两种不同血管旁路移植术联合贴敷术治疗烟雾病的疗效比较OA

Objective To compare the clinical efficacy of large craniotomy with superficial temporal artery-middle cerebral artery(STA-MCA)end-to-side anastomosis bypass combined with encephalo-myo-synangiosis(EMS)versus small bone window STA-MCA side-to-side anastomosis bypass combined with galeal aponeurosis pial synangiosis for the treatment of Moyamoya disease(MMD).Methods Consecutive patients with MMD who underwent cerebral revascularization at the Department of Neurosurgery Ⅱ,Guangdong Sanjiu Brain Hospital,from January 2024 to January 2026 were retrospectively enrolled.Patients were divided into the end-to-side anastomosis group(large craniotomy with STA-MCA end-to-side anastomosis bypass combined with EMS)and the side-to-side anastomosis group(small bone window STA-MCA side-to-side anastomosis bypass combined with galeal aponeurosis pial synangiosis)according to the surgical approach.A 1∶1 propensity score matching(PSM)was performed between the two groups.Baseline and clinical characteristics were compared before and after PSM,including sex,age,MMD type(hemorrhagic,ischemic),Suzuki stage(≤ Ⅳ,＞Ⅳ),medical history(hypertension,diabetes),concomitant intracranial aneurysm,bilateral disease,and operative side.Surgical parameters,functional outcomes,and revascularization efficacy were also compared before and after PSM,including operative time,intraoperative blood loss,postoperative hospital stay,Glasgow outcome scale(GOS)score at postoperative day 7 and postoperative month 1,operative-side complications within 7 days after surgery(cerebral infarction,intracranial hemorrhage,impaired wound healing,epidural or subdural effusion),modified Rankin scale(mRS)score at last follow-up at 3-6 months postoperatively,graft patency rate at postoperative day 7 and postoperative month 3(evaluated by head and neck CT angiography[CTA]),perfusion improvement at 3 months postoperative relative to preoperative baseline(evaluated by arterial spin labeling or CT perfusion imaging),and 1-year mortality.Results A total of 105 patients with MMD who underwent either large craniotomy with STA-MCA end-to-side anastomosis bypass combined with EMS or small bone window STA-MCA side-to-side anastomosis bypass combined with galeal aponeurosis pial synangiosis at the Department of Neurosurgery Ⅱ,Guangdong Sanjiu Brain Hospital,from January 2024 to January 2026 were enrolled,comprising 51 males and 54 females,aged 8 to 73 years,with a mean age of(41±11)years.There were 76 patients in the end-to-side anastomosis group and 29 in the side-to-side anastomosis group.After 1∶1 PSM,29 patients remained in each group.(1)No statistically significant differences were observed in baseline or clinical characteristics between the two groups before or after PSM(all P＞0.05).(2)Compared with the end-to-side anastomosis group,the side-to-side anastomosis group demonstrated shorter operative time(before PSM:260.00[210.00,340.00]min va.347.50[310.00,423.75]min,P=0.001;after PSM:260.00[210.00,340.00]min vs.360.00[300.00,450.00]min,P=0.005)and shorter postoperative hospital stay(before PSM:14.00[10.00,22.00]d vs.20.00[16.75,25.00]d,P=0.001;after PSM:14.00[10.00,22.00]d vs.19.00[13.00,25.00]d,P=0.026),lower mRS score at last follow-up at 3-6months(before PSM:0[0,0]vs.1[0,2],P＜0.01;after PSM:0[0,0]vs.1[0,1],P=0.001),and higher perfusion improvement rate at 3 months(before PSM:93.1％[27/29]vs.72.4％[55/76],P=0.022;after PSM:93.1％[27/29]vs.69.0％[20/29],P=0.019)and higher graft patency rate at 3months(before PSM:93.1％[27/29]vs.69.7％[53/76],P=0.012;after PSM:93.1％[27/29]vs.72.4％[21/29],P=0.037)both before and after PSM.No statistically significant differences were observed between the two groups before or after PSM in intraoperative blood loss,GOS score at postoperative day 7 and month 1,overall incidence of operative-side complications within 7 days or incidence of any individual complication,or 1-year mortality(all P＞0.05).Before PSM,the graft patency rate at postoperative day 7 in the side-to-side anastomosis group was higher than that in the end-to-side anastomosis group(96.6％[28/29]vs.75.0％[57/76],P=0.012);however,no statistically significant difference was observed between the two groups after PSM(P=0.102).Conclusions Small bone window STA-MCA side-to-side anastomosis bypass combined with galeal aponeurosis pial synangiosis may be superior to large craniotomy STA-MCA end-to-side anastomosis bypass combined with EMS in improving cerebral perfusion and maintaining graft patency in patients with MMD,with additional advantages of shorter operative time and shorter postoperative hospital stay.These findings await further validation by large-scale,prospective studies.