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Specific clinical features and one-stage revascularization surgery for moyamoya disease with severe cerebral ischemia in the territory of posterior cerebral artery

  • Original Article - Vascular Neurosurgery - Other
  • Published:
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Abstract

Background

There are no reports describing the surgical procedure for moyamoya disease (MMD) patients with severe cerebral ischemia in the territory of the posterior cerebral artery (PCA) at initial presentation. In this study, therefore, we describe their clinical and radiological features and clinical results of one-stage revascularization surgery for both anterior and posterior circulation.

Methods

This study included 6 MMD patients who had severe cerebral ischemia in the PCA territory and underwent one-stage revascularization surgery for both anterior and posterior circulation. Of these, one patient underwent it on both sides. Their clinical and radiological data were precisely analyzed. Compared with usual procedure, craniotomy was extended towards the temporo-parietal area more widely. The parietal branch of superficial temporal artery (STA) was anastomosed to the angular or posterior temporal artery, while the frontal branch was anastomosed to the frontal branch of MCA. Ultimate indirect bypass was added. Their clinical and radiological outcomes were evaluated.

Results

Their neurological symptoms included visual and speech disturbance as well as numbness of the extremities. Cerebral infarct was distributed in the posterior temporal, parietal, and/or occipital lobe. Cerebral hemodynamics and metabolism were also impaired in the same regions. These findings were completely different from those in MMD patients without PCA lesion. Postoperative course was uneventful, and none of them recurred stroke during a mean follow-up period of 10.5 years. Surgical collaterals widely provided blood flow to the entire hemispheres, including the occipital lobe. Cerebral hemodynamics and metabolism markedly improved after surgery.

Conclusion

One-stage revascularization surgery for both anterior and posterior circulation is feasible and effective to prevent future stroke in MMD patients with severe cerebral ischemia in the PCA territory at initial presentation.

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Funding

The Research Committee on Moyamoya Disease, the Japanese Ministry of Health, Labour and Welfare provided financial support in the form of a research grant.

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Authors and Affiliations

  1. Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science for Education, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan

    Hisayasu Saito, Daina Kashiwazaki, Haruto Uchino, Shusuke Yamamoto & Satoshi Kuroda

  2. Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan

    Hisayasu Saito, Haruto Uchino, Kiyohiro Houkin & Satoshi Kuroda

Authors
  1. Hisayasu Saito
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  2. Daina Kashiwazaki
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  3. Haruto Uchino
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  4. Shusuke Yamamoto
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  5. Kiyohiro Houkin
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  6. Satoshi Kuroda
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Contributions

Satoshi Kuroda contributed to the study conception and design. Material preparation, data collection and analysis were performed by Hisayasu Saito, Daina Kashiwazaki, Haruto Uchino, and Shusuke Yamamoto. The first draft of the manuscript was written by Hisayasu Saito and all authors commented on previous versions of the manuscript. Kiyohiro Houkin supervised this study and gave critical advices. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Satoshi Kuroda.

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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 national research committee (The IRB of Toyama University Hospital) and with the 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.

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Comments

The authors reported their one-stage revascularization surgery for Moyamoya Disease (MMD) with severe cerebral ischemia in the territory of posterior cerebral artery. They successfully demonstrated rich revascularization in the whole hemisphere after one-stage revascularization surgery in six patients. MMD has been reported to have an interaction between anterior and posterior circulation1,2. The posterior circulation involvement causes severe ischemia in whole hemisphere due to a decrease in the leptomeningeal collateral from posterior circulation to anterior circulation. No MMD patients with posterior circulation involvement in this study experienced recurrent stroke during long-term follow-up after one-stage extended revascularization surgery. The therapeutic strategy and procedure proposed by Saito et al. are theoretical and feasible in consideration of pathophysiology of MMD. Primary prevention for severe ischemia due to posterior circulation involvement in MMD is an important issue in the future.Tomohito Hishikawa

Kenji Sugiu

Okayama, Japan

References

1. Miyamoto S, Kikuchi H, Karasawa J, Nagata I, Ikota T and Takeuchi S: Study of the posterior circulation in moyamoya disease. Clinical and neuroradiological evaluation. J Neurosurg (1984) 61: 1032-1037.

2. Hishikawa T, Tokunaga K, Sugiu K and Date I: Assessment of the difference in posterior circulation involvement pediatric and adult patients with moyamoya disease. J Neurosurg (2013) 119: 961-965.

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Saito, H., Kashiwazaki, D., Uchino, H. et al. Specific clinical features and one-stage revascularization surgery for moyamoya disease with severe cerebral ischemia in the territory of posterior cerebral artery. Acta Neurochir 163, 583–592 (2021). https://doi.org/10.1007/s00701-020-04580-7

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