Surgical revascularization for pediatric moyamoya: the role of surgical mentorship in sustaining and developing a neurovascular service

Adikarige Haritha Dulanka Silva MPhil, FRCS1,3, Sanjay Bhate MRCP, MRCPCH2,3, Vijeya Ganesan MD, MRCP2,3, Dominic Thompson BSc, FRCS1,3, and Greg James PhD, FRCS1,3
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  • 1 Department of Neurosurgery, Great Ormond Street Hospital for Children NHS Foundation Trust;
  • | 2 Department of Paediatric Neurology, Great Ormond Street Hospital for Children NHS Foundation Trust; and
  • | 3 Great Ormond Street Institute of Child Health, University College London, United Kingdom
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OBJECTIVE

Obtaining operative experience for the treatment of rare conditions in children represents a challenge for pediatric neurosurgeons. Starting in November 2017, a surgeon was mentored in surgical revascularization (SR) for pediatric moyamoya with a view to service development and sustainability. The aim of this audit was to evaluate early outcomes of SR for pediatric moyamoya during and following a surgical mentorship.

METHODS

A retrospective cohort study with chart/database review of consecutive moyamoya surgeries performed by a new attending surgeon (between November 2017 and March 2020) was compared to a previously published cohort from the authors’ institution in terms of clinical and angiographic outcomes, complications, operating time, and length of stay. A standardized technique of encephaloduroarteriomyosynangiosis with the superficial temporal artery was used.

RESULTS

Twenty-two children underwent 36 indirect SRs during the study period. Patient demographics were similar between cohorts. The first group of 6 patients had 11 SRs performed jointly by the new attending surgeon mentored by an established senior surgeon (group A), followed by 10 patients with 16 SRs performed independently by the new attending surgeon (group B). The last 6 patients had 9 SRs with the new attending surgeon mentoring a senior fellow (group C) in performing SR.

Good angiographic collateralization (Matsushima grades A and B) was observed in 80% of patients, with similar proportions across all 3 groups. A total of 18/19 symptomatic patients (95%) derived symptomatic benefit. There was no perioperative death and, compared to the historical cohort, a similar proportion had a recurrent arterial ischemic event (i.e., acute ischemic stroke) necessitating a second SR (1/22 vs 3/73). Operative times were longest in group C, with no difference in length of hospital stay among the 3 groups.

CONCLUSIONS

Early outcomes demonstrate the feasibility of mentorship for safely incorporating new neurosurgeons in sustaining and developing a tertiary-level surgical service.

ABBREVIATIONS

AIS = acute ischemic stroke; CCA = cerebral catheter angiography; EDAMS = encephaloduroarteriomyosynangiosis; ICA = internal carotid artery; MCA = middle cerebral artery; MMD = moyamoya disease; MMS = moyamoya syndrome; SR = surgical revascularization; STA = superficial temporal artery; TIA = transient ischemic attack.
Illustration from Cinalli et al. (pp 119–127). Printed with permission from © CC Medical Arts.

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