• Omar Alwakaa, Alejandro Enriquez-Marulanda, Felipe Ramirez-Velandia, Jean Filo, Emmanuel Mensah, Aryan Wadhwa, Thomas B Fodor, Samuel D Pettersson, Evan Paul McNeil, Michael Young, Sandeep Muram, Alfred P See, Justin H Granstein, Philipp Taussky, and Christopher S Ogilvy.
• Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
• World Neurosurg. 2024 Sep 10.

BackgroundThe Matsushima grade has traditionally been used to evaluate vessel ingrowth from the superficial temporal artery after encephalo-duro-arterio-synangiosis (EDAS) for Moyamoya disease (MMD) patients. However, this grading is subjective and prone to measurement variability. Herein, we propose the orbital grading system quantifying leptomeningeal and burr hole-related vessel-ingrowth from the superficial temporal artery and/or middle meningeal artery to the middle and anterior cerebral arteries post EDAS in MMD patients.MethodsAn anatomical classification was developed by reference to 2 parallel vertical lines from the bony landmarks of the orbit, categorized from Grade 0-3. Regression models were used to compare clinical and functional outcomes of our grading system with the Matsushima scale.ResultsForty MMD patients, with median age of 48 years, mostly females (72.5%), underwent 56 EDAS procedures. Presentation included ischemic events (65.0%), hemorrhage (22.5%), and seizures (7.5%). Most patients were categorized as Suzuki ≥ IV (69.5%). Fifty EDAS (89.9%) had concurrent burr holes placed (parietal and frontal regions). At a median follow-up of 13.7 months, collateral growth was graded as follows: grade 0 (6; 10.8%), grade 1 (12; 21.4%), grade 2 (23; 41.1%), and grade 3 (15; 26.8%). Linear regression showed similarities in the distribution between the orbital grading system and Matsushima grading (r = 0.86; P < 0.01). Ischemic events were fewer in hemispheres categorized as grade 2-3 compared to grade 0-1 (P = 0.047) as well as in Matsushima grading A or B compared to C (P = 0.047).ConclusionsThe orbital grading system demonstrated agreement in identifying postoperative ischemic events as the Matsushima grade and provides a more practical and objective evaluation of collateral vessel ingrowth after EDAS with and without burr holes.Copyright © 2024 Elsevier Inc. All rights reserved.

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