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Salvage STA-MMA anastomosis for intraoperative middle meningeal artery in moyamoya disease: a technical note
Jinghui Lin1,2, Jiancong Zheng2, Ben Chat Fong Ng3
1School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
Background:
In numerous cases of Moyamoya disease (MMD), the middle meningeal artery (MMA) develops as a spontaneous collateral prior to surgery, providing an extracranial-intracranial compensatory pathway. However, the MMA is vulnerable to iatrogenic injury during surgery. There is a lack of literature regarding managing iatrogenic injuries to the MMA which has collateral supply to the cerebral hemisphere.
Case Description:
We report a case of a 61-year-old woman with MMD with collateral flows from the MMA. During a right-sided direct revascularization surgery, the MMA was inadvertently ruptured. After the bleeding is controlled, a salvage bypass was created by anastomosing the frontal branch of the superficial temporal artery (STA) end-to-end to the MMA, while the parietal branch of STA branch was anastomosed to a cortical middle cerebral artery (MCA) branch in an end-to-side fashion. Intraoperative indocyanine green video angiography (ICG-VA) confirmed good patency of the bypasses. Follow-up cerebral computed tomography angiography (CTA) confirmed the patency of the STA-MMA and STA-MCA anastomosis. Magnetic resonance imaging (MRI) showed no cerebral infarction.
Conclusion:
A remedial STA-MMA anastomosis can be a technically feasible salvage strategy when the MMA with collateral flow to the brain is injured intraoperatively. This approach preserves cortical collateral flow and expands the surgical options for complex revascularization cases.
Insights
A novel surgical technique successfully repaired an injured middle meningeal artery (MMA) in a Moyamoya disease (MMD) patient. This salvage bypass using the superficial temporal artery (STA) restored crucial collateral blood flow to the brain.
Area of Science:
- Neurosurgery
- Vascular Surgery
- Neurology
Background:
- Moyamoya disease (MMD) often involves the middle meningeal artery (MMA) as a critical collateral pathway.
- Iatrogenic injury to the MMA during surgery poses a risk, with limited literature on management.
- The MMA provides essential extracranial-intracranial compensatory blood flow to the cerebral hemisphere.
Purpose of the Study:
- To report a case of managing inadvertent iatrogenic injury to the MMA during MMD surgery.
- To demonstrate a salvage bypass technique to restore collateral flow.
- To evaluate the feasibility and outcomes of a superficial temporal artery to MMA anastomosis.
Main Methods:
- A case report of a 61-year-old woman with MMD undergoing direct revascularization surgery.
- Inadvertent intraoperative rupture of the MMA was managed with a salvage bypass.
- The bypass involved end-to-end anastomosis of the superficial temporal artery (STA) frontal branch to the MMA and end-to-side anastomosis of the STA parietal branch to a middle cerebral artery (MCA) branch.
- Intraoperative indocyanine green video angiography (ICG-VA) and postoperative CT angiography (CTA) were used to confirm bypass patency.
Main Results:
- The salvage STA-MMA anastomosis was technically feasible and successfully controlled bleeding.
- Intraoperative and postoperative angiography confirmed the patency of both the STA-MMA and STA-MCA bypasses.
- Postoperative MRI revealed no evidence of cerebral infarction, indicating successful reperfusion.
Conclusions:
- A superficial temporal artery to middle meningeal artery (STA-MMA) anastomosis is a viable salvage strategy for intraoperative MMA injuries in MMD.
- This technique effectively preserves critical cortical collateral flow.
- It expands surgical options for managing complex revascularization in MMD patients.
