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Review
. 2021 Aug;44(4):1877-1887.
doi: 10.1007/s10143-020-01393-1. Epub 2020 Sep 21.

Limits and pitfalls of indirect revascularization in moyamoya disease and syndrome

Pietro Fiaschi  1   2 , Marcello Scala  3   4 , Gianluca Piatelli  5 , Domenico Tortora  6 , Francesca Secci  5 , Armando Cama  5 , Marco Pavanello  5
Affiliations
Review

Limits and pitfalls of indirect revascularization in moyamoya disease and syndrome

Pietro Fiaschi et al. Neurosurg Rev. 2021 Aug.

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.

Keywords: Bypass; EDAS; Indirect revascularization; Moyamoya disease; Moyamoya syndrome.

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Figures

Fig. 1
Fig. 1
Illustration of EDAS procedure. a Surgical procedure of encephaloduroarteriosynangiosis (EDAS) with the arterial flap containing the parietal branch of the superficial temporal artery (STA) and surrounding galea tissue for an extension of 10 cm directly in contact with the cerebral cortex. The extremities of the bridge gently degrade so as not to create kinking of artery. Preoperative (b) and 1-year postoperative (c) magnetic resonance angiography (MRA) study shows the extensive collateralization in territory ACM (yellow circle)
Fig. 2
Fig. 2
Illustration of burr hole complication. a Skin intraoperative burr holes mapping with neuronavigation system. b Closed or non-functional burr holes dissected in the periosteum flap. Preservation of effective holes at temporal base. c Residues of the dural route corresponding to the burr holes after craniotomy. d Cortical ischemia (black arrow) in a circumvolution corresponding to a non-functional hole
See this image and copyright information in PMC

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