Perioperative Practices in Moyamoya Syndrome Revascularization: An International Transdisciplinary Survey

Abstract

Background There are no evidence‐based resources guiding the perioperative management of patients with moyamoya syndrome who are undergoing revascularization surgery. We investigated practice patterns among a transdisciplinary group aiming at identifying possible heterogeneity of practices on key components of care that warrant prospective studies. Methods We disseminated a web‐based Qualtrics survey internationally to physician members of the following: Neurocritical Care Society, Society of Critical Care Medicine, American Academy of Neurology, Society for Neuroscience in Anesthesiology and Critical Care, American Association of Neurological Surgeons, Asian Society of Neuroanesthesia and Critical Care, Indian Society of Neuroanesthesia and Critical Care, Japanese Society for Neuroscience in Anesthesiology and Critical Care, and World Federation of Neurosurgical Societies. The survey contained questions on demographics and aspects of preoperative, intraoperative, and postoperative care. Results Among the 175 physicians who managed at least 1 adult (aged ≥18 years) undergoing moyamoya revascularization in the preceding 24 months, 18 countries (United States, 84.6%) and 4 disciplines (anesthesiology [44.7%, 76/170], critical care medicine [30.6%, 52/170], neurology [32.4%, 55/170], and neurosurgery [15.3%, 26/170]) were represented. Anesthesiologists preferred total intravenous over volatile anesthesia (56.3%, 40/71 versus 42.3%, 30/71) and arterial line zeroing at the circle of Willis/tragus over the phlebostatic axis/right atrium intraoperatively (84.3%, 59/70 versus 11.4%, 8/70) and postoperatively (68.9%, 42/61 versus 24.6%, 15/61). Intraoperative blood pressure goals were primarily targeted to baseline blood pressure (34.8%, 48/138), whereas postoperative blood pressure goals were mainly determined by neurosurgeon preference (48.9%, 65/133). The predominant hemodynamic target was mean arterial pressure intraoperatively (50.4%, 68/135) and systolic blood pressure postoperatively (48.5%, 63/130). Crystalloid infusion was the preferred method to achieve perioperative hemodynamic goals (median rank, 1.0), followed by colloid infusion (median rank, 2.0) and phenylephrine (median rank, 2.0); however, colloid infusion and phenylephrine were considered contraindicated by 18.2% (10/55) and 20.0% (11/55), respectively. Conclusions We demonstrate perioperative practice heterogeneity for moyamoya syndrome revascularization among physicians for both methods and targets of hemodynamic management, constituting equipoise for prospective studies targeting optimal management strategies.

Keywords

• cerebral revascularization
• hemodynamic monitoring
• moyamoya disease
• moyamoya syndrome
• neurocritical care
• perioperative