Imai Hideaki, Miyawaki Satoru, Ono Hideaki, Nakatomi Hirofumi, Yoshimoto Yuhei, Saito Nobuhito
Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
World Neurosurg. 2015 May;83(5):691-9. doi: 10.1016/j.wneu.2015.01.016. Epub 2015 Feb 3.
The optimal surgical procedure (direct, indirect, or combined anastomosis) for management of moyamoya disease is still debated. We evaluated the outcome of our broad area revascularization protocol, the Tokyo Daigaku (The University of Tokyo) (TODAI) protocol, analyzing the relative importance of direct, indirect, and combination revascularization strategies to identify the optimal surgical protocol.
The TODAI protocol was used to treat 65 patients with moyamoya disease (91 hemispheres, including 48 in 29 childhood cases collected during 1996-2012). The TODAI protocol combined direct superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis with indirect revascularization using encephalo-myo-synangiosis (EMS) for patients ≥10 years old or indirect revascularization using encephalo-duro-arterio-synangiosis (EDAS) with EMS for patients ≤9 years old. Clinical outcome was evaluated retrospectively. Digital subtraction angiography was performed for postoperative evaluation of revascularization in 47 patients (62 hemispheres; 27 adults and 35 children). Based on the relative contribution of additional flow from each revascularization path, 4 revascularization patterns were established.
The mean follow-up period was 90 months in children and 72 months in adults. Perioperative complications were seen in 4 of 48 operations in children and 1 of 43 operations in adults. Except for 1 child with recurrent transient ischemic attacks and 1 adult with intracerebral hemorrhage, the patients showed excellent clinical outcomes. Postoperative digital subtraction angiography evaluation showed that in STA-MCA anastomosis + EMS cases (34 hemispheres; 25 adults and 9 children), STA-MCA anastomosis provided greater revascularization than EMS (STA-MCA anastomosis > EMS) in 7 hemispheres, the opposite was true (STA-MCA anastomosis < EMS) in 14 hemispheres, an equivalent contribution to revascularization (STA-MCA anastomosis ≈ EMS) was present in 12 hemispheres, and no functioning anastomosis was present in 1 hemisphere. In cases of EDAS + EMS (28 hemispheres; 2 adults and 26 children), all hemispheres showed revascularization: EDAS was dominant to EMS (EDAS > EMS) in 1 hemisphere, the opposite (EMS > EDAS) was true in 14 hemispheres, and EDAS was equivalent to EMS (EDAS ≈ EMS) in 13 hemispheres. EMS plus direct or indirect anastomosis is an effective surgical procedure in adults and children.
The TODAI protocol provided efficient revascularization and yielded excellent results in preventing strokes in patients with moyamoya disease with very few complications. EMS had a main role in revascularization in each of the combined techniques.
烟雾病治疗的最佳手术方式（直接、间接或联合吻合术）仍存在争议。我们评估了我们的大面积血管重建方案，即东京大学（TODAI）方案的效果，分析直接、间接和联合血管重建策略的相对重要性，以确定最佳手术方案。
采用TODAI方案治疗65例烟雾病患者（91个半球，包括1996 - 2012年收集的29例儿童病例中的48个半球）。TODAI方案对于≥10岁的患者，将直接颞浅动脉（STA）-大脑中动脉（MCA）吻合术与采用脑-肌-血管融合术（EMS）的间接血管重建相结合；对于≤9岁的患者，将采用脑-硬膜-动脉-血管融合术（EDAS）与EMS的间接血管重建相结合。对临床结果进行回顾性评估。对47例患者（62个半球；27例成人和35例儿童）进行数字减影血管造影，以评估术后血管重建情况。根据每个血管重建路径额外血流的相对贡献，建立了4种血管重建模式。
儿童的平均随访期为90个月，成人的平均随访期为72个月。儿童48例手术中有4例出现围手术期并发症，成人43例手术中有1例出现围手术期并发症。除1例儿童复发性短暂性脑缺血发作和1例成人脑出血外，患者的临床结果均良好。术后数字减影血管造影评估显示，在STA - MCA吻合术 + EMS病例（34个半球；25例成人和9例儿童）中，7个半球中STA - MCA吻合术提供的血管重建比EMS更多（STA - MCA吻合术 > EMS），14个半球中情况相反（STA - MCA吻合术 < EMS），12个半球中对血管重建的贡献相当（STA - MCA吻合术 ≈ EMS），1个半球中无功能性吻合。在EDAS + EMS病例（28个半球；2例成人和26例儿童）中，所有半球均显示有血管重建：1个半球中EDAS对EMS占优势（EDAS > EMS），14个半球中情况相反（EMS > EDAS），13个半球中EDAS与EMS相当（EDAS ≈ EMS）。EMS加直接或间接吻合术对成人和儿童都是一种有效的手术方法。
TODAI方案提供了有效的血管重建，在预防烟雾病患者中风方面取得了优异的效果，且并发症极少。在每种联合技术中，EMS在血管重建中起主要作用。
