Perioperative management for patients with moyamoya disease: complications’ definition, technical advances, and outcomes

Perioperative management for patients with moyamoya disease: complications’ definition, technical advances, and outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perioperative management for patients with moyamoya disease: complications’ definition, technical advances, and outcomes Xiangru Ye, Lijian Lang, Ruizhe Zheng, Jin Hu, Cong Yuan, Bin Xu, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6418317/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract OBJECTIVE We aimed to present our experience with the complications’ definition, technical advances, and outcomes patients who underwent superficial temporal artery-middle cerebral artery (STA-MCA) bypass combined with encephalo-duro-myo-synangiosis (EDMS) surgery. METHODS STA-MCA combined with EDMS surgery was certified effective in patients with MMD who were treated by an experienced team. Patients received conventional management from Dec 2012 to April 2018 in our hospital. After a perioperative paradigm had been developed, patients received comprehensive management from May 2018 to June 2023. RESULTS A total of 240 MMD patients who underwent STA-MCA combined with EDMS surgery were sampled and divided into two cohorts according to the chronological order. Among them, 132 (55.0%) patients underwent routine management mode, and 108 (45.0%) patients underwent the proposed perioperative management mode. The clinical characteristics of the two cohorts was homogenous, and the postoperative outcomes are differential. We redefined the surgical complications of STA-MCA combined with EDMS surgery range from a mild complication lasting a few weeks to a serious, reversible stage lasting months or years, and to a terrible, irreversible condition that causing long-term unfavorable outcome or neurological deterioration. Accordingly, patients who received our proposed paradigm presented a significantly decreased incidence of grade I and grade II complications. Although there was no statistical difference in grade III complications, patients in developed cohort tend to have a lower incidence of 6-months unfavorable outcomes. CONCLUSIONS This evolved perioperative paradigm could effectively prevent risk factors and reduce related complications of STA-MCA combined with EDMS surgery. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Moyamoya disease (MMD) is characterized by stenotic and occlusive arterial changes of the distal internal carotid artery (ICA) or the proximal middle cerebral artery (MCA), eliciting compensatory angiogenesis at the base of the brain [1] . Although there was no standardized method for a curable therapy of MMD patients, extracranial-intracranial revascularization surgery has gradually been accepted as an effective measure for preventing future cerebrovascular events and improving the quality of life of MMD [2, 3] . In 2012, we have reported that the superficial temporal artery-middle cerebral artery (STA-MCA) bypass combined with encephalo-duro-myo-synangiosis (EDMS) can achieve a good therapeutic effect in patients with MMD [4] . Since then, numerous neurosurgeons have expanded their focus on STA-MCA combined with EDMS procedure-related complications with the extensive use of such surgery. Generally, transient neurological dysfunctions (TNDs) (e.g., aphasia, seizures, and limb numbness), and permanent neurological deficits [i.e., cerebral hyperperfusion syndrome (CHS) or postoperative ischemia] have been increasingly reported in recent years [5-7] . To our knowledge, postoperative complications of the revascularization procedures were significantly associated with worse outcomes at discharge [8] . Therefore, preventing and managing immediate or long-term postoperative complications are essential for ensuring the benefits for patients with MMD. However, many challenges remain, which are augmented further by the differences in STA-MCA anastomosis techniques and craniotomy details [9] . With the efforts being made to modify the surgical outcome for the better, we have following to introduce such technique of STA to MCA bypass with figures and video in 2022 [10] . Despite all this, an optimized MMD surgery often relies on comprehensive perioperative management, which includes well-calculated pre- and post-operative management and several optimized surgical techniques. In this study, we compared the incidence of complications between patients who received evolving management and those who received conventional treatment in the past ten years. Accordingly, we aim to propose a perioperative paradigm for preventing surgical complications in MMD patients who underwent STA-MCA bypass combined with EDMS surgery. METHODS Study Design and Participants To address potential sources of selected bias, we randomly sampled MMD patients who underwent STA-MCA bypass combined with EDMS surgery between 2012 and 2023 at Huashan Hospital, National Center for Neurological Disorders via the patients’ inpatient code random numbers generation. Cases with incomplete data, cases involving patients who were lost to follow-up at 6 months post-surgery, cases who were not underwent STA-MCA bypass combined with EDMS surgery as a one-staged revascularization strategy, cases with a history of brain surgery were excluded from analysis. Taking April 2018 as the time boundary, we divided these randomly selected MMD cases into two study cohorts in this study. Specifically, conventional management was implemented for MMD patients underwent STA-MCA bypass combined with EDMS surgery between December 2012 and April 2018. Based on the conventional perioperative procedure, management optimization was introduced to form the evolving perioperative paradigm in those who underwent STA-MCA bypass combined with EDMS surgery between May 2018 and June 2023 ( Fig.1 ). The medical records, radiographic files [include digital subtraction angiography (DSA), magnetic resonance angiography (MRA), computed tomography angiography (CTA)], and operative videos and notes were reviewed for each patient according to the standards of the institutional review board of the electronic medical system in Huashan Hospital. MMD was confirmed by the criteria from the Japanese Ministry of Health, Labor, and Welfare (2012) [11] . Patient’s demographics, medical history, onset of presentation, radiological images, surgical techniques, and clinician assessment were recorded. Classification of Surgical Complications We performed a literature review in PubMed for articles describing the complications of MMD published in the English language during the past ten years. The search terms “revascularization”, “STA-MCA”, “EDMS”, and “moyamoya” were used. 150 literature results were retrieved, and then 85 full texts were read. Then, STA-MCA bypass combined with EDMS surgery-related complications were finally recorded according to their relevance to the scope of this study, which includes CHS, subdural effusion, impaired wound healing, new infarction, and hemorrhage. In this study, we innovatively classified the postoperative complications into three main types [12, 13] : 1) grade I, transient neurological reaction or surgical complication, 2) grade II, reversible neurological dysfunction or surgical complication, and 3) grade III, long-term neurological deterioration or irreversible complication. The descriptions of classification and illustrative cases are shown in Fig.2 . In addition, if a patient presents with a combination of multiple complications (such as the combination of grade I and grade II or the combination of grade II and grade III, the highest or most serious complications will be taken as a statistical indicator. An Evolved P erioperative Paradigm After a study that reported the risk factors of postoperative complications in MMD surgery in 2018 [8] , we accordingly proposed a perioperative paradigm for STA-MCA bypass combined with EDMS surgery in our hospital. The descriptive texts of this paradigm are as follows ( Fig.3. ): Preoperative part: we emphasized the preparation of the anticoagulants and the systemic state of MMD patients. STA-MCA combined with EDMS surgery is allowed for hemorrhagic-onset MMD patients who were medically stable more than 3 months from the last bleeding. For ischemic-onset MMD patients, a detailed inquiry about the history of an oral anticoagulant agent is indispensable: aspirin does not need to be stopped because it can increase the bypass patency rate rather than increase the bleeding risk [14] ; clopidogrel was stopped for about 7-10 days before the operation and each patient was given an intravenous administration for more than 1000ml solution daily till operation day. Antiepileptic prevention therapy should not be less than 3 days before operation both for hemorrhagic-onset and ischemic-onset MMD. Oral medicine for chronic diseases should be routinely taken until the day of operation, and nutrition and psychological supports were introduced for a better preoperative state. Intraoperative part: we highlight a series of craniotomy and vascular anastomosis techniques for STA-MCA bypass combined with EDMS surgery ( Fig.4 ). “Scale”: customizing the ratio of the incision scale flap to cover the parietal or anterior branches of STA (the width of the flap to the height of the flap should be greater than one, a/b>1). “Protection”: polishing the external plate of the skull to form forming a 2-3cm bone groove at the vertical site of the middle meningeal artery (MMA) through a high-speed drill and reserve a thin bone layer at the lower junction of the MMA (detail surgical demonstration are available in Supplemental video 1-3 ). “Polishing”: polishing the skull edge to form two symmetrical ladder sections, thus reconstructing a flat surface between the temporal muscle and the skull (detail surgical demonstration are available in Supplemental video 4 ). “Covering”: using a snowflake-shaped titanium plate to cover the skull hole surface. “Repairing”: using a trimmed endocranium to repair the surface of the STA wound. “Site”: setting the site of the anastomosis before the bifurcation of M4 artery. “Angle”: using sharp angle anastomosis between donor and recipient vessel if the STA pressure is low than or equivalent to the MCA pressure. “Direction”: ensuring the same blood flow direction of donor STA and recipient MCA. “Swerving”: swerving the donor vessel to reduce the pressure of anastomosis when the STA pressure is significantly higher than the MCA pressure, if necessary. “Restriction”: using the absorbable suture (0.4 to 0.5 mm diameter) to ligate the high flow of STA, if necessary. Postoperative part: we pay more attention to hemodynamic management and epilepsy control. Sufficient fluid resuscitation is necessary, and the patients would be given more than 3000 ml intravenous fluids during the first 24 hours, and gradually alleviate to 1000 ml daily until discharge. Blood pressure was strictly controlled below 140/90 mmHg with the help of antihypertensive drugs in hypertensive patients and controlled at the baseline level in non-hypertensive patients. Advocate intravenous antiepileptic agent maintenance and low-dose sedation therapy during the first 24 hours. Clinical Evaluation and Follow-Up The possible risk factors of postoperative complications in STA-MCA bypass combined with EDMS surgery reported in the literature, such as age, sex, onset symptoms, medical history, neurological status, and unilateral or bilateral involvement are reviewed from the medical records of the included cases [8] . The modified Rankin Scale (mRS) was used to evaluate the neurological functional status of MMD patients at admission, discharge, and six-month follow-up [15] . Telephone, WeChat, and face-to-face interviews were used for post-discharge follow-up. The mRS scores at discharge and the 6-month evaluation were dichotomized into two categories: favorable (0-2 points) and unfavorable (3-5 points) outcomes [16] . Statistical Analysis Nonnormally distributed quantitative data are presented as the median and interquartile range. Normally distributed quantitative data are presented as the mean ± standard deviation (mean ± SD). For the comparisons of baseline covariates for conventional cohort versus developed cohort. Fisher’s exact test or Pearson’s chi-square test was used to analyze differences in incidences between the two cohorts. The independent T-test and Wilcoxon rank-sum test were used to analyze parametric and nonparametric discrete variables, respectively. Statistical inference was conducted at a significance level of P<0.05. All statistical analyses were performed with SPSS 22.0. Because of the random sampling analysis, missing data were not imputed. Results Baseline Characteristics of Sampled Patients A total of 240 MMD patients (130 males and 110 females) were sampled in this study. Among them, 151 secondary revascularizations on their contralateral hemisphere were ruled out for further analysis. The mean age of these MMD patients at the time of the initial STA-MCA bypass combined with EDMS procedure was 44.80 ± 12.65 years. Analyzed the chief complaint, the symptom of their prevention was ischemia in 140 (58.3%) cases, hemorrhage in 56 (23.3%) cases, dizziness, or headache in 35 (14.5%) cases, and non-symptom in 9 (3.7%) cases. The demographic and clinical characteristics of 240 sampled MMD patients with and without postoperative complications are described in Table 1 . Incidence of Redefined Postoperative Complications According to our definition, the grade I complications were observed after 100 (41.6%) of the operations, including new postoperative incision pain, postoperative pyrexia, weakness, headache, or dizziness; the grade II complications were observed after 67 (27.9%) of the operations, including epilepsy, aphasia, subcutaneous effusion, subcutaneous infection, impaired wound healing, or minor subarachnoid hemorrhage; and the grade III complications were observed after 16 (6.6%) of the operations, including new stroke events confirmed by neuroimaging or neurological deterioration in clinical evaluation. Patients with postoperative complications tended to be higher Suzuki stages (P<0.05), and shorter surgical time (P<0.0001), and there was no significant difference in age at operation, gender, unilateral or bilateral involvement, and chronic diseases history in patients with or without postoperative complications. Importantly, patients without any subjective symptoms tended to appear in the right- than left-hemisphere surgery (89.4% vs 10.5%). Redefined Postoperative Complications in Postoperative Outcomes All postoperative complications recorded in medical history were collected and analyzed as the primary outcome measures in this study. Based on the results presented above, we investigated whether our redefined complications could affect the postoperative outcomes of MMD patients. Significantly, although there was no obvious difference of mRS scores at admission, patients with postoperative complications have statistically higher mRS score than these without postoperative complications at 6-months follow up (P<0.05) rather than them at discharge (P=0.14) ( Fig.5A. ). In addition, our results shown that the patients with grade II complications tend to have higher mRS scores than those with asymptomatic complications (P = 0.214); and the patients with grade III complications tend to have higher mRS scores than those with asymptomatic complications (P < 0.0001), grade I complications (P = 0.002) and grade II complications (P = 0.03) ( Fig.5B. ). These findings indicate that our new defined postoperative complications can early waring the long-term outcome in MMD patients who underwent STA-MCA bypass combined with EDMS surgery. Comparison of Postoperative Complications in Two Cohorts A comparison of the demographic and clinical characteristics of 240 MMD patients with redefined postoperative complications between the conventional cohort and the developed cohort was presented in Table 2. In general, the numbers and rates of redefined complications in MMD patients who underwent developed perioperative paradigm were lower than those who underwent conventional perioperative paradigm [75 (69.4%) vs. 108 (81.8%), P = 0.025]. With the developed paradigm, the percentage of patients with grade I complications was significantly lower than the conventional cohort [47 (43.5%) vs. 53 (61.6%), P = 0.012]; the percentage of patients with grade II complications was significantly lower than the conventional cohort [23 (21.3%) vs. 47 (35.6%), P = 0.015]; and the percentage of patients with grade II complications was significantly lower than the conventional cohort [23 (21.3%) vs. 47 (35.6%), P = 0.015] ( Fig.6.A ). Although there were no statistical differences in incidence of grade III complications in the developed cohort and the conventional cohort [5 (4.6%) vs. 11 (8.3%), P = 0.253], our results shown that the patients in developed cohort has a lower incidence of 6-months unfavorable outcomes[7 (6.5%) vs. 19 (14.4%), P = 0.049], rather than the discharge unfavorable outcomes [14 (13.0%) vs. 19 (14.4%), P = 0.32] than those in conventional cohort ( Fig.6.B ). Discussion The revascularization surgery for MMD treatment is progressing gradually based on each surgeon’s practice, in this study, we reported a single center management experience on such a procedure. Significantly, in the Methods part of this article, we summarized and evaluated a developed perioperative paradigm for preventing postoperative complications in STA-MCA bypass combined with EDMS surgery of MMD patients. By comparing the MMD patients who received conventional management in the early years, our proposed managements paradigm indicated lower incidences of postoperative complications in our clinical practice of ten years, including CHS, cerebral ischemia, or transient neurological events (TNEs) [7, 17] . The heterogeneity of postoperative complications of STA-MCA bypass combined with EDMS surgery is strongly rooted in different studies, which are augmented further by the different types of complications. For example, the previously reported rate of postoperative CHS or cerebral ischemia varies from 1.5% to 11.4% for direct or combined bypass surgery in patients with MMD [2, 8, 18] . It has been suggested that CHS or cerebral ischemia was an uneven cerebral hemodynamic change phenomenon caused by the excessive incoming flow that disturbs the routine blood flow [19] . To reduce the risk factor of such complications, a novel anastomosis strategy has been proposed to prevent the distal outflow of the donor STA, such as the side-to-side STA-MCA bypass surgery [20] . A recent study has reported that side-to-side STA-MCA bypass could reduce the incidence of postoperative CHS from 10.0% to 5.7% relatively [21] . However, the recipient selection, donor direction, and anastomosis location may be a series of concerns in such surgical or principles innovation. Even without them, the 5.7% incidence of postoperative CHS or cerebral ischemia is unacceptable in a large-scale vascular treatment center as the occurrence of it is often limited to time-consuming and costly conservative therapies, such as strict blood pressure control or intravenous drug administration [22] . In addition, with the possibility of stroke and progression to irreversible sequelae, some TNEs such as numbness, weakness, headaches, and aphasia that occurred 14.0% to 77.0% following MMD revascularization surgery have received increasing attention in recent years [7, 12] . Therefore, a comprehensive perioperative paradigm for the prevention of TNEs, CHS, or cerebral ischemia are essential for ensuring the benefits of MMD patients who underwent STA-MCA bypass combined with EDMS surgery. Generally, the surgical complications of STA-MCA bypass combined with EDMS surgery can be grouped into different categories. Based on the time dimension, the surgical complications can be divided into early (e.g. TNEs, CHS, acute bleeding or occlusion [17, 23] ) and late complications (e.g. late stroke, late morbidity and mortality, or long-term unfavorable outcomes [24-26] ). Based on the spatial dimension, the surgical complications can be classified as neurological (e.g. TNEs, CHS, or cerebral infarction [8] ) and non-neurological complications (e.g. impaired wound healing or subdural effusion [5] ). However, most of them are derived from reports and there is no relatively comprehensive classification standard for them. In this study, we innovatively redefined the surgical complications of STA-MCA bypass combined with EDMS surgery from a severity dimension. As is shown in Fig.1 , it can range from a mild complication lasting a few weeks to a serious, reversible stage lasting months or years, and to a terrible, irreversible condition that can lead to a long-term unfavorable outcome or neurological deterioration. The results that MMD patients who have different grade of postoperative complications has different outcomes in mRS scores revealed that the grade difference of our redefined surgical complications may contribute to the discrepancy in surgical efficacy. Accordingly, developing a comprehensive perioperative paradigm to prevent the risk factors for these complications after STA-MCA bypass combined with EDMS surgery is not only a pressing need but a practical possibility. In the preoperative part, we highlight the preparation of the antiplatelet therapy and the management of epilepsy prevention was essential before surgery. To our knowledge, in most patients with an ischemic or transient ischemic attack (TIA) onset MMD, long-term combination administration of aspirin and clopidogrel, known as dual antiplatelet therapy, can effectively reduce the risk of novel occurrence of stroke events [27, 28] . Hence, a majority of patients with ischemic-onset MMD could have a history of the replacement therapy of oral antiplatelet drugs (single or dual) before revascularization admisson [29, 30] . In the view that aspirin can increase the bypass patency rate rather than the bleeding risk, we suggest not stopping it before surgery [14] . As for clopidogrel administration, we suggest an oral interruption for 7-10 days, which is equivalent to the average platelet lifespan, so as to normalize platelet function in patients [31] . During the interruption period, a preoperative bridging through haemodilution or volume expansion (5% glucose saline or ringer lactate solution) is a means of increasing the cerebral tolerance to the bypass procedure [32] . Meanwhile, a dual antiepileptic therapy for MMD is necessary because preoperative epilepsy is a prognostic factor for postoperative epilepsy, and patients with controlled epilepsy before surgery is more likely to be epilepsy free after bypass [33, 34] . The craniotomy via extended pterion approach has been routine for the STA-MCA bypass combined with EDMS surgery. At first, we plan the safe operation position individually through the anatomical positions of the parietal branch of the STA, the sulcus of the MMA, and the coronary suture to ensure blood supply of a scalp incision. Then, we adopt a “bone-bridge method” (that is, use the high-speed grinding drill to polish the outer lamina of skull until exposed the inner lamina of skull) to protect the MMA near the pterion position [35] . During the procedure, STA has been only for direct anastomosis in our procedure because the STA as the indirect donor vascular graft is not always effective [4] . To reduce the risk of cerebral ischemia [36] , the arteries for anastomosis were selected according to the following criteria: 1) setting the site of the anastomosis before the bifurcation of M4 artery; 2) using sharp angle anastomosis between STA and MCA, and 3) ensuring the same blood flow direction of donor STA and recipient MCA. To reduce the risk of CHS, surgical techniques innovations are as follows: 1) swerving the donor vessel to reduce the pressure of anastomosis, 2) sing the absorbable suture to ligate the high flow of STA, and 3) intensify the postoperative blood pressure management (see follow). Finally, a reconstruction principle of plastic surgery, including polishing the skull edge, covering the skull hole surface, and repairing the STA wound has been applied to restore skull and suture scalp. After surgery, sufficient fluid resuscitation was performed and all the MMD patients would be given more than 3000 ml of intravenous fluids within the first 24 hours. It should be noted that if an MMD patient’s recipient vessel is too thin or the donor pressure is too high (according to the experience of the neurosurgeon), aggressive blood pressure lowering therapy (lower than 130/80 mmHg) will be started immediately. Otherwise, the blood pressure is controlled below 140/90 mmHg in a patient with a history of hypertension and controlled nearly or slightly exceed the pre-operative levels in a patient without a history of hypertension. That is because recently we found that the early postoperative hemodynamic stable could affect the prognosis; the higher levels and large variability of mean arterial pressure were correlated with worse outcomes in patients with MMD [37] . In addition, dehydrating agents such as mannitol were routinely used to prevent brain edema caused by surgery. Then gradually reduce the volume of intravenous fluids to 1000 ml daily until discharge. Limitations and Suggestions Several limitations of our study should be illustrated. At first, the Method article could not provide high-level evidence from randomized controlled trials due to its single-center retrospective design. Secondly, although we randomly sampled MMD cases from a single surgical team, the bias caused by the heterogeneity of neurosurgeon proficiency within the past ten years was inevitable in this study. Thirdly, we failed to compare the A-type and the B-type complications because of the low incidence of grade III complications. Future multiple operators involved in the multicenter prospective study were hoped to present more reliable data. However, the comparison between the two cohorts still presented effective technologies for reducing surgical complications, which makes further comparative and prospective research more valuable. This paradigm we presented was based on the long-term clinical experience that focuses on cerebral revascularization surgery in patients with MMD. More importantly, this study provides a comprehensive paradigm (including preoperative preparation, intraoperative technique, and postoperative management) for the STA-MCA bypass combined with EDMS surgery. We expect this paradigm to serve as a reference tool for future clinical practice and that the included concepts will provide greater benefit to MMD patients. Conclusions Hitherto, no report has sought the comprehensive perioperative management of cerebral revascularization surgery in patients with MMD. In this study, we initially proposed a comprehensive perioperative paradigm to prevent various risk factors for surgical complications after the STA-MCA bypass combined with EDMS surgery. Our proposed perioperative managements paradigm for MMD treatment are mostly based on the practice of a single center for ten years. With this developed paradigm, the rate of grade I and grade II complications in patients with MMD were significantly reduced, and the incidence of unfavorable outcomes was significantly decreased. Declarations Ethical approval: This paradigm was approved by the ethics committee of the Department of Neurosurgery, Huashan Hospital. All procedures performed in studies involving human participants were in accordance with the Helsinki declaration and its later amendments or comparable ethical standards. As this is a retrospective study, informed consent was not required. Consent for publication : This manuscript complies with all instructions to authors and all authors have read and agreed to the final version of the manuscript. This manuscript has not been published elsewhere and is not under consideration by another journal. Availability of data and materials : The data that support the findings of this study are available on request from corresponding authors. The data are not publicly available due to privacy or ethical restrictions. Conflict of interest: All authors have disclosed that they do not have a potential conflict of interest Fundings : This work was supported by the National Key Scientific Instrument and Equipment Development Project of China (Grant No. 2021YFF0702500); National Natural Science Foundation of China (Grand No. 82471407 and 82171382); Minhang District Natural Science Research Project (Grant No. 2024MHZ053), Shanghai, China; National Key Research and Development Program of China for Cancer, Cardiovascular and Cerebrovascular, Respiratory, and Metabolic Disease Prevention and Treatment (Grant No. 2023ZD0505003). Authors' contributions : Xr. Y. and Lj.L. contributed to the conception and design of the work and drafted this manuscript; Rz. Z. and C.Y. performed the statistical analyses and prepared the clinical data; Xr. Y., Lj.L. and Rz. Z. prepared figures and tables; B.X. and F.x. supervised this study. 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Individualized Perioperative Blood Pressure Management for Adult Moyamoya Disease: Experience from 186 Consecutive Procedures. J Stroke Cerebrovasc Dis 2021;30:105413. doi: 10.1016/j.jstrokecerebrovasdis.2020.105413. Karsten MB, Smith ER, Scott RM. Late morbidity and mortality following revascularization surgery for moyamoya disease in the pediatric population. J Neurosurg Pediatr 20211-6. doi: 10.3171/2021.1.PEDS20944. Araki Y, Yokoyama K, Uda K, Kanamori F, Mamiya T, Nishihori M , et al. Ipsilateral late stroke after revascularization surgery for patients with Moyamoya disease. Acta Neurochir (Wien) 2021;163:1493-1502. doi: 10.1007/s00701-021-04773-8. Cho WS, Kim JE, Kim CH, Ban SP, Kang HS, Son YJ , et al. Long-term outcomes after combined revascularization surgery in adult moyamoya disease. Stroke 2014;45:3025-3031. doi: 10.1161/STROKEAHA.114.005624. Zhao Y, Zhang Q, Zhang D, Zhao Y. Effect of Aspirin in Postoperative Management of Adult Ischemic Moyamoya Disease. World Neurosurg 2017;105:728-731. doi: 10.1016/j.wneu.2017.06.057. Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C , et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med 2013;369:11-19. doi: 10.1056/NEJMoa1215340. Kraemer M, Berlit P, Diesner F, Khan N. What is the expert's option on antiplatelet therapy in moyamoya disease? Results of a worldwide Survey. Eur J Neurol 2012;19:163-167. doi: 10.1111/j.1468-1331.2011.03481.x. Ye F, Li J, Wang T, Lan K, Li H, Yin H , et al. Efficacy and Safety of Antiplatelet Agents for Adult Patients With Ischemic Moyamoya Disease. Front Neurol 2020;11:608000. doi: 10.3389/fneur.2020.608000. Tafur A, Douketis J. Perioperative management of anticoagulant and antiplatelet therapy. Heart 2018;104:1461-1467. doi: 10.1136/heartjnl-2016-310581. Gross CE, Bednar MM, Lew SM, Florman JE, Kohut JJ. Preoperative volume expansion improves tolerance to carotid artery cross-clamping during endarterectomy. Neurosurgery 1998;43:222-226; discussion 226-228. doi: 10.1097/00006123-199808000-00016. Ma Y, Zhao M, Zhang Q, Liu X, Zhang D, Wang S , et al. Risk Factors for Epilepsy Recurrence after Revascularization in Pediatric Patients with Moyamoya Disease. J Stroke Cerebrovasc Dis 2018;27:740-746. doi: 10.1016/j.jstrokecerebrovasdis.2017.10.012. Alramadan A, Ul Haq A, Basindwah S, Alshail E. Seizure outcome in moyamoya after indirect revascularization in pediatric patients: Retrospective study and literature review. Surg Neurol Int 2021;12:73. doi: 10.25259/SNI_633_2020. Yu J, Guo Y, Xu B, Xu K. Clinical importance of the middle meningeal artery: A review of the literature. Int J Med Sci 2016;13:790-799. doi: 10.7150/ijms.16489. Qian Y, Huang B, Hu Z, Wang J, Zhao P, Li X. Analysis of Factors Related to Cerebral Infarction after Direct Bypass Surgery in Adults with Moyamoya Disease. Cerebrovasc Dis 2020;49:55-61. doi: 10.1159/000504743. Song J, Lei Y, Chen L, Gao C, Ni W, Wu X , et al. The First 24 h Hemodynamic Management in NICU after Revascularization Surgery in Moyamoya Disease. Behav Neurol 2021;2021:5061173. doi: 10.1155/2021/5061173. Tables Table 1. Demographic and clinical characteristics of a total of 240 sampled MMD patients. Variables All patents (n=240) Postoperative Complications Asymptomatic (n=57) Grade I (n=100) Grade II (n=67) Grade III (n=16) Age at operation (years) 44.80 ± 12.7 46.02 ± 14.6 43.20 ± 12.7 45.46 ± 11.5 47.69 ± 8.6 Gender Male 131 (54.5) 34 (59.6) 49 (49.0) 41 (61.1) 7 (43.7) Female 109 (45.4) 23 (40.3) 51 (51.0) 26 (38.8) 9 (56.2) Medical history Hypertension 68 (28.4) 12 (21.0) 28 (28.0) 24 (35.8) 4 (25.0) Diabetes 24 (10.0) 6 (10.5) 12 (12.0) 4 (6.0) 2 (12.5) Coronary disease 4 (1.7) 1 (1.7) 1 (1.0) 2 (3.0) 0 (0.0) Others 6(2.5) 1 (1.7) 3 (3.0) 2 (3.0) 0 (0.0) Onset symptom Hemorrhagic 56 (23.3) 3 (5.2) 26 (26.0) 20 (29.8) 7 (43.7) Ischemic 140 (58.3) 41 (71.9) 56 (56.0) 38 (56.7) 5 (31.3) Infarction 76 (31.6) 18 (31.5) 29 (29.0) 25 (37.3) 4 (25.0) TIA 64 (26.6) 23 (40.3) 27 (27.0) 13 (19.4) 1 (6.2) Headache or dizziness 35 (14.6) 11 (19.2) 16 (16.0) 5 (7.5) 3 (18.8) Asymptomatic 9 (3.7) 2 (3.5) 2 (2.0) 4 (5.9) 1 (6.2) Disease involved Bilateral 151 (62.9) 30 (52.6) 63 (63.0) 46 (68.6) 12 (75%) Unilateral 89 (37.0) 27 (47.3) 37 (37.0) 21 (31.3) 4 (25%) Surgical hemisphere Left 108 (45.0) 6 (10.5) 48 (48.0) 48 (71.6) 6 (37.5) Right 132 (55.0) 51 (89.4) 52 (52.0) 19 (28.3) 10 (62.5) mRS score (points) Admission 1.50 ± 0.8 1.18 ± 0.5 1.58 ± 0.9 1.66 ± 0.9 1.63 ± 1.0 Discharge 1.33 ± 1.1 1.04 ± 0.7 1.30 ± 1.1 1.43 ± 1.1 2.13 ± 1.3 Follow-up 0.85 ± 1.3 0.60 ± 1.4 0.77 ± 1.2 0.97 ± 1.3 1.75 ± 1.3 Suzuki stage Mean 2.32 ± 1.0 2.00 ± 1.0 2.38 ± 0.9 2.45 ± 1.1 2.56 ± 1.1 I 56 (23.3) 19 (33.3) 18 (18.0) 16 (23.8) 3 (18.7) II 84 (35.0) 24 (42.1) 38 (38.0) 18 (26.8) 4 (25.0) III 74 (30.8) 11 (19.2) 33 (33.0) 23 (34.3) 7 (43.7) IV 20 (8.3) 2 (3.5) 10 (10.0) 7 (10.4) 1 (6.2) V 5 (2.0) 1 (1.7) 1 (1,0) 3 (4.4) 1 (6.2) VI 1 (0.4) 1 (0.4) 0 (0.0) 0 (0.0) 0 (0.0) Surgical time (hours) 2.75 ± 0.5 2.47 ± 0.5 2.79 ± 0.5 2.87 ± 0.5 3.00 ± 0.6 Postoperative hospitalization (days) 11.48 ± 5.1 7.70 ± 1.2 10.01 ± 2.5 14.70 ± 4.9 20.56 ± 8.0 Table 2. Comparison of the general information in MMD patients in two cohorts. Variables Conventional cohort (n=132) Developed cohort (n=108) P value Age at operation (years) 44.25 ± 12.3 45.47 ± 13.1 0.46 Gender 0.20 Male 67 (50.8) 64 (59.3) Female 65 (49.2) 44 (40.7) Medical history 0.98 Hypertension 30 (22.7) 38 (35.2) Diabetes 10 (7.6) 14 (13.0) Coronary disease 2 (1.5) 2 (1.9) Others 2 (1.5) 4 (3.7) Onset symptom 0.05 Hemorrhagic 39 (29.5) 17 (15.7) Ischemic 66 (50.0) 74 (68.5) Infarction 34 (25.7) 42 (38.8) TIA 32 (24.2) 32 (29.6) Headache or dizziness 21 (15.9) 14 (13.0) Asymptomatic 6 (4.5) 3 (2.7) Disease involved 0.28 Bilateral 79 (59.8) 72 (66.6) Unilateral 53 (40.1) 36 (33.3) Surgical hemisphere 0.88 Left 60 (45.4) 48 (44.4) Right 72 (54.5) 60 (55.5) mRS score (points) Admission 1.56 ± 0.9 1.44 ± 0.8 0.29 Discharge 1.30 ± 1.3 1.36 ± 1.0 0.68 Follow-up 1.02 ± 1.2 0.66 ± 1.0 0.0136* Suzuki stage Mean 2.36 ± 1.0 2.27 ± 1.1 0.47 I 27 (20.4) 29 (26.8) II 45 (34.0) 39 (36.1) III 48 (36.3) 26 (24.0) IV 9 (6.8) 11 (10.1) V 3 (2.2) 2 (1.8) VI 0 (0.0) 1 (0.6) Surgical time (hours) 2.98 ± 0.5 2.46 ± 0.4 <0.0001**** Postoperative hospitalization (days) 13.39 ± 5.2 9.14 ± 3.8 <0.0001**** Supplementary Videos Supplementary Videos not available with this version Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6418317","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":462517359,"identity":"65da4832-c6ba-4f16-92e3-667adab228f8","order_by":0,"name":"Xiangru Ye","email":"","orcid":"","institution":"Huashan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiangru","middleName":"","lastName":"Ye","suffix":""},{"id":462517360,"identity":"3a5b6b20-59b5-4216-a526-3c5f9d3e780a","order_by":1,"name":"Lijian Lang","email":"","orcid":"","institution":"Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Lijian","middleName":"","lastName":"Lang","suffix":""},{"id":462517361,"identity":"6c60958d-6063-4752-a8a5-6757100d1e50","order_by":2,"name":"Ruizhe Zheng","email":"","orcid":"","institution":"Huashan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ruizhe","middleName":"","lastName":"Zheng","suffix":""},{"id":462517362,"identity":"3b8f2886-25ab-4a17-990a-a49e05a223a1","order_by":3,"name":"Jin Hu","email":"","orcid":"","institution":"Huashan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jin","middleName":"","lastName":"Hu","suffix":""},{"id":462517367,"identity":"81241ffd-ac92-4567-9ed5-690af096f38f","order_by":4,"name":"Cong Yuan","email":"","orcid":"","institution":"Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Cong","middleName":"","lastName":"Yuan","suffix":""},{"id":462517369,"identity":"2fb87e0e-1e2d-4d48-8e0d-e185b0b5dd9f","order_by":5,"name":"Bin Xu","email":"","orcid":"","institution":"Huashan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Xu","suffix":""},{"id":462517371,"identity":"51cd0517-8ace-4511-b8c7-c0e23c866bf5","order_by":6,"name":"Feng Xu","email":"","orcid":"","institution":"Huashan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Feng","middleName":"","lastName":"Xu","suffix":""},{"id":462517373,"identity":"b9bab586-0585-4ceb-99bb-6f9894e1aa81","order_by":7,"name":"Caihua Xi","email":"","orcid":"","institution":"Huashan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Caihua","middleName":"","lastName":"Xi","suffix":""},{"id":462517375,"identity":"2a426c84-e107-4ffb-a919-d818c039558f","order_by":8,"name":"Yujun Liao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYFAC5oYDIIqxgYHxQUKFDTFaGOFamA0enEkjTguMxSb5sO0QYQ3m/AcbD/yoOJzYPCP3WEUC2wEG/vbuBLxaLGckNhzsOXM4sXFGXtqNBJ47DBJnzm7Aq8XgBtAvvG0gLTlmNxIknjEYSOQS0HL+YMPBv1AtBQkGh4nQciCx4TDMFoaEBGK03ABqkTmTbtzY88ZYIuFAGg9hv5w/fPjjmwpr2Y3tOYYff/6zkeNv78WvBQqaGQwbICweYpSDQB2DPLFKR8EoGAWjYOQBAMGMVV373+NNAAAAAElFTkSuQmCC","orcid":"","institution":"Huashan Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yujun","middleName":"","lastName":"Liao","suffix":""}],"badges":[],"createdAt":"2025-04-10 08:54:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6418317/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6418317/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83681118,"identity":"7735cafa-bc21-40a0-ac7f-35990ae54175","added_by":"auto","created_at":"2025-05-30 16:09:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":226142,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow-chart of this study. \u003c/strong\u003eMMD= moyamoya disease; STA-MCA= superficial temporal artery-middle cerebral artery; EDMS: encephalo-duro-myo-synangiosis.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6418317/v1/e3a0d65bad2ba3268d635ff1.png"},{"id":83681121,"identity":"00bdf389-d15d-4347-aba5-7167c5c36530","added_by":"auto","created_at":"2025-05-30 16:09:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":448979,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eClassification of surgical complications and illustrative cases. A.\u003c/strong\u003e Postoperative subcutaneous hydrops, grade II. \u003cstrong\u003eB.\u003c/strong\u003e Impaired wound healing after seizures, grade II. \u003cstrong\u003eC.\u003c/strong\u003eHemorrhage in surgical field, grade III-A type.\u003cstrong\u003e D.\u003c/strong\u003e infarction in surgical field, grade III-A type. \u003cstrong\u003eE. \u003c/strong\u003eHemorrhage not in surgical field, grade III-B type.\u003cstrong\u003e F.\u003c/strong\u003e Infarction in surgical field, grade III-B type.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6418317/v1/8b1e6be162c1f533e6718b20.png"},{"id":83681123,"identity":"294440a0-cfe3-4d96-8ccc-59c9acd02b43","added_by":"auto","created_at":"2025-05-30 16:09:42","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":423755,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProposed perioperative paradigm for preventing surgical complications of MMD patients in our hospital. \u003c/strong\u003eCTA= computed tomography angiography; MRA= magnetic resonance angiography; DSA= digital subtraction angiography; MMD= moyamoya disease.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6418317/v1/ce9cee06d1443a93d8426eb2.png"},{"id":83681122,"identity":"d0794504-569f-4c1b-bbd4-5924388794f2","added_by":"auto","created_at":"2025-05-30 16:09:42","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":709846,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCraniotomy and vascular anastomosis techniques for STA-MCA bypass combined with EDMS surgery. \u003c/strong\u003eSTA: superficial temporal artery, MCA: middle cerebral artery.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6418317/v1/7e49615f66390b63b5d39d63.png"},{"id":83681119,"identity":"bdcde58e-ef90-4b08-8ad2-4c05112fc73f","added_by":"auto","created_at":"2025-05-30 16:09:42","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":84573,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe role of redefined postoperative complications in postoperative outcomes.\u003c/strong\u003e \u003cstrong\u003eA.\u003c/strong\u003e Comparison of mRS scores in patients with and without postoperative complications at admission, discharge and 6-months follow-up. \u003cstrong\u003eB.\u003c/strong\u003e Comparison of mRS scores in patients who presents with different postoperative complications (mRS = modified Rankin Scale).\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6418317/v1/f0eda11faf24873d275c40aa.png"},{"id":83681120,"identity":"47e65d5f-e999-42f7-9653-49afad9003cc","added_by":"auto","created_at":"2025-05-30 16:09:42","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":85251,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePercentage of patients in two cohorts. A. \u003c/strong\u003eComparison of the percentage of patients with postoperative complications and their outcomes in two cohorts.\u003cstrong\u003e B. \u003c/strong\u003eComparison of the patients with different clinical outcomes at discharge and 6-months follow-up.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6418317/v1/7bac6a1fdb6c760ca603441d.png"},{"id":85626363,"identity":"059d5090-aed2-488f-9716-fcf97fc94097","added_by":"auto","created_at":"2025-06-29 23:01:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3267673,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6418317/v1/7d49c10e-156b-45b5-9016-266a76a1cce3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perioperative management for patients with moyamoya disease: complications’ definition, technical advances, and outcomes","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMoyamoya disease (MMD) is characterized by stenotic and occlusive arterial changes of the distal internal carotid artery (ICA) or the proximal middle cerebral artery (MCA), eliciting compensatory angiogenesis at the base of the brain\u003csup\u003e[1]\u003c/sup\u003e.\u0026nbsp;Although there was no standardized method for a curable therapy of MMD patients, extracranial-intracranial revascularization surgery has gradually been accepted as an effective measure for preventing future cerebrovascular events and improving the quality of life of MMD\u003csup\u003e[2, 3]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn 2012, we have reported that the superficial temporal artery-middle cerebral artery (STA-MCA) bypass combined with encephalo-duro-myo-synangiosis (EDMS) can achieve a good therapeutic effect in patients with MMD\u003csup\u003e[4]\u003c/sup\u003e. Since then, numerous neurosurgeons have expanded their focus on STA-MCA combined with EDMS procedure-related complications with the extensive use of such surgery. Generally, transient neurological dysfunctions (TNDs) (e.g., aphasia, seizures, and limb numbness), and permanent neurological deficits [i.e., cerebral hyperperfusion syndrome (CHS) or postoperative ischemia] have been increasingly reported in recent years\u003csup\u003e[5-7]\u003c/sup\u003e. To our knowledge, postoperative complications of the revascularization procedures were significantly associated with worse outcomes at discharge\u003csup\u003e[8]\u003c/sup\u003e.\u0026nbsp;Therefore, preventing and managing immediate or long-term postoperative complications are essential for ensuring the benefits for patients with MMD. However, many challenges remain, which are augmented further by the differences in STA-MCA anastomosis techniques and craniotomy details\u003csup\u003e[9]\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWith the efforts being made to modify the surgical outcome for the better, we have following to introduce such technique of STA to MCA bypass with figures and video in 2022\u003csup\u003e[10]\u003c/sup\u003e. Despite all this, an optimized MMD surgery often relies on comprehensive perioperative management, which includes well-calculated pre- and post-operative management and several optimized surgical techniques. In this study, we compared the incidence of complications between patients who received evolving management and those who received conventional treatment in the past ten years. Accordingly, we aim to propose a perioperative paradigm for preventing surgical complications in MMD patients who underwent STA-MCA bypass combined with EDMS surgery.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo address potential sources of selected bias, we randomly sampled MMD patients who underwent STA-MCA bypass combined with EDMS surgery between 2012 and 2023 at Huashan Hospital, National Center for Neurological Disorders via the patients’ inpatient code random numbers generation. Cases with incomplete data, cases involving patients who were lost to follow-up at 6 months post-surgery, cases who were not underwent STA-MCA bypass combined with EDMS surgery as a one-staged revascularization strategy, cases with a history of brain surgery were excluded from analysis. Taking April 2018 as the time boundary, we divided these randomly selected MMD cases into two study cohorts in this study. Specifically, conventional management was implemented for MMD patients underwent STA-MCA bypass combined with EDMS surgery between December 2012 and April 2018. Based on the conventional perioperative procedure, management optimization was introduced to form the evolving perioperative paradigm in those who underwent STA-MCA bypass combined with EDMS surgery between May 2018 and June 2023 (\u003cstrong\u003eFig.1\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eThe medical records, radiographic files [include digital subtraction angiography (DSA), magnetic resonance angiography (MRA), computed tomography angiography (CTA)], and operative videos and notes were reviewed for each patient according to the standards of the institutional review board of the electronic medical system in Huashan Hospital. MMD was confirmed by the criteria from the Japanese Ministry of Health, Labor, and Welfare (2012)\u003csup\u003e[11]\u003c/sup\u003e. Patient’s demographics, medical history, onset of presentation, radiological images, surgical techniques, and clinician assessment were recorded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClassification of Surgical Complications\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe performed a literature review in PubMed for articles describing the complications of MMD published in the English language during the past ten years. The search terms “revascularization”, “STA-MCA”, “EDMS”, and “moyamoya” were\u0026nbsp;used. 150 literature results were retrieved, and then\u0026nbsp;85 full texts were read. Then,\u0026nbsp;STA-MCA bypass combined with EDMS surgery-related complications were finally recorded according to their relevance to the scope of this study, which includes CHS, subdural effusion, impaired wound healing, new infarction, and hemorrhage.\u003c/p\u003e\n\u003cp\u003eIn this study, we innovatively classified the postoperative complications into three main types\u003csup\u003e[12, 13]\u003c/sup\u003e: 1) grade I, transient neurological reaction or surgical complication, 2) grade II, reversible neurological dysfunction or surgical complication, and 3) grade III, long-term neurological deterioration or irreversible complication. The descriptions of classification and illustrative cases are shown in \u003cstrong\u003eFig.2\u003c/strong\u003e. In addition, if a patient presents with a combination of multiple complications (such as the combination of grade I and grade II or the combination of grade II and grade III, the highest or most serious complications\u0026nbsp;will be taken as a statistical indicator.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAn Evolved P\u003c/strong\u003e\u003cstrong\u003eerioperative Paradigm\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter a study that reported the risk factors of postoperative complications in MMD surgery in 2018\u003csup\u003e[8]\u003c/sup\u003e, we accordingly proposed a perioperative paradigm for STA-MCA bypass combined with EDMS surgery in our hospital.\u0026nbsp;The descriptive texts of this paradigm are as follows (\u003cstrong\u003eFig.3.\u003c/strong\u003e):\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreoperative part:\u003c/strong\u003e we emphasized the preparation of the anticoagulants and the systemic state of MMD patients.\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eSTA-MCA combined with EDMS surgery is allowed for hemorrhagic-onset MMD patients who were\u0026nbsp;medically stable more than 3 months from the last bleeding.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFor ischemic-onset MMD patients, a detailed inquiry about the history of an oral anticoagulant agent is indispensable: aspirin does not need to be stopped because it can increase the bypass patency rate rather than increase the bleeding risk\u003csup\u003e[14]\u003c/sup\u003e;\u0026nbsp;clopidogrel was stopped for about 7-10 days before the operation and\u0026nbsp;each patient was given an intravenous administration for more than 1000ml solution daily till operation day.\u003c/li\u003e\n \u003cli\u003eAntiepileptic prevention therapy should not be less than 3 days before operation both for\u0026nbsp;hemorrhagic-onset and ischemic-onset MMD.\u003c/li\u003e\n \u003cli\u003eOral medicine for chronic diseases should be routinely taken until the day of operation, and nutrition and psychological supports were introduced for a better preoperative state.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eIntraoperative part:\u0026nbsp;\u003c/strong\u003ewe highlight a series of craniotomy and vascular anastomosis techniques for STA-MCA bypass combined with EDMS surgery (\u003cstrong\u003eFig.4\u003c/strong\u003e).\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e“Scale”: customizing the ratio of the incision scale flap to cover the parietal or anterior branches of STA (the width of the flap to the height of the flap should be greater than one, a/b\u0026gt;1).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e“Protection”: polishing the external plate of the skull to form forming a 2-3cm bone groove at the vertical site of the middle meningeal artery (MMA) through a high-speed drill and reserve a thin bone layer at the lower junction of the MMA\u0026nbsp;(detail surgical demonstration are available in \u003cstrong\u003eSupplemental video 1-3\u003c/strong\u003e).\u003c/li\u003e\n \u003cli\u003e“Polishing”: polishing the skull edge to form two symmetrical ladder sections, thus reconstructing a flat surface between the temporal muscle and the skull\u0026nbsp;(detail surgical demonstration are available in \u003cstrong\u003eSupplemental video 4\u003c/strong\u003e).\u003c/li\u003e\n \u003cli\u003e“Covering”: using a snowflake-shaped titanium plate to cover the skull hole surface.\u003c/li\u003e\n \u003cli\u003e“Repairing”: using a trimmed endocranium to repair the surface of the STA wound.\u003c/li\u003e\n \u003cli\u003e“Site”: setting the site of the anastomosis before the bifurcation of M4 artery.\u003c/li\u003e\n \u003cli\u003e“Angle”: using sharp angle anastomosis between donor and recipient vessel if the STA pressure is low than or equivalent to the MCA pressure.\u003c/li\u003e\n \u003cli\u003e“Direction”: ensuring the same blood flow direction of donor STA and recipient MCA.\u003c/li\u003e\n \u003cli\u003e“Swerving”: swerving the donor vessel to reduce the pressure of anastomosis when the STA pressure is significantly higher than the MCA pressure, if necessary.\u003c/li\u003e\n \u003cli\u003e“Restriction”: using the absorbable suture (0.4 to 0.5 mm diameter) to ligate the high flow of STA, if necessary.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative part:\u0026nbsp;\u003c/strong\u003ewe pay more attention to hemodynamic management and epilepsy control.\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eSufficient fluid resuscitation is necessary, and the patients would be given more than 3000 ml intravenous fluids during the first 24 hours, and gradually alleviate to 1000 ml daily until discharge.\u003c/li\u003e\n \u003cli\u003eBlood pressure was strictly controlled below 140/90 mmHg with the help of antihypertensive drugs in hypertensive patients and controlled at the baseline level in non-hypertensive patients.\u003c/li\u003e\n \u003cli\u003eAdvocate intravenous antiepileptic agent maintenance and low-dose sedation therapy during the first 24 hours.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Evaluation and Follow-Up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe possible risk factors of postoperative complications in\u0026nbsp;STA-MCA bypass combined with EDMS surgery reported in the literature, such as age, sex, onset symptoms, medical history, neurological status, and unilateral or bilateral involvement are reviewed from the medical records of the included cases\u003csup\u003e[8]\u003c/sup\u003e.\u0026nbsp;The modified Rankin Scale (mRS) was used to evaluate the neurological functional status of MMD patients at admission, discharge, and six-month follow-up\u003csup\u003e[15]\u003c/sup\u003e. Telephone, WeChat, and face-to-face interviews were used for post-discharge follow-up. The mRS scores at discharge and the 6-month evaluation were dichotomized into two categories: favorable (0-2 points) and unfavorable (3-5 points) outcomes\u003csup\u003e[16]\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNonnormally distributed quantitative data are presented as the median and interquartile range. Normally distributed quantitative data are presented as the mean ± standard deviation (mean ± SD). For the comparisons of baseline covariates for conventional cohort versus developed cohort. Fisher’s exact test or Pearson’s chi-square test was used to analyze differences in incidences between the two cohorts. The independent T-test and Wilcoxon rank-sum test were used to analyze parametric and nonparametric discrete variables, respectively. Statistical inference was conducted at a significance level of P\u0026lt;0.05. All statistical analyses were performed with SPSS 22.0. Because of the\u0026nbsp;random sampling analysis, missing data were not imputed.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCharacteristics of Sampled Patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 240 MMD patients (130 males and 110 females) were sampled in this study. Among them, 151 secondary\u0026nbsp;revascularizations on their contralateral hemisphere were ruled out for further analysis. The mean age of these MMD patients at the time of the initial STA-MCA bypass combined with EDMS procedure was 44.80 ± 12.65 years. Analyzed the chief complaint, the symptom of their prevention was ischemia in 140 (58.3%) cases, hemorrhage in 56 (23.3%) cases, dizziness, or headache in 35 (14.5%) cases, and non-symptom in 9 (3.7%) cases. The demographic and clinical characteristics of 240 sampled MMD patients with and without postoperative complications are described in \u003cstrong\u003eTable 1\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIncidence of Redefined Postoperative Complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to our definition, the grade I complications were observed after 100 (41.6%) of the operations, including new postoperative incision\u0026nbsp;pain, postoperative pyrexia, weakness, headache, or dizziness; the grade II complications were observed after 67 (27.9%) of the operations, including epilepsy, aphasia, subcutaneous effusion, subcutaneous infection, impaired wound healing, or minor subarachnoid hemorrhage; and the grade III complications were observed after 16 (6.6%) of the operations, including new stroke events confirmed by neuroimaging or neurological deterioration in clinical evaluation. Patients with postoperative complications tended to be higher Suzuki stages (P\u0026lt;0.05), and shorter surgical time (P\u0026lt;0.0001), and there was no significant difference in age at operation, gender, unilateral or bilateral involvement, and chronic diseases history in patients with or without postoperative complications. Importantly, patients without any subjective symptoms tended to appear in the right- than left-hemisphere surgery (89.4% vs 10.5%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRedefined Postoperative Complications in Postoperative Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll postoperative complications recorded in medical history were collected and analyzed as the primary outcome measures in this study. Based on the results presented above, we investigated whether our redefined complications could affect the postoperative outcomes of MMD patients. Significantly, although there was no obvious difference of mRS scores at admission, patients with postoperative complications have statistically higher mRS score than these without postoperative complications at 6-months follow up (P\u0026lt;0.05) rather than them at discharge (P=0.14) (\u003cstrong\u003eFig.5A.\u003c/strong\u003e). In addition, our results shown that the patients with grade II complications tend to have higher mRS scores than those with asymptomatic complications (P = 0.214); and the patients with grade III complications tend to have higher mRS scores than those with asymptomatic complications (P \u0026lt; 0.0001), grade I complications (P = 0.002) and grade II complications (P = 0.03) (\u003cstrong\u003eFig.5B.\u003c/strong\u003e). These findings indicate that our new defined postoperative complications can early waring the long-term outcome in MMD patients who underwent STA-MCA bypass combined with EDMS surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of Postoperative Complications in Two Cohorts\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA comparison of the demographic and clinical characteristics of 240 MMD patients with redefined postoperative complications between the conventional cohort and the developed cohort was presented in \u003cstrong\u003eTable 2.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn general, the numbers and rates of redefined complications in MMD patients who underwent developed perioperative paradigm were lower than those who underwent conventional perioperative paradigm\u0026nbsp;[75 (69.4%) vs. 108 (81.8%), P = 0.025]. With the developed paradigm, the percentage of patients with grade I complications was significantly lower than the conventional cohort [47 (43.5%) vs. 53 (61.6%), P = 0.012]; the percentage of patients with grade II complications was significantly lower than the conventional cohort [23 (21.3%) vs. 47 (35.6%), P = 0.015]; and the percentage of patients with grade II complications was significantly lower than the conventional cohort [23 (21.3%) vs. 47 (35.6%), P = 0.015] (\u003cstrong\u003eFig.6.A\u003c/strong\u003e). Although there were no statistical differences in incidence of grade III complications in the developed cohort and the conventional cohort [5 (4.6%) vs. 11 (8.3%), P = 0.253], our results shown that the patients in developed cohort has a lower incidence of 6-months unfavorable outcomes[7 (6.5%) vs. 19 (14.4%), P = 0.049], rather than the discharge unfavorable outcomes [14 (13.0%) vs. 19 (14.4%), P = 0.32] than those in conventional cohort (\u003cstrong\u003eFig.6.B\u003c/strong\u003e).\u003c/p\u003e"},{"header":"Discussion ","content":"\u003cp\u003eThe revascularization surgery for MMD treatment is progressing gradually based on each surgeon’s practice, in this study, we reported a single center management experience on such a procedure. Significantly, in the Methods part of this article, we summarized and evaluated a developed perioperative paradigm for preventing postoperative complications in STA-MCA bypass combined with EDMS surgery of MMD patients. By comparing the MMD patients who received conventional management in the early years, our proposed managements paradigm indicated lower incidences of postoperative complications in our clinical practice of ten years, including CHS, cerebral ischemia, or transient neurological events (TNEs)\u003csup\u003e[7, 17]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe heterogeneity of postoperative complications of\u0026nbsp;STA-MCA bypass combined with EDMS surgery is strongly rooted in different studies, which are augmented further by the different types of complications. For example, the previously reported rate of postoperative CHS or cerebral ischemia varies from 1.5% to 11.4% for direct or combined bypass surgery in patients with MMD\u003csup\u003e[2, 8, 18]\u003c/sup\u003e. \u0026nbsp;It has been suggested that CHS or cerebral ischemia was an uneven cerebral hemodynamic change phenomenon caused by the excessive incoming flow that disturbs the routine blood flow\u003csup\u003e[19]\u003c/sup\u003e. To reduce the risk factor of such complications, a novel anastomosis strategy has been proposed to prevent the distal outflow of the donor STA, such as the side-to-side STA-MCA bypass surgery\u003csup\u003e[20]\u003c/sup\u003e. A recent study has reported that side-to-side STA-MCA bypass could reduce the incidence of postoperative CHS from 10.0% to 5.7% relatively\u003csup\u003e[21]\u003c/sup\u003e. However, the recipient selection, donor direction, and anastomosis location may be a series of concerns in such surgical or principles innovation. Even without them, the 5.7% incidence of postoperative CHS or cerebral ischemia is unacceptable in a large-scale vascular treatment center as the occurrence of it is often limited to time-consuming and costly conservative therapies, such as strict blood pressure control or intravenous drug administration\u003csup\u003e[22]\u003c/sup\u003e. In addition, with the possibility of stroke and progression to irreversible sequelae, some TNEs such as numbness, weakness, headaches, and aphasia that occurred 14.0% to 77.0% following MMD revascularization surgery have received increasing attention in recent years\u003csup\u003e[7, 12]\u003c/sup\u003e. Therefore, a comprehensive perioperative paradigm for the prevention of TNEs, CHS, or cerebral ischemia are essential for ensuring the benefits of MMD patients who underwent STA-MCA bypass combined with EDMS surgery.\u003c/p\u003e\n\u003cp\u003eGenerally, the surgical complications of STA-MCA bypass combined with EDMS surgery can be grouped into different categories. Based on the time dimension, the surgical complications can be divided into early (e.g. TNEs, CHS,\u0026nbsp;acute bleeding or occlusion\u003csup\u003e[17, 23]\u003c/sup\u003e) and\u0026nbsp;late complications (e.g. late stroke, late morbidity and mortality, or long-term unfavorable outcomes\u003csup\u003e[24-26]\u003c/sup\u003e). Based on the spatial dimension, the surgical complications can be classified as neurological (e.g. TNEs, CHS, or cerebral infarction\u003csup\u003e[8]\u003c/sup\u003e) and non-neurological complications (e.g. impaired wound healing or subdural effusion\u003csup\u003e[5]\u003c/sup\u003e). However, most of them are derived from\u0026nbsp;reports and there is no relatively comprehensive classification standard for them. In this study, we innovatively redefined the surgical complications of STA-MCA bypass combined with EDMS surgery from a severity dimension. As is shown in \u003cstrong\u003eFig.1\u003c/strong\u003e, it can range from a mild complication lasting a few weeks to a serious, reversible stage lasting months or years, and to a terrible, irreversible condition that can lead to a long-term unfavorable outcome or neurological deterioration. The results that MMD patients who have different grade of postoperative complications has different outcomes in mRS scores revealed that the grade difference of our redefined surgical complications may contribute to the discrepancy in surgical efficacy. Accordingly, developing a comprehensive perioperative paradigm to prevent the risk factors for these complications after STA-MCA bypass combined with EDMS surgery is not only a pressing need but a practical possibility.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; In the preoperative part, we highlight the preparation of the antiplatelet therapy and the management of epilepsy prevention was essential before surgery. To our knowledge, in most patients with an ischemic or transient ischemic attack (TIA) onset MMD, long-term combination administration of aspirin and clopidogrel, known as dual antiplatelet therapy, can effectively reduce the risk of novel occurrence of stroke events\u003csup\u003e[27, 28]\u003c/sup\u003e. Hence, a majority of patients with ischemic-onset MMD could have a history of the replacement therapy of oral antiplatelet drugs (single or dual) before revascularization admisson\u003csup\u003e[29, 30]\u003c/sup\u003e. In the view that aspirin can increase the bypass patency rate rather than the bleeding risk, we suggest not stopping it before surgery\u003csup\u003e[14]\u003c/sup\u003e. As for clopidogrel administration, we suggest an oral interruption for 7-10 days, which is equivalent to the average platelet lifespan, so as to normalize platelet function in patients\u003csup\u003e[31]\u003c/sup\u003e. During the interruption period, a preoperative bridging through haemodilution or volume expansion (5% glucose saline or ringer lactate solution) is a means of increasing the cerebral tolerance to the bypass procedure\u003csup\u003e[32]\u003c/sup\u003e. Meanwhile, a dual antiepileptic therapy for MMD is necessary because preoperative epilepsy is a prognostic factor for postoperative epilepsy, and patients with controlled epilepsy before surgery is more likely to be epilepsy free after bypass\u003csup\u003e[33, 34]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe craniotomy via extended pterion approach has been routine for the STA-MCA bypass combined with EDMS surgery. At first, we plan the safe operation position individually through the anatomical positions of the parietal branch of the STA, the sulcus of the MMA, and the coronary suture to ensure blood supply of a scalp incision. Then, we adopt a “bone-bridge method” (that is, use the high-speed grinding drill to polish the outer lamina of skull until exposed the inner lamina of skull) to protect the MMA near the pterion position\u003csup\u003e[35]\u003c/sup\u003e. During the procedure, STA has been only for direct anastomosis in our procedure because the STA as the indirect donor vascular graft is not always effective\u003csup\u003e[4]\u003c/sup\u003e. To reduce the risk of cerebral ischemia\u003csup\u003e[36]\u003c/sup\u003e, the arteries for anastomosis were selected according to the following criteria: 1) setting the site of the anastomosis before the bifurcation of M4 artery; 2) using sharp angle anastomosis between STA and MCA, and 3) ensuring the same blood flow direction of donor STA and recipient MCA.\u0026nbsp;To reduce the risk of CHS, surgical techniques innovations are as follows: 1) swerving the donor vessel to reduce the pressure of anastomosis, 2) sing the absorbable suture to ligate the high flow of STA, and 3) intensify the postoperative blood pressure management (see follow). Finally, a reconstruction principle of plastic surgery, including polishing the skull edge, covering the skull hole surface, and repairing the STA wound has been applied to restore skull and suture scalp.\u003c/p\u003e\n\u003cp\u003eAfter surgery, sufficient fluid resuscitation was performed and all the MMD patients would be given more than 3000 ml of intravenous fluids within the first 24 hours.\u0026nbsp;It should be noted that if an MMD patient’s recipient vessel is too thin or the donor pressure is too high (according to the experience of the neurosurgeon), aggressive blood pressure lowering therapy (lower than 130/80 mmHg) will be started immediately. Otherwise, the blood pressure is controlled below 140/90 mmHg in a patient with a history of hypertension and controlled nearly or slightly exceed the pre-operative levels in a patient without a history of hypertension. That is because recently we found that the early postoperative hemodynamic stable could affect the prognosis; the higher levels and large variability of mean arterial pressure were correlated with worse outcomes in patients with MMD\u003csup\u003e[37]\u003c/sup\u003e. In addition, dehydrating agents such as mannitol were routinely used to prevent brain edema caused by surgery. Then gradually reduce the volume of intravenous fluids to 1000 ml daily until discharge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations and Suggestions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral limitations of our study should be illustrated. At first, the Method article could not provide high-level evidence from randomized controlled trials due to its single-center retrospective design. Secondly, although we randomly sampled MMD cases from a single surgical team, the bias caused by the heterogeneity of neurosurgeon proficiency within the past ten years was inevitable in this study. Thirdly, we failed to compare the A-type and the B-type complications because of the low incidence of grade III complications. Future multiple operators involved in the multicenter prospective study were hoped to present more reliable data. However, the comparison between the two cohorts still presented effective technologies for reducing surgical complications, which makes further comparative and prospective research more valuable. This paradigm we presented was based on the long-term clinical experience that focuses on cerebral revascularization surgery in patients with MMD. More importantly, this study provides a comprehensive paradigm (including preoperative preparation, intraoperative technique, and postoperative management) for the STA-MCA bypass combined with EDMS surgery. We expect this paradigm to serve as a reference tool for future clinical practice and that the included concepts will provide greater benefit to MMD patients.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eHitherto, no report has sought the comprehensive perioperative management of cerebral revascularization surgery in patients with MMD. In this study, we initially proposed a comprehensive perioperative paradigm to prevent various risk factors for surgical complications after the STA-MCA bypass combined with EDMS surgery. Our proposed perioperative managements paradigm for MMD treatment are mostly based on the practice of a single center for ten years. With this developed paradigm, the rate of grade I and grade II complications in patients with MMD were significantly reduced, and the incidence of unfavorable outcomes was significantly decreased.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval:\u0026nbsp;\u003c/strong\u003eThis paradigm was approved by the ethics committee of the\u0026nbsp;Department of Neurosurgery, Huashan Hospital. All procedures performed in studies involving human participants were in accordance with the Helsinki declaration and its later amendments or comparable ethical standards. As this is a retrospective study, informed consent was not required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e:\u0026nbsp;This manuscript complies with all instructions to authors and all authors have read and agreed to the final version of the manuscript. This manuscript has not been published elsewhere and is not under consideration by another journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The data that support the findings of this study are available on request from corresponding authors. \u0026nbsp;The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eAll authors have disclosed that they do not have a potential conflict of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFundings\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Key Scientific Instrument and Equipment Development Project of China (Grant No. 2021YFF0702500); National Natural Science Foundation of China (Grand No. 82471407 and 82171382); Minhang District Natural Science Research Project (Grant No. 2024MHZ053), Shanghai, China; National Key Research and Development Program of China for Cancer, Cardiovascular and Cerebrovascular, Respiratory, and Metabolic Disease Prevention and Treatment (Grant No. 2023ZD0505003).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e: Xr. Y. and Lj.L. contributed to the conception and design of the work and drafted this manuscript; Rz. Z. and C.Y. performed the statistical analyses and prepared the clinical data; Xr. Y., Lj.L. and Rz. Z. prepared figures and tables; B.X. and F.x. supervised this study. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":" References","content":"\u003col\u003e\n \u003cli\u003eScott RM, Smith ER. Moyamoya disease and moyamoya syndrome. N Engl J Med\u003cem\u003e\u0026nbsp;\u003c/em\u003e2009;360:1226-1237. doi: 10.1056/NEJMra0804622.\u003c/li\u003e\n \u003cli\u003eGuzman R, Lee M, Achrol A, Bell-Stephens T, Kelly M, Do HM\u003cem\u003e, et al.\u003c/em\u003e Clinical outcome after 450 revascularization procedures for moyamoya disease. Clinical article. J Neurosurg\u003cem\u003e\u0026nbsp;\u003c/em\u003e2009;111:927-935. doi: 10.3171/2009.4.JNS081649.\u003c/li\u003e\n \u003cli\u003eMayeku J, Lopez-Gonzalez MA. Current Surgical Options for Moyamoya Disease. Cureus\u003cem\u003e\u0026nbsp;\u003c/em\u003e2020;12:e11332. doi: 10.7759/cureus.11332.\u003c/li\u003e\n \u003cli\u003eXu B, Song DL, Mao Y, Gu YX, Xu H, Liao YJ\u003cem\u003e, et al.\u003c/em\u003e Superficial temporal artery-middle cerebral artery bypass combined with encephalo-duro-myo-synangiosis in treating moyamoya disease: surgical techniques, indications and midterm follow-up results. Chin Med J (Engl)\u003cem\u003e\u0026nbsp;\u003c/em\u003e2012;125:4398-4405. doi.\u003c/li\u003e\n \u003cli\u003eFujimura M, Tominaga T. Current status of revascularization surgery for Moyamoya disease: special consideration for its \u0026apos;internal carotid-external carotid (IC-EC) conversion\u0026apos; as the physiological reorganization system. Tohoku J Exp Med\u003cem\u003e\u0026nbsp;\u003c/em\u003e2015;236:45-53. doi: 10.1620/tjem.236.45.\u003c/li\u003e\n \u003cli\u003eChoi JW, Chong S, Phi JH, Lee JY, Kim HS, Chae JH\u003cem\u003e, et al.\u003c/em\u003e Postoperative Symptomatic Cerebral Infarction in Pediatric Moyamoya Disease: Risk Factors and Clinical Outcome. World Neurosurg\u003cem\u003e\u0026nbsp;\u003c/em\u003e2020;136:e158-e164. doi: 10.1016/j.wneu.2019.12.072.\u003c/li\u003e\n \u003cli\u003eLu J, Zhao Y, Ma L, Chen Y, Li M, Chen X\u003cem\u003e, et al.\u003c/em\u003e Predictors and clinical features of transient neurological events after combined bypass revascularization for moyamoya disease. Clin Neurol Neurosurg\u003cem\u003e\u0026nbsp;\u003c/em\u003e2019;186:105505. doi: 10.1016/j.clineuro.2019.105505.\u003c/li\u003e\n \u003cli\u003eZhao M, Deng X, Zhang D, Wang S, Zhang Y, Wang R\u003cem\u003e, et al.\u003c/em\u003e Risk factors for and outcomes of postoperative complications in adult patients with moyamoya disease. J Neurosurg\u003cem\u003e\u0026nbsp;\u003c/em\u003e20181-12. doi: 10.3171/2017.10.JNS171749.\u003c/li\u003e\n \u003cli\u003eRumalla K, Srinivasan VM, Gaddis M, Kan P, Lawton MT, Burkhardt JK. Readmission following extracranial-intracranial bypass surgery in the United States: nationwide rates, causes, risk factors, and volume-driven outcomes. J Neurosurg\u003cem\u003e\u0026nbsp;\u003c/em\u003e20201-9. doi: 10.3171/2020.6.JNS202117.\u003c/li\u003e\n \u003cli\u003eLiao Y, Xu F, Xu B. How I do it: superficial temporal artery to middle cerebral artery bypass for moyamoya disease. Acta Neurochir (Wien)\u003cem\u003e\u0026nbsp;\u003c/em\u003e2022;164:1855-1859. doi: 10.1007/s00701-022-05255-1.\u003c/li\u003e\n \u003cli\u003eResearch Committee on the P, Treatment of Spontaneous Occlusion of the Circle of W, Health Labour Sciences Research Grant for Research on Measures for Infractable D. Guidelines for diagnosis and treatment of moyamoya disease (spontaneous occlusion of the circle of Willis). Neurol Med Chir (Tokyo)\u003cem\u003e\u0026nbsp;\u003c/em\u003e2012;52:245-266. doi: 10.2176/nmc.52.245.\u003c/li\u003e\n \u003cli\u003eUda K, Araki Y, Muraoka S, Ota S, Wada K, Yokoyama K\u003cem\u003e, et al.\u003c/em\u003e Intraoperative evaluation of local cerebral hemodynamic change by indocyanine green videoangiography: prediction of incidence and duration of postoperative transient neurological events in patients with moyamoya disease. J Neurosurg\u003cem\u003e\u0026nbsp;\u003c/em\u003e20181-9. doi: 10.3171/2017.10.JNS171523.\u003c/li\u003e\n \u003cli\u003eHamano E, Kataoka H, Morita N, Maruyama D, Satow T, Iihara K\u003cem\u003e, et al.\u003c/em\u003e Clinical implications of the cortical hyperintensity belt sign in fluid-attenuated inversion recovery images after bypass surgery for moyamoya disease. J Neurosurg\u003cem\u003e\u0026nbsp;\u003c/em\u003e2017;126:1-7. doi: 10.3171/2015.10.JNS151022.\u003c/li\u003e\n \u003cli\u003eLu J, Shi G, Zhao Y, Wang R, Zhang D, Chen X\u003cem\u003e, et al.\u003c/em\u003e Effects and safety of aspirin use in patients after cerebrovascular bypass procedures. Stroke Vasc Neurol\u003cem\u003e\u0026nbsp;\u003c/em\u003e2021;6:624-630. doi: 10.1136/svn-2020-000770.\u003c/li\u003e\n \u003cli\u003eKim M, Park W, Chung Y, Lee SU, Park JC, Kwon DH\u003cem\u003e, et al.\u003c/em\u003e Development and validation of a risk scoring model for postoperative adult moyamoya disease. J Neurosurg\u003cem\u003e\u0026nbsp;\u003c/em\u003e2020;134:1505-1514. doi: 10.3171/2020.2.JNS193221.\u003c/li\u003e\n \u003cli\u003eKang K, Lu J, Ju Y, Ji R, Wang D, Shen Y\u003cem\u003e, et al.\u003c/em\u003e Clinical and Radiological Outcomes After Revascularization of Hemorrhagic Moyamoya Disease. Front Neurol\u003cem\u003e\u0026nbsp;\u003c/em\u003e2020;11:382. doi: 10.3389/fneur.2020.00382.\u003c/li\u003e\n \u003cli\u003eSussman ES, Madhugiri V, Teo M, Nielsen TH, Furtado SV, Pendharkar AV\u003cem\u003e, et al.\u003c/em\u003e Contralateral acute vascular occlusion following revascularization surgery for moyamoya disease. J Neurosurg\u003cem\u003e\u0026nbsp;\u003c/em\u003e2018;131:1702-1708. doi: 10.3171/2018.8.JNS18951.\u003c/li\u003e\n \u003cli\u003eJung YJ, Ahn JS, Kwon DH, Kwun BD. Ischemic complications occurring in the contralateral hemisphere after surgical treatment of adults with moyamoya disease. J Korean Neurosurg Soc\u003cem\u003e\u0026nbsp;\u003c/em\u003e2011;50:492-496. doi: 10.3340/jkns.2011.50.6.492.\u003c/li\u003e\n \u003cli\u003eTu XK, Fujimura M, Rashad S, Mugikura S, Sakata H, Niizuma K\u003cem\u003e, et al.\u003c/em\u003e Uneven cerebral hemodynamic change as a cause of neurological deterioration in the acute stage after direct revascularization for moyamoya disease: cerebral hyperperfusion and remote ischemia caused by the \u0026apos;watershed shift\u0026apos;. Neurosurg Rev\u003cem\u003e\u0026nbsp;\u003c/em\u003e2017;40:507-512. doi: 10.1007/s10143-017-0845-9.\u003c/li\u003e\n \u003cli\u003eLang MJ, Kan P, Baranoski JF, Lawton MT. Side-to-Side Superficial Temporal Artery to Middle Cerebral Artery Bypass Technique: Application of Fourth Generation Bypass in a Case of Adult Moyamoya Disease. Oper Neurosurg (Hagerstown)\u003cem\u003e\u0026nbsp;\u003c/em\u003e2020;18:480-486. doi: 10.1093/ons/opz268.\u003c/li\u003e\n \u003cli\u003eZhang J, Yu J, Xin C, Fujimura M, Lau TY, Hu M\u003cem\u003e, et al.\u003c/em\u003e A flow self-regulating superficial temporal artery-middle cerebral artery bypass based on side-to-side anastomosis for adult patients with moyamoya disease. J Neurosurg\u003cem\u003e\u0026nbsp;\u003c/em\u003e20221-10. doi: 10.3171/2022.8.JNS221379.\u003c/li\u003e\n \u003cli\u003eUchino H, Nakayama N, Kazumata K, Kuroda S, Houkin K. Edaravone Reduces Hyperperfusion-Related Neurological Deficits in Adult Moyamoya Disease: Historical Control Study. Stroke\u003cem\u003e\u0026nbsp;\u003c/em\u003e2016;47:1930-1932. doi: 10.1161/STROKEAHA.116.013304.\u003c/li\u003e\n \u003cli\u003eLi C, Zhang N, Yu S, Xu Y, Yao Y, Zeng M\u003cem\u003e, et al.\u003c/em\u003e Individualized Perioperative Blood Pressure Management for Adult Moyamoya Disease: Experience from 186 Consecutive Procedures. J Stroke Cerebrovasc Dis\u003cem\u003e\u0026nbsp;\u003c/em\u003e2021;30:105413. doi: 10.1016/j.jstrokecerebrovasdis.2020.105413.\u003c/li\u003e\n \u003cli\u003eKarsten MB, Smith ER, Scott RM. Late morbidity and mortality following revascularization surgery for moyamoya disease in the pediatric population. J Neurosurg Pediatr\u003cem\u003e\u0026nbsp;\u003c/em\u003e20211-6. doi: 10.3171/2021.1.PEDS20944.\u003c/li\u003e\n \u003cli\u003eAraki Y, Yokoyama K, Uda K, Kanamori F, Mamiya T, Nishihori M\u003cem\u003e, et al.\u003c/em\u003e Ipsilateral late stroke after revascularization surgery for patients with Moyamoya disease. Acta Neurochir (Wien)\u003cem\u003e\u0026nbsp;\u003c/em\u003e2021;163:1493-1502. doi: 10.1007/s00701-021-04773-8.\u003c/li\u003e\n \u003cli\u003eCho WS, Kim JE, Kim CH, Ban SP, Kang HS, Son YJ\u003cem\u003e, et al.\u003c/em\u003e Long-term outcomes after combined revascularization surgery in adult moyamoya disease. Stroke\u003cem\u003e\u0026nbsp;\u003c/em\u003e2014;45:3025-3031. doi: 10.1161/STROKEAHA.114.005624.\u003c/li\u003e\n \u003cli\u003eZhao Y, Zhang Q, Zhang D, Zhao Y. Effect of Aspirin in Postoperative Management of Adult Ischemic Moyamoya Disease. World Neurosurg\u003cem\u003e\u0026nbsp;\u003c/em\u003e2017;105:728-731. doi: 10.1016/j.wneu.2017.06.057.\u003c/li\u003e\n \u003cli\u003eWang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C\u003cem\u003e, et al.\u003c/em\u003e Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med\u003cem\u003e\u0026nbsp;\u003c/em\u003e2013;369:11-19. doi: 10.1056/NEJMoa1215340.\u003c/li\u003e\n \u003cli\u003eKraemer M, Berlit P, Diesner F, Khan N. What is the expert\u0026apos;s option on antiplatelet therapy in moyamoya disease? Results of a worldwide Survey. Eur J Neurol\u003cem\u003e\u0026nbsp;\u003c/em\u003e2012;19:163-167. doi: 10.1111/j.1468-1331.2011.03481.x.\u003c/li\u003e\n \u003cli\u003eYe F, Li J, Wang T, Lan K, Li H, Yin H\u003cem\u003e, et al.\u003c/em\u003e Efficacy and Safety of Antiplatelet Agents for Adult Patients With Ischemic Moyamoya Disease. Front Neurol\u003cem\u003e\u0026nbsp;\u003c/em\u003e2020;11:608000. doi: 10.3389/fneur.2020.608000.\u003c/li\u003e\n \u003cli\u003eTafur A, Douketis J. Perioperative management of anticoagulant and antiplatelet therapy. Heart\u003cem\u003e\u0026nbsp;\u003c/em\u003e2018;104:1461-1467. doi: 10.1136/heartjnl-2016-310581.\u003c/li\u003e\n \u003cli\u003eGross CE, Bednar MM, Lew SM, Florman JE, Kohut JJ. Preoperative volume expansion improves tolerance to carotid artery cross-clamping during endarterectomy. Neurosurgery\u003cem\u003e\u0026nbsp;\u003c/em\u003e1998;43:222-226; discussion 226-228. doi: 10.1097/00006123-199808000-00016.\u003c/li\u003e\n \u003cli\u003eMa Y, Zhao M, Zhang Q, Liu X, Zhang D, Wang S\u003cem\u003e, et al.\u003c/em\u003e Risk Factors for Epilepsy Recurrence after Revascularization in Pediatric Patients with Moyamoya Disease. J Stroke Cerebrovasc Dis\u003cem\u003e\u0026nbsp;\u003c/em\u003e2018;27:740-746. doi: 10.1016/j.jstrokecerebrovasdis.2017.10.012.\u003c/li\u003e\n \u003cli\u003eAlramadan A, Ul Haq A, Basindwah S, Alshail E. Seizure outcome in moyamoya after indirect revascularization in pediatric patients: Retrospective study and literature review. Surg Neurol Int\u003cem\u003e\u0026nbsp;\u003c/em\u003e2021;12:73. doi: 10.25259/SNI_633_2020.\u003c/li\u003e\n \u003cli\u003eYu J, Guo Y, Xu B, Xu K. Clinical importance of the middle meningeal artery: A review of the literature. Int J Med Sci\u003cem\u003e\u0026nbsp;\u003c/em\u003e2016;13:790-799. doi: 10.7150/ijms.16489.\u003c/li\u003e\n \u003cli\u003eQian Y, Huang B, Hu Z, Wang J, Zhao P, Li X. Analysis of Factors Related to Cerebral Infarction after Direct Bypass Surgery in Adults with Moyamoya Disease. Cerebrovasc Dis\u003cem\u003e\u0026nbsp;\u003c/em\u003e2020;49:55-61. doi: 10.1159/000504743.\u003c/li\u003e\n \u003cli\u003eSong J, Lei Y, Chen L, Gao C, Ni W, Wu X\u003cem\u003e, et al.\u003c/em\u003e The First 24 h Hemodynamic Management in NICU after Revascularization Surgery in Moyamoya Disease. Behav Neurol\u003cem\u003e\u0026nbsp;\u003c/em\u003e2021;2021:5061173. doi: 10.1155/2021/5061173.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Demographic and clinical characteristics of a total of 240 sampled MMD patients.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"560\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll patents (n=240)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative Complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAsymptomatic\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=57)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade I\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=100)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade II\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=67)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade III\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=16)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAge at operation (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44.80 \u0026plusmn; 12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e46.02 \u0026plusmn; 14.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e43.20 \u0026plusmn; 12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45.46 \u0026plusmn; 11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e47.69 \u0026plusmn; 8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e131 (54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34 (59.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e49 (49.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41 (61.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (43.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e109 (45.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23 (40.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e51 (51.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26 (38.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (56.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMedical history\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eHypertension\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68 (28.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (21.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28 (28.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24 (35.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eDiabetes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCoronary disease\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eOthers\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6(2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOnset symptom\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eHemorrhagic\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56 (23.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26 (26.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 (29.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (43.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eIschemic\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e140 (58.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41 (71.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56 (56.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38 (56.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (31.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eInfarction\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e76 (31.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18 (31.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29 (29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25 (37.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eTIA\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e64 (26.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23 (40.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27 (27.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eHeadache or dizziness\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35 (14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eAsymptomatic\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDisease involved\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e151 (62.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30 (52.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e63 (63.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e46 (68.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUnilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e89 (37.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27 (47.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37 (37.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (31.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical hemisphere\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eLeft\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e108 (45.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48 (48.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48 (71.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eRight\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e132 (55.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e51 (89.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e52 (52.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19 (28.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003emRS score (points)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eAdmission\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.50 \u0026plusmn; 0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.18 \u0026plusmn; 0.5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.58 \u0026plusmn; 0.9\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.66 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.63 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eDischarge\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.33 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.04 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.30 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.43 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.13 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eFollow-up\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.85 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.60 \u0026plusmn; 1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.77 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.97 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.75 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSuzuki stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eMean\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.32 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.00 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.38 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.45 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.56 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eI\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56 (23.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18 (18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16 (23.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (18.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eII\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e84 (35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24 (42.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38 (38.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18 (26.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eIII\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e74 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33 (33.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23 (34.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (43.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eIV\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eV\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (1,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eVI\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical time (hours)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.75 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.47 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.79 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.87 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.00 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative hospitalization (days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.48 \u0026plusmn; 5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.70 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.01 \u0026plusmn; 2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14.70 \u0026plusmn; 4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20.56 \u0026plusmn; 8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Comparison of the general information in MMD patients in two cohorts.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConventional cohort (n=132)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDeveloped cohort (n=108)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge at operation (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e44.25 \u0026plusmn; 12.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e45.47 \u0026plusmn; 13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e67 (50.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e64 (59.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e65 (49.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e44 (40.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedical history\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eHypertension\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e30 (22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e38 (35.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eDiabetes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e10 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e14 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eCoronary disease\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e2 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e2 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eOthers\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e2 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e4 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOnset symptom\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eHemorrhagic\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e39 (29.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e17 (15.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eIschemic\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e66 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e74 (68.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eInfarction\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e34 (25.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e42 (38.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eTIA\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e32 (24.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e32 (29.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eHeadache or dizziness\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e21 (15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e14 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eAsymptomatic\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e6 (4.5)\u003c/p\u003e\n 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\u003cp\u003e\u003cstrong\u003emRS score (points)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eAdmission\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1.56 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e1.44 \u0026plusmn; 0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eDischarge\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1.30 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e1.36 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eFollow-up\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1.02 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e0.66 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.0136*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuzuki 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27px;\"\u003e\n \u003cp\u003e27 (20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e29 (26.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eII\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e45 (34.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e39 (36.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eIII\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e48 (36.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e26 (24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eIV\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e9 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e11 (10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eV\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e3 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e2 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003eVI\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e1 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical time (hours)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e2.98 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e2.46 \u0026plusmn; 0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative hospitalization (days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e13.39 \u0026plusmn; 5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e9.14 \u0026plusmn; 3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026lt;0.0001****\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Supplementary Videos","content":"\u003cp\u003eSupplementary Videos not available with this version\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6418317/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6418317/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eOBJECTIVE \u003c/strong\u003eWe aimed to present our experience with the complications’ definition, technical advances, and outcomes patients who underwent superficial temporal artery-middle cerebral artery (STA-MCA) bypass combined with encephalo-duro-myo-synangiosis (EDMS) surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMETHODS \u003c/strong\u003eSTA-MCA combined with EDMS surgery was certified effective in patients with MMD who were treated by an experienced team. Patients received conventional management from Dec 2012 to April 2018 in our hospital. After a perioperative paradigm had been developed, patients received comprehensive management from May 2018 to June 2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRESULTS \u003c/strong\u003eA total of 240 MMD patients who underwent STA-MCA combined with EDMS surgery were sampled and divided into two cohorts according to the chronological order. Among them, 132 (55.0%) patients underwent routine management mode, and 108 (45.0%) patients underwent the proposed perioperative management mode. The clinical characteristics of the two cohorts was homogenous, and the postoperative outcomes are differential. We redefined the surgical complications of STA-MCA combined with EDMS surgery range from a mild complication lasting a few weeks to a serious, reversible stage lasting months or years, and to a terrible, irreversible condition that causing long-term unfavorable outcome or neurological deterioration. Accordingly, patients who received our proposed paradigm presented a significantly decreased incidence of grade I and grade II complications. Although there was no statistical difference in grade III complications, patients in developed cohort tend to have a lower incidence of 6-months unfavorable outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSIONS\u003c/strong\u003e This evolved perioperative paradigm could effectively prevent risk factors and reduce related complications of STA-MCA combined with EDMS surgery.\u003c/p\u003e","manuscriptTitle":"Perioperative management for patients with moyamoya disease: complications’ definition, technical advances, and outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-30 16:09:38","doi":"10.21203/rs.3.rs-6418317/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"412f6cdd-cb82-4dba-9ce2-cce86945da05","owner":[],"postedDate":"May 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-29T22:53:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-30 16:09:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6418317","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6418317","identity":"rs-6418317","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}