Superficial temporal artery–to–middle cerebral artery bypass in combination with indirect revascularization in moyamoya patients ≤ 3 years of age

Restricted access

Analysis of direct STA-MCA bypass procedures in young children to achieve flow augmentation via direct revascularization.

ABBREVIATIONS EDAS = encephaloduroarteriosynangiosis; EMS = encephalomyosynangiosis; MCA = middle cerebral artery; MMD = moyamoya disease; mRS = modified Rankin Scale; STA = superficial temporal artery; TIA = transient ischemic attack.

Article Information

Correspondence Michael T. Lawton: Barrow Neurological Institute, Phoenix, AZ.

INCLUDE WHEN CITING Published online November 16, 2018; DOI: 10.3171/2018.9.PEDS18224.

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.



  • View in gallery

    Patient 6. This 23-month-old girl with Down syndrome and bilateral moyamoya syndrome received a right STA-MCA bypass after a right hemispheric stroke. Four months after surgery, the patient presented with a new stroke, this time involving the left hemisphere with a right arm weakness. A and B: Catheter angiography of the left internal carotid artery (A) showed the classic pattern of moyamoya syndrome, and an external carotid artery injection showed a small, but present STA (B, arrow). C: Ischemia in the left MCA territory was seen on MR imaging. After harvesting the STA, a mini pterional craniotomy was performed, and an M4 segment was selected as a recipient artery for the end-to-side anastomosis. D: The donor artery was fish-mouthed and approximated to the recipient with 2 interrupted 10-0 sutures. E: Running continuous sutures were sewn along both suture lines. F and G: After completion of the anastomosis, temporary clips were removed (F) and indocyanine green videoangiography showed early filling of the M4 branch through the STA (G). H: Before closure, EMS was performed as an indirect bypass (D = dura; TM = temporalis muscle). I and J: The patient recovered well, and postoperative MRI and MRA demonstrated recovery of the stroke on diffusion-weighted imaging (I) and patency of bilateral STA-MCA bypasses (J). Figure is available in color online only.

  • View in gallery

    Box plots showing MCA (A) and STA (B) vessel diameters before and after direct STA-MCA bypass procedures in 5 patients. Boxes represent the IQR of the median (lines within the boxes), and whiskers represent the entire range.



Burke GMBurke AMSherma AKHurley MCBatjer HHBendok BR: Moyamoya disease: a summary. Neurosurg Focus 26(4):E112009


Guzman RLee MAchrol ABell-Stephens TKelly MDo HM: Clinical outcome after 450 revascularization procedures for moyamoya disease. Clinical article. J Neurosurg 111:9279352009


Ikezaki K: Rational approach to treatment of moyamoya disease in childhood. J Child Neurol 15:3503562000


Imaizumi THayashi KSaito KOsawa MFukuyama Y: Long-term outcomes of pediatric moyamoya disease monitored to adulthood. Pediatr Neurol 18:3213251998


Jackson EMLin NManjila SScott RMSmith ER: Pial synangiosis in patients with moyamoya younger than 2 years of age. J Neurosurg Pediatr 13:4204252014


Kim SKSeol HJCho BKHwang YSLee DSWang KC: Moyamoya disease among young patients: its aggressive clinical course and the role of active surgical treatment. Neurosurgery 54:8408462004


Kim TOh CWBang JSKim JECho WS: Moyamoya disease: treatment and outcomes. J Stroke 18:21302016


Kuroda SHoukin K: Moyamoya disease: current concepts and future perspectives. Lancet Neurol 7:105610662008


Matsushima TInoue TIkezaki KMatsukado KNatori YInamura T: Multiple combined indirect procedure for the surgical treatment of children with moyamoya disease. A comparison with single indirect anastomosis and direct anastomosis. Neurosurg Focus 5(5):e41998


Rashad SFujimura MNiizuma KEndo HTominaga T: Long-term follow-up of pediatric moyamoya disease treated by combined direct-indirect revascularization surgery: single institute experience with surgical and perioperative management. Neurosurg Rev 39:6156232016


Scott RMSmith ER: Moyamoya disease and moyamoya syndrome. N Engl J Med 360:122612372009


Smith ERScott RM: Surgical management of moyamoya syndrome. Skull Base 15:15262005


Thines LPetyt GAguettaz PBodenant MHimpens FXLenci H: Surgical management of Moyamoya disease and syndrome: current concepts and personal experience. Rev Neurol (Paris) 171:31442015


Veeravagu AGuzman RPatil CGHou LCLee MSteinberg GK: Moyamoya disease in pediatric patients: outcomes of neurosurgical interventions. Neurosurg Focus 24(2):E162008


Wang KCPhi JHLee JYKim SKCho BK: Indirect revascularization surgery for moyamoya disease in children and its special considerations. Korean J Pediatr 55:4084132012


Yu JShi LGuo YXu BXu K: Progress on complications of direct bypass for moyamoya disease. Int J Med Sci 13:5785872016


Zipfel GJFox DJ JrRivet DJ: Moyamoya disease in adults: the role of cerebral revascularization. Skull Base 15:27412005




All Time Past Year Past 30 Days
Abstract Views 54 54 54
Full Text Views 31 31 31
PDF Downloads 37 37 37
EPUB Downloads 0 0 0


Google Scholar