Study Of Factors Related To Cerebralinfarction,hypeper-fusion Syndrome And Prognosis Analysis In Adults With Moyamoya Disease After Direct Bypass Surgery

PART Ⅰ:ANALYSIS OF FACTORS RELATED TO CEREBRAL INFARCTION AND HYPERPERFUSION SYNDROME AFTER DIRECT BYPASS SURGERY IN ADULTS WITH MOYAMOYA DISEASEObjective:The basic factors of the patients with moyamoya disease were analyzed,and the high risk factors were found to provide the theoretical basis for the prediction and management of cerebral infarction and hyperperfusion syndrome after direct bypass surgery in adults with moyamoya disease.Methods:1.Retrospective analysis of the clinical datas in adult patients with moyamoya disease,who were performed direct bridge(that is the superficial temporal artery-middle cerebral artery,STA-MCA)surgery in our hospital from July 2013 to December 2017.Entry criteria:1)All patients were conformed to the 2015 clinical guidelines for moyamoya disease;2)Patients received Digital Subtraction Angiography(DSA)within a month before operation;3)All patients(≥18 years old)performed STA-MCA surgery,and indirect bridge patients were excluded.2.The preoperative cerebral angiography was graded according to Suzuki staging,which was performed on the operative side,the non-operative side,and the posterior circulation involved or not.3.According to the clinical manifestations,the patients were divided into the patients with hemorrhagic and infarct type.To assess neurological function,the patients were classified according to the modified Rankin Scale(mRS)score before the operation;The clinical typing was divided according to the classification standard proposed by Matsushima in 1990.4.The basic clinical data were analyzed as follows:sex,age,history of drinking,smoking history,distory of diabetes,history of hypertension,history of pre-operation cerebral infarction,Transient Ischemia Attack(TIA)onset,clinical typing,classification of clinical manifestations,preoperative mRS score and Suzuki staging(operative side,non-operative side,and posterior circulation involved or not),then we conducted logistic regression analysis on the potential factors related to cerebral infarction and hyperperfusion syndrome after STA-MCA surgery.Results:1.At last 236 patients were counted,of which 14 patients underwent bilateral bypass surgery,that was,250 hemispherical bypass surgery from July 2013 to December 2017 in our hospital.The complications included 31 cases of postoperative cerebral infarction(31/250),6 cases of scalp healing,2 cases of cerebral hemorrhage,2 cases of epidural hematoma,and 1 case of epilepsy.The total complication rate was 16.8%,and the incidence of postoperative cerebral infarction was 12.4%.In addition,there were 19 cases of hyperperfusion syndrome after operation in our department,and the incidence rate was 7.6%.There were 4 patients with cerebral infarction and hyperperfusion syndrome at the same time.2.There were significant differences in clinical typing,preoperative infarction,classification of clinical manifestations and Suzuki staging of non-operative side between postoperative cerebral infarction group and control group(P<0.05).The proportion of hemorrhagic type in the control group was 17.4%higher than that in the cerebral infarction group(0%);the proportion of infarction in the control group was 67.6%lower than that in the cerebral infarction group.The proportion of anterior infarction was 90.3%,and the proportion of clinical V type in the control group was 30.6%significantly lower than that in the cerebral infarction group,which was 45.2%.The largest proportion of postoperative infarction was stage V(38.7%)in Suzuki staging of the non-operative side,while most of the control group was stage Ⅲ(37%).3.Logistic regression analysis showed that the pre-operation infarction(OR:4.184,95%CI:1.217-14.382)and Suzuki staging of non-operative side(OR:1.640,95%CI:1.207-2.227)were risk factors affecting postoperative cerebral infarction.4.Related factors analysis of hyperperfusion syndrome:there was no significant difference in the basic factors between the two groups(P>0.05).Conclusion:1.The possibility of new cerebral infarction in patients with the history of cerebral infarction was greater after operation.2.The higher the Suzuki staging of non-operative side was,the higher the probability of cerebral infarction after operation was.PART II ANALYSIS OF FACTORS ERLATED TO PATENCY OF PROGN OSIS AFTER DIRECT BYPASS SURGERY IN ADULTS WITH MOYAMOYA DISEASEObjective:To analyze and summarize the follow-up data at discharge,6 months and 2 years after discharge,as well as the data of DSA reexamination at 3-6 months after bypass surgery in adult patients with moyamoya disease,we explore the factors affecting the patency of the bridging vessels and the improvement of postoperative neurological function,in order to evaluate the influence on vascular bypass before operation for guiding the adjustment of surgicalstrategies.Methods:1.Retrospective analysis of the clinical DSA datas at 3-6 months after STA-MCA surgery in adult patients from July 2013 to December 2017.2.According to the blood vessel formation of the direct bridge,the patients were divided into four grades:grade 0,grade Ⅰ(vascular coverage<1/3),grade Ⅱ(1/3<vascular coverage<2/3),and grade Ⅲ(vascular coverage>2/3).According to the blood vessel formation of the indirect bridge,the patients were divided into two groups.3.The Logistic regression analasis of the age,sex,smoking history,history of drinking,history of diabetes,history of hypertension,history of pre-operation cerebral infarction,TIA,clinical typing,classification of clinical manifestations,preoperative mRS score,and Suzuki staging(operative side,non-operative side,and posterior circulation involved or not),we explore related factors affecting the vascular patency and prognosis.4.Outpatient or telephone follow-up:we collect the symptom improvement data at discharge,6 months after discharge and 2 years after discharge after bypass surgery in adult patients with moyamoya disease through outpatient or telephone follow-up,and evaluate the postoperative neurological function through mRS score.Linear mixed effect model was used to analyze the effects of related factors on the changes of mRS score.Results:1.89 patients were reexamined in the patients who underwent direct bypass surgery from July 2013 to December 2017.2.There were significant differences in the history of hypertension and indirect bridge angiogenesis between the grade of direct bridge angiogenesis(P<0.05).3.Logistic regression analysis further confirmed that the history of hypertension(OR:0.24,95%Cl:0.10-0.56)was a risk factor affecting direct bridge angiogenesis after operation.Compared with grade 0 of direct bridge vessels,grade Ⅱ vascular patency was related to the decrease of indirect angiogenesis(OR:0.14,95%CI:0.03-0.64),but the results of trend test showed that indirect bridge angiogenesis decreased with the increase of grade(P=0.030).4.The follow-up data(250 cases)were processed by linear mixed effect model.It was found that although the patients with high perfusion had the risk of intracranial hemorrhage,the neurological function recovered relatively quickly;The neurological function of patients with postoperative cerebral infarction is poor as a whole,but the recovery speed is relatively fast,and the prognosis is still worse than that of patients without cerebral infarction.Conclusion:1.Patients with hypertension have poor vascular elasticity and high resistance,and are prone to direct bridge vascular occlusion after operation;2.Direct bridge angiogenesis is related to indirect bridge angiogenesis after operation.Direct bridge angiogenesis after operation is better,which will inhibit indirect bridge angiogenesis;Direct bridge angiogenesis is poor after operation,which will promote indirect bridge angiogenesis.3.Patients with high perfusion after operation have large blood flow.Although they have the risk of bleeding,their neurological function recovers relatively quickly;Although the recovery rate of patients with postoperative cerebral infarction is relatively fast,the prognosis is still poor.