Impact of Revascularization Timing on Clinical Outcomes of Symptomatic Moyamoya Disease: A Systematic Review and Multivariate Analysis

BACKGROUND AND OBJECTIVES

Despite a substantial body of literature describing the efficacy of revascularization compared with conventional management of moyamoya disease (MMD), the impact of the timing of revascularization relative to stroke onset remains inadequately characterized. The aim of this review was to synthesize existing research to guide clinicians in the optimal timing of revascularization in symptomatic MMD.

METHODS

A comprehensive literature review was performed to identify studies reporting on timing of revascularization. Studies were divided into revascularization within 3 months of stroke, between 3 and 6 months of stroke, or >6 months from stroke event.

RESULTS

A total of 3049 cases and 3151 treated cerebral hemispheres were included. There were 91 individuals (2.98%) in the 3 months to intervention cohort, 152 (4.92%) individuals in the 3 to 6 months to the intervention cohort, and 2806 (92.0%) individuals in the >6 months to the intervention cohort. The average follow-up time was 43.8 ± 35.19 months. Clinical improvement was reported in 83.4% of cases overall. The 3-to-6-month poststroke preoperative interval has the highest frequency of clinical improvement (90.2%), followed by the >6-month preoperative interval (83.4%). The preoperative interval of <3 months had the lowest frequency of clinical improvement (76.5%). Comparison of average treatment effect in the treated demonstrated reduced frequency of improved clinical outcome (Mean difference: -22.6, SE: 9.15, P = .013) and increased frequency of worse clinical outcome (Mean difference: 20.1, SE: 7.38, P = .006) in the <3 months cohort. The >6 months cohort was found to be associated with a reduced frequency of worse clinical outcome (Mean difference -1.81, SE: 0.349, P = .001).

CONCLUSION

The findings of this meta-analysis suggest that, in cases where it is clinically feasible to delay revascularization following an acute neurological event in patients with MMD, postponing intervention is warranted.

Risk factors associated with in-hospital complications for pediatric sickle-cell disease-associated moyamoya syndrome: a nationwide cross-sectional study

PURPOSE

Sickle-cell disease-associated moyamoya syndrome (SCD-MMS) carries a high risk for recurrent strokes and cerebrovascular morbidity in children. However, few data are available about complications that occur in children hospitalized with SCD-MMS. The purpose of this analysis was to determine the risk factors for in-hospital complications in pediatric SCD-MMS admissions, and thus aid physicians in optimizing future treatment plans.

METHODS

A national database of pediatric hospital admissions was examined across the years 2003-2019. ICD-9 and ICD-10 diagnosis codes were analyzed to identify discharges with a primary diagnosis of SCD-MMS and identify in-hospital complications, defined as complication-associated diagnostic codes logged during the same admission. Patient demographics, comorbidities, and hospital characteristics were examined using univariate and multivariate logistic regression analyses to determine associations with in-hospital complications.

RESULTS

In total, 274 admissions with a primary diagnosis of SCD-MMS were identified. During 64 (23.4%) admissions, transfusion therapy was given, and in 86 admissions (31.4%), surgical revascularization was performed. In 10 admissions (3.6%), a total of 11 in-hospital complications were identified. After multivariate regression, both comorbid chronic lung disease (adjusted OR 5.3 [1.1, 26.9], P = 0.04) and surgical revascularization (adjusted OR 10.2 [2.0, 52.4], P = 0.006) were associated with development of complications.

CONCLUSIONS

In this nationwide database of pediatric SCD-MMS hospitalizations, comorbid chronic lung disease and surgical revascularization were associated with development of in-hospital complications. Patients with comorbid chronic lung disease or who are admitted for revascularization may warrant closer monitoring and greater medical optimization during the hospitalization.

[Moyamoya disease in adults: treatment methods in modern era]

Moyamoya angiopathy is a chronic progressive cerebrovascular disease characterized by stenosis and occlusion of the distal segments of the internal carotid arteries and/or proximal segments of the middle and anterior cerebral arteries, with a gradual compensatory restructuring of the cerebral circulation to the system of the external carotid arteries. Today, the main treatment method for Moyamoya angiopathy is surgical revascularization of the brain. A search and analysis of publications on the treatment of adult patients with Moyamoya angiopathy was carried out in the PubMed and Medscape databases over the past 10 years. We present a case of an adult female patient with a hemorrhagic form of Moyamoya angiopathy stage IV according to J. Suzuki, who underwent staged combined revascularization of both cerebral hemispheres. Surgical revascularization included the creation of a low-flow extra-intracranial shunt combined with a combination of indirect synangiosis. The combination of direct and indirect methods of surgical revascularization enables to achieve the development of an extensive network of collaterals and fully compensate for cerebral circulatory disorders both in the early and late postoperative periods, which is confirmed by instrumental diagnostic data. Combined revascularization is the most effective modern method of treating patients with Moyamoya angiopathy due to the complementary influence of direct and indirect components of revascularization.

Safety and efficacy of remote ischemic conditioning in adult moyamoya disease patients undergoing revascularization surgery: a pilot study

Background and purpose

Revascularization surgery for patients with moyamoya disease (MMD) is very complicated and has a high rate of postoperative complications. This pilot study aimed to prove the safety and efficacy of remote ischemic conditioning (RIC) in adult MMD patients undergoing revascularization surgery.

Methods

A total of 44 patients with MMD were enrolled in this single-center, open-label, prospective, parallel randomized study, including 22 patients assigned to the sham group and 22 patients assigned to the RIC group. The primary outcome was the incidence of major neurologic complications during the perioperative period. Secondary outcomes were the modified Rankin Scale (mRS) score at discharge, at 90 days post-operation, and at 1 year after the operation. The outcome of safety was the incidence of adverse events associated with RIC. Blood samples were obtained to monitor the serum concentrations of cytokines (VEGF, IL-6).

Results

No subjects experienced adverse events during RIC intervention, and all patients could tolerate the RIC intervention in the perioperative period. The incidence of major neurologic complications was significantly lower in the RIC group compared with the control group (18.2% vs. 54.5%, P = 0.027). The mRS score at discharge in the RIC group was also lower than the control group (0.86 ± 0.99 vs. 1.18 ± 1.22, P = 0.035). In addition, the serum IL-6 level increased significantly at 7 days after bypass surgery in the control group and the serum level of VEGF at 7 days post-operation in the RIC group.

Conclusion

In conclusion, our study demonstrated the neuroprotective effect of RIC by reducing perioperative complications and improving cerebral blood flow in adult MMD patients undergoing revascularization surgery. Thus, RIC seems to be a potential treatment method for MMD.

Clinical trial registration

ClinicalTrials.gov, identifier: NCT05860946.