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Table of Contents    
EDITORIAL
Year : 2015  |  Volume : 63  |  Issue : 5  |  Page : 654-655

Outcome after revascularization surgery for moyamoya disease: An anesthesiologist’s perspective


Department of Anaesthesiology and Intensive Care, GB Pant Institute of Postgraduate Medical Education and Research, New Delhi, India

Date of Web Publication6-Oct-2015

Correspondence Address:
Pragati Ganjoo
Department of Anaesthesiology and Intensive Care, GB Pant Institute of Postgraduate Medical Education and Research, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.166578

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How to cite this article:
Ganjoo P. Outcome after revascularization surgery for moyamoya disease: An anesthesiologist’s perspective. Neurol India 2015;63:654-5

How to cite this URL:
Ganjoo P. Outcome after revascularization surgery for moyamoya disease: An anesthesiologist’s perspective. Neurol India [serial online] 2015 [cited 2019 Oct 23];63:654-5. Available from: http://www.neurologyindia.com/text.asp?2015/63/5/654/166578


Moyamoya disease (MMD) is a potentially devastating cerebrovascular disorder characterized by progressive narrowing or stenosis of the distal internal carotid arteries and proximal anterior and middle cerebral arteries, leading to extensive proliferation of penetrating arteries at the base of brain. Ischemic stroke, transient ischemic attack (TIA), intracranial hemorrhage, and seizures are among its grave manifestations; recurrent ischemic episodes lead to progressive neurological and cognitive decline in the affected patients.[1] Surgery is the treatment of choice and involves direct or indirect cerebral revascularization. Indirect revascularization options such as encephaloduroarteriosynangiosis (EDAS), encephaloduroarteriomyosynangiosis (EDAMS), and pial synangiosis are preferred in children, while a direct anastomosis procedure such as superficial temporal artery–middle cerebral artery (STA-MCA) bypass is usually performed in adults.[2]

The outcome of revascularization is impacted by the development of potentially serious perioperative complications such as ischemic stroke, hemorrhage, and postoperative neurological deterioration (POND). These, in turn, are determined by the severity of the underlying disease, type and course of the surgical procedure, and various anesthesia-related factors. History of multiple preoperative ischemic episodes (frequent TIAs), presence of hypodensity on computed tomography (CT) scan, and a high signal intensity on diffusion-weighted magnetic resonance imaging (MRI) are significantly associated with perioperative ischemic complications. Direct anastomosis, particularly a combined procedure such as STA-MCA bypass with EDAMS, is associated with fewer ischemic complications compared to indirect revascularization; minimizing brain retraction and sparing vital collaterals are helpful surgical measures.[3]

Ongoing research on this subject has led to the identification of certain risk factors for ischemia related to the use of anesthetic drugs and techniques. Two excellent reviews, including the most recent one by Chui et al., describe these potential risks and make recommendations for optimal anesthetic management that can help to improve the postsurgery outcome in patients with MMD.[4],[5] Anesthesia is directed toward maintaining a balance between cerebral oxygen supply and demand, that is, ensuring adequate cerebral blood flow (CBF) and perfusion pressure, and avoiding increases in cerebral oxygen consumption and intracranial pressure. There is insufficient evidence supporting the use of any particular anesthesia technique or drug; no significant difference in postoperative complications was observed with the use of either inhalational or total intravenous anesthesia techniques. Important preoperative concerns include control of seizures and hypertension, prevention of dehydration and anxiety, and management of anticoagulation, wherever required. Intraoperative monitoring of cerebral ischemia with an electroencephalogram may be useful during direct bypass surgery; however, there is no evidence that use of near-infrared spectroscopy, somatosensory-evoked potentials, and transcranial doppler (TCD) results in an improved outcome. Newer monitoring methods such as indocyanine green videoangiography and flow measurement with perivascular probes allow evaluation of graft patency and flow, and are considered reliable predictors of postoperative ischemia. Tight perioperative hemodynamic control is crucial in MMD as hypotension can cause graft thrombosis and hypertension can cause bleeding at the anastomotic site. Keeping the blood pressure (BP) within 10–20% of the preoperative baseline by maintaining hypervolemia, avoiding hyperosmotic drugs and hypotensive anesthesia, and promptly treating hypotension with vasoactive drugs is recommended. Hypercapnia, which can decrease blood flow to areas supplied by diseased vessels, as well as hypocapnia, which causes cerebral vasoconstriction and consequent cerebral ischemia, are to be avoided. Other intraoperative measures include maintaining a hematocrit of 30–42%, a slight hypervolemic state, and normothermia or mild hypothermia. The role of cerebral-protective techniques (e.g., hypothermia) or drugs (e.g., barbiturates/propofol) during temporary vessel occlusion is debatable. Smooth emergence from anesthesia with a good hemodynamic control is essential to prevent hemorrhagic complications and graft thrombosis; use of skull blocks provides better awakening and pain relief. Early neurological assessment; prompt management of pain, crying, seizures, and anemia; and early resumption of antiplatelet medications are important postoperative considerations. Hyperperfusion syndrome may develop after direct bypass in a previously underperfused cerebral vascular bed due to impaired cerebral autoregulation; cerebral hyperperfusion-related POND is reported in 17–38% of adult MMD patients. Keeping the BP below 120/80 mmHg and CBF monitoring with TCD and dynamic imaging are effective in preventing permanent neurological sequelae.[4],[5]

Due to a relatively lower prevalence of MMD in India, there are, as yet, insufficient patient data and few studies on this subject. In the current issue of this journal, Jagadevan et al., have reported four patients who developed new POND.[6] However, no anesthesia-related factors were found to be predictive of the adverse neurological outcome; a standardized anesthesia management protocol was used in all their patients. The presence of preexisting neurological deficits in three of these patients points toward the possible severe underlying diseases, while bilateral cerebral infarction and the death of one patient is attributable to extensive surgery. Though perioperative anemia and hypotension were observed in two patients, their contribution to the development of POND is not clear. Two more recently published retrospective studies assessing the impact of anesthesia factors on outcome in the Indian scenario also do not present any conclusive evidence.[7],[8] All the three studies emphasize the importance of an overall good anesthetic technique in preventing perioperative complications in MMD patients; owing to our own anesthesia experience with this disease, though limited, we also endorse this view. Prospective randomized trials are, however, necessary to clearly ascertain the impact of anesthesia-related factors on the outcome of revascularization in MMD.

 
  References Top

1.
Ghosh AK. Moyamoya disease presenting with acute subdural hemorrhage. Neurol India 2014;62:202-3.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Gosalakkal JA. Moyamoya disease: A review. Neurol India 2002;50:6-10.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Pandey P, Steinberg GK. Neurosurgical advances in the treatment of Moyamoya disease. Stroke 2011;42:3304-10.  Back to cited text no. 3
    
4.
Chui J, Manninen P, Sacho RH, Venkatraghavan L. Anesthetic management of patients undergoing intracranial bypass procedures. Anesth Analg 2015;120:193-203.  Back to cited text no. 4
    
5.
Parray T, Martin TW, Siddiqui S. Moyamoya disease: A review of the disease and anesthetic management. J Neurosurg Anesthesiol 2011;23:100-9.  Back to cited text no. 5
    
6.
Jagdevan S, Sriganesh K, Pandey P, Reddy M, Umamaheswara Rao GS. Anesthetic factors and outcome in children undergoing indirect revascularization procedure for moyamoya disease: An Indian perspective. Neurol India 2015;63:702-6.  Back to cited text no. 6
  Medknow Journal  
7.
Sharma VB, Prabhakar H, Rath GP, Bithal PK. Anaesthetic management of patients undergoing surgery for Moyamoya disease-our institutional experience. J Neuroanaesthesiol Crit Care 2014;1:131-6.  Back to cited text no. 7
  Medknow Journal  
8.
Samagh N, Bhagat H, Grover VK, Sahni N, Agarwal A, Gupta SK. Retrospective analysis of perioperative factors on outcome of patients undergoing surgery for Moyamoya disease. J Neurosci Rural Pract 2015;6:262-5.  Back to cited text no. 8
[PUBMED]  Medknow Journal  



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