Direct double bypass using the posterior auricular artery as initial surgery for moyamoya disease: technical note

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Surgical treatments for moyamoya disease (MMD) include direct revascularization procedures with proven efficacy, for example, superficial temporal artery (STA) to middle cerebral artery (MCA) bypass, STA to anterior cerebral artery bypass, occipital artery (OA) to MCA bypass, or OA to posterior cerebral artery bypass. In cases with poor development of the parietal branch of the STA, the posterior auricular artery (PAA) is often developed and can be used as the bypass donor artery. In this report, the authors describe double direct bypass performed using only the PAA as the donor in the initial surgery for MMD.

In the authors’ institution, MMD is routinely treated with an STA-MCA double bypass. Some patients, however, have poor STA development, and in these cases the PAA is used as the donor artery. The authors report the use of the PAA in the treatment of 4 MMD patients at their institution from 2013 to 2016. In all 4 cases, a double direct bypass was performed, with transposition of the PAA as the donor artery. Good patency was confirmed in all cases via intraoperative indocyanine green angiography and postoperative MRA or cerebral angiography. The mean blood flow measurement during surgery was 58 ml/min. No patients suffered a stroke after revascularization surgery.

ABBREVIATIONS ICGA = indocyanine green angiography; MCA = middle cerebral artery; MMD = moyamoya disease; PAA = posterior auricular artery; STA = superficial temporal artery.

Article Information

Correspondence Koji Yamaguchi: Tokyo Women’s Medical University, Tokyo, Japan. yamaguchi.koji@twmu.ac.jp.

INCLUDE WHEN CITING Published online August 23, 2019; DOI: 10.3171/2019.5.JNS19173.

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.

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Figures

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    Preoperative MR angiographic image (case 1) and angiographic images (cases 2–4) of the 4 cases described in this report. Case 1: hypoplastic frontal and parietal branches of the STA. Case 2: hypoplastic parietal branch of the STA and development of the PAA. Case 3: hypoplastic parietal branch of the STA, low-lying position of the frontal branch of the STA, and development of the PAA. Case 4: hypoplastic parietal branch of the STA, low-lying position of the frontal branch of the STA, and development of the PAA.

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    Typical course of the PAA-MCA double bypass and transposition procedure (case 3). A: Preoperative angiographic image shows the hypoplastic parietal branch of the STA and a skin incision over the PAA. B: Preparation of only the PAA as the donor artery and recipient arteries of the infra- and suprasylvian M4. C and D: Cutting and transposition of the PAA. E and F: Careful trimming and anastomosis to the proximal side of the PAA. G: First anastomosis (transposed PAA to infrasylvian M4). H: Good flow from the main trunk of the PAA to the transposed PAA and the recipient artery. I: Second anastomosis (main trunk of the PAA to the suprasylvian M4). J: Intraoperative ICGA image. Figure is available in color online only.

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    Postoperative MR angiographic image (cases 1, 3, and 4) and an angiographic image (case 2) of the 4 cases described in this report. The patency of the direct bypass was confirmed in all cases.

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