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Introduction and Aims At present, the treatment for moyamoya disease (MMD) primarily consists of combined direct and indirect bypass surgery. Nevertheless, more than half of indirect bypass surgeries fail to develop good collaterals from the dura and temporal muscle. This study aimed to investigate whether microRNAs (miRNAs) in cerebrospinal fluid (CSF) could serve as biomarkers for the prediction of postoperative collateral formation. Methods Moyamoya disease patients with indirect bypass surgery were divided into angiogenesis and non‐angiogenesis groups, CSF was obtained, and miRNA sequencing was performed using the CSF. Candidate miRNAs were filtered and subsequently verified through qRT‐PCR. The diagnostic utility of these differential miRNAs was investigated by using receiver operating characteristic (ROC) curve analysis. Finally, the potential biological processes and signaling pathways associated with candidate miRNAs were analyzed using R software. Results The expression levels of four miRNAs (miR‐92a‐3p, miR‐486‐3p, miR‐25‐3p, and miR‐155‐5p) were significantly increased in the angiogenesis group. By combining these four miRNAs (area under the curve [AUC] =0.970), we established an accurate predictive model of collateral circulation after indirect bypass surgery in MMD patients. GO and KEGG analyses demonstrated a high correlation with biological processes and signaling pathways related to angiogenesis. Conclusion The 4‐miRNA signature is a good model to predict angiogenesis after indirect bypass surgery and help the surgeon to select a appreciate bypass strategy., According to the establishment of collaterals, Moyamoya disease (MMD) patients who suffered direct bypass and indirect bypass were divided into two group, obtained their cerebrospinal fluid (CSF), and screened the small RNA sequencing, bioinformatics analysis for all differential miRNAs, and filtering the candidate miRNAs. For validated of candidate miRNAs, qRT‐PCR was further used to analyzed the miRNAs which differential expression in two group. Then, ROC curve analysis was performed to evaluate the diagnostic value of the four identified miRNAs for the establishment of collaterals. To further understand the potential biological functions of the four miRNAs, we identified the functions of target genes using GO and KEGG pathway enrichment analyses.

Objective: This work aims to present our experience of patients with complex cerebral aneurysm treated with a hybrid approach: superficial temporal artery–middle cerebral artery (STA–MCA) bypass in combination with endovascular exclusion of the aneurysm.Method: Patients with aneurysms deemed unclippable and uncoilable were included. All patients were treated with a hybrid approach. After STA–MCA bypass, the parent artery was temporarily occluded. If the intraoperative motor evoked potential (MEP) and somatosensory evoked potential (SEP) waveforms remain normal and last for 30 min, the aneurysm and te parent artery will be embolized permanently with detachable balloons or coils.Results: A total of 20 patients with 22 aneurysms were included in this study. There were 13 women and 7 men, with an average age of 42.5 years. Intraoperative angiography showed the good patency of all the STA grafts, and neither SEP nor MEP abnormalities were detected. After the parent artery and the aneurysm were occluded, the intraoperative angiography showed an immediately successful exclusion of the aneurysm in 20 aneurysms and immediate contrast stasis in two. All patients recovered uneventfully without ischemic or hemorrhagic complication. Angiography at 6-month follow-up showed the total obliteration in 20 aneurysms. Two aneurysms showed residuals and were recoiled. All STA grafts showed a good patency, and the mean graft flow was 124.2 ml/min.Conclusion: STA–MCA bypass in combination with endovascular exclusion is an appropriate option for patients with complex cerebral aneurysms that are not amenable to direct surgical clipping or endovascular embolization.

Background Moyamoya disease (MMD) is an important cause of stroke in children and young adults in Asia. To date, diagnosis remains challenging due to varying clinical manifestations and unknown pathogenesis. The study aims to identify cerebrospinal fluid (CSF) exosomal microRNAs (exomiRs) that can serve as a novel diagnostic biomarker for diagnosis and assess its clinical applications. Methods CSF samples were taken from 31 MMD patients and 31 healthy controls. Initial screening of miRNA expression was performed on samples pooled from MMD patients and controls using microarray and validated using quantitative reverse transcription polymerase chain reaction (qRT-PCR). The diagnostic accuracy of the potential exosomal miRNAs was evaluated using receiver operating characteristic curve analyses in an independent patient cohort. The potential pathways regulated by the miRNAs was also determined using bioinformatics analysis. Results The microarray results demonstrated that six exomiRs were dysregulated in the MMD patients compared to the controls. Using qRT-PCR, we validated four of the miRNAs (miR-3679-5p, miR-6165, miR-6760-5p, and miR-574-5p) as a biomarker for MMD diagnosis. The four exomiRs showed enhanced sensitivity (75%) and specificity (93.75%) in terms of differentiating MMD patients from healthy subjects [area under the curve (AUC) = 0.9453]. Pathway enrichment analysis for potential targets of six exomiRs identified proteins involved in cell adhesion and junction formation in the brain. Conclusions We identified a novel and highly sensitive exomiRs signature for MMD detection and explored its potential targets using bioinformatics analysis.

Purpose To date, digital subtraction angiography (DSA) has been considered as the gold imaging modality for assessing graft patency after extracranial–intracranial bypass. The utility of a noninvasive and quantitative method of assessing graft flow postoperatively was evaluated by using quantitative ultrasonography. Method All STA-MCA bypass surgery performed over a 5-year period at a single institution were reviewed. Measured by duplex ultrasonography, pre-operative (day1) and post-operative (day1, day7, 3month and 6 month) graft blood flow rates were recorded and analyzed. Results were correlated to Matsushima grade determined by DSA performed within 24 h when ultrasonography was conducted to confirm the graft function. Results 100 patients with 131 operated hemispheres were included in this study. The mean flow rates in the STA graft on pre-operative day1, post-operative day 1 and 7, at 3- and 6-month postoperatively were 24.1, 106.7, 112.6, 97.4 and 79.7 ml/min respectively. The mean post-operative flow in the STA graft graded as A/B/C were significantly different (168.0 ± 34.8 ml/min, 91.0 ± 15.5, 42.1 ± 17.2 ml/min, respectively, p = 0.000). 124.5 ml/min and 65.5 ml/min are good cut-off value for predicting post-operative graft Matsushima grade. The analysis also showed excellent agreement between ultrasonography and DSA for assessing bypass function (κ = 0.78). Conclusions The patency of the STA grafts can be assessed noninvasively by quantitative ultrasonography, which results are comparable to those of conventional DSA. This, therefore, suggest that quantitative ultrasonography may be an alternative method to standard DSA for serial follow up of STA grafts.

Objective To introduce a membrane retraction technique that can provide good exposure of deep-seated recipient arteries in cortical sulci and simplify the anastomosis procedure. Methods Only those adult patients with moyamoya disease who underwent superficial temporal artery to middle cerebral artery bypass surgery during which the suitable recipient arteries were located deep in cortical sulci were included in this retrospective study. By placing 10–0 prolene sutures to the arachnoid membrane of the 2 banks of sulcus, arachnoid retraction was applied to pull the sulcus apart and then the deep-seated recipient arteries were exposed. Standard end-to-side anastomosis was completed. The mean occlusion time and successful rate were recorded and compared with those of the normal procedure. Results From June to November 2019, 124 superficial temporal artery to middle cerebral artery bypass surgeries for the treatment of moyamoya disease were performed in Nanfang Hospital. The membrane retraction technique was used in 5 patients (5/110, 4.5%) and the success rates were 100%. The mean temporary occlusion time was 27.2 minutes. No procedure-related complications were observed. All patients recovered uneventfully. The postoperative angiograms confirmed good patency of bypass grafts in all 5 cases. Conclusions The membrane retraction technique is an effective and safe method for the treatment of adult patients with moyamoya disease with deep-seated recipient arteries within the sulci.