Surgical management of moyamoya disease

Baaj, Ali A.; Agazzi, Siviero; Sayed, Zafar A.; Toledo, Maria; Spetzler, Robert F.; Loveren, Harry van

doi:10.3171/2009.01.focus08293

Cited by 170 publications

(70 citation statements)

References 46 publications

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“…Even worse, skin necrosis can be a life-threatening problem when infection arises in the nonvascularized bone used in the primary operation. 7 Intracranial revascularization surgeries are an efficient treatment for moyamoya disease (MMD)-which is characterized by progressive stenosis or occlusion of the bilateral internal carotid arteries (ICAs) that is associated with a compensatory abnormal vascular network 4,8,11,12,14,21 and cerebral major artery occlusive diseases such as arterial occlusion and aneurysm. The surgical procedure involves several surgical techniques, including superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass, superficial temporal artery-to-superior cerebral artery (STA-SCA) bypass, encephalo-duro-arterio-synangiosis (EDAS), and encephalo-duro-arterio-myo-synangiosis (EDAMS).…”

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confidence: 99%

Operative wound-related complications after cranial revascularization surgeries

Takanari

Araki²,

Okamoto³

et al. 2015

JNS

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aBBreViatiONS BA = basilar artery; DM = diabetes mellitus; EDAMS = encephalo-duro-arterio-myo-synangiosis; EDAS = encephalo-duro-arterio-synangiosis; EMS = encephalo-myo-synangiosis; ICA = internal carotid artery; MCA = middle cerebral artery; MMD = moyamoya disease; SCA = superior cerebral artery; SPECT = singlephoton emission computed tomography; STA = superficial temporal artery; STSG = split-thickness skin graft. SuBmitted January 13, 2014. accepted December 5, 2014. iNclude wheN citiNg Published online July 3, 2015; DOI: 10.3171/2014.12.JNS132602. diSclOSure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. * Drs. Takanari and Araki contributed equally to this work. OBJect Intracranial revascularization surgeries are an effective treatment for moyamoya disease and other intracranial vascular obliterative diseases. However, in some cases, wound-related complications develop after surgery. Although the incidence of wound complication is supposed to be higher than that with a usual craniotomy, this complication has rarely been the focus of studies in the literature that report the outcomes of revascularization surgeries. Here, the relationship between intracranial revascularization surgeries and their complications is statistically assessed. . Multivariate logistic regression analysis also revealed that double procedures demonstrated a significantly higher incidence of wound complications than single procedures (OR 3.087, p = 0.048). DM was found to be a risk factor for wound complication (OR 9.42, p = 0.02), but age, sex, hypertension, and hyperlipidemia were not associated with the incidence of complications. Even though the blood supply to the scalp is abundant due to 5 arteriovenous systems, sometimes cutaneous necrosis develops after intracranial revascularization surgeries. The galeal blood supply is thought to be crucial for preventing wound-related complications. Special care is also thought to be required for DM patients. cONcluSiONS Revascularization surgeries seemed to demonstrate a higher risk of wound-related complications. Double-type procedures, which use both branches of the STA, and a history of DM were found to be risk factors for wound-related complications. Attention should be paid to the design of the galeal incision and vessel harvest line. Also, special attention should be paid to patients with DM.http://thejns.org/doi/abs/10.3171/2014.12.JNS132602KeY wOrdS cranial revascularization surgery; extracranial to intracranial bypass; infection; skin necrosis; superficial temporal artery-to-middle cerebral artery anastomosis; wound-related complication; vascular disorders 1145

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confidence: 99%

Operative wound-related complications after cranial revascularization surgeries

Takanari

Araki²,

Okamoto³

et al. 2015

JNS

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“…Surgical procedures for MMD may be basically classified into three categories: Direct bypass, including superficial temporal artery-middle cerebral artery (STA-MCA) and occipital artery-MCA, indirect bypass, including encephalo-duroarterio-synangiosis, encephalo-myo-synangiosis (EMS), encephalo-duroarterio-myo-synangiosis and encephaloduro-myo-synangiosis (EDMS), and combined bypass. However, the optimal revascularization strategy for symptomatic adult moyamoya patients remains controversial (4). Direct bypass offers the advantage of immediate revascularization, and indirect bypass induces in-growth of collaterals over time.…”

Section: Introductionmentioning

confidence: 99%

Clinical and angiographic outcomes after combined direct and indirect bypass in adult patients with moyamoya disease: A retrospective study of 76 procedures

et al. 2018

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Abstract. The present retrospective study was performed to evaluate the clinical outcome, as well as post-operative collateral formation and revascularization patterns in combined bypass. Surgical revascularization has been the mainstay of treatment for moyamoya patients. A total of 76 hemispheres from 64 moyamoya patients undergoing combined superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and encephalo-duro-myo-synangiosis (EDMS) were retrospectively reviewed. Computed tomography perfusion and DSA were routinely performed. Modified Rankin scale (mRS) scoring and Kaplan-Meier analysis were performed, and post-operative collateral grading on digital subtraction angiography (DSA), reconstruction patterns and vessel diameter were measured to evaluate the revascularization area and vascular compensatory effect. During the follow-up period, the chief complaint was partially alleviated in 57/64 patients (89.1%). In all patients, mRS was significantly decreased after the operation. Good revascularization was established in most patients at 6 months after the surgery: 92.1% of sides were scored as 2 and 77.6% were scored as 3 by post-operative collateral grading on DSA. Dominant collateral revascularization originating from EDMS was more frequent than that from STA-MCA anastomosis (31 vs. 19 hemispheres) at 6-month follow-up. Morphologically, the calibers of the STA main trunk (2.60±0.65 mm) increased profoundly at the first 10 post-operative days (3.32±1.05 mm) and shrank back to pre-operative status at 6 months (2.20±1.01 mm) and 12 months (2.36±0.73 mm) according to DSA examination. Middle meningeal artery (MMA) and deep temporal artery (DTA) demonstrated continuous augmentation during the follow-up time (from 1.30±0.46 to 1.87±0.69 mm for MMA and 1.11±0.25 to 2.11±1.16 mm for DTA). These results strongly suggested that combined STA-MCA bypass and EDMS provided efficient revascularization and reduced acute cerebral events. The direct STA-MCA bypass provided early augmentation of cerebral perfusion, whereas the indirect EDMS provided a more durable long-term revascularization, indicating a complementary association between the two revascularization methods.

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“…Indirect methods for cerebral revascularization are based on the approximation of vascularized tissue such as the temporal muscle, pericranium, dura or omentum onto the cortex in order to promote neoangiogenesis over time. [1,4] Combined techniques provide the advantages of both methods, however there is no evidence of one technique having advantages over the other.…”

Section: Introductionmentioning

confidence: 99%

“…[22] Surgical cerebral revascularization is considered the only effective treatment modality and can be achieved by direct, indirect or combined methods. [1,3,14] Direct techniques consist of an anastomosis of a donor artery, generally the superficial temporal artery (STA), to a cortical recipient arterial branch of the middle cerebral artery (MCA), which instantly augments blood supply. Indirect methods for cerebral revascularization are based on the approximation of vascularized tissue such as the temporal muscle, pericranium, dura or omentum onto the cortex in order to promote neoangiogenesis over time.…”

Section: Introductionmentioning

confidence: 99%

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

Kronenburg

Esposito

Fierstra

et al. 2014

Acta Neurochirurgica Supplement

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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.

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Surgical management of moyamoya disease

Cited by 170 publications

References 46 publications

Operative wound-related complications after cranial revascularization surgeries

Operative wound-related complications after cranial revascularization surgeries

Clinical and angiographic outcomes after combined direct and indirect bypass in adult patients with moyamoya disease: A retrospective study of 76 procedures

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

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