How I do it: combined direct (STA-MCA) and indirect (EDAS) EC-IC bypass

Area of Science:

• Neurosurgery
• Vascular Surgery
• Cerebrovascular Disease

Background:

• Moyamoya disease necessitates revascularization for symptomatic patients.
• Direct (STA-MCA) and indirect (EDAS) EC-IC bypass is the preferred treatment for hypoperfused hemispheres.
• Combined bypasses offer immediate flow augmentation and long-term collateral circulation.

Observation:

• A combined direct and indirect bypass was performed on a 41-year-old woman with moyamoya syndrome.
• The patient presented with transient ischemic attacks (TIAs) and cognitive decline.
• Technical nuances of the combined procedure were detailed.

Findings:

• Meticulous attention to Superficial Temporal Artery (STA) branch preservation is crucial.
• Careful vessel handling minimizes spasm and thrombosis risks.
• Aggressive distal dissection and a blood-free field ensure successful anastomosis.
• Intraoperative flow measurements and ICG angiography can obviate the need for intraoperative angiography.
• Proper bone flap reconstruction and skin closure prevent graft compression.

Implications:

• Combined direct and indirect bypass should be a familiar technique for vascular neurosurgeons.
• This approach provides a dual mechanism for improving cerebral blood flow.
• Optimized surgical techniques enhance patient outcomes in moyamoya syndrome treatment.