Analysis Of Risk Factors Of Transient Neurological Deficit And Stroke In Peri-operation Period Following Revascularization Surgery In Patients With Moyamoya Disease

Background:MMD（moyamoya disease）is a cerebrovascular disease characterized by chronic,progressive stenosis or occlusion of terminal internal carotid artery and proximal anterior and middle cerebral arteries along with abnormal collateral vessels at the skull base.Revascularization surgery is the optimal method for the treatment of neurological impairment and prevention of disease deterioration in patients with Moyamoya disease.Surgical methods include direct bypass,indirect bypass and combined revascularization,of which the last one is the most common.Although the surgical techniques have become increasingly sophisticated,some patients suffer various kinds of postoperative complications,including postoperative ischemic events,cerebral infarction,intracranial hemorrhage,blood flow disorder syndrome,poor healing of scalp,subcutaneous hydrops,epilepsy,et al.The clinical manifestations of postoperative complications are different due to the location and extent of the lesions.Patients with mild symptoms may experience Transient/Reversible Neurological Deficit（TND/RND）,which may manifest as headache,aphasia,muscle weakness,et al.Most patients can recover within 1 month.In severe cases,patients may develop cerebral infarction or hemorrhage and even death.Therefore,prevention and timely treatment of these complications is of great significance to improve the surgical efficacy and prognosis of patients.Our study aimed to explore the risk factors associated with postoperative TND and stoke in MMD,so as to facilitate early intervention in high-risk patients to reduce the incidence of complications.Objective:This study intends to explore the risk factors associated with TND and stroke after bypass surgery to provide a certain basis for the prevention and treatment of complications in future clinical work.Methods:This study retrospectively analyzed data of 203 bypass surgeries（183 patients,20 of whom received two surgeries twice in two stages）from January 2018 to August2020.Patients were divided into positive and negative group according to occurrence of complication or not.Patients’age,gender,medical history,the type of presentation,operation method,intraoperative situation,perioperative blood pressure and other clinical data of single factor analysis,then the binary Logistic regression analysis were performed to explore the risk factors associated with postoperative complications.Results:1.203 operations were performed in 183 patients,and TND occurred in 26 cases during perioperative period.Among these complications,aphasia was the mainmanifestation in 7 cases,epilepsy in 4 cases,muscle weakness in 3 cases,severe vomiting,vertigo in 3 cases,facial and lingual paralysis in 2 cases,temporary disturbance of consciousness in 2 cases,paresthesia in 1 case,blurred vision in 1 case,choking in drinking water in 1 case.The complications were observed on the 3rd（1-9）day after operation,lasting for 3（1-10）days.All symptoms disappeared at discharge.Perioperative stroke occurred in 12 cases,10 of which showed new cerebral infarction or increased infarct area compared with that before surgery（1 case occurred on the contralateral side of the operation,3 cases on the bilateral cerebral hemisphere,and 6cases on the operative side）,and 2 cases had intracranial hemorrhage（both cases occurred on the operative side）.2.26 cases（12.81%）had TND.Univariate analysis indicated that:Diabetes,incidence of symptoms≥2 before surgery,pathological changes involving the posterior circulation,high blood pressure after surgery were risk factors for postoperative TND（P<0.05）;age,gender,history of hypertension,aneurysm,presentation,the time from the last symptom to operation,preoperative imaging staging,m RS on admission,operation method,operation side of bypass surgery,operation time,intraoperative blood pressure,intraoperative blood loss,intraoperative CO₂,cranial drainage volume 24h after operation had no statistical significance（P>0.05）.The results of binary Logistic regression indicated that the incidence of symptoms≥2 before surgery（OR=3.134,95%CI:1.236-7.943）and the involvement of posterior circulation（OR=3.061,95%CI:1.250-7.497）were independent risk factors for TND.3.Perioperative stroke occurred in 12 patients（5.91%）.Univariate analysis showed that:age,type of presentation,involvement of posterior circulation,the history of hypertension,intraoperative and postoperative high blood pressure were associated with perioperative stroke（P<0.05）;other clinical factors had no statistical significance.Multivariate binary Logistic regression showed that perioperative stroke was more common in patients with onset of cerebral infarction than in patients with hemorrhagic moyamoya disease.Conclusions:1.The incidence of symptoms had happen twice or more before surgery and the involvement of posterior circulation are independent risk factors for TND after bypass surgery with MMD patients.2.Perioperative stroke is more common in patients with cerebral infarction than in patients with hemorrhagic moyamoya disease.