Limits and pitfalls of indirect revascularization in moyamoya disease and syndrome

Abstract

Moyamoya vasculopathy is a rare chronic cerebrovascular disorder characterized by the stenosis of the terminal branches of the internal carotid arteries and the proximal tracts of anterior and middle cerebral arteries. Although surgical revascularization does not significantly change the underlying pathogenic mechanisms, it plays a pivotal role in the management of affected individuals, allowing to decrease the risk of ischemic and hemorrhagic complications. Surgical approaches may be direct (extracranial-intracranial bypass), indirect, or a combination of the two. Several indirect techniques classifiable according to the tissue (muscle, periosteum, galea, dura mater, and extracranial tissues) or vessel (artery) used as a source of blood supply are currently available. In this study, we reviewed the pertinent literature and analyzed the advantages, disadvantages, and pitfalls of the most relevant indirect revascularization techniques. We discussed the technical aspects and the therapeutical implications of each procedure, providing a current state-of-the-art overview on the limits and pitfalls of indirect revascularization in the treatment of moyamoya vasculopathy.

Outcomes after superficial temporal artery–middle cerebral artery anastomosis combined with multiple burr hole surgery and dural inversion synangiosis for moyamoya disease in adults

“…In this study, the diameter of the F-STA increased by an average of 23.2% (P < 0.001), the diameter of the MMA increased by an average of 51.0% (P < 0.001), the diameter of the DTA increased by an average of 29.3% (P < 0.001), and the diameter of the distal STA increased by an average of 34.8% (P < 0.001). According to the data above, MMA seems to be the most effective choice for neovascularization induced by indirect revascularization, which is consistent with other studies (17)(18)(19). Although the incidence of perioperative complications was 24.2%, most of them were reversible, and no patient experienced stoke recurrence after the first postoperative month.…”

A rare triad of morning glory disc anomaly, moyamoya vasculopathy, and transsphenoidal cephalocele: pathophysiological considerations and surgical management

“…Due to the inadequate caliber of the superficial temporal artery, instead of a combined direct-indirect revascularization, we opted for EDAMPS, which was bilaterally performed with a 3-month interval. Indeed, it has been demonstrated that indirect revascularization improves cerebral hemodynamics and reduces the incidence of subsequent ischemic events in children with moyamoya vasculopathy [8,37,38]. Accordingly, in the present case, we noted regression of the ivy sign on FLAIR images and marked improvement of cerebral blood flow on ASL studies after surgery.…”

Surgical Treatment of Moyamoya Disease

“…Perioperative complications happen in 9.4-13.6% of BR procedures [116,149,194,205,219,221,226] with a 0-0.5% [188] mortality rate. Indirect BR has a significantly higher postoperative stroke rate than direct techniques [116,205] but fewer haemorrhages and no hyperperfusion syndrome [140,229,230]. The incidence of postoperative surgical complications is higher in Asian than other racial groups (6.51/100,00 inhabitants/year versus 5.21/100,000/persons/year) [198,231].…”