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Neurosurgery. 2013 Dec;73(6):962-7; discussion 967-8. doi: 10.1227/NEU.0000000000000139.

Combined direct and indirect bypass for moyamoya: quantitative assessment of direct bypass flow over time.

Author information

1
*Department of Neurosurgery, and ‡Center for Magnetic Resonance Research, University of Illinois at Chicago, Chicago, Illinois.

Abstract

BACKGROUND:

The optimal revascularization strategy for symptomatic adult moyamoya remains controversial. Whereas direct bypass offers immediate revascularization, indirect bypass can effectively induce collaterals over time.

OBJECTIVE:

Using angiography and quantitative magnetic resonance angiography, we examined the relative contributions of direct and indirect bypass in moyamoya patients after combined direct superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass and indirect encephaloduroarteriosynangiosis (EDAS).

METHODS:

A retrospective review of moyamoya patients undergoing combined STA-MCA bypass and EDAS was conducted, excluding pediatric patients and hemorrhagic presentation. Patients with quantitative magnetic resonance angiography measurements of the direct bypass immediately and > 6 months postoperatively were included. Angiographic follow-up, when available, was used to assess EDAS collaterals at similar time intervals.

RESULTS:

Of 16 hemispheres in 13 patients, 11 (69%) demonstrated a significant (> 50%) decline in direct bypass flow at > 6 months compared with baseline, averaging a drop from 99 ± 35 to 12 ± 7 mL/min. Conversely, angiography in these hemispheres demonstrated prominent indirect collaterals, in concert with shrinkage of the STA graft. Decline in flow was apparent at a median of 9 months but was evident as early as 2 to 3 months.

CONCLUSION:

In this small cohort, a reciprocal relationship between direct STA bypass flow and indirect EDAS collaterals frequently occurred. This substantiates the notion that combined direct/indirect bypass can provide temporally complementary revascularization.

PMID:
23949274
DOI:
10.1227/NEU.0000000000000139
[Indexed for MEDLINE]

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