Postoperative Symptomatic Cerebral Infarction in Pediatric Moyamoya Disease: Risk Factors and Clinical Outcome
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Published on: April 21, 2017
Jung Won Choi1, Sangjoon Chong2, Ji Hoon Phi3
1Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
Insights
Early stroke after indirect bypass surgery for moyamoya disease (MMD) is linked to young age, MTHFR gene mutations, and surgical factors like two craniotomies. Maintaining higher hemoglobin levels post-surgery may reduce stroke risk in pediatric MMD patients.
Area of Science:
- Neurosurgery
- Pediatric Neurology
- Vascular Surgery
Background:
- Indirect bypass surgery aims to improve hemodynamics in pediatric moyamoya disease (MMD) patients.
- Symptomatic cerebral infarction is a significant early postoperative complication.
- This study investigates risk factors for early postoperative symptomatic cerebral infarction in pediatric MMD.
Purpose of the Study:
- To identify factors associated with early postoperative symptomatic cerebral infarction in pediatric moyamoya disease patients undergoing indirect bypass surgery.
- To analyze patient-centered and management-related risk factors.
- To inform strategies for reducing postoperative stroke incidence.
Main Methods:
- Retrospective analysis of 1241 indirect bypass surgeries in 659 pediatric MMD patients (January 2000 - February 2014).
- Diagnosis of symptomatic cerebral infarction in 63 operations (61 patients).
- Matched analysis to assess the impact of immediate postoperative hemoglobin levels.
Main Results:
- Overall incidence of symptomatic cerebral infarction was 5.1%.
- Higher infarction rates observed in patients undergoing two craniotomies and in younger children (age < 6 years).
- Immediate postoperative hemoglobin >13 g/dL was associated with decreased infarction risk (OR, 0.144; P = 0.003); MTHFR gene mutation was common in the infarction cohort.
Conclusions:
- Early postoperative symptomatic infarctions can occur despite standardized surgical and perioperative protocols.
- Risk factors include young age, MTHFR gene mutation, hyperthyroidism, renovascular hypertension, hemolytic uremic syndrome, two craniotomies, and low immediate postoperative hemoglobin.
- Patient-specific and management factors are crucial for predicting and potentially preventing early postoperative cerebral infarction.
Background:
Indirect bypass surgery is used to improve the hemodynamic status of pediatric patients with moyamoya disease (MMD). Symptomatic cerebral infarction during the early postoperative period may be the most frustrating complication. This study was conducted to investigate the factors associated with early postoperative symptomatic cerebral infarction.
Methods:
Between January 2000 and February 2014, we performed 1241 indirect bypass surgeries in 659 pediatric MMD patients. Symptomatic infarction during the early postoperative period was diagnosed in 63 operations in 61 patients.
Results:
The overall incidence of symptomatic cerebral infarction after indirect bypass surgery was 5.1%. The median age of the patients with postoperative infarction was 6 years (mean, 6.4 years; range, 1-15 years). The performance of 2 craniotomies in single operation was associated with a higher rate of cerebral infarction. Moreover, the incidence was higher in young patients (age <6 years) compared with older patients. In a matched analysis, an immediate postoperative hemoglobin level >13 g/dL was associated with decreased risk of infarction (odds ratio, 0.144; P = 0.003). Mutation of the methylenetetrahydrofolate reductase (MTHFR) gene occurred in a relatively high proportion of our infarction cohort.
Conclusions:
Postoperative symptomatic infarctions can occur despite a unified surgical method and formulaic perioperative management protocol. Patient-centered factors, such as young age, genetic background of MTHFR, and certain medical conditions, including hyperthyroidism, renovascular hypertension, and hemolytic uremic syndrome, as well as management-related factors, including 2 craniotomies and low immediate postoperative hemoglobin level, could be risk factors for early postoperative symptomatic cerebral infarction.
