Occipital pial synangiosis

Indirect revascularization techniques for posterior circulation moyamoya are infrequently described in the literature given the relative rarity of the disease process, particularly in the best candidates for indirect approaches-children.

We present a detailed, illustrated video demonstration of the occipital pial synangiosis procedure performed in a 5-year-old child.

The specific advantages of the pial synangiosis technique-suturing the donor vessel to the pia and a wide arachnoidal opening-can be successfully applied to posterior circulation indirect revascularization.

• Perioperative hydration and aspirin limit the risk of perioperative stroke. • Pain control and maintained normocapnea limit the risk of perioperative ischemic events. • The posterior auricular artery may be an alternative donor vessel. • The donor vessel is dissected from distal to proximal; forceps protect it during skin incision. • The donor vessel is dissected along a generous length to minimize tension. • Coagulation of the dura is limited as meningeal vessels may serve as synergistic collaterals. • A wide arachnoidal opening facilitates the ingrowth of collateral vessels. • Suturing the donor vessel to the pia ensures it remains well apposed to the brain surface. • The dura is left open to encourage ingrowth of collateral vessels and limit tension on the donor vessel. • EEG monitoring is a crucial adjunct.