Pediatric Moyamoya Revascularization Perioperative Care: A Modified Delphi Study

Lisa R. Sun, Division of Cerebrovascular Neurology, Division of Pediatric Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, USA. Lsun20@jhmi.edu.
Lori C. Jordan, Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.
Edward R. Smith, Department of Neurosurgery, Boston Children's Hospital, Boston, MA, USA.
Philipp R. Aldana, Division of Pediatric Neurosurgery, University of Florida College of Medicine, Section of Neurosurgery, Wolfson Children's Hospital, Jacksonville, FL, USA.
Matthew P. Kirschen, Departments of Anesthesiology and Critical Care Medicine, Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
Kristin Guilliams, Departments of Neurology, Pediatrics, and Radiology, Washington University School of Medicine, St. Louis, MO, USA.
Nalin Gupta, Departments of Neurological Surgery and Pediatrics, University of California, San Francisco, CA, USA.
Gary K. Steinberg, Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.
Christine Fox, Department of Neurology, University of California, San Francisco, CA, USA.
Dana B. Harrar, Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA.
Sarah Lee, Division of Child Neurology, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA.
Melissa G. Chung, Department of Pediatrics, Divisions of Pediatric Neurology and Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
Peter Dirks, Division of Neurosurgery, The Hospital for Sick Children, Toronto, Canada.
Nomazulu Dlamini, Division of Neurology, The Hospital for Sick Children, Toronto, Canada.
Cormac O. Maher, Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.
Laura L. Lehman, Department of Neurology, Boston Children's Hospital, Boston, MA, USA.
Sue J. Hong, Department of Pediatrics, Divisions of Critical Care and Child Neurology, Lurie Children's Hospital of Chicago, Chicago, IL, USA.
Jennifer M. Strahle, Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA.
Jose A. Pineda, Department of Critical Care, Children's Hospital of Los Angeles, Los Angeles, CA, USA.
Lauren A. Beslow, Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
Lindsey Rasmussen, Department of Critical Care, Stanford University School of Medicine, Stanford, CA, USA.
Janette Mailo, Division of Pediatric Neurology, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
Joseph Piatt, Division of Neurosurgery, Nemours Children's Hospital Delaware, Wilmington, DE, USA.
Shih-Shan Lang, Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
P David Adelson, Department of Neurosurgery, WVU Medicine and WVU Medicine Children's Hospital, Morgantown, WV, USA.
Michael C. Dewan, Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA.
Aleksandra Mineyko, Department of Pediatrics, Section on Neurology, University of Calgary, Calgary, AB, Canada.
Samuel McClugage, Department of Neurosurgery, Texas Children's Hospital, Houston, TX, USA.
Sudhakar Vadivelu, Division of Pediatric Neurosurgery and Interventional Neuroradiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
Michael M. Dowling, Departments of Pediatrics and Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
David S. Hersh, Division of Neurosurgery, Connecticut Children's, Hartford, CT, USA.

Document Type

Journal Article

Publication Date

7-20-2023

Journal

Neurocritical care

DOI

10.1007/s12028-023-01788-0

Keywords

Cerebral revascularization; Children; Delphi technique; Ischemic stroke; Moyamoya disease; Pediatric stroke; Perioperative care

Abstract

BACKGROUND: Surgical revascularization decreases the long-term risk of stroke in children with moyamoya arteriopathy but can be associated with an increased risk of stroke during the perioperative period. Evidence-based approaches to optimize perioperative management are limited and practice varies widely. Using a modified Delphi process, we sought to establish expert consensus on key components of the perioperative care of children with moyamoya undergoing indirect revascularization surgery and identify areas of equipoise to define future research priorities. METHODS: Thirty neurologists, neurosurgeons, and intensivists practicing in North America with expertise in the management of pediatric moyamoya were invited to participate in a three-round, modified Delphi process consisting of a 138-item practice patterns survey, anonymous electronic evaluation of 88 consensus statements on a 5-point Likert scale, and a virtual group meeting during which statements were discussed, revised, and reassessed. Consensus was defined as ≥ 80% agreement or disagreement. RESULTS: Thirty-nine statements regarding perioperative pediatric moyamoya care for indirect revascularization surgery reached consensus. Salient areas of consensus included the following: (1) children at a high risk for stroke and those with sickle cell disease should be preadmitted prior to indirect revascularization; (2) intravenous isotonic fluids should be administered in all patients for at least 4 h before and 24 h after surgery; (3) aspirin should not be discontinued in the immediate preoperative and postoperative periods; (4) arterial lines for blood pressure monitoring should be continued for at least 24 h after surgery and until active interventions to achieve blood pressure goals are not needed; (5) postoperative care should include hourly vital signs for at least 24 h, hourly neurologic assessments for at least 12 h, adequate pain control, maintaining normoxia and normothermia, and avoiding hypotension; and (6) intravenous fluid bolus administration should be considered the first-line intervention for new focal neurologic deficits following indirect revascularization surgery. CONCLUSIONS: In the absence of data supporting specific care practices before and after indirect revascularization surgery in children with moyamoya, this Delphi process defined areas of consensus among neurosurgeons, neurologists, and intensivists with moyamoya expertise. Research priorities identified include determining the role of continuous electroencephalography in postoperative moyamoya care, optimal perioperative blood pressure and hemoglobin targets, and the role of supplemental oxygen for treatment of suspected postoperative ischemia.

Department

Neurology

Link to Full Text

Share

COinS