(Stroke. 1996;27:282-289.)
© 1996 American Heart Association, Inc.
Articles |
Preoperative and Postoperative Evaluation of Cerebral Perfusion and Vasodilatory Capacity With 99mTc-HMPAO SPECT and Acetazolamide in Childhood Moyamoya Disease
From the Department of Neurosurgery, Osaka Neurological Institute (Japan).
Correspondence to Hajime Touho, MD, Department of Neurosurgery, Osaka Neurological Institute, 2-6-23 Shonai Takara-machi, Toyonaka, Osaka 561, Japan.
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Abstract |
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Background and Purpose The results of long-term follow-up studies of cerebral perfusion and vasodilatory capacity following administration of acetazolamide after serial vascular reconstructions in 25 patients with childhood moyamoya disease are reported.
Methods Cerebral perfusion was measured with 99mTc-hexamethylpropyleneamine oxime single-photon emission CT before and after IV administration of 10 mg/kg acetazolamide, which was performed both before and after vascular reconstruction by superficial temporal artery-middle cerebral artery anastomosis and encephalomyosynangiosis (first and second operations) and/or omental transplantation to the brain (third operation).
Results Follow-up periods ranged between 12 and 24 months (mean±SD, 18.5±3.2 months) after the first operation. Repetitive transient ischemic attacks disappeared completely after serial vascular reconstructions in all patients. Before the first operation, cerebral perfusion in the territory of the middle cerebral artery on the side of initial operation was 83.9±4.7% and was significantly lower than that in the contralateral side (88.3±4.9%, n=25; P<.0001, paired t test). Vasodilatory capacity on the side of the first operation was -18.4±2.5% and that on the contralateral side -14.4±2.1%. The former value was significantly lower than the latter value (n=25; P<.0001, paired t test). After the first operation, cerebral perfusion and vasodilatory capacity on the side of initial operation were markedly improved, to 87.8±4.5% and -14.7±2.7%, respectively (n=25; P<.0001, both cases, paired t test). Before the second operation, cerebral perfusion and vasodilatory capacity on the side of the second operation were 76.6±4.1% and -20.1±1.9%, respectively, and significantly lower than those before the first operation (n=25; P<.0001, both cases, paired t test). Eight patients subsequently required bifrontal omental transplantation for repetitive paraparetic transient ischemic attacks after the second operation; they had low cerebral perfusion and vasodilatory capacity bilaterally in the territories of the anterior cerebral arteries (72.4±2.7% and -18.6±1.7%, respectively). After omental transplantation, both were significantly increased, to 81.9±3.4% and -11.8±1.9%, respectively (n=25; P<.0001, both cases, paired t test).
Conclusions Hemodynamic compromise existed in patients with childhood moyamoya disease and was a major cause of development of ischemic symptoms. Regions in which hemodynamic compromise was present could be determined by measuring regional cerebral perfusion and vasodilatory capacity.
Key Words: acetazolamide • child • moyamoya disease • perfusion • vasodilation
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Introduction |
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TopAbstractIntroductionSubjects and Methods Results Discussion References |
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Moyamoya disease is a chronically progressive cerebrovascular occlusive disease affecting the territories of the ACA, MCA, and PCA. In recent years, a number of reports of vascular reconstruction in patients with moyamoya disease have appeared.1 2 3 4 5 6 7 8 9 10 11 12 Understanding cerebral hemodynamics is thought to be essential in determining the indications for vascular reconstruction in patients with childhood moyamoya disease. Decreased cerebral blood flow, increased cerebral blood volume, and reduced reactivity to acetazolamide or carbon dioxide have been demonstrated in patients with moyamoya disease.13 14 15 16 17 18 19 20 21 However, long-term follow-up studies of CP and hemodynamic reserve after vascular reconstruction for moyamoya disease have not been reported.
In this report we describe the results of long-term follow-up studies of CP and VDC before and after administration of acetazolamide before and after serial vascular reconstructions; we also report our findings concerning the usefulness of these parameters for detecting regions of low perfusion and hemodynamic compromise and for determining regions of vascular reconstruction in childhood moyamoya disease.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and Methods Results Discussion References |
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Subjects
Between February 1992 and December 1994, 72 patients with childhood moyamoya disease were admitted to and underwent surgery in our institute. We selected 25 patients from among these 72 for this study. These 25 patients underwent bilateral STA-MCA anastomosis3 and EMS,1 reconstructing first one side and then the other, or bilateral reconstruction for failed EDAS,5 reconstructing first one side and then the other, and/or intracranial OMT2 4 8 (the latter in 9 of the 25 patients). CP studies with the use of 99mTc-HMPAO SPECT were completed both before and after these operations. Two of the 25 patients had previously undergone EDAS bilaterally but had developed no collaterals to the brain via the indirectly anastomosed STA. We performed bilateral vascular reconstruction for the failed EDAS, reconstructing first one side and then the other.10 All patients were initially treated with unilateral STA-MCA anastomosis or vascular reconstruction for failed EDAS. The cerebral hemisphere to be treated was determined based on the side of appearance of cerebral ischemia, including hemiparesis. After the first operation, ischemic symptoms of hemiparesis on the contralateral side appeared, and patients underwent the same surgical procedure on the contralateral cerebral hemisphere.
The 25 patients had experienced only
TIAs and/or minor completed
stroke, and CT scans demonstrated either no low-density areas or
only small low-density areas in the cortex or subcortex (Table
1
).
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CP Studies
CP was measured by 99mTc-HMPAO
SPECT,22 which was performed with the use of a
triple-headed SPECT system (Neurocam, General Electric Co) with
low-energy parallel hole collimators. Patients were placed in the
supine position with head fixed in a hemicylindrical plastic head
holder. The orbitomeatal line served as the reference for patient
position. During the examination, changes in the relative position of
the patient's head were carefully monitored.
We prepared 99mTc-HMPAO using a nonradioactive kit (Ceretec, Amersham International plc) in accordance with the manufacturer's recommendations. After ligand preparation, a 185-MBq solution was withdrawn from the vial and immediately injected into the patient after completion of quality control. The injection was made with the patient's eyes closed. Data acquisition was begun 5 minutes after the injection with a three-headed rotating gamma camera, and at the same time 10 mg/kg of acetazolamide was injected IV.23 After the rotation of each gamma camera with a three-step angle, with one step each 18 seconds, and with the use of a 128x128 acquisition matrix, projection data from 128 steps were acquired over a 15-minute period. Sorenson's technique (attenuation coefficient (µ)=0.11 cm-l) was used for collection of attenuation data, and a 0.55 cycle per pixel cutoff frequency for the Butterworth filter was used to generate reconstructed images. After completion of data acquisition in the baseline examination, which required 15 minutes, 259 MBq of 99mTc-HMPAO was injected, and data acquisition was restarted 5 minutes after this second injection of tracer. The acquired data yielded combined preacetazolamide/postacetazolamide acquisition values, and decay-corrected subtraction of the preacetazolamide acquisition values from the combined preacetazolamide/postacetazolamide acquisition values yielded postacetazolamide values.24
ROIs were established on the CP map obtained by
99mTc-HMPAO
SPECT before and after administration of acetazolamide in
the cerebellum (ROI0) and bilaterally in the territory of
the MCA (ROI1 and ROI2), the ACA
(ROI3 and ROI4), and the PCA (ROI5
and ROI6). ROI1,
ROI3, and ROI5 were on the initial side
of operation, and ROI2, ROI4, and
ROI6 were on the second side of operation (Fig 1).
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The value obtained from the division of RU in each supratentorial ROI by the average RU in ROI0 was defined as CP (expressed as a percentage) in each territory. The change in CP after administration of acetazolamide was defined as VDC (expressed as a percentage). By definition, if the percentage of acetazolamide-induced increase in perfusion in the cerebrum equals that in the cerebellum, the VDC is zero. These relationships may be expressed as follows:
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CP and VDC in the bifrontal regions were defined as follows and measured before and after bilateral OMT:
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Operative
Procedures
Twenty-three of the 25 patients had not been treated for
moyamoya disease before admission to our institute and therefore
underwent bilateral STA-MCA anastomosis and EMS, reconstructing first
one side and then the other. Six of these 23 patients then underwent
bifrontal OMT for the treatment of ischemic symptoms in the
territories of the ACAs bilaterally. One patient (patient 6) had
repetitive TIAs with blindness even after bilateral STA-MCA anastomosis
and EMS and therefore underwent bioccipital OMT.
Two patients who had been treated with bilateral EDAS had repetitive TIAs and/or minor completed stroke bilaterally and underwent bilateral vascular reconstruction for failed EDAS, reconstructing first one side and then the other (patients 2 and 12). Moreover, they suffered paraparetic TIAs after these procedures and were treated with bifrontal OMT.
Clinical, radiological, and hemodynamic follow-up studies were performed two or three times after the first operation. The first evaluation was performed before the first operation, the second after the first operation and just before the second operation, and the third after the second operation. For the nine patients who underwent OMT, the fourth evaluation was performed after OMT.
The
second operation was performed 2 to 9 months (mean, 3.8±1.4
months) after the first operation. The third operation (OMT) was
performed 2 to 6 months (mean, 4.2±1.2 months) after the second
operation. Follow-up periods varied between 12 and 24 months (mean,
18.5±3.2 months) after the first operation (Table 1
).
Control Studies
CP and VDC were measured in 10 healthy
children who were
siblings of children with moyamoya disease. The parents of these
children wanted them examined with MR angiography and
acetazolamide-loading 99mTc-HMPAO SPECT to
determine whether they had moyamoya disease. The 10 children were
first clinically examined and then underwent electroencephalography, CT
studies, MR angiography, and CP studies with the use of
99mTc-HMPAO SPECT and acetazolamide. These
examinations disclosed no abnormalities in any of the 10 children,
whose ages ranged from 3 to 12 years (mean, 7.8±2.5
years).
Control CP and VDC values were defined as follows:
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Statistical analysis was performed with the use of Student's paired or unpaired t test.
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Results |
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TopAbstractIntroductionSubjects and Methods Results Discussion References |
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Clinical Outcome
Twenty patients had only TIAs during their clinical course and after surgical interventions. TIAs disappeared completely within 3 months postoperatively. The remaining 5 patients had minor completed stroke and repetitive TIAs during their clinical course, and TIAs completely disappeared and persistent symptoms due to minor completed stroke partially improved within 3 months postoperatively (Table 1
).
Angiographic Findings
In all patients, development of new
collateral circulation
via the STA-MCA anastomosis and EMS was classified as excellent, as
described by Touho et al.10 In these patients, more than
three cortical branches of the MCA were clearly visualized via the
anastomosis.
The development of collateral circulation via the OMT was classified as excellent, as described by Touho et al, in 5 patients who underwent bifrontal OMT. In these patients, bifrontal lobes were supplied via the OMT (excellent collaterals). The other 3 patients who underwent bifrontal OMT had good collaterals via the omentum to the brain. In the latter 3 patients, the unilateral frontal lobe was supplied via the OMT and the contralateral side was via transdural anastomoses (good collaterals). One patient (patient 6) underwent bioccipital OMT and developed good collaterals via the omentum to the brain.25
Hemodynamic Parameters Before and After
STA-MCA Anastomosis and EMS
CP Studies
Control CP values
in the territories of the MCA, ACA, and
PCA were 94.4±1.5%, 92.8±2.4%, and 105.7±8.4%
(mean±SD),
respectively, before administration of acetazolamide. After
administration of acetazolamide, they were 92.7±2.9%,
92.6±2.1%, and 105.0±7.8%, respectively. Control VDC values in
the
territories of the MCA, ACA, and PCA were -1.7±3.1%,
-0.2±2.1%, and -0.7±1.6%, respectively.
Before the first operation, CP in the territory of the MCA on the operative side was 83.9±4.7% (n=25), which was significantly lower than that in the control subjects (n=10; P<.0001, unpaired t test). CP in the territory of the ACA on the operative side was 82.6±5.0% (n=25), which was also significantly lower than that in the control subjects (n=10; P<.0001, unpaired t test). CP in the territory of the PCA on the operative side was 94.4±3.0% (n=25), which was significantly lower than that in the control subjects (n=10; P<.0001, unpaired t test). On the side contralateral to the initial surgery, CP in the territory of the MCA was 88.3±4.9%, which was significantly higher than that on the operative side (n=25; P<.0001, paired t test). CP values in the territories of the contralateral ACA and PCA did not differ from those for the initial side of operation (n=25; paired t test).
After the first operation and just before the second, CP in the territory of the MCA on the initial side of the operation was significantly increased, to 87.8±4.5% (n=25; P<.0001, paired t test). CP in the territory of the MCA on the second operative side was significantly less, at 76.6±4.1%, than that on the ipsilateral side before the first operation (n=25; P<.0001, paired t test). CP in the territory of the MCA on the second side of the operation was significantly lower than that in the territory of the MCA on the side of the initial operation (n=25; P<.0001, paired t test). CP values in the territories of the ACA and PCA after the first operation did not change significantly on either side from the corresponding values before the first operation (n=25; paired t test).
After the second
operation, CP in the territory of the MCA on the
side of the second operation was significantly higher, 88.5±4.4%,
than that just before the second operation (n=25; P<.0001,
paired t test). CP values in the other regions exhibited no
significant change (n=25; paired t test) (Table
2).
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VDC Studies
VDC in the territory
of the MCA on the side of the initial
operation before the first operation was -18.4±2.5%
(n=25), which was significantly lower than that in the control subjects
(n=10; P<.0001, unpaired t test). VDC on the
contralateral side was -14.4±2.1%. VDC in the territory of the
MCA on the side of the initial operation before the first operation was
significantly lower than that on the contralateral side (n=25;
P<.0001, paired t test). VDC values in the
territories of the ACAs (n=25) were significantly lower than those in
the control subjects (n=10; P<.0001, unpaired t
test). VDC values in the territories of the PCAs (n=25) did not differ
significantly from control values (n=10; unpaired t
test).
Just before the second operation, VDC in the territory of the MCA on the side of the initial operation was significantly higher, at -14.7±2.7%, than before the first operation (n=25; P<.0001, paired t test). On the other hand, VDC on the contralateral side, which underwent the second operation, was significantly lower, at -20.1±1.9%, than on the ipsilateral side before the first operation (n=25; P<.0001, paired t test). VDC in the territory of the MCA on the side of second operation before the second operation was significantly lower than that in the territory of the contralateral MCA before the second operation (n=25; P<.0001, paired t test).
After the second operation, VDC in the territory of the MCA on the side of the second operation was significantly increased, to -14.0±2.5%, compared with that before the second operation (n=25; P<.0001, paired t test).
VDC values
in the other regions tested exhibited no significant change
in any period tested for the group of all 25 patients (paired
t test) (Table 3).
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Hemodynamic
Studies in the Eight Patients Treated
With Bifrontal OMT
After the second operation and just before
bifrontal OMT, CP in
the bifrontal regions in the 8 patients who underwent bifrontal OMT was
72.4±2.7%, which was significantly lower than that in the other 17
patients who did not undergo bifrontal OMT (P<.0001,
unpaired t test). VDC in the bifrontal regions in the 8
patients was -18.6±1.7%, which was significantly lower than
that in the 17 patients (P<.0001, unpaired t
test). These values significantly increased to 81.9±3.4% and
-11.8±1.9%, respectively, after bifrontal OMT (n=8;
P<.0001, both cases, paired t test) (Table
4).
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Illustrative Case (Patient 2)
A 4-year-old girl was admitted
to our institute on April 13,
1992, with repetitive left hemiparetic TIAs. She had undergone
bilateral EDAS that involved parietal branches of the STAs. On
admission, she displayed quadriparesis as a residuum of previous
cerebral infarction. CT scans performed on admission demonstrated small
low-density areas in the right temporo-occipital lobes and in
the left frontal lobe. Cerebral angiography performed on April 17,
1992, revealed that the previously performed EDAS had yielded no
collaterals to either side of the brain (Fig 2, left).
CP studies with the use of 99mTc-HMPAO SPECT and
acetazolamide showed that CP in the territory of the right
MCA was markedly decreased (79.1%). CP after administration of
acetazolamide was further decreased to 65.1% (Fig 3B). The
patient underwent vascular reconstruction of
the right failed EDAS on April 22, 1992. The left hemiparetic TIAs
completely disappeared just after this operation, and she was
discharged on May 6, 1992.
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She was readmitted to our institute on July
21, 1992, for repetitive
right hemiparetic TIAs beginning in June 1992. CT scans on readmission
were not significantly different from those obtained on the first
admission. Cerebral angiography demonstrated that collaterals had
developed to the territory of the right MCA via the anastomosed right
STA and EMS. No collaterals had developed via the left EDAS. CP studies
showed that CP in the territory of the right MCA was markedly increased
(87.6%), and it was still 78.5% after administration of
acetazolamide. On the other hand, CP in the territory of
the left MCA had decreased to 80.3% and after administration of
acetazolamide decreased markedly to 67.3% (Fig 3C). She
underwent vascular reconstruction of the left failed EDAS on July 30,
1992. The right hemiparetic TIAs completely disappeared early after
this second operation, and she was discharged on August 14, 1992.
Paraparetic TIAs appeared in October 1992, and the patient was
admitted on November 24, 1992. CT scans on this third admission
demonstrated no significant change. Cerebral angiography disclosed
development of collaterals via the anastomosed left STA and EMS to the
territory of the left MCA (Fig 2, middle). CP studies showed
that CP in
the territory of the left MCA had increased to 85.4% and was 74.9%
after administration of acetazolamide. However, CP in the
territories of the ACAs had decreased to 72.1% and further decreased
to 66.4% after administration of acetazolamide (Fig 3D).
The patient underwent bifrontal OMT that involved a frontal branch of
the left STA on December 3, 1992. The postoperative course was
uneventful, and she was discharged on December 16, 1992. She
experienced no further paraparetic TIAs after the bifrontal OMT. She
was admitted to our institute for follow-up angiography and CP
studies on December 25, 1993. Cerebral angiography showed that the left
frontal lobe was supplied via the transplanted omentum and that
collaterals had developed via transdural anastomoses on the
contralateral side (Fig 2, right). CP studies were then
performed and
showed that CP in the territories of the ACA had increased to 80.5%
and was 78.2% after administration of acetazolamide (Fig 3E).
She displayed slight quadriparesis but experienced no further
TIAs.
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Discussion |
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TopAbstractIntroductionSubjects and Methods Results Discussion References |
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A previous extracranial-intracranial bypass study clearly demonstrated that the indiscriminate use of extracranial-intracranial bypass surgery for the treatment of cerebral ischemia is not justified.26 A minority of patients who have stenosis and/or occlusion in the cerebral circulation do appear to have significant hemodynamic compromise and inadequate collaterals.27 28 29 30 31 32 Bypass surgery for childhood moyamoya disease should be considered separately from those patients with stenosis and/or occlusion due to atherosclerosis in the cerebral circulation.
Chronic ischemia in childhood moyamoya disease has been shown to favor the development of natural collaterals between extracranial and intracranial arteries from dural and scalp arteries. This finding has provided the rationale for such procedures as EDAS, EMS, encephaloduroarteriomyosynangiosis, or OMT.1 2 4 5 8 9 11 These procedures have been shown to encourage the development of natural collaterals, and they may favorably alter the course of progressive hemodynamic cerebral ischemia in patients with childhood moyamoya disease.13 14 15 16 17 18 19 20 21
STA-MCA anastomosis with EMS can increase the blood supply to the territory of the MCA and improve neurological symptoms due to ischemia there. However, ischemia in the territories of the ACA and PCA cannot be reversed with this procedure.7 Instead, indirect anastomosis with the use of omentum is thought to be the treatment of choice for symptoms of ischemia in the territory of the ACA or PCA.2 4 8
Acetazolamide administered intravenously induces marked dilatation of cerebral vessels and thereby increases both cerebral blood flow and cerebral blood volume. Maximum response is noted approximately 25 minutes after injection. Decreased reactivity to acetazolamide is thought to be due in large part to decrease in cerebral vascular reserve secondary to vasodilation in the resting state, which occurs in compensation for proximal stenosis and/or occlusion. Cerebral blood flow measurements before and after acetazolamide injection have been performed to assess cerebral perfusion reserve before extracranial-intracranial artery bypass surgery.23 33 34 35
In recent years, a number of reports of vascular reconstruction in patients with moyamoya disease have appeared.1 2 3 4 5 6 7 8 9 10 11 12 This type of treatment is thought to be effective, since progressive changes in regional cerebral blood flow occur as the disease progresses. However, because the decrease in regional cerebral blood flow in moyamoya disease is in fact so drastic,36 it is evident that further study of surgical techniques and methods for vascular reconstruction for affected patients is required.
Hoshi et al,21 using administration of acetazolamide, reported that cerebral vascular reserve in the cerebral cortex in the territories of the ACA and MCA was significantly lower than that in the territory of the PCA and the central region around the basal ganglia. Also, N-isopropyl-p-[123I]iodoamphetamine SPECT imaging is useful for evaluating regional cerebral blood flow in patients with moyamoya disease.
Ikezaki et al37 studied underlying cerebral circulation and metabolism and the effect of bypass surgery with positron emission tomography in childhood moyamoya disease. Regional cerebral blood volume and the regional oxygen extraction fraction had significantly increased to compensate for reduced regional cerebral blood flow and perfusion pressure and to maintain the regional cerebral metabolic rate of oxygen. Postoperative improvements were observed predominantly near the regions of cortex where bypass surgery had been performed.
In our study we measured regional CP and VDC before and after administration of acetazolamide before and after STA-MCA anastomosis and EMS and before and after OMT. Both CP and VDC were significantly less in both territories of the MCA, especially on the side that induced ischemic symptoms, than corresponding control values. Both CP and VDC were also decreased in the territories of the ACA before STA-MCA anastomosis and EMS and did not significantly increase after STA-MCA anastomosis and EMS. CP was also slightly but significantly decreased in the territories of the PCA before STA-MCA anastomosis and EMS and was not significantly changed by STA-MCA anastomosis and EMS.
Before bifrontal OMT, both CP and VDC in the territories of the ACA in the 8 patients who underwent bifrontal OMT were significantly lower than those in the remaining 17 patients who did not require bifrontal OMT. After the bifrontal OMT, both these parameters were significantly increased.
These findings indicate that STA-MCA anastomosis and EMS are effective in treating focal ischemic symptoms in the territories of the MCA but are ineffective in treating these symptoms in the territories of the ACA and PCA. However, OMT eliminated ischemic symptoms of disease in the territories of the ACA and PCA and significantly improved both CP and VDC in the territories of the ACA and PCA.
In summary, hemodynamic compromise exists in patients with moyamoya disease and is a major cause of the development of ischemic symptoms. Ischemia in the territories of the MCA can be treated with STA-MCA anastomosis and EMS. On the other hand, ischemic symptoms in the territories of the ACA and PCA should be treated with OMT. Measurement of CP and VDC with the use of acetazolamide-loading 99mTc-HMPAO SPECT is thought to be useful in evaluation of the hemodynamic state of the cerebral circulation in moyamoya disease.
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Selected Abbreviations and Acronyms |
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Received May 16, 1995; revision received September 25, 1995; accepted October 30, 1995.
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