Cranial burr hole for revascularization in moyamoya disease

Abstract

Currently, superficial temporal artery-middle cerebral artery (MCA) anastomosis, encephalomyosynangiosis (EMS), and encephalo-duro-arterio-synangiosis are used to treat moyamoya disease and are reported to effectively improve ischemic symptoms. All are methods of reversing the flow of blood from the external carotid artery system into the cortical branches of the MCA. As moyamoya disease advances, these operations alone will predictably not correct the deterioration in blood flow in the territory of the anterior cerebral artery. It was noted in a case of moyamoya disease with intraventricular hemorrhage that a burr hole, made in the frontal region for drainage purposes, induced marked neovascularization. Since then, similar frontal burr holes have been made in five juvenile cases of moyamoya disease; this procedure involved making a burr hole in both frontal bones and incising both the dura and the arachnoid membrane. In two cases a frontal burr hole in both frontal bones and incising both the dura and the arachnoid membrane. In two cases a frontal burr hole was placed simultaneously with EMS, and in the others the frontal burr hole was made following EMS. The clinical symptoms improved after the frontal burr hole was made, and dynamic computerized tomography revealed improved circulation in the frontal regions. Together with conventional surgical therapy for juvenile cases of moyamoya disease, this operation is considered beneficial both to the circulation in the frontal region and for the protection of frontal brain function.

Understanding and treating moyamoya disease in children

“…The multiple cranial bur hole technique is an additional indirect technique that can be used to treat moyamoya disease. 11,84 Until recently, this technique has been used in combination with other techniques, such as the STA-MCA bypass, EMS, EDAS, or pial synangiosis, to provide supplemental collateralization, especially to the frontal and occipital lobes, which typically are not well vascularized by these other techniques. 95 Unfortunately, the rate of collateral development as determined by postoperative angiography is variable.…”

“…12,16,17,29,34,48,54,81,91,113 Revascularization procedures can be divided into 3 main groups: indirect (nonanastomotic) bypass techniques, direct (anastomotic) bypass techniques, and indirect and/or direct bypass techniques combined. Indirect bypass techniques include pial synangiosis, 2,91 EDAS, 67,69 EMS (temporalis muscle with its rich blood supply is sutured to the dura mater), 33 encephaloduroateriomyosynangiosis (EDAMS), 43 ribbon EDAMS, 44 encephalogaleosynangiosis (EGS), 110 encephalogaleomyosynangiosis (EGMS), 92 omental transplantation, 23,31,35 bifrontal encephalogaleoperiosteal synangiosis (EGPS), 42,80 and multiple bur hole surgery, with opening of dura and arachnoid over affected areas, 11,84 as well as a combination of ≥ 1 of these techniques. One of the biggest criticisms of the indirect techniques has been that the beneficial effects are not immediate because it takes ≥ 3-4 months for collaterals to develop, 25,113 and during that time there is a risk of perioperative ischemic stroke.…”

Simultaneous Superficial Temporal Artery to Middle Cerebral or Anterior Cerebral Artery Bypass With Pan-synangiosis for Moyamoya Disease Covering Both Anterior and Middle Cerebral Artery Territories-Technical Note-

“…Direct STA-ACA bypass surgery was performed as a secondary surgery for refractory ischemic episodes. 5,7) Indirect bypass surgery targeting the frontal lobe, 21) ribbon EDAMS, 13) burr holes, 1,11) and dural pedicle insertion over the brain surface combined with encephalo-galeo-synangiosis 23) have also been reported. The present study describes the technical procedure to establish vasoreconstructive surgery including direct bypass for the ACA territory at the first intervention.…”

“…Various methods of vasoreconstructive surgery are accepted as treatment for moyamoya disease, including direct bypass such as superficial temporal artery (STA) to middle cerebral artery (MCA) bypass 8) ; indirect bypass such as encephalo-duroarterio-synangiosis, 20) encephalo-duro-arterio-myosynangiosis (EDAMS), 12) and omentum transplantation 9) ; multiple burr holes 1,11) ; and a combination of direct and indirect bypasses. 4,10,12) Such methods provide good neovascularization through the extracranial arteries and reduced risk of cerebral ischemia after the surgery.…”

History of the Development of Surgical Treatments for Moyamoya Disease

“…EMS and EDAS are the two principal procedures for single indirect bypass and have spurred the development of a multitude of variants that have used the scalp arteries, galea, dura mater, muscles, and omentum as donor tissues. 15,17,21,40,59) Endo et al, 2) Kawaguchi et al, 19) and Seinte-Rose et al 52) even reported a multiple burr hole surgery technique for children with moyamoya disease.…”