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  • Pedicled temporoparietal fascial flap use in combined revascularization to prevent adult moyamoya disease ischemic complications

    Final Number:
    149

    Authors:
    Kristine Ravina MD; Robert Rennert MD; Ben Allen Strickland MD; Mark Chien BA; Joseph Carey; Jonathan Russin MD

    Study Design:
    Other

    Subject Category:
    Ischemic Stroke

    Meeting: AANS/CNS Cerebrovascular Section 2018 Annual Meeting

    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.

    References: 1. Houkin K, Kuroda S, Ishikawa T, Abe H. Neovascularization (angiogenesis) after revascularization in moyamoya disease. Which technique is most useful for moyamoya disease? Acta Neurochir (Wien). 2000;142(3):269-276. 2. Kuroda S, Houkin K. Moyamoya disease: current concepts and future perspectives. Lancet Neurol. 2008;7(11):1056-1066. 3. Lee SB, Kim DS, Huh PW, Yoo DS, Lee TG, Cho KS. Long-term follow-up results in 142 adult patients with moyamoya disease according to management modality. Acta Neurochir (Wien). 2012;154(7):1179-1187. 4. Mokal NJ, Ghalme AN, Kothari DS, Desai M. The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases. Indian J Plast Surg. 2013;46(3):493-501. 5. Zipfel GJ, Fox DJ, Jr., Rivet DJ. Moyamoya disease in adults: the role of cerebral revascularization. Skull Base. 2005;15(1):27-41.

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