Postoperative hemorrhage during the acute phase after direct or combined revascularization for moyamoya disease: risk factors, prognosis, and literature review

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  • 1 Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University;
  • 2 Department of Neurosurgery, Peking University International Hospital, Peking University;
  • 3 China National Clinical Research Center for Neurological Diseases;
  • 4 Stroke Center, Beijing Institute for Brain Disorders;
  • 5 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease; and
  • 6 Beijing Translational Engineering Center for 3D Printer in Clinical Neuroscience, Beijing, People’s Republic of China
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OBJECTIVE

Postoperative hemorrhage during the acute phase is rarely observed after revascularization surgery for moyamoya disease (MMD) but can have severe complications. Its risk factors and outcomes are still unclear. The aim of this study was to investigate the predictors of postoperative hemorrhage during the acute phase in MMD and examine the outcomes of the hemorrhage.

METHODS

The authors reviewed the preoperative clinical characteristics and radiographic features of 465 consecutive MMD cases (518 procedures) that had undergone direct or combined bypass surgery at their institution between 2009 and 2015. Patients with postoperative intracerebral hemorrhage (ICH) or ICH plus intraventricular hemorrhage (IVH) during the acute phase were screened, and then the incidence, location, and risk factors of hemorrhage in these patients were analyzed. Short-term and long-term outcomes (modified Rankin Scale scores) for these patients were also collected. Outcomes were compared between patients with and those without postoperative ICH using propensity score analysis to reduce the between-group differences in baseline characteristics.

RESULTS

Postoperative hemorrhage occurred in 11 (2.1%; ICH = 9, IVH = 2) of 518 procedures (mean patient age 39.82 ± 8.8 years). Hemorrhage occurred in the first 24 hours after the operation in 8 cases (72.7%). In the ICH group, most of the hemorrhage sites (77.8%) were located beneath the anastomosed area, and the mean hematoma volume was 16.98 ± 22.45 ml (range 3–57 ml). One case from the ICH group required hematoma evacuation. Among the adult patients (463 procedures [89.4%]), preoperative hypertension (p = 0.008), CT perfusion (CTP) stage > III (p = 0.013), and posterior circulation involvement (p = 0.022) were significantly associated with postoperative ICH. No significant differences between the postoperative ICH group and the no-hemorrhage group were detected in terms of postoperative neurofunctional status at discharge (p = 0.569) or at the last follow-up (p = 1.000). Neither was there a significant difference in future stroke risk (p = 0.538) between these two groups.

CONCLUSIONS

Preoperative hypertension, CTP stage > III, and posterior circulation involvement are independent risk factors for postoperative ICH after direct or combined revascularization for MMD. After appropriate perioperative management, postoperative ICH has no significant correlations with the postoperative short-term and long-term neurofunctional status.

ABBREVIATIONS BP = blood pressure; CBF = cerebral blood flow; CBV = cerebral blood volume; CHS = cerebral hyperperfusion syndrome; CTA = CT angiography; CTP = CT perfusion; DSA = digital subtraction angiography; ICH = intracerebral hemorrhage; IVH = intraventricular hemorrhage; MCA = middle cerebral artery; MMD = moyamoya disease; MRA = MR angiography; mRS = modified Rankin Scale; STA = superficial temporal artery; TIA = transient ischemic attack.

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Contributor Notes

Correspondence Yuanli Zhao: Beijing Tiantan Hospital, Capital Medical University, Beijing, China. zhaoyuanli@126.com.

INCLUDE WHEN CITING Published online October 18, 2019; DOI: 10.3171/2019.7.JNS19885.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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