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

We determined the time course of bronchial blood flow alterations after pulmonary microembolization. Embolization was induced by injecting 100-micrometers-diam glass beads into the right atrium so as to increase pulmonary arterial pressure from 13.8 +/- 1.8 to 35.7 +/- 2.6 Torr in 14 dogs. The increase in pulmonary vascular resistance averaged threefold after embolization (PE). The bronchial blood flow (Qb) was measured using the reference sample method with the 15 +/- 5-micrometers-diam labeled microspheres injected into the left atrium. Simultaneous blood reference samples were collected at constant rates from a femoral artery and the pulmonary artery. The pulmonary arterial reference sample was used to quantify the contribution of peripheral arteriovenous shunts to the total pulmonary activity, and the femoral arterial reference blood was used to quantify Qb. The Qb was decreased to one-third of its base-line value at 60-min PE (P less than 0.05) but not at 5 min PE. Qb was increased 300% at 2 wk PE. The decrease in flow was associated with an increased bronchovascular resistance, whereas the increase in flow was associated with a decreased resistance. The decrease in Qb at 60 min PE may be due to release of peripheral vasoconstrictor substances associated with pulmonary embolism. The finding that bronchial perfusion increased gradually after pulmonary vascular obstruction suggests that increased flow is due to neovascularization.

Structure-based constitutive modeling investigates the mechanical aspects of myocardial remodeling in response to pulmonary arterial hypertension.

Multipoint laser Doppler velocimetry provides three-dimensional in vivo observation of blood flow velocity and blood vessel position.