Abstract
Background: Moyamoya disease (MMD) is a progressive cerebrovascular disease with stenosis of intracranial internal carotid artery and its proximal branches leading to the gradual development of a collateral circulation to compensate for the blockage. This neovasculature is weak and prone to bleeding and aneurysms. Since we are dealing with a fragile cerebral vasculature on one hand and stenosed vessels on the other, anaesthesia management is challenging.
Aim: Aim of this case series was to formulate an ideal plan for the anesthesia management of patients undergoing surgery for Moyamoya disease by understanding the perioperative factors so as to deliver safe and hemodynamically stable anesthesia with minimal effect on perioperative oxygenation and blood flow leading to reduction in neurological complications, length of ICU and hospital stay.
Material and Method: Retrospective evaluation of 25 pediatric patients for surgery for MMD from Feb 2005 to June 2021 was undertaken. Direct vascularization was performed in 3 patients (12%) and 22 (88%) underwent Indirect vascularization procedures. Anaesthesia protocol designed was applied to all the patients. Data related to anaesthesia monitoring and outcomes was charted to assess the efficiency of anaesthesia plan.
Observations and Results: A total of 25 pediatric patient records were evaluated. Ischemic presentations were 80% and Haemorrhagic presentations were 20%. Endtidal CO2 was maintained at 35 to 40 mmHg, There was no hypocapnia or hypercapnia and oxygen saturations were maintained at 100%. Intraoperatively two patients n= 2(8%) had hypertension and tachycardia at the time of scalp incision. 4 patients n= 4(16 %) had hypotension after induction of anaesthesia . None of the patients had low urine output, n= 0(0%) and no patient developed hypothermia. Two patients required blood transfusion, n=2 (8%). Postoperatively haemoglobin dropped to 10 ± 0.52, seizures were seen in 4 patients (16%), one child developed infarction n=1 (4%) and none had haemorrhage or hematoma (0%). It was thus observed that with vigilant and targeted perioperative protocol, ICU stay was just 2 days (1.84 ±0.39) and discharge from hospital was within 11 days (10.34±1.039) without any new neurological deficits with the exception of one patient who had an unfortunate event of infarction, n=1 (4%) requiring emergency decompression surgery.
Conclusion: Cerebral haemodynamics is at the core and an extremely crucial determinant of success rate in revascular- ization procedures used in MMD. Perioperative anesthesia care has a direct effect on these hemodynamic parameters. We designed and titrated anaesthetics for achieving and maintaining normotension, normo- capnia, normovolemia and normothermia. This was to ensure that we maintain adequate Cerebral Blood Flow (CBF) and Cerebral Perfusion Pressure (CPP) and Cerebral Metabolic Rate of oxygen consumption (CmRO2), thereby avoiding perioperative cerebral ischemic consequences and neurological worsening, and thus minimising the ICU/Hospital stay.
Keywords: MMD, revascularisation surgery, anaesthesia risk factors, length of hospital stay.
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Corresponding Author
Dr Roshni Cheema
MD Anaesthesiology Resident, BHIMS, Mumbai, India
DOI: https://dx.doi.org/10.18535/jmscr/v10i5.20
