The Controlled Trial Of Superficial Temporal Artery To Anterior Cerebral Artery Direct Bypass In Patients With Moyamoya Disease

Objective: The surgical plan for moyamoya disease is mainly composed of three methods,the first is direct cerebral blood flow reconstruction,the second is indirect cerebral blood flow reconstruction,and the third is a combination of the first two surgical methods,the common superficial temporal artery-Cerebrovascular bypass,mainly superficial temporal artery-Middle cerebral artery(STA-MCA)bypass.For the patients who have ischaemia of the anterior cerebral artery(ACA)blood supply area,postoperative period and in the follow-up period,there is a high risk of cerebral ischaemia.Regarding the improvement of blood flow in this area,the surgical plan is still inconclusive.There are currently two methods,one is STA-ACA bypass and the other is Encephalo-duro-periosteal-synangiosis.After inquiries in Chinese and English literature,there are currently only Seven open literatures carried out related surgical reports.This research will focus on the direct bypass method.The distal blood vessel diameter of ACA is small,and the direct bypass between STA and ACA is a challenging operation for doctors.Our hospital began to conduct research on STA-ACA direct bypass surgery in2019,but the current Chinese and English literature only has case studies,and there are no controlled studies that are consistent with STA-MCA bypass.We believe that the direct arterial bypass of STA-ACA is more advantageous for the improvement of cerebral blood supply in the ACA area.This study will conduct a controlled analysis of the two surgical methods to observe the efficacy of the operation,and retrospectively analyze the differences between STA-ACA bypass and MCA bypass.Analyze the efficacy of STA-ACA surgery.Methods: A controlled analysis of patients who were diagnosed with moyamoya disease from January 2017 to December 2020 in the First Hospital of China Medical University and completed the double bypass of intracranial and extracranial vessels combined with encephalo-myo-synangiosis.All cases had cerebral ischaemia in the blood supply area of ACA.All surgical patients completed STA-cerebrovascular double bypass combined with Encephalo-myo-synangiosis(EMS),a total of 32 cases,9 patients underwent bilateral surgery in stages,and a total of 41 operations were performed.For the patients who completed the operation type STA-ACA,STA-MCA double bypass combined with encephalo-myo-synangiosis,there were 10 cases as the ACA group.And the completed operation type was STA-MCA double bypass combined with encephalo-myo-synangiosis,there were 31 cases as the MCA group.The baseline of the two groups were well matched except that there were fewer cases of adults over 16 years old in the ACA group(P=0.036<0.05).Statistical analysis of death,cerebral ischemia,cerebral hemorrhage,Modified Rankin Scale(m RS);STA cut flow(CF),STA cut flow index(CFI),bypass patency,and CT perfusion data of the frontal lobe on the operative side.Results: A total of 32 patients were enrolled in the study,and a total of 41 operations were performed,including 10 cases in the ACA group and 31 cases in the MCA group.There was no difference in the baseline level of gender,age,symptoms,hypertension,smoking history,drinking history,dyslipidemia.symptoms from the operation time and preoperative m RS score.Among the two groups,there were significantly more surgical cases in children under 16 years old in the ACA group than in the MCA group(P=0.036<0.05).During the postoperative period,1 case of bilateral frontal lobe ischaemia(10%)in the ACA group;4 cases(12.9%)of frontal lobe ischaemia on the surgical side in the MCA group,cerebral hemorrhage(large infarction of the temporal occipital lobe on the surgical side with temporal lobe hemorrhage)1 case(3.2%)(P=1.000>0.05);during the one-year follow-up period after operation,1 case(3.2%)of frontal lobe ischaemia in the MCA group(P =1.000>0.05).There was no significant difference in m RS scores changes between the two groups at after surgery(P=0.088>0.05)and follow-up(P=0.276>0.05).Three months after the operation,Digital subtraction angiography confirmed that the bypass patency(100.0%)of the ACA group was similar to that of the MCA group(81.6%)(P= 0.260>0.05).Cut flow in the ACA group of STA is significantly less than the MCA group(P=0.018<0.05).The CFI of STA in the ACA group(3.2±1.6)was significantly higher than that of the MCA group(1.2±0.6)(P = 0.007<0.05).The indexes of CT perfusion of frontal lobe brain tissue on the operative side one week before and after operation are the same.Conclusion:1.STA-ACA direct revascularization surgery is a technically feasible method of direct revascularization for patients with moyamoya disease in the frontal lobe.The revascularization patency is better,and satisfactory long-term curative effects can be obtained.In pediatric patients,the gradual revascularization patency is good,which is also a feasible technical method for direct revascularization surgery in children.2.For STA-ACA,STA-MCA double revascularization and STA-MCA double revascularization,ACA bypass operation has significantly STA cut flow index bigger for patients with moyamoya disease on the frontal lobe,and STA flow changes more obvious.3.Two surgical plans are used for moyamoya disease patients with frontal lobe fractures.In the postoperative period and 1 year after the operation,the clinical symptoms and m RS score changes evaluated.There is no statistical difference.The safety of the two operations are the same,and the efficacy of the two operation are the same.