From the Department of Neurosurgery, Shimane Medical University, Izumo,
Japan (Y.O.), and the Department of Neurosurgery, Chugoku Rousai Hospital
(T.S., M.N., K.Y., T.Y., C.Y.), Hiroshima, Japan.
Correspondence to Yoshikazu Okada, MD, Department of Neurosurgery, Shimane Medical University, 1–89 Enya-cho, Izumo, Shimane 693, Japan.
Methods—Fifteen patients with cerebral ischemic
attacks (ischemia group) and 15 patients with intracranial
hemorrhages (hemorrhage group) were investigated.
Clinicoangiographic features and regional cerebral blood flow (rCBF) of
the MCA territory were preoperatively and postoperatively investigated,
and cortical arterial pressure (CAP) and anastomotic blood
flow (AF) were intraoperatively measured.
Results—In the ischemia group, the preoperative
rCBF of 38.4 mL/100 g per minute was significantly increased to 42.1
mL/100 g per minute with a diminution of angiographic moyamoya
vessels in 67% of patients after surgery. The mean CAP and AF were
25.6 mm Hg and 34.7 mL/min, respectively. Proximal and distal
cerebral vascular resistance (PCVR=[Mean Systemic Arterial
Blood Pressure-Mean CAP]/rCBF and DCVR=[Mean CAP/rCBF]) were 1.78
and 0.68, respectively. One patient died
perioperatively as a result of
intracerebral hemorrhage. During follow-up
(mean, 67 months), 12 of 14 patients recovered without neurological
deficits, 1 was moderately disabled because of the initial insult, and
another patient experienced an intracerebral
hemorrhage but recovered fully. In the hemorrhage
group, the preoperative rCBF of 38.0 mL/100 g per minute was
significantly increased to 42.7 mL/100 g per minute with a diminution
of moyamoya vessels in 60% after surgery. The mean CAP and AF were
29.1 mm Hg and 24.1 mL/min, respectively. PCVR and DCVR were 1.72
and 0.77, respectively. One patient became hemiparetic because of
perioperative intracerebral
hemorrhage. During follow-up (mean, 94 months), 3 patients had
fatal intracranial hemorrhages, 10 had good recoveries, and 2
had moderate disabilities.
Conclusions—This study revealed a high PCVR and a very low
DCVR in both the ischemia and hemorrhage groups of
patients. STA-MCA anastomosis partially normalized cerebral circulation
and decreased moyamoya vessels but did not completely prevent
rebleeding.
In this study 30 consecutive patients with adult moyamoya
disease who successfully underwent STA-MCA anastomosis were
analyzed by means of the following methods: (1) measurements of
preoperative and postoperative rCBF; (2) intraoperative measurement of
CAP and AF; and (3) angiographic changes and clinical course in the
perioperative and long-term follow-up periods.
The clinical course of each patient was followed for at least 2
years. Clinical results were evaluated with regard to
recurrence of ischemic and/or hemorrhagic attacks and
adaptation to daily living. Angiographic examination was performed 2 to
6 months after surgery to assess the patency of the anastomosis, the
area perfused through the anastomosed STA, and any changes in the
moyamoya vessels at the base of the brain.
Our criteria for direct revascularization in adult
moyamoya disease were as follows: (1) Patients in the
ischemia group did not present a major completed stroke,
and those in the hemorrhage group recovered fully without
serious neurological deficits. (2) On CT scans, low-density areas due
to ischemic insults were less than 2 cm in diameter, and
intraventricular, intracerebral,
and/or subarachnoid hemorrhages had completely
resolved. (3) The angiographic stage of the moyamoya disease
according to the Kodama and Suzuki15
classification was II to IV. (4) The timing of the operation was at
least 2 months after the most recent prior attack.
Angiographic Investigation
Measurements of rCBF
Intraoperative Measurements of CAP and AF
In the ischemia group, 4 patients underwent bilateral STA-MCA
anastomoses, and the remaining 11 patients had a unilateral STA-MCA
anastomosis on the affected side. In the hemorrhage group, 7
patients underwent bilateral STA-MCA anastomoses, and 8 had a
unilateral STA-MCA anastomosis on the affected side.
During the operation, arterial blood gases were monitored
to ensure normocapnia and normoxia.
Statistical Analysis
Preoperative and Postoperative rCBF Measurements
Postoperative rCBF in the ischemia group was 42.1±4.5 mL/100 g
per minute, and that in the hemorrhage group was 42.7±5.2
mL/100 g per minute. These postoperative rCBF values were significantly
increased in both groups (P<.001) but were still
significantly low compared with those in the control subjects
(P<.001).
The end-tidal CO2 concentration of the
ischemia group was 39.7±4.3 mm Hg preoperatively and
38.6±4.3 mm Hg postoperatively. In the hemorrhage group,
the end-tidal CO2 concentration was
42.4±4.4 mm Hg preoperatively and 40.5±5.0 mm Hg
postoperatively. No significant changes in preoperative and
postoperative end-tidal CO2 concentrations were
observed in either the ischemia group or the hemorrhage
group.
Vascular Resistance in the MCA Territory
Angiographic Changes
Clinical Course
Complicated cases during the follow-up periods are also shown in
the Table
Moyamoya disease has two primary clinical
presentations, ischemic and hemorrhagic
attacks.1 5 Additionally, the hemorrhagic attacks
have rarely been described, but the main causes of death were massive
intracranial hemorrhage. At present, some causes of the
rupture of the vessels in moyamoya disease have been reported.
Mauro et al16 suggested that lipohyalinosis and
miliary aneurysms were the source of fatal
intracerebral hemorrhage. Kodama and
Suzuki15 reported that microaneurysms
resulting from fragility and localized disruption of the vascular wall
could cause an intracerebral hemorrhage.
Although some reports have demonstrated ruptured aneurysms in
cerebral hemorrhages seen in moyamoya
disease,17 18 19 few cases have demonstrated small
aneurysms on angiographic examination. Yamashita et
al20 suggested that the rupture of the vessels in
moyamoya disease could occur in the absence of
microaneurysm or fibrinoid necrosis. In their meticulous
morphological studies in moyamoya patients, elastic laminae were
usually well preserved, and the wall of the vessels was ruptured
without fibrinoid necrosis but was associated with fibrosis and
attenuation of the medial smooth muscle cell. From these
clinicopathological studies, hemorrhagic attacks in moyamoya
disease were thought to be due to the existence of several vascular
lesions and the severity of the lesions, which was closely related to
the hemodynamic stress of basal moyamoya vessels
and aging of the patients.
Several hemodynamic findings in moyamoya
disease have been reported by measurements of rCBF and CAP. Yonekawa et
al21 reported the hemodynamics of
moyamoya disease in children before and after STA-MCA anastomoses.
They found that the CAP measured in six children with moyamoya
disease was below the level observed in most atherosclerotic occlusive
cerebrovascular diseases and noted that rCBF increased in both the
operated and contralateral hemispheres. Ogawa et
al22 reported that CBF was significantly lower in
moyamoya patients than in normal subjects of the same age and that
the distribution of CBF showed a dominant posterior distribution in
contrast to the dominant anterior distribution observed in normal
control subjects. Taki et al23 investigated
cerebral circulation and metabolism in patients with adult
moyamoya disease using positron emission tomography and reported
that the cerebral circulation in adult moyamoya disease appeared to
be characterized by a mild decrease in perfusion pressure and prolonged
circulation time. We observed a prominently reduced CAP, 25.6
mm Hg in the ischemia group and 29.1 mm Hg in the
hemorrhage group, and moderately reduced rCBF in the MCA
territory. From these findings, we demonstrated significantly higher
PCVR (cerebral vascular resistance from the ICA to the cortical
arteries of the MCA) than DCVR (cerebral vascular resistance from the
cortical arteries of the MCA to the vein). In an experimental study,
Symon24 demonstrated that normal CAP of the MCA
territory in dogs and macaques was 80% to 95% of SABP obtained from
the femoral artery. Additionally, our unpublished normal CAP in humans
was 78 mm Hg in contrast to 93 mm Hg of SABP, which was
obtained from four patients having vein graft bypass from the external
carotid artery to the MCA to trap giant cavernous aneurysms
(Y.O. et al, unpublished data, 1995). When these CAP and SABP data and
our normal rCBF data were applied to calculate normal cerebral vascular
resistance, PCVR and DCVR were 0.31 and 1.31, respectively. These
calculated cerebrovascular resistance values clarified characteristics
of cerebral circulation in moyamoya disease such as prominent high
vascular resistance from the main cerebral arteries to the cortical
arteries and remarkable dilatation of distal resistance vessels. It is
well known that CBF itself is not a reliable indicator to assess the
effectiveness of STA-MCA anastomosis for occlusive cerebrovascular
diseases. Our hemodynamic studies suggested that the
STA-MCA anastomosis could normalize not only rCBF but also cortical
perfusion pressure in moyamoya disease.
The theoretical basis for surgical
revascularization in moyamoya disease is to
decrease hemodynamic stress, thereby reducing
moyamoya vessels. Currently three procedures are frequently used:
STA-MCA anastomosis, encephaloduroarteriosynangiosis, and
encephalomyosynangiosis.2 5 7 8 10 11 12 Most
published reports support the efficacy of these procedures in
children.2 7 8 9 Although these techniques have
also been used in adults to prevent ischemic attacks as well as
to decrease the risk of bleeding, the effectiveness of these techniques
in preventing hemorrhagic attacks in adult moyamoya disease remains
unproven.2 13 14 25 STA-MCA anastomosis is a
rapid procedure and is a potential method for supplying blood with
normal cortical arterial perfusion pressure. In this study
angiographic moyamoya vessels were reduced in over 60% of patients
with excellent visualization of the MCA cortical arteries after STA-MCA
anastomoses, but prevention of rebleeding was not accomplished in all
of these cases. Wanifuchi et al14 studied 59
adult moyamoya patients, 38 of whom were treated conservatively and
21 of whom were surgically treated. Their results suggested that
hemorrhagic recurrence in the surgically treated group was less
frequent than in the conservatively treated group. Suzuki et
al25 reviewed long-term clinical results in 28
adult moyamoya patients who had had ischemic symptoms in
childhood. Fourteen percent of the patients who had not undergone
bypass surgery had hemorrhagic attacks as adults. Conversely, 18
patients who had undergone bypass surgery in the pediatric period
showed no hemorrhagic attacks later. In their results, bypass surgery
performed in the pediatric period appeared to prevent later
hemorrhage in adult moyamoya disease. Their results may
indicate that STA-MCA anastomosis can halt progression of moyamoya
vessels, in severity and distribution, by generating normal perfusion
pressure and significant blood supply in the cortical artery in the
early period of the disease. Houkin et al13
studied 35 patients with adult moyamoya disease, 24 patients with
intracerebral hemorrhage at onset, and 11
patients with cerebral ischemia at onset who underwent both
STA-MCA anastomosis and indirect revascularization
using encephaloduroarteriomyosynangiosis. Three of 24 patients with
hemorrhagic-type onset showed rebleeding, and 2 of 11 patients
with ischemic-type onset showed intracerebral
hemorrhage after surgery. From these results they concluded
that revascularization could not always prevent
rebleeding in adult moyamoya disease but that moyamoya vessels
were decreased only by direct revascularization
surgery, which may ultimately reduce the risk of hemorrhage
more effectively than conservative treatment.
The hemodynamics of cerebral circulation in
moyamoya disease are characterized by low CBF with extremely high
vascular resistance in the collaterals at the base of the brain, and
therefore STA-MCA anastomosis has appeared to be a logical treatment
for providing a readily accessible blood supply. However, certain
disadvantages of STA-MCA anastomosis have been proposed. First,
the anastomosis is difficult to accomplish because the recipient
arteries are very small, thin, and fragile. In addition, the STA-MCA
bypass may not have the potential to perfuse the territory of the
anterior cerebral artery and posterior cerebral artery. Second, some
neurological deterioration has been observed as a result of abrupt
changes in CBF caused by the abundant blood supply and an increase in
perfusion pressure through the STA. In our series,
perioperative intracranial hemorrhage was
observed in two patients with poorly controlled blood pressure. These
results indicate that moyamoya disease patients who undergo direct
revascularization should be monitored carefully
during the perioperative period.
The clinical outcomes of STA-MCA anastomosis for adult
moyamoya disease were obtained from a very small group of patients
with few pathophysiological studies. Therefore, it
will be necessary to perform a randomized study with angiographic and
CBF studies to test the efficacy of STA-MCA anastomosis in reducing the
risk of cerebral ischemia and hemorrhage in adult
moyamoya disease.
Received September 15, 1997;
revision received December 16, 1997;
accepted December 18, 1997.
© 1998 American Heart Association, Inc.
Original Contributions
Effectiveness of Superficial Temporal Artery–Middle Cerebral Artery Anastomosis in Adult Moyamoya Disease
Cerebral Hemodynamics and Clinical Course in Ischemic and Hemorrhagic Varieties
Abstract
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Background and Purpose—The
efficacy of superficial temporal artery–middle cerebral artery
(STA-MCA) anastomosis in adult moyamoya disease was evaluated by
clinicopathophysiological studies.
Key Words: bypass surgery • cerebral blood flow • cerebral hemorrhage • moyamoya disease • vascular resistance
Introduction
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Moyamoya disease is
characterized angiographically by an abnormal network of fine
"moyamoya" vessels at the base of the brain arising from the
trunks of the main cerebral arteries in association with progressive
occlusion of the distal portions of the ICA.1 2 3 4 5
In moyamoya disease, characteristic clinical
presentations have been reported, including serious
neurological deficits due to cerebral ischemic insults and/or
brain hemorrhages.1 5 The age
distribution of clinical presentation indicated two peaks,
the first in childhood and the second in
adulthood.1 5 Among pediatric patients the
initial symptoms are mainly due to cerebral ischemia, but in
adult patients intracranial hemorrhage is a more common
clinical manifestation.1 5 The incidence of
hemorrhage exceeds 60% in adult moyamoya disease and is
only 10% among afflicted children.6 With regard
to the treatment of moyamoya disease,
revascularization surgeries have been among the
more interesting methods used to decrease hemodynamic
stress in the involved vessels.2 7 8 9 10 11 12 Such
strategies have proven effective in decreasing deficits in cerebral
ischemia. Karasawa et al9 demonstrated
that surgical revascularization procedures for
moyamoya disease could supply the territory of the MCA through the
external carotid artery with measurable increases in CBF and result in
a diminution of basal moyamoya vessels. Based on these
observations, they suggested that surgical
revascularization could protect the territory of
the MCA from ischemia and might decrease the frequency of
intracerebral hemorrhage in adult moyamoya
disease. However, whether revascularization is
useful in preventing rebleeding in the hemorrhagic group of adults with
moyamoya disease remains
controversial.2 12 13 14 Therefore, precise
clinicopathophysiological studies with assessment
of angiographic changes in moyamoya vessels, rCBF, and
hemodynamic stress on the collateral blood vessels will
be necessary to determine the efficacy of surgical treatments.
Subjects and Methods
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Patients and Clinical Features
In this study, moyamoya disease was defined as adult type if
a patient had the initial attack of moyamoya disease after age 17
years. We treated 30 patients with STA-MCA anastomosis at Chugoku
Rousai Hospital between 1984 and 1994. All patients were examined
angiographically and were diagnosed with moyamoya disease. Fifteen
patients had ischemic attacks (ischemia group), and the
remaining 15 had hemorrhagic attacks (hemorrhage group). In the
ischemia group, 11 patients were female and 4 were male. They
ranged in age from 17 to 56 years (mean, 39 years). Ten of the 15
patients experienced transient ischemic attacks, 3 had
reversible ischemic neurological deficits, and the remaining 2
had minor completed strokes. On CT scans, ischemic lesions
characterized by low-density areas were observed in 7 patients, but no
lesion was seen in the other 8 patients. In the hemorrhage
group, 8 patients were female and 7 were male, ranging in age from 25
to 57 years (mean, 42 years). Fourteen of these patients
presented with complaints of severe headache and
disturbances of consciousness due to intracranial
hemorrhage. CT scans revealed
intraventricular hemorrhage in 12 patients,
intracerebral hemorrhage in 3 patients, and
subarachnoid hemorrhage in 3 patients.
Conventional angiography was performed preoperatively to
diagnose moyamoya disease and postoperatively to assess the
contribution of the STA-MCA anastomosis to cerebral circulation. The
anastomosis was evaluated as follows: 0=no evidence of patency;
1=bypass was patent, and the STA only perfused the recipient artery
without significant changes in basal moyamoya vessels; and 2=bypass
was patent, and the STA widely perfused the MCA territory with evidence
of a diminution of basal moyamoya vessels.
rCBF maps were obtained preoperatively and postoperatively
with single-photon emission CT (Tomomatic 32) by the
133Xe inhalation method. Imaging was directed at
a point 5 cm above the orbitomeatal line, from which we calculated the
flow value in the MCA territory on the anastomosed side. Preoperative
rCBF studies were performed within the 2 weeks before surgery, and
postoperative studies were done 6 to 12 months after surgery. In these
rCBF measurements, we monitored end-tidal CO2
concentration to approximate the arterial
PCO2.
Surgery was performed under general anesthesia with
the use of neuroleptanalgesia (patients were intubated with fentanyl,
thiamylal, and pancuronium bromide and were maintained with oxygen plus
nitrous oxide). All patients underwent STA-MCA anastomosis more than 2
months after either ischemic or hemorrhagic attacks. In
moyamoya disease, the STA-MCA anastomosis is quite challenging
because the recipient artery is very small in diameter and the
arterial wall is thin and translucent. We inserted our
designed silicone stent (400 µm in diameter, 3 to 4 mm in
length; Xanthopren Byern) into the recipient artery through an
arteriotomy to facilitate surgical preparation. A polyethylene tube was
cannulated into a branch of the STA, and CAP was defined as the back
pressure measured during temporary occlusion of the STA trunk on
completion of the anastomosis (Fig 1
, top
panel). AF was measured with an electromagnetic flowmeter (Nihon Kohden
MFV 1100) with the probe applied to the STA (Fig 1, top panel). SABP
was measured at the radial artery.
View larger version (103K):
[in a new window]
Figure 1. A, Intraoperative measurements of CAP through a
cannula to a branch of the STA (small arrow) and AF with an
electromagnetic flowmeter (large arrow). B,
Representative recording of CAP and AF. CAP is
obtained by temporary clipping of the proximal STA, resulting in an
abrupt decrease in the anastomotic blood pressure (ABP) recorded
from the cannula.
Statistical analyses were performed with the use of
Student's paired or unpaired t test, and statistical
significance was determined by P<.05. All values shown are
mean±SD.
Results
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Intraoperative Measurements of CAP and AF
Figure 1
, bottom panel, shows a
representative recording of CAP and AF in
moyamoya disease. CAP is extremely low and anastomotic flow is
relatively high despite the small recipient artery. All anastomoses
were confirmed to be patent by the intraoperative measurements of CAP
and AF. Figure 2 shows CAP and AF
measured intraoperatively in both groups. In the ischemia
group, mean SABP was 95.5±13.1 mm Hg (range, 74 to 118
mm Hg), mean CAP was 25.6±7.7 mm Hg (range, 15 to 50
mm Hg), and mean AF was 34.7±21.3 mL/min (range, 10 to 110 mL/min).
The ratio of mean CAP to mean SABP was 0.27±0.08. In the
hemorrhage group, mean SABP was 94.5±14.5 mm Hg (range,
65 to 123 mm Hg), mean CAP was 29.1±8.4 mm Hg (range, 15
to 45 mm Hg), and mean AF was 24.1±10.9 mL/min (range, 10 to 55
mL/min). The ratio of mean CAP to mean SABP was 0.31±0.09. The mean
SABP of the ischemia group was similar to that of the
hemorrhage group. There were no significant differences in
either CAP or AF between the ischemia and hemorrhage
groups or in the ratio of mean CAP to mean SABP.
View larger version (20K):
[in a new window]
Figure 2. Intraoperative CAP ( 
) and AF (
) in the
ischemia and hemorrhage groups. The larger closed
circles with the vertical bars and the larger open circles with the
vertical bars indicate the mean±SD of CAP and AF, respectively.
In our previous rCBF studies, the mean rCBF value in normal
control subjects in the MCA territory was 48.4±4.6 mL/100 g per minute
(mean age, 39 years; mean SABP, 91±15 mm Hg). Figure 3 shows preoperative and postoperative
rCBF in the ischemia and hemorrhage groups.
Preoperative rCBF was obtained from 19 hemispheres (14 patients) in the
ischemia group and from 21 hemispheres (14 patients) in the
hemorrhage group. The mean rCBF was 38.4±4.8 mL/100 g per
minute in the ischemia group and 38.0±4.5 mL/100 g per minute
in the hemorrhage group. These rCBF values were significantly
low compared with those in the control subjects
(P<.001).
View larger version (24K):
[in a new window]
Figure 3. Changes in rCBF before and after STA-MCA
anastomosis in the ischemia and hemorrhage groups.
Preoperative ( ) and postoperative () rCBF values are shown.
Intraoperative CAP and preoperative rCBF in the MCA
territory were used to evaluate cerebral vascular resistance in all
patients with moyamoya disease (Fig 4). We calculated PCVR and DCVR using the
following equations: (1) PCVR=(Mean SABP-Mean CAP)/rCBF, and (2)
DCVR=Mean CAP/rCBF. In these analyses, venous pressure was
assumed to be zero. Mean PCVR and mean DCVR in the ischemic
group were 1.78±0.44 and 0.68±0.28, respectively. Mean PCVR and mean
DCVR in the hemorrhage group were 1.72±0.36 and 0.77±0.24,
respectively. There was a significant difference between mean PCVR and
mean DCVR in both groups (P<.001), but there were no
significant differences in mean PCVR and mean DCVR between the
ischemia and the hemorrhage groups.
View larger version (16K):
[in a new window]
Figure 4. Vascular resistance calculated from mean SABP,
CAP, and rCBF. Vascular resistance at the proximal site (from the ICA
to the cortical artery) ( ) and resistance at the distal site (from
the cortical artery to the vein) () are shown.
Eighteen anastomosed hemispheres (14 patients) in the
ischemia group and 20 anastomosed hemispheres (13 patients) in
the hemorrhage group were angiographically investigated. An
angiographic score of 2 (bypass was patent and the STA widely perfused
the MCA territory with a diminution of basal moyamoya vessels, as
shown in Fig 5) was observed in 12 of 18
anastomosed sites (67%) in the ischemia group and in 12 of 20
anastomosed sites (60%) in the hemorrhage group. In the
remaining patients of both groups, carotid angiography showed that the
STA only perfused the recipient cortical artery without changes in
basal moyamoya vessels.
View larger version (96K):
[in a new window]
Figure 5. A, Preoperative right carotid angiography reveals
carotid occlusion with moyamoya vessels at the base of the brain.
B, Postoperative angiography shows the STA perfusing the cortical
arteries and prominent reduction of moyamoya vessels.
Perioperatively complicated cases are shown in the
Table (cases 1 and 2).
Intracerebral hemorrhage was observed on the
second day in 2 patients who showed hypertension (>200 mm Hg
systolic pressure). One patient (from the ischemia
group) died as a result, and the other patient (from the
hemorrhage group) developed hemiparesis. The remaining 28
patients, including 2 who were moderately disabled as a result of their
primary insults, returned to their previous occupations after
discharge.
View this table:
[in a new window]
Table 1. Summaries of the Clinical Features and
Hemodynamics in Moyamoya Disease Patients With
Postoperative Complications (cases 3 through 6). In the ischemic group, patients
were followed up for an average of 67 months. During follow-up, 1
patient with an angiographic score of 2, who had been working as a
housewife without any problems, had an intracerebral
hemorrhage of the left frontal lobe 5 years after bilateral
STA-MCA anastomosis (Table, case 3). Her initial attack had been a
transient ischemic attack with a right hemiparesis without
lesions on CT scans. Fortunately, she recovered almost completely. The
remaining 12 patients of the ischemia group had good
recoveries, and 1 patient had moderate disability due to her initial
attack. All these patients had uneventful courses without
recurrence of ischemic attacks. In the
hemorrhage group, the patients were followed up for an average
of 94 months. Three patients died during the follow-up period. In each
case the patient had fully recovered without deficits until the fatal
second attack (Table, cases 4 through 6). The first patient with an
angiographic score of 2, who had been an engineer, died as the result
of a serious intraventricular hemorrhage 4
years after unilateral bypass surgery. The second patient with an
angiographic score of 2, who had been engaged in the Self-Defense Force
of Japan, died 2 years after bilateral STA-MCA anastomosis. He also
sustained a serious intraventricular
hemorrhage. The third patient with an angiographic score of 1,
who had been a public official, died 3 years after unilateral STA-MCA
anastomosis. He developed alcoholic hepatic cirrhosis and experienced a
massive cerebral hemorrhage on the operated side. In the
remaining 12 patients, 10 maintained a good level of recovery and 2
were moderately disabled during the follow-up period. Moderate
disability in 1 patient was due to perioperative
intracerebral hemorrhages and in the other was
due to her initial attack. No ischemic attacks were observed in
the hemorrhage group, but a total of 4 patients
presented rebleeding during the follow-up period. The
hemodynamic variables in these patients are
summarized in the Table. No prominent differences in these
variables were found when these patients were compared with the
remaining patients in both groups.
Discussion
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
This study demonstrated that successful STA-MCA anastomosis in
adult moyamoya disease partially normalized cerebral circulation
with a reduction of moyamoya vessels and helped prevent further
ischemic attacks but did not ward off hemorrhagic attacks.
Hemodynamic studies revealed markedly low CAP and
moderately decreased rCBF due to occlusive changes in the ICA with high
vascular resistant collaterals of the basal moyamoya
vessels. However, no significant differences in these CAP, rCBF, and
vascular resistance values were observed between patients with cerebral
ischemic attacks at onset and those with cerebral hemorrhagic
attacks.
Selected Abbreviations and Acronyms
AF
=
anastomotic blood flow
CAP
=
cortical arterial pressure
CBF
=
cerebral blood flow
DCVR
=
distal cerebral vascular resistance
ICA
=
internal carotid artery
MCA
=
middle cerebral artery
PCVR
=
proximal cerebral vascular resistance
rCBF
=
regional cerebral blood flow
SABP
=
systemic arterial blood pressure
STA
=
superficial temporal artery
References
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
This article has been cited by other articles:
 |
|
 |
|
  M. Czabanka, P. Pena-Tapia, G. A. Schubert, J. Woitzik, P. Vajkoczy, and P. Schmiedek Characterization of Cortical Microvascularization in Adult Moyamoya Disease Stroke, June 1, 2008; 39(6): 1703 - 1709. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Kuroda, N. Hashimoto, T. Yoshimoto, Y. Iwasaki, and for the Research Committee on Moyamoya Disease in Radiological Findings, Clinical Course, and Outcome in Asymptomatic Moyamoya Disease: Results of Multicenter Survey in Japan Stroke, May 1, 2007; 38(5): 1430 - 1435. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Stoll and M. Bendszus Inflammation and Atherosclerosis: Novel Insights Into Plaque Formation and Destabilization Stroke, July 1, 2006; 37(7): 1923 - 1932. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Y. Fushimi, Y. Miki, K.-i. Kikuta, T. Okada, M. Kanagaki, A. Yamamoto, K. Nozaki, N. Hashimoto, T. Hanakawa, H. Fukuyama, et al. Comparison of 3.0- and 1.5-T Three-dimensional Time-of-Flight MR Angiography in Moyamoya Disease: Preliminary Experience Radiology, April 1, 2006; 239(1): 232 - 237. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. Tsuchiya, K. Honya, A. Fujikawa, H. Tateishi, and Y. Shiokawa Postoperative Assessment of Extracranial-Intracranial Bypass by Time-Resolved 3D Contrast-Enhanced MR Angiography Using Parallel Imaging AJNR Am. J. Neuroradiol., October 1, 2005; 26(9): 2243 - 2247. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Kuroda, T. Ishikawa, K. Houkin, R. Nanba, M. Hokari, and Y. Iwasaki Incidence and Clinical Features of Disease Progression in Adult Moyamoya Disease Stroke, October 1, 2005; 36(10): 2148 - 2153. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Morioka, J.-I. Hamada, T. Kawano, T. Todaka, S. Yano, Y. Kai, and Y. Ushio Angiographic Dilatation and Branch Extension of the Anterior Choroidal and Posterior Communicating Arteries Are Predictors of Hemorrhage in Adult Moyamoya Patients Stroke, January 1, 2003; 34(1): 90 - 95. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Y. Yoshida, T. Yoshimoto, R. Shirane, and Y. Sakurai Clinical Course, Surgical Management, and Long-Term Outcome of Moyamoya Patients With Rebleeding After an Episode of Intracerebral Hemorrhage : An Extensive Follow-Up Study Stroke, November 1, 1999; 30(11): 2272 - 2276. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. W. Albers, R. G. Hart, H. L. Lutsep, D. W. Newell, and R. L. Sacco Supplement to the Guidelines for the Management of Transient Ischemic Attacks : A Statement From the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association Stroke, November 1, 1999; 30(11): 2502 - 2511. [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||