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Published on: April 25, 2014
Imaging Pattern and the Mechanisms of Postoperative Infarction After Indirect Revascularization in Patients with
Shoko Hara1, Tadashi Nariai1, Motoki Inaji1
1Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan.
Objective:
To develop preventive strategies against postoperative infarction after indirect revascularization surgery in patients with moyamoya disease (MMD), we evaluated clinical information, with a specific focus on the imaging pattern of postoperative infarction.
Methods:
We retrospectively evaluated 421 surgical procedures performed in 354 (262 pediatric and 159 adult) patients with MMD from April 1991 to March 2021 at our institute. In addition to clinical information, raw images of postoperative infarction were collected and categorized into subtypes by the location of the infarction.
Results:
Symptomatic and asymptomatic postoperative infarction occurred in 47 and 12 patients (11.1% and 2.6%), respectively, and more than half (51.7%) of these cases of postoperative infarction occurred immediately or the day after the surgery. Cortical infarction around the craniotomy site was the most frequent pattern observed (50/59, 84.8%), and some of these cases seemed to occur under local compression from epidural or subdural hematomas (15/50, 30.0%). Ipsilateral white matter infarctions located in the watershed area (9/59, 15.3%) and contralateral infarctions (3/59, 5.1%) were also observed. Four patients (1.0%) showed sudden occlusions of ipsilateral or contralateral large intracranial arteries immediately after surgery. Postoperative infarction caused permanent neurologic deficits in 7 patients (1.7%), and all included the cortex outside the craniotomy site.
Conclusions:
Local cortical irritation, hemodynamic fluctuation, and thromboembolic events were suggested as possible mechanisms of postoperative infarction after indirect revascularization in patients with MMD. Minimizing cortical irritation, maintaining adequate cerebral blood flow, and perioperative antiplatelet agents might decrease the incidence of postoperative infarction.
Insights
Postoperative infarction after moyamoya disease (MMD) surgery is often cortical and occurs early. Strategies to minimize irritation and maintain blood flow may reduce MMD surgical risks.
Area of Science:
- Neurosurgery
- Neurology
- Vascular Surgery
Background:
- Moyamoya disease (MMD) requires surgical revascularization to prevent stroke.
- Postoperative infarction is a known complication, necessitating preventive strategies.
Purpose of the Study:
- To analyze the patterns of postoperative infarction after indirect revascularization in MMD patients.
- To identify potential mechanisms and preventive measures for infarction.
Main Methods:
- Retrospective review of 421 procedures in 354 MMD patients (pediatric and adult).
- Analysis of clinical data and imaging patterns of postoperative infarction.
- Categorization of infarction subtypes based on location.
Main Results:
- Overall postoperative infarction rate was 13.7% (symptomatic 11.1%, asymptomatic 2.6%).
- Most infarctions (51.7%) occurred within 24 hours post-surgery.
- Cortical infarction near the craniotomy site was most common (84.8%), sometimes linked to hematomas.
Conclusions:
- Mechanisms include cortical irritation, hemodynamic changes, and thromboembolism.
- Minimizing cortical irritation, ensuring adequate cerebral blood flow, and using antiplatelet agents are potential preventive strategies.
