Indirect Cerebral Revascularization With a Temporoparietal Fascial Flap in Pediatric Moyamoya Patients

Abstract

Moyamoya syndrome is a progressive occlusive disease of the cerebral vessels. There are a variety of surgical treatments directed at revascularizing the ischemic brain in pediatric moyamoya disease. Many reports of varying success with both direct and indirect type of procedures can be found in medical literature. We present a novel technique, encephalo-TPF-synangiosis (ETS) with a pedicled bone flap, for indirect moyamoya revascularization in pediatric patients. A three-quarters osteoplastic temporal craniotomy was created. A pedicled temporoparietal fascial flap was passed intracranially through the temporalis muscle and placed into contact with the pial surface. The bone flap was the reaffixed to the skull. We performed 8 ETS in 6 patients. This is a well-vascularized, highly reliable method that offers broad-based surface area for revascularization. We also offer a composite overview of current surgical indirect revascularization techniques.

Pedicled temporoparietal fascial flap for combined revascularization in adult moyamoya disease

“…In addition, avoiding the use of the temporalis muscle eliminates the risk of myoelectric activity-induced epileptic seizures and offers better cosmetic and functional results. 35 Finally, the vascular pedicle of the flap allows preservation of the STV, which helps to prevent flap venous engorgement and swelling. Despite these potential benefits, sufficiently sized cohort studies of long-term outcomes in adult MMD patients treated with this novel combined approach are certainly necessary to assess the benefit and complication rates.…”

“…The isolated use of indirect revascularization does not provide immediate blood flow supplementation, has been associated with less favorable outcomes, and is typically not considered the treatment of choice in adult MMD. 12,22,23,32,35,39 Here, we present a novel revascularization technique combining direct STA-MCA bypass with indirect revascularization through a pedicled TPFF. Besides direct cerebral blood flow augmentation from the STA, this technique offers supplemented collateral neovascularization from a large surface area of a highly vascular TPFF placed in direct contact with the brain surface.…”

Modified pedicled temporoparietal fascial flap combined revascularization in adult moyamoya angiopathy

“…The Matsushima grading system was used to evaluate direct and indirect collateral compensation. The postoperative collateral formation was graded as follows: grade A, >2/3 of the middle cerebral artery (MCA) territory; grade B, between 1/3 and 2/3 of the MCA territory; and grade C, <1/3 of the MCA territory ( 1 , 12 ). Radiological examinations were performed on admission, 1 month postoperatively, and ≥6 months postoperatively.…”

“…Pedicled temporoparietal fascial flap (TPFF) has been widely used for head and neck flap reconstruction in plastic surgery, due to its free, flexible, thin, and highly vascularized characteristics (9). In view of the above characteristics of the TPFF, some neurosurgeons have tried to replace the TPFF in the revascularization in MMA and succeeded (10)(11)(12). However, few reports have been published, as the technique is still in the exploratory stage.…”