Konzentrische Kontrastmittelaufnahme der Gefäßwände bei Moyamoya Erkrankung als Risikofaktor perioperativer Schlaganfälle bei revaskularisierenden Eingriffen

Concentric vessel-wall contrast enhancement (VW-CE) of the terminal carotid artery and its proximal branches is linked to disease activity and progression in Moyamoya angiopathy (MMA). In this study, the incidence of perioperative stroke during revascularization procedures was evaluated and correlated with the occurrence of concomitant VW-CE.

All previously untreated MMA patients with indicated bypass surgery who had preoperative MR imaging with contrast-enhanced T1 vessel-wall sequences to visualize a possible VW-CE were included. A perioperative stroke was detected by CT angiography and/or diffusion-weighted MRI sequences <48h postoperatively.

Of the 110 patients included (female-to-male ratio 2.7:1, median age 45.1 (16.6-69.2); n=157 (64.9%) direct EC-IC bypasses), a priori VW-CE was present in 67.3% of cases (mean time interval MRI to first surgery 86 days ±82). A perioperative stroke occurred in 5 patients in the primary revascularization procedure (stroke rate per bypass 2.1%), all of whom had a preoperative pathological VW-CE in the vascular segment corresponding to the stroke area (likelihood ratio: chi²=4.1, p=.0434; OR 5.8). 3 of these 5 patients (60%) suffered strokes in a vascular territory other than the revascularized one, also showing VW-CE as sign of disease activity. No other perioperative strokes occurred during subsequent revascularizations in the case of multistage procedures (n=38), such as ACA or PCA revascularization as second step.

Patients with preoperative VW-CE are at a higher risk of perioperative stroke at the time of first revascularization. This specifically applies to the vascular territory that is supplied by the vascular segment affected by VW-CE. To achieve an optimal outcome, vessel wall imaging must be performed when planning surgical revascularizations in Moyamoya patients. If VW-CE is found, strict perioperative monitoring of these high-risk patients must be performed to achieve the best results possible.