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Do Direct Bypasses Really Resolve Capillary Vessels in Moyamoya Disease? Delayed Hemorrhage Potentially Relevant to
Seiichiro Eguchi1, Yasuo Aihara2, Kentaro Chiba1
1Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan.
Insights
Direct bypass surgery for moyamoya disease improves cerebral blood flow, preventing ischemic strokes. However, it may not reduce moyamoya vessels, potentially still risking hemorrhagic strokes.
Area of Science:
- Neurology
- Neurosurgery
- Vascular Surgery
Background:
- Moyamoya disease is a progressive cerebrovascular disorder affecting internal carotid arteries, leading to strokes.
- Surgical revascularization aims to restore blood flow but its impact on moyamoya vessels is not fully understood.
Observation:
- A pediatric case of moyamoya disease underwent bilateral revascularization with direct bypasses.
- Post-surgery, pathological examination revealed neovascularization with microvessels, similar to capillary telangiectasia.
- Despite angiographic reduction of moyamoya vessels, direct bypasses confirmed capillary vessel proliferation.
Findings:
- Direct bypass surgery effectively prevents further ischemic strokes by enhancing cerebral perfusion.
- Revascularization may not significantly reduce the burden of moyamoya vessels.
- The proliferation of microvessels post-bypass suggests a complex vascular response.
Implications:
- Direct bypasses are crucial for mitigating ischemic events in moyamoya disease.
- While reducing hemorrhagic stroke risk, bypasses may not eliminate it due to persistent moyamoya vessels.
- Further research is needed to understand the long-term vascular remodeling after direct bypass surgery.
Objective:
Moyamoya disease is a chronic but progressive obliterative cerebrovascular disease of bilateral internal carotid arteries (ICAs) causing hemorrhagic or ischemic cerebral strokes. Surgical revascularization has the potential for resolving the capillary vessels, but the effect on the occlusive ICA and the moyamoya vessels after a direct bypass remains unclear.
Patient:
A 2-year-old girl with a history of repeated transient ischemic attacks and direct bypasses but demonstrating improvement and associated anomaly is reported. A year and a half later, after a bilateral revascularization, an intracerebral capsulized hematoma growth was identified, and it was removed surgically. Neovascularization including many microvessels similar to capillary telangiectasia were identified by pathological investigation despite the reduction of moyamoya vessels on the repeated angiograms after the revascularization surgeries. In the present case, proliferation of capillary vessels was clearly confirmed by direct bypasses.
Conclusion:
There is no doubt that direct bypasses prevent further ischemic stroke by improving cerebral blood flow. However, they may result in failure in reducing the load of moyamoya vessels, albeit decreasing the potential risk of hemorrhagic strokes.
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