Kuroda Satoshi, Nakayama Naoki, Yamamoto Shusuke, Kashiwazaki Daina, Uchino Haruto, Saito Hisayasu, Hori Emiko, Akioka Naoki, Kuwayama Naoya, Houkin Kiyohiro
1Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama; and.
2Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
J Neurosurg. 2020 Mar 13;134(3):909-916. doi: 10.3171/2019.12.JNS192938. Print 2021 Mar 1.
Surgical revascularization is known to reduce the incidence of further ischemic and hemorrhagic events in patients with moyamoya disease, but the majority of previous studies report only short-term (< 5 years) outcomes. Therefore, in this study the authors aimed to evaluate late (5-20 years) outcomes of moyamoya patients after superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis and indirect bypass (encephalo-duro-myo-arterio-pericranial synangiosis [EDMAPS]).
Cumulative incidences of late morbidity/mortality and disease progression were evaluated among 93 patients who underwent STA-MCA anastomosis and EDMAPS. All of the patients were prospectively followed up for longer than 5 years postsurgery (10.5 ± 4.4 years). There were 35 pediatric and 58 adult patients. Initial presentation included transient ischemic attack/ischemic stroke in 80 patients and hemorrhagic stroke in 10 patients, and 3 patients were asymptomatic. Surgery was performed in a total of 141 hemispheres. Follow-up MRI/MRA was performed within a 6- or 12-month interval during the follow-up periods.
During the follow-up periods, 92/93 patients were free from any stroke or death, but 1 patient had a recurrence of hemorrhagic stroke (0.10% per patient-year). Disease progression occurred in the territory of the contralateral carotid or posterior cerebral artery (PCA) in 19 hemispheres of 15 patients (1.5% per patient-year). The interval between initial surgery and disease progression varied widely, from 0.5 to 15 years. Repeat bypass surgery for the anterior and posterior circulation resolved ischemic attacks in all 10 patients.
The study results indicate that STA-MCA anastomosis and EDMAPS would be the best choice to prevent further ischemic and hemorrhagic stroke for longer than 10 years on the basis of the demonstrated widespread improvement in cerebral hemodynamics in both the MCA and ACA territories in the study patients. However, after 10 years postsurgery regular follow-up is essential to detect disease progression in the territory of the contralateral carotid artery and PCA and prevent late cerebrovascular events.
已知外科血管重建术可降低烟雾病患者进一步发生缺血性和出血性事件的发生率，但大多数既往研究仅报告了短期（<5年）结果。因此，在本研究中，作者旨在评估颞浅动脉至大脑中动脉（STA-MCA）吻合术和间接搭桥术（脑-硬膜-肌-动脉-颅周血管吻合术[EDMAPS]）后烟雾病患者的远期（5-20年）结果。
在93例行STA-MCA吻合术和EDMAPS的患者中评估远期发病率/死亡率和疾病进展的累积发生率。所有患者术后均进行了超过5年的前瞻性随访（10.5±4.4年）。其中有35例儿科患者和58例成年患者。初始表现包括80例短暂性脑缺血发作/缺血性卒中、10例出血性卒中，3例无症状。共对141个半球进行了手术。在随访期间，每隔6或12个月进行一次随访MRI/MRA检查。
在随访期间，92/93例患者未发生任何卒中或死亡，但有1例患者发生了出血性卒中复发（每年每例患者0.10%）。15例患者的19个半球在对侧颈动脉或大脑后动脉（PCA）区域出现了疾病进展（每年每例患者1.5%）。初次手术至疾病进展的间隔时间差异很大，从0.5年至15年不等。对前循环和后循环进行的再次搭桥手术使所有10例患者的缺血发作得到缓解。
研究结果表明，基于本研究患者大脑中动脉（MCA）和大脑前动脉（ACA）区域脑血流动力学的广泛改善，STA-MCA吻合术和EDMAPS将是预防10年以上进一步缺血性和出血性卒中的最佳选择。然而，术后10年定期随访对于发现对侧颈动脉和PCA区域的疾病进展以及预防晚期脑血管事件至关重要。
