Issues in Revascularization Surgery for Elderly Patients with Moyamoya Disease

Abstract

Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis prevents cerebral ischemic attack by improving cerebral blood flow in patients with moyamoya disease (MMD). STA-MCA anastomosis is generally recommended for adult MMD patients with ischemic symptom, but its efficacy for elderly patients is unclear.
Among 144 consecutive cases with MMD undergoing STA-MCA anastomosis with pial synangiosis in 197 hemispheres, nine patients (10 hemispheres) were over 60 years old (mean 63.5 years old). The incidence of surgical complications including infarction and cerebral hyperperfusion (CHP) was compared to those of the patients under 60 years old.
In nine elderly patients undergoing revascularization surgery for 10 hemispheres, the incidence of symptomatic CHP was as high as 30% (3/10), and two of the three patients developed intracranial hemorrhage in the acute stage. One patient developed cerebral infarction at the remote area during the blood pressure lowering against CHP (10%, 1/10). The incidence of symptomatic hemorrhage due to CHP was significantly higher in elderly patients (20%, 2/10) compared to younger patients (1.6%, 3/187) (p＝0.0101). Regarding final outcome of elderly patients, seven patients showed improvement of modified Rankin Scale, and two temporarily deteriorated but recovered to the preoperative status three months after surgery.
Elderly patients with MMD may potentially have a higher risk of intracranial hemorrhage due to CHP compared to younger patients. Surgical indication should be carefully decided for elderly MMD patients, and intensive peri-operative management is essential to avoid surgical complications including CHP and ischemia.