The Comparison Of Indirect And Combined Vascular Reconstruction In The Treatment Of Adult Ischemic Moyamoya Disease

Background As a chronic occlusive cerebral vascular disease,moyamoya disease can be divided into ischemic moyamoya disease and hemorrhagic moyamoya disease according to the first symptoms.The mortality and disability rate of the disease is high.There is no effective drug treatment for the disease at present.The main treatment method is revascularization.Vascular reconstruction can be divided into direct vascular reconstruction,indirect vascular reconstruction and combined vascular reconstruction.In recent years,combined vascular reconstruction and indirect vascular reconstruction have been widely used.At present,there are differences on collateral circulation establishment and neurological function recovery in adult patients with ischemic moyamoya disease in different surgical methods.In order to improve the prognosis of patients with ischemic moyamoya disease,we retrospectively analyzed the related cases.Objective To compare the effects of indirect and combined revascularization on collateral circulation establishment,blood supply recovery and complications in adult patients with ischemic moyamoya disease.Methods From September 2015 to June 2018,132 patients with ischemic moyamoya disease were selected from the Department of Neurosurgery of the First Affiliated Hospital of Zhengzhou University.All patients were operated on and reexamined in our hospital,excluding cases of missing follow-up and incomplete data.There were 132 patients with 163 sides of operation.The clinical data were collected,including sex,age,preoperative blood pressure,preoperative symptoms,postoperative symptoms recovery,preoperative angiography,post-operative angiography,post-operative complications and so on.The patients were divided into combined vascular reconstruction group and indirect vascular reconstruction group.Among them,80 were in the combined vascular reconstruction group and 52 were in the indirect vascular reconstruction group.The preoperative conditions(such as blood pressure,modified Rankin score(m RS),preoperative angiography(Suzuki staging),preoperative hemodynamics)and postoperative conditions(such as post-operative angiography,post-operative hemodynamics,improvement of postoperative symptoms)of each group were analyzed and compared.The combined revascularization and indirect revascularization were evaluated.The establishment and efficacy of collateral circulation after operation.Results 1.By comparing the preoperative clinical symptoms and angiography,we found that the neurological function level and vascular growth were basically the same in the combined reconstruction group and the indirect reconstruction group(according to the m RS score,there was no significant difference between the combined reconstruction group and the indirect reconstruction group(P=0.323>0.05).According to the Suzuki staging,there was no significant difference in the preoperative Suzuki staging between the combined reconstruction group and the indirect reconstruction group(P = 0.904 > 0.05).2.During an average follow-up period of(11.8 ± 4.7)months,DSA results showed that the collateral circulation establishment in the combined reconstruction group was better than that in the indirect reconstruction group(according to the Songdao classification,the collateral circulation establishment in the combined reconstruction group was excellent(grade A)in 37 sides,good(grade B)in 47 sides,and normal(grade C)in 15 sides,with an excellent and good rate of 84.9%.In the indirect reconstruction group,16 sides had excellent collateral circulation(grade A),30 sides were good(grade B)and 18 sides were normal(grade C).The excellent and good rate was 71.9%.The difference was statistically significant(P=0.030 < 0.05).3.Comparing CT perfusion imaging,r CBF was improved after operation,MTT was decreased after operation in both groups(P < 0.05),and r CBV was not significantly different after operation(P > 0.05);r TTP in combined reconstruction group was decreased after operation(P = 0.029 < 0.05),while r TTP in indirect reconstruction group was not significantly different from that before operation(P = 0.118 > 0.05).The r CBF was higher in the combined reconstruction group(1.01 ±0.35 vs 0.89 ±0.48,P=0.037 < 0.05),and the MTT was lower in the combined reconstruction group than in the indirect group(3.92±0.71 vs 4.76±0.68,P=0.011 < 0.05).4.The rate of poor wound healing in the combined reconstruction group was 11.3%(9/80),higher than that in the indirect reconstruction group(1.9%(1/51),and the difference was statistically significant(P = 0.048 < 0.05).There were 9 TIA cases(11.3%)in the combined reconstruction group and 6 TIA cases(11.5%)in the indirect reconstruction group.There was no significant difference(P=0.959 > 0.05).There were 4 new cerebral infarction cases(5.0%)in the combined reconstruction group and 3 new cerebral infarction cases(5.8%)in the indirect reconstruction group.There was no significant difference between the two groups(P > 0.05).There were 3 epileptic seizures(3.8%)in the combined reconstruction group and 1 epileptic seizure(1.9%)in the indirect reconstruction group.There was no significant difference between the two groups(P=0.937 > 0.05).Conclusion 1.Compared with indirect revascularization,combined revascularization is more conducive to collateral circulation formation and blood supply recovery in adult patients with ischemic moyamoya disease.2.Compared with indirect reconstruction,combined vascular reconstruction is prone to delayed wound healing,and the incidence of other complications is basically the same.