| Moyamoya Disease(MMD).also called spontaneous occlusion of the circle of Wills,is a occlusive cerebrovascular disease of unknown etiology characterized by progressive stenosis at the terminal portion of the internal carotid artery(ICA)and an abnormal vascular network at the base of the brain.It was firstly reported in Japan in 1957 and was named with "moyamoya".In 1997,the diagnosis guildeline on moyamoya disease was enacted by the Research Committee of MMD of the Japanese Ministry of Health,Labour,and Welfare.It was updated in 2015,and stated that patients with both bilateral and unilateral presentation of terminal ICA stenosis with an abnormal vascular network at the base of the brain in spite of underlying diseases.If patients had underlying diseases,we called it Moyamoya Syndrome(MMS).Some researchers considered a new concept that moyamoya angiopathy includes moyamoya disease and moyamoya syndrome.However,it was not generally accepted.In this paper.MMD is used including moyamoya disease and moyamoya syndrome.As the time goes by,the precalence and the incidence of MMD is increasing.According to the report performed in Japan in 1995,the prevalence of MMD is only 3.16/100.000.and the incidence is 0.35/100.000.However,a survey in 2004 showed that the prevalence had increased to 6.03/100,000.with the incidence of 0.54/100,000.With the rapid increase,it is particularly important to treat MMD.However,there is no drug or treatment that can regulate and reverse the MMD progress.But it is generally accepted that it could compensate partly ischemic brain and improve the clinal syndrome for a long time by the revascularization.There is two kinds of revascularization:direct revascularization usually usd to the children and indirect revascularization usually used to adults.Anticoagulant therapy such as aspirin is usually used after revascularization,to improve microcirculation and prevent microembolism.However,this therapy also might increase the risk of stroke.So.it is important to evaluate the effiency of the anticoagulant therapy afer the revascularization.This is the aim of this article.Method:330 MMD patients received revascularization surgery at Nanjing Jinling Hospital from February 2005 to February 2014.Revascularization procedures were performed using indirect encephaloduroarteriosynangiosis(EDAS)alone(29 patients),or combination with direct superficial temporal artery-middle cerebral artery(STA-MCA)bypass(46 patients).If direct revascularization was technically unachievable,EDAS was performed alone.Data were collected retrospectively,including demographic,clinical.imaging,and treatment information.The patients enrolled in this study met the following criteria:moyamoya vasculopathy according to Movamova Guidelines;without on-going pregnancy during the surgical procedure and follow-up period;no active brain hemorrhage,no ischemic attack,no administration of anti-thrombotic agents within 7 days preoperatively;no abnormality in blood coagulation test before surgery;no mutual-effect drugs administration postoperatively;and at least 12-month follow-up.Thus,only 75 patients(88 hemisphere)were included in this study.Among them,33 patients(44%)did not received aspirin treatment,42 patients(56%)received postoperative antiplatelet therapy(0.1 g Aspirin per day)for a long time.Oral consent was obtained from all patients.Then we collected statistics how they recovered by telephone follow-up and clinical follow-up for at least 12 months,including language compentence,muscle strength,mRS scores,angiography,and so on.Results:Patient's characteristics75 MMD patients(88 hemispheres)were included in this study.Patients' characteristics are summarized in Table 1.There were 44 male and 31 female patients,with an age peak between 31 and 40 years old.Different types of patients included 29 hemorrhage MMD(38.67%),39 ischemic MMD(52.00%)and 7 atypical MMD(9.33%).Most of patients were ranked as ? grade by Suzuki Classification(68%),with normal limb muscle strength(MRC scale 5 points accounting for 84%),and mild disability(mRS score 1 point accounting for 72%).Postoperative cerebral strokeThe recovery of patients was examined by regular follow-up until the first postoperative stroke event or death occurred or at least 12 months.There is no difference in follow-up time between patients with or without postoperative aspirin use(t-test.P=0.877).Five patients with postoperative aspirin treatment,while 12 patients without aspirin treatment suffered from postoperative cerebral stroke.The result of Chi-square showed that the patients with postoperative aspirin treatment had significantly lower risk for postoperative cerebral stroke(?2=6.31,P=0.024).Then we conducted a binary logistic regression analysis to evaluate the risk factors for postoperative stroke.There is a statistically significant effect of aspirin use on the occurrence of postoperative stroke(P=0.013,OR=0.079,95%Cl:0.01-0.582).We also found that the surgical hemispheres(Unilateral or bilateral)might affect postoperative stroke(P=0.024,OR=0.06,95%CI:0.005-0.696).In this analysis,no statistically significance was found in gender(P=0.53),patient age(P=0.589),Suzuki classification(P=0.672),MMD Type(P=0.750).Surgery type(P=0.909)and Preoperative mRS score(P=0.813).Postoperative changes of contralateral limb's muscle strength(MRC)In this study,with postoperative aspirin treatment,2 patients(4.76%)had better outcomes,35 patients(83.33%)had no significant difference,while 5 patients(11.91%)had worse outcomes according to the changes of contralateral limb's muscle strength.On the other hand,in the other group.2 patients(6.06%)had better outcomes,25 patients(75.76%)had no significant difference,while 6 patients(18.18%)had worse outcomes.The result of Chi-square showed that there is no significant difference of contralateral limb's muscle strength between two groups(P=0.377).Then we conducted a binary logistic regression analysis to evaluate the risk factors for the changes of contralateral limb's muscle strength.There is a statistically significant effect of Suzuki classification on the occurrence of contralateral limb's muscle strength changes(P=0.023,P=0.024).Postoperative changes of modified rank score(mRS)In this study,with postoperative aspirin treatment.2 patients(4.76%)had much better outcomes,30 patients(71.43%)had better outcomes.3 patients(16.67%)had no significant difference,2 patients(4.76%)had worse outcomes,while 1 patient(2.38%)had much worse outcomes according to the changes of modified rank score.On the other hand,in the other group,2 patients(6.06%)had much better outcomes,17 patients(51.52%)had better outcomes,10 patients(30.30%)had no significant difference.3 patients(9.09%)had worse outcomes,while 1 patient(3.03%)had much worse outcomes.The result of Chi-square showed that there is no significant difference of modified rank score changes between two groups(P=0.274).Then we conducted a binany logistic regression analysis to evaluate the risk factors for the changes of modified rank score.There is a statistically significant effect of Suzuki classification(P=0.027).surgical sites(P=0.026),aspirin use(P=0.018)on the occurrence of modified rank score changes(P=0.023,P=0.024).Postoperative hemorrhage and deathIn this study,only one patient died postoperatively(male.24 years old.Suzuki classification:grade ?,is chemic MMD type,with indirect bilateral revascularization,with postoperative aspirin treatment).There was no significant difference in the mortality between two groups(P=0.372).Meanwhile,2 patients in the aspirin group and 1 patient in the untreated group suffered from postoperative hemorrhage(P=0.372).Then we conducted a binary logistic regression analysis to evaluate the risk factors for postoperative hemorrhage.There is no statistically significant differences botween gender,age,Suzuki classification,MMD type,aspirin use,and so on.Conclusion:Postoperative aspirin use can reduce postoperative stroke rate in MMD patients,and improve the stroke-free survival.Postoperative aspirin use did not increase the postoperative hemorrhage risk in MMD patients.There is no significant differene of postoperative contralateral limb's muscle strength and mRS whether aspirin use or not. |
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