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Pediatric Moyamoya Revascularization Perioperative Care: A Modified Delphi Study.
Lisa R Sun1, Lori C Jordan2, Edward R Smith3
1Division of Cerebrovascular Neurology, Division of Pediatric Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, USA. Lsun20@jhmi.edu.
Neurocritical Care
|July 20, 2023
Summary
Expert consensus was reached on perioperative care for pediatric moyamoya surgery, emphasizing preadmission for high-risk patients and specific fluid, medication, and monitoring protocols. This guides best practices for indirect revascularization in children.
Area of Science:
- Pediatric Neurosurgery
- Neurology
- Intensive Care Medicine
Background:
- Moyamoya arteriopathy in children poses a significant stroke risk.
- Surgical revascularization reduces long-term stroke risk but carries perioperative risks.
- Limited evidence-based guidelines exist for perioperative care in pediatric moyamoya surgery.
Purpose of the Study:
- To establish expert consensus on perioperative care for pediatric moyamoya undergoing indirect revascularization.
- To identify research priorities in areas of clinical equipoise for moyamoya management.
Main Methods:
- A modified Delphi process involving 30 North American pediatric moyamoya experts.
- Three rounds included a survey, anonymous Likert scale evaluations, and a virtual meeting.
- Consensus defined as ≥80% agreement or disagreement on 88 statements.
Main Results:
- Consensus reached on 39 statements regarding perioperative care for indirect revascularization.
- Key agreements include preadmission for high-risk patients, specific IV fluid protocols, continuous aspirin use, prolonged arterial line monitoring, and detailed postoperative care (hourly vitals, neurologic checks, pain control, normothermia/normoxia, avoiding hypotension).
- Intravenous fluid bolus is recommended for new focal neurologic deficits post-surgery.
Conclusions:
- The Delphi process defined consensus areas for perioperative care in pediatric moyamoya surgery.
- Identified research priorities include continuous EEG, optimal blood pressure and hemoglobin targets, and the role of supplemental oxygen for postoperative ischemia.
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