title: Outcome in adult patients with hemorrhagic moyamoya disease after combined extracranial-intracranial bypass.
abstract: OBJECTIVE
  The outcome of patients with hemorrhagic moyamoya disease (MMD) after cerebral revascularization is uncertain. The purpose of this study was to delineate the efficacy of this surgical method in the treatment of hemorrhagic MMD.
  
  
  METHODS
  Between January 2007 and August 2011, a consecutive cohort of 113 patients with hemorrhagic MMD was enrolled into this prospective single-center cohort study. The surgical method was combined direct and indirect bypass. The cumulative probability of the primary end point (all stroke and deaths from surgery through 30 days after surgery and ipsilateral recurrent hemorrhage afterward) was analyzed. The angiographic outcome was measured by the following parameters: bypass patency, reduction of basal MMD vessels, improved degree of dilation, and branch extension of the anterior choroidal and posterior communicating arteries (AChA-PCoA).
  
  
  RESULTS
  Of the 113 enrolled cases, CT scans revealed pure intraventricular hemorrhage (IVH) in 63 cases (55.7%), pure intracranial hemorrhage (ICH) in 14 cases (12.4%), and ICH with IVH in 36 cases (31.9%). In 74 of 113 hemorrhagic hemispheres (65.5%), the AChA-PCoA was extremely dilated with extensive branches beyond the choroidal fissure. A total of 114 surgeries were performed. No patient suffered ischemic or hemorrhagic stroke through 30 days after surgery. Ipsilateral rebleeding occurred in 5 patients, 4 of whom died of the rebleeding event. The cumulative probability of the primary end point was 0% at 1 year and 1.9% at 2 years. The annual rebleeding rate was 1.87%/person/year. The improvement in AChA-PCoA extension was observed in 75 of 107 operated hemispheres (70.1%), which was higher than that in 7 of 105 unoperated hemispheres (35.2%).
  
  
  CONCLUSIONS
  Revascularization may provide a benefit over conservative therapy for hemorrhagic MMD patients. The improvement of dilation and branch extension of AChA-PCoA might be correlated with the low rebleeding rate.
authors.affiliation: Division of Cerebrovascular Surgery and Interventional Neuroradiology, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China.
authors.forename: Hanqiang
authors.initials: H
authors.lastname: Jiang
authors.forename: Wei
authors.initials: W
authors.lastname: Ni
authors.forename: Bin
authors.initials: B
authors.lastname: Xu
authors.forename: Yu
authors.initials: Y
authors.lastname: Lei
authors.forename: Yanlong
authors.initials: Y
authors.lastname: Tian
authors.forename: Feng
authors.initials: F
authors.lastname: Xu
authors.forename: Yuxiang
authors.initials: Y
authors.lastname: Gu
authors.forename: Ying
authors.initials: Y
authors.lastname: Mao
mesh_terms: D000328:Adult; D002543:Cerebral Hemorrhage / Q000150:complications / Q000401:mortality / Q000601:surgery*; D002548:Cerebral Revascularization / Q000379:methods* / Q000401:mortality; D015331:Cohort Studies; D023381:Endpoint Determination; D005260:Female; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009072:Moyamoya Disease / Q000150:complications / Q000401:mortality / Q000601:surgery*; D011446:Prospective Studies; D012008:Recurrence; D016896:Treatment Outcome; D055815:Young Adult
keywords: AChA = anterior choroidal artery; DSA = digital subtraction angiography; DTA = deep temporal artery; ICA = internal carotid artery; ICG = indocyanine green; ICH = intracranial hemorrhage; IVH = intraventricular hemorrhage; MCA = middle cerebral artery; MMA = middle meningeal artery; MMD = moyamoya disease; PCoA = posterior communicating artery; STA = superficial temporal artery; TIA = transient ischemic attack; hemorrhagic moyamoya disease; mRS = modified Rankin Scale; rebleeding rate; revascularization; vascular disorders