Establishment of collateral circulation in patients with moyamoya disease after combined revascularization

Objective To observe the establishment of postoperative collateral circulation and its types after the combined revascularization for the treatment of patients with moyamoya disease. Methods From January 2010 to January 2015, 57 patients with moyamoya disease (67 hemispheres) treated with direct vascular reconstruction (superficial temporal artery-middle cerebral artery anastomosis, STA-MCA) combined with indirect vascular reconstruction (encephalo-duro-myo-synangiosis, EDMS) at the Department of Neurosurgery, Brain Hospital Affiliated to Nanjing Medical University were analyzed retrospectively. Head CT or MR perfusion imaging was use to evaluate cerebral blood flow. According to the digital subtraction angiography (DSA) images, the establishment of collateral circulation after procedure (the cerebral hemisphere blood supply range) was evaluated. The blood supply range of revascularization of 2 surgical methods after procedure was compared. Results The postoperative follow-up was 6-60 months (mean, 23±12 months). At 6 months after procedure, 60 (89.6%) of 67 hemispheres showed increased cerebral blood flow perfusion on the operated sides. The direct vascular anastomosis was patent in 65 sides (97.0%). DSA showed that the feeding range of neovascularization in patients ≥1/3 of the middle cerebral artery (MCA) blood supply region accounted for 97.0% (65 sides), among them, in patients >2/3 blood supply region accounted for 82.1% (55 sides). The neovascularization was sparse only in 2 sides, and the blood supply range the indirect one; and 23 sides (34.3%) were < the indirect revascularization blood supply range; and 25 sides (37.3%) were equal to the indirect revascularization blood supply range. At 6 months after procedure, there was no significant difference in the establishment of collateral circulation between the patients with ischemic and hemorrhagic moyamoya disease. Conclusions The effect of the direct revascularization combined with the indirect revascularization for the treatment of revascularization of moyamoya disease is better. The direct revascularization may immediately improve the cerebral perfusion in ischemic area, while the indirect revascularization may provide a more lasting effect of revascularization. Key words: Moyamoya disease; Cerebral revascularization; Collateral circulation