Predictors of perioperative stroke in patients with Ischemic-type moyamoya disease treated with surgical revascularization: A retrospective multicenter study

Basel Musmar¹, Joanna M Roy², Hammam Abdalrazeq¹, Elias Atallah³, Kareem El Naamani⁴, Ching-Jen Chen⁵, Roland Jabre⁶, Hassan Saad⁷, Jonathan A Grossberg⁸, Adam A Dmytriw⁹, Aman B Patel¹⁰, Mirhojjat Khorasanizadeh¹¹, Christopher S Ogilvy¹², Ajith J Thomas¹³, Andre Monteiro¹⁴, Adnan Siddiqui¹⁵, Gustavo M Cortez¹⁶, Ricardo A Hanel¹⁷, Guilherme Porto¹⁸, Alejandro M Spiotta¹⁹, Anthony J Piscopo²⁰, David M Hasan²¹, Mohammad Ghorbani²², Joshua Weinberg²³, Shahid M Nimjee²⁴, Kimon Bekelis²⁵, Mohamed M Salem²⁶, Jan-Karl Burkhardt²⁷, Akli Zetchi²⁸, Charles Matouk²⁹, Brian M Howard³⁰, Rosalind Lai³¹, Rose Du³², Rawad Abbas³³, Georgios S Sioutas³⁴, Abdelaziz Amllay³⁵, Alfredo Munoz¹, Nabeel A Herial¹, Stavropoula I Tjoumakaris³⁶, Michael Reid Gooch³⁷, Robert H Rosenwasser³⁸, Pascal Jabbour³⁹

Affiliations

¹ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
² Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: joanna.roy21@yahoo.in.
³ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: elias.atallah@jefferson.edu.
⁴ Department of Neurosurgery, University of Arizona college of medicine, Tucson, AZ, USA. Electronic address: Kareem.elnaamani@bannerhealth.com.
⁵ Department of Neurosurgery, The University of Texas Health Science Center, Houston, TX, USA.
⁶ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: roland.jabre@umontreal.ca.
⁷ Department of Neurosurgery, Emory University, Atlanta, GA, USA. Electronic address: hassan.saad@emory.edu.
⁸ Department of Neurosurgery, Emory University, Atlanta, GA, USA. Electronic address: jonathan.a.grossberg@emory.edu.
⁹ Department of Medical Imaging, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada; Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA.
¹⁰ Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA. Electronic address: abpatel@mgh.harvard.edu.
¹¹ Department of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
¹² Department of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA. Electronic address: cogilvy@bidmc.harvard.edu.
¹³ Department of Neurological Surgery, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, NJ, USA. Electronic address: thomas-ajith@cooperhealth.edu.
¹⁴ Department of Neurosurgery, University of New York at Buffalo, Buffalo, NY, USA. Electronic address: amonteiro@ubns.com.
¹⁵ Department of Neurosurgery, University of New York at Buffalo, Buffalo, NY, USA. Electronic address: asiddiqui@ubns.com.
¹⁶ Lyerly Neurosurgery, Baptist Health System, Jacksonville, Jacksonville, FL, USA. Electronic address: gcortez@ubns.com.
¹⁷ Lyerly Neurosurgery, Baptist Health System, Jacksonville, Jacksonville, FL, USA. Electronic address: drricardohanel@icloud.com.
¹⁸ Department of Neurosurgery and Neuroendovascular Surgery, Medical University of South Carolina, SC, USA. Electronic address: porto@musc.edu.
¹⁹ Department of Neurosurgery and Neuroendovascular Surgery, Medical University of South Carolina, SC, USA. Electronic address: spiotta@musc.edu.
²⁰ Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, IA, USA. Electronic address: anthony-piscopo@uiowa.edu.
²¹ Department of Neurosurgery, Duke University, Durham, NC, USA. Electronic address: david.hasan@duke.edu.
²² Department of Neurosurgery, Firoozgar Hospital, Iran. Electronic address: ghorbani.m@iums.ac.ir.
²³ Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: Joshua.weinberg@osumc.edu.
²⁴ Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: shahid.nimjee@osumc.edu.
²⁵ Good Samaritan Hospital Medical Center, Babylon, NY, USA.
²⁶ Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA. Electronic address: mohamed.salem@cuanschutz.edu.
²⁷ Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA. Electronic address: jan.burkhardt@pennmedicine.upenn.edu.
²⁸ Department of Neurosurgery, Yale University, New Haven, CT, USA; Department of Neurosurgery and of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA.
²⁹ Department of Neurosurgery, Yale University, New Haven, CT, USA; Department of Neurosurgery and of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA. Electronic address: Charles.matouk@yale.edu.
³⁰ Department of Neurosurgery, Emory University, Atlanta, GA, USA. Electronic address: brian.howard@emory.edu.
³¹ Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA. Electronic address: rlai@ubns.com.
³² Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA. Electronic address: rdu@bwh.harvard.edu.
³³ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: Abbas.Rawad@mayo.edu.
³⁴ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: georgios.sioutas@pennmedicine.upenn.edu.
³⁵ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: abdelaziz.amllay@yale.edu.
³⁶ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: stavropoula.tjoumakaris@jefferson.edu.
³⁷ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: reid.gooch@jefferson.edu.
³⁸ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: robert.rosenwasser@jefferson.edu.
³⁹ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: pascal.jabbour@jefferson.edu.

PMID: 40057254
DOI: 10.1016/j.jstrokecerebrovasdis.2025.108277

Free article

Multicenter Study

Predictors of perioperative stroke in patients with Ischemic-type moyamoya disease treated with surgical revascularization: A retrospective multicenter study

Basel Musmar et al. J Stroke Cerebrovasc Dis. 2025 May.

Free article

. 2025 May;34(5):108277.

doi: 10.1016/j.jstrokecerebrovasdis.2025.108277. Epub 2025 Mar 7.

Authors

Affiliations

¹ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
² Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: joanna.roy21@yahoo.in.
³ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: elias.atallah@jefferson.edu.
⁴ Department of Neurosurgery, University of Arizona college of medicine, Tucson, AZ, USA. Electronic address: Kareem.elnaamani@bannerhealth.com.
⁵ Department of Neurosurgery, The University of Texas Health Science Center, Houston, TX, USA.
⁶ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: roland.jabre@umontreal.ca.
⁷ Department of Neurosurgery, Emory University, Atlanta, GA, USA. Electronic address: hassan.saad@emory.edu.
⁸ Department of Neurosurgery, Emory University, Atlanta, GA, USA. Electronic address: jonathan.a.grossberg@emory.edu.
⁹ Department of Medical Imaging, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada; Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA.
¹⁰ Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA. Electronic address: abpatel@mgh.harvard.edu.
¹¹ Department of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
¹² Department of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA. Electronic address: cogilvy@bidmc.harvard.edu.
¹³ Department of Neurological Surgery, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, NJ, USA. Electronic address: thomas-ajith@cooperhealth.edu.
¹⁴ Department of Neurosurgery, University of New York at Buffalo, Buffalo, NY, USA. Electronic address: amonteiro@ubns.com.
¹⁵ Department of Neurosurgery, University of New York at Buffalo, Buffalo, NY, USA. Electronic address: asiddiqui@ubns.com.
¹⁶ Lyerly Neurosurgery, Baptist Health System, Jacksonville, Jacksonville, FL, USA. Electronic address: gcortez@ubns.com.
¹⁷ Lyerly Neurosurgery, Baptist Health System, Jacksonville, Jacksonville, FL, USA. Electronic address: drricardohanel@icloud.com.
¹⁸ Department of Neurosurgery and Neuroendovascular Surgery, Medical University of South Carolina, SC, USA. Electronic address: porto@musc.edu.
¹⁹ Department of Neurosurgery and Neuroendovascular Surgery, Medical University of South Carolina, SC, USA. Electronic address: spiotta@musc.edu.
²⁰ Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, IA, USA. Electronic address: anthony-piscopo@uiowa.edu.
²¹ Department of Neurosurgery, Duke University, Durham, NC, USA. Electronic address: david.hasan@duke.edu.
²² Department of Neurosurgery, Firoozgar Hospital, Iran. Electronic address: ghorbani.m@iums.ac.ir.
²³ Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: Joshua.weinberg@osumc.edu.
²⁴ Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address: shahid.nimjee@osumc.edu.
²⁵ Good Samaritan Hospital Medical Center, Babylon, NY, USA.
²⁶ Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA. Electronic address: mohamed.salem@cuanschutz.edu.
²⁷ Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA. Electronic address: jan.burkhardt@pennmedicine.upenn.edu.
²⁸ Department of Neurosurgery, Yale University, New Haven, CT, USA; Department of Neurosurgery and of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA.
²⁹ Department of Neurosurgery, Yale University, New Haven, CT, USA; Department of Neurosurgery and of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA. Electronic address: Charles.matouk@yale.edu.
³⁰ Department of Neurosurgery, Emory University, Atlanta, GA, USA. Electronic address: brian.howard@emory.edu.
³¹ Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA. Electronic address: rlai@ubns.com.
³² Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA. Electronic address: rdu@bwh.harvard.edu.
³³ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: Abbas.Rawad@mayo.edu.
³⁴ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: georgios.sioutas@pennmedicine.upenn.edu.
³⁵ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: abdelaziz.amllay@yale.edu.
³⁶ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: stavropoula.tjoumakaris@jefferson.edu.
³⁷ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: reid.gooch@jefferson.edu.
³⁸ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: robert.rosenwasser@jefferson.edu.
³⁹ Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address: pascal.jabbour@jefferson.edu.

PMID: 40057254
DOI: 10.1016/j.jstrokecerebrovasdis.2025.108277

Abstract

Introduction: Moyamoya disease (MMD) is a chronic cerebrovascular disorder characterized by progressive stenosis or occlusion of the internal carotid arteries and the development of collateral moyamoya vessels. Surgical revascularization is commonly used to prevent future ischemic events in ischemic-type MMD, but there remains a high rate of stroke perioperatively. This study aims to analyze the predictive factors for perioperative stroke in patients with ischemic-type MMD undergoing surgical revascularization using a large multicenter database.

Methods: We conducted a multicenter retrospective study in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. This study included patients with ischemic-type MMD who underwent surgical revascularization across 13 academic institutions in North America. Data were collected and analyzed on a per-hemisphere basis, covering patient demographics, disease characteristics, procedural details, and outcomes. Statistical analyses were performed using Stata (V.17.0), comparing baseline characteristics, and using univariable and multivariable logistic regression to identify predictors of perioperative stroke.

Results: A total of 301 patients with ischemic-type MMD underwent surgical revascularization, with 34 patients (11.3 %) experiencing perioperative stroke. Patients who experienced perioperative stroke had a mean age of 43.6 years (SD 14.0) compared to 40.0 years (SD 13.9) in those without perioperative stroke (P = 0.16). Hypertension was significantly more prevalent in the perioperative stroke group (73.5 % vs. 47.9 %, P = 0.005). Current smoking was also more common in the perioperative stroke group (55.8 % vs. 38.2 %, P = 0.04). Multivariate logistic regression identified hypertension (OR 2.32, 95 % CI 1.01 to 5.37, P = 0.04) and current smoking (OR 2.28, 95 % CI 1.04 to 4.97, P = 0.03) as significant independent predictors of perioperative stroke.

Conclusion: Hypertension and smoking were significant predictors of perioperative stroke in patients with ischemic-type MMD undergoing surgical revascularization. These findings emphasize the importance of managing risk factors in ischemic-type MMD. Further prospective studies are needed to validate these findings.

Keywords: Ischemic-type Moyamoya Disease; MMD; Perioperative Stroke; Revascularization.

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Conflict of interest statement

Declaration of competing interest Dr. Jabbour is a consultant for Medtronic, MicroVention, Balt and Cerus Endovascular. Dr. Tjoumakaris is a consultant for MicroVention. Dr. Gooch is a consultant for Stryker. Dr. Spiotta is a consultant for Terumo, Stryker, Penumbra, RapidAI, Cerenovus. Dr. Patel is a consultant for MicroVention and Medtronic. Dr. Du is a consultant for grand rounds. Dr. Burkhardt is a consultant for Longeviti Neuro solutions, Q-Apel Medical, Stryker. Dr. Hanel is a consultant for Medtronic, Balt, Stryker, Q'Apel Medical, Inc, Codman Neuro (J&J), Cerenovus, Microvention, Imperative Care, Inc, Phenox, Inc, Rapid Medical. Dr. Siddiqui is a consultant for Amnis Therapeutics, Apellis Pharmaceuticals, Inc., Boston Scientific, Canon Medical Systems USA, Inc., Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc., Cerenovus, Cerevatech Medical, Inc., Cordis, Corindus, Inc., Endostream Medical, Ltd, Imperative Care, InspireMD, Ltd., Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Inc., Peijia Medical, Penumbra, Q'Apel Medical, Inc., Rapid Medical, Serenity Medical, Inc., Silk Road Medical, StimMed, LLC, Stryker Neurovascular, Three Rivers Medical, Inc., VasSol, Viz.ai, Inc. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

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Predictors of perioperative stroke in patients with Ischemic-type moyamoya disease treated with surgical revascularization: A retrospective multicenter study

Affiliations

Predictors of perioperative stroke in patients with Ischemic-type moyamoya disease treated with surgical revascularization: A retrospective multicenter study

Authors

Affiliations

Abstract

Conflict of interest statement

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LinkOut - more resources

Full Text Sources

Medical