การตัดต่อเส้นเลือดสมองในผู้ป่วยเส้นเลือดสมองตีบ Moyamoya และเส้นเลือดสมองโป่งพอง

When it comes to diseases related to cerebral blood vessels or cerebrovascular diseases, most people often think of ischemic stroke commonly found in the elderly, which leads to stroke symptoms causing paralysis or death. But did you know! Cerebral artery stenosis can also be congenital, caused by progressive blockage of cerebral blood vessels. This is known as Moyamoya disease. Today, we will introduce the symptoms, diagnosis, and treatment, including cerebral aneurysm disease, which is related and can be detected and treated before a brain hemorrhage occurs.
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<h2>Getting to Know Blood Vessels First</h2>
Blood vessels in the body are mainly of three types: Arteries, which carry blood and oxygen from the heart to various organs; Veins, which return used blood back to the heart; and Capillaries, which function to exchange nutrients and oxygen between blood and cells.
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Each type of blood vessel has its own special characteristics. For example, arteries have thick and strong walls to withstand blood pressure, veins have thinner walls, and capillaries have the thinnest walls. Additionally, cerebral blood vessels have a special structure different from vessels in other organs, such as the blood-brain barrier that helps prevent toxins from entering the brain.
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<h2>What Are the Common Cerebrovascular Diseases?</h2>
<ul>
<li>Ischemic stroke occurs due to blockage of blood vessels supplying the brain, causing cerebral ischemia. Another less common ischemic stroke is Moyamoya disease, a condition where the large carotid arteries have chronic stenosis or occlusion of unknown cause, often congenital.</li>
<li>Hemorrhagic stroke results from rupture of blood vessels in the brain, causing bleeding into brain tissue. Part of this is caused by cerebral aneurysm in the vessel walls. Risk factors include aging (over 40 years), high blood pressure, long-term smoking, family history of cerebral aneurysm, congenital vascular abnormalities such as vessel wall weakness, and alcohol consumption. Nowadays, technology allows early detection of cerebral aneurysms, enabling assessment of severity and risk of rupture, allowing timely treatment before severe symptoms appear.</li>
</ul>
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<h2>What Are the Symptoms When a Cerebral Blood Vessel Ruptures?</h2>
Symptoms of cerebral vessel rupture include:
<ul>
<li>Severe and sudden headache, often described as the worst headache of life</li>
<li>Nausea and vomiting</li>
<li>Loss of consciousness or rapid drowsiness</li>
<li>Neurological symptoms such as slurred speech, double vision, hemiplegia, seizures, or unconsciousness</li>
<li>Neck stiffness or rigidity, which may result from bleeding in the brain’s meninges (subarachnoid hemorrhage)</li>
</ul>
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<h2>Diagnostic Procedures for Cerebral Vessel Rupture</h2>
Diagnosis of cerebral vessel rupture includes:
<ul>
<li>CT scan (Computerized Tomography) to image the brain and identify bleeding areas</li>
<li>CT angiography (CTA) or Magnetic Resonance Angiography (MRA) to visualize blood vessels and detect aneurysms or vascular injuries</li>
<li>Cerebral Angiogram, which involves injecting contrast dye into cerebral vessels to examine blood flow and vessel structure for rupture or blockage severity</li>
</ul>
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<h2>Treatment by Cerebral Revascularization</h2>
When cerebral vessels are stenosed, occluded, ruptured, or aneurysmal and require surgery, there are two main goals:
<ul>
<li>Increase blood flow (Flow augmentation) and</li>
<li>Preserve blood flow (Flow preservation), detailed as follows:</li>
</ul>
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<h3>1. To Increase Blood Flow (Flow Augmentation)</h3>
Increasing blood flow focuses on helping patients with stenosis, occlusion, or cerebral ischemia, such as Moyamoya disease, caused by progressive stenosis or occlusion of the carotid arteries of unknown cause, reducing cerebral blood flow and causing ischemia.
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Moyamoya disease is often found in children under 10 years old or adults aged 30-40 years. Symptoms usually present as paralysis or weakness, seizures, severe headaches, or cognitive impairment, similar to ischemic stroke or stroke symptoms.
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Doctors diagnose the disease by examining cerebral vessels using CTA or MRA, which use magnetic resonance imaging to visualize blood vessels and cerebral blood flow.
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However, Moyamoya syndrome can also result from various causes or triggers such as:
<ul>
<li>Post-treatment leukemia</li>
<li>Post-radiation therapy</li>
<li>Vasculitis</li>
<li>Atherosclerosis</li>
<li>Antiphospholipid syndrome</li>
<li>Hyperthyroidism</li>
</ul>
Additionally, surgery to increase blood flow is often performed in patients with severe stenosis or occlusion (Severe Stenosis or Occlusion), such as intracranial atherosclerotic disease caused by fat accumulation in vessel walls, reducing cerebral blood flow and leading to severe cerebrovascular disease.
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<h3>2. To Preserve Blood Flow (Flow Preservation)</h3>
Preserving blood flow aims to prevent interruption of cerebral blood flow and is usually done in cases such as:
<ul>
<li>Dissecting aneurysm, where blood enters the vessel wall causing aneurysm formation, which if untreated risks rupture and brain hemorrhage</li>
<li>Fusiform aneurysm, which has a high risk of rupture</li>
<li>Vascular-related tumors, where tumor removal surgery may require cerebral vessel surgery to prevent ischemic stroke post-operation</li>
</ul>
Surgical cerebral revascularization is an important treatment for ischemic cerebrovascular disease and is much more effective in clear cases of Moyamoya disease than medication alone. It is also beneficial for patients with cerebral aneurysms, aiming to increase and preserve cerebral blood flow, reducing the risk of future ischemic or hemorrhagic stroke.
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<h2>Key Techniques and Procedures in Cerebral Revascularization Surgery</h2>
Cerebral vessel surgery is complex and requires a specialized team of cerebrovascular or neurosurgeons. The treatment method is chosen based on the size and location of the problematic vessels and the patient’s condition, as follows:
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<ul>
<li>Bypass surgery creates a new pathway to bypass stenosed or occluded areas, used in cases of severe stenosis or vessel damage from rupture</li>
<li>Endovascular coiling involves inserting coils into stenosed or occluded vessels or placing a stent via the groin or wrist to repair and improve blood flow. This minimally invasive surgery avoids large incisions. Coiling in aneurysms stops blood flow into the aneurysm sac, reducing rupture risk.</li>
</ul>
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<h2>Risks and Safety in Cerebral Vessel Surgery</h2>
Cerebral vessel surgery requires careful consideration of risks and benefits. Risks include brain hemorrhage during or after surgery, vessel occlusion from blood clots at the surgical site causing recurrent stenosis, and brain tissue injury leading to paralysis or neurological problems.
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Risk prevention involves selecting an expert medical team. During surgery, doctors assess treatment outcomes, monitor blood flow, and closely follow up post-operation to reduce and promptly manage potential complications.
&nbsp;
<h2>Who Is Not Suitable for Cerebral Vessel Surgery?</h2>
Not everyone is eligible for cerebral vessel surgery or revascularization. Some patients have treatment limitations such as:
<ul>
<li>Patients with multiple severe comorbidities like heart disease, chronic kidney disease, or uncontrolled infections, making surgery too risky</li>
<li>Patients with extensive brain damage, such as brain death or severe brain tissue injury, where surgery may not improve quality of life</li>
</ul>
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<h2>Preparation Before Cerebral Vessel Surgery</h2>
Preparation before cerebral vessel surgery is crucial due to the complexity of the procedure. Proper preparation reduces risks and increases chances of rapid recovery, including:
<ol>
<li>Comprehensive physical examination such as blood tests, electrocardiogram (ECG/EKG), CT scan or MRI to assess symptoms and disease complexity</li>
<li>Some patients may need to stop certain medications such as antiplatelet drugs, at the doctor’s discretion</li>
<li>Fasting from food and water for at least 8 hours before surgery to prevent complications during anesthesia</li>
<li>Mental preparation to reduce anxiety; doctors may recommend patients and families consult with mental health teams</li>
</ol>
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<h2>Recovery After Cerebral Vessel Surgery</h2>
After cerebral vessel surgery, patients must stay in the hospital for close monitoring in the intensive care unit (ICU) for about 1-3 days. Then, they are transferred to a general ward for about 7 days of further observation. Before discharge, doctors provide advice on preventing risk factors to avoid recurrence, such as controlling blood pressure, managing blood lipid levels, and avoiding behaviors that harm blood vessels like smoking or consuming high-fat foods.
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If you or someone close is at risk or has suspicious symptoms, you should promptly undergo screening at a hospital to prevent risks or receive early treatment, especially if experiencing a severe headache unlike any before, not relieved by painkillers. Seek hospital care immediately, as timely treatment increases recovery chances and prevents excessive brain damage or life-threatening brain hemorrhage.
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Dr. Saranya Yuttakowit 
Neurosurgeon 
Phyathai 1 Hospital

Cerebral revascularization surgery is effective in treating Moyamoya disease because it helps increase blood flow and improves circulation.

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Cerebral revascularization in patients with Moyamoya disease and cerebral aneurysms

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