Ahead of Print: Can Combined Bypass Surgery at Middle Cerebral Artery Territory Save Anterior Cerebral Artery Territory in Adult Moyamoya Disease?

BACKGROUND: Patients with moyamoya disease are frequently encountered with improved symptoms related to anterior cerebral artery territory (ACAt) and middle cerebral artery territory (MCAt) after bypass surgery at MCAt.

OBJECTIVE: To evaluate hemodynamic changes in MCAt and ACAt after bypass surgery in adult moyamoya disease.

METHODS: Combined bypass surgery was performed on 140 hemispheres in 126 patients with MCAt symptoms. Among them, 87 hemispheres (62.1%) accompanied preoperative ACAt symptoms. Clinical, hemodynamic, and angiographic states were evaluated preoperatively and approximately 6 months after surgery.

RESULTS: Preoperative symptoms resolved in 127 MCAt (90.7%) and 82 ACAt (94.3%). Hemodynamic analysis of total patients showed a significant improvement in MCAt basal perfusion and reservoir capacity (P < .001 and P = .002, respectively) and ACAt basal perfusion (P = .001). In a subgroup analysis, 82 hemispheres that completely recovered from preoperative ACAt symptoms showed a significant improvement in MCAt basal perfusion and reservoir capacity (P < .001 and P = .05, respectively) and ACAt basal perfusion (P = .04). Meanwhile, 53 hemispheres that had never experienced ACAt symptoms significantly improved MCAt basal perfusion and reservoir capacity (P < .001 and P = .05, respectively); however, no ACAt changes were observed. A qualitative angiographic analysis demonstrated a higher trend of leptomeningeal formation from MCAt to ACAt in the former subgroup (P = .05). During follow-up, no ACAt infarctions were observed.

CONCLUSION: Combined bypass surgery at MCAt resulted in hemodynamic improvements in ACAt and MCAt, especially in patients with preoperative ACAt symptoms.

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