Direct versus indirect revascularization in the treatment of moyamoya disease

Seong-eun Park Department of Pediatric Neurosurgery, Severance Hospital, Yonsei University, College of Medicine, Seoul, South Korea

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Ju-seong Kim Department of Pediatric Neurosurgery, Severance Hospital, Yonsei University, College of Medicine, Seoul, South Korea

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Eun Kyung Park Department of Pediatric Neurosurgery, Severance Hospital, Yonsei University, College of Medicine, Seoul, South Korea

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Kyu-Won Shim Department of Pediatric Neurosurgery, Severance Hospital, Yonsei University, College of Medicine, Seoul, South Korea

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Dong-Seok Kim Department of Pediatric Neurosurgery, Severance Hospital, Yonsei University, College of Medicine, Seoul, South Korea

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OBJECTIVE

For patients with moyamoya disease (MMD), surgical intervention is usually required because of progressive occlusion of the internal carotid artery. The indirect bypass method has been widely accepted as the treatment of choice in pediatric patients. However, in adult patients with MMD, the most effective treatment method remains a matter of debate. Here, the authors compared the clinical outcomes from MMD patients treated with either extracranial-intracranial arterial bypass (EIAB; 43 hemispheres) or modified encephaloduroarteriosynangiosis (mEDAS; 75 hemispheres) to investigate whether mEDAS is an effective surgical method for treating adults with symptomatic MMD.

METHODS

A comparative analysis was performed in patients treated using either mEDAS or EIAB. Collateral grading, collateral vein counting, and symptom analysis were used to assess the outcome of surgery.

RESULTS

Seventy-seven percent (58/75) of mEDAS cases and 83.7% (36/43) of EIAB cases in the analysis experienced improvement in their symptoms after surgery. Furthermore, patients in 98.7% (74/75) of mEDAS cases and those in 95.3% (41/43) of EIAB cases exhibited improved collateral grades. Increases in regions of perfusion were seen after both procedures.

CONCLUSIONS

Modified EDAS and EIAB both result in positive outcomes for symptomatic adults with MMD. However, when considering the benefit of both surgeries, the authors propose mEDAS, a simpler and less strenuous surgery with a lower risk of complications, as a sufficient and safe treatment option for symptomatic adults with MMD.

ABBREVIATIONS

DSA = digital subtraction angiography; EIAB = extracranial-intracranial arterial bypass; ICA = internal carotid artery; ICU = intensive care unit; LOS = length of stay; MCA = middle cerebral artery; mEDAS = modified encephaloduroarteriosynangiosis; MMD = moyamoya disease; MRA = magnetic resonance angiography; STA = superficial temporal artery; TIA = transient ischemic attack.
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