Incidental De-novo Cerebral Micro-hemorrhages are Predictive of Future Symptomatic Macro-hemorrhages after Surgical Revascularization in Moyamoya Disease. (16th November 2020)

• Record Type: Journal Article
• Authors: Li, Yiping; Steinberg, Gary K; Esene, Ignatius N; Bigder, Mark G; Mandel, Mauricio
• Is Part Of: Neurosurgery. Volume 67(2010)Supplement 1
• Publication Date: 2020-11-16
• Subjects: Nervous system -- Surgery -- Periodicals; 617.48005
• DOI: 10.1093/neuros/nyaa447_286
• Languages: English
• ISSNs: 0148-396X

Abstract

Abstract: INTRODUCTION: Patients with moyamoya disease who develop incidental cerebral microhemorrhages (CMHs) on MRI have higher risk of developing subsequent symptomatic repeat hemorrhages. METHODS: We retrospectively reviewed a prospectively managed departmental database of all patients presenting with HOMMD treated between 1987 and 2019. The search yielded 121 patients with adequate MRI follow-up for inclusion into the study. RESULTS: Forty-two pre-operative CMHs were identified in 18 patients (15) ranging from 1–8 lesions. Patients presenting with pre-operative CMH were more likely to develop de-novo CMH although there were no differences in clinical outcome or delayed repeat hemorrhage in these patients. On follow-up imaging 29 (69%) of the pre-operative CMHs resolved completely while 13 (31%) persisted with reduced intensity on susceptibility weighted imaging. Seven de-novo CHMs were identified in six patients (5%) on routine post-operative MRI at distinct locations from previous sites of hemorrhage or CMH. Symptomatic re-hemorrhage was confirmed radiographically in 15 patients (12%). Five (83%) of six patients with de-novo CMHs later suffered symptomatic repeat hemorrhage with four of five (80%) hemorrhages occurring at sites of previous CMH. On univariate and multivariate analysis, de-novo CMHs was the only significant variable predictive for developing repeat symptomatic hemorrhage ( P -value < .001). The median pre-operative mRS was two (range of mRS 1–5). After surgical revascularization and at last evaluation the median MRS was one (range of mRS 0–6) over a median follow-up period of 41.5 months (range 0.2-261 mos). Post-operatively, the median change in mRS was an improvement of one grade. On multivariate analysis, development of delayed repeat hemorrhage was prognostic for higher mRS and therefore poorer functional status while pre-operative function was predictive of long-term outcome ( P -value < .001). CONCLUSION: De-novo CMHs after surgical revascularization might serve as a radiographic biomarker for refractory disease and suggest these patients are at risk for future hemorrhage.