Differentiated method in surgical revascularization of the brain for the treatment of pediatric patients with moyamoya angiopathy

Abstract

The study objective is to study the results of the differentiated method of surgical revascularization of the brain for the treatment of pediatric patients with moyamoya angiopathy. Materials and methods . Twelve surgical interventions were performed on 12 hemispheres in 8 patients (4 male, 4 female) with moyamoya angiopathy from December 2015 to March 2020. The age of patients ranged from 6 months to 14 years old, the average age is 8 years old. To clarify the clinical course of the disease the Y. Matsushima classification was used: type I (n = 3), type III (n = 2), type IV (n = 2) and type V (n = 1) of Y. Matsushima. Stages of the disease are classified according to J. Suzuki: stage III was revealed in 5 patients, stage IV— in 3. Cerebral angiography, magnetic resonance imaging of the brain and vessels were performed; computed tomography perfusion of the brain was made in every patient. Encephaloduroarteriomyosynangiosis was used in 2 hemispheres. Extra-intracranial bypass and encephaloduro-myosynangiosis in 1; extracranial-intracranial bypass and encephaloduroarteriomyosynangiosis — in 2; extracranial-intracranial bypass and encephaloduromyoperiosteosynangiosis in 5 hemispheres; double-barreled bypass and encephaloduromyosynangiosis — in 1 hemisphere; double-barreled bypass and encephaloduromyoperiosteosynangiosis — in 1 hemisphere. In the follow-up period (6—36 months) neurological status testing, digital subtraction angiography (6 vascular territories), magnetic resonance imaging of the brain and vessels and computed tomography perfusion of the brain were performed. Results . All patients in the follow-up period had no clinically significant ischemic events on the side of surgical intervention; there was an increase in the perfusion of the brain in comparison with preoperational values. In 1 case, transient ischemic attack occurred on the nonoperated hemisphere that did not recur after surgery. There was a regression of symptoms among children with initial neurological deficits. The angiographic result, in accordance with the method suggested by Y. Matsushima, was excellent (A group) and good (B group), except the case of moyamoya syndrome and case after indirect revascularization in zone of brain atrophy. Based on our experience, we have determined the optimal method of suturing the wound with a good cosmetic effect. Conclusion . We can assume, that differentiated method in surgical treatment of pediatric patients with moyamoya angiopathy is highly effective for the prevention of ischemic stroke, and also has good clinic, angiographic and cosmetic result. With suitable arterial sizes, combined revascularization showed better results than indirect, especially in the clinically significant hemisphere.