Abstract
Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis prevents cerebral ischemic attack by improving cerebral blood flow in patients with moyamoya disease. Cerebral hyperperfusion (CHP) is a potential complication of STA-MCA anastomosis for moyamoya disease, but the optimal postoperative management has not been determined. To establish the optimal postoperative management protocol, we prospectively performed prophylactic blood pressure lowering during the acute stage after STA-MCA anastomosis for moyamoya disease.
N-isopropyl-p-[123I]iodoamphetamine single-photon emission computed tomography was performed 1 and 7 days after STA-MCA anastomosis on 59 hemispheres from 43 consecutive patients (aged 9–69, mean 33.4 years) with moyamoya disease, who were prospectively subjected to intensive blood pressure lowering (below 130 mmHg of systolic blood pressure) immediately after surgery. Then the incidence and the clinical presentation of symptomatic CHP were evaluated.
Systolic blood pressure the day after surgery was as low as 120.9 mmHg (mean) in this series. Symptomatic CHP was seen only in four patients with four surgeries (6.7%, 4/59), which was much lower than the incidence of CHP in the previous reports. Three patients suffered temporary focal neurological deterioration, and one patient manifested as symptomatic subarachnoid hemorrhage due to CHP. Symptomatic CHP was relieved in all patients without developing permanent neurological deficit due to CHP, while one patient with symptomatic subarachnoid hemorrhage had a cerebral infarction in the ipsilateral occipital lobe during the blood pressure lowering.
Prophylactic blood pressure lowering prevents symptomatic CHP after STA-MCA anastomosis in patients with moyamoya disease. Accurate diagnoses of CHP and blood pressure lowering, while considering the severity of hemodynamic compromise in the contralateral and/or remote areas, are essential for postoperative management of moyamoya disease.
