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Comment on "Transient Neurological Events After Surgery for Pediatric Moyamoya Disease: A Retrospective Study of Postoperative Sedation Practices".

To JNA Readers: We read with great interest the article by Matsuura et al1 regarding transient neurological events (TNEs) after surgery for pediatric moyamoya disease. We would like to highlight 2 important issues in relation to this study. First, we agree that anesthesia was not the cause of the postoperative TNEs in moyamoya disease children. In our opinion, the revascularization surgery itself, rather than crying, is the main reason for TNE in pediatric moyamoya disease. A recent study of pediatric patients with moyamoya disease who received general anesthesia for imaging studies and surgical procedures excluding neurosurgical revascularization found that the incidence of TNE during anesthesia encounters was 0.85%.2 Interestingly, in the study reported by Matsuura et al,1 in which pediatric moyamoya disease patients received not only general anesthesia but also revascularization surgery, there was a higher incidence (39%) of TNEs within 1 week after surgery. This difference suggests that revascularization surgery may play a major role in the occurrence of postoperative TNEs. Second, although Matsuura et al1 concluded that crying was associated with increased TNEs, there are other issues that must be considered. One of the biggest impacts of crying may be the associated increases in carbon dioxide and decreases in oxygen tensions in the blood. However, the authors did not find a significant correlation between partial pressure of carbon dioxide and postoperative TNEs. According to a previous study, postoperative changes, such as cerebral hyperperfusion, hypoperfusion, and vasogenic edema, play vitally important roles in the development of TNEs after revascularization surgery in moyamoya disease.3 However, the lack of examinations such as magnetic resonance imaging and single-photon emission computed tomography, in the by Matsuura et al1 made it impossible to determine whether crying was related to these important changes. Last but not least, crying may also be the result of discomfort in moyamoya disease children. Thus, the administration of sedatives may mask the clinical manifestations of TNEs.