Prediction of cerebral infarction after combined revascularization by three-dimensional-time-of-flight magnetic resonance angiography in adult patients with moyamoya disease

This study aims to investigate the predictive factors of postoperative cerebral infarction in adult patients with moyamoya disease (MMD) by integrating preoperative three-dimensional-time-of-flight magnetic resonance angiography (3D-TOF MRA) with general clinical data. The clinical, follow-up, and MRI data of adult MMD patients from September 2019 to September 2023 were collected from our neurosurgery department’s electronic records. The MRA scoring was based on the blood flow signals identified by 3D-TOF MRA preoperatively. Retrospective analysis of preoperative data and MRA scores was performed, followed by univariate and Firth penalized likelihood regression to identify postoperative cerebral infarction predictors. Bayesian regression tested Firth analysis sensitivity, and Bootstrap resampling assessed estimate robustness. A total of 78 patients were included, who underwent combined revascularization. 12 cases (15.3%) developed cerebral infarction after surgery. Univariate analysis linked preoperative ischemic stroke events ( P = 0.025), higher Suzuki stage ( P = 0.008), and elevated ICA ( P = 0.023), MCA ( P = 0.001), ACA ( P = 0.018), and hemispheric MRA scores ( P < 0.001) to postoperative cerebral infarction. Firth penalized likelihood regression analysis identified a higher hemispheric MRA score as an independent risk factor for predicting postoperative cerebral infarction (OR = 3.470, 95% CI 1.701–10.720, P < 0.001). Bayesian (OR = 4.155, 95% CrI = 2.123–9.059) and Bootstrap analyses (OR = 7.317, 95% CI 2.517–49.371) confirmed the findings of the Firth regression. ROC analysis set an optimal hemispheric MRA threshold of 8.5 (AUC = 0.956, P < 0.001; sensitivity 0.917, specificity 0.894). The preoperative hemispheric 3D-TOF MRA scoring system appears to be a promising strategy for predicting cerebral infarction following combined revascularization in adult patients with MMD, though large-scale prospective studies are urgently needed for validation.