Department of Neurosurgery, The University of Tennessee Health Sciences Center, Memphis (V.N.N., M.M., K.A.M., L.E.M., M.B., N.G., L.E., P.K., D.A.H., A.S.A., N.R.K.).
Department of Neurosurgery, University of Miami, FL (T.E., J.J.M.).
Stroke. 2022 Dec;53(12):3572-3582. doi: 10.1161/STROKEAHA.122.039584. Epub 2022 Sep 22.
Moyamoya disease is a chronic, progressive cerebrovascular disease involving occlusion or stenosis of the terminal portion of the internal carotid artery. We conducted an updated systematic review and meta-analysis to investigate clinical and angiographic outcomes comparing direct, combined, and indirect bypass for the treatment of moyamoya disease in adults.
Two independent authors performed Preferred Reporting Items for Systematic reviews and Meta-Analyses guided literature searches in December 2021 to identify articles reporting clinical/angiographic outcomes in adult moyamoya disease patients undergoing bypass. Primary end points used were ischemic and hemorrhagic strokes, clinical outcomes, and angiographic revascularization. Study quality was evaluated with Newcastle-Ottawa and the Oxford Center for Evidence-Based Medicine scales.
Four thousand four hundred fifty seven articles were identified in the initial search; 143 articles were analyzed. There were 3827 direct, 3826 indirect, and 3801 combined bypasses. Average length of follow-up was 3.59±2.93 years. Pooled analysis significantly favored direct (odds ratio [OR], 0.62 [0.48-0.79]; <0.0001; OR, 0.44 [0.32-0.59]; <0.0001; OR, 0.56 [0.42-0.74]; <0.0001; OR, 3.1 [2.5-3.8]; =0.0001) and combined (OR, 0.53 [0.41-0.69]; <0.0001; OR, 0.28 [0.2-0.41]; <0.0001; OR, 0.41 [0.3-0.56]; <0.0001; OR, 3.1 [2.8-4.3]; =0.0001) over indirect bypass for early stroke, late stroke, late intracerebral hemorrhage, and favorable outcomes, respectively. Indirect bypass was favored over combined (OR, 3.1 [1.7-5.6]; <0.0001) and direct (OR, 4.12 [2.34-7.25]; <0.0001) for early intracerebral hemorrhage. The meta-analysis significantly favored direct (OR, 0.37 [0.23-0.60]; <0.001; OR, 0.49 [0.31-0.77]; =0.002) and combined (OR, 0.23 [0.12-0.43]; <0.00001; OR, 0.30 [0.18-0.49]; <0.00001) bypass over indirect bypass for late stroke and late hemorrhage, respectively. Combined bypass was favored over indirect bypass for favorable outcomes (OR, 2.06 [1.18-3.58]; =0.01).
Based on combined meta-analysis (43 articles) and pooled analysis (143 articles), the existing literature indicates that combined and direct bypasses have significant benefits for patients suffering from late stroke and hemorrhage versus indirect bypass. Combined bypass was favored over indirect bypass for favorable outcomes. This is a strong recommendation based on low-quality evidence when utilizing the Grades of Recommendation, Assessment, Development, and Evaluation system. These findings have important implications for bypass strategy selection.
烟雾病是一种慢性、进行性的脑血管疾病，涉及颈内动脉末端的闭塞或狭窄。我们进行了一项更新的系统评价和荟萃分析，以研究直接、联合和间接旁路治疗成人烟雾病的临床和血管造影结果。
两位独立作者于 2021 年 12 月按照系统评价和荟萃分析的 Preferred Reporting Items 指南进行文献检索，以确定报告接受旁路治疗的成人烟雾病患者临床/血管造影结果的文章。主要终点为缺血性和出血性中风、临床结果和血管造影再通。使用纽卡斯尔-渥太华和牛津循证医学中心量表评估研究质量。
初步搜索共确定了 4457 篇文章，分析了 143 篇文章。有 3827 例直接旁路、3826 例间接旁路和 3801 例联合旁路。平均随访时间为 3.59±2.93 年。荟萃分析显著有利于直接旁路（比值比[OR]，0.62[0.48-0.79]；<0.0001；OR，0.44[0.32-0.59]；<0.0001；OR，0.56[0.42-0.74]；<0.0001；OR，3.1[2.5-3.8]；=0.0001）和联合旁路（OR，0.53[0.41-0.69]；<0.0001；OR，0.28[0.2-0.41]；<0.0001；OR，0.41[0.3-0.56]；<0.0001；OR，3.1[2.8-4.3]；=0.0001），有利于早期中风、晚期中风、晚期颅内出血和良好的结果，而间接旁路有利于早期颅内出血。间接旁路优于联合旁路（OR，3.1[1.7-5.6]；<0.0001）和直接旁路（OR，4.12[2.34-7.25]；<0.0001）。荟萃分析显著有利于直接旁路（OR，0.37[0.23-0.60]；<0.001；OR，0.49[0.31-0.77]；=0.002）和联合旁路（OR，0.23[0.12-0.43]；<0.00001；OR，0.30[0.18-0.49]；<0.00001），有利于晚期中风和晚期出血，而间接旁路有利于晚期出血。联合旁路有利于良好的结果（OR，2.06[1.18-3.58]；=0.01）。
基于联合荟萃分析（43 篇文章）和汇总分析（143 篇文章），现有文献表明，联合和直接旁路对患有晚期中风和出血的患者具有显著益处，优于间接旁路。联合旁路有利于良好的结果。这是一项强有力的推荐，基于低质量证据，利用推荐评估、制定和评估系统的等级。这些发现对旁路策略选择具有重要意义。
