Longitudinal neurocognitive outcomes and predictors after unilateral combined cerebral revascularization in adult moyamoya vasculopathy

OBJECTIVE: While most studies on adult moyamoya vasculopathy (MMV) have focused on the stroke incidence after bypass surgery, neurocognitive outcomes and predictors have rarely been investigated. The aim of this study was to evaluate the neurocognitive outcomes of adult patients with MMV after combined revascularization surgery and identify factors contributing to unfavorable outcomes. METHODS: Adult patients with MMV who underwent combined revascularization surgery from March 2019 to July 2024 at a single center were prospectively observed. Neuropsychological assessments and DSA were performed approximately 6 months after surgery. Neurocognitive changes were assessed using a distribution-based approach to calculate the minimal clinically important difference. RESULTS: A total of 204 patients (mean age 43.8 years) were included in the analysis, with a mean ± SD follow-up duration of 183.0 ± 18.2 days. Postoperatively, 166 patients (81.4%) demonstrated favorable neurocognitive outcomes, with 94 patients (46.1%) showing significant improvement and 72 patients (35.3%) remaining stable. Conversely, 38 patients (18.6%) experienced significant neurocognitive deterioration. The prevalence of vascular cognitive impairment (VCI) (p < 0.001) and the modified Rankin Scale scores (p = 0.002) significantly decreased following bypass. Multivariate analysis identified postoperative stroke complications (OR 3.57 [95% CI 1.47-8.68], p = 0.005) and posterior cerebral artery involvement (OR 2.23 [95% CI 1.01-4.93], p = 0.047) as independent risk factors for neurocognitive deterioration. Diabetes mellitus (OR 3.86 [95% CI 1.62-9.19], p = 0.002) and left-sided surgery (OR 2.01 [95% CI 1.09-3.70], p = 0.025) were independent risk factors against neurocognitive improvement, while the hemorrhagic type of MMV (OR 0.36 [95% CI 0.17-0.72], p = 0.004) was an independent protective factor. CONCLUSIONS: Combined revascularization surgery appears to be an effective treatment for improving neurocognition in patients with MMV and VCI. Insufficient preexisting collateral reserve and postoperative stroke complications might contribute to neurocognitive deterioration, while diabetes mellitus and left-sided surgery hindered neurocognitive improvement.