Golby A J, Marks M P, Thompson R C, Steinberg G K
Department of Neurosurgery, Stanford University School of Medicine, California, USA.
Neurosurgery. 1999 Jul;45(1):50-8; discussion 58-60. doi: 10.1097/00006123-199907000-00013.
Surgical revascularization of moyamoya disease can improve neurological outcomes, compared with the natural history of the disease or the results of medical treatment. Controversy exists regarding whether direct or indirect revascularization yields better outcomes. This study involves a single-center experience with direct anastomosis and is the first North American series using direct revascularization for pediatric patients with moyamoya disease.
Twelve patients (age range, 5-17 yr; mean age, 10.2 yr) underwent direct revascularization of 21 hemispheres. Two patients had experienced failure of previous indirect revascularization procedures, with continued clinical deterioration. Superficial temporal artery-middle cerebral artery anastomosis was performed in 19 hemispheres (with concurrent encephaloduroarteriosynangiosis in 6). Middle meningeal artery-middle cerebral artery anastomosis and omental transposition were each performed in one hemisphere. Follow-up periods ranged from 12 to 65 months (mean, 35 mo), and monitoring included neurological examinations, angiography, magnetic resonance imaging, and cerebral blood flow studies.
The neurological conditions of all patients were stable or improved after surgery. None of the patients developed new strokes, and no new ischemic lesions were seen in magnetic resonance imaging scans. All grafts evaluated by follow-up angiography were patent. Postoperative cerebral blood flow studies showed significantly improved blood flow (54.4 versus 42.5 ml/100 g/min; P = 0.017, n = 4) and hemodynamic reserve (70.3 versus 43.9 ml/100 g/min; P = 0.009, n = 4), compared with preoperative studies.
Surgical revascularization by direct anastomosis in pediatric patients is technically feasible, is well tolerated, and can improve the progressive natural history, the angiographic appearance, and the cerebral blood flow abnormalities associated with the disease. Direct revascularization has the advantage of providing immediate and high-flow revascularization and is particularly useful for patients who have experienced failure of previous indirect revascularization procedures.
与烟雾病的自然病程或药物治疗结果相比，烟雾病的外科血管重建可改善神经功能结局。关于直接或间接血管重建哪种能产生更好的结果存在争议。本研究涉及单中心直接吻合术的经验，且是北美首个对小儿烟雾病患者采用直接血管重建的系列研究。
12例患者（年龄范围5 - 17岁；平均年龄10.2岁）对21个半球进行了直接血管重建。2例患者先前的间接血管重建手术失败，临床持续恶化。19个半球进行了颞浅动脉 - 大脑中动脉吻合术（其中6例同时进行了脑硬脑膜动脉血管融合术）。1个半球分别进行了脑膜中动脉 - 大脑中动脉吻合术和网膜移植术。随访期为12至65个月（平均35个月），监测包括神经学检查、血管造影、磁共振成像和脑血流研究。
所有患者术后神经状况稳定或改善。无患者发生新的中风，磁共振成像扫描未见新的缺血性病变。随访血管造影评估的所有移植物均通畅。与术前研究相比，术后脑血流研究显示血流量显著改善（54.4对42.5 ml/100 g/min；P = 0.017，n = 4）和血流动力学储备改善（70.3对43.9 ml/100 g/min；P = 0.009，n = 4）。
小儿患者通过直接吻合进行外科血管重建在技术上是可行的，耐受性良好，且可改善与该疾病相关的进行性自然病程、血管造影表现和脑血流异常。直接血管重建具有提供即时和高流量血管重建的优势，对先前间接血管重建手术失败的患者尤其有用。
