Improvement in multiple cognitive domains via combined revascularization by 6 months’ follow-up: a new potential surgical indication in moyamoya disease

OBJECTIVE: Moyamoya disease (MMD) is a cerebrovascular condition characterized by progressive stenosis of the main branches of the cerebral artery. Patients with MMD are prone to cognitive decline due to chronic hypoperfusion. Whether revascularization surgery can reverse cognitive dysfunction by improving cerebral blood flow perfusion and what types and levels of cognitive dysfunction can benefit most from the surgery remain unclear. METHODS: Between July 31, 2022, and May 15, 2024, a total of 155 patients were prospectively enrolled in this trial and underwent combined or indirect revascularization with an average 6-month follow-up. Eleven types of cognitive domains were tested. Subgroup analysis was used to compare the postoperative benefits of different surgical procedures and preoperative cognitive levels. RESULTS: Choice reaction time (adjusted p = 0.032), verbal working memory (adjusted p = 0.006), mental rotation (adjusted p = 0.002), complex subtraction (adjusted p < 0.001), and word memory (adjusted p < 0.001) improved significantly after surgery. Combined revascularization led to improvement in more cognitive domains (choice reaction time, p < 0.001; mental rotation, p < 0.001; word memory, p < 0.001; executive inhibition in the same direction, p = 0.016; complex subtraction, p = 0.001; and verbal working memory in reverse order, p = 0.001) than indirect revascularization (word memory, p = 0.023; and complex subtraction, p = 0.007). CONCLUSIONS: Revascularization can selectively reverse cognitive dysfunction by improving cerebral blood flow perfusion in adults with MMD. Combined revascularization may allow more definite hemodynamic improvement than indirect revascularization, leading to more frequent and greater potential improvement in more cognitive domains; however, more studies are needed to confirm this. A population with lower preoperative cognition and good postoperative collateral formation may benefit more from the surgery.