title: Direct versus indirect revascularization procedures for moyamoya disease: a comparative effectiveness study.
abstract: OBJECTIVE Moyamoya disease (MMD) is a chronic cerebrovascular disease that can lead to devastating neurological outcomes. Surgical intervention is the definitive treatment, with direct, indirect, and combined revascularization procedures currently employed by surgeons. The optimal surgical approach, however, remains unclear. In this decision analysis, the authors compared the effectiveness of revascularization procedures in both adult and pediatric patients with MMD. METHODS A comprehensive literature search was performed for studies of MMD. Using complication and success rates from the literature, the authors constructed a decision analysis model for treatment using a direct and indirect revascularization technique. Utility values for the various outcomes and complications were extracted from the literature examining preferences in similar clinical conditions. Sensitivity analysis was performed. RESULTS A structured literature search yielded 33 studies involving 4197 cases. Cases were divided into adult and pediatric populations. These were further subdivided into 3 different treatment groups: indirect, direct, and combined revascularization procedures. In the pediatric population at 5- and 10-year follow-up, there was no significant difference between indirect and combination procedures, but both were superior to direct revascularization. In adults at 4-year follow-up, indirect was superior to direct revascularization. CONCLUSIONS In the absence of factors that dictate a specific approach, the present decision analysis suggests that direct revascularization procedures are inferior in terms of quality-adjusted life years in both adults at 4 years and children at 5 and 10 years postoperatively, respectively. These findings were statistically significant (p < 0.001 in all cases), suggesting that indirect and combination procedures may offer optimal results at long-term follow-up.
authors.affiliation: Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Luke
authors.initials: L
authors.lastname: Macyszyn
authors.affiliation: Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Mark
authors.initials: M
authors.lastname: Attiah
authors.affiliation: Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Tracy S
authors.initials: TS
authors.lastname: Ma
authors.affiliation: Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Zarina
authors.initials: Z
authors.lastname: Ali
authors.affiliation: Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Ryan
authors.initials: R
authors.lastname: Faught
authors.affiliation: Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Alisha
authors.initials: A
authors.lastname: Hossain
authors.affiliation: Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Karen
authors.initials: K
authors.lastname: Man
authors.affiliation: Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Hiren
authors.initials: H
authors.lastname: Patel
authors.affiliation: Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Rosanna
authors.initials: R
authors.lastname: Sobota
authors.affiliation: Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Eric L
authors.initials: EL
authors.lastname: Zager
authors.affiliation: Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Sherman C
authors.initials: SC
authors.lastname: Stein
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D002548:Cerebral Revascularization; D002648:Child; D000066491:Clinical Decision-Making; D005260:Female; D006801:Humans; D008297:Male; D009072:Moyamoya Disease / Q000601:surgery*; D018579:Patient Selection; D011183:Postoperative Complications / Q000453:epidemiology; D011788:Quality of Life; D016896:Treatment Outcome
keywords: MMD = moyamoya disease; QALY = quality-adjusted life year; QOL = quality of life; decision analysis; direct; indirect; moyamoya; revascularization; vascular disorders