Direct versus indirect bypass procedure for the treatment of ischemic moyamoya disease: results of an individualized selection strategy

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  • 1 Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine;
  • 2 Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine; and
  • 3 Department of Radiology, NeuroInterventional Radiology Section, and Stanford Stroke Center, Stanford University School of Medicine, Stanford, California
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OBJECTIVE

The only effective treatment for ischemic moyamoya disease (iMMD) is cerebral revascularization by an extracranial to intracranial bypass. The preferred revascularization method remains controversial: direct versus indirect bypass. The purpose of this study was to test the hypothesis that method choice should be personalized based on angiographic, hemodynamic, and clinical characteristics to balance the risk of perioperative major stroke against treatment efficacy.

METHODS

Patients with iMMD were identified retrospectively from a prospectively maintained database. Those with mild to moderate internal carotid artery or M1 segment stenosis, preserved cerebrovascular reserve, intraoperative M4 segment anterograde flow ≥ 8 ml/min, or the absence of frequent and severe transient ischemic attacks (TIAs) or stroke had been assigned to indirect bypass. The criteria for direct bypass were severe ICA or M1 segment stenosis or occlusion, impaired cerebrovascular reserve or steal phenomenon, intraoperative M4 segment retrograde flow or anterograde flow < 8 ml/min, and the presence of frequent and severe TIAs or clinical strokes. The primary study endpoint was MRI-confirmed symptomatic stroke ≤ 7 days postoperatively resulting in a decline in the modified Rankin Scale (mRS) score from preoperatively to 6 months postoperatively. As a secondary endpoint, the authors assessed 6-month postoperative DSA-demonstrated revascularization, which was classified as < 1/3, 1/3–2/3, or > 2/3 of the middle cerebral artery territory.

RESULTS

One hundred thirty-eight patients with iMMD affecting 195 hemispheres revascularized in the period from March 2016 to June 2018 were included in this analysis. One hundred thirty-three hemispheres were revascularized with direct bypass and 62 with indirect bypass. The perioperative stroke rate was 4.7% and 6.8% in the direct and indirect groups, respectively (p = 0.36). Degree of revascularization was higher in the direct bypass group (p = 0.03). The proportion of patients improving to an mRS score 0–1 (from preoperatively to 6 months postoperatively) tended to be higher in the direct bypass group, although the difference between the two bypass groups was not statistically significant (p = 0.27).

CONCLUSIONS

The selective use of an indirect bypass procedure for iMMD did not decrease the perioperative stroke rate. Direct bypass provided a significantly higher degree of revascularization. The authors conclude that direct bypass is the treatment of choice for iMMD.

ABBREVIATIONS DWI = diffusion-weighted imaging; EDAS = encephalodurosynangiosis; EMS = encephalomyosynangiosis; ICA = internal carotid artery; iMMD = ischemic MMD; MCA = middle cerebral artery; MMD = moyamoya disease; mRS = modified Rankin Scale; STA = superficial temporal artery; TIA = transient ischemic attack.

Supplementary Materials

    • Supplementary Table 1 (PDF 395 KB)

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Contributor Notes

Correspondence Gary K. Steinberg: Stanford University School of Medicine, Stanford, CA. gsteinberg@stanford.edu.

INCLUDE WHEN CITING Published online June 12, 2020; DOI: 10.3171/2020.3.JNS192847.

Disclosures Dr. Steinberg is a consultant for Qool Therapeutics, Peter Lazic US, NeuroSave, SanBio, and Zeiss. Dr. Heit is a consultant for Medtronic and MicroVention.

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