Strategy and effect of repeat bypass surgery for anterior/posterior circulation in refractory moyamoya disease

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OBJECTIVE

In this study the authors aimed to describe clinical features, surgical techniques, and long-term outcomes of repeat bypass surgery required for a certain subset of patients with moyamoya disease.

METHODS

The authors retrospectively reviewed a total of 22 repeat bypass surgeries for 20 patients (age range 1–69 years) performed during the last 20 years at their institutions. The patients were classified into 2 groups. Group A included 10 patients who underwent repeat bypass surgery for anterior circulation due to insufficient revascularization on the ipsilateral side. Group B included 10 patients who underwent repeat bypass surgery for posterior circulation due to the involvement of the posterior cerebral artery (PCA) after successful initial surgery for anterior circulation.

RESULTS

Preoperative symptoms included headache in 3 patients, transient ischemic attack in 10, cerebral infarction in 3, and intracranial hemorrhage in 4 patients. Intervals between the initial bypass surgery and repeat bypass surgery were 0.3–30 years (median 3 years). In group A, superficial temporal artery to middle cerebral artery (MCA) anastomosis and indirect bypass were performed on 7 hemispheres. Only indirect bypass was performed on 3 hemispheres because of the lack of suitable donor or recipient arteries. In group B, occipital artery (OA) to PCA anastomosis and indirect bypass were conducted on 4 hemispheres, and OA-MCA anastomosis and indirect bypass on 1 hemisphere. Only indirect bypass was conducted on 7 hemispheres because of the lack of suitable recipient arteries. All 22 repeat bypass surgeries were successfully conducted. During follow-up periods (median 4 years), none of the patients suffered repeat stroke except 1 patient who died of recurrent intracerebral hemorrhage 3 years after repeat bypass surgery for anterior circulation.

CONCLUSIONS

Repeat bypass surgery was feasible and effective to reduce further incidence of headache attack, transient ischemic attack, and ischemic/hemorrhagic stroke in moyamoya disease patients. Through precise radiological analysis, surgical procedures should be planned to yield maximal therapeutic effects.

ABBREVIATIONS CBF = cerebral blood flow; EDAS = encephalo-duro-arterio-synangiosis; EDMAPS = encephalo-duro-myo-arterio-pericranio-synangiosis; EDPS = encephalo-duro-pericranio-synangiosis; EMAS = encephalo-myo-arterio-synangiosis; EMS = encephalo-myo-synangiosis; ICH = intracranial hemorrhage; MCA = middle cerebral artery; MMD = moyamoya disease; OA = occipital artery; PCA = posterior cerebral artery; STA = superficial temporal artery; TIA = transient ischemic attack.

Article Information

Correspondence Haruto Uchino: Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, Japan. uchino-hok@umin.ac.jp.

INCLUDE WHEN CITING Published online May 31, 2019; DOI: 10.3171/2019.3.JNS181979.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Illustrative drawing of repeat bypass surgery (group A) shows the surgical procedures in case 10. In previous surgery, the parietal branch of the STA was anastomosed to the MCA through temporo-parietal craniotomy (A). After creating an additional craniotomy anterior to the previous one, the frontal branch of the STA was anastomosed to the frontal branch of the MCA (B). The dural flap was inverted to cover the area outside the craniotomy and the brain surface was covered with the pericranium (P) as an EDPS (C). Copyright Haruto Uchino. Used with permission. Figure is available in color online only.

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    Illustrative drawing of repeat bypass surgery (group B) shows the surgical procedures in case 12. An inverse U-shaped skin incision was performed on the bilateral occipital area and the bilateral OAs were exposed (A). After performing bilateral occipital craniotomy and opening the dura while preserving the superior sagittal sinus (SSS), the right OA was anastomosed to the cortical branch of the PCA (B). The dural flaps were inverted to cover the outside of the craniotomy, and the brain surface was covered with the pericranium (P) to form a bilateral (bil.) EDPS (C). Copyright Haruto Uchino. Used with permission. Figure is available in color online only.

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    Schematic illustration of the area and size of craniotomies for the initial and repeat bypass surgeries in the 10 patients in group A. The white areas represent the area and size of initial bypass surgeries, while the blue- and pink-colored areas represent indirect and combined repeat bypass surgeries, respectively. Figure is available in color online only.

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    Radiological findings of a patient (case 2) who previously underwent EMS on the right side. FLAIR imaging (A) on admission demonstrated an old subcortical infarction in the deep frontal lobe. The antero-posterior (B) and lateral (C) views of the right common carotid angiography show findings typical of MMD. Lateral view of right external carotid angiography (D) shows the good surgical collaterals through previous indirect surgery (arrowheads), but these vessels did not provide blood flow to the frontal lobe. Postoperative 3D skull CT after repeat bypass surgery (E) clearly shows the localization of initial (asterisk) and additional craniotomies (white arrow). Lateral view of right external carotid angiography 4 months after repeat bypass surgery (F) shows that additional surgical collaterals widely covered the frontal lobe (arrowheads).

  • View in gallery

    Schematic illustration of the area and size of craniotomies for the initial and repeat bypass surgeries in the 11 patients in group B. The white areas represent the area and size of initial bypass surgeries, while the blue- and pink-colored areas represent indirect and combined repeat bypass surgeries, respectively. Figure is available in color online only.

  • View in gallery

    Radiological findings of a patient (case 12) who previously underwent STA-MCA anastomosis and indirect bypass on both sides. MRA on admission (A) showed a marked development of surgical collaterals through initial surgeries for anterior circulation on both sides. Note the occlusion of the PCA on both sides. Antero-posterior view of left vertebral artery angiography (B) shows severe stenosis and insufficient collateral supply of the bilateral PCA. Lateral view of right external carotid angiography (C) demonstrates that the OA was predominantly dilated and considered suitable as a donor for direct bypass (arrowhead). Intraoperative photograph (D) demonstrates that the right OA was successfully anastomosed to the cortical branch of the right PCA followed by bilateral EDPS as indirect bypass. Lateral view of right external carotid angiography 3 months after repeat bypass surgery (E) demonstrates good development of surgical collaterals to the right occipital lobe via direct/indirect bypass (arrows). Preoperative (upper) and postoperative (lower) SPECT (F) demonstrate the normalization of cerebral blood flow and its reactivity to acetazolamide (ACZ) in the bilateral occipital lobes. Figure is available in color online only.

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