Angiographic Results of Indirect and Combined Bypass Surgery for Adult Moyamoya Disease

Abstract

ObjectiveThe aim of this study was to compare the efficacy of indirect and combined bypass surgery for treatment of adult moyamoya disease (MMD). The definition of combined bypass surgery is a combination of superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and indirect anastomosis. Development of collateral circulation after surgery was investigated.MethodsForty three patients (58 hemispheres) with MMD were followed by cerebral angiography for at least six months after surgery, between May 2002 and July 2011. Indirect and combined revascularization surgeries were performed in 33 and 25 cases, respectively. Good outcome was defined as more than group B, in accordance with the method suggested by Matsushima.ResultsDevelopment of collateral circulation was not affected by sex (p = 0.493), clinical features (p = 0.206), or Suzuki stage (p = 0.428). Based on postoperative cerebral angiography, the combined bypass surgery group showed a better angiographic outcome, than the encephaloduroarteriomyosynangiosis (EDAMS) group (p = 0.100, odds ratio [OR] 4.107, 95% confidence interval [CI] 0.700 - 24.096). The combined bypass group showed a better response than the encephaloduroarteriogaleosynangiosis (EDAGS) group (p = 0.088, OR 4.600, 95% CI 0.721 - 29.332). Similar responses were observed for EDAGS and EDAMS (p = 0.886, OR 1.120, 95% CI 0.239 - 5.251). The combined bypass group showed a better response than the indirect group (p = 0.064, OR 4.313, 95% CI 0.840 - 22.130).ConclusionResults of this study demonstrate that combined bypass results in better revascularization on angiographic evaluation in adult MMD. Therefore, among surgical procedures, combined bypass is a choice that can be recommended.

Combined Direct and Indirect Cerebral Revascularization Using Local and Flow-Through Flaps

“…10 Comparative analysis of cerebral angiography after revascularization has also shown that combined bypass results in increased development of collateral vessels when compared with various types of indirect revascularization alone. 6 Combined revascularization has been previously reported in the neurosurgery literature using a 2-to 3-cm wide strip of galea and/or temporalis muscle, in combination with low-flow STA bypass. We sought to improve the size and quality of the indirect component, as knowledge of axial arterial flaps allows the plastic surgeon to raise vascularized flaps in excess of 80 cm 2 , providing a theoretical advantage to the indirect revascularization territory size.…”

“…5 The development of collateral vasculature between vascularized tissue and the brain has been repeatedly demonstrated by angiography and autopsy. [6][7][8] Direct and indirect revascularization methods can also be combined for acute revascularization and delayed angiogenesis. 9 In an effort to improve outcomes, we have utilized a multidisciplinary approach with neurosurgery revascularization techniques and plastic surgery flap elevation techniques for combined revascularization procedures.…”

A Recent Update of Clinical and Research Topics Concerning Adult Moyamoya Disease

“…They concluded that EDAGS can be a reliable alternative to combined bypass in adult MMD cases, however, they did not provide detailed information on the future stroke rate according to surgical method. Choi et al7) showed an improved revascularization angiographic outcome of combined bypass, than from indirect bypass, in adult MMD patients. In their study, a revascularization area of more than two-thirds of the MCA distribution was more frequently observed in the combined bypass group (n=12, 48.0%), than the indirect bypass group (n=9, 27.3%).…”

Treatment of moyamoya disease by multipoint skull drilling for indirect revascularization combined with mobilization of autologous bone marrow stem cells

“…The clinical manifestations include insufficient cerebral perfusion, transient cerebral ischemia, cerebral apoplexy, and epilepsy (Choi et al, 2012;Southerland et al, 2013). Focal neurofunctional deficit within the dominated region of the diseased blood vessels after cerebral ischemia severely affects the patients' quality of life.…”