Kang Kaijiang, Lu Jingjing, Ju Yi, Ji Ruijun, Wang Dandan, Shen Yuan, Yu Lebao, Gao Bin, Zhang Dong, Zhao Xingquan
Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.
Front Neurol. 2020 May 7;11:382. doi: 10.3389/fneur.2020.00382. eCollection 2020.
To evaluate clinical and radiological outcomes after revascularization of hemorrhagic moyamoya disease (MMD). We retrospectively collected patients with hemorrhagic MMD who received revascularization from January 2011 to June 2018 at a high-volume stroke center. Rebleeding, ischemic stroke, modified Rankin Scale (mRS) and death after revascularization were used to evaluate long-term clinical outcome. Poor neurological outcome was defined as a mRS>2. The changes of original and revascularization collaterals were used to evaluate radiological outcome. The clinical and radiological outcomes between patients with different surgical revascularization were compared. A total of 312 patients (319 hemispheres) were recruited, including 133 hemispheres (41.7%) with indirect revascularization and 186 hemispheres (58.3%) with direct revascularization. In 308 hemispheres with clinical follow-up data, Postoperative rebleeding, ischemic stroke, poor neurological outcome and death occurred in 13.0% (40/308), 2.6% (8/308), 12.0% (37/308), and 6.2% (19/308) of the hemispheres, respectively. The rates of postoperative rebleeding (8.5 vs. 19.1%, = 0.006) and poor neurological outcome (8.5 vs. 16.8%, = 0.026) were lower in hemispheres with direct revascularization than those with indirect revascularization. However, there was no statistically significant difference in the rates of postoperative ischemic stroke (1.1 vs. 4.6%, = 0.129) and death (4.5 vs. 8.4%, = 0.162) between the two groups. Multivariate logistic regression analysis indicated that the risk of postoperative rebleeding was higher in those with untreated aneurysms, repetitive bleeding episodes, normal perfusion status, and indirect revascularization ( < 0.05). In 78 hemispheres with radiological follow-up data, the regression of moyamoya vessels, anterior choroidal artery (AchA), posterior communicating artery (PcomA) and aneurysms were present in 44.9, 47.4, 25.6, and 11.5% of the hemispheres, respectively. The regression of original collaterals and establishment of revascularization collaterals were more significant in hemispheres with direct revascularization than those with indirect revascularization ( < 0.05). Direct revascularization may be superior to indirect revascularization for prevention of rebleeding and poor neurological outcome in adults with hemorrhagic MMD. The risk of postoperative rebleeding was higher in those with untreated aneurysms, repetitive bleeding episodes, normal perfusion status, and indirect revascularization. The regression of original collaterals and establishment of revascularization collaterals after revascularization were more significant in hemispheres with direct revascularization than those with indirect revascularization.
评估出血性烟雾病（MMD）血运重建后的临床和影像学结果。我们回顾性收集了2011年1月至2018年6月在一家大型卒中中心接受血运重建的出血性MMD患者。采用再出血、缺血性卒中、改良Rankin量表（mRS）及血运重建后的死亡情况来评估长期临床结局。神经功能预后不良定义为mRS>2。利用原始侧支循环和血运重建侧支循环的变化来评估影像学结果。比较不同手术血运重建患者的临床和影像学结果。共纳入312例患者（319个半球），其中133个半球（41.7%）接受间接血运重建，186个半球（58.3%）接受直接血运重建。在308个有临床随访数据的半球中，术后再出血、缺血性卒中、神经功能预后不良及死亡的发生率分别为13.0%（40/308）、2.6%（8/308）、12.0%（37/308）和6.2%（19/308）。直接血运重建半球的术后再出血率（8.5%对19.1%，P = 0.006）和神经功能预后不良率（8.5%对16.8%，P = 0.026）低于间接血运重建半球。然而，两组间术后缺血性卒中发生率（1.1%对4.6%，P = 0.129）和死亡率（4.5%对8.4%，P = 0.162）无统计学显著差异。多因素logistic回归分析表明，未治疗动脉瘤、反复出血发作、灌注状态正常及间接血运重建的患者术后再出血风险较高（P<0.05）。在78个有影像学随访数据的半球中，烟雾状血管、脉络膜前动脉（AchA）、后交通动脉（PcomA）及动脉瘤的消退分别出现在44.9%、47.4%、25.6%和11.5%的半球中。直接血运重建半球原始侧支循环的消退及血运重建侧支循环的建立比间接血运重建半球更显著（P<0.05）。对于预防出血性MMD成人患者的再出血和神经功能预后不良，直接血运重建可能优于间接血运重建。未治疗动脉瘤、反复出血发作、灌注状态正常及间接血运重建的患者术后再出血风险较高。血运重建后，直接血运重建半球原始侧支循环的消退及血运重建侧支循环的建立比间接血运重建半球更显著。
