Bypass surgery versus medical treatment for symptomatic moyamoya disease in adults.
OBJECTIVE In this study the authors evaluated whether extracranial-intracranial bypass surgery can prevent stroke occurrence and decrease mortality in adult patients with symptomatic moyamoya disease (MMD). METHODS The medical records of 249 consecutive adult patients with symptomatic MMD that was confirmed by digital subtraction angiography between 2002 and 2011 at 8 institutions were retrospectively reviewed. The study outcomes of stroke recurrence as a primary event and death during the 6-year follow-up and perioperative complications within 30 days as secondary events were compared between the bypass and medical treatment groups. RESULTS The bypass group comprised 158 (63.5%) patients, and the medical treatment group comprised 91 (36.5%) patients. For 249 adult patients with MMD, bypass surgery showed an HR of 0.48 (95% CI 0.27-0.86, p = 0.014) for stroke recurrence calculated by Cox regression analysis. However, for the 153 patients with ischemic MMD, the HR of bypass surgery for stroke recurrence was 1.07 (95% CI 0.43-2.66, p = 0.887). For the 96 patients with hemorrhagic MMD, the multivariable adjusted HR of bypass surgery for stroke recurrence was 0.18 (95% CI 0.06-0.49, p = 0.001). For the treatment modality, indirect bypass and direct bypass (or combined bypass) did not show any significant difference for stroke recurrence, perioperative stroke, or mortality (log rank; p = 0.524, p = 0.828, and p = 0.616, respectively). CONCLUSIONS During the treatment of symptomatic MMD in adults, bypass surgery reduces stroke recurrence for the hemorrhagic type, but it does not do so for the ischemic type. The best choice of bypass methods in adult patients with MMD is uncertain. In adult ischemic MMD, a prospective randomized study to evaluate the effectiveness and safety of bypass surgery to prevent recurrent stroke is necessary.
Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon.
Dong-Kyu
DK
Jang
Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul.
Kwan-Sung
KS
Lee
Department of Neurosurgery, Youido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul.
Hyoung Kyun
HK
Rha
Department of Neurosurgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu.
Pil-Woo
PW
Huh
Department of Neurosurgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon.
Ji-Ho
JH
Yang
Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon.
Ik Seong
IS
Park
Department of Neurosurgery, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul; and.
Jae-Geun
JG
Ahn
Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea.
Jae Hoon
JH
Sung
Department of Neurosurgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon.
Young-Min
YM
Han
D000328:Adult; D002544:Cerebral Infarction / Q000209:etiology; D002548:Cerebral Revascularization / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009072:Moyamoya Disease / Q000150:complications / Q000175:diagnosis / Q000601:surgery / Q000628:therapy*; D012189:Retrospective Studies; D020521:Stroke / Q000209:etiology
DSA = digital subtraction angiography; ECA = external carotid artery; EDAGS = encephalo-duro-arterio-galeo-synangiosis; EDAMS = encephalo-duro-arterio-myo-synangiosis; EDAS = encephalo-duro-arterio-synangiosis; EMS = encephalo-myo-synangiosis; ICA = internal carotid artery; JAM = Japanese Adult Moyamoya; MCA = middle cerebral artery; MMD = moyamoya disease; STA = superficial temporal artery; TIA = transient ischemic attack; adult; bypass surgery; hemorrhagic; ischemic; mRS = modified Rankin Scale; moyamoya disease; vascular disorders