Wonhyoung Park 1, Eun Suk Park 2, Seungjoo Lee 1, Jung Cheol Park 1, Jaewoo Chung 1, Jung Min Lee 1, Jae Sung Ahn 3
Abstract
Background: Intracranial hemorrhage, such as intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and intraventricular hemorrhage (IVH), is an extremely rare complication after surgical revascularization for moyamoya disease (MMD). However, the incidence, timing, prognosis, possible mechanism, and prevention are not well known.
Methods: Adult patients with MMD who underwent direct bypass or combined bypass and experienced ICH, SAH, or IVH within 7 days postoperatively were enrolled in this study. The medical records and radiologic findings of these patients, together with their intraoperative video recordings, were reviewed retrospectively.
Results: Direct superficial temporal artery (STA)-middle cerebral artery (MCA) bypass or combined bypass was performed for 222 hemispheres in 193 adult patients with MMD between January 2001 and December 2016. Intracranial hemorrhage occurred perioperatively in 8 hemispheres (3.6%) in 8 patients. The hemorrhages developed immediately after STA-MCA direct anastomosis during surgery in 3 patients. Hemorrhage on computed tomography and neurologic deterioration were also observed immediately postoperatively in 2 patients and during the postoperative period in 3 patients. Although 4 patients received medical management, neurosurgical treatment was needed in the other 4 patients. One patient died, and 6 patients were left with moderate or severe disabilities.
Conclusions: Intracranial hemorrhage (ICH, IVH, or SAH) after direct bypass for adult patients with MMD is an extremely rare but fatal complication. Although these hemorrhages can be associated with hyperperfusion syndrome, no effective prevention has been established.
Keywords: Cerebral revascularization; Intracerebral hemorrhage; Moyamoya disease; Subarachnoid hemorrhage.
Figure 2. Illustrative case 2 (patient 4). Moyamoya disease owing to acute cerebral infarction was diagnosed in a 44-year-old man. (A) Conventional cerebral angiography showed Suzuki stage V moyamoya disease with involvement of the posterior cerebral artery. (B) The patient underwent direct anastomosis between the parietal branch of the superficial temporal artery and the right middle cerebral artery. The patency of the bypass graft was good, and no significant unusual events occurred during surgery. Postoperatively, however, the patient's consciousness was not clear, and he developed a left hemiparesis that worsened to motor grade II in the immediately postoperative period. (C) Brain computed tomography showed intracerebral hemorrhage and intraventricular hemorrhage.
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