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Neurosurgical Review

, Volume 40, Issue 4, pp 679–684 | Cite as

Intra-operative hemorrhage due to hyperperfusion during direct revascularization surgery in an adult patient with moyamoya disease: a case report

  • Hiroki Uchida
  • Hidenori EndoEmail author
  • Miki Fujimura
  • Toshiki Endo
  • Kuniyasu Niizuma
  • Teiji Tominaga
Case Report

Abstract

Hemorrhagic complication is one of the notable surgical complications of the revascularization surgery for moyamoya disease (MMD). Cerebral hyperperfusion (CHP) has been considered as the underlying cause of this complication. It mostly occurs several days after surgery, but the intra-operative hemorrhage immediately after bypass has not been reported previously. A 21-year-old woman presented right thalamic hemorrhage and was diagnosed as having MMD by cerebral angiography. In light of the location of the hemorrhage at the vascular territory of posterior circulation and the manifestation of transient ischemic attack during the follow-up period, she underwent revascularization surgery to prevent future ischemic attack and rebleeding. Superficial temporal artery (STA) was uneventfully anastomosed to the temporal M4 branch of the middle cerebral artery in an end-to-side manner. A few minutes after the completion of the anastomosis, hemorrhage occurred in the fissure adjacent to the site of anastomosis. Indocyanine green (ICG) video angiography just before hemorrhage showed focal early filling through the STA graft with early venous filling around the site of the anastomosis. The bleeding was controlled by immediate hypotensive therapy (systolic blood pressure 117 to 91 mmHg). The mean blood flows of the STA graft measured by ultrasonic flowmetry before and after hypotensive therapy were 52.8 and 24.2 ml/min, respectively. Single-photon emission computed tomography (SPECT) on the next day after surgery showed focal hyperperfusion in the surgical side. Intra-operative ultrasonic flowmetry, ICG, and postoperative SPECT would explain that CHP was the potential cause of the hemorrhagic complication. This is the first case describing intra-operative hemorrhagic complication during revascularization surgery for MMD. Surgeons need to be aware of this rare complication and its management method.

Keywords

Moyamoya disease Hyperperfusion Hemorrhagic complication Direct revascularization surgery 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or nation research committee and with 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

0:00 Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis was performed in an end-to-side manner. 0:36 STA-MCA anastomosis was finished. The color of the cortical vein adjacent to the site of anastomosis changed to red. 0:40 Indocyanine green (ICG) video angiography after the anastomosis showed focal early filling through the STA graft with early venous filling of that red vein around the site of anastomosis. 0:53 The subarachnoid hemorrhage occurred in the fissure adjacent to the site of anastomosis. 1:03 The bleeding source was not apparent in the surgical field. Immediate hypotensive therapy was started. 1:44 The bleeding was controlled by immediate hypotensive therapy. (MP4 29,410 kb)

References

  1. 1.
    Fujimura M, Tominaga T (2012) Lessons learned from moyamoya disease: outcome of direct/indirect revascularization surgery for 150 affected hemispheres. Neurol Med Chir (Tokyo) 52:327–332CrossRefGoogle Scholar
  2. 2.
    Suzuki J, Takaku A (1969) Cerebrovascular “moyamoya” disease. Disease showing abnormal net-like vessels in base of brain. Arch Neurol 20:288–299CrossRefPubMedGoogle Scholar
  3. 3.
    Miyamoto S, Yoshimoto T, Hashimoto N, Okada Y, Tsuji I, Tominaga T, Nakagawara J, Takahashi JC, Investigators JAMT (2014) Effects of extracranial-intracranial bypass for patients with hemorrhagic moyamoya disease: results of the Japan Adult Moyamoya Trial. Stroke 45:1415–1421CrossRefPubMedGoogle Scholar
  4. 4.
    Takahashi JC, Funaki T, Houkin K, Inoue T, Ogasawara K, Nakagawara J, Kuroda S, Yamada K, Miyamoto S, Investigators JAMT (2016) Significance of the hemorrhagic site for recurrent bleeding: prespecified analysis in the Japan Adult Moyamoya Trial. Stroke 47:37–43CrossRefPubMedGoogle Scholar
  5. 5.
    Fujimura M, Kaneta T, Shimizu H, Tominaga T (2009) Cerebral ischemia owing to compression of the brain by swollen temporal muscle used for encephalo-myo-synangiosis in moyamoya disease. Neurosurg Rev 32:245–249 discussion 9CrossRefPubMedGoogle Scholar
  6. 6.
    Fujimura M, Shimizu H, Inoue T, Mugikura S, Saito A, Tominaga T (2011) Significance of focal cerebral hyperperfusion as a cause of transient neurologic deterioration after extracranial-intracranial bypass for moyamoya disease: comparative study with non-moyamoya patients using N-isopropyl-p-[(123)I]iodoamphetamine single-photon emission computed tomography. Neurosurgery 68:957–964 discussion 64-5CrossRefPubMedGoogle Scholar
  7. 7.
    Uchino H, Kuroda S, Hirata K, Shiga T, Houkin K, Tamaki N (2012) Predictors and clinical features of postoperative hyperperfusion after surgical revascularization for moyamoya disease: a serial single photon emission CT/positron emission tomography study. Stroke 43:2610–2616CrossRefPubMedGoogle Scholar
  8. 8.
    Fujimura M, Kaneta T, Mugikura S, Shimizu H, Tominaga T (2007) Temporary neurologic deterioration due to cerebral hyperperfusion after superficial temporal artery-middle cerebral artery anastomosis in patients with adult-onset moyamoya disease. Surg Neurol 67:273–282CrossRefPubMedGoogle Scholar
  9. 9.
    Fujimura M, Shimizu H, Mugikura S, Tominaga T (2009) Delayed intracerebral hemorrhage after superficial temporal artery-middle cerebral artery anastomosis in a patient with moyamoya disease: possible involvement of cerebral hyperperfusion and increased vascular permeability. Surg Neurol 71:223–227 discussion 7CrossRefPubMedGoogle Scholar
  10. 10.
    Hayashi K, Horie N, Suyama K, Nagata I (2012) Incidence and clinical features of symptomatic cerebral hyperperfusion syndrome after vascular reconstruction. World Neurosurg 78:447–454CrossRefPubMedGoogle Scholar
  11. 11.
    Yamashita M, Oka K, Tanaka K (1983) Histopathology of the brain vascular network in moyamoya disease. Stroke 14:50–58CrossRefPubMedGoogle Scholar
  12. 12.
    Kim JE, Oh CW, Kwon OK, Park SQ, Kim SE, Kim YK (2008) Transient hyperperfusion after superficial temporal artery/middle cerebral artery bypass surgery as a possible cause of postoperative transient neurological deterioration. Cerebrovasc Dis 25:580–586CrossRefPubMedGoogle Scholar
  13. 13.
    van Mook WN, Rennenberg RJ, Schurink GW, van Oostenbrugge RJ, Mess WH, Hofman PA, de Leeuw PW (2005) Cerebral hyperperfusion syndrome. Lancet Neurol 4:877–888CrossRefPubMedGoogle Scholar
  14. 14.
    Fujimura M, Mugikura S, Kaneta T, Shimizu H, Tominaga T (2009) Incidence and risk factors for symptomatic cerebral hyperperfusion after superficial temporal artery-middle cerebral artery anastomosis in patients with moyamoya disease. Surg Neurol 71:442–447CrossRefPubMedGoogle Scholar
  15. 15.
    Fujimura M, Niizuma K, Inoue T, Sato K, Endo H, Shimizu H, Tominaga T (2014) Minocycline prevents focal neurological deterioration due to cerebral hyperperfusion after extracranial-intracranial bypass for moyamoya disease. Neurosurgery 74:163–170 discussion 70CrossRefPubMedGoogle Scholar
  16. 16.
    Nakagawa A, Fujimura M, Arafune T, Sakuma I, Tominaga T (2009) Clinical implications of intraoperative infrared brain surface monitoring during superficial temporal artery-middle cerebral artery anastomosis in patients with moyamoya disease. J Neurosurg 111:1158–1164CrossRefPubMedGoogle Scholar
  17. 17.
    Horie N, Fukuda Y, Izumo T, Hayashi K, Suyama K, Nagata I (2014) Indocyanine green videoangiography for assessment of postoperative hyperperfusion in moyamoya disease. Acta Neurochir 156:919–926CrossRefPubMedGoogle Scholar
  18. 18.
    Uchino H, Kazumata K, Ito M, Nakayama N, Kuroda S, Houkin K (2014) Intraoperative assessment of cortical perfusion by indocyanine green videoangiography in surgical revascularization for moyamoya disease. Acta Neurochir 156:1753–1760CrossRefPubMedGoogle Scholar
  19. 19.
    Machida T, Ono J, Nomura R, Fujikawa A, Nagano O, Higuchi Y (2014) Venous reddening as a possible sign of hyperperfusion after superficial temporal artery-middle cerebral artery anastomosis for moyamoya disease: case report. Neurol Med Chir (Tokyo) 54:827–831CrossRefGoogle Scholar
  20. 20.
    Amin-Hanjani S, Alaraj A, Charbel FT (2010) Flow replacement bypass for aneurysms: decision-making using intraoperative blood flow measurements. Acta Neurochir 152:1021–1032 discussion 32CrossRefPubMedGoogle Scholar
  21. 21.
    Fujimura M, Inoue T, Shimizu H, Saito A, Mugikura S, Tominaga T (2012) Efficacy of prophylactic blood pressure lowering according to a standardized postoperative management protocol to prevent symptomatic cerebral hyperperfusion after direct revascularization surgery for moyamoya disease. Cerebrovasc Dis 33:436–445CrossRefPubMedGoogle Scholar
  22. 22.
    Sakata H, Fujimura M, Mugikura S, Sato K, Tominaga T (2015) Local vasogenic edema without cerebral hyperperfusion after direct revascularization surgery for moyamoya disease. J Stroke Cerebrovasc Dis 24:e179–e184CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  1. 1.Department of NeurosurgeryTohoku University Graduate School of MedicineSendaiJapan
  2. 2.Department of NeurosurgeryKohnan HospitalSendaiJapan

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