title: Impact of extracranial-intracranial bypass on cerebrovascular reactivity and clinical outcome in patients with symptomatic moyamoya vasculopathy.
abstract: OBJECTIVE
  The purpose of this study was to evaluate in symptomatic moyamoya patients the effect of surgical revascularization on impaired cerebrovascular reactivity (CVR) and its relationship to clinical outcome.
  
  
  METHODS
  Brain revascularization was performed using a direct superficial temporal artery to middle cerebral artery bypass or indirect encephalo-dural-arterial synangiosis. CVR was measured pre- and 3 months postoperatively using blood oxygen level-dependent MRI during iso-oxic hypercapnic changes in end-tidal carbon dioxide. Outcomes were assessed by MRI, clinical examination, and modified Rankin Scale scores.
  
  
  RESULTS
  Fifty-five hemispheres were revascularized in 39 patients (superficial temporal artery to middle cerebral artery in 47, encephalo-dural-arterial synangiosis in 8). Surgery reversed CVR impairment in 52 hemispheres (94.5%) and in 36 of 39 patients (92.3%; Fisher exact test, P<0.001), and this was predictive of a patent extracranial-intracranial bypass. New, clinically silent perioperative hemorrhages, cortical foci of ischemia, or new white matter T2 hyperintensities were detected after 11 surgeries (20%), but no new lesions arose after 3 postoperative months. One patient had a clinical perioperative stroke (1.8%). In clinical follow-up, 37 of 39 patients (95%) had stable or improved modified Rankin Scale scores and 2 patients (5.1%) worsened. No patients with patent bypasses or CVR improvements exhibited new clinical symptoms, but failure of CVR improvement corresponded to a poorer long-term outcome (Fisher exact test, P<0.001).
  
  
  CONCLUSIONS
  Cerebral revascularization surgery is a safe and effective treatment for reversing preoperative CVR defects and may prevent recurrence of preoperative symptoms. Moreover, CVR measurements may be useful in long-term follow-up and for predicting bypass patency.
authors: Department of Anesthesia, University of Toronto and University Health Network, Toronto, Canada.
authors: Jay S
authors: JS
authors: Han
authors: Amal
authors: A
authors: Abou-Hamden
authors: Daniel M
authors: DM
authors: Mandell
authors: Julien
authors: J
authors: Poublanc
authors: Adrian P
authors: AP
authors: Crawley
authors: Joseph A
authors: JA
authors: Fisher
authors: David J
authors: DJ
authors: Mikulis
authors: Michael
authors: M
authors: Tymianski
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002548:Cerebral Revascularization / Q000379:methods; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000473:pathology / Q000601:surgery; D009072:Moyamoya Disease / Q000473:pathology* / Q000601:surgery*; D011446:Prospective Studies; D013699:Temporal Arteries / Q000473:pathology / Q000601:surgery; D016896:Treatment Outcome; D055815:Young Adult