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Grading of moyamoya disease allows stratification for postoperative ischemia in bilateral revascularization surgery

  • Clinical Article - Vascular
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Abstract

Background

Moyamoya disease (MMD) may be graded based on DSA, the presence of ischemia in MRI and cerebrovascular reserve capacity allowing the prediction of ischemic symptoms in patients. Cerebral ischemia represents a severe complication in revascularization surgery. Focusing on different clinical features of hemodynamic impairment, MMD grading may allow prediction of ischemic complications. It was the aim to analyze whether MMD grading stratifies for ischemic complications in revascularization surgery for MMD.

Method

In 37 MMD patients a bilateral, standardized, one-staged revascularization approach consisting of STA-MCA bypass/encephalomyosynangiosis (EMS) and single EMS on the contralateral hemisphere was performed. Clinical data including DSA, MRI and rCBF (Xenon-CT) studies were assessed and used for grading MMD. All patients were observed on the ICU for at least 24 h and received CT imaging on the first postoperative day and in case of neurological deterioration. Ischemic complications were analyzed until the day of discharge and at 6-month follow-up.

Results

Grading of MMD revealed 11 hemispheres (15 %) as grade I, 33 hemispheres (44 %) as grade II and 30 hemispheres (41 %) as grade III. Eight ischemic complications were observed (11 %). MMD grading demonstrated a significant correlation with ischemic complications: 0 complications in grade I, 3 in grade II (9 %) and 5 in grade III hemispheres (16 %; p < 0.05, Fisher’s exact test).

Conclusions

The proposed grading system allows to stratify for ischemic complications in MMD patients that receive bilateral, one-staged revascularization surgery. Future studies will have to investigate its use for predicting ischemic complications in other revascularization strategies for MMD.

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Authors and Affiliations

  1. Department of Neurosurgery, Charite Universitätsmedizin Berlin, Augustenburgerplatz 1, 13353, Berlin, Germany

    M. Czabanka, G. Acker & P. Vajkoczy

  2. Department of Neurosurgery, AOU Careggi, University of Florence, Florence, Italy

    A. Boschi

  3. Department of Neurosurgery, Klinikum Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany

    P. Peña-Tapia, G. A. Schubert & P. Schmiedek

  4. Department of Neurosurgery, RWTH Aachen University, Aachen, Germany

    G. A. Schubert

  5. Center for Stroke Research, Charité-Universitätsmedizin Berlin, Berlin, Germany

    P. Vajkoczy

Authors
  1. M. Czabanka
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  2. A. Boschi
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  3. G. Acker
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  4. P. Peña-Tapia
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  5. G. A. Schubert
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  6. P. Schmiedek
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  7. P. Vajkoczy
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Corresponding author

Correspondence to M. Czabanka.

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Funding

This work was funded by the “Friedrich C. Luft” Clinical Scientist Pilot Program (funded by Volkswagen Foundation and Charité Foundation) and the Berlin Institute of Health (BIH) Clinical Fellow Program. The sponsors had no role in the design or conduct of this research.

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the local research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

For this type of study formal consent is not required.

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Comments

This article examines the ischemic complications that occur in adult moyamoya disease patients following bilateral, one-staged revascularization using a combination of direct/indirect bypass and the use of a proposed grading system for predicting these ischemic complications. The authors found no difference in ischemic events relative to the surgical strategy employed and concluded that their grading system correlates with ischemic complications. Few studies have been published on this topic, and so it is an original work that is of interest to our readership.

Fady T. Charbel

Sophia F. Shakur

Chicago, IL, USA

The authors reported the usefulness of their grading system for predicting postoperative ischemia in bilateral revascularization surgery. Although I do not agree with their strategy to perform bilateral revascularization simultaneously, this article will help the surgeons to predict ischemic complications for MMD.

Kenji Sugiu

Okayama, Japan

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Czabanka, M., Boschi, A., Acker, G. et al. Grading of moyamoya disease allows stratification for postoperative ischemia in bilateral revascularization surgery. Acta Neurochir 158, 1895–1900 (2016). https://doi.org/10.1007/s00701-016-2941-y

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  • DOI: https://doi.org/10.1007/s00701-016-2941-y

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