Comparative Outcomes of Unilateral vs Bilateral Revascularization in Moyamoya Disease: A Multicenter Retrospective Study

Basel Musmar; Joanna M Roy; Hammam Abdalrazeq; Anand Kaul; Elias Atallah; Kareem El Naamani; Ching-Jen Chen; Roland Jabre; Hassan Saad; Jonathan A Grossberg; Adam A Dmytriw; Aman B Patel; Mirhojjat Khorasanizadeh; Christopher S Ogilvy; Ajith J Thomas; Andre Monteiro; Adnan Siddiqui; Gustavo M Cortez; Ricardo A Hanel; Guilherme Porto; Alejandro M Spiotta; Anthony J Piscopo; David M Hasan; Mohammad Ghorbani; Joshua Weinberg; Shahid M Nimjee; Kimon Bekelis; Mohamed M Salem; Jan-Karl Burkhardt; Akli Zetchi; Charles Matouk; Brian M Howard; Rosalind Lai; Rose Du; Rawad Abbas; Georgios S Sioutas; Abdelaziz Amllay; Alfredo Munoz; Nabeel A Herial; Stavropoula I Tjoumakaris; Michael Reid Gooch; Robert H Rosenwasser; Pascal Jabbour

doi:10.1227/neu.0000000000003243

Comparative Outcomes of Unilateral vs Bilateral Revascularization in Moyamoya Disease: A Multicenter Retrospective Study

Neurosurgery. 2024 Oct 28. doi: 10.1227/neu.0000000000003243. Online ahead of print.

Authors

Basel Musmar¹, Joanna M Roy¹, Hammam Abdalrazeq¹, Anand Kaul¹, Elias Atallah¹, Kareem El Naamani¹, Ching-Jen Chen², Roland Jabre¹, Hassan Saad³, Jonathan A Grossberg³, Adam A Dmytriw^{4

5}, Aman B Patel⁵, Mirhojjat Khorasanizadeh⁶, Christopher S Ogilvy⁶, Ajith J Thomas⁷, Andre Monteiro⁸, Adnan Siddiqui⁸, Gustavo M Cortez⁹, Ricardo A Hanel⁹, Guilherme Porto¹⁰, Alejandro M Spiotta¹⁰, Anthony J Piscopo¹¹, David M Hasan¹², Mohammad Ghorbani¹³, Joshua Weinberg¹⁴, Shahid M Nimjee¹⁴, Kimon Bekelis¹⁵, Mohamed M Salem¹⁶, Jan-Karl Burkhardt¹⁶, Akli Zetchi^{17

18}, Charles Matouk^{17

18}, Brian M Howard³, Rosalind Lai⁵, Rose Du⁵, Rawad Abbas¹, Georgios S Sioutas¹, Abdelaziz Amllay¹, Alfredo Munoz¹, Nabeel A Herial¹, Stavropoula I Tjoumakaris¹, Michael Reid Gooch¹, Robert H Rosenwasser¹, Pascal Jabbour¹

Affiliations

¹ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
² Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA.
³ Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.
⁴ Department of Medical Imaging, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada.
⁵ Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
⁶ Department of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.
⁷ Department of Neurological Surgery, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey, USA.
⁸ Department of Neurosurgery, University of New York at Buffalo, Buffalo, New York, USA.
⁹ Department of Neurosurgery, Lyerly Neurosurgery, Baptist Health System, Jacksonville, Jacksonville, Florida, USA.
¹⁰ Department of Neurosurgery and Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.
¹¹ Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, Iowa, USA.
¹² Department of Neurosurgery, Duke University, Durham, North Carolina, USA.
¹³ Department of Neurosurgery, Firoozgar Hospital, Tehran, Iran.
¹⁴ Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
¹⁵ Department of Neurosurgery, Good Samaritan Hospital Medical Center, Babylon, New York, USA.
¹⁶ Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA.
¹⁷ Department of Neurosurgery, Yale University, New Haven, Connecticut, USA.
¹⁸ Department of Neurosurgery and of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut, USA.

PMID: 39465938
DOI: 10.1227/neu.0000000000003243

Abstract

Background and objectives: Moyamoya disease (MMD) is characterized by progressive steno-occlusion of the internal carotid arteries, leading to compensatory collateral vessel formation. The optimal surgical approach for MMD remains debated, with bilateral revascularization potentially offering more comprehensive protection but involving more extensive surgery compared to unilateral revascularization. This study aims to compare bilateral revascularization and unilateral revascularization short-term safety profile in the treatment of MMD.

Methods: This multicenter retrospective study included patients with MMD who underwent surgical revascularization at 13 academic institutions. Patients were categorized into unilateral and bilateral revascularization groups. Data collected included demographics, clinical characteristics, and outcomes. Propensity score matching was used to balance baseline characteristics. Statistical analyses were conducted using Stata (V.17.0; StataCorp).

Results: A total of 497 patients were included, including 90 who had bilateral revascularization and 407 who had unilateral revascularization. Bilateral revascularization was associated with more perioperative asymptomatic strokes (10% vs 2.4%; odds ratio [OR] 4.41, 95% CI 1.73 to 11.19, P = .002) and higher rates of excellent functional outcomes (modified Rankin Scale 0-1) at discharge (92.2% vs 79.1%; OR 3.12, 95% CI 1.39 to 7, P = .006). After propensity score matching, 57 matched pairs were analyzed. There was a higher rate, though not statistically significant difference, of perioperative stroke in the bilateral revascularization group (15.7% vs 8.7%; OR 1.95, 95% CI 0.61 to 6.22, P = .26). No significant differences were noted in modified Rankin scale 0 to 1 and 0 to 2 scores at discharge, National Institute of Health Stroke Scale at discharge, intraoperative complications, or length of hospital stay. The follow-up stroke rates were also not significantly different (OR 0.40, 95% CI 0.11 to 1.39, P = .15).

Conclusion: This study found no significant differences between bilateral and unilateral revascularization in MMD. Patients who had bilateral revascularization had higher tendency of perioperative stroke, though not statistically significant. Further prospective studies are needed to validate these results.