Efficacy of Prophylactic Blood Pressure Lowering according to a Standardized Postoperative Management Protocol to Prevent Symptomatic Cerebral Hyperperfusion after Direct Revascularization Surgery for Moyamoya Disease

Fujimura, Miki; Inoue, Takashi; Shimizu, Hiroaki; Saito, Atsushi; Mugikura, Shunji; Tominaga, Teiji

doi:10.1159/000336765

Cited by 113 publications

(94 citation statements)

References 71 publications

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“…13 For hyperperfusion management, strict perioperative blood pressure control is essential. 14 Recently, minocycline has also been reported to prevent hyperperfusion-related TNDs; the mechanism of this has been suggested to be similar to that of edaravone. 2 The present study had some limitations.…”

Section: Discussionmentioning

confidence: 99%

Edaravone Reduces Hyperperfusion-Related Neurological Deficits in Adult Moyamoya Disease

Uchino

Nakayama

Kazumata

et al. 2016

Stroke

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Background and Purpose-Postoperative hyperperfusion-related transient neurological deficits (TNDs) are frequently observed in adult patients with moyamoya disease who undergo direct bypass procedures. The present study evaluated the effect of the free radical scavenger edaravone on postoperative hyperperfusion in adult moyamoya disease. Methods-This study included 92 hemispheres in 72 adult patients who underwent direct bypass for moyamoya disease.Serial measurements of cerebral blood flow were conducted immediately after surgery and on postoperative days 2 and 7. In 40 hemispheres for 36 patients, edaravone (60 mg/d) was administered from the day of surgery to postsurgical day 7. The incidence of postoperative hyperperfusion and associated TNDs were compared with a control group that included 52 hemispheres in 36 patients. Results-Radiological hyperperfusion was observed in 28 of 40 (70.0%) and 39 of 52 (75.0%) hemispheres in the edaravone and control groups, respectively (P=0.30). Hyperperfusion-related TND incidences were significantly lower in the edaravone group compared with the control group (12.5% versus 32.7%; P=0.024). Multivariate analysis demonstrated that edaravone administration (P=0.009) and left-sided surgery (P=0.037) were significantly correlated with hyperperfusionrelated TNDs (odds ratios, 0.3 and 4.2, respectively). Conclusions-Perioperative administration of edaravone reduced the incidence of hyperperfusion-related TNDs after direct bypass procedures in adult patients with moyamoya disease.

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Section: Discussionmentioning

confidence: 99%

Edaravone Reduces Hyperperfusion-Related Neurological Deficits in Adult Moyamoya Disease

Uchino

Nakayama

Kazumata

et al. 2016

Stroke

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“…However, because revascularization using the indirect procedure often results in insufficient revascularization in adults, the direct/combined procedure has been increasingly used. 1,2,6,9,14,15,26,39,44 A limitation of this study was its retrospective nature. Because our surgical procedure also includes several steps of the indirect procedure (inverting dura matter, suturing temporalis muscle to the dura, and the placement of the pericranial flap), the result cannot be simply interpreted as a direct comparison between the direct STA-MCA bypass and indirect procedure alone.…”

Section: Discussionmentioning

confidence: 99%

The frequency of postoperative stroke in moyamoya disease following combined revascularization: a single-university series and systematic review

Kazumata

Ito

Tokairin

et al. 2014

JNS

162

111

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M oyaMoya disease (MMD) is a progressive stenoocclusive cerebrovascular disease characterized by collateral vascular networks that look like "a puff of smoke" (moyamoya vessels) at the base of the brain. 35,58 Various revascularization procedures have been shown to improve cerebral hemodynamics and decrease the risk of ischemic attack; however, hemodynamic compromises and bleeding-prone vasculopathy lead to postoperative neurological morbidity. In anesthesia management, hypocapnia during surgery induces critical decreases in cerebral blood flow. It is also well known that crying induces hyperventilation and stroke during the perioperative period in children. 45,51 Hemodynamic compromise is also aggravated by blood loss, decreased circulating volume, and low blood pressure. 38,53 Furthermore, recent studies have shown that postoperative hyperperfusion develops frequently after surgery. 11,60 A previous review suggested that direct and combined bypass for MMD provide better collateral circula- Object. Although combined direct and indirect anastomosis in patients with moyamoya disease immediately increases cerebral blood flow, the surgical procedure is more complex. Data pertinent to the postoperative complications associated with combined bypass are relatively scarce compared with those associated with indirect bypass. This study investigated the incidence and characteristics of postoperative stroke in combined bypass and compared them with those determined from a literature review to obtain data from a large population.Methods. A total of 358 revascularization procedures in 236 patients were retrospectively assessed by reviewing clinical charts and radiological data. PubMed was searched for published studies on surgical treatment to determine the incidence of postoperative complications in a larger population.Results. Seventeen instances of postoperative stroke were observed in 16 patients (4.7% per surgery, 95% CI 2.8%-7.5%). Postoperative stroke was more frequent (7.9% per surgery) in adults than in pediatric patients (1.7% per surgery, OR 4.07, 95% CI 1.12-14.7; p < 0.05). Acute progression of stenoocclusive changes were identified in the major cerebral arteries (anterior cerebral artery, n = 3; middle cerebral artery, n = 1; posterior cerebral artery, n = 2). The postoperative stroke rate was comparable with that (5.4%) determined from a literature search that included studies reporting more than 2000 direct/combined procedures. No differences in the stroke rates between the direct/combined and indirect procedures were found. In the literature review, direct/combined bypass was more often associated with excellent revascularization (angiographic opacification greater than two-thirds) than indirect bypass (p < 0.05).Conclusions. This experience of 358 consecutive procedures is one of the largest series for which the postoperative stoke rate for direct/combined bypass performed with a unified strategy has been reported. A systematic review confirmed that the postoperative stroke rate for the direct/combined pro...

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“…3,4 This hyperperfusion leads to transient neurological deterioration, seizures, or delayed intracerebral hemorrhage; therefore, early detection and careful management of hyperperfusion is mandatory after bypass for MMD. 6 However, the mechanism of postoperative hyperperfusion in MMD remains undetermined, and no evidence has been established to explain the difference in the frequency of postoperative hyperperfusion between MMD and atherosclerotic disease. In this study, we assessed the relationship between an ivy sign increase (de novo ivy sign) and postoperative hyperperfusion.…”

Section: Discussionmentioning

confidence: 99%

De Novo Ivy Sign Indicates Postoperative Hyperperfusion in Moyamoya Disease

Horie

Morikawa

Morofuji

et al. 2014

Stroke

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MethodsBeginning January 2010, consecutive patients with MMD who underwent STA-MCA anastomosis were prospectively analyzed. The indication for surgical revascularization was symptomatic or hemodynamic compromise on single-photon emission computed tomography. All patients were diagnosed with MMD according to angiographic Background and Purpose-The ivy sign on fluid-attenuated inversion recovery MRI is a specific finding in moyamoya disease (MMD). This sign indicates decreased cerebral perfusion, dilated pial vasculature, and slow leptomeningeal collateral flow. This study aimed to clarify the characteristics of perioperative changes in the ivy sign in relation to cerebral hyperperfusion, which frequently occurs in MMD of unknown pathogenesis. Methods-This prospective study included patients with MMD who underwent superior temporal artery-middle cerebral artery single bypass. Fluid-attenuated inversion recovery MRI was performed to evaluate the appearance of the ivy sign in the ipsilateral hemisphere preoperatively and on postoperative days 2 and 30. The ivy sign was assessed in combination with perioperative symptoms and cerebral hemodynamics using single-photon emission computed tomography. Results-Of 42 consecutive patients (55 sides) who underwent bypass surgery, 32 (58.2%) showed an increase in the ivy sign (de novo ivy sign) on postoperative day 2; this had disappeared by day 30. Interestingly, these 32 patients had a significantly higher incidence of hyperperfusion on single-photon emission computed tomography and hyperperfusion syndrome, and there was no correlation between the de novo ivy sign and a preoperative ivy sign or the preoperative cerebral hemodynamics. In multivariate analysis, a de novo ivy sign was significantly correlated with postoperative hyperperfusion. Conclusions-In

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Efficacy of Prophylactic Blood Pressure Lowering according to a Standardized Postoperative Management Protocol to Prevent Symptomatic Cerebral Hyperperfusion after Direct Revascularization Surgery for Moyamoya Disease

Cited by 113 publications

References 71 publications

Edaravone Reduces Hyperperfusion-Related Neurological Deficits in Adult Moyamoya Disease

Edaravone Reduces Hyperperfusion-Related Neurological Deficits in Adult Moyamoya Disease

The frequency of postoperative stroke in moyamoya disease following combined revascularization: a single-university series and systematic review

De Novo Ivy Sign Indicates Postoperative Hyperperfusion in Moyamoya Disease

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