Clinical Characteristics And Risk Factors Of Reversible Neurological Deficits After Cerebral Revascularization In Adult Moyamoya Disease

Background: Moyamoya disease is a rare cerebrovascular disease characterized by progressive stenosis or occlusion of the internal carotid artery and its branching arteries,accompanied by the formation of smoky vessels in the basilar ring.Various surgical intracranial and extracranial bypass techniques have been widely used in adult patients to improve cerebral perfusion and prevent the onset of bleeding or ischemic stroke.However,adult patients with moyamoya disease have unstable hemodynamics and a high incidence of postoperative reversible neurological deficits(RND),and the risk factors remain uncertain.Objective: This study aims to understand the clinical characteristics of adult patients with moyamoya disease and explore the high risk factors of postoperative RND.Optimize the perioperative diagnosis and treatment,reduce the occurrence of postoperative neurological defects,and improve the safety and effectiveness of bypass surgery.Methods: The case data of adult patients with moyamoya disease diagnosed by total cerebral angiography and undergoing cerebral revascularization in our hospital from October 2016 to October 2020 were retrospectively collected.The clinical manifestations of the patients on admission were recorded,including gender and age,first symptoms(signs),diagnostic methods,imaging examination results and other cerebrovascular diseases(aneurysm or vascular malformation).Postoperative RND was defined as 1)Reversible neurological deficits such as numbness,weakness,hemiplegia,epilepsy,and aphasia occur in patients with moyamoya disease after surgery.2)Postoperative intracranial hemorrhage and new cerebral infarction were excluded by CT or MRI.3)The symptoms returned to normal or improved significantly within 2weeks after operation.The clinical manifestations of patients with RND were recorded in detail.The patients were divided into two groups according to whether postoperative RND occurred or not,and the differences in demographic characteristics and clinical characteristics between the two groups were analyzed for statistical significance.The possible risk factors were analyzed by univariate analysis and Multivariate regression analysis,a regression model was established to analyze the risk factors of postoperative RND.Results: Finally,73 adult patients with moyamoya disease who underwent 78 intracranial and extracranial reconstruction operations were included.There were 26 cases of direct bypass,48 cases of combined bypass and 4 cases of indirect bypass.The patient cohort was 29-68 years old,with a mean age of 48.3 years.The male-female ratio was about 1:1.35.Symptoms include transient ischemic attack(25.6%),hemiplegia 15.4%,epilepsy(2.6%),headache(35.9%),dizziness(38.5%),decreased body movement or muscle strength(38.5%),cognitive dysfunction(16.7%),numbness(11.5%),blurred vision(10.3%),memory loss(21.8%),personality change(3.8%),impaired speech function(21.8%).There were61.5% of patients with ischemic stroke,32.1% of patients with hemorrhagic stroke,and 16.7% of patients with hemorrhagic combined with ischemic stroke.There were 32 cases(41%)of perioperative complications,including 20 cases(25.6%)of RND,10 cases(12.8%)of cerebral infarction,and 1 case(1.3%)of intracranial hemorrhage.There were no statistically significant differences between the RND group and the asymptomatic group in gender,symptom grouping,admission MRS score,underlying disease,smoking history,new infarction,frequent TIA,unstable moyamoya disease,cerebral perfusion stage,surgical method,operative time and other aspects(P>0.05).In terms of age,the mean age of the RND group was significantly lower than that of the asymptomatic group(44.1 ± 7.8 years VS 50.4 ± 8.7 years,P=0.007).The length of stay in the RND group was longer than that in the asymptomatic group(26.1 ±15.0 days VS 20.9 ± 6.1days,P=0.045).The temporal muscle edema rate in RND group was significantly higher than that in asymptomatic group.(25.0% VS 0%,P<0.001).Univariate and multivariate analyses indicated that posterior cerebral artery(PCA)stenosis and DSA stage were independent risk factors for postoperative RND in patientsConclusion: The incidence ratio of adult moyamoya disease between male and female is about 1:1.35,and patients with ischemic blood type are more than those with hemorrhagic blood type,and the onset age of patients with ischemic blood type is higher than that of hemorrhagic blood type.PCA stenosis and DSA stage are high risk factors for postoperative RND.It is very necessary to conduct perfect preoperative examination and postoperative close monitoring and blood pressure control for patients with moyamoya disease bypass.