Effects of different surgical modalities on the clinical outcome of patients with moyamoya disease: a prospective cohort study
Effects of different surgical modalities on the clinical outcome of patients with moyamoya disease: a prospective cohort study
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不同手术方式对烟雾病患者临床结局的影响：一项前瞻性队列研究
DOI：
10.3171/2016.12.jns162626
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发表时间：
2018-05-01
影响因子：
4.1
通讯作者：
Zhao, Jizong
中科院分区：
文献类型：
--
作者：
Deng, Xiaofeng;Gao, Faliang;Zhao, Jizong
目的：搭桥手术是烟雾病（MMD）最常见的治疗方法，但对于哪种手术方式最好存在争议。本研究的目的是评估烟雾病患者在接受不同手术方式后的临床结果。方法在这项前瞻性队列研究中筛选了2009年6月至2015年5月期间连续治疗的696例烟雾病患者。未接受血运重建手术和双侧半球接受不同手术方式的患者被排除在外。最后纳入529例观察至少12个月的患者：438例患者接受单侧手术，91例患者接受双侧手术。其中，241例患者接受了直接搭桥术（DB）；81、复合旁路（CB）；207，间接旁路（IB）。评估和比较手术组之间的三个临床结果：卒中复发事件、改良Rankin量表（mRS）评分和主要症状的改变。结果平均随访时间为40个月。随访期间卒中复发43例，其中出血15例，缺血26例（短暂性脑缺血发作19例，脑梗死7例），出血合并脑梗死2例。Kaplan-Meier分析显示，接受CB或DB的患者比接受IB的患者无缺血时间更长（p = 0.013）；不同手术方式无出血时间差异无统计学意义（p = 0.534）。495例（93.6%）患者获得良好的神经系统状态（mRS评分= 2），其中儿童（98.2%）明显多于成人（92.3%;p = 0.022）。手术方式与预后神经状态无显著相关（p = 0.860）。449例患者（84.9%）出现症状改善，儿童（93.0%）明显多于成人（82.7%,p = 0.006）。不同手术方式间差异无统计学意义（p = 0.548）。结论：CB和DB在预防缺血性卒中复发方面比IB更有效，然而，没有证据表明这3种手术方式在预防复发性出血方面有显著差异。
OBJECTIVE Bypass surgery is the most common treatment for moyamoya disease (MMD), but there is controversy over which surgical modality is best. The objective of this study was to evaluate the clinical outcome of patients with MMD after undergoing different surgical modalities.METHODS A series of 696 consecutive MMD patients treated between June 2009 and May 2015 were screened in this prospective cohort study. Patients who did not undergo revascularization surgeries and those who underwent different surgical modalities in bilateral hemispheres were excluded. Finally, 529 patients who were observed for at least 12 months were included: 438 patients underwent unilateral surgery, and 91 patients underwent bilateral surgery. Of these, 241 patients underwent direct bypass (DB); 81, a combined bypass (CB); and 207, an indirect bypass (IB). Three clinical outcomes were evaluated and compared between surgical groups: recurrent stroke events, modified Rankin Scale (mRS) scores, and change in the main symptoms.RESULTS The mean follow-up period was 40 months. During the follow-up period, recurrent stroke was observed in 43 patients, including 15 patients with hemorrhage, 26 patients with ischemia (transient ischemic attack in 19 patients and infarction in 7 patients), and 2 patients with both hemorrhage and cerebral infarction. Kaplan-Meier analysis showed that patients who underwent a CB or DB had a longer ischemia-free time than those who underwent IB (p = 0.013); however, there was no significant difference in the hemorrhage-free time between the different surgical modalities (p = 0.534). A good neurological status (mRS score = 2) was achieved in 495 patients (93.6%) and was significantly achieved by more children (98.2%) than adults (92.3%; p = 0.022). Surgical modalities were not significantly associated with outcome neurological status (p = 0.860). Moreover, improvement in symptoms was observed in 449 patients (84.9%) and was also significantly more common in children (93.0%) than in adults (82.7%; p = 0.006). No significant difference was observed between the different surgical modalities (p = 0.548).CONCLUSIONS CB and DB are more effective at preventing recurrent ischemic strokes than IB. However, there is no evidence that these 3 surgical modalities demonstrate significant differences in preventing recurrent hemorrhage.