Minocycline in Moyamoya Bypass Surgery

Dosage used in the study:

  • intraoperative and postoperative IV minocycline hydrochloride (200 mg/d) until 4 days after surgery



  • semisynthetic tetracycline
  • clinically used as an antibiotic and anti-inflammatory drug
  • Neuroprotection:
    • neuroprotective potential reported in animal models of cerebral ischemia
    • reduces infarction size in rats due to the prevention of inflammatory reactions by suppressing microglial activation, down-regulating proinflammatory cytokines, and blocking MMP expression
    • prevents reperfusion-related ICH by blocking MMP-9 in mice
    • neuroprotective role as an antiapoptotic agent and antioxidant
  • Mechanism in ischemia-reperfusion injury
    • maintains BBB? –> reducing risk of vasogenic edema and hemorrhagic convesrion?
    • Moyamoya patients have higher expression of MMP-9 –> can perioperative minocycline prevent surgical complications (cerebral hyperperfusion or ischemia)




Proposed mechanisms:

  1. Minocycline blocks MMP-9, prevents neurological deterioration due to cerebral hyperperfusion.
  2. Minocycline compensated for deleterious effect of BP lowering by protecting contralateral and/or remote brain


Higher risk of reperfusion injury in Moyamoya due to

  1. poor network formation of pial arteries –> poorer hemodyamic distribution after revascularization
  2. fragile peripheral pial artery (thin media and internal elastic lamina) in Moyamoya disease
  3. increased expression of VEGF and MMP-9


Study conclusion:

The administration of minocycline in combination with strict blood pressure control could represent secure and effective postoperative management for the prevention of symptomatic CHP after STA-MCA anastomosis for MMD.



  1. small number of patients who developed focal deficits
  2. heterogenous group
  3. no data on preoperative hemodynamic status – no SPECT stress testing
  4. CBF studies performed under different institutions
  5. did not measure MMP-9 levels




Fujimura, Miki et al. “Minocycline Prevents Focal Neurological Deterioration Due To Cerebral Hyperperfusion After Extracranial-Intracranial Bypass For Moyamoya Disease”. Neurosurgery74.2 (2014): 163-170.



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