Optimizing Surgical Timing to Reduce Stroke Risk in Pediatric Moyamoya Disease.

Abstract

Background: Identifying the optimal surgical timing is critical for reducing stroke risk in pediatric patients with Moyamoya disease, but evidence to guide clinical decision-making remains limited. This study aimed to determine the optimal surgical timing based on different symptom onset patterns.

Methods: We retrospectively reviewed pediatric patients with Moyamoya disease who underwent revascularization surgery at a single center in China between July 2007 and July 2018. Patients were categorized by symptom onset pattern: infarction-onset, transient ischemic attack (TIA)-onset, or nonischemic. The TIA-onset group was further subdivided into high-risk and low-risk subgroups. Data on preoperative/perioperative stroke events and diagnosis-to-operation intervals were collected. Receiver operating characteristic curves and multivariate analyses were used to identify surgical timing thresholds. Stroke incidences were compared across groups stratified by surgical interval.

Results: A total of 736 patients (mean age 7.2±3.9 years; 50.7% male) were included. The incidence density of preoperative cerebral infarction was 11.83 per 1000 person-months, while that of cerebral hemorrhage was 1.21 per 1000 person-months. For patients with infarction-onset and high-risk TIA-onset patterns, a surgical waiting time exceeding 2.5 months (area under the curve, 0.722; specificity, 0.561; sensitivity, 0.882; P<0.001) and 6.5 months (area under the curve, 0.631; specificity, 0.400; sensitivity, 0.804; P=0.006), respectively, was associated with a significantly increased risk of preoperative cerebral infarction. In nonischemic patients, a prolonged surgical waiting time exceeding 5 years (area under the curve, 0.761; specificity, 0.856; sensitivity, 0.571; P<0.05) was associated with a significantly increased risk of cerebral hemorrhage. For patients with initial symptoms of infarction or high-risk TIA, earlier surgery did not increase the incidence of perioperative stroke events.

Conclusions: For children with Moyamoya disease, surgical intervention was beneficial within 2.5 months for patients with infarction-onset, 6.5 months for patients with high-risk TIA onset, and 5 years for nonischemic patients in reducing stroke risk.