Analysis of middle cerebral artery blood flow in moyamoya disease and comparison of orthodromic and antidromic bypass

Abstract

Objective To analysis the middle cerebral artery (MCA) blood flow direction and compare the efficacy and safety of orthodromic and antidromic bypass. Methods Fifty cases with moyamoya disease (MMD) surgical treated in Huashan Hospital of Fudan University from June to December 2010 were enrolled in the study. MCA blood flow direction was analysed according to DSA and classified into two types (antegrade flow and reversed flow). The surgical procedure was superficial temporal artery (STA)⁃MCA bypass, combined with encephalo⁃duro⁃myo⁃synangiosis (EDMS) and dural subvolution. For the bypass procedure, when blood flow in donor and recipient artery was in same direction, the case would be classified into orthodromic bypass group (orthodromic group, 32 cases), otherwise as antidromic bypass group (antidromic group, 18 cases). Blood flow interference phenomenon on cortex surface detected by intraoperative indocyanine green angiography (ICGA), postoperative transient neurological dysfunction (TND) and ischemic stroke in postoperative 30 d. DSA data and Matsushima grading system were used to evaluate anastomotic patency and bypass blood perfusion area in mid⁃term follow⁃up (mean 7.31 months). Hemodynamic parameters such as peak systolic velocity (PSV), end diastolic velocity (EDV) and resistant index (RI) demonstrated by transcranial Doppler (TCD) in long⁃term follow⁃up (mean 39.72 months) were all documented and used to compare the safety and efficacy between 2 groups. Results Patency of all stomas were confirmed by ICGA. The orthodromic group demonstrated a lower rate of blood flow interference (χ2=4.668, P=0.031) and TND (χ2=6.630, P=0.010) compared with antidromic group. The incidence of ischemic stroke had no difference between 2 groups (χ2=0.177, P=0.674). In mid⁃term follow⁃up, DSA confirmed the patency of all stomas, and no difference in bypass blood perfusion area between 2 groups (χ2=0.613, P=0.434). During long⁃term follow⁃up, syndromic group showed higher PSV (t=3.599, P=0.001) and EDV (t=2.993, P=0.004), and lower RI (t=3.328, P=0.002) compared with antidromic group. Conclusions Orthodromic bypass may reduce the risk of watershed shift and TND in perioperative period, increase blood flow velocity and decrease RI in the bypass vessel in long⁃term follow⁃up.

Keywords

• moyamoya disease
• cerebral revascularization
• middle cerebral artery
• hemodynamics
• intraoperative complications
• postoperative complications