Hayashi Toshiaki, Shirane Reizo, Tominaga Teiji
Department of Neurosurgery, Miyagi Children's Hospital, Sendai, Japan.
Neurosurgery. 2009 Jan;64(1):E195-6; discussion E196. doi: 10.1227/01.NEU.0000336311.60660.26.
In patients with moyamoya disease, surgery to revascularize the ischemic brain is a recommended treatment. However, there are a few patients who require additional revascularization surgery because of progression of the disease. Even patients who show no postoperative ischemic symptoms at first may experience late deterioration. We performed additional surgery for such lesions using occipital artery (OA)-posterior cerebral artery (PCA) bypass with indirect revascularization. The efficacy of the procedure is reported.
We treated 3 patients with moyamoya disease who showed a transient ischemic attack after revascularization surgery. Three female patients, ranging in age from 6.0 to 35.2 years (mean age, 23.8 years) at the time of surgery, with ischemic symptoms (leg monoparesis in 2, visual impairment in 1) underwent the additional revascularization procedure. Preoperatively, all patients underwent indirect and/or direct revascularization surgery for initial treatment. All patients showed progression of the disease, especially in the PCA. OA-PCA bypass with encephalogaleodurosynangiosis and burr hole surgery were performed for postoperative ischemic symptoms.
All patients showed clinical and radiological improvement. The transient ischemic attack was improved in all 3 patients. They did not complain of transient ischemic attack in the recent follow-up period. Follow-up magnetic resonance imaging showed no additional cerebral infarction. Magnetic resonance angiography showed widening of the OA and development of peripheral collateral vessels. Postoperative single-photon emission computed tomographic studies showed marked increase of uptake in both anterior cerebral artery and PCA territories. Cerebral vasodilatory capacity evaluated by an acetazolamide test also showed marked improvement. One patient showed postoperative cerebral edema as a result of focal cerebral hyperperfusion.
OA-PCA anastomosis with indirect revascularization was effective for postoperative ischemia that showed symptoms in the anterior cerebral artery and PCA territories as a result of progression of a PCA lesion.
在烟雾病患者中，对缺血性脑进行血管重建的手术是一种推荐的治疗方法。然而，有少数患者由于疾病进展需要额外的血管重建手术。即使最初没有术后缺血症状的患者也可能出现晚期病情恶化。我们使用枕动脉（OA）-大脑后动脉（PCA）搭桥术并结合间接血管重建术对这类病变进行了额外手术。报告了该手术的疗效。
我们治疗了3例烟雾病患者，这些患者在血管重建手术后出现了短暂性脑缺血发作。3例女性患者，手术时年龄在6.0至35.2岁之间（平均年龄23.8岁），有缺血症状（2例为腿部单瘫，1例为视力障碍），接受了额外的血管重建手术。术前，所有患者均接受了间接和/或直接血管重建手术进行初始治疗。所有患者均显示疾病进展，尤其是在PCA区域。针对术后缺血症状，进行了OA-PCA搭桥术并结合脑硬脑膜-软脑膜联合血管重建术和钻孔手术。
所有患者均显示出临床和影像学改善。3例患者的短暂性脑缺血发作均得到改善。在最近的随访期内，他们均未诉说短暂性脑缺血发作。随访磁共振成像显示没有额外的脑梗死。磁共振血管造影显示OA增宽以及外周侧支血管形成。术后单光子发射计算机断层扫描研究显示大脑前动脉和PCA区域的摄取明显增加。通过乙酰唑胺试验评估的脑血管舒张能力也显示出明显改善。1例患者因局灶性脑过度灌注出现术后脑水肿。
OA-PCA吻合术并结合间接血管重建术对于因PCA病变进展导致大脑前动脉和PCA区域出现症状的术后缺血有效。
