Modified encephaloduroarteriosynangiosis with bifrontal encephalogaleoperiosteal synangiosis for the treatment of pediatric moyamoya disease

Abstract

The authors describe a modified technique of encephaloduroarteriosynangiosis (EDAS) with bifrontal encephalogaleoperiosteal synangiosis (EGPS) and present the preliminary results of the procedure. Between January 2004 and June 2005 the authors performed modified EDAS with bifrontal EGPS in 17 patients with moyamoya disease. Surgical results were evaluated in terms of clinical outcomes, changes visible on neuroimages, extent of revascularization noted on angiograms, and hemodynamic changes demonstrated on single-photon emission computed tomography (SPECT) scans. The follow-up period ranged from 6 to 21 months (mean 11.5 months). The overall clinical outcomes were excellent or good in 15 patients (88.2%) and poor in two (11.8%). The overall morbidity rate was 5.9% (one of 17 patients). Based on changes in the anterior cerebral artery (ACA) and middle cerebral artery (MCA) territories after surgery, as shown on SPECT scans following administration of acetazolamide, 14 patients (82.4%) exhibited an improved vascular reserve capacity in both the ACA and MCA territories. It is the authors' opinion that wide covering of the cortex is necessary for sufficient revascularization. In the present study they demonstrate that modified EDAS with bifrontal EGPS is a safe and efficient surgical approach that covers not only the MCA territory but also the ACA territory.

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

“…Next to revascularization in the MCA territory, re-establishing CBF in the anterior cerebral artery (ACA) area is most likely to be of importance, in particular in children with MMV [20,[23][24]; neurocognitive development has been correlated to frontal lobe CBF. [18,24] In this report we described a cerebral revascularization technique for patients with MMV which enables increasing CBF in three different vascular territories.…”

“…(8,11,13,16,18,20,23) The novelty of this technique is unfolded in the one-staged approach combining direct and indirect revascularization in three different areas, with minimal surgical risks (by avoiding the IF and SSS). To our knowledge, this one-staged procedure has not been reported in the literature.…”

“…[20] In the technical modification presented, the revascularized frontal area is further expanded by inverting and reflecting dural flaps over the cortex for each craniotomy. This bifrontal EDPS method is easy to perform and can be applied in patients with MMV who suffer from bifrontal hypoperfusion with hemodynamic impairment documented on PET examination.…”

“…[2,5,12,24] Re-establishing cerebral blood flow (CBF) in the frontal territory may prevent, stabilize or improve neurocognitive decline. [6][7]15,[17][18][19][20]24] In this paper, we describe a combined one-staged procedure for revascularization of the MCA territory unilaterally by a direct STA-MCA bypass and the bifrontal territory by an encephalo-duro-periosteal-synangiosis (EDPS). To illustrate the procedure, the treatment of a girl affected by MMS is reported.…”

Involuntary Movements Induced and Remitted by Indirect Bypass Surgery in a Patient with Moyamoya Disease

“…Initially, the patient underwent encephalo-duro-arteriomyosynangiosis on the right middle cerebral artery (MCA) territory and encephalo-duro-periostealsynangiosis on the bifrontal anterior cerebral artery (ACA) territory, which ameliorated his transient motor weakness in the left side [2]. However, involuntary movement appeared in his right upper extremity without symptoms in his lower extremities three months after the surgery.…”