Intraoperative Anesthesiology Management and Patient Outcomes for Surgical Revascularization for Moyamoya Disease: A Review and Clinical Experience

Abstract

Background Moyamoya disease (MMD) is a rare cerebrovascular condition, often presenting as a headache or stroke in adults. Anesthetic management of this illness may challenge providers because it can affect the long-term neurologic outcome and hospital length of stay (LOS) in patients with MMD. Materials and Methods A literature search was conducted to assess etiology and epidemiology, as well as existing reports of intraoperative management of MMD. Due to sparse findings, the search was expanded to include studies of the use of intraoperative anesthetic agents during other neurosurgical procedures. We also retrospectively reviewed all MMD cases from January 1, 2009, to December 31, 2015, at Memorial Hermann Hospital-Texas Medical Center, where intraoperative management involved craniotomy and surgical revascularization. Data were collected primarily on the use of several anesthetic agents. The LOS and any adverse events were also recorded for each case. The data were divided into two equivalent case cohorts: (1) January 1, 2009, to February 18, 2013, and (2) February 19, 2013, to December 31, 2015. Results Remifentanil use notably increased between the first and second time periods while fentanyl use decreased. Desflurane usage also demonstrated an observed increase when our two cohorts were compared. Additionally, there was a decrease in the mean LOS between the first and second periods of 3.9 and 3.3 days, respectively. Conclusion Increasing use of remifentanil in MMD cases could be attributed to its ability to provide more stable hemodynamics during induction, maintenance, and emergence of anesthesia when compared with fentanyl. Lower systolic pressures, diastolic pressures, and heart rates were reported in patients receiving remifentanil over fentanyl.

The First 24 h Hemodynamic Management in NICU after Revascularization Surgery in Moyamoya Disease

“…Practically, the fluid management is part of the BP management. Patients with MMD can be hypotensive because preoperative fasting and intraoperative fluid loss often leave them in a state of dehydration [1,8,14,23]. Furthermore, the metabolism of residual anesthetics and the use of mannitol to improve brain edema will exacerbate early postoperative patients' insufficient fluid volume.…”

“…Efforts have been made to modify surgical modalities for better effect and fewer complications, but revascularization surgery of MMD may instantly aggravate the chaotic state of cerebral blood flow, causing acute stroke or hyperperfusion syndrome [4,[9][10][11][12]. During the perioperative period, the type of anesthetic drug, fluid resuscitation, blood loss and hematocrit (Hct), end tidal carbon dioxide (EtCO2), temperature regulation, urine output, and the type of surgical procedure being done may affect cerebral blood flow and cerebral perfusion pressure [8,[12][13][14]. Under these conditions, inadequate cerebral perfusion may augment the risk for the occurrence of cerebral infarctions in MMD with middle cerebral artery stenosis or carotid artery occlusion [13,15,16].…”

Perioperative Considerations for Revascularization and Non-Revascularization Surgeries in Moyamoya Disease

“…Anesthetic considerations for patients with MMD have been described in many literatures for both adult and pediatric populations [12][13][14][15][16][17][18][19]. Significant hemodynamic changes are expected throughout the perioperative period, and thus, it necessitates intensive care management.…”

“…The anesthetic management of MMD presents unique challenges, as it can ensue further complications of the disease. Therefore, in-depth knowledge of pathophysiology and institutional guidelines for intraoperative optimal care of MMD patients improves perioperative care and long term outcomes [14,17,20]. Most of the following discussion highlights general anesthetic consideration in MMD (see Table 3).…”