Giant and complex aneurysm of the posterior circulation can pose several technical challenges with high operative morbidity. Recent advances in cardiac surgery have raised interest in the technique of deep hypothermic circulatory arrest for the management of giant and complex intracranial aneurysms of posterior circulation. The criteria for selecting patients for this procedure can be based on a preoperative analysis of available studies that suggests high risk with standard intervention. Using the technique of deep hypothermic circulatory arrest, we have successfully operated on a case of complex basilar tip aneurysm with MoyaMoya disease resulting in no significant neurological complications. We therefore suggest that patients with giant and complex intracranial aneurysms of posterior circulation might benefit from the use of deep hypothermic circulatory arrest technique.
Aneurysm* ; Cardiopulmonary Bypass ; Circulatory Arrest, Deep Hypothermia Induced* ; Humans ; Intracranial Aneurysm ; Moyamoya Disease* ; Thoracic Surgery

Anticoagulants ; Atrial Appendage/surgery* ; Atrial Fibrillation/complications* ; Brain Ischemia ; Cardiac Catheterization ; Female ; Humans ; Moyamoya Disease/surgery* ; Stroke ; Treatment Outcome

A 36-year-old man was diagnosed with a right temporal lobe grade II cerebral arteriovenous malformation (cAVM) and was treated with radiosurgery. At nine months after the cAVM radiosurgery, the patient began to develop bilateral focal narrowing at the M1 segments of the bilateral middle cerebral arteries. The narrowing progressively deteriorated as was demonstrated on longitudinal serial follow-up MR imaging. X-ray angiography performed at 51 months after radiosurgery confirmed that the cAVM was cured and a diagnosis of moyamoya disease. To the best of our knowledge, this is the first case of cAVM-associated moyamoya disease that developed after radiosurgery. Given the chronological sequence of disease development and radiation dose distribution of radiosurgery, it is proposed that humoral or unknown predisposing factors, rather than direct radiation effects, are the cause of moyamoya disease associated with cAVM.
Adult ; Humans ; Intracranial Arteriovenous Malformations/diagnosis/*surgery ; Magnetic Resonance Imaging ; Male ; Moyamoya Disease/*etiology ; Postoperative Complications ; Radiosurgery

Moyamoya disease is an occlusive intracranial arteriopathy owing to intimal hyperplasia with formation of abnormal cerebrovascular collateral networks; however, the etiology remains unclear. Although this disease is known to be associated with renovascular hypertension, it is extremely rare for it to be associated with stenoses of the coronary arteries. We herein described a case of a 56-year-old female with angina and asymptomatic moyamoya disease. We performed off-pump coronary artery bypass grafting (OPCAB) to avoid cardiopulmonary bypass and the risk of intraoperative hypotension. Conventional coronary artery bypass grafting has a potential risk of brain ischemia in moyamoya patients, but OPCAB may avoid this perioperative cerebral ischemic complication.
*Coronary Artery Bypass, Off-Pump/adverse effects ; Coronary Stenosis/complications/surgery ; Female ; Humans ; Intraoperative Complications/prevention & control ; Middle Aged ; Moyamoya Disease/complications/*surgery ; Risk Factors

BACKGROUNDSurgical interventions for moyamoya disease include direct and indirect revascularizations. This study aimed to evaluate the therapeutic effect of superficial temporal artery-middle cerebral artery bypass combined with an indirect revascularization procedure, encephalo-duro-myo-synangiosis, in the treatment of moyamoya disease.

METHODSFrom October 2005 to November 2009, we performed this combined revascularization procedure in 111 patients with different types and stages of moyamoya disease. The superficial temporal artery, middle meningeal artery and the deep temporal artery were evaluated for individualized surgical planning in these cases. The integrity of the deep temporal artery and the middle meningeal artery network, and the pre-existing spontaneous anastomoses of the distal branches of the external carotid artery with the cortical arteries were well preserved. The mean follow-up time was 72.5 months, all clinical and radiological data were retrospectively reviewed.

RESULTSA total of 198 stomas were performed in 122 hemispheres, all remaining patent until the last follow-up. The encephalo-duro-myo-synangiosis resulted in extensive anastomoses of the deep temporal artery (100%), the middle meningeal artery (90.9%), and the sphenopalatine artery (39.8%) with the cortical arteries, respectively. The superficial temporal artery, deep temporal artery, and the middle meningeal artery were significantly thickened in 88 patients as determined by digital subtraction angiography at follow-up. The relative cerebral blood flow increased significantly within one week after the operation. At 6 months post the operation, the relative cerebral blood flow was further increased by 15.5% from the gradual formation of anastomoses as a result of indirect revascularization. Transient ischemic attacks were effectively reduced or totally arrested. The neurological deficits significantly improved in 37 patients, with the National Institutes of Health Stroke Scale scores lowered by 2-8. There was no rehemorrhage in hemorrhagic moyamoya disease patients.

CONCLUSIONThis study showed that the superficial temporal artery-middle cerebral artery bypass combined with encephalo-duro-myo-synangiosis can achieve good therapeutic effect in the treatment of moyamoya disease.

Adolescent ; Adult ; Cerebral Revascularization ; methods ; Child ; Female ; Humans ; Male ; Middle Aged ; Middle Cerebral Artery ; pathology ; surgery ; Moyamoya Disease ; pathology ; surgery ; Young Adult

BACKGROUNDStandard superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery is an effective treatment for moyamoya disease, but recent evidence suggests that postoperative cerebral hyperperfusion can occur. In this study, the trendline of changes in regional cerebral blood flow (rCBF) after surgery were continually monitored near the site of anastomosis in order to investigate both the efficacy of the procedure for improving rCBF and the possible risk of hyperperfusion.

METHODSStandard STA-MCA bypass surgery was performed on 13 patients. rCBF was measured continually using laser Doppler flowmetry (LDF) until the 5th day after the operation with the LDF probe implanted adjacent to the area of the anastomosis. The trendline of rCBF changes postoperatively was recorded for the analysis performed using SPSS 13.0.

RESULTSThe baseline LDF value of cortical rCBF was (84.68 + or - 14.39) perfusion unit (PU), which was linear relative to absolute perfusion volume before anastomosis and (88.90 + or - 11.26) PU immediately after anastomosis (P > 0.05). The value changed significantly from before to after anastomosis (P < 0.05); it was (417.72 + or - 21.35) PU on the 1st day after surgery, and (358.99 + or - 18.01) PU, (323.46 + or - 17.38) PU, (261.60 + or - 16.38) PU and (375.72 + or - 18.45) PU on the following 4 days, respectively. The rCBF decreased gradually from the 2nd day until the 4th postoperative day, but still was at a high level (P < 0.05). However, on the 5th postoperative day the rCBF increased again to the second highest level, which was significantly different compared with the baseline value (P < 0.05), but not significantly different compared with the values on the other 4 days (P > 0.05).

CONCLUSIONSSTA-MCA anastomosis improves the cerebral blood supply significantly in the early stage after surgery, however, the risk of symptomatic hyperperfusion may exist, which may possibly occur on the 1st day and 5th day after surgery. A LDF is useful for postoperative monitoring for both the efficacy of bypass and possible risk of neurologic deterioration or bleeding from hyperperfusion.

Adolescent ; Adult ; Cerebral Revascularization ; methods ; Child ; Female ; Humans ; Laser-Doppler Flowmetry ; Male ; Middle Aged ; Middle Cerebral Artery ; surgery ; Moyamoya Disease ; surgery ; Regional Blood Flow ; physiology ; Young Adult

Moyamoya disease is an unusual cerebrovascular disorder characterized by occlusive intimal dysplasia of the distal internal carotid and proximal cerebral arteries, but the etiology remains unclear. Angiographic characteristics include bilateral stenosis or occlusion of the terminal portions of the intracranial internal carotid arteries and bilateral development of fine collateral vessels at the base of the brain known as 'Moyamoya vessels'. Cardiac surgery using cardiopulmonary bypass due to coronary artery disease and others among patients with moyamoya disease is very rare, and cardiac surgery for such patients has a potential risk of intraoperative and perioperative brain ischemia. We successfully treated a patient who underwent artrial septal defect closure and coronary artery bypass graft using the cardiopulmonary bypass, so we report this case with a brief literature review.
Brain ; Brain Ischemia ; Cardiopulmonary Bypass ; Carotid Artery, Internal ; Cerebral Arteries ; Cerebrovascular Disorders ; Constriction, Pathologic ; Coronary Artery Bypass ; Coronary Artery Disease ; Humans ; Moyamoya Disease* ; Thoracic Surgery* ; Transplants

Moyamoya disease (MMD) is a progressive cerebrovascular occlusive disease of the internal carotid arteries and anterior and middle cerebral arteries. Non-neurological surgery in patients with MMD is often complicated by cerebral ischemia or infarction. The goals of perioperative management are to maintain normotension, normocarpnia, normovolemia and normothermia. Here we report a case of a patient with MMD who underwent patch closure of an atrial septal defect and pulmonary valvotomy by use of a normothermic and non-hemodiluted cardiopulmonary bypass. To prevent intraoperative neurological complications we performed total intravenous anesthesia with propofol, made burst suppression in EEG and monitored the jugular bulb oxygen saturation (SjvO2) for cerebral desaturation.
Anesthesia ; Anesthesia, Intravenous ; Brain Ischemia ; Cardiopulmonary Bypass ; Carotid Artery, Internal ; Electroencephalography ; Heart ; Heart Septal Defects, Atrial ; Humans ; Infarction ; Middle Cerebral Artery ; Moyamoya Disease ; Oxygen ; Propofol ; Thoracic Surgery

The histopathological features of the middle cerebral artery (MCA) and superficial temporal artery (STA) from moyamoya disease (MMD) and their relationships with gender, age, angiography stage were explored. The causes and the clinical significance of vasculopathy of STA were also discussed. The clinical data and specimens of MCA and STA from 30 MMD patients were collected. Twelve samples of MCA and STA from non-MMD patients served as control group. Histopathological examination was then performed by measuring the thickness of intima and media, and statistical analysis was conducted. The MCA and STA specimens from MMD group had apparently thicker intima and thinner media than those from the control group. There was no significant pathological difference between the hemorrhage group and non-hemorrhage group, and between the males and females in MMD patients. Neither the age nor the digital subtraction angiography (DSA) stage was correlated with the thickness of intima in MCA and STA. MMD is a systemic vascular disease involving both intracranial and extracranial vessels. Preoperative external carotid arteriography, especially super-selective arteriography of the STA, benefits the selection of donor vessel.
Adult ; Angiography ; Case-Control Studies ; Female ; Humans ; Male ; Middle Aged ; Middle Cerebral Artery ; diagnostic imaging ; pathology ; Moyamoya Disease ; diagnostic imaging ; pathology ; surgery ; Temporal Arteries ; diagnostic imaging ; pathology ; Tunica Intima ; diagnostic imaging ; pathology

From January to December in 1983, neurosurgical statistics of 38 training hospitals in Korea was summarized as follows. The total number of neurosurgical admission was 27,185. The total operations were 10,980. Each of 25( out of the 38) training units performed 100 to 400 operations during this one year period. Out of 10,980 operations, 3,938 cases were trauma, approximately 36% against the total. Of the trauma surgery, 88% was done for head injuries and remaining 12% for spine injuries. There were 2,233 cases(20.34% of the total) of spine surgery, which was next to trauma surgery. Surgery for lumbar disc herniation(2,047 cases) occupied 92% of spine surgery. Of 1,302 operations(11.86% of the total) for cerebrovascular diseases. 719 cases(55.23%) were spontaneous intracerebral hematomas and 441 cases(33.87%) were ruptured cerebral aneurysms. Forty-two per cent of aneurysms was found in anterior communicating artery and 25% in internal carotid-posterior communicating artery junction. It is interesting to note that only 1% of posterior circulation aneurysms was detected by the four vessel angiography. Another remarkable finding was the cerebrovascular occlusive lesion was rarely found among Korean patients, and consequently, the surgery for ischemic stroke was performed infrequently Remaining vascular surgery was done for the cerebral vascular malformations such as arteriovenous malformation and Moya Moya disease. Tumor surgery was done for 1,060 cases, which represents 9.65% of all. Of these tumor surgeries, 97.73% was done for primary brain tumors. Glial tumors were 41.2% of all primary brain tumors and 20.8% was meningiomas. The pituitary tumor was 10% of all primary brain tumors, and 56% of pituitary tumors was operated on by transsphenoidal approach. Five per cent of all primary brain tumors was pineal tumors, but most of pineal tumors were treated by shunt surgery and radiation therapy. Consequently, direct operation for pineal tumor was performed only in 13 case. Shunt operation was performed in 650 cases. Functional neurosurgery cases were 207 and 148(71.5%) of them were pain surgery. Twenty-two cases of microvascular decompression were performed for hemifacial spasm. Surgery for infection was 3.57% of the total.
Aneurysm ; Angiography ; Arteries ; Arteriovenous Malformations ; Brain Neoplasms ; Craniocerebral Trauma ; Hematoma ; Hemifacial Spasm ; Humans ; Intracranial Aneurysm ; Korea* ; Meningioma ; Microvascular Decompression Surgery ; Moyamoya Disease ; Neurosurgery ; Pinealoma ; Pituitary Neoplasms ; Spine ; Stroke ; Vascular Malformations