Tohru Yamada

Effectiveness of Superficial Temporal Artery–Middle Cerebral Artery Anastomosis in Adult Moyamoya Disease Cerebral Hemodynamics and Clinical Course in Ischemic and Hemorrhagic Varieties

BACKGROUND AND PURPOSE The efficacy of superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis in adult moyamoya disease was evaluated by clinicopathophysiological studies. METHODS Fifteen patients with cerebral ischemic attacks (ischemia group) and 15 patients with intracranial hemorrhages (hemorrhage group) were investigated. Clinicoangiographic features and regional cerebral blood flow (rCBF) of the MCA territory were preoperatively and postoperatively investigated, and cortical arterial pressure (CAP) and anastomotic blood flow (AF) were intraoperatively measured. RESULTS In the ischemia group, the preoperative rCBF of 38.4 mL/100 g per minute was significantly increased to 42.1 mL/100 g per minute with a diminution of angiographic moyamoya vessels in 67% of patients after surgery. The mean CAP and AF were 25.6 mm Hg and 34.7 mL/min, respectively. Proximal and distal cerebral vascular resistance (PCVR = [Mean Systemic Arterial Blood Pressure-Mean CAP]/rCBF and DCVR = [Mean CAP/rCBF]) were 1.78 and 0.68, respectively. One patient died perioperatively as a result of intracerebral hemorrhage. During follow-up (mean, 67 months), 12 of 14 patients recovered without neurological deficits, 1 was moderately disabled because of the initial insult, and another patient experienced an intracerebral hemorrhage but recovered fully. In the hemorrhage group, the preoperative rCBF of 38.0 mL/100 g per minute was significantly increased to 42.7 mL/100 g per minute with a diminution of moyamoya vessels in 60% after surgery. The mean CAP and AF were 29.1 mm Hg and 24.1 mL/min, respectively. PCVR and DCVR were 1.72 and 0.77, respectively. One patient became hemiparetic because of perioperative intracerebral hemorrhage. During follow-up (mean, 94 months), 3 patients had fatal intracranial hemorrhages, 10 had good recoveries, and 2 had moderate disabilities. CONCLUSIONS This study revealed a high PCVR and a very low DCVR in both the ischemia and hemorrhage groups of patients. STA-MCA anastomosis partially normalized cerebral circulation and decreased moyamoya vessels but did not completely prevent rebleeding.

Carotid Imaging by Real-time B-mode Doppler in Cerebrovascular Disease

Clinical application of noninvasive imaging of the extracranial carotid arteries was compared using real-time B-time Doppler and angiography (including DSA). Two hundred eighty-nine ultrasonograms (152 patients) were performed. B-mode ultrasonography permitted the identification of several characteristic findings of plaques. There were several types of plaque: (1) homogeneous (2) heterogeneous (3) sonolucent (4) hyperchoic (5) others (skip plaques spotty plaque, etc.) Overall accuracy was 84.3% in 127 carotid arteries. Correlation between B-mode Doppler and angiography is relatively good, but accuracy in complete occlusion and/or severe stenosis was rather low. Even relatively small plaque was apt to be found by B-mode Doppler imaging. The noninvasive ultrasonography examination is very a useful method of evaluating carotid artery disease, especially, in older patients or in postoperative follow-up of carotid surgery.