Additional Revascularization Using Multiple Burr Holes for PCA Involvement in Moyamoya Disease

Area of Science:

• Neurosurgery
• Vascular Neurology
• Pediatric Neurology

Background:

• Moyamoya disease (MMD) can involve posterior circulation, specifically the posterior cerebral artery (PCA), even after anterior circulation treatment.
• Posterior cerebral artery stenosis may necessitate further revascularization in MMD patients previously treated for anterior circulation issues.
• Transient ischemic attacks (TIAs) can persist post-anterior circulation revascularization, indicating potential posterior circulation compromise.

Observation:

• Two MMD cases presented with worsening PCA stenosis and TIAs despite bilateral superficial temporal artery-middle cerebral artery bypass.
• Magnetic resonance angiography (MRA) confirmed progressive PCA stenosis in these patients.
• Indirect revascularization using a multiple burr hole technique was performed for posterior circulation involvement.

Findings:

• The multiple burr hole indirect revascularization successfully improved TIA symptoms in both patients.
• Post-operative cerebral angiography demonstrated the development of collateral circulation through the burr holes.
• No perioperative complications were observed, highlighting the safety of the procedure.

Implications:

• Indirect revascularization with multiple burr holes alone is a viable option for MMD with PCA involvement, particularly when direct revascularization is not feasible.
• This technique offers a simpler, less invasive alternative to traditional direct revascularization, especially beneficial for pediatric MMD cases.
• The findings underscore the importance of addressing posterior circulation in MMD and suggest a promising treatment strategy for complex cases.