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Xiaofeng Deng, Faliang Gao, Dong Zhang, Yan Zhang, Rong Wang, Shuo Wang, Yong Cao, Yuanli Zhao, Yuesong Pan, Xingju Liu, Qian Zhang and Jizong Zhao

MMD can lead to ischemic or hemorrhagic strokes such as transient ischemia attack (TIA), cerebral infarction, and intraventricular hemorrhage. Depending on the manifestation, MMD is usually classified into 2 main phenotypes: ischemic or hemorrhagic. 14 , 32 The ideal treatment of MMD should be effective in both improving symptoms and preventing recurrent strokes. In recent decades, bypass surgical procedures have been developed and are the most popular treatment strategy nowadays. The most commonly used surgical modalities include indirect bypass (IB), direct bypass

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Troels H. Nielsen, Kumar Abhinav, Eric S. Sussman, Summer S. Han, Yingjie Weng, Teresa Bell-Stephens, CNRN, Jeremy J. Heit and Gary K. Steinberg

procedures versus conservative management. Some authors believe that direct procedures are associated with higher morbidity rates than those following indirect procedures, and their reasoning is most commonly attributed to hyperperfusion syndrome and a higher perioperative stroke rate. 3 On the other hand, the direct procedure is believed to provide a superior outcome in terms of protection from recurrent strokes. We hypothesized that treatment selection—that is, direct versus indirect bypass procedure—is associated with surgical outcomes, including perioperative major

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Tomohide Hayashi, Seiji Yamamoto, Takeru Hamashima, Hisashi Mori, Masakiyo Sasahara and Satoshi Kuroda

resolve hemodynamic impairment and reduce the risk of subsequent ischemic/hemorrhagic stroke. Of these treatments, direct bypass procedures such as superficial temporal artery–middle cerebral artery anastomosis can immediately increase cerebral blood flow (CBF) after surgery, although the procedure is sometimes challenging. 3 On the other hand, indirect bypass is very specific for moyamoya disease. Indirect bypass surgery readily stimulates spontaneous angiogenesis between the brain surface and the vascularized donor tissues, including the temporal muscle. The

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Robert M. Starke, Ricardo J. Komotar and E. Sander Connolly

moyamoya disease for > 30 years. 11 , 13 , 22 , 25 , 26 Many case series have demonstrated a decrease in ischemic symptoms and/or the maintenance of cognitive abilities in patients treated with direct bypass, but these series have been composed chiefly of children and often have included patients treated with indirect bypass or a combination of direct and indirect bypasses. 4 , 11 , 13 , 25 , 34 , 37 , 43 Thus far, no study has documented overall long-term rates of ischemic events in adult patients treated solely with direct bypass. Indirect Bypass for Moyamoya

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Maki Mukawa, Tadashi Nariai, Motoki Inaji, Natsumi Tamada, Taketoshi Maehara, Yoshiharu Matsushima, Kikuo Ohno, Mariko Negi and Daisuke Kobayashi

A technique for indirect bypass surgery was developed as a unique treatment strategy for juvenile patients with moyamoya disease (MMD). 9 , 12 In this technique, a newly formed vascular network connects the external and internal carotid systems spontaneously without direct mechanical vessel-to-vessel sutures. Many recent studies have suggested that indirect bypass surgery is useful for MMD in adults as well as juveniles. 1 , 2 , 21 The efficacy of the procedure for adult atherosclerotic intracranial occlusive disease has also been documented by an

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Makoto Goda, Mitsuo Isono, Keisuke Ishii, Tohru Kamida, Tatsuya Abe and Hidenori Kobayashi

(c), right ECA (d), and left VA (e). In this case, PCA—MCA leptomeningeal collateral formations were not prominent before surgery and there were no obvious changes in these formations 12 years after surgery. On the other hand, abnormal collateral formations from the PChAs and the pericallosal artery markedly decreased. Discussion Although the number of cases was limited in this study, indirect bypass surgery failed to reduce the abnormal collateral formations from the posterior circulation, especially those involving midline structures, during long

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Mario K. Teo, Venkatesh S. Madhugiri and Gary K. Steinberg

Direct anastomoses are also associated with excellent clinical outcomes, including a higher rate of symptomatic improvement, lower risk of recurrent ischemia, and increased stroke-free survival compared with indirect bypass. 1 , 11 , 12 In their comparative analysis of adult patients, the authors included 6 adult series (one of which was our Stanford series), in which 762 cases had direct bypasses and 1524 had indirect bypasses. The perioperative risks of death, ischemic stroke, and intracranial hemorrhage were very similar between the two groups. However, the long

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Rimal H. Dossani and Hai Sun

TO THE EDITOR: We read with interest the article by Deng et al. 2 ( Deng X, Gao F, Zhang D, et al: Direct versus indirect bypasses for adult ischemic-type moyamoya disease: a propensity score–matched analysis. J Neurosurg [epub ahead of print August 11, 2017. DOI: 10.3171/2017.2.JNS162405 ]) demonstrating that direct bypass (DB) is better than indirect bypass (IB) in preventing recurrent ischemic strokes in adults with ischemic-type moyamoya disease. A common shortcoming of some studies on moyamoya disease is the heterogeneity of the patient population (adult

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Huai-Yu Tong, Yuan-Zheng Zhang, Sheng Li and Xin-Guang Yu

clinically soon (several hours or days) after the operation, despite the fact that the STA did not immediately develop anastomosis. The mechanism should be further researched. Komotar et al. 9 concluded that indirect bypass does not promote adequate pial collateral artery development and appears to be of limited utility in patients with symptomatic internal carotid artery (ICA) or MCA stenoocclusive disease and secondary hemodynamic failure. Dusick et al. thought that Komotar's patients represented a different group from their own because Komotar's cohort presented with

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Katie P. Fehnel, Craig D. McClain and Edward R. Smith

.2% risk of preterm birth. 3 , 5 , 17 The patient elected to pursue surgery for moyamoya treatment and accepted the potential risk to both mother and fetus. Indirect bypass via right pial synangiosis was planned, given outcomes of low operative morbidity (4% operative stroke risk), short average operative times, early revascularization over a period of weeks, and improved perfusion by 6 months, with Matsushima grade A or B in 90% of patients treated at our high-volume center. 3 , 5 , 17 , 26 , 31 Operative Course Anesthesia. Unrelated to parturition, patients with