Introduction: Moyamoya disease (MMD) is a progressive, idiopathic cerebrovascular occlusive disease associated with devastating ischemic and hemorrhagic complications. Although various revascularization techniques including direct, indirect and combined microvascular bypasses have been described, there is still an ongoing controversy regarding the most effective revascularization approach. Direct superficial temporal artery – middle cerebral artery (STA-MCA) bypass is a widely used technique in adult MMD revascularization. The incorporation of indirect revascularization through pedicled temporoparietal fascia flap (TPFF) offers supplemented neovascularization and hemodynamic support to ischemic brain regions. We here present a modified combined revascularization approach for MMD utilizing the TPFF.
Methods: Surgical technique of combined direct STA-MCA bypass and indirect pedicled TPFF revascularization for adult MMD is described along with a case presentation.
Results: Described method of combined bypass for treatment of adult MMD utilizes highly vascular galeal flap with preserved STA and vein within the pedicle in combination with direct extracranial-intracranial bypass and has been successfully implemented at our facility since May, 2016.
Conclusions: Revascularization with a pedicled TPFF can achieve direct STA-MCA bypass also providing a well vascularized, sizable indirect graft. Our initial experience shows that it is a safe and reproducible method combining benefits of direct and indirect bypass.
Patient Care: There is still an ongoing controversy regarding the most effective revascularization approach for the moyamoya disease. We here describe a novel revascularization approach for adult moyamoya disease combining the benefits of direct and indirect revascularization that has a potential to provide additional hemodynamic support and prevent ischemic complications.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Describe the benefits of pedicled temporoparietal fascial flap use in combined revascularization for adult moyamoya disease;
2) Understand the surgical technique peculiarities of the pedicled temporoparietal fascial flap harvest and microvascular anastomosis.
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