Recovery for Moyamoya Disease in Children

Postoperative Orders

• Vital Signs and Fluids: Hypovolemia, anemia and hypotension, if present, should be corrected to avoid postoperative ischemia-related complications. To detect the most common postoperative complications, ischemic brain damage, postoperative epidural or subdural hemorrhage and scalp necrosis, attention should be paid on the changes of neurological and wound status.
• Special case of hyperperfusion and hypertension: The hyperperfusion syndrome is absent in cases with indirect revascularization. However, it may occur after direct revascularization, in cases of chronic profound brain ischemia (9,26). In these cases, hypertension should be strictly avoided (mean arterial blood pressure, within 20-30 mm Hg from preoperative level, for postoperative 7 days) as well as hypotension (26).
• Ventilation: It is important to avoid hyperventilation. Young children who easily become irritable when separated from parents are vulnerable to postoperative hyperventilation and subsequent ischemic damage of the brain.  For young children who need close parental care, parents are recommended to stay beside the bed even when the patient is observed in the intensive care unit. Sometimes sedation or intermittent re-breathing using a plastic bag is helpful for maintenance of PaCO2 level.
• Anticonvulsants: Prophylactic anticonvulsants may be recommended to prevent postoperative seizures in some cases, which may aggravate ischemic brain injury. If there is no postoperative seizure for 1-4 weeks, anticonvulsants are typically stopped.
• Resuscitation of TIAs: Fluid challenge with volume expanders is effective for reversal of TIA or minimization of cerebral infarct. In children older than 3-5 years, new cerebral infarction is very rare at the surgical area after postoperative one week, even though TIA may persist. However, in very young children, new cerebral infarction may occur even a week after surgery.