| No known treatment will prevent the progression of moyamoya disease(MMD). Surgical treatment of moyamoya disease, especially ischemic type of moyamoya disease has gradually formed a consensus. Surgical treatments are designed to prevent strokes by improving blood flow to the affected cerebral hemisphere. Improvement in cerebral blood flow may provide protection against future stroke, effect a concurrent reduction in moyamoya-associated collaterals, and reduce the frequency of symptoms. Among many types of revascularization, EDAS is a widely used method of indirect revascularization. However the outcome of revascularization reported was quite difference. Even through about 56-95% of patients could achieve good vascular remodeling; some patients can not establish collateral formation from the superficial temporal artery. Although it is important to understand the effect of the collateral circulation formation from STA, few related research has been reported. We will discuss the issue in this paper.ObjectiveTo survey the effects of cerebral revascularization in the cerebral hemispheres where the EDAS were performed, we summarized the clinical data of the patients who suffered moyamoya disease(MMD) and analyzed the characteristics such as age at first surgery, gender, imaging performance, cerebral vascular lesions and effect of superficial temporal artery revascularization, conclude the efficacy and predictive factors of revascularization for ischemic MMD with encephalo-duro-arterio-synangiosis (EDAS) procedures.MethodsRetrospectively analyze the data of 610 patients who had MMD and admitted to PLA 307 hospital from Apr 2004 to Jun 2009. According to the case inclusion criteria, a total of 120 patients were included in our study. The following characteristics were recorded: age of the first surgery, gender, imaging performance, cerebral metabolism of preoperative PET, stage of the internal carotid artery (ICA) bifurcation steno-occlusive lesion, grade of the posterior cerebral artery(PCA) lesion, compensation between anterior and posterior circulation, compensation between left and right hemisphere. To design of the evaluation criteria for reconstruction after superficial temporal artery, the transpial at the synangiosis site were graded accoreding Matsushima classification method. Based on the lateral view of external carotid artery angiography, collaterals extent at the sites of the revascularization were scored in four grades. The effect of the extent of revascularization after surgery and impact facters such as gender, age at first surgery, glucose metabolism, cerebral infarction type, surgical side, stage of the internal carotid artery (ICA) bifurcation steno-occlusive lesion, grade of the posterior cerebral artery(PCA) lesion, compensation between anterior and posterior circulation, compensation between left and right hemisphere were analyzed by SAS 9.1.3 software. Data were processed by accumulated logistic regression analysis.Results1. A total of 610 cases of patients were treated in our department between Apr 2004 and Jun 2009. There are 120 ischemic moyamoya cases meet the conditions of enrollment, of which 61 cases of male(50.8%), female 59 cases (49.2%), male to female ratio was 1.03:1. The gender composition was no obvious difference, men slightly more than women. Minimum age at treatment was 3 years, maximum was 52 years, mean age was 24.6±14.6 years. There were 57 cases of minor (47.5%), 63 cases of adult (52.5%). No significant difference between Adult onset MMD and minor onset. Adults were more than minor onset ones. Since 102 of them received bilateral procedures, and 18 of them received unilateral procedures. 109 cases of surgery on the left and right operation was 113 cases. The total procedures performed were 222.2. Background information on preoperative imaging. There were 68(30.6%) hemispheres show no abnormal brain performance on MRI. A total of 154 sides showed some type of cerebral infarction , of which 67 hemispheres of cortical infarct, 27 hemispheres of subcortical white matter infarction, 13 hemispheres of deep brain infarction, 47 hemispheres of point-like infarction. There were 60(27.1%) hemispheres show no abnormal brain performance on PET glucose metabolism . A total of 162(72.9%) sides showed some lesions on PET glucose metabolism , of which 98 hemispheres showed metabolic reduction, 14 hemispheres showed metabolic deficiency, and both suffered metabolic deficiency and reduction were 50 hemispheres. A total of 222 sides of the hemisphere preoperative DSA were graded. According to Suzuki stage, there were 20 hemispheres of stage I(9.0%), 51 hemispheres of stage II(23.0%),32 hemispheres of stage III (14.4%), 49 hemispheres of stage IV (22.1%), 41 hemispheres of stage V (18.5%), and 29 hemispheres of stage VI(13.1%). According to the posterior cerebral artery lesion, 148 hemispheres(66.7%) showed normal performance, 19 hemispheres of stage I(8.6%), 24 hemispheres of stage II(10.8%),24 hemispheres of stage III (10.8%), 7 hemispheres of stage IV (3.2%). During compensation between anterior and posterior circulation, there were 65(29.3%) hemispheres showed type 0, 148 (66.7%) showed type 1, 9 (4.1%) showed type 2. During compensation between left and right hemisphere, 157 (70.7%) showed type 0, 65 (29.3%) showed type 1.3. Revascularization cases. Angiography after review, Collateral formation in the middle cerebral artery (MCA) territory from superficial temporal artery (STA) was seen in 174 hemispheres (78.4%). 48 (21.6%) hemispheres showed stage I, 55 (24.8%) showed stage II, 56 (25.2%) showed stage III, 63 (28.4%) showed stage IV. The rate of efficient revascularization (II +III+IV) was 78.4%.4. Results of statistical analysis. Forward method, backward method and step by step method were used to select independent variables, and eventually the independent variables into the model were age, cerebral infarction type, compensation between left and right hemisphere, posterior cerebral artery lesions. A multivariate logistic regression analysis of age at first surgery(OR=1.030, 95%CI 1.012-1.049,P=0.0011), grade of the PCA lesion(OR=0.767, 95%CI 0.601-0.977,P=0.0319), compensation between left and right hemisphere(OR=0.499, 95%CI 0.280-0.891,P=0.0188 ) and certain type of infarction showed a correlation for better revascularization. Relative to normal brain tissue, cortical infarction(OR=0.275, 95%CI 0.133-0.569,P=0.0005), subcortical white matter infarction(OR=0.317, 95%CI 0.131-0.763 , P=0.0104 ) , point-like infarction ( OR=0.392 , 95%CI 0.193-0.796,P=0.0096)showed better revascularization.Conclusion1. Surgical treatment with EDAS is effective at establishing extra-intracranial revascularization. EDAS could be effectively established ex-intracranial revascularization in patients at different ages or of different genders. Even if preoperative brain infarction lesions appear, patients can get a good revascularization.2. Follow factors such as age, grade of the PCA lesion, compensation between left and right hemisphere and certain type of infarction, play a important role in affect revascularization. Patients with lower preoperative age, higher grade of the PCA , appearance of compensation between left and right circulation showed better revascularization. Relative to normal brain, patients have ischemic lesions involving the cortical, subcortical and dot-like will get better revascularization results.3. There was no significant difference in vascular remodeling between different genders and surgical sides. Cerebral glucose metabolism, preoperative Suzuki staging did not show statistically significant effects on revascularization.4. Patients with the following characteristics, such as lower age, appearance of brain infarction before surgery, especially cortical infarction, subcortical infarction and dot-like infarction, involvement posterior cerebral artery and appearance compensation between left and right cerebral hemisphere, have good surgical adaptation with EDAS. They should be actively considered for EDAS surgery. |
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