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Background: Untreated, moyamoya angiopathy is a progressive vaso-occlusive process that can lead to ischemic or hemorrhagic stroke., Objective: To review 1 institution's surgical experience with both direct and indirect bypass (encephaloduroarteriosynangiosis) in adult and pediatric groups., Methods: A retrospective review was conducted of a consecutive series of patients treated for moyamoya angiopathy between 1995 and 2009., Results: Thirty-nine adult patients underwent indirect bypass as their initial therapy; 29 adult patients underwent direct bypass. Twenty-four pediatric patients included 20 indirect bypasses and 4 direct bypasses. Overall, 140 hemispheres were treated; 48 patients received revascularization of both hemispheres. There were 14 additional revascularization procedures (10% per hemisphere) performed over a site of continued hypoperfusion postoperatively. Fourteen postoperative ischemic strokes occurred during the entire follow-up (10% per hemisphere), and the Kaplan-Meier analysis was not significantly different between groups (P = .59). Four grafts (9.09%) had failed at radiographic follow-up of the 44 direct bypasses performed. Before the initial surgery, the modified Rankin Scale score was 1.58 ± 0.93, 1.48 ± 0.74, and 1.8 ± 1.1 in the pediatric, adult direct, and adult indirect groups (P = .39). At last follow-up, it was 1.29 ± 1.31, 1.09 ± 0.90, and 1.94 ± 1.51 (P = .04) in the pediatric, adult direct, and adult indirect groups., Conclusion: This series demonstrates that both direct and indirect bypasses can be equally effective in preventing stroke. However, in adult patients, direct bypass patients had significantly greater improvement in symptoms, as seen in modified Rankin Scale scores. Pediatric patients, despite undergoing predominantly indirect bypasses, fared roughly the same as the adults in the direct bypass group.

There has been a substantial increase in the number of neuroendovascular procedures performed over the last 15 years. Although rare, complications of cerebral angiography and neuroendovascular procedures have the potential to be devastating. Fortunately, dedication to careful patient selection, meticulous attention to technical detail, and standardization of endovascular treatment protocols results in an acceptably low complication rate. Factors that may predispose one to complications with cerebral angiography include age, smoking, functional stats, medical comorbidities, and duration of the procedure. The most common complication of angiography is vascular access site complication, with a rate of up to 5%. The overall neurologic complication rate for diagnostic angiography is 1.3-2.6%, with a permanent neurologic deficit rate of 0.14-0.50%. Neuroendovascular interventions are more invasive, take longer to perform, and have higher rates of complication. Procedure specific complications include aneurysm rupture, arterial dissection, stroke, hemorrhage, thromboembolism, and microembolism, and rates of neurologic deficit are higher than those for diagnostic angiography. With knowledge of the common complications, strategies to minimize them, and a meticulous attention to the technical detail of the procedure, complications of neuroendovascular interventions can be minimized.

Objective: Antiplatelet therapy is critical to endovascular neurosurgical procedures. Some patients are aspirin-resistant nonresponders. We reviewed our endovascular neurosurgery patients who were premedicated with aspirin and clopidogrel and identified nonresponders to aspirin. Factors associated with aspirin resistance were determined., Methods: Consecutive endovascular neurosurgery patients were identified who were treated by the senior author (BLH) from December 2006 to October 2007 and who were premedicated with aspirin (325 mg) and clopidogrel (75 mg) for 7 days before the procedure. We retrospectively reviewed values from the platelet function analyzer-100 test (Dade-Behring, Deerfield, IL) from 1 day before the procedures. The following factors were evaluated for association with aspirin drug resistance: age, sex, body mass index, and smoking history; patients with hypertension, diabetes, coronary artery disease/ peripheral vascular disease, or hypercholesterolemia; disease pathology (aneurysm, intracranial stenosis, or extracranial stenosis); patients taking statins, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, or antidepressants; and white blood cell count, hemoglobin, hematocrit, and platelet levels. A stepwise logistic model selection was used to select important factors and their interactions., Results: Eighty-one consecutive patients with the following interventions were included in the study: 35 aneurysm coilings (43%), 21 stent-assisted aneurysm coilings (26%), 13 carotid stent and angioplasties (16%), 7 intracranial stents and angioplasties (9%), and 5 extracranial vertebral artery stents and angioplasties (6%). Seventeen patients (21%) were nonresponders to aspirin. After model selection, the only factor associated with aspirin resistance was not taking an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (P = 0.0348; odds ratio, 0.214; 95% confidence interval, 0.051-0.896)., Conclusion: Twenty-one percent of patients premedicated with aspirin and clopidogrel dual therapy for 7 days before endovascular neurosurgical procedures were nonresponders to aspirin. Patients not taking an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker may be at higher risk for aspirin drug resistance.