SEOUL NATIONAL UNIVERSITY HOSPITAL

Standard operation method is established for adult Moyamoya disease

Combined revascularization surgery has been revealed to be very effective in adult moyamoya disease with ischemic presentation.

The team of professors Jeong Eun Kim and Won-Sang Cho of Neurosurgery Department of Seoul National University Hospital (SNUH) has announced the world’s first long-term outcomes (at least 5 years) of 77 hemispheres in 60 patients which underwent combined revascularization surgery during the period from 2004 to 2008, in terms of clinical, hemodynamic, and radiological states.

This research has been published in the latest issue of Stroke, which is the most prominent international academic journal on cerebrovascular disease.

Moyamoya disease is an idiopathic and progressive occlusive disease of the cerebral vessels which provide blood to the brain. In severe cases, it is the cause of cerebral infarction (the status where the brain tissue suffers from lack of blood due to the narrowing of the brain blood vessel, which provides blood to the brain) or cerebral hemorrhage.

In patients with minor or no symptoms, medical management alone may suffice; however, in severe cases, operation is required. This study reveals that the patients who underwent combined revascularization surgery have annual incidence rates of 0.2% in cerebral infarction and 0.4% in cerebral hemorrhage. This numbers are much lower those of 241 patients who were conservatively managed in the same hospital, in which the annual incidence rate of cerebral infarction was 3% and that of cerebral hemorrhage was 4.3% (published in the latest issue of Journal of Neurosurgery).

The stroke-free survival rate of patients who received combined revascularization surgery was 98.7%, while that of patients for whom only the progression was monitored was 83%.

Considering that the symptoms were more severe in surgical group than in observation group, the superb effect of combined revascularization surgery is confirmed.

Professor Jeong Eum Kim stated that, “surgical treatment is well-known to be effective for pediatric patients; however, there has not been any long-term study on whether surgical treatment is effective for adult patients. This research reveals that combined revascularization surgery is very effective for adult moyamoya patients with ischemic presentation”.

Moyamoya disease is known to mainly occur in Asians such as Japanese, Chinese and Koreans. Affective age group is divided into children and adults. Most of pediatric patients present with the symptoms of ischemic stroke while adult patients show the symptoms of both hemorrhagic and ischemic strokes.

The following operation is implemented for the adult patients with severe symptoms.

Direct revascularization surgery is an operation in which blood vessel outside the cranium is directly connected to the blood vessel inside the cranium, which creates a bypass so that the blood can flow into the ischemic part of the brain. When cerebral blood flow (CBF) is scarce, it immediately increase the CBF. However, this operation is difficult for pediatric patients whose blood vessels are too small and the long operation time can be too strenuous. It can cause postoperative complications such as brain edema and brain hemorrhage.

Indirect revascularization surgery is to open the cranium and endocranium (the inner part of cranium that surrounds the brain) and place the blood vessel outside the cranium on the surface of the brain. This enables the new blood vessel slowly to grow into the brain, which pumps the blood into the ischemic part of the brain. This is normally operated on pediatric patients. Once the brain blood vessel is grown into the brain, it helps to consistently increase the CBF. The operation time is relatively short, however, its downside is that it takes at least a couple of months for the newly created blood vessels to take roots in the brain.

combined revascularization surgery is to combine the strengths of the two methods and use them in combination.