Importance: Moyamoya disease (MMD) is a rare chronic cerebrovascular disease, and the outcomes of bypass management in adult patients remain controversial.Objective: To categorize adult MMD based on asymptomatic, ischemic, and hemorrhagic onset and compare the outcomes (death, hemorrhagic stroke [HS], and ischemic stroke [IS]) of bypass surgery (direct or indirect) with those of conservative management.Design, Setting, and Participants: This retrospective, nationwide, population-based longitudinal cohort study used Korean National Health Insurance Research data to identify adults (aged ≥15 years) with MMD who were diagnosed between January 1, 2008, and December 31, 2020, and followed up until December 31, 2021 (median follow-up, 5.74 [IQR, 2.95-9.42] years). A total of 19 700 participants (3194 with hemorrhagic, 517 with ischemic, and 15 989 with asymptomatic MMD) were included. Data were analyzed from January 2 to April 1, 2023.Exposures: Bypass surgery and conservative management.Main Outcomes and Measures: Death constituted the primary outcome; secondary outcomes consisted of HS or IS. Kaplan-Meier survival curve and Cox proportional hazards regression analysis were applied. The propensity score–matching and stratified analyses were performed to control covariate effects.Results: A total of 19 700 patients (mean [SD] age, 45.43 [14.98] years; 12 766 [64.8%] female) were included. Compared with conservative management, bypass was associated with a reduced risk of death (adjusted hazard ratio [AHR], 0.50 [95% CI, 0.41-0.61]; P < .001) and HS (AHR, 0.36 [0.30-0.40]; P < .001) in hemorrhagic MMD; reduced risk of IS (AHR, 0.55 [95% CI, 0.37-0.81]; P = .002) in ischemic MMD; and reduced risk of death (AHR, 0.74 [95% CI, 0.66-0.84]; P < .001) in asymptomatic MMD. However, bypass was associated with an increased risk of HS (AHR, 1.76 [95% CI, 1.56-2.00]; P < .001) in asymptomatic MMD. Both direct and indirect bypass demonstrated similar effects in hemorrhagic and asymptomatic MMD, except only direct bypass was associated with a reduced risk of IS (AHR, 0.52 [95% CI, 0.33- 0.83]; P = .01) in ischemic MMD. After stratification, bypass was associated with a reduced risk of death in patients younger than 55 years with ischemic (AHR, 0.34 [95% CI, 0.13- 0.88]; P = .03) and asymptomatic (AHR, 0.69 [95% CI, 0.60-0.79]; P < .001) MMD, but an increased risk of HS in patients 55 years or older with ischemic MMD (AHR, 2.13 [95% CI, 1.1-4.16]; P = .03).Conclusions and Relevance: The findings of this cohort study of bypass outcomes for patients with MMD emphasize the importance of tailoring management strategies in adult patients based on onset types.

The aim of this study was to evaluate the clinical outcomes between endovascular treatment (EVT) and surgery of the ruptured posterior inferior cerebellar artery (PICA) aneurysms and suggest proper management strategies according to the PICA segment. We retrospectively analyzed clinical and radiological data of patients with ruptured PICA aneurysms who underwent surgery or EVT from three different institutes. Clinical outcomes were evaluated by mRS. We collected 39 consecutive patients with 39 ruptured PICA aneurysms; 26 patients were with proximal segment aneurysm and 13 patients were with distal. Of the 26 proximal PICA aneurysms, 20 aneurysms were treated with EVT and 6 aneurysms were treated with surgery. EVT seemed to have more favorable clinical outcome (mRS 0-2; mean mRS, 1.75 for EVT vs 3.50 for surgery, P = 0.152). Of the 13 distal PICA aneurysms, 7 aneurysms were treated with EVT and 6 were treated with surgery. Surgery showed more favorable clinical outcome (mean mRS, 2.63 for EVT vs 0.33 for surgery, P = 0.023) and lower procedure-related complication rate (42.9% for EVT vs 0% for surgery, P = 0.046) than EVT. For the treatment of ruptured PICA aneurysms, EVT seemed to have more favorable outcomes for proximal segment, while surgery showed more favorable outcomes for distal segment. Additional experience and follow-up are needed in a larger series to state the efficacy of this strategy.

Background: Patients with aortic disease (AD) might have a higher prevalence of intracranial aneurysm (IA). The present study evaluated the prevalence of IA in patients with AD and identified potential risk factors of IA using nationwide representative cohort sample data. Methods and Results: We defined AD as both aortic dissections and aortic aneurysms. This study used a nationwide representative cohort sample from the Korea National Health Insurance Service–National Sample Cohort database from 1.1million patients. Using χ ² or Fisher’s exact tests, the prevalence of the IA in patients with AD and potential risk factors for their concurrence were analyzed. The prevalence of IA in patients with AD was 6.8% (155/2285). The adjusted odds ratios (OR) for having concurrent IA in patients with AD was 3.809 (95% CI, 3.191–4.546; P 19 times more likely to be affected by IA (adjusted OR, 18.679; 95% CI, 16.555–21.076; P 60 years), and male sex were >4, 3, and 2 times more likely to be affected by IA, respectively (adjusted OR, 4.291, 3.469, and 1.983, respectively; 95% CI, 3.914–4.704, 3.152–3.878, and 1.779–2.112, respectively). Subgroup analysis with socioeconomic status or disability revealed that the prevalence of IA was significantly higher in all groups. Conclusions: In the current population‐based study, the prevalence of IA in patients with AD was quadrupled compared with that in the general population. Early IA screening might be considered among patients with AD for appropriate management.

Kim YN, et al. Korean J Radiol. 2022 Feb;23(2):246-255. https://doi.org/10.3348/kjr.2021.0332

Background: In the treatment of unruptured intracranial aneurysms, the risk was usually estimated by objective neurological sequelae. However, their effects on depression and anxiety are rare and remain controversial. We aimed to evaluate the risk of depression and anxiety in patients with unruptured intracranial aneurysm stratified by management strategies in a population-based, longitudinal cohort study. Methods: Using the Korean National Health Insurance Research Database, 71 750 patients with unruptured intracranial aneurysms between 2008 and 2011 were identified and followed up until the end of 2020. The risk of depression and anxiety was compared among management strategies with respect to age, sex, and medical comorbidities. Results: The Kaplan-Meier survival curves indicated that the treatment (clipping and endovascular treatment) group developed depression more frequently than the observation group ( P <0.001). The adjusted hazard ratio was 1.11 (95% CI, 1.07–1.15) in the treatment group. According to the management modality, the Kaplan-Meier survival curves indicated that clipping and endovascular treatment groups developed depression more frequently than the observation group ( P <0.0001). The adjusted hazard ratio was 1.15 (95% CI, 1.10–1.21) for clipping and 1.07 (95% CI, 1.02–1.12) for endovascular treatment. The depression risk was higher with advanced age (hazard ratio for 45–64 years, 1.37 [95% CI, 1.29–1.45] and hazard ratio for ≥65 years, 2.04 [95% CI, 1.92–2.17]). The risk for anxiety did not differ among the management modalities. Conclusions: In this study, the risk of depression was slightly greater after clipping surgery than endovascular treatment. Data on treatment-related, long-term psychological outcomes, such as depression, may aid decision-making for preventive treatment of asymptomatic unruptured intracranial aneurysm patients.

BACKGROUND AND PURPOSE: The aim of the present study was to report the feasibility, safety, and periprocedural complications associated with EVT of ruptured intracranial aneurysms according to the depth of anesthesia. In most centers, endovascular treatment of intracranial aneurysm is performed under general anesthesia. MATERIALS AND METHODS: Between March 2011 and December 2016, a total of 183 consecutive patients with 183 aneurysms were treated endovascularly at the authors9 center. The data about the depth of anesthesia (local anesthesia, conscious sedation, deep sedation, and general anesthesia), procedural details, and clinical and radiologic outcomes were reviewed. RESULTS: A total of 183 consecutive patients with 183 aneurysms (mean age, 60.2 ± 14.8 years; 54 men and 129 women) were successfully treated. Of these, 70 (38.3%) patients underwent endovascular treatment under local anesthesia, 33 (18.0%) patients underwent endovascular treatment under conscious sedation, 78 (42.6%) patients underwent endovascular treatment under deep sedation, and only 2 (1.1%) patients underwent endovascular treatment under general anesthesia. For patients who presented with Hunt and Hess grades 1, 2, 3, 4, and 5, 75%, 59.6%, 59.1%, 53.3%, and 35.3% were treated under local anesthesia or conscious sedation, respectively. The procedure-related complication rates amounted to 8.7% (16/183, with 11 thromboembolic complications and 5 intraprocedural ruptures) overall, and 7.7% (14/183) of complications were symptomatic events. In the patients with good clinical grade (Hunt and Hess 1 or 2), the procedure-related complication rate was 4.1% (4/97), and all complications were symptomatic events under local anesthesia or conscious sedation. CONCLUSIONS: In the authors9 experience, local anesthesia or conscious sedation seemed safe and feasible for the patients with good clinical grade SAH.