| Objective: To analyze the data of patients who have MMD, survey the cortical microvascular density in the cerebral hemispheres where the EDAS were performed, conclude the characteristics such as age, sex, onset performance and cortical microvascular density, explore the relationship of clinical and cortical microvascular features and the outcomes of EDAS in MMD.Methods: Retrospectively analyze the data of 497 patients who had MMD and admitted to PLA 307 hospital from Nov 2002 to Oct 2008. According to the case inclusion criteria, a total of 77 patients were included in our study. The following characteristics were recorded: age of the first surgery, sex, onset performance, the Suzuki stage of preoperative DSA, clinical symptoms preoperative, clinical symptoms postoperative, cerebral metabolism of preoperative PET, cerebral metabolism of postoperative PET, the extent of revascularization of postoperative DSA. Cortical microvascular density was carried out semi-quantitative measurement and graded.The relationship of age of the first surgery, onset performance, cortical microvascular density and the outcomes of EDAS were analyzed. The evaluation for the outcomes of EDAS included improvement of clinical symptoms, improvement of cerebral metabolism, and the extent of revascularization after surgery. Differences of the outcomes of EDAS between the groups were examined withχ2 test, the relationship of the Suzuki stage and cortical microvascular density with the outcomes of EDAS were examined with Spearman rank correlation analysis. All of these were completed by SPSS 11.0 statistics software.Results: 1. A total of 77 cases of patients into the group, of which 38 cases of male (49.35%), female 39 cases (50.65%), male to female ratio was 1:1.03; 28 cases of minor (36.36%), 49 cases of adult (63.64%); 58 cases of ischemic type (75.32%), 19 cases of hemorrhagic type (24.68%). In the minor group, 23 cases of ischemic type (82.14%), 5 cases of hemorrhagic type (17.86%); in adult, 35 cases of ischemic type (71.43%), 14 cases of hemorrhagic type (28.57%). The gender composition was no obvious difference, women slightly more than men. Adult onset MMD patients were more than minor onset ones. Furthermore, although the hemorrhagic type cases of adult group were more than the proportion of minor group, the clinical manifestation of MMD was mostly of ischemic symptoms, whether a minor or adult group. According to Suzuki stage, a total of 152 sides of the hemisphere preoperative DSA were graded, of which 49 hemispheres of stageⅣ(32.24%), 47 hemispheres of stageⅤ(30.92%), stageⅣ,Ⅴof all hemispheres accounted for more than 60%.2. In minor group, the significant efficiency of improvement of clinical symptoms was 85.71%, of improvement of metabolism in the left cerebral hemisphere was 84%, of improvement of metabolism in the right cerebral hemisphere was 72%, of the extent of revascularization in the left cerebral hemisphere was 92%, of the extent of revascularization in the right cerebral hemisphere was 88%. In adult group, the significant efficiency of improvement of clinical symptoms was 55.10%, of improvement of metabolism in the left cerebral hemisphere was 51.11%, of improvement of metabolism in the right cerebral hemisphere was 44.44%, of the extent of revascularization in the left cerebral hemisphere was 57.14%, of the extent of revascularization in the right cerebral hemisphere was 51.22%. There was a statistically significant difference between the two groups. Patients of minor group were superior to adult patients in improvement of clinical symptoms, improvement of cerebral metabolism and the extent of revascularization.3. In ischemic type group, the significant efficiency of improvement of clinical symptoms was 67.24%, of improvement of metabolism in the left cerebral hemisphere was 69.81%, of improvement of metabolism in the right cerebral hemisphere was 54.72%, of the extent of revascularization in the left cerebral hemisphere was 76.00%, of the extent of revascularization in the right cerebral hemisphere was 71.15%. In hemorrhagic type group, the significant efficiency of improvement of clinical symptoms was 63.15%, of improvement of metabolism in the left cerebral hemisphere was 41.18%, of improvement of metabolism in the right cerebral hemisphere was 52.94%, of the extent of revascularization in the left cerebral hemisphere was 52.94%, of the extent of revascularization in the right cerebral hemisphere was 42.86%. Although the data of ischemic type patients was always higher or slightly higher than that of hemorrhagic type patients, there was no statistically difference in these evaluation indicators of the outcomes of EDAS between the two groups. 4. Cases in this study showed that the Suzuki stage of preoperative DSA was rank correlation with the extent of revascularization after EDAS.5. In our study, there are 105 hemispheres of which intraoperative photographs of cortical blood vessels suitable for data processing. The value of cortical microvascular density was between 25/100-92/100, to 33%, 66% percentile for division, of which 37 hemispheres of low-density, 35 hemispheres of medium-density, 33 hemispheres of high-density.6. This study showed that cortical microvascular density of patients with MMD was rank correlation with improvement of clinical symptoms, improvement of cerebral metabolism, and the extent of revascularization after EDAS. Conclusion: 1. This study objectively demonstrates the clinical and cortical microvascular features of inhospital MMD in China. Although the age distribution, gender composition and onset performance of these cases are not consistent with those of Japan, Korea and other countries of high incidence of MMD, they are similar to part of other clinical reports of domestic.2. Patients of minor group are superior to adult patients in improvement of clinical symptoms, improvement of cerebral metabolism and the extent of revascularization.3. Although the significant efficiency of improvement of clinical symptoms , improvement of metabolism, the extent of revascularization of ischemic type patients are always higher or slightly higher than those of hemorrhagic type patients, there is no statistically difference in these evaluation indicators of the outcomes of EDAS between the two groups.4. The Suzuki stage of preoperative DSA is rank correlation with the extent of revascularization after EDAS.The higher Suzuki stage of preoperative DSA, the better the extent of revascularization after EDAS. The Suzuki stage of preoperative DSA can be considered to be one of the indicators predict the outcomes of EDAS in patients with MMD.5. The difference among cortical microvascular density does exist in patients with MMD. Cortical microvascular density measurement and classification methods used in this study can classify the degree of increased cortical microvascularization in MMD intuitively and easily, its feasibility is high, and its reliability requires further research.6. Cortical microvascular density of patients with MMD is rank correlation with improvement of clinical symptoms, improvement of cerebral metabolism, and the extent of revascularization after EDAS. The higher cortical microvascular density, the better the outcomes of EDAS.7. Whether ischemic type patients or hemorrhagic type patients, age, preoperative Suzuki stage and cortical microvascular density can be used as the indicators of choice of surgical approach and prediction of surgical treatment. For those younger, higher preoperative Suzuki stage of patients, EDAS is appropriate. While open the dura, if a higher cortical microvascular density can be seen, this approach will be confirmed. For those older, lower preoperative Suzuki stage, or lower cortical microvascular density of patients, the surgeon should consider all aspects of patients, adjust the revascularization approach timely, perform direct revascularization or a combination of direct and indirect approaches, and optimize the postoperative treatment. So that, further improvement of the quality of life in patients with MMD is promising.
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