{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,6]],"date-time":"2026-03-06T20:11:07Z","timestamp":1772827867377,"version":"3.50.1"},"reference-count":32,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,6,1]]},"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVE<\/jats:title>\n                    <jats:p>Patients with advanced moyamoya disease have chronic cerebrovascular insufficiency with superimposed acute ischemic insults, leading to brain atrophy and cognitive decline. The outcomes of revascularization procedures in moyamoya patients with marked brain atrophy are not yet clearly known.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS<\/jats:title>\n                    <jats:p>This retrospective study used an approach based on the global cerebral atrophy scale to identify patients with severe brain atrophy from a single-surgeon series of patients with moyamoya disease undergoing revascularization from January 2015 to January 2024. Clinical outcomes (modified Rankin Scale [mRS] score, improvement in symptoms and cognitive function) and radiological outcomes (arterial spin labeling [ASL] perfusion) were studied and compared between direct and indirect revascularization groups.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS<\/jats:title>\n                    <jats:p>Of 153 patients in the series, 16 (mean age 8.9 years) had severe brain atrophy (cortical atrophy score \u2265 8). The presenting symptoms were recurrent transient ischemic attack in 6 patients (37.5%), major stroke in 7 patients (43.75%), and seizure in 3 patients (18.75%). Fourteen patients underwent surgeries for both hemispheres and 2 patients underwent surgery for 1 hemisphere. Of the 30 hemispheres, 17 (56.7%) were treated with direct revascularization and 13 (43.3%) with indirect revascularization. The mean follow-up duration was 38.8 months. The median mRS score improved from 3 (preoperative) to 1.5 (last follow-up), with 11 patients (68.75%) showing improvement in mRS score. Thirteen patients (81.25%) showed improvement in presenting symptoms. Overall, 12 of 16 patients (75%) showed improvement in cognitive function at the last follow-up. The mean preoperative and follow-up ASL scores improved for the lower-perfusion hemispheres from 7.9 to 8.9 and for the higher-perfusion hemispheres from 9.6 to 10.45, respectively. Differences between preoperative and postoperative ASL scores for both groups were statistically significant. There was no significant difference in clinical and radiological outcomes between the direct and indirect revascularization groups. Clinical outcomes were comparable across patient groups based on the distribution of brain atrophy (unilateral\/bilateral, predominant left\/right side, predominant vascular territory involved).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS<\/jats:title>\n                    <jats:p>Moyamoya patients with severe brain atrophy showed improvement in paroxysmal symptoms, cognitive function, and overall clinical functioning status, as well as radiological perfusion, after undergoing either direct or indirect revascularization. Comparative efficacy of direct and indirect revascularization in these patients needs further investigation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/2024.12.peds24542","type":"journal-article","created":{"date-parts":[[2025,3,22]],"date-time":"2025-03-22T13:03:53Z","timestamp":1742648633000},"page":"591-598","source":"Crossref","is-referenced-by-count":0,"title":["Outcomes of surgical revascularization in a case series of moyamoya patients with severe brain atrophy"],"prefix":"10.3171","volume":"35","author":[{"given":"Kautilya R.","family":"Patel","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, University of Nebraska Medical Center, Omaha, Nebraska;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Prathik","family":"Rudrappa","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Soumya Ranjan","family":"Malla","sequence":"additional","affiliation":[{"name":"Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hima","family":"Pendharkar","sequence":"additional","affiliation":[{"name":"Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mithun G.","family":"Sattur","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Nebraska Medical Center, Omaha, Nebraska;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nupur","family":"Pruthi","sequence":"additional","affiliation":[{"name":"Departments of Neurosurgery and"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"11","key":"b1","series-title":"Lancet Neurol","first-page":"1056","article-title":"Moyamoya disease: current concepts and future perspectives","volume":"7","author":"Kuroda S","year":"2008","unstructured":"Kuroda S, Houkin K. Moyamoya disease: current concepts and future perspectives. Lancet Neurol. 2008;7(11):1056\u20131066."},{"key":"b2","series-title":"Clin Imaging","first-page":"71","article-title":"Cortical thickness changes in adult moyamoya disease assessed by structural magnetic resonance imaging","volume":"46","author":"Qiao PG","year":"2017","unstructured":"Qiao PG, Zuo ZW, Han C,  Cortical thickness changes in adult moyamoya disease assessed by structural magnetic resonance imaging. Clin Imaging. 2017;46:71\u201377."},{"issue":"3","key":"b3","series-title":"Arch Neurol","first-page":"288","article-title":"Cerebrovascular \"moyamoya\" disease. Disease showing abnormal net-like vessels in base of brain","volume":"20","author":"Suzuki J","year":"1969","unstructured":"Suzuki J, Takaku A. Cerebrovascular \"moyamoya\" disease. Disease showing abnormal net-like vessels in base of brain. Arch Neurol. 1969;20(3):288\u2013299."},{"issue":"3","key":"b4","series-title":"Neurol Med Chir (Tokyo)","first-page":"189","article-title":"Diagnosis of moyamoya disease: international standard and regional differences","volume":"55","author":"Fujimura M","year":"2015","unstructured":"Fujimura M, Tominaga T. Diagnosis of moyamoya disease: international standard and regional differences. Neurol Med Chir (Tokyo). 2015;55(3):189\u2013193."},{"issue":"2","key":"b5","series-title":"J Neurosurg","first-page":"495","article-title":"Prior Infarcts, Reactivity, and Angiography in Moyamoya Disease (PIRAMD): a scoring system for moyamoya severity based on multimodal hemodynamic imaging","volume":"126","author":"Ladner TR","year":"2017","unstructured":"Ladner TR, Donahue MJ, Arteaga DF,  Prior Infarcts, Reactivity, and Angiography in Moyamoya Disease (PIRAMD): a scoring system for moyamoya severity based on multimodal hemodynamic imaging. J Neurosurg. 2017;126(2):495\u2013503.PubMed"},{"issue":"5","key":"b6","series-title":"Cerebrovasc Dis","first-page":"347","article-title":"Novel magnetic resonance angiography stage grading for moyamoya disease","volume":"20","author":"Houkin K","year":"2005","unstructured":"Houkin K, Nakayama N, Kuroda S, Nonaka T, Shonai T, Yoshimoto T. Novel magnetic resonance angiography stage grading for moyamoya disease. Cerebrovasc Dis. 2005;20(5):347\u2013354."},{"issue":"1","key":"b7","series-title":"Cerebrovasc Dis","first-page":"41","article-title":"Proposal for a new grading of Moyamoya disease in adult patients","volume":"32","author":"Czabanka M","year":"2011","unstructured":"Czabanka M, Pe\u00f1a-Tapia P, Schubert GA,  Proposal for a new grading of Moyamoya disease in adult patients. Cerebrovasc Dis. 2011;32(1):41\u201350."},{"issue":"10","key":"b8","series-title":"Stroke","first-page":"2708","article-title":"Collateral circulation in Moyamoya disease: a new grading system","volume":"50","author":"Liu ZW","year":"2019","unstructured":"Liu ZW, Han C, Zhao F,  Collateral circulation in Moyamoya disease: a new grading system. Stroke. 2019;50(10):2708\u20132715."},{"issue":"4","key":"b9","series-title":"Neurol Med Chir (Tokyo)","first-page":"165","article-title":"2021 Japanese Guidelines for the Management of Moyamoya Disease: guidelines from the Research Committee on Moyamoya Disease and Japan Stroke Society","volume":"62","author":"Fujimura M","year":"2022","unstructured":"Fujimura M, Tominaga T, Kuroda S,  2021 Japanese Guidelines for the Management of Moyamoya Disease: guidelines from the Research Committee on Moyamoya Disease and Japan Stroke Society. Neurol Med Chir (Tokyo). 2022;62(4):165\u2013170."},{"issue":"5","key":"b10","series-title":"Eur Neurol","first-page":"268","article-title":"Inter- and intraobserver reproducibility of cerebral atrophy assessment on MRI scans with hemispheric infarcts","volume":"36","author":"Pasquier F","year":"1996","unstructured":"Pasquier F, Leys D, Weerts JGE, Mounier-Vehier F, Barkhof F, Scheltens P. Inter- and intraobserver reproducibility of cerebral atrophy assessment on MRI scans with hemispheric infarcts. Eur Neurol. 1996;36(5):268\u2013272."},{"key":"b11","article-title":"The PROCESS Statement","unstructured":"The PROCESS Statement. Accessed January 5, 2025. https:\/\/www.processguideline.com\/"},{"issue":"1","key":"b12","series-title":"Cerebrovasc Dis Extra","first-page":"76","article-title":"Antiplatelet treatment in moyamoya disease: a systematic review","volume":"14","author":"Kijpaisalratana N","year":"2024","unstructured":"Kijpaisalratana N, Ariyaprakai C, Sriamornrattanakul K,  Antiplatelet treatment in moyamoya disease: a systematic review. Cerebrovasc Dis Extra. 2024;14(1):76\u201385."},{"issue":"5","key":"b13","series-title":"Neurol Res","first-page":"480","article-title":"Cilostazol may improve cognition better than clopidogrel in non-surgical adult patients with ischemic moyamoya disease: subanalysis of a prospective cohort","volume":"41","author":"Ando S","year":"2019","unstructured":"Ando S, Tsutsui S, Miyoshi K,  Cilostazol may improve cognition better than clopidogrel in non-surgical adult patients with ischemic moyamoya disease: subanalysis of a prospective cohort. Neurol Res. 2019;41(5):480\u2013487."},{"issue":"11","key":"b14","series-title":"J Stroke Cerebrovasc Dis","first-page":"3373","article-title":"Comparison of effects between clopidogrel and cilostazol on cerebral perfusion in nonsurgical adult patients with symptomatically ischemic moyamoya disease: subanalysis of a prospective cohort","volume":"27","author":"Chiba T","year":"2018","unstructured":"Chiba T, Setta K, Shimada Y,  Comparison of effects between clopidogrel and cilostazol on cerebral perfusion in nonsurgical adult patients with symptomatically ischemic moyamoya disease: subanalysis of a prospective cohort. J Stroke Cerebrovasc Dis. 2018;27(11):3373\u20133379."},{"issue":"6","key":"b15","series-title":"J Neurosurg Pediatr","first-page":"663","article-title":"Surgical outcomes for pediatric moyamoya: a systematic review and meta-analysis","volume":"24","author":"Ravindran K","year":"2019","unstructured":"Ravindran K, Wellons JC, Dewan MC. Surgical outcomes for pediatric moyamoya: a systematic review and meta-analysis. J Neurosurg Pediatr. 2019;24(6):663\u2013672."},{"key":"b16","series-title":"World Neurosurg","first-page":"181","article-title":"Post-surgical cognitive outcomes of moyamoya disease: a systematic review","volume":"178","author":"Mitchell DL","year":"2023","unstructured":"Mitchell DL, Shlobin NA, LoPresti MA, Scoville JP, Winterhalter E, Lam S. Post-surgical cognitive outcomes of moyamoya disease: a systematic review. World Neurosurg. 2023;178:181\u2013190.e1."},{"issue":"11","key":"b1","series-title":"Lancet Neurol","first-page":"1056","article-title":"Moyamoya disease: current concepts and future perspectives","volume":"7","author":"Kuroda S","year":"2008","unstructured":"Kuroda S, Houkin K. Moyamoya disease: current concepts and future perspectives. Lancet Neurol. 2008;7(11):1056\u20131066."},{"key":"b2","series-title":"Clin Imaging","first-page":"71","article-title":"Cortical thickness changes in adult moyamoya disease assessed by structural magnetic resonance imaging","volume":"46","author":"Qiao PG","year":"2017","unstructured":"Qiao PG, Zuo ZW, Han C,  Cortical thickness changes in adult moyamoya disease assessed by structural magnetic resonance imaging. Clin Imaging. 2017;46:71\u201377."},{"issue":"3","key":"b3","series-title":"Arch Neurol","first-page":"288","article-title":"Cerebrovascular \"moyamoya\" disease. Disease showing abnormal net-like vessels in base of brain","volume":"20","author":"Suzuki J","year":"1969","unstructured":"Suzuki J, Takaku A. Cerebrovascular \"moyamoya\" disease. Disease showing abnormal net-like vessels in base of brain. Arch Neurol. 1969;20(3):288\u2013299."},{"issue":"3","key":"b4","series-title":"Neurol Med Chir (Tokyo)","first-page":"189","article-title":"Diagnosis of moyamoya disease: international standard and regional differences","volume":"55","author":"Fujimura M","year":"2015","unstructured":"Fujimura M, Tominaga T. Diagnosis of moyamoya disease: international standard and regional differences. Neurol Med Chir (Tokyo). 2015;55(3):189\u2013193."},{"issue":"2","key":"b5","series-title":"J Neurosurg","first-page":"495","article-title":"Prior Infarcts, Reactivity, and Angiography in Moyamoya Disease (PIRAMD): a scoring system for moyamoya severity based on multimodal hemodynamic imaging","volume":"126","author":"Ladner TR","year":"2017","unstructured":"Ladner TR, Donahue MJ, Arteaga DF,  Prior Infarcts, Reactivity, and Angiography in Moyamoya Disease (PIRAMD): a scoring system for moyamoya severity based on multimodal hemodynamic imaging. J Neurosurg. 2017;126(2):495\u2013503.PubMed"},{"issue":"5","key":"b6","series-title":"Cerebrovasc Dis","first-page":"347","article-title":"Novel magnetic resonance angiography stage grading for moyamoya disease","volume":"20","author":"Houkin K","year":"2005","unstructured":"Houkin K, Nakayama N, Kuroda S, Nonaka T, Shonai T, Yoshimoto T. Novel magnetic resonance angiography stage grading for moyamoya disease. Cerebrovasc Dis. 2005;20(5):347\u2013354."},{"issue":"1","key":"b7","series-title":"Cerebrovasc Dis","first-page":"41","article-title":"Proposal for a new grading of Moyamoya disease in adult patients","volume":"32","author":"Czabanka M","year":"2011","unstructured":"Czabanka M, Pe\u00f1a-Tapia P, Schubert GA,  Proposal for a new grading of Moyamoya disease in adult patients. Cerebrovasc Dis. 2011;32(1):41\u201350."},{"issue":"10","key":"b8","series-title":"Stroke","first-page":"2708","article-title":"Collateral circulation in Moyamoya disease: a new grading system","volume":"50","author":"Liu ZW","year":"2019","unstructured":"Liu ZW, Han C, Zhao F,  Collateral circulation in Moyamoya disease: a new grading system. Stroke. 2019;50(10):2708\u20132715."},{"issue":"4","key":"b9","series-title":"Neurol Med Chir (Tokyo)","first-page":"165","article-title":"2021 Japanese Guidelines for the Management of Moyamoya Disease: guidelines from the Research Committee on Moyamoya Disease and Japan Stroke Society","volume":"62","author":"Fujimura M","year":"2022","unstructured":"Fujimura M, Tominaga T, Kuroda S,  2021 Japanese Guidelines for the Management of Moyamoya Disease: guidelines from the Research Committee on Moyamoya Disease and Japan Stroke Society. Neurol Med Chir (Tokyo). 2022;62(4):165\u2013170."},{"issue":"5","key":"b10","series-title":"Eur Neurol","first-page":"268","article-title":"Inter- and intraobserver reproducibility of cerebral atrophy assessment on MRI scans with hemispheric infarcts","volume":"36","author":"Pasquier F","year":"1996","unstructured":"Pasquier F, Leys D, Weerts JGE, Mounier-Vehier F, Barkhof F, Scheltens P. Inter- and intraobserver reproducibility of cerebral atrophy assessment on MRI scans with hemispheric infarcts. Eur Neurol. 1996;36(5):268\u2013272."},{"key":"b11","article-title":"The PROCESS Statement","unstructured":"The PROCESS Statement. Accessed January 5, 2025. https:\/\/www.processguideline.com\/"},{"issue":"1","key":"b12","series-title":"Cerebrovasc Dis Extra","first-page":"76","article-title":"Antiplatelet treatment in moyamoya disease: a systematic review","volume":"14","author":"Kijpaisalratana N","year":"2024","unstructured":"Kijpaisalratana N, Ariyaprakai C, Sriamornrattanakul K,  Antiplatelet treatment in moyamoya disease: a systematic review. Cerebrovasc Dis Extra. 2024;14(1):76\u201385."},{"issue":"5","key":"b13","series-title":"Neurol Res","first-page":"480","article-title":"Cilostazol may improve cognition better than clopidogrel in non-surgical adult patients with ischemic moyamoya disease: subanalysis of a prospective cohort","volume":"41","author":"Ando S","year":"2019","unstructured":"Ando S, Tsutsui S, Miyoshi K,  Cilostazol may improve cognition better than clopidogrel in non-surgical adult patients with ischemic moyamoya disease: subanalysis of a prospective cohort. Neurol Res. 2019;41(5):480\u2013487."},{"issue":"11","key":"b14","series-title":"J Stroke Cerebrovasc Dis","first-page":"3373","article-title":"Comparison of effects between clopidogrel and cilostazol on cerebral perfusion in nonsurgical adult patients with symptomatically ischemic moyamoya disease: subanalysis of a prospective cohort","volume":"27","author":"Chiba T","year":"2018","unstructured":"Chiba T, Setta K, Shimada Y,  Comparison of effects between clopidogrel and cilostazol on cerebral perfusion in nonsurgical adult patients with symptomatically ischemic moyamoya disease: subanalysis of a prospective cohort. J Stroke Cerebrovasc Dis. 2018;27(11):3373\u20133379."},{"issue":"6","key":"b15","series-title":"J Neurosurg Pediatr","first-page":"663","article-title":"Surgical outcomes for pediatric moyamoya: a systematic review and meta-analysis","volume":"24","author":"Ravindran K","year":"2019","unstructured":"Ravindran K, Wellons JC, Dewan MC. Surgical outcomes for pediatric moyamoya: a systematic review and meta-analysis. J Neurosurg Pediatr. 2019;24(6):663\u2013672."},{"key":"b16","series-title":"World Neurosurg","first-page":"181","article-title":"Post-surgical cognitive outcomes of moyamoya disease: a systematic review","volume":"178","author":"Mitchell DL","year":"2023","unstructured":"Mitchell DL, Shlobin NA, LoPresti MA, Scoville JP, Winterhalter E, Lam S. Post-surgical cognitive outcomes of moyamoya disease: a systematic review. 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