RESUMEN

Objective: To investigate the imaging factors associated with postoperative cerebral infarction in adult patients aged 18 and above with ischemic Moyamoya disease. Methods: The clinical data of adult patients who underwent surgeries for ischemic Moyamoya disease in the Department of Neurosurgery at Peking University International Hospital from October 2015 to October 2020 were retrospectively analyzed. Of the 239 patients, 120 were male and 119 were female, with ages ranging from 18 to 63 (41.7±10.3) years. A total of 239 patients(290 cases) underwent direct and indirect combined revascularization (CR).Gender, age, surgical side, preoperative transient ischemic attack (TIA), presence of old cerebral infarction, and imaging features were compared between the patients with (48 cases) and without (242 cases) cerebral infarction within 1 week after surgery. Multivariate logistic binary regression model was used to analyze the imaging risk factors of postoperative cerebral infarction. Results: Cerebral infarction occurred in 48 cases(16.5%) among the 290 CR group within 1 week after surgery. The proportion of patients with TIA, old cerebral infarction, ICA stenosis, A1 segment stenosis, M1 segment stenosis, abnormal posterior cerebral artery (PCA), and unstable compensation before CR in the cerebral infarction group was higher than that in the non-cerebral infarction group (P<0.05).Preoperative TIA (OR=4.514, 95%CI: 1.920-10.611), old cerebral infarction (OR=2.856,95%CI:1.176-6.936), A1 stenosis (OR=7.027,95%CI:1.877-26.308), M1 stenosis (OR=6.968,95%CI:2.162-22.459), abnormal PCA (OR=4.114,95%CI:1.330-12.728)and unstable compensation (OR=4.488,95%CI:1.194-16.865) were risk factors for cerebral infarction after CR surgery (all P<0.05). Conclusion: Among the imaging factors, TIA, old cerebral infarction, A1 stenosis, M1 stenosis, abnormal PCA and unstable compensation were risk factors for cerebral infarction in adult patients with ischemic Moyamoya disease treated by combined revascularization.


Asunto(s)
Revascularización Cerebral , Ataque Isquémico Transitorio , Enfermedad de Moyamoya , Adulto , Humanos , Masculino , Femenino , Enfermedad de Moyamoya/cirugía , Estudios Retrospectivos , Constricción Patológica/complicaciones , Revascularización Cerebral/efectos adversos , Revascularización Cerebral/métodos , Infarto Cerebral , Factores de Riesgo , Resultado del Tratamiento
6.
Turk Neurosurg ; 34(2): 289-298, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-38497182

RESUMEN

AIM: To evaluate and compare postoperative ischemic complications to determine the risk factors for ischemic complications following revascularization surgery for Moyamoya disease (MMD). MATERIAL AND METHODS: This single-center retrospective study included 266 procedures between 2016 and 2021. Three types of revascularization approaches including direct bypass, indirect bypass, and combined bypass were performed. To identify risk factors for postoperative ischemic complications and contralateral cerebral infarction, preoperative clinical characteristics and radiographic features were examined using multivariate and ordinal logistic regression analyses. RESULTS: Postoperative ischemic complications occurred in 103 (6.6%) procedures. Ischemic presentation (p=0.001, odds ratios [OR] 5.59, 95% confidence interval [CI] 2.05-15.23), hypertension (p=0.030, OR 2.75, 95%CI 1.11- 6.83), advanced Suzuki stage (p=0.006, OR 3.19, 95%CI 1.40-7.26), and collateral circulation (p=0.001 OR 0.17, 95%CI 0.06-0.47) were risk factors for postoperative ischemic complications. Ordinal regression analysis revealed that unilateral involvement (p=0.043, OR 2.70, 95%CI 0.09-5.31), hemorrhagic presentation (p=0.013, OR 3.45, 95%CI 0.72-6.18), surgical approach (p=0.032, OR -1.38, 95%CI -2.65, -0.12), and collateral circulation [p=0.043, OR -1 .27, 95%CI -2.51, -0.04)] were associated with the type of ischemic complications. History of hypertension (p=0.031) and contralateral computed tomography (CT) perfusion stage (p=0.045) were associated with contralateral infarction. CONCLUSION: Inability of cerebral vessels to withstand changes in blood pressure induced by revascularization-related hemodynamic instability might be associated with postoperative complications in patients with Moyamoya disease.


Asunto(s)
Revascularización Cerebral , Hipertensión , Enfermedad de Moyamoya , Humanos , Enfermedad de Moyamoya/complicaciones , Enfermedad de Moyamoya/diagnóstico por imagen , Enfermedad de Moyamoya/cirugía , Estudios Retrospectivos , Factores de Riesgo , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Revascularización Cerebral/efectos adversos , Revascularización Cerebral/métodos , Hipertensión/epidemiología , Hipertensión/complicaciones , Resultado del Tratamiento
7.
Nagoya J Med Sci ; 86(1): 82-90, 2024 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-38505724

RESUMEN

For patients with moyamoya disease, antiplatelet agents are often used during the perioperative periods of revascularization surgeries to prevent ischemic events. However, antiplatelet therapy is associated with the risk of hemorrhagic complications. Further, the influence of antiplatelet therapy on perioperative ischemic or hemorrhagic complications has not been investigated. This study aimed to determine the impact of antiplatelet agents on adult moyamoya disease patients with ischemic onset during the perioperative period. From January 2016 to December 2020, 183 consecutive combined (direct and indirect) revascularization surgeries for moyamoya disease patients were performed. Among these surgeries, 96 consecutive combined revascularization surgeries for adult moyamoya disease patients with ischemic onset were analyzed and perioperative ischemic and hemorrhagic complications were reviewed. Antiplatelet agents were continued during the perioperative period including on the day of surgery and the day after the surgery. Among 96 surgeries, no hemorrhagic complications occurred postoperatively. Infarction occurred in five cases (5.2%). Among the five cases, neurological deficits persisted in two cases and improved in three. The median value of bleeding volume was 112.5 mL (interquartile range, 80.0 - 200.0). Twenty-five cases (26.0%) needed blood transfusion. The modified Rankin Scale score deteriorated in two cases due to cerebral infarction. The incidence of hemorrhagic and ischemic complications after combined revascularization surgery in patients with ischemic moyamoya disease under antiplatelet therapy was low, indicating the safety of continued antiplatelet therapy.


Asunto(s)
Revascularización Cerebral , Enfermedad de Moyamoya , Adulto , Humanos , Inhibidores de Agregación Plaquetaria/efectos adversos , Resultado del Tratamiento , Enfermedad de Moyamoya/cirugía , Periodo Perioperatorio/efectos adversos , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Revascularización Cerebral/efectos adversos
8.
Curr Neurovasc Res ; 20(5): 623-629, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-38321905

RESUMEN

BACKGROUND: Cerebral hyperperfusion syndrome (CHS) is known as a complication after bypass surgery for Moyamoya disease (MMD). However, the incidence of CHS has not been accurately reported, and there is no consensus on the risk factors associated with it. AIM: The aim of this study was to determine the risk factors associated with postoperative CHS after surgical combined revascularization used to treat adult patients with MMD. OBJECTIVE: To assess the frequency and characteristics of CHS in patients with MMD after revascularization operations. METHODS: Patients who received combined revascularization from Jan 2021 to Nov 2022 were retrospectively reviewed. Preoperative clinical characteristics and radiographic features were recorded. Postoperative CHS after surgery were examined. Multivariate logistic regression analyses were performed to identify the risk factors for CHS. RESULTS: A total of 133 patients (141 hemispheres) were included in this study. Postoperative CHS were observed in 28 hemispheres (19.8%), including focal cerebral hyperperfusion syndrome (FCHS) in 20 hemispheres (14.2%), hemorrhage in 4 (2.8%) hemispheres, seizures in 4 (2.8%) hemispheres. The results of multivariate logistic regression analysis indicated that preoperative hypertension (OR 4.705, 95% CI 1.323 ~ 12.554, p = 0.014), cerebral hemorrhage onset (OR 5.390, 95% CI 1.408 ~ 20.642, p = 0.014) and higher Hct level (OR 1.171, 95% CI 1.051 ~ 1.305, p = 0.004) were significantly associated with CHS after combined revascularization. CONCLUSIONS: Preoperative hypertension, cerebral hemorrhage onset, and higher Hct level were independent risk factors for CHS after combined revascularization.


Asunto(s)
Revascularización Cerebral , Enfermedad de Moyamoya , Complicaciones Posoperatorias , Humanos , Enfermedad de Moyamoya/cirugía , Masculino , Femenino , Adulto , Factores de Riesgo , Revascularización Cerebral/efectos adversos , Revascularización Cerebral/métodos , Revascularización Cerebral/tendencias , Estudios Retrospectivos , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Adulto Joven , Circulación Cerebrovascular/fisiología , Adolescente , Trastornos Cerebrovasculares/etiología , Trastornos Cerebrovasculares/diagnóstico por imagen , Trastornos Cerebrovasculares/epidemiología
9.
J Stroke Cerebrovasc Dis ; 33(4): 107638, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-38360250

RESUMEN

OBJECTIVE: To assess the longitudinal evolution of cerebral perfusion after revascularization surgery in patients with moyamoya disease (MMD) by CT perfusion (CTP). MATERIALS AND METHODS: Thirty-one clinically confirmed MMD patients (12 males and 19 females, average age: 33.26 y, Suzuki stages 3 and 4: 19 and 11, respectively) who underwent revascularization surgery (bilateral (n=13) or unilateral (n=18)) were studied retrospectively. All patients underwent CTP examinations before and in the week after surgery and long-term (>3 months). CTP metrics (CBF, CBV, MTT, TTP, and delay TTP) were derived. The corresponding CTP metric values of the ROIs, which were manually drawn in the white matter (WM) and gray matter (GM), were recorded. RESULTS: Six patients developed a new or progressive cerebral infarction/hemorrhage. In all patients, compared with the preoperative level, the TTP of GM and WM decreased in the short term after the surgery (P ≤ 0.005). Concurrently, the WM CBF increased significantly a week after surgery (P =0.02). However, in the long-term follow-up, the CBV and CBF in the GM and WM decreased to equal to or lower than the preoperative level, especially for CBV in the WM (P =0.012). Furthermore, cerebral perfusion began to decrease in the sixth month, and a continuous decline was observed over the next two months. It returned to the presurgical level after one year. In addition, the improvement in postsurgical perfusion was greater in Suzuki stage 3 patients than stage 4 patients. CONCLUSION: Cerebral perfusion in patients with MMD improved shortly after surgery. However, in the long-term, brain perfusion decreased, most seriously in 6-8 months postoperatively, which might indicate that patients with MMD need timely follow-up and long-term intervention.


Asunto(s)
Revascularización Cerebral , Enfermedad de Moyamoya , Masculino , Femenino , Humanos , Adulto , Enfermedad de Moyamoya/diagnóstico por imagen , Enfermedad de Moyamoya/cirugía , Estudios Retrospectivos , Perfusión , Hemorragia Cerebral , Tomografía Computarizada por Rayos X , Circulación Cerebrovascular , Revascularización Cerebral/efectos adversos
10.
Neurol Med Chir (Tokyo) ; 64(3): 108-115, 2024 Mar 15.
Artículo en Inglés | MEDLINE | ID: mdl-38267055

RESUMEN

The opportunity to treat older patients with Moyamoya disease (MMD) is increasing. However, the surgical outcomes after combined direct and indirect revascularization for elderly patients with MMD are not fully understood, especially for those ≥60 years old. This retrospective study examined 232 consecutive hemispheres of 165 adults with MMD who underwent combined revascularization. Clinical features and surgical outcomes were compared between the elderly (≥60 years) and nonelderly group (<60 years). Thirteen (5.6%, 64.4 ± 4.0 years old) and 219 hemispheres (94.4%, 40.2 ± 10.8 years old) were included in the elderly and nonelderly group, respectively. The proportion of clinical presentations before surgery did not differ. However, the prevalence of hypertension and hyperlipidemia was significantly higher in the elderly group than in the nonelderly group. Meanwhile, hyperthyroidism was observed only in the nonelderly group. No significant intergroup differences were observed in the incidence of perioperative complications occurring within four weeks postsurgery. Notably, the elderly group was more prone to develop perioperative intracerebral hemorrhage (odds ratio (OR) 3.14, 95% confidence interval (CI) 0.45-13.5) than the nonelderly group. During a median follow-up period of 7.8 years, the incidence of stroke recurrence occurring later than four weeks postsurgery was not significantly different between the groups (hazard ratio, 1.19; 95% CI 0.133-10.6). The prevalence of independent outcomes (76.9% vs. 90.4%, P = 0.14) and mortality (7.7% vs. 1.4%, P = 0.21) did not differ significantly between the elderly and nonelderly groups, respectively. Perioperative intracerebral hemorrhage may be common in the elderly and should be considered to achieve a favorable surgical outcome.


Asunto(s)
Revascularización Cerebral , Enfermedad de Moyamoya , Adulto , Humanos , Anciano , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Enfermedad de Moyamoya/cirugía , Enfermedad de Moyamoya/complicaciones , Revascularización Cerebral/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Hemorragia Cerebral/complicaciones
12.
J Neurosurg Pediatr ; 33(2): 185-189, 2024 Feb 01.
Artículo en Inglés | MEDLINE | ID: mdl-37976515

RESUMEN

OBJECTIVE: Perioperative stroke is a major complication of revascularization surgery in patients with moyamoya. Vomiting is common after neurosurgical procedures and may result in acute changes in intracranial pressure and cerebral blood flow. The authors instituted a standardized perioperative nausea and vomiting protocol for children with moyamoya undergoing indirect bypass surgery at their institution and analyzed its association with perioperative stroke. They hypothesized that instituting a standardized perioperative nausea and vomiting protocol would be associated with reduction in the number of perioperative strokes in children with moyamoya undergoing indirect bypass surgery. METHODS: The authors retrospectively reviewed consecutive cases of children and young adults with moyamoya who underwent indirect bypass surgery before and after implementation of a new perioperative nausea and vomiting protocol at a single institution. They compared the rate of strokes in the perioperative period (postoperative days 0 and 1) in the 31 months following implementation to 31 months prior to implementation using Fisher's exact test. RESULTS: The median ages pre- and postimplementation were 8.5 (IQR 4-12) years and 8.3 (IQR 5-15) years, respectively. There were no significant differences between the cohorts in disease severity or other potentially confounding factors. In the 31 months prior to initiation of the perioperative nausea and vomiting protocol, there were 5 strokes in 137 surgically treated hemispheres (3.6%). After initiation of the protocol, there were no strokes in 114 surgically treated hemispheres (p = 0.065). CONCLUSIONS: Instituting a standardized perioperative nausea and vomiting protocol was associated with reduction in perioperative strokes in children with moyamoya treated with indirect bypass surgery.


Asunto(s)
Revascularización Cerebral , Enfermedad de Moyamoya , Accidente Cerebrovascular , Adulto Joven , Niño , Humanos , Preescolar , Estudios Retrospectivos , Resultado del Tratamiento , Revascularización Cerebral/efectos adversos , Revascularización Cerebral/métodos , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/cirugía , Atención Perioperativa , Enfermedad de Moyamoya/cirugía , Enfermedad de Moyamoya/complicaciones , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Náusea/complicaciones , Vómitos
13.
J Stroke Cerebrovasc Dis ; 33(1): 107476, 2024 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-37976795

RESUMEN

OBJECTIVES: Surgical revascularization for moyamoya arteriopathy decreases long-term stroke risk but carries a risk of perioperative ischemic complications. We aimed to evaluate modifiable stroke risk factors in children undergoing surgical revascularization for moyamoya. MATERIALS AND METHODS: In this exploratory, single-center, retrospective cohort study, medical records of pediatric patients undergoing surgical revascularization for moyamoya arteriopathy at our center between 2003 and 2021 were reviewed. Candidate modifiable risk factors were analyzed for association with perioperative stroke, defined as ischemic stroke ≤7 days after surgery. RESULTS: We analyzed 53 surgeries, consisting of 39 individual patients undergoing indirect surgical revascularization of 74 hemispheres. Perioperative ischemic stroke occurred following five surgeries (9.4%). There were no instances of hemorrhagic stroke. Larger pre-to-postoperative decreases in hemoglobin (OR 3.90, p=0.017), hematocrit (OR 1.69, p=0.012) and blood urea nitrogen (OR 1.83, p=0.010) were associated with increased risk of perioperative ischemic stroke. Weight-adjusted intraoperative blood loss was not associated with risk of perioperative ischemic stroke (OR 0.94, p=0.796). Among children with sickle cell disease, all of whom underwent exchange transfusion within one week prior to surgery, none experienced perioperative stroke. CONCLUSIONS: Decreases in hemoglobin, hematocrit, and blood urea nitrogen between the preoperative and postoperative periods are associated with increased risk of perioperative stroke. These novel findings suggest that dilutional anemia, possibly due to standardly administered hyperhydration, may increase the risk of perioperative stroke in some children with moyamoya. Further work optimizing both mean arterial pressure and oxygen-carrying capacity in these patients, including consideration of alternative blood transfusion thresholds, is necessary.


Asunto(s)
Anemia de Células Falciformes , Revascularización Cerebral , Accidente Cerebrovascular Isquémico , Enfermedad de Moyamoya , Accidente Cerebrovascular , Niño , Humanos , Estudios Retrospectivos , Resultado del Tratamiento , Revascularización Cerebral/efectos adversos , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/complicaciones , Anemia de Células Falciformes/complicaciones , Accidente Cerebrovascular Isquémico/complicaciones , Enfermedad de Moyamoya/complicaciones , Enfermedad de Moyamoya/diagnóstico por imagen , Enfermedad de Moyamoya/cirugía , Hemoglobinas , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología
14.
J Neurosurg Pediatr ; 33(1): 29-34, 2024 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-37856402

RESUMEN

OBJECTIVE: Transient neurological events (TNEs) are among the most important events after revascularization surgery in pediatric patients with moyamoya disease (MMD). Although hemodynamic changes and crying are representative factors of TNEs, brain compression by encephalomyosynangiosis (EMS) is another important cause of TNEs. Therefore, the authors assumed that making the EMS as thin as possible reduces the frequency of TNEs. However, thin-split EMS can lead to insufficient development of collateral vessels. This study aimed to evaluate the effects of thin-split EMS in combined revascularization surgery on postoperative outcomes in pediatric patients with MMD. METHODS: The authors retrospectively included 56 consecutive combined revascularization surgeries in the anterior cerebral circulation in pediatric patients with MMD. These surgeries were classified into the former group and thin-split EMS group. The temporal muscle was halved in the former EMS group and split as thinly as possible in the thin-split EMS group. The authors performed between-group comparisons of postoperative stroke events and TNEs during the acute period and the development of collateral flow and stroke events during the chronic period. RESULTS: Former and thin-split EMS procedures were performed in 37 and 19 patients, respectively. TNEs without crying or hemodynamic changes were observed significantly less frequently in the thin-split EMS group than in the former EMS group (0 [0.0%] in the thin-split EMS group vs 9 [24.3%] in the former EMS group, p = 0.021). There were no significant between-group differences in the development of indirect bypass during the chronic period (good: 34 [91.9%] and poor: 3 [8.1%] in the former EMS group vs good: 16 [84.2%] and poor: 3 [15.8%] in the thin-split EMS group; p = 0.397). Additionally, there were no significant between-group differences in the incidence of chronic clinical events, including death or stroke. CONCLUSIONS: Thin-split EMS can reduce TNEs that do not accompany crying or hemodynamic changes. Furthermore, the procedure has sufficient prevention effects against stroke events during the chronic postoperative period in pediatric patients with MMD.


Asunto(s)
Revascularización Cerebral , Enfermedad de Moyamoya , Accidente Cerebrovascular , Humanos , Niño , Enfermedad de Moyamoya/diagnóstico por imagen , Enfermedad de Moyamoya/cirugía , Enfermedad de Moyamoya/complicaciones , Estudios Retrospectivos , Revascularización Cerebral/efectos adversos , Revascularización Cerebral/métodos , Accidente Cerebrovascular/etiología , Complicaciones Posoperatorias/etiología
15.
J Cereb Blood Flow Metab ; 44(3): 345-354, 2024 03.
Artículo en Inglés | MEDLINE | ID: mdl-37910856

RESUMEN

Little has been reported about the association between cerebral hyperperfusion syndrome (CHS) and blood-brain barrier (BBB) disruption in human. We aimed to investigate the changes in permeability after bypass surgery in cerebrovascular steno-occlusive diseases using dynamic contrast-enhanced MRI (DCE-MRI) and to demonstrate the association between CHS and BBB disruption. This retrospective study included 36 patients (21 hemispheres in 18 CHS patients and 20 hemispheres in 18 controls) who underwent combined bypass surgery for moyamoya and atherosclerotic steno-occlusive diseases. DCE-MRI and arterial spin labeling perfusion-weighted imaging (ASL-PWI) were obtained at the baseline, postoperative state, and discharge. Perfusion and permeability parameters were calculated at the MCA territory (CBF(territorial), Ktrans(territorial), Vp(territorial)) and focal perianastomotic area (CBF(focal), Ktrans(focal), Vp(focal)) of operated hemispheres. As compared with the baseline, both CBF(territorial) and CBF(focal) increased in the postoperative period and decreased at discharge, corresponding well to symptoms in the CHS group. Vp(focal) was lower in the postoperative period and at discharge, as compared with the baseline. In the control group, no parameters significantly differed among the three points. In conclusion, Vp at the focal perianastomotic area significantly decreased in patients with CHS during the postoperative period. BBB disruption may be implicated in the development of CHS after bypass surgery.


Asunto(s)
Revascularización Cerebral , Trastornos Cerebrovasculares , Enfermedad de Moyamoya , Humanos , Barrera Hematoencefálica/diagnóstico por imagen , Estudios Retrospectivos , Imagen por Resonancia Magnética/métodos , Enfermedad de Moyamoya/diagnóstico por imagen , Enfermedad de Moyamoya/cirugía , Trastornos Cerebrovasculares/diagnóstico por imagen , Trastornos Cerebrovasculares/etiología , Periodo Posoperatorio , Circulación Cerebrovascular/fisiología , Revascularización Cerebral/efectos adversos , Revascularización Cerebral/métodos
16.
Neurocrit Care ; 40(2): 587-602, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-37470933

RESUMEN

BACKGROUND: Surgical revascularization decreases the long-term risk of stroke in children with moyamoya arteriopathy but can be associated with an increased risk of stroke during the perioperative period. Evidence-based approaches to optimize perioperative management are limited and practice varies widely. Using a modified Delphi process, we sought to establish expert consensus on key components of the perioperative care of children with moyamoya undergoing indirect revascularization surgery and identify areas of equipoise to define future research priorities. METHODS: Thirty neurologists, neurosurgeons, and intensivists practicing in North America with expertise in the management of pediatric moyamoya were invited to participate in a three-round, modified Delphi process consisting of a 138-item practice patterns survey, anonymous electronic evaluation of 88 consensus statements on a 5-point Likert scale, and a virtual group meeting during which statements were discussed, revised, and reassessed. Consensus was defined as ≥ 80% agreement or disagreement. RESULTS: Thirty-nine statements regarding perioperative pediatric moyamoya care for indirect revascularization surgery reached consensus. Salient areas of consensus included the following: (1) children at a high risk for stroke and those with sickle cell disease should be preadmitted prior to indirect revascularization; (2) intravenous isotonic fluids should be administered in all patients for at least 4 h before and 24 h after surgery; (3) aspirin should not be discontinued in the immediate preoperative and postoperative periods; (4) arterial lines for blood pressure monitoring should be continued for at least 24 h after surgery and until active interventions to achieve blood pressure goals are not needed; (5) postoperative care should include hourly vital signs for at least 24 h, hourly neurologic assessments for at least 12 h, adequate pain control, maintaining normoxia and normothermia, and avoiding hypotension; and (6) intravenous fluid bolus administration should be considered the first-line intervention for new focal neurologic deficits following indirect revascularization surgery. CONCLUSIONS: In the absence of data supporting specific care practices before and after indirect revascularization surgery in children with moyamoya, this Delphi process defined areas of consensus among neurosurgeons, neurologists, and intensivists with moyamoya expertise. Research priorities identified include determining the role of continuous electroencephalography in postoperative moyamoya care, optimal perioperative blood pressure and hemoglobin targets, and the role of supplemental oxygen for treatment of suspected postoperative ischemia.


Asunto(s)
Revascularización Cerebral , Enfermedad de Moyamoya , Accidente Cerebrovascular , Niño , Humanos , Técnica Delphi , Enfermedad de Moyamoya/cirugía , Accidente Cerebrovascular/etiología , Atención Perioperativa , Cuidados Posoperatorios , Revascularización Cerebral/efectos adversos , Resultado del Tratamiento , Estudios Retrospectivos
17.
J Neurol Neurosurg Psychiatry ; 95(3): 256-263, 2024 Feb 14.
Artículo en Inglés | MEDLINE | ID: mdl-37673641

RESUMEN

BACKGROUND: Moyamoya is a chronic occlusive cerebrovascular disease of unknown etiology causing neovascularization of the lenticulostriate collaterals at the base of the brain. Although revascularization surgery is the most effective treatment for moyamoya, there is still no consensus on the best surgical treatment modality as different studies provide different outcomes. OBJECTIVE: In this large case series, we compare the outcomes of direct (DR) and indirect revascularisation (IR) and compare our results to the literature in order to reflect on the best revascularization modality for moyamoya. METHODS: We conducted a multicenter retrospective study in accordance with the Strengthening the Reporting of Observational studies in Epidemiology guidelines of moyamoya affected hemispheres treated with DR and IR surgeries across 13 academic institutions predominantly in North America. All patients who underwent surgical revascularization of their moyamoya-affected hemispheres were included in the study. The primary outcome of the study was the rate of symptomatic strokes. RESULTS: The rates of symptomatic strokes across 515 disease-affected hemispheres were comparable between the two cohorts (11.6% in the DR cohort vs 9.6% in the IR cohort, OR 1.238 (95% CI 0.651 to 2.354), p=0.514). The rate of total perioperative strokes was slightly higher in the DR cohort (6.1% for DR vs 2.0% for IR, OR 3.129 (95% CI 0.991 to 9.875), p=0.052). The rate of total follow-up strokes was slightly higher in the IR cohort (8.1% vs 6.6%, OR 0.799 (95% CI 0.374 to 1.709) p=0.563). CONCLUSION: Since both modalities showed comparable rates of overall total strokes, both modalities of revascularization can be performed depending on the patient's risk assessment.


Asunto(s)
Revascularización Cerebral , Enfermedad de Moyamoya , Accidente Cerebrovascular , Humanos , Estudios Retrospectivos , Revascularización Cerebral/efectos adversos , Revascularización Cerebral/métodos , Resultado del Tratamiento , Accidente Cerebrovascular/etiología , Enfermedad de Moyamoya/cirugía
18.
Curr Probl Cardiol ; 49(1 Pt B): 102082, 2024 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-37714319

RESUMEN

To analyze the long-term results of transposition of the internal carotid artery (ICA) into the lateral wall of the external carotid artery (ECA) in the presence of hemodynamically significant stenosis of the ICA. During the period from 3.10.2017 to 28.12.2020, 784 patients with isolated hemodynamically significant ICA orifice stenosis were included in the present retrospective multicentric open comparative study "Russian Birch." Depending on the implemented surgical technique, groups were formed: group 1 (n = 517) - eversion carotid endarterectomy (eCEA); group 2 (n = 193) classic CEA with implantation of a xenopericardium patch treated with di-epoxy compounds; group 3 (n = 74) - transposition of the ICA into the lateral wall of the ECA. Transposition of the ICA into the lateral wall of the ECA is performed as follows. The common carotid artery, ECA, and ICA are isolated and then they are clamped with vascular clamps. At the same time, the ICA and ECA are clamped 4 cm above the orifice. The ICA is cut 2.5 cm above the orifice. Then the section of the ICA with local stenosis in the orifice is sutured with a polypropylene suture. At the same time, the redundant nonfunctioning ICA stump is not resected due to the fact that there are receptors of the carotid sinus at the ICA orifice. Thus, such manipulation may damage the sinus, causing arterial hypertension that is difficult to control in the postoperative period. Then, in the lateral wall of the ECA 2.5 cm above the orifice, a 0.5 cm diameter round hole is formed using a scalpel and angled vascular scissors. Then an end-to-side anastomosis between the severed section of the ICA and the rounded opening formed in the lateral wall of the ECA is performed using a polypropylene suture. Vascular clamps are removed and blood flow is started. No complications were detected in the hospital postoperative period. No adverse cardiovascular events were registered in group 3 in the long-term follow-up period. The group of classic CEA with implantation of a xenopericardium patch treated with di-epoxy compounds showed the highest number of fatal outcomes from acute cerebrovascular accident (CVA) (Group 1: 0.2%, n = 1; group 2: 2.6%; n = 5; p = 0.008); nonfatal ischemic CVA (group 1: 0.6%, n = 3; group 2: 14.0%, n = 27; p < 0.0001); ICA restenosis (more than 60%) requiring a repeat revascularization (group 1: 0.8%, n = 4; group 2: 16.6%, n = 32; p < 0.0001). The cause of all CVAs after classical CEA was restenosis of the ICA due to neointimal hyperplasia; after eversion CEA and progression of atherosclerosis. The composite end point was statistically more frequent after classical CEE with plasty of the reconstruction area with a diepoxy-treated xenopericardium patch (group 1: 1.0%, n = 5; group 2: 17.7%, n = 33; p < 0.0001). When analyzing the survival curves free of ICA restenosis, it was determined that the overwhelming number of all ICA restenosis requiring revascularization in the group of classical CEA with implantation of a diepoxy-treated xenopericardium patch is diagnosed as early as 6 months after surgery. In the group of eversion CEA, the loss of the vessel lumen is most often visualized more than a year after the intervention. When comparing the survival curves (Logrank test), it was determined that restenosis of the ICA develops statistically more frequently (p < 0.0001) after classical CEA with implantation of a diepoxytreated xenopericardium patch. Transposition of the ICA into the lateral wall of the ECA is not accompanied by the risk of ICA restenosis due to the absence of inflammation of the internal artery wall after endarterectomy. Thus, this technique can be an alternative to CEA and be routinely used in case of local hemodynamically significant stenosis of the ICA orifice. Classical CEA with patch implantation is the least preferable operation due to the high risk of ICA restenosis in the mid-term and long-term follow-up.


Asunto(s)
Estenosis Carotídea , Revascularización Cerebral , Accidente Cerebrovascular , Humanos , Arteria Carótida Interna/cirugía , Constricción Patológica/complicaciones , Estudios Retrospectivos , Revascularización Cerebral/efectos adversos , Polipropilenos , Resultado del Tratamiento , Estenosis Carotídea/cirugía , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico , Accidente Cerebrovascular/etiología , Compuestos Epoxi , Estudios Multicéntricos como Asunto
19.
BMC Anesthesiol ; 23(1): 419, 2023 12 19.
Artículo en Inglés | MEDLINE | ID: mdl-38114904

RESUMEN

BACKGROUND: Moyamoya disease (MMD) is a cerebrovascular disease with unknown cause. Patients with MMD disease usually experience transient neurological events (TNEs) after revascularization surgery. This retrospective single-center study was aimed to explore the risk factors of postoperative TNEs after surgical revascularization in patients with MMD. METHODS: We selected 324 patients who underwent surgical revascularization between January 2017 and September 2022 in our center. The perioperative characteristics of the patients were recorded and the outcome was TNEs after surgery. An analysis of risk factors contributing to postoperative TNEs by using logistic regression model. RESULTS: Three hundred twelve patients were enrolled, and the incidence of postoperative TNEs was 34% in our study. Males were more likely to suffer from postoperative TNEs (OR = 2.344, p = 0.002). Preoperative ischemic presentation (OR = 1.849, p = 0.048) and intraoperative hypotension (OR = 2.332, p = 0.002) were associated with postoperative TNEs. Compared to patients with blood type O, patients with blood type A (OR = 2.325, p = 0.028), B (OR = 2.239, p = 0.027) and AB (OR = 2.938, p = 0.019) had a significantly higher incidence of postoperative TNEs. A risk prediction model for postoperative TNEs was established, and the established risk prediction area under the receiver operating characteristic curve (ROC) of the model was 0.741. CONCLUSIONS: Males, preoperative ischemic presentation and intraoperative hypotension were associated with postoperative TNEs. We also found a possible link between postoperative TNEs and ABO blood types after surgical revascularization for moyamoya patients.


Asunto(s)
Revascularización Cerebral , Hipotensión , Enfermedad de Moyamoya , Masculino , Humanos , Estudios Retrospectivos , Enfermedad de Moyamoya/cirugía , Enfermedad de Moyamoya/complicaciones , Revascularización Cerebral/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Hipotensión/etiología , Resultado del Tratamiento
20.
Acta Neurochir (Wien) ; 165(12): 3613-3622, 2023 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-37993630

RESUMEN

PURPOSE: This study is aimed at analyzing clinical outcome, absence of stroke recurrence, revascularization, and complications and long-term follow-up in the surgical treatment of moyamoya angiopathy (MMA) using the multiple burr holes (MBH) technique with dura opening and arachnoid preservation as a single procedure. To the best of our knowledge, this is the first to describe an MBH technique with arachnoid preservation. METHOD: We retrospectively reviewed all patients operated from June 2001 to March 2021, for a symptomatic and progressive MMA operated with opening of the dura but arachnoid preservation. Clinical examinations were obtained in all patients, and radiological monitoring was performed by cerebral 3D-magnetic resonance angiography (MRA) with perfusion or single-photon emission computed tomography (SPECT) with acetazolamide. RESULTS: In total, 21 consecutive patients (6 children and 15 adults) were included with a mean age of 7.4 years in the pediatric group and 36.9 years in the adult group. Initial presentation was permanent ischemic stroke in 15 cases, transient ischemic attack (TIA) in 5 cases, and cerebral hemorrhage in one case. The MBH with dura opening and arachnoid preservation was performed bilaterally in 9 cases (43%) and unilaterally in 12 cases (57%). One patient died due to intraoperative bilateral ischemic stroke. Of the 20 other patients, 30% demonstrated clinical stability and 70% showed partial or complete recovery. Although one patient experienced a perioperative stroke, we did not observe any pseudomeningocele or postoperative ischemic stroke (IS) recurrence in all surviving cases during the average follow-up period of 55.5 months (range: 1-195). These outcomes emphasize the importance of preoperative monitoring to ensure the effectiveness and safety of the intervention. Postoperative angiography studies showed revascularization in 96.3% of treated hemispheres (100% in the adult group vs 80% in the pediatric group). CONCLUSIONS: Our results on this small cohort suggest that the MBH technique with opening of the dura and arachnoids preservation can prevent recurrent strokes and reduce the risk of pseudomeningocele.


Asunto(s)
Revascularización Cerebral , Accidente Cerebrovascular Isquémico , Enfermedad de Moyamoya , Accidente Cerebrovascular , Adulto , Niño , Humanos , Estudios Retrospectivos , Resultado del Tratamiento , Enfermedad de Moyamoya/diagnóstico por imagen , Enfermedad de Moyamoya/cirugía , Enfermedad de Moyamoya/complicaciones , Angiografía Cerebral , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular Isquémico/complicaciones , Revascularización Cerebral/efectos adversos , Revascularización Cerebral/métodos
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