ИСТИНА

PURPOSE The aim of the study was to assess the outcomes of various methods of surgical revascularization of patients with MMD. MATERIALS AND METHODS From 2008 to 2018 in Burdenko Neurosurgical Institute 73 patients with MMD were observed. Among them there were 19 adults (aged 19-41 years, mean age 30,7) and 54 children (aged 2-17, mean age 7,4). Male/female ratio was 1:2,1. The clinical manifestations included those of ischemic strokes (56%), transient ischemic attacks (48%), epilepsy (19%), intracranial hemorrhage (12,3%) and headache (48%). Diagnostics were performed by subtraction angiography, MR- and CT-angiography, CT- and ASL-perfusion. The aim of the diagnostics was to determine the stage of the disease, to assess the angiographic characteristics of the donor and recipient vessels, the state of collateral circulation and the degree of cerebrovascular insufficiency. Surgical revascularization was performed in 54 patients: in 14 adults (18 sides) and 40 children (65 sides). Total number of operations was 82. Indirect revascularization was performed in 13 patients (25 sides), direct revascularization was performed in 13 patients (18 sides), and combined revascularization was performed in 28 patients (39 sides). Indirect revascularization was performed only in children of younger age and in 12 patients there was bilateral revascularization. Direct revascularization was performed in 11 adults and 2 children, among them – 5 bilateral revascularizations. Combined revascularization was performed in 24 children and 4 adults, 9 – bilateral revascularization. Follow-up period was 3-83 months (mean 20,6 months). RESULTS Indirect revascularization Immediate clinical improvement was not expected after indirect procedures, deterioration occurred in 12% of cases. Within 7 days of surgery TIAs were observed in 26 cases (38% of procedures), ischemic strokes occurred in 2 (7,6%). During follow-up period the improvement was seen in 70%, no improvement was seen in 15% and deterioration was seen in 15% of cases. Angiographic study was available in 12 of 13 patients, among them formation of extensive collateral vessels bilaterally was seen in 83% (n=10), unilaterally – in 8,5% (n=1), and no signs of collateral formation was seen in 8,5% of cases (n=1). The study of cerebral perfusion after the operation was available in 6 of 13 patients, among them improvement of the perfusion was seen in 3 patients, no improvement was seen in 3 patients. Direct revascularization In group of direct revascularization improvement of the symptoms immediately after the surgery was seen in 50% of cases, no improvement was seen in 50%. TIA within 7 days of surgery was seen in 1 case (5,5%), ischemic strokes were not observed in this group (0%). During follow-up period the improvement was seen in 83%, no improvement was seen in 17% of cases. Angiographic study was available in 8 of 13 patients, among them signs of functioning of anastomosis were seen in 7 patients. Combined revascularization In group of combined revascularization improvement of the symptoms immediately after the surgery was seen in 51% of cases, no improvement was seen in 43%, deterioration was seen in 6% of cases. Within 7 days of combined procedure surgery TIAs were observed in 8 cases (23% of procedures), ischemic stroke occurred in 1 (2,8%). During follow-up period the improvement was seen in 93%, no improvement was seen in 7% of cases. Angiographic and perfusion study was available in 14 of 26 patients, the signs of functioning of anastomoses were seen in 13 patients, among them the formation of extensive collateral vessels was seen in 6 patients. The improvement of perfusion was seen in 57%, no improvement was seen in 17% and deterioration was seen in 8% of cases. CONCLUSION Based on our experience combined revascularization is an optimal and effective method of treatment patients with Moyamoya Disease that shows good clinical outcome with acceptable level of complications and morbidity.