Surgical revascularization vs. conservative treatment for adult hemorrhagic moyamoya disease: analysis of rebleeding in 322 consecutive patients

Yu, Shaojie; Zhang, Nan; Liu, Jian; Li, Changwen; Qian, Sheng; Xu, Yong; Yang, Tao; Li, Nan; Zeng, Minghui; Li, Dongxue; Xia, Chengyu

doi:10.1007/s10143-021-01689-w

Cited by 9 publications

(7 citation statements)

References 32 publications

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“…These findings are consistent with those of the bypass surgery trial in adult patients with MMD with hemorrhagic presentation in Japan and other observational studies. 8 , 13 , 14 , 15 However, a previous population‐based study in Korea failed to show the effectiveness of bypass surgery for mortality reduction compared with nonsurgical control. 2 Ahn et al note that their insignificant results might have arisen from selection bias and uncontrolled confounding factors such as disease severity.…”

Section: Discussionmentioning

confidence: 99%

Association of Bypass Surgery and Mortality in Moyamoya Disease

Park,

Han,

Jang

et al. 2023

JAHA

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Background Patients with moyamoya disease (MMD) have a high risk of stroke or death. We investigated whether extracranial to intracranial bypass surgery can reduce mortality by preventing strokes in patients with MMD. Methods and Results This nationwide retrospective cohort study encompassed patients with MMD registered under the Rare Intractable Diseases program via the Relieved Co‐Payment Policy between 2006 and 2019, using the Korean National Health Insurance Service database. Following a 4‐year washout period, landmark analyses were employed to assess mortality and stroke occurrence between the bypass surgery group and the nonsurgical control group at specific time points postindex date (1 month and 3, 6, 12, and 36 months). The study included 18 480 patients with MMD (mean age, 40.7 years; male to female ratio, 1:1.86) with a median follow‐up of 5.6 years (interquartile range, 2.5–9.3; mean, 6.1 years [SD, 4.0 years]). During 111 775 person‐years of follow‐up, 265 patients in the bypass surgery group and 1144 patients in the nonsurgical control group died (incidence mortality rate of 618.1 events versus 1660.3 events, respectively, per 10 5 person‐years). The overall adjusted hazard ratio (HR) revealed significantly lower all‐cause mortality in the bypass surgery group from the 36‐month landmark time point, for any stroke mortality from 3‐ and 6‐month landmark time points, and for hemorrhagic stroke mortality from the 6‐month landmark time point. Furthermore, the overall adjusted HRs for hemorrhagic stroke occurrence were beneficially maintained from all 5 landmark time points in the bypass surgery group. Conclusions Bypass surgery in patients with MMD was associated with a lower risk of all‐cause and hemorrhagic stroke mortality and hemorrhagic stroke occurrence compared with nonsurgical control.

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Section: Discussionmentioning

confidence: 99%

Association of Bypass Surgery and Mortality in Moyamoya Disease

Park,

Han,

Jang

et al. 2023

JAHA

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“…Surgical revascularization has been applied in the treatment and effectively improves the long-term outcome of MMD ( 13 , 14 ). Direct revascularization immediately improves impaired hemodynamic status after surgery, but ischemic parenchymal tissues are possibly unadaptable to dramatic hemodynamic changes.…”

Section: Discussionmentioning

confidence: 99%

The Recipient Vessel Hemodynamic Features Affect the Occurrence of Cerebral Edema in Moyamoya Disease After Surgical Revascularization: A Single-Center Retrospective Study

Tong

et al. 2022

Front. Neurol.

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ObjectiveIn moyamoya disease (MMD) with direct or combined revascularization, the initially hemodynamic recipient features are likely one of the main causes of acute hemodynamic disruption. Previous studies have explored the relationship between recipient diameter or flow velocity and postoperative complications, but there are still no optimal selection criteria with multiple potential recipient vessels. Cerebral edema is one of the most common radiological manifestations in the acute postoperative period. This study assessed the hemodynamic characteristics of cortex vessels related to postoperative cerebral edema.MethodsAll patients who had undergone direct or combined revascularization with preoperative digital subtraction angiography (DSA) between 2019 and 2021 were eligible for inclusion in this study. The application of DSA was performed and regular radiological examinations were employed after surgery. DSA was analyzed with the hemodynamic features within chosen recipient vessels. Cerebral edema was identified as a low-density image on CT or high signaling in the MRI T2 phase. The recipient hemodynamic characteristics and demographic presentation, as well as clinical data, were retrospectively analyzed in this study.ResultsA total of 103 patients underwent direct or combined revascularization with preoperative DSA. The mean age of this enrolled cohort was 44.31 ± 10.386 years, in which bilaterally involved MMD accounted for the main part. The preliminary correlation analysis found preoperative disease period (p = 0.078), recipients observed in angiography (p = 0.002), and surgery on the left (p = 0.097) may be associated with cerebral edema. The following regression analysis confirmed low occurrence of cerebral edema was accompanied by recipients observed in angiography (p = 0.003). After subdividing by flow direction and hemodynamic sources, the incidence rate of anterograde direction, anterior sources, and posterior sources were significantly lower than undetected recipients.ConclusionsCerebral edema is a common radiological manifestation in MMDs after surgery. In this study, the observation in angiography reliably identifies a variety of physiological or pathological recipient detection, flow direction, and hemodynamic sources in patients with MMD after revascularization, which indicates the selection strategy of potential recipients and highlights the importance of recipient observability in DSA. Meanwhile, vascular conditions determined by recipient hemodynamics meditate the occurrence of postoperative cerebral edema.

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“…These fragile collateral vessels, while compensatory, introduce a pronounced susceptibility to rupture and intracerebral hemorrhage. Notably, revascularization techniques can alleviate the stresses on these collaterals, thus mitigating rupture risk[ 10 ]. Contrastingly, spontaneous intracerebral hemorrhage predominantly originates from microaneurysm rupture, frequently corollary to chronic hypertension[ 11 ].…”

Section: Introductionmentioning

confidence: 99%

Is medical management useful in Moyamoya disease?

Muengtaweepongsa,

Panpattanakul

2024

World J Clin Cases

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Moyamoya disease (MMD), characterized by progressive internal carotid artery stenosis and collateral vessel formation, prompts cerebral perfusion complications and is stratified into idiopathic and Moyamoya syndrome subtypes. A multifaceted approach toward MMD management addresses cerebral infarctions through revascularization surgery and adjunctive medical therapy, while also navigating risks such as intracranial hemorrhage and cerebral infarction resulting from arterial stenosis and fragile collateral vessels. Addressing antithrombotic management reveals a potential role for treatments like antiplatelet agents and anticoagulants, despite the ambiguous contribution of thrombosis to MMD-related infarctions and the critical balance between preventing ischemic events and averting hemorrhagic complications. Transcranial doppler has proven useful in thromboembolic detection, despite persisting challenges concerning the efficacy and safety of antithrombotic treatments. Furthermore, antihypertensive interventions aim to manage blood pressure meticulously, especially during intracerebral hemorrhage, with recommendations and protocols varying based on the patient’s hypertension status. Additionally, lipid-lowering therapeutic strategies, particularly employing statins, are appraised for their possible beneficial role in MMD management, even as comprehensive data from disease-specific clinical trials remains elusive. Comprehensive guidelines and protocols to navigate the multifaceted therapeutic avenues for MMD, while maintaining a delicate balance between efficacy and safety, warrant further meticulous research and development. This protocol manuscript seeks to elucidate the various aspects and challenges imbued in managing and navigating through the complex landscape of MMD treatment.

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Surgical revascularization vs. conservative treatment for adult hemorrhagic moyamoya disease: analysis of rebleeding in 322 consecutive patients

Cited by 9 publications

References 32 publications

Association of Bypass Surgery and Mortality in Moyamoya Disease

Association of Bypass Surgery and Mortality in Moyamoya Disease

The Recipient Vessel Hemodynamic Features Affect the Occurrence of Cerebral Edema in Moyamoya Disease After Surgical Revascularization: A Single-Center Retrospective Study

Is medical management useful in Moyamoya disease?

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