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Hemodynamics and changes after STA–MCA anastomosis in moyamoya disease and atherosclerotic cerebrovascular disease measured by micro-Doppler ultrasonography

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Abstract

Moyamoya disease (MMD) and atherosclerotic cerebrovascular disease (ACVD) differ in angiographic appearance and probably hemodynamics. Pediatric MMD (PMMD) usually presents with cerebral ischemia, while intracranial hemorrhage is more common in adult MMD (AMMD), suggesting differences in cerebral hemodynamics. We analyzed the cortical flow velocity and direction of recipient arteries using micro-Doppler ultrasonography to evaluate the cortical circulation before and after anastomosis in MMD and ACVD. Twenty-eight patients with adult MMD (AMMD), 7 with pediatric MMD (PMMD), 16 with ACVD, and 12 control patients were studied. A micro-Doppler probe was applied on the cortical recipient artery (A4 or M4) before and after anastomosis. Systolic maximum flow velocity (V max) and blood flow direction were investigated at proximal and distal parts of anastomosed sites in recipient arteries. Pre- and postoperative regional cerebral blood flow was measured by cold xenon-computed tomography (Xe-CT). Before anastomosis, retrograde cortical flow was significantly more common in PMMD patients, and V max in cortical artery was significantly lower in AMMD patients. Bypass surgery changed the direction of blood flow from the anastomosis site to proximal and distal sites of the recipient artery in most patients, but pre-anastomosis flow direction was preserved more frequently in PMMD patients. The rate of V max increase after anastomosis was significantly higher in AMMD than in PMMD (11.6 ± 9.8 vs. 3.9 ± 1.8; P = 0.01). Micro-Doppler ultrasonography identified differences in cortical circulation among AMMD, PMMD, and ACVD. In AMMD, significantly low velocity in the cortical artery was observed before anastomosis, and bypass surgery reversed the flow and significantly increased flow velocity. The data of PMMD showed unique hemodynamics of the cortical artery before anastomosis, characterized by a higher frequency of retrograde flow and preserved velocity. The V max increase rate was significantly higher in patients with postoperative cerebral hyperperfusion on Xe-CT, and further study is warranted to validate the clinical use of intraoperative micro-Doppler monitoring to predict postoperative hyperperfusion.

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Acknowledgments

We thank the radiological technicians at the Departments of Neurosurgery and Radiology, Tokyo Women’s Medical University, Tokyo, Japan, for measurements of rCBF and CVR on cold Xe-CT. This study was supported by research funds of the Department of Neurosurgery, Tokyo Women’s Medical University.

Conflict of interest

All authors have no conflict of interest to declare.

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Authors and Affiliations

  1. Department of Neurosurgery, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan

    Hanako Morisawa, Takakazu Kawamata, Akitsugu Kawashima, Masataka Hayashi, Kohji Yamaguchi, Taku Yoneyama & Yoshikazu Okada

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  1. Hanako Morisawa
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  2. Takakazu Kawamata
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  3. Akitsugu Kawashima
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  4. Masataka Hayashi
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  7. Yoshikazu Okada
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Correspondence to Takakazu Kawamata.

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Comments

Yasuhiro Yonekawa, Zürich, Switzerland

Morisawa et al. are to be congratulated for delivering interesting information concerning the hemodynamics of cortical flow in three different cerebrovascular occlusive diseases, PMMD, AMMD, and ACVD, in comparison with a control group obtained at the time of aneurysm surgery. These examinations have been done with the aid of micro-Doppler sonography that we are using only to check vascular patency, especially after construction of an EC–IC bypass or in aneurysm surgery. Originally, the authors advocated the theory that the increase of the post-anastomotic V max could predict a hyperperfusion syndrome; however, they somewhat toned down, presumably due to an insufficient number of cases, stating that their finding may help in preventing this undesirable complication. To be honest, I miss some additional explanation or speculation about the mechanism responsible for such hemodynamic differences between patients with moyamoya disease, both pediatric and adult, or between moyamoya and atherosclerotic occlusive disease, even though some information regarding leptmeningeal anastomosis and rCVR has been given. Perhaps such an explanation could be possible with additional data obtained by measuring the intraarterial pressure or the local rCBF with the use of a thermocouple [1, 2]. Such measurements would also furnish evidence of changes in cortical flow direction after bypass surgery.

Table

 

V max: cortical flow

Retrograde flow

∆V max

PMMD

⇒

+++

+

AMMD

⇓

++

+++

ACVD

⇒

+

++

References

1 Yonekawa Y: Brain vascularization by extracranial–intracranial arterial bypass. In Sindou M (ed). Practical hand book of neurosurgery. Vol 1. Springer, Wien, 2009, pp 355-381

2 Ogata N, Fournier JY, Imhof HG, Yonekawa Y: Thermal diffusion blood flow monitoring during aneurysm surgery. Acta Neurochir (Wien) 138: 726-731, 1996

Kiyohiro Houkin, Sapporo, Japan

The authors clearly have demonstrated quantitative flow measurement in moyamoya disease using micro-Doppler ultrasonography. This work is praiseworthy for clinical application. They have also revealed that in pediatric moyamoya cases, the cortical flow shows retrograde flow and its V max (systolic maximum flow velocity) is higher than the adult moyamoya cases. This may mean that retrograde flow due to the pial anastomosis in pediatric cases is well established than in adult case.

As it is well-known, the collateral flow is dependent on the stages of this disease. In addition, the flow dynamics may depend on its location (area of craniotomy). We have to be careful to evaluate these quantitative data. I am confident that the intraoperative flow measurement using micro-Doppler ultrasonography is practical and convenient in intraoperative flow measurement based on my personal experience. Moreover, the hyperperfusion that is a serious issue after successful direct bypass to moyamoya disease can be predicted using this very convenient tool. More additional clinical experience with this tool is necessary and the establishment of a standard way of reliable evaluation using this weapon is expected.

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Morisawa, H., Kawamata, T., Kawashima, A. et al. Hemodynamics and changes after STA–MCA anastomosis in moyamoya disease and atherosclerotic cerebrovascular disease measured by micro-Doppler ultrasonography. Neurosurg Rev 36, 411–419 (2013). https://doi.org/10.1007/s10143-012-0441-y

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