Objective: Postoperative complications of surgical revascularization in moyamoya disease (MMD) are difficult to predict because of poor knowledge of the underlying pathophysiological process. Since the aim of surgery is to improve brain dynamics by increasing regional blood flow, we hypothesize that postoperative complications are closely related to aberrant electrophysiological changes. Thus, we evaluated the clinical significance of intraoperative electrocorticography (iECoG) in bypass surgery for adult MMD. Methods: Ninetyone adult patients operated on by the same neurosurgeon in our institute were involved (26 in the iECoG group, 65 in the traditional group). Two 1 × 6 subdural electrode grids were placed parallel to the middle frontal gyrus and superior temporal gyrus to record ECoG data continuously during the procedure in the iECoG group. Selected from several M4 candidate arteries, the recipient artery was determined to be closer to the cortex with lower power spectral density (PSD) in the beta band. The PSD parameter we used was the (delta+theta)/(alpha+beta) (DTAB) ratio (DTABR). Next, the pre-and post-bypass PSD values were evaluated, and correlations between post-/pre-bypass PSD parameter ratios and neurological/neuropsychological performance (in terms of changes in National Institutes of Health Stroke Scale [NIHSS] and Mini-Mental State Examination [MMSE] scores) were analyzed. Results: Postoperative complications (transient neurological events) in the iECoG group were significantly lower than those in the traditional group (p = 0.046). In the iECoG group, the post-/pre-bypass DTABR ratio in the bypass area was significantly correlated with postoperative NIHSS (p = 0.002, r 2 = 0.338) and MMSE changes (p = 0.007, r 2 = 0.266). In the nonbypass area, neither postoperative NIHSS nor MMSE changes showed a significant correlation with the post-/pre-bypass DTABR ratio (p > 0.05). Additionally, patients with postoperative complications exhibited significantly higher DTABR (1.67 ± 0.33 vs. 0.95 ± 0.08, p = 0.003) and PSD of the theta band (1.54 ± 0.21 vs. 1.13 ± 0.08, p = 0.036). Conclusions: This study is the first to explain and guide surgical revascularization from the perspective of electrophysiology. Intraoperative ECoG is not only sensitive in reflecting and predicting postoperative neurological and cognitive performance but also usable as a reference for recipient artery selection.

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