Anesthetic Management for Laparoscopic Radical Colectomy in a Patient with Moyamoya Disease: Case Report

Anesthetic Management for Laparoscopic Radical Colectomy in a Patient with Moyamoya Disease: Case Report | 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 Case Report Anesthetic Management for Laparoscopic Radical Colectomy in a Patient with Moyamoya Disease: Case Report Yong Chen, Lin Jiang, Hua Hong, Dapeng Yu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8650013/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 Moyamoya disease is a chronic, progressive occlusive cerebrovascular disorder characterized by bilateral stenosis or occlusion of the terminal internal carotid arteries and the development of a fine, abnormal vascular network (the "moyamoya" vessels) at the base of the brain. Its pathophysiology involves impaired cerebral autoregulation, making cerebral blood flow (CBF) pressure-dependent, along with reduced perfusion pressure and blood flow in the anterior circulation, and impaired cerebrovascular reactivity to CO₂. Anesthesia management in these patients is challenging due to the high risk of cerebral ischemia or hemorrhage. We report the successful anesthetic management of a patient with Moyamoya disease and a history of hemiparesis who underwent laparoscopic radical colectomy for colon cancer without neurological deterioration. Moyamoya Disease General anesthesia Cerebral blood flow Figures Figure 1 Introduction The incidence of Moyamoya disease in China is 3.92 per 100,000 [2], with annual rates of intracranial hemorrhage and cerebral infarction reported as 0.22/100,000 and 0.16/100,000, respectively [2, 3]. Cerebral infarction is the most common complication, with an incidence of 12.4% [4]. This case highlights the perioperative considerations and strategies for managing such high-risk patients undergoing non-neurological surgery. Case Report A 70-year-old male (height 167 cm, weight 70 kg) was admitted with a colonic mass. His medical history included hypertension, controlled with captopril and nifedipine, and a cerebral infarction three years prior, which resulted in motor aphasia and right-sided hemiparesis. Physical examination revealed a conscious patient with bilateral, equal, and reactive pupils (2.0 mm). Brain Magnetic Resonance Imaging (MRI) showed the absence of bilateral internal carotid, anterior cerebral, and middle cerebral arteries, with a left temporal lobe encephalomalacia (Fig. 1 ), confirming the diagnosis of Moyamoya disease. A multidisciplinary team involving colorectal surgeons, anesthesiologists, neurosurgeons, and oncologists decided to proceed with an elective laparoscopic radical colectomy due to impending intestinal obstruction from the colonic tumor. Neurosurgeons recommended preoperative subcutaneous low-molecular-weight heparin (LMWH) at 0.5 mg/kg once daily. Upon arrival in the operating room, the patient's non-invasive blood pressure (NIBP) was 189/102 mmHg, heart rate (HR) 95 bpm, and oxygen saturation (SpO₂) 98%. After rest, NIBP decreased to 176/97 mmHg with HR 92 bpm. An arterial catheter was placed in the left radial artery under local anesthesia for continuous blood pressure monitoring. An intravenous line was established. Anesthesia was induced with intravenous lidocaine (60 mg), propofol (90 mg), sufentanil (25 µg), dexamethasone (10 mg), ondansetron (8 mg), and cisatracurium (10 mg). Tracheal intubation was performed with a 7.5 mm ID tube, and pressure-controlled mechanical ventilation was initiated. Anesthesia was maintained with sevoflurane (1.5–2.6%) and target-controlled infusion of remifentanil (2–3 ng/ml). A right internal jugular venous catheter was inserted. Monitoring included Bispectral Index (BIS), nasopharyngeal temperature, urine output, and serial arterial blood gas analyses, with potassium supplementation as needed. The laparoscopic right hemicolectomy lasted 4 hours. Intraoperative parameters were maintained within target ranges: Arterial Blood Pressure (ABP) 140–160/75–90 mmHg, HR 60–80 bpm, PaCO₂ 41–45 mmHg, BIS 39–51, and temperature 35.9–36.6°C. Fluid administration included approximately 800 ml of hydroxyethyl starch and 1300 ml of Ringer's solution. Total urine output was 1200 ml, with an estimated blood loss of 30 ml. The patient emerged from anesthesia approximately 20 minutes after arrival in the Post-Anesthesia Care Unit (PACU) and was extubated. Neurological examination revealed bilateral limb muscle strength comparable to the preoperative state. The patient was transferred to the ward and discharged about 10 days later without complications. Discussion The fundamental pathology in Moyamoya disease is impaired CBF, predisposing patients to cerebral infarction [5]. Risk factors for perioperative infarction include a history of prior stroke, high Suzuki stage on the non-operative side, involvement of the posterior cerebral artery, specific surgical revascularization techniques (indirect or combined bypass), diabetes, and preoperative hemodynamic instability [6–9]. Among these, preoperative hemodynamic instability is a key modifiable risk factor. This case demonstrates the application of various anesthetic strategies aimed at preventing cerebral ischemia in a patient with Moyamoya disease undergoing major abdominal surgery. The multidisciplinary decision for preoperative LMWH was crucial for thromboembolism prophylaxis. Careful anesthetic management is paramount for patients with Moyamoya disease (MMD) or Moyamoya syndrome (MMS) during surgery. While evidence for specific protocols is limited, consensus principles guide management. Control of Cerebral Blood Flow (CBF): CBF is tightly regulated to match metabolic demand [10]. It constitutes 15–20% of cardiac output (CO). Understanding how CO influences CBF is fundamental, as CBF depends on receiving a significant portion of CO. Blood pressure and CO are interrelated but distinct hemodynamic parameters that often change concurrently and can differentially impact cerebral perfusion [11]. A decrease in CO leads to a slight downward shift of the CBF autoregulation plateau, and vice versa, though the autoregulatory mechanism itself is generally preserved. Blood pressure is the product of CO and systemic vascular resistance (SVR). CO is determined by heart rate (HR) and stroke volume (SV), the latter influenced by preload, contractility, and afterload. SVR depends on vascular radius, length, and blood viscosity [12]. With constant SVR, CO becomes a primary determinant of blood pressure. From this perspective, monitoring CO might be more insightful than blood pressure alone. It is also essential to recognize that CO is the product of SV and HR, underscoring the importance of maintaining an adequate heart rate. Fluid Management and Volume Status: Preoperative fasting can lead to hypovolemia and reduced CBF. Adequate volume loading before induction is essential. Effective fluid therapy helps maintain oxygen delivery-demand balance in vital organs [13]. Patients with MMD, having compromised cerebral hemodynamics, impaired cerebrovascular reactivity, and autoregulation, are particularly vulnerable to cerebral hypoperfusion and postoperative infarction [14]. Therefore, maintaining a hypervolemic state perioperatively is recommended to prevent hypotension and low cerebral perfusion pressure [15]. In this case, we administered approximately 200 ml of hydroxyethyl starch before induction and 500 ml before skin incision, with a total intraoperative fluid intake of 800 ml colloid and 1300 ml crystalloid. Goal-directed fluid therapy aimed at optimizing CO has been associated with improved outcomes after intracranial surgery [16, 17]. Urine output serves as a reliable indicator of volume status. Low urine output in MMD patients is a high-risk factor for perioperative neurological complications. The total perioperative urine output was 1200 ml. Hematocrit (HCT) also requires attention; low HCT impairs cerebral oxygen delivery, while high HCT increases the risk of infarction. Although the ideal HCT remains debated, maintaining it between 30% and 42% is generally advised [18]. Blood Pressure Management: Maintaining blood pressure at or slightly above the patient's baseline is critical [19]. Hypotension can lead to decreased CBF and perfusion pressure, precipitating ischemia or infarction. Thus, invasive arterial monitoring before induction is necessary. The target systolic blood pressure was set between 140–160 mmHg, based on the patient's ward readings of 119–140 mmHg, while avoiding pressures above 180 mmHg. Vasoactive drugs should be used as needed to ensure stability. It is important to note that interventions like dobutamine and volume expansion can increase CO without necessarily raising blood pressure. Conversely, high doses of vasoconstrictors (e.g., phenylephrine, norepinephrine) may sustain blood pressure but potentially reduce CO [20, 21]. Their net effect on CBF likely depends on the specific drug, the disease state, and the functional status of cerebral perfusion mechanisms [22, 23]. In this case, we employed a combination of low-dose dobutamine and metaraminol to support both CO and pressure. Acute changes in CO during surgery are common due to factors like dehydration, bleeding, positioning, pneumoperitoneum, vasodilation, sympathetic blockade, anesthetics, and arrhythmias. Since a decrease in CO can reduce CBF, we believe it is imperative to correct detrimental reductions in CO. Ventilation and Temperature: Hyperventilation-induced hypocapnia causes cerebral vasoconstriction and increases the risk of ischemia [24]. Therefore, normocapnia was maintained, with PaCO₂ kept between 41–45 mmHg. While mild hypothermia may offer neuroprotection, evidence is scarce; thus, maintaining normal body temperature is standard practice [25]. Postoperative Care: Postoperative management focused on maintaining hypervolemia to prevent hypotension and low cerebral perfusion pressure, along with continued LMWH for thrombosis prophylaxis. Conclusion Effective prevention and management of perioperative stroke risk in Moyamoya disease require comprehensive preoperative assessment and optimization, individualized intraoperative strategies to maintain cerebral perfusion and minimize embolic risk, and systematic postoperative monitoring for early detection and intervention of neurological events. A multidisciplinary collaborative model involving surgeons, anesthesiologists, and the perioperative care team is crucial for addressing the multifaceted nature of this risk. Hypoperfusion is a key mechanism for perioperative infarction, underscoring the importance of strict hemodynamic management to ensure adequate cerebral perfusion during critical periods.Further research is warranted to determine how to provide rational, individualized perioperative management for patients with Moyamoya disease undergoing cerebral revascularization and other surgeries to minimize complications. Declarations Declatation of conflicting: The authors do not have any possible conflicts of interest. Research funding： This research did not receive funding. Clinical trial number： Not applicable. Patient informed consent to publish: The patients written the consents for the Material about them/the patients to appear in a publication. The case details with identifying images can be publish without institutional approval. Ethics approval and consent to participate： Not applicable. Availability of Data and Materials： The materials described in the manuscript, including all relevant raw data, will be freely available to any scientist wishing to use them for non-commercial purposes, without breaching participant confidentiality. The authors' contributions are listed as follows: Yong Chen collected the data of this case, Hua Hong and Lin Jiang gave some writing advice，Dapeng Yu completed the article. Acknowledgements: I would like to express my gratitude to all individuals and organizations who provided me with support and assistance during the preparation and writing of this paper. References Autosomal dominant moyamoya disease maps to chromosome 17q25.3.[J].Neurology, 2008.DOI:10.1212/01.wnl.0000291012.49986.f9. Miao W , Zhao P L , Zhang Y S ,et al.Epidemiological and clinical features of Moyamoya disease in Nanjing, China[J].CLINICAL NEUROLOGY AND NEUROSURGERY, 2010. DOI:10.1016/j.clineuro.2009.11.009. Ding YH, Chen JY, Zheng ES, Wang ZQ, Liang RS, Shi SS, Tu XK. Clinical features, surgical treatment, and long-term outcomes of moyamoya disease in a single institution of Fujian, Southeast China: A retrospective study. Medicine (Baltimore). 2023 Oct 27;102(43):e35684. doi: 10.1097/MD.0000000000035684. PMID: 37904447; PMCID: PMC10615558. Qian Y , Huang B , Hu Z ,et al.Analysis of Factors Related to Cerebral Infarction after Direct Bypass Surgery in Adults with Moyamoya Disease[J].Cerebrovascular diseases (Basel, Switzerland), 2020, 49(1):55-61.DOI:10.1159/000504743. Kim J W , Hayashi T , Kim S K ,et al.Technical evolution of pediatric neurosurgery: moyamoya disease[J].Child's Nervous System, 2023, 39(10).DOI:10.1007/s00381-023-06017-9. Wei W , Chen X , Jun Y ,et al.Risk factors for postoperative stroke in adults patients with moyamoya disease: a systematic review with meta-analysis[J]. 2019.DOI:10.21203/rs.2.304/v2． Kazumata K , Ito M , Tokairin K ,et al.The frequency of postoperative stroke in moyamoya disease following combined revascularization: a single-university series and systematic review[J].Journal of Neurosurgery, 2014, 121(2):432-440.DOI:10.3171/2014.1.JNS13946.． Toru I , Nobuo H , Yasuhiro Y .The relevance of hemodynamic factors to perioperative ischemic complications in childhood moyamoya disease [J]. Neurosurgery, 1996(6):1120-1125. DOI:10.1097/00006123-199606000-00011. Lee J K , Williams M , Reyes M ,et al.Cerebrovascular blood pressure autoregulation monitoring and postoperative transient ischemic attack in pediatric moyamoya vasculopathy[J].Paediatric Anaesthesia, 2017.DOI:10.1111/pan.13293. Bor-Seng-Shu E, Kita WS, Figueiredo EG, Paiva WS, Fonoff ET, Teixeira MJ, Panerai RB. Cerebral hemodynamics: concepts of clinical importance. Arq Neuropsiquiatr. 2012 May;70(5):352-6. doi: 10.1590/s0004-282x2012000500010. PMID: 22618788. Meng L , Cannesson M , Alexander B S ,et al.Effect of phenylephrine and ephedrine bolus treatment on cerebral oxygenation in anaesthetized patients[J].British Journal of Anaesthesia, 2011(2):209-217.DOI:10.1093/bja/aer150. Meng L , Hou W , Chui J ,et al.Cardiac Output and Cerebral Blood Flow [J]. Anesthesiology,2015,123(5):1198-1208.DOI:10.1097/aln.0000000000000872 van der Jagt M. Fluid management of the neurological patient: a concise review. Crit Care. 2016 May 31;20(1):126. doi: 10.1186/s13054-016-1309-2. PMID: 27240859; PMCID: PMC4886412. Shu L , Aziz Y N , Msci A D H , ,et al.Perioperative Stroke: Mechanisms, Risk Stratification, and Management[J].Stroke, 2025, 56(9):12.DOI:10.1161/STROKEAHA.125.051673. Smith E R , Scott R M .Surgical Management of Moyamoya Syndrome[J].Skull Base Surgery, 2005, 15(1):15-26.DOI:10.1055/s-2005-868160. Gan TJ, Soppitt A, Maroof M, el-Moalem H, Robertson KM, Moretti E, Dwane P, Glass PS. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002 Oct;97(4):820-6. doi: 10.1097/00000542-200210000-00012. PMID: 12357146. Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF, Barclay GR, Fleming SC. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005 Nov;95(5):634-42. doi: 10.1093/bja/aei223. Epub 2005 Sep 9. PMID: 16155038. Dutta B , Dehran M , Sinha R .Anaesthetic management of a parturient with Moyamoya disease [J]. Singapore Med J, 2011, 52(6):108-10.DOI:doi:10.3325/cmj.2011.52. 436. Narisawa A , Fujimura M , Tominaga T .Efficacy of the revascularization surgery for adult-onset moyamoya disease with the progression of cerebrovascular lesions[J].Clin Neurol Neurosurg, 2009, 111(2):123-126.DOI:10.1016/j.clineuro.2008.09.022. Meng L, Cannesson M, Alexander BS, Yu Z, Kain ZN, Cerussi AE, Tromberg BJ, Mantulin WW. Effect of phenylephrine and ephedrine bolus treatment on cerebral oxygenation in anaesthetized patients. Br J Anaesth. 2011 Aug;107(2):209-17. doi: 10.1093/bja/aer150. Epub 2011 Jun 3. PMID: 21642644; PMCID: PMC3136202. Maas JJ, Pinsky MR, de Wilde RB, de Jonge E, Jansen JR. Cardiac output response to norepinephrine in postoperative cardiac surgery patients: interpretation with venous return and cardiac function curves. Crit Care Med. 2013 Jan;41(1):143-50. doi: 10.1097 / CCM. 0b013e318265ea64. PMID: 23128382. Steiner LA, Johnston AJ, Czosnyka M, Chatfield DA, Salvador R, Coles JP, Gupta AK, Pickard JD, Menon DK. Direct comparison of cerebrovascular effects of norepinephrine and dopamine in head-injured patients. Crit Care Med. 2004 Apr; 32(4):1049-54. doi: 10.1097/01.ccm.0000120054.32845.a6. PMID: 15071400. Ogoh S , Sato K , Fisher J P ,et al.The effect of phenylephrine on arterial and venous cerebral blood flow in healthy subjects[J].Clinical Physiology and Functional Imaging, 2011, 31(6).DOI:10.1111/j.1475-097X.2011.01040.x. Catchlove S J , Helen M , Hughes M E ,et al.An investigation of cerebral oxygen utilization, blood flow and cognition in healthy aging[J].Plos One, 2018, 13(5):e0197055.DOI:10.1371/journal.pone.0197055. Smith E R , Scott R M .Surgical Management of Moyamoya Syndrome[J].Skull Base Surgery, 2005, 15(1):15-26.DOI:10.1055/s-2005-868160. 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-8650013","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":604725417,"identity":"e3a76ddb-c915-48b1-b7da-ec5a41cacdcc","order_by":0,"name":"Yong Chen","email":"","orcid":"","institution":"Taizhou Gaogang Traditional Chinese Medicine Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Chen","suffix":""},{"id":604725418,"identity":"c6eac093-0f6b-4019-890b-913695c93446","order_by":1,"name":"Lin Jiang","email":"","orcid":"","institution":"Taizhou People’s Hospital, Taizhou, Jiangsu Province,","correspondingAuthor":false,"prefix":"","firstName":"Lin","middleName":"","lastName":"Jiang","suffix":""},{"id":604725419,"identity":"5376f793-85e2-433c-a287-bb828016f126","order_by":2,"name":"Hua Hong","email":"","orcid":"","institution":"Taizhou People’s Hospital, Taizhou, Jiangsu Province,","correspondingAuthor":false,"prefix":"","firstName":"Hua","middleName":"","lastName":"Hong","suffix":""},{"id":604725420,"identity":"12ac7ee8-c819-4e3d-9205-e5e6b661907c","order_by":3,"name":"Dapeng Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIie3RsQqCUBTG8SMX7nRsvlDo0BxcCAJJbOhFlMAWH8DRqa09wbcIpPHIXX2AtgihyUH3hhxr8rYF3f/+g/NxAEymH4y7DVH09HFza0iPTCCOqM/iGVAc6hEHknmVZ8oHSqTmYVCDsi8Krazury0EziIbI9aRlF3vkVnHs1fAbrmiMcImoUK+Rs7scopAUTlKOMqBMESOD02CKKv8sEUxIE0ieEhdHaMUfOkVUmOLe2KqC1N/IwW7X9s0cEbJRwI1X/NOvhUmk8n0F70AbII/DTv5fzYAAAAASUVORK5CYII=","orcid":"","institution":"Taizhou People’s Hospital, Taizhou, Jiangsu Province,","correspondingAuthor":true,"prefix":"","firstName":"Dapeng","middleName":"","lastName":"Yu","suffix":""}],"badges":[],"createdAt":"2026-01-20 14:17:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8650013/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8650013/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104594140,"identity":"3a29c9d4-e132-4856-99b5-6c3a390a0a36","added_by":"auto","created_at":"2026-03-13 17:48:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":229208,"visible":true,"origin":"","legend":"\u003cp\u003eA: Cerebral vascular MRA on July 23, 2025: No visualization of bilateral internal carotid arteries, anterior cerebral arteries, and middle cerebral arteries.\u003c/p\u003e\n\u003cp\u003eB: Cranial MRI on July 23, 2025: Left temporal lobe encephalomalacia.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8650013/v1/20dfe54d049dfd3bf776c635.png"},{"id":107036504,"identity":"1821a96f-d979-4885-b844-676e6cdb3d75","added_by":"auto","created_at":"2026-04-16 04:40:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":639172,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8650013/v1/7a046146-b05f-487e-bac7-62d1bf5c92b9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anesthetic Management for Laparoscopic Radical Colectomy in a Patient with Moyamoya Disease: Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe incidence of Moyamoya disease in China is 3.92 per 100,000 [2], with annual rates of intracranial hemorrhage and cerebral infarction reported as 0.22/100,000 and 0.16/100,000, respectively [2, 3]. Cerebral infarction is the most common complication, with an incidence of 12.4% [4]. This case highlights the perioperative considerations and strategies for managing such high-risk patients undergoing non-neurological surgery.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 70-year-old male (height 167 cm, weight 70 kg) was admitted with a colonic mass. His medical history included hypertension, controlled with captopril and nifedipine, and a cerebral infarction three years prior, which resulted in motor aphasia and right-sided hemiparesis. Physical examination revealed a conscious patient with bilateral, equal, and reactive pupils (2.0 mm). Brain Magnetic Resonance Imaging (MRI) showed the absence of bilateral internal carotid, anterior cerebral, and middle cerebral arteries, with a left temporal lobe encephalomalacia (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), confirming the diagnosis of Moyamoya disease.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA multidisciplinary team involving colorectal surgeons, anesthesiologists, neurosurgeons, and oncologists decided to proceed with an elective laparoscopic radical colectomy due to impending intestinal obstruction from the colonic tumor. Neurosurgeons recommended preoperative subcutaneous low-molecular-weight heparin (LMWH) at 0.5 mg/kg once daily.\u003c/p\u003e \u003cp\u003eUpon arrival in the operating room, the patient's non-invasive blood pressure (NIBP) was 189/102 mmHg, heart rate (HR) 95 bpm, and oxygen saturation (SpO₂) 98%. After rest, NIBP decreased to 176/97 mmHg with HR 92 bpm. An arterial catheter was placed in the left radial artery under local anesthesia for continuous blood pressure monitoring. An intravenous line was established.\u003c/p\u003e \u003cp\u003eAnesthesia was induced with intravenous lidocaine (60 mg), propofol (90 mg), sufentanil (25 \u0026micro;g), dexamethasone (10 mg), ondansetron (8 mg), and cisatracurium (10 mg). Tracheal intubation was performed with a 7.5 mm ID tube, and pressure-controlled mechanical ventilation was initiated. Anesthesia was maintained with sevoflurane (1.5\u0026ndash;2.6%) and target-controlled infusion of remifentanil (2\u0026ndash;3 ng/ml). A right internal jugular venous catheter was inserted. Monitoring included Bispectral Index (BIS), nasopharyngeal temperature, urine output, and serial arterial blood gas analyses, with potassium supplementation as needed.\u003c/p\u003e \u003cp\u003eThe laparoscopic right hemicolectomy lasted 4 hours. Intraoperative parameters were maintained within target ranges: Arterial Blood Pressure (ABP) 140\u0026ndash;160/75\u0026ndash;90 mmHg, HR 60\u0026ndash;80 bpm, PaCO₂ 41\u0026ndash;45 mmHg, BIS 39\u0026ndash;51, and temperature 35.9\u0026ndash;36.6\u0026deg;C. Fluid administration included approximately 800 ml of hydroxyethyl starch and 1300 ml of Ringer's solution. Total urine output was 1200 ml, with an estimated blood loss of 30 ml.\u003c/p\u003e \u003cp\u003eThe patient emerged from anesthesia approximately 20 minutes after arrival in the Post-Anesthesia Care Unit (PACU) and was extubated. Neurological examination revealed bilateral limb muscle strength comparable to the preoperative state. The patient was transferred to the ward and discharged about 10 days later without complications.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe fundamental pathology in Moyamoya disease is impaired CBF, predisposing patients to cerebral infarction [5]. Risk factors for perioperative infarction include a history of prior stroke, high Suzuki stage on the non-operative side, involvement of the posterior cerebral artery, specific surgical revascularization techniques (indirect or combined bypass), diabetes, and preoperative hemodynamic instability [6\u0026ndash;9]. Among these, preoperative hemodynamic instability is a key modifiable risk factor.\u003c/p\u003e \u003cp\u003eThis case demonstrates the application of various anesthetic strategies aimed at preventing cerebral ischemia in a patient with Moyamoya disease undergoing major abdominal surgery. The multidisciplinary decision for preoperative LMWH was crucial for thromboembolism prophylaxis.\u003c/p\u003e \u003cp\u003eCareful anesthetic management is paramount for patients with Moyamoya disease (MMD) or Moyamoya syndrome (MMS) during surgery. While evidence for specific protocols is limited, consensus principles guide management.\u003c/p\u003e \u003cp\u003eControl of Cerebral Blood Flow (CBF): CBF is tightly regulated to match metabolic demand [10]. It constitutes 15\u0026ndash;20% of cardiac output (CO). Understanding how CO influences CBF is fundamental, as CBF depends on receiving a significant portion of CO. Blood pressure and CO are interrelated but distinct hemodynamic parameters that often change concurrently and can differentially impact cerebral perfusion [11]. A decrease in CO leads to a slight downward shift of the CBF autoregulation plateau, and vice versa, though the autoregulatory mechanism itself is generally preserved.\u003c/p\u003e \u003cp\u003eBlood pressure is the product of CO and systemic vascular resistance (SVR). CO is determined by heart rate (HR) and stroke volume (SV), the latter influenced by preload, contractility, and afterload. SVR depends on vascular radius, length, and blood viscosity [12]. With constant SVR, CO becomes a primary determinant of blood pressure. From this perspective, monitoring CO might be more insightful than blood pressure alone. It is also essential to recognize that CO is the product of SV and HR, underscoring the importance of maintaining an adequate heart rate.\u003c/p\u003e \u003cp\u003eFluid Management and Volume Status: Preoperative fasting can lead to hypovolemia and reduced CBF. Adequate volume loading before induction is essential. Effective fluid therapy helps maintain oxygen delivery-demand balance in vital organs [13]. Patients with MMD, having compromised cerebral hemodynamics, impaired cerebrovascular reactivity, and autoregulation, are particularly vulnerable to cerebral hypoperfusion and postoperative infarction [14]. Therefore, maintaining a hypervolemic state perioperatively is recommended to prevent hypotension and low cerebral perfusion pressure [15]. In this case, we administered approximately 200 ml of hydroxyethyl starch before induction and 500 ml before skin incision, with a total intraoperative fluid intake of 800 ml colloid and 1300 ml crystalloid. Goal-directed fluid therapy aimed at optimizing CO has been associated with improved outcomes after intracranial surgery [16, 17].\u003c/p\u003e \u003cp\u003eUrine output serves as a reliable indicator of volume status. Low urine output in MMD patients is a high-risk factor for perioperative neurological complications. The total perioperative urine output was 1200 ml. Hematocrit (HCT) also requires attention; low HCT impairs cerebral oxygen delivery, while high HCT increases the risk of infarction. Although the ideal HCT remains debated, maintaining it between 30% and 42% is generally advised [18].\u003c/p\u003e \u003cp\u003eBlood Pressure Management: Maintaining blood pressure at or slightly above the patient's baseline is critical [19]. Hypotension can lead to decreased CBF and perfusion pressure, precipitating ischemia or infarction. Thus, invasive arterial monitoring before induction is necessary. The target systolic blood pressure was set between 140\u0026ndash;160 mmHg, based on the patient's ward readings of 119\u0026ndash;140 mmHg, while avoiding pressures above 180 mmHg. Vasoactive drugs should be used as needed to ensure stability.\u003c/p\u003e \u003cp\u003eIt is important to note that interventions like dobutamine and volume expansion can increase CO without necessarily raising blood pressure. Conversely, high doses of vasoconstrictors (e.g., phenylephrine, norepinephrine) may sustain blood pressure but potentially reduce CO [20, 21]. Their net effect on CBF likely depends on the specific drug, the disease state, and the functional status of cerebral perfusion mechanisms [22, 23]. In this case, we employed a combination of low-dose dobutamine and metaraminol to support both CO and pressure. Acute changes in CO during surgery are common due to factors like dehydration, bleeding, positioning, pneumoperitoneum, vasodilation, sympathetic blockade, anesthetics, and arrhythmias. Since a decrease in CO can reduce CBF, we believe it is imperative to correct detrimental reductions in CO.\u003c/p\u003e \u003cp\u003eVentilation and Temperature: Hyperventilation-induced hypocapnia causes cerebral vasoconstriction and increases the risk of ischemia [24]. Therefore, normocapnia was maintained, with PaCO₂ kept between 41\u0026ndash;45 mmHg. While mild hypothermia may offer neuroprotection, evidence is scarce; thus, maintaining normal body temperature is standard practice [25].\u003c/p\u003e \u003cp\u003ePostoperative Care: Postoperative management focused on maintaining hypervolemia to prevent hypotension and low cerebral perfusion pressure, along with continued LMWH for thrombosis prophylaxis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEffective prevention and management of perioperative stroke risk in Moyamoya disease require comprehensive preoperative assessment and optimization, individualized intraoperative strategies to maintain cerebral perfusion and minimize embolic risk, and systematic postoperative monitoring for early detection and intervention of neurological events. A multidisciplinary collaborative model involving surgeons, anesthesiologists, and the perioperative care team is crucial for addressing the multifaceted nature of this risk. Hypoperfusion is a key mechanism for perioperative infarction, underscoring the importance of strict hemodynamic management to ensure adequate cerebral perfusion during critical periods.Further research is warranted to determine how to provide rational, individualized perioperative management for patients with Moyamoya disease undergoing cerebral revascularization and other surgeries to minimize complications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclatation of conflicting:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors do not have any possible conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch funding：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient informed consent to publish:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patients written the consents for the Material about them/the patients to appear in a publication. The case details with identifying images can be publish without institutional approval.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate：\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials：\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe materials described in the manuscript, including all relevant raw data, will be freely available to any scientist wishing to use them for non-commercial purposes, without breaching participant confidentiality.\u003c/p\u003e\n\u003cp\u003eThe authors\u0026apos; contributions are listed as follows:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYong Chen \u0026nbsp;collected the data of this case, \u0026nbsp;Hua Hong and \u0026nbsp; Lin \u0026nbsp;Jiang gave some writing advice，Dapeng Yu completed the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI would like to express my gratitude to all individuals and organizations who provided me with support and assistance during the preparation and writing of this paper.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAutosomal dominant moyamoya disease maps to chromosome 17q25.3.[J].Neurology, 2008.DOI:10.1212/01.wnl.0000291012.49986.f9.\u003c/li\u003e\n\u003cli\u003eMiao W , Zhao P L , Zhang Y S ,et al.Epidemiological and clinical features of Moyamoya disease in Nanjing, China[J].CLINICAL NEUROLOGY AND NEUROSURGERY, 2010. 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PMID: 15071400.\u003c/li\u003e\n\u003cli\u003eOgoh S , Sato K , Fisher J P ,et al.The effect of phenylephrine on arterial and venous cerebral blood flow in healthy subjects[J].Clinical Physiology and Functional Imaging, 2011, 31(6).DOI:10.1111/j.1475-097X.2011.01040.x.\u003c/li\u003e\n\u003cli\u003eCatchlove S J , Helen M , Hughes M E ,et al.An investigation of cerebral oxygen utilization, blood flow and cognition in healthy aging[J].Plos One, 2018, 13(5):e0197055.DOI:10.1371/journal.pone.0197055.\u003c/li\u003e\n\u003cli\u003eSmith E R , Scott R M .Surgical Management of Moyamoya Syndrome[J].Skull Base Surgery, 2005, 15(1):15-26.DOI:10.1055/s-2005-868160.\u003c/li\u003e\n\u003c/ol\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":"Moyamoya Disease, General anesthesia, Cerebral blood flow ","lastPublishedDoi":"10.21203/rs.3.rs-8650013/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8650013/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMoyamoya disease is a chronic, progressive occlusive cerebrovascular disorder characterized by bilateral stenosis or occlusion of the terminal internal carotid arteries and the development of a fine, abnormal vascular network (the \"moyamoya\" vessels) at the base of the brain. Its pathophysiology involves impaired cerebral autoregulation, making cerebral blood flow (CBF) pressure-dependent, along with reduced perfusion pressure and blood flow in the anterior circulation, and impaired cerebrovascular reactivity to CO₂. Anesthesia management in these patients is challenging due to the high risk of cerebral ischemia or hemorrhage. We report the successful anesthetic management of a patient with Moyamoya disease and a history of hemiparesis who underwent laparoscopic radical colectomy for colon cancer without neurological deterioration.\u003c/p\u003e","manuscriptTitle":"Anesthetic Management for Laparoscopic Radical Colectomy in a Patient with Moyamoya Disease: Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-13 17:47:58","doi":"10.21203/rs.3.rs-8650013/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":"7b367815-7414-4bcf-85bb-1a7b49cba9bd","owner":[],"postedDate":"March 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-16T04:40:34+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-13 17:47:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8650013","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8650013","identity":"rs-8650013","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}