Combined Bypass Technique for Contemporary Revascularization of Unilateral MCA and Bilateral Frontal Territories in Moyamoya Vasculopathy

Abstract

Moyamoya vasculopathy (MMV) leads to chronic hypoperfusion predominantly in the middle cerebral artery (MCA) and anterior cerebral artery (ACA) territories. Most revascularization techniques focus on revascularization of the MCA territory. Augmentation of blood flow in the frontal area is important for neurocognition and lower extremity function. In this article we describe a new combined (direct and indirect) one-stage bypass technique consisting of a superficial temporal artery to middle cerebral artery (STA-MCA) bypass with encephalo-duro-synangiosis (EDS) for unilateral MCA revascularization, along with an encephalo-duro-periosteal-synangiosis (EDPS) for bifrontal blood flow augmentation. The strength of this technique is the revascularization of three vascular territories during a single surgical intervention: the MCA unilaterally; and the frontal territories bilaterally. Bifrontal EDPS may also be considered as a supplementary independent procedure for patients who previously underwent revascularization treatment in the MCA territory, but develop symptoms due to frontal hypoperfusion. bypass with an encephalo-duro-myo-synangiosis (EDMS) for unilateral MCA revascularization, along with a encephalo-duro-periosteal-synangiosis (EDPS) for bifrontal blood flow augmentation. The strength of this technique is the revascularization of 3 vascular territories during a single surgical intervention: the MCA unilaterally and the frontal territories bilaterally. Bifrontal EDPS can also be considered as a supplementary independent procedure for patients who previously underwent revascularization treatment in the MCA territory, but develop symptoms due to frontal hypoperfusion.

“STA-MCA bypass with encephalo-duro-myo-synangiosis combined with bifrontal encephalo-duro-periosteal-synangiosis” as a one-staged revascularization strategy for pediatric moyamoya vasculopathy

“…We report a case series consisting of 8 pediatric patients treated with a single stage direct STA-MCA with EDMS for unilateral revascularization of MCA territory, in combination with bifrontal EDPS for bilateral frontal revascularization [3]. The indication to perform the one-step combined revascularization procedure was to have hemodynamic compromise and clinical symptoms involving concurrently both a MCA territory and the bifrontal areas.…”

“…[1] Applied techniques of revascularization vary and it remains unclear whether one technique should be preferred over the other, both in adults and in children. [1][2][3] The most commonly used direct revascularization procedure is the superficial temporal artery to middle cerebral artery (STA-MCA) bypass that instantly augments blood supply to the middle cerebral artery (MCA) territory. Indirect techniques rely on the overlay of vascularized tissue (like the temporal muscle, pericranium and dura) onto the cerebral cortex in order to promote neoangiogenesis over time.…”

“…Indirect techniques rely on the overlay of vascularized tissue (like the temporal muscle, pericranium and dura) onto the cerebral cortex in order to promote neoangiogenesis over time. [1][2][3] Combined revascularization procedures provide the advantages of both techniques. [2][3][4][5][6][7] In addition to symptoms that can be ascribed to the MCA territory, children may present with lower extremity motor weakness and neuropsychological dysfunctions probably due to involvement of the frontal lobes.…”

“…[1][2][3] Combined revascularization procedures provide the advantages of both techniques. [2][3][4][5][6][7] In addition to symptoms that can be ascribed to the MCA territory, children may present with lower extremity motor weakness and neuropsychological dysfunctions probably due to involvement of the frontal lobes. [8][9][10][11][12] In pediatric MMV, the cerebral blood flow (CBF) in the bifrontal areas as well as in the anterior watershed territory may continue to worsen despite good collateral formation or successful revascularization of the MCA territory.…”

“…This technique consists of unilateral STA-MCA bypass with encephalo-duro-myo-synangiosis (EDMS) and bifrontal encephalo-duro-periosteal-synangiosis (EDPS). [3] The purpose of this article is to report our surgical experience in a series of eight pediatric moyamoya patients and to emphasize the rational for bifrontal revascularization.…”