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

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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. michael.lawton@barrowbrainandspine.com.

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.

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    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.

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    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.

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