Intracranial Hemorrhage After Superficial Temporal Artery-Middle Cerebral Artery Direct Anastomosis for Adults with Moyamoya Disease.

Background: Intracranial hemorrhage, such as intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and intraventricular hemorrhage (IVH), is an extremely rare complication after surgical revascularization for moyamoya disease (MMD). However, the incidence, timing, prognosis, possible mechanism, and prevention are not well known.

Methods: Adult patients with MMD who underwent direct bypass or combined bypass and experienced ICH, SAH, or IVH within 7 days postoperatively were enrolled in this study. The medical records and radiologic findings of these patients, together with their intraoperative video recordings, were reviewed retrospectively.

Results: Direct superficial temporal artery (STA)-middle cerebral artery (MCA) bypass or combined bypass was performed for 222 hemispheres in 193 adult patients with MMD between January 2001 and December 2016. Intracranial hemorrhage occurred perioperatively in 8 hemispheres (3.6%) in 8 patients. The hemorrhages developed immediately after STA-MCA direct anastomosis during surgery in 3 patients. Hemorrhage on computed tomography and neurologic deterioration were also observed immediately postoperatively in 2 patients and during the postoperative period in 3 patients. Although 4 patients received medical management, neurosurgical treatment was needed in the other 4 patients. One patient died, and 6 patients were left with moderate or severe disabilities.

Conclusions: Intracranial hemorrhage (ICH, IVH, or SAH) after direct bypass for adult patients with MMD is an extremely rare but fatal complication. Although these hemorrhages can be associated with hyperperfusion syndrome, no effective prevention has been established.