You are here

Article Text

Article menu
Download PDFPDF
Cerebrovascular disease
Original research
Direct Versus Indirect Revascularization for Moyamoya: a Large Multicenter Study
  1. Kareem El Naamani1,
  2. Ching-Jen Chen2,
  3. Roland Jabre1,
  4. Hassan Saad3,
  5. Jonathan A Grossberg3,
  6. Adam A Dmytriw4,5,
  7. Aman B Patel6,
  8. Mirhojjat Khorasanizadeh7,
  9. Christopher S Ogilvy7,
  10. Ajith Thomas7,
  11. Andre Monteiro8,
  12. Adnan Siddiqui8,
  13. Gustavo M Cortez9,
  14. Ricardo A Hanel9,
  15. Guilherme Porto10,
  16. Alejandro M Spiotta10,
  17. Anthony J Piscopo11,
  18. David M Hasan12,
  19. Mohammad Ghorbani13,
  20. Joshua Weinberg14,
  21. Shahid M Nimjee14,
  22. Kimon Bekelis15,
  23. Mohamed M Salem16,
  24. Jan-Karl Burkhardt16,
  25. Akli Zetchi17,
  26. Charles Matouk17,
  27. Brian M Howard18,
  28. Rosalind Lai19,
  29. Rose Du19,
  30. Rawad Abbas1,
  31. Georgios S Sioutas1,
  32. Abdelaziz Amllay1,
  33. Alfredo Munoz1,
  34. Elias Atallah1,
  35. Nabeel A Herial1,
  36. Stavropoula I Tjoumakaris1,
  37. Michael Reid Gooch1,
  38. Robert H Rosenwasser1,
  39. Pascal Jabbour1
  1. 1 Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
  2. 2 Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
  3. 3 Neurosurgery, Emory University, Atlanta, Georgia, USA
  4. 4 Neuroradiology and Neurointervention Service, Brigham and Women's Hospital, Boston, Massachusetts, USA
  5. 5 Department of Medical Imaging, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
  6. 6 Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
  7. 7 Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  8. 8 Neurosurgery, University at Buffalo, Buffalo, New York, USA
  9. 9 Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
  10. 10 Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
  11. 11 Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
  12. 12 Neurosurgery, Duke University, Durham, North Carolina, USA
  13. 13 Neurosurgery, Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
  14. 14 Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
  15. 15 Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
  16. 16 Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
  17. 17 Neurosurgery, Yale University, New Haven, Connecticut, USA
  18. 18 Neurological Surgery, Emory University, Atlanta, Georgia, USA
  19. 19 Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Pascal Jabbour, Neurosurgery, Thomas Jefferson University, Philadelphia, PA 19107, USA; pascal.jabbour{at}jefferson.edu

Abstract

Background Moyamoya is a chronic occlusive cerebrovascular disease of unknown etiology causing neovascularization of the lenticulostriate collaterals at the base of the brain. Although revascularization surgery is the most effective treatment for moyamoya, there is still no consensus on the best surgical treatment modality as different studies provide different outcomes.

Objective In this large case series, we compare the outcomes of direct (DR) and indirect revascularisation (IR) and compare our results to the literature in order to reflect on the best revascularization modality for moyamoya.

Methods We conducted a multicenter retrospective study in accordance with the Strengthening the Reporting of Observational studies in Epidemiology guidelines of moyamoya affected hemispheres treated with DR and IR surgeries across 13 academic institutions predominantly in North America. All patients who underwent surgical revascularization of their moyamoya-affected hemispheres were included in the study. The primary outcome of the study was the rate of symptomatic strokes.

Results The rates of symptomatic strokes across 515 disease-affected hemispheres were comparable between the two cohorts (11.6% in the DR cohort vs 9.6% in the IR cohort, OR 1.238 (95% CI 0.651 to 2.354), p=0.514). The rate of total perioperative strokes was slightly higher in the DR cohort (6.1% for DR vs 2.0% for IR, OR 3.129 (95% CI 0.991 to 9.875), p=0.052). The rate of total follow-up strokes was slightly higher in the IR cohort (8.1% vs 6.6%, OR 0.799 (95% CI 0.374 to 1.709) p=0.563).

Conclusion Since both modalities showed comparable rates of overall total strokes, both modalities of revascularization can be performed depending on the patient’s risk assessment.

  • STROKE
  • CEREBROVASCULAR DISEASE
  • VASCULAR SURGERY

Data availability statement

Data are available on reasonable request.

https://doi.org/10.1136/jnnp-2022-329176

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Data availability statement

    Data are available on reasonable request.

    View Full Text

    Footnotes

    • Twitter @porto_md, @Weinbergjh, @ShahidNimjee, @PascalJabbourMD

    • Contributors KEN and C-JJC collected and analysed the data. KEN drafted the work. PJ supervised the work. All other authors revise the work and contributed equally to the project. PJ is the author acting as a guarantor

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests Please refer to ICJME forms.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.