title: The frequency of postoperative stroke in moyamoya disease following combined revascularization: a single-university series and systematic review.
abstract: OBJECTIVE
  Although combined direct and indirect anastomosis in patients with moyamoya disease immediately increases cerebral blood flow, the surgical procedure is more complex. Data pertinent to the postoperative complications associated with combined bypass are relatively scarce compared with those associated with indirect bypass. This study investigated the incidence and characteristics of postoperative stroke in combined bypass and compared them with those determined from a literature review to obtain data from a large population.
  
  
  METHODS
  A total of 358 revascularization procedures in 236 patients were retrospectively assessed by reviewing clinical charts and radiological data. PubMed was searched for published studies on surgical treatment to determine the incidence of postoperative complications in a larger population.
  
  
  RESULTS
  Seventeen instances of postoperative stroke were observed in 16 patients (4.7% per surgery, 95% CI 2.8%-7.5%). Postoperative stroke was more frequent (7.9% per surgery) in adults than in pediatric patients (1.7% per surgery, OR 4.07, 95% CI 1.12-14.7; p < 0.05). Acute progression of stenoocclusive changes were identified in the major cerebral arteries (anterior cerebral artery, n = 3; middle cerebral artery, n = 1; posterior cerebral artery, n = 2). The postoperative stroke rate was comparable with that (5.4%) determined from a literature search that included studies reporting more than 2000 direct/combined procedures. No differences in the stroke rates between the direct/combined and indirect procedures were found. In the literature review, direct/combined bypass was more often associated with excellent revascularization (angiographic opacification greater than two-thirds) than indirect bypass (p < 0.05).
  
  
  CONCLUSIONS
  This experience of 358 consecutive procedures is one of the largest series for which the postoperative stoke rate for direct/combined bypass performed with a unified strategy has been reported. A systematic review confirmed that the postoperative stroke rate for the direct/combined procedure was comparable to that for the indirect procedure.
authors.affiliation: Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo;
authors.forename: Ken
authors.initials: K
authors.lastname: Kazumata
authors.forename: Masaki
authors.initials: M
authors.lastname: Ito
authors.forename: Kikutaro
authors.initials: K
authors.lastname: Tokairin
authors.forename: Yasuhiro
authors.initials: Y
authors.lastname: Ito
authors.forename: Kiyohiro
authors.initials: K
authors.lastname: Houkin
authors.forename: Naoki
authors.initials: N
authors.lastname: Nakayama
authors.forename: Satoshi
authors.initials: S
authors.lastname: Kuroda
authors.forename: Tatsuya
authors.initials: T
authors.lastname: Ishikawa
authors.forename: Hiroyasu
authors.initials: H
authors.lastname: Kamiyama
mesh_terms: D002544:Cerebral Infarction / Q000453:epidemiology / Q000209:etiology; D002548:Cerebral Revascularization / Q000009:adverse effects*; D006801:Humans; D020300:Intracranial Hemorrhages / Q000453:epidemiology / Q000209:etiology; D009072:Moyamoya Disease / Q000150:complications* / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000009:adverse effects*; D011183:Postoperative Complications / Q000453:epidemiology*; D020521:Stroke / Q000453:epidemiology* / Q000209:etiology
keywords: ACA = anterior cerebral artery; ICH = intracerebral hemorrhage; MCA = middle cerebral artery; MMD = moyamoya disease; PCA = posterior cerebral artery; STA = superficial temporal artery; TIA = transient ischemic attack; cerebral infarction; complication; intracranial hemorrhage; moyamoya disease; revascularization; vascular disorders