Exploration of the risk factor for infarction after revascularization in moyamoya disease

Figures & data

Figure 1. The flowchart of patient enrolled in this study.

Figure 2. A 62-year-old male with MMD who underwent left revascularization, MRI test showed infarction in the left corona radiata and basal ganglia, accompanied by local liquefaction (A: T1 sequence, B: T2 sequence, C: flair sequence, D: diffusion weighted imaging sequence). MMD: moyamoya disease; MRI: magnetic resonance imaging.

Table 1. Demographic and clinical characteristics of the 108 patients.

Characteristic	Value (%)
Gender
Male	56(51.85)
Female	52(48.15)
Age (mean ± SD; Y)	47.81 ± 12.88
Initial manifestation
Transient ischemic attack	22(20.37)
Infarction	61(56.48)
Hemorrhage	23(21.30)
Seizure	2(1.85)
Smoking history	26(24.07)
Drinking history	19(17.59)
Hypertension	38(35.16)
Diabetes	19(17.59)

Abbreviations: SD: standard deviation; Y: years.

Table 2. Univariate analysis of patients with or without new or expanded infarction.

		New or expanded infarction
Characteristic	All (n = 174)	Yes (n = 13)	No (n = 161)	p Value
Age(Y)	47.39 ± 12.79	50.15 ± 10.16	47.16 ± 12.98	.419^a
Gender				.387^b
Female	87	5	82
Male	87	8	79
Initial symptom				.121^c
Transient ischaemic attack	35	3	32
Infarction	96	8	88
hemorrhage	41	1	40
Seizure	2	1	1
Side of surgery				.260^b
Left	93	5	88
Right	81	8	73
Revascularization type				.884^c
Direct	17	1	16
Indirect	24	1	23
Combined	133	11	122
Smoking history				.928^b
Yes	45	4	41
No	129	9	120
Drinking history				.890^d
Yes	31	3	28
No	143	10	133
Hypertension				.992^d
Yes	60	5	55
No	114	8	106
Diabetes				.554^d
Yes	24	3	21
No	150	10	140
Cholesterol (mmol/L)	4.36 ± 1.22	3.97 ± 1.17	4.39 ± 1.22	.236^a
Triglyceride (mmol/L)	1.64 ± 1.09	1.53 ± 0.77	1.65 ± 1.11	.696^a
High-density lipoprotein (mmol/L)	1.07 ± 0.28	1.03 ± 0.21	1.07 ± 0.28	.597^a
Low-density lipoprotein (mmol/L)	2.65 ± 1.03	2.28 ± 1.07	2.68 ± 1.02	.170^a
Operative side Suzuki score				.773^b
≥ 4	87	6	81
< 4	87	7	80
Nonoperative side Suzuki score				.001^d*
≥ 4	44	9	35
< 4	130	4	126
PCA involvement				.004^d*
Yes	52	9	43
No	122	4	118
Revascularization history				.090^d
Yes	57	1	56
No	117	12	105
Preoperative use of antiplatelet agent				.662^b
Yes	97	8	89
No	77	5	72
Duration of surgery (min)	209.95 ± 40.63	222.23 ± 46.46	208.96 ± 40.12	.258^a
Duration of anaesthesia (min)	231.57 ± 40.16	245.62 ± 52.44	230.43 ± 38.99	.191^a
Intraoperative hypotension				.001^d*
Yes	29	7	22
No	145	6	139

Abbreviations: Y: years old; min: minutes; PCA: posterior cerebral artery; min: minute.

^a Unpaired two-tailed Welch’s t-test.

^b Pearson’s chi-squared test.

^c Fisher’s exact test.

^d Continuity correction.

* p < .05.

Table 3. Multivariate analyses for independent risk factors of new or expanded cerebral infarction.

Characteristic	Coefficient of regression	Standard error	Wald	p Value	OR (95% CI)
Intraoperative hypotension	1.687	0.658	6.571	.010*	5.404 (1.488–19.630)
PCA involvement	1.350	0.676	3.990	.046*	3.859 (1.026–14.519)
Higher Suzuki stage on the nonoperative side	1.735	0.673	6.657	.010*	5.670 (1. 517–21.188)
Conbination^a	−4.450	0.695	40.961	< .001*	0.012

Abbreviations: CI: confidence interval; PCA: posterior cerebral artery; OR: odds ratio.

^a Combination means considering the three mentioned factors together.

* p < .05.

Figure 3. ROC curves depicted the AUC of predictive equation. (A) ROC curves for Suzuki stage on the non-operative side, PCA involvement, and intraoperative hypotension. (B) The ROC curves for the predictive equation with combination of all the three factors. ROC: receiver operating characteristic; AUC: area under the ROC curve; PCA: posterior cerebral artery.

Table 4. Evaluation efficiency for the risk factors by ROC.

Factor	AUC	95% CI	p Value	Sensitivity (%)	Specificity (%)
Suzuki stage on the non-operative side	0.737	0.587–0.888	.004*	0.692	0.783
PCA involvement	0.713	0.562–0.863	.011*	0.692	0.733
Intraoperative hypotension	0.701	0.533–0.869	.016*	0.538	0.863
Constant^a	0.762	0.571–0.952	.002*	0.692	0.907

Abbreviations: ROC: receiver operating characteristic; AUC: area under the receiver operating characteristic curve; CI: confidence interval; PCA: posterior cerebral artery.

^aConstant means considering the three mentioned factors together.

* p < .05.

Table 5. Comparison of characteristics between patients with or without PCA involvement.

Characteristic	All (n = 174)	PCA involvement (n = 52)	PCA non-involvement (n = 122)	p Value
Age(Y)	47.39 ± 12.79	51.00 ± 10.22	45.89 ± 13.47	.016^a*
Gender				.320^b
Male	87	29	58
Female	87	23	64
Initial symptom				.610^c
Transient ischaemic attack	35	8	27
Infarction	96	30	66
hemorrhage	41	13	28
Seizure	2	1	1
Side of surgery				.792^b
Left	93	27	66
Right	81	25	56
Smoking history				< .001^b*
Yes	45	23	22
No	129	29	100
Drinking history				.013^b*
Yes	31	15	16
No	143	37	106
Hypertension				.981^b
Yes	60	18	42
No	114	34	80
Diabetes				.380^b
Yes	24	9	15
No	152	43	107
Cholesterol (mmol/L)	4.36 ± 1.22	4.22 ± 1.21	4.41 ± 1.22	.354^a
Triglyceride (mmol/L)	1.64 ± 1.09	1.72 ± 1.02	1.60 ± 1.11	.525^a
High-density lipoprotein (mmol/L)	1.07 ± 0.28	1.01 ± 0.26	1.09 ± 0.29	.112^a
Low-density lipoprotein (mmol/L)	2.65 ± 1.03	2.61 ± 1.04	2.67 ± 1.03	.724^a

Abbreviations: Y: years old; PCA: posterior cerebral artery.

^a Unpaired two-tailed Welch’s t-test.

^b Pearson’s chi-squared test.

^c Fisher’s exact test.

* p < .05.

Figure 4. The figure illustrated the mechanism of infarction remotely located from the anastomosis site in patients with MMD after revascularization. (A) The branch of MCA and their distal perfusion in patients with moyamoya disease. (B) The ideal hemodynamic condition after revascularization, which was, however, challenging to achieve. (C) and (D) The watershed shift after bypass, where (C) depicted the watershed shift proximally at the bifurcation, with partial perfusion still present in the remote site, while (D) showed the watershed shift at the bifurcation, with minimal and even no perfusion in the remote site. MMD: moyamoya disease; MCA: middle cerebral artery.

Data availability statement

All data are available without restriction by contacting Tao Sun or Hui Wang.