Postoperative Functional Outcomes and Prognostic Factors in Two Types of Adult Moyamoya Diseases

https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104846Get rights and content

Highlights

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    Postoperative transient neurological aggravation was more common in ischemic moyamoya diseases.

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    Ischemic and hemorrhagic moyamoya diseases both showed postoperative functional improvements.

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    Ischemic and hemorrhagic moyamoya diseases might have distinct prognostic factors.

Abstract

Background

To determine the functional outcomes in each period for adult ischemic and hemorrhagic Moyamoya disease (MMD) patients and identify prognostic factors.

Methods

The current retrospective study reviewed consecutive adult MMD patients surgically treated from January 2012 to June 2017. Perioperative clinical data were collected and follow-up was conducted via telephone interviews. Functional outcomes and prognostic factors were analyzed.

Results

A total of 219 ischemic MMD patients (268 hemispheres) and 157 hemorrhagic patients (193 hemispheres) were included. The median follow-up time was 18 months (3–69 months). MMD type had no significant effect on the modified Rankin Scale(mRS) score at discharge. Perioperative complications (P = 0.004) and the mRS score at baseline (P < 0.001) were risk factors correlated with the short-term functional outcomes in both groups, while diabetes mellitus (DM, P = 0.022) also played a role in the ischemic group. During the follow-up period, functional outcomes obviously improved in both groups, but two groups showed nonproportional cumulative curves for favorable functional outcomes (log-rank test, P = 0.483). Stroke recurrence (P < 0.001) and mRS at discharge (P < 0.001) were common factors related with long-term functional outcomes in two types of MMD patients. Particularly, female patients with ischemic MMD were more likely to have higher mRS scores (P = 0.028) and Suzuki stage was positively associated with long-term functional outcomes in hemorrhagic group (P = 0.044).

Conclusions

MMD type had no significant effect on prognosis while both types of MMD patients showed overall significant improvements in functional outcomes after surgery. Different types of MMD patients have distinct prognostic factors for short-term and long-term functional outcomes.

Introduction

Moyamoya disease (MMD) is characterized by chronic progressive stenosis or occlusion of the terminal portion of the bilateral internal carotid arteries, leading to the formation of an abnormal vascular network at the base of the brain.1 Ischemic and hemorrhagic symptoms are the most common symptoms in adult MMD patients.2

Currently, revascularization is considered to be a standard treatment for MMD patients because it can theoretically lead to the augmentation of cerebral blood flow and elimination of hemodynamic stress in fragile collaterals. Nevertheless, the short-term and long-term functional outcomes of ischemic and hemorrhagic MMD patients have not been clearly determined. Recently, perioperative complications, especially ischemic events and cerebral hyperperfusion syndrome (CHS),3,4 have been increasingly reported because of their adverse effects on clinical status in the short term. Moreover, although the long-term effectiveness of surgical revascularization for MMD patients has already been indicated in some studies,5,6 patients who are surgically treated may have distinct prognoses. At present, studies are rare that compare the functional outcome in each period among adult patients with different types of MMD, and limited information is available on the prognostic factors that predict the functional outcomes.

The current study focused on functional outcome comparisons between adult ischemic and hemorrhagic MMD patients and investigated the prognostic factors.

Section snippets

Study population

The current study was conducted as a retrospective investigation. We reviewed 376 consecutive MMD patients admitted to Huashan Hospital from January 2012 to June 2017. The inclusion criteria were as follows: (1) age ≥16 years; (2) MMD confirmed by digital subtraction angiography (DSA) according to the diagnostic guidelines, as suggested by the Research Committee on the Pathology and Treatment of Spontaneous Occlusion of the Circle of Willis in 2012;5 (3) presented with ischemic or hemorrhagic

Patient characteristics

We reviewed 420 adult MMD patients; 44 patients were excluded, 1 (0.2%) with epileptic-type MMD, 9 (2.1%) with asymptomatic-type MMD, 16 (3.8%) with headache-type MMD, 11 (2.6%) with incomplete information and 7 (1.7%) with missing follow-up data. However, we did not exclude patients who died from perioperative complications in the analysis of short-term outcomes. Thus, a total of 376 adult MMD patients (461 hemispheres) were included, consisting of 219 ischemic patients (268 hemispheres) and

Discussion

The current study, a single-center study in Huashan Hospital with a large sample size, demonstrated the functional outcomes and prognostic factors of surgical procedures among adult ischemic and hemorrhagic MMD patients. Our results indicated the followings: (1) ischemic MMD hemispheres might be more likely to suffer perioperative ischemic events, reducing clinical status aggravation in the short term; (2) the MMD type had no significant effect on prognosis, and functional outcomes actually

Conclusions

In this single-center study, MMD type had no significant effect on prognosis, while both types of MMD patients showed overall significant improvements in functional outcomes after surgery, although ischemic MMD hemispheres were more likely to suffer transient neurological aggravation due to perioperative complications. Patients with different types of MMD might have distinct prognostic factors for short-term and long-term functional outcomes; accordingly, comprehensive assessments are needed.

Declaration of Competing Interest

None.

Acknowledgements

This work was supported by the Science and Technology Innovation Action plan (17140900603), National Key Research and Development Program (2016YFC1300600, 2016YFC1301603), the Science and Technology Commission of Shanghai Municipality (18411962100) and the National Natural Science Foundation of China (81671151).

References (25)

  • Zhao M, Deng X, Zhang D, et al. Risk factors for and outcomes of postoperative complications in adult patients with...
  • DK Jang et al.

    Bypass surgery versus medical treatment for symptomatic moyamoya disease in adults

    J Neurosurg

    (2017)
    • View full text
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