OBJECTIVE:Microsurgical approaches for intracranial aneurysms are more invasive than endovascular treatments and are associated with longer recovery periods and worse cosmetic outcomes. To reduce the significant surgical burden on patients, neurosurgeons have developed more refined techniques. In this study, headache rates and postoperative scar satisfaction were compared between standard pterional and minipterional craniotomies for anterior circulation aneurysm clipping. METHODS:A single-institution, mixed prospective and retrospective cohort study of patients treated by a single surgeon from 2018 to 2021 was conducted. Headache rate and severity were preoperatively and postoperatively measured with the Migraine Disability Assessment Test (MIDAS) and the Headache Impact Test (HIT-6). Secondary outcomes included cosmetic outcomes, assessed by the SCAR-Q questionnaire, and health function, measured by the 36-Item Short-Form Health Survey (SF-36) and the Patient Global Impression of Change (PGIC). RESULTS:Of the 36 patients enrolled (25 (69%) women, 11 (31%) men; mean age: 64.9 (range: 34-82) years), 21 underwent standard pterional craniotomy, and 15 underwent minipterional craniotomy. No significant difference was found in HIT-6 and MIDAS grade between approaches; however, a larger percentage of patients in the standard pterional group than in the minipterional group reported severe disability three months postoperatively. All standard-approach patients reported a moderate change in PGIC, but patients in the minipterional group reported the greatest improvement in clinical status. Both groups had similar postoperative headache rates. Patients in the minipterional group had significantly better outcomes for scar appearance than patients in the standard pterional group (p=0.03). CONCLUSION:The minipterional approach offered cosmetic advantages without worsening headache burden. Although the sample size and follow-up rates were limited, the results support this less invasive approach as a patient-centered alternative. This work highlights the importance of tailored treatment for brain lesions and offers insight into ways to achieve optimal patient outcomes.

INTRODUCTION: Microanastomosis is a complex surgical technique that demands delicate and coordinated hand movement. Advances in machine learning technology have enabled new methods to study human motion. Convolutional neural networks are algorithms specialized in visual tasks that enable discrete object detection and tracking including the hands of a surgeon. METHODS: A machine learning hand detector was developed using a pre-trained convolutional neural network capable of tracking 21 hand landmarks without sensors attached. En-to-side microanastomosis was simulated using 2 mm polyvinyl-alcohol vessels and 10/0 micro-suture and recorded with a video camera capturing hand movement in the surgical field. Participants (n = 4) were expert cerebrovascular surgeons with significant operative experience in cerebral bypass surgery. Calculation of motion of 14 hand joint angles was performed using a vectorization method from landmark detections. Time series analysis was performed to calculate the absolute angular motion for each joint of the hand. RESULTS: Four minutes of simulation for each surgeon yielded a total of 784.294 angular detections (14 hand joints total). For the dominant hand, the mean (SD) absolute angular motion was expert 1: 178.2 rad (98.3); expert 2: 261.8 rad (164.3); expert 3: 449.9 rad (307); expert 4: 380.1 rad (198.1).For the non-dominant hand, the mean (SD) absolute angular motion was expert 1: 132.9 rad (64.6), expert 2: 149.2 rad (72.3); expert 3: 389.2 rad (243); expert 4: 162.6 rad (87.2). CONCLUSIONS: A machine learning hand detector system can calculate hand joint motion during microvascular anastomosis. The absolute angular motion is a quantitative performance metric providing information about hand stability during microanastomosis simulation. Such studies using powerful artificial intelligence detection algorithms may have educational potential in the assessment of complex and delicate surgical skills and supervision of surgical training.

OBJECTIVE: Deep learning enables precise hand tracking without the need for physical sensors, allowing for unsupervised quantitative evaluation of surgical motion and tasks. We quantitatively assessed the hand motions of experienced cerebrovascular neurosurgeons during simulated microvascular anastomosis using deep learning. We explored the extent to which surgical motion data differed among experts. METHODS: A deep learning detection system tracked 21 landmarks corresponding to digit joints and the wrist on each hand of 5 expert cerebrovascular neurosurgeons. Tracking data for each surgeon were analyzed over long and short time intervals to examine gross movements and micromovements, respectively. Quantitative algorithms assessed the economy and flow of motion by calculating mean movement distances from the baseline median landmark coordinates and median times between sutures, respectively. RESULTS: Tracking data correlated with specific surgical actions observed in microanastomosis video analysis. Economy of motion during suturing was calculated as 19, 26, 29, 27, and 28 pixels for surgeons 1, 2, 3, 4, and 5, respectively. Flow of motion during microanastomosis was 31.96, 29.40, 28.90, 7.37, and 47.21 seconds for surgeons 1, 2, 3, 4, and 5, respectively. CONCLUSIONS: Hand tracking data showed similarities among experts, with low movements from baseline, minimal excess motion, and rhythmic suturing patterns. The data revealed unique patterns related to each expert's habits and techniques. The results showed that surgical motion can be correlated with hand motion and assessed using mathematical algorithms. We also demonstrated the feasibility and potential of deep learningebased motion detection to enhance surgical training.

BACKGROUND AND OBJECTIVES:Benchmarks represent the best possible outcome and help to improve outcomes for surgical procedures. However, global thresholds mirroring an optimal and reachable outcome for microsurgical clipping of unruptured intracranial aneurysms (UIA) are not available. This study aimed to define standardized outcome benchmarks in patients who underwent clipping of UIA. METHODS:A total of 2245 microsurgically treated UIA from 15 centers were analyzed. Patients were categorized into low- ("benchmark") and high-risk ("nonbenchmark") patients based on known factors affecting outcome. The benchmark was defined as the 75th percentile of all centers' median scores for a given outcome. Benchmark outcomes included intraoperative (eg, duration of surgery, blood transfusion), postoperative (eg, reoperation, neurological status), and aneurysm-related factors (eg, aneurysm occlusion). Benchmark cutoffs for aneurysms of the anterior communicating/anterior cerebral artery, middle cerebral artery, and posterior communicating artery were determined separately. RESULTS:Of the 2245 cases, 852 (37.9%) patients formed the benchmark cohort. Most operations were performed for middle cerebral artery aneurysms (53.6%), followed by anterior communicating and anterior cerebral artery aneurysms (25.2%). Based on the results of the benchmark cohort, the following benchmark cutoffs were established: favorable neurological outcome (modified Rankin scale ≤2) ≥95.9%, postoperative complication rate ≤20.7%, length of postoperative stay ≤7.7 days, asymptomatic stroke ≤3.6%, surgical site infection ≤2.7%, cerebral vasospasm ≤2.5%, new motor deficit ≤5.9%, aneurysm closure rate ≥97.1%, and at 1-year follow-up: aneurysm closure rate ≥98.0%. At 24 months, benchmark patients had a better score on the modified Rankin scale than nonbenchmark patients. CONCLUSION:This study presents internationally applicable benchmarks for clinically relevant outcomes after microsurgical clipping of UIA. These benchmark cutoffs can serve as reference values for other centers, patient registries, and for comparing the benefit of other interventions or novel surgical techniques.

OBJECTIVE Disparities in the epidemiology and growth rates of aneurysms between the sexes are known. However, little is known about sex-dependent outcomes after microsurgical clipping of unruptured intracranial aneurysms (UIAs). The aim of this study was to examine sex differences in characteristics and outcomes after microsurgical clipping of UIAs and to perform a propensity score–matched analysis using an international multicenter cohort. METHODS This retrospective cohort study involved the participation of 15 centers spanning four continents. It included adult patients who underwent clipping of UIAs between January 2016 and December 2020. Patients were stratified according to their sex and analyzed for differences in morbidities and aneurysm characteristics. Based on this stratification, female patients were matched to male patients in a 1:1 ratio with a caliper width of 0.1 using propensity score matching. Endpoints included postoperative complications, neurological performance, and aneurysm occlusion at discharge and 24 months after clip placement. RESULTS A total of 2245 patients with a mean age of 57.3 (range 20–87) years were included. Of these patients, 1675 (74.6%) were female. Female patients were significantly older (mean 57.6 vs 56.4 years, p = 0.03) but had fewer comorbidities. Aneurysms of the internal carotid artery (7.1% vs 4.2%), posterior communicating artery (6.9% vs 1.9%), and ophthalmic artery (6.0% vs 2.8%) were more commonly treated surgically in females, while clipping of aneurysms of the anterior communicating artery was more frequent in males (17.0% vs 25.3%; all p < 0.001). After propensity score matching, female patients were found to have had significantly fewer pulmonary complications (1.4% vs 4.2%, p = 0.01). However, general morbidity (24.5% vs 25.2%, p = 0.72) and mortality (0.5% vs 1.1%, p = 0.34), as well as neurological performance (p = 0.58), were comparable at discharge in both sexes. Lastly, rates of aneurysm occlusion at the time of discharge (95.5% vs 94.9%, p = 0.71) and 24 months after surgery (93.8% vs 96.1%, p = 0.22) did not significantly differ between male and female patients. CONCLUSIONS Despite overall differences between male and female patients in demographics, comorbidities, and treated aneurysm location, sex did not relevantly affect surgical performance or perioperative complication rates.

BACKGROUND AND OBJECTIVES:Microsurgical aneurysm repair by clipping continues to be highly important despite increasing endovascular treatment options, especially because of inferior occlusion rates. This study aimed to present current global microsurgical treatment practices and to identify risk factors for complications and neurological deterioration after clipping of unruptured anterior circulation aneurysms.METHODS:Fifteen centers from 4 continents participated in this retrospective cohort study. Consecutive patients who underwent elective microsurgical clipping of untreated unruptured intracranial aneurysm between January 2016 and December 2020 were included. Posterior circulation aneurysms were excluded. Outcome parameters were postsurgical complications and neurological deterioration (defined as decline on the modified Rankin Scale) at discharge and during follow-up. Multivariate regression analyses were performed adjusting for all described patient characteristics.RESULTS:Among a total of 2192 patients with anterior circulation aneurysm, complete occlusion of the treated aneurysm was achieved in 2089 (95.3%) patients at discharge. The occlusion rate remained stable (94.7%) during follow-up. Regression analysis identified hypertension (P < .02), aneurysm diameter (P < .001), neck diameter (P < .05), calcification (P < .01), and morphology (P = .002) as preexisting risk factors for postsurgical complications and neurological deterioration at discharge. Furthermore, intraoperative aneurysm rupture (odds ratio 2.863 [CI 1.606-5.104]; P < .01) and simultaneous clipping of more than 1 aneurysm (odds ratio 1.738 [CI 1.186-2.545]; P < .01) were shown to be associated with an increased risk of postsurgical complications. Yet, none of the surgical-related parameters had an impact on neurological deterioration. Analyzing volume-outcome relationship revealed comparable complication rates (P = .61) among all 15 participating centers.CONCLUSION:Our international, multicenter analysis presents current microsurgical treatment practices in patients with anterior circulation aneurysms and identifies preexisting and surgery-related risk factors for postoperative complications and neurological deterioration. These findings may assist in decision-making for the optimal therapeutic regimen of unruptured anterior circulation aneurysms.

Background: Glioblastoma is the most aggressive and common primary brain tumor. Patients usually present with a short clinical history that often includes focal neurological deficits. Historically 1- and 5-year survival of patients with this disease has been low. There are now increasing reports of patients living longer, making it important to understand the clinical progression of the disease to predict patient needs.Methods: Patients & GE; 18 years who were enrolled in the central nervous system (CNS) tumor registry at HonorHealth in Scottsdale, Arizona between April 7, 2017 and February 5, 2020 were included. Demographic data and data on adverse events were collected from the CNS tumor registry. The data was analyzed and reported as means and standard deviations.Results: 12 male and 7 female patients were included in the study. The average time to follow-up was 15.12 months and patients experienced the onset of psychiatric/neurological adverse events an average of 3.29 months after surgery, cardiovascular/respiratory adverse events 3.42 months after surgery, and general adverse events 3.71 months after surgery. Additionally, 63.2% of patients experienced a seizure with an average time to onset of 6.75 months after surgery.Conclusions: Patients with glioblastoma experience psychiatric/neurological adverse events first, followed by cardiovascular/respiratory adverse events, and finally followed by general adverse events. Most patients will experience at least one seizure.

Background: Hangman’s fractures comprise approximately 20% of C2 fractures and often require surgery to correct significant angulation and/or subluxation. Recently, anchored anterior cervical cages (ACCs) have been used to fuse C2-3 as they reduce the risks of soft-tissue dissection, bone drilling, operative time, and postoperative dysphagia. Methods: This single-center and retrospective study (2012–2019) included 12 patients (3 type I, 6 type II, and 3 type IIa fractures) undergoing C2-3 ACCs (zero profile, half plate, full plate). Preoperative and postoperative radiographic and clinical data were analyzed. Results: The 12 patients demonstrated the following findings: a mean operative time of 106 ± 21 min, blood loss averaging 67 ± 58 mL, and mean length of stay of 9.8 ± 7.7 days (6.4 ± 5.5 days in intensive care). The mean differences in preoperative versus postoperative radiographs showed an increase in disc angle (9.0° ± 9.4° vs. 14.0° ± 7.2°), reduction of subluxation (18.5% ± 13.6% vs. 2.6% ± 6.2%), and maintenance of C2-7 lordosis (14.3° ± 9.5° vs. 14.4° ± 9.5°). All patients demonstrated fusion on dynamic films obtained >6 months postoperatively. In addition, only one patient had Grade 0 subsidence, three had transient postoperative dysphagia, whereas none had either intraoperative complications or 90-day readmissions. Conclusion: ACCs proved to be a viable alternative to traditional anterior cervical discectomy/fusion to treat 12 patients with C2-3 hangman’s fractures in this preliminary study.

-OBJECTIVE: The main treatment for moyamoya disease (MMD) is revascularization surgery. Most bypasses use the superficial temporal artery (STA) as the donor vessel. However, even if the STAemiddle cerebral artery (MCA) bypass is functioning, the affected hemisphere can continue to be symptomatically malperfused. We sought to assess the efficacy of salvage direct revascularization surgery using the occipital artery (OA) as a donor vessel in patients with ischemic MMD who experience continued cerebral malperfusion despite previous successful STA-MCA bypass.-METHODS: We retrospectively analyzed the cerebro-vascular databases of 2 surgeons and described patients in whom the OA was used as the donor vessel for direct revascularization.-RESULTS: Seven patients were included (5 women). Previous STA-MCA bypasses were direct (n = 2), indirect (n = 3), or combined/multiple (n = 2). The mean (SD) interval between STA-MCA and OA-MCA procedures was 29.2 (13.1) months. Despite an intact STA-MCA bypass in all 7 cases, all 7 patients had recurrent symptoms and demonstrated residual impaired cerebral perfusion. All 7 patients underwent successful OA-MCA direct revascularization. Follow-up perfusion imaging was obtained for 6 of 7 patients. All 6 of these patients demonstrated improved cerebral blood flow to the revascularized hemispheres. All 7 patients demonstrated clinical improvement.-CONCLUSIONS: Patients with ischemic MMD who have continued symptoms and cerebral malperfusion despite previous successful STA-MCA bypass present a challenging clinical scenario. Our series highlights the potential utility of the OA-MCA direct bypass as a salvage therapy for these patients.

RationaleThe etiology and pathophysiological mechanisms of moyamoya angiopathy (MMA) remain largely unknown. MMA is a progressive, occlusive cerebrovascular disorder characterized by recurrent ischemic and hemorrhagic strokes; with compensatory formation of an abnormal network of perforating blood vessels that creates a collateral circulation; and by aberrant angiogenesis at the base of the brain. Imbalance of angiogenic and vasculogenic mechanisms has been proposed as a potential cause of MMA. Moyamoya vessels suggest that aberrant angiogenic, arteriogenic, and vasculogenic processes may be involved in the pathophysiology of MMA. Circulating endothelial progenitor cells have been hypothesized to contribute to vascular remodeling in MMA. MMA is associated with increased expression of angiogenic factors and proinflammatory molecules. Systemic inflammation may be related to MMA pathogenesis. ObjectiveThis literature review describes the molecular mechanisms associated with cerebrovascular dysfunction, aberrant angiogenesis, and inflammation in MMA and related cerebrovascular diseases along with treatment strategies and future research perspectives. Methods and resultsReferences were identified through a systematic computerized search of the medical literature from January 1, 1983, through July 29, 2022, using the PubMed, EMBASE, BIOSIS Previews, CNKI, ISI web of science, and Medline databases and various combinations of the keywords "moyamoya," "angiogenesis," "anastomotic network," "molecular mechanism," "physiology," "pathophysiology," "pathogenesis," "biomarker," "genetics," "signaling pathway," "blood-brain barrier," "endothelial progenitor cells," "endothelial function," "inflammation," "intracranial hemorrhage," and "stroke." Relevant articles and supplemental basic science articles almost exclusively published in English were included. Review of the reference lists of relevant publications for additional sources resulted in 350 publications which met the study inclusion criteria. Detection of growth factors, chemokines, and cytokines in MMA patients suggests the hypothesis of aberrant angiogenesis being involved in MMA pathogenesis. It remains to be ascertained whether these findings are consequences of MMA or are etiological factors of MMA. ConclusionsMMA is a heterogeneous disorder, comprising various genotypes and phenotypes, with a complex pathophysiology. Additional research may advance our understanding of the pathophysiology involved in aberrant angiogenesis, arterial stenosis, and the formation of moyamoya collaterals and anastomotic networks. Future research will benefit from researching molecular pathophysiologic mechanisms and the correlation of clinical and basic research results.

Moyamoya disease (MMD) and moyamoya syndrome (MMS) are progressive vascular pathologies unique to the cerebrovasculature that are important causes of stroke in both children and adults. The natural history of MMD is characterized by primary progressive stenosis of the supraclinoid internal carotid artery, followed by the formation of fragile collateral vascular networks. In MMS, stenosis and collateralization occur in patients with an associated disease or condition. The pathological features of the stenosis associated with MMD include neointimal hyperplasia, disruption of the internal elastic lamina, and medial attenuation, which ultimately lead to progressive decreases in both luminal and external arterial diameter. Several molecular pathways have been implicated in the pathophysiology of stenosis in MMD with functions in cellular proliferation and migration, extracellular matrix remodeling, apoptosis, and vascular inflammation. Importantly, several of these molecular pathways overlap with those known to contribute to diseases of systemic arterial stenosis, such as atherosclerosis and fibromuscular dysplasia (FMD). Despite these possible shared mechanisms of stenosis, the contrast of MMD with other stenotic pathologies highlights the central questions underlying its pathogenesis. These questions include why the stenosis that is associated with MMD occurs in such a specific and limited anatomic location and what process initiates this stenosis. Further investigation of these questions is critical to developing an understanding of MMD that may lead to disease-modifying medical therapies. This review may be of interest to scientists, neurosurgeons, and neurologists involved in both moyamoya research and treatment and provides a review of pathophysiologic processes relevant to diseases of arterial stenosis on a broader scale.

RATIONALE:This literature review describes the pathophysiological mechanisms of the current classes of proteins, cells, genes, and signaling pathways relevant to moyamoya angiopathy (MA), along with future research directions and implementation of current knowledge in clinical practice. OBJECTIVE:This article is intended for physicians diagnosing, treating, and researching MA. METHODS AND RESULTS:References were identified using a PubMed/Medline systematic computerized search of the medical literature from January 1, 1957, through August 4, 2020, conducted by the authors, using the key words and various combinations of the key words "moyamoya disease," "moyamoya syndrome," "biomarker," "proteome," "genetics," "stroke," "angiogenesis," "cerebral arteriopathy," "pathophysiology," and "etiology." Relevant articles and supplemental basic science articles published in English were included. Intimal hyperplasia, medial thinning, irregular elastic lamina, and creation of moyamoya vessels are the end pathologies of many distinct molecular and genetic processes. Currently, 8 primary classes of proteins are implicated in the pathophysiology of MA: gene-mutation products, enzymes, growth factors, transcription factors, adhesion molecules, inflammatory/coagulation peptides, immune-related factors, and novel biomarker candidate proteins. We anticipate that this article will need to be updated in 5 years. CONCLUSION:It is increasingly apparent that MA encompasses a variety of distinct pathophysiologic conditions. Continued research into biomarkers, genetics, and signaling pathways associated with MA will improve and refine our understanding of moyamoya's complex pathophysiology. Future efforts will benefit from multicenter studies, family-based analyses, comparative trials, and close collaboration between the clinical setting and laboratory research.

BACKGROUND: Indications for reconstruction of the common carotid artery (CCA) include trauma, iatrogenic injury, neoplastic growth (such as invasive neck carcinomas), postoperative infection, and cervical carotid aneurysm. Although various techniques and conduits have been described, the clinical scenario may preclude the use of the most commonly used grafts. We describe a case using a superficial femoral artery (SFA) interposition graft to repair the CCA and review the available literature, highlighting the feasibility of this technique for carotid artery reconstruction. CASE DESCRIPTION: A patient aged 51 years presented with a ruptured mycotic CCA pseudoaneurysm that developed in the setting of a pharyngeal-carotid fistula. Because of the presence of a pharyngeal-carotid fistula and active infection within the vessel wall, endovascular treatment of the pseudoaneurysm was not feasible, and open surgical correction was required to repair the fistulous connection. Furthermore, owing to the extensive soft tissue infection, the use of a synthetic or venous autograft conduit for repair of the artery was contraindicated. Therefore, we harvested a segment of the SFA and used it as an interposition graft to reconstruct the diseased CCA, achieving an excellent anatomic and clinical result. CONCLUSIONS: This case highlights the feasibility of using an SFA interposition graft for short-segment CCA reconstruction, which can provide significant utility in the setting of a hostile operative field due to prior infection or radiation.

ABBREVIATIONS BRAT = Barrow Ruptured Aneurysm Trial; ICG = indocyanine green; ISAT = International Subarachnoid Aneurysm Trial.

BACKGROUND:Surgical revascularization for adults with moyamoya disease (MD) includes direct, indirect, or combination bypasses. It is unclear which provides the best outcomes. We sought to determine the best surgical management for adults with MD by comparing perioperative complications and long-term outcomes among 3 bypass types. METHODS:Literature databases were searched for articles reporting revascularization bypass outcomes for adults with MD. A pooled analysis of all qualified studies and meta-analysis using only studies reporting direct comparisons of 2 bypass types were performed. Overall odds ratios (ORs) comparing 2 bypass types were computed and publication bias was assessed. Rates of perioperative and long-term hemorrhage and ischemia and favorable outcomes were compared. RESULTS:Forty-seven studies were analyzed; 8 had level 1 or 2 evidence. Pooled analyses showed that perioperative hemorrhage rates were significantly (P = 0.02) lower with indirect compared with direct (OR, 0.03; 95% confidence interval [CI], 0.002-0.55) or combined (OR, 0.03; 95% CI, 0.002-0.53) bypasses. Meta-analysis showed that direct bypass was better at preventing long-term hemorrhage than was indirect bypass (OR, 0.26; 95% CI, 0.09-0.79; P = 0.02). Pooled analyses showed that direct is significantly better (P < 0.01) than indirect (OR, 0.51; 95% CI, 0.33-0.77) and combined (OR, 0.47; 95% CI, 0.31-0.72) bypasses in preventing long-term ischemia. Meta-analysis showed that direct was better than indirect bypass in producing long-term favorable outcomes (OR, 2.62; 95% CI, 1.19-5.79; P = 0.02), and the pooled analysis showed that combined bypass was better than indirect bypass in producing long-term favorable outcomes (OR, 1.26; 95% CI, 1.03-1.54; P = 0.02). CONCLUSIONS:Overall, our analyses suggest that direct bypass with or without indirect augmentation provides the best outcomes for adults with MD.

BACKGROUND: In 3% L15% of patients with moyamoya disease, aneurysms occur throughout the circle of Willis. In moyamoya patients treated with a superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass, treatment of a new or an enlarging aneurysm can be complicated by the presence of the bypass and by limitations on the use of standard frontotemporal craniotomies to gain access to the aneurysm. Furthermore, endovascular access can be limited by the presence of fragile moyamoya vessels and precluded by atresia of large vessels.CASE DESCRIPTION: A 45-year-old female patient with a history of moyamoya disease and previous left STA-MCA bypass presented with an enlarging left superior cerebellar artery aneurysm. We used a keyhole supraorbital craniotomy as a minimally invasive route to treat this aneurysm of the circle of Willis, with minimal interruption to the existing bypass or collateral circulation.CONCLUSIONS: In patients with moyamoya disease who have existing STA-MCA bypass and de novo or expanding aneurysms, treatment is fraught with challenges. We advocate the use of a minimally invasive keyhole supraorbital craniotomy with an eyebrow incision for aneurysms associated with moyamoya disease occurring on the proximal anterior cerebral and middle cerebral arteries, the anterior communicating artery, the basilar apex, the posterior communicating artery, the proximal superior cerebellar artery, and the posterior cerebral artery.

BACKGROUND: Moyamoya angiopathy most often manifests in patients in the second and third decades of life. Although uncommon, it can also manifest later in life. We present our results in patients >50 years old with moyamoya angiopathy who were treated with surgical revascularization via either direct bypass or indirect bypass (encephaloduroarteriosynangiosis).METHODS: A retrospective review was conducted to identify patients with moyamoya disease who were treated with surgical revascularization at our institution between 2002 and 2015. Outcomes and complications were analyzed.RESULTS: We identified 33 patients with moyamoya angiopathy >50 years old (mean age 59.0 years +/- 7.6) who were treated with surgical revascularization of 45 affected hemispheres. Of the affected hemispheres, 27 (60%) were treated with indirect bypasses and 18 (40%) were treated with direct bypasses. Neurologic complications occurred in 4 (12%) patients. The mean length of follow-up was 18.7 months +/- 18.6; 4 patients were lost to follow-up. At last follow-up, 11 of 18 (61%) direct bypasses were patent. Treatment failed in 5 of 45 (11%) treated hemispheres (stroke in 2 and persistent transient ischemic attacks in 3). In terms of functional outcome at last follow-up, 16 of 29 (55%) patients were the same as before surgery, 10 (35%) were better, and 3 (10%) were worse (including 1 death).CONCLUSIONS: Although uncommon, moyamoya angiopathy can manifest in older adults. Surgical revascularization is a reasonable treatment option with good functional outcomes and an acceptable complication rate.

BACKGROUND:Recent studies have questioned the utility of surgical resection of unruptured brain arteriovenous malformations (bAVMs). OBJECTIVE:We performed an assessment of outcomes and complications of surgical resection of low-grade bAVMs (Spetzler-Martin grade I or II) at a single high-volume neurosurgical center. METHODS:We reviewed all unruptured low-grade bAVMs treated with surgery (with or without preoperative embolization) between January 2004 and January 2014. Stroke rate, mortality, and clinical and radiographic outcomes were examined. RESULTS:Of 95 patients treated surgically, 85 (25 grade I, 60 grade II) met inclusion criteria, and all achieved radiographic cure postoperatively. Ten patients (11.8%) were lost to follow-up; the mean follow-up of the remaining 85 was 3.3 years. Three patients (3.5%) with grade II bAVMs experienced a stroke; no patients died. Although 20 patients (23.5%) had temporary postoperative neurological deficit, only 3 (3.5%) had new clinical impairment (modified Rankin Scale score ≥2) at last follow-up. Eight of the 13 patients (61.5%) with preexisting clinical impairment had improved modified Rankin Scale scores of 0 or 1; and 17 of 30 patients (56.7%) with preoperative seizures were seizure-free without antiepileptic medication postoperatively. No significant differences existed in stroke rate or clinical outcome between grades I and II patients at follow-up (Fisher exact test, P = .55 and P > .99, respectively). CONCLUSION:Surgical resection of low-grade unruptured bAVMs is safe, with a high rate of improvement in functional status and seizure reduction. Although transient postoperative neurological deficit was observed in some patients, permanent treatment-related neurological morbidity was rare. ABBREVIATIONS:ARUBA, A Randomized Trial of Unruptured Brain Arteriovenous MalformationsbAVM, brain arteriovenous malformationmRS, modified Rankin Scale.