Lessons Learned From the Initial Experience With Pedicled Temporoparietal Fascial Flap for Combined Revascularization in Moyamoya Angiopathy: A Case Series

Abstract

Abstract INTRODUCTION The pedicled temporoparietal fascial flap (TPFF) with a direct superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass is a novel combined revascularization approach for moyamoya angiopathy (MMA). We aim to report the initial experience with pedicled TPFF combined revascularization for MMA treatment. METHODS Data from fourteen consecutive patients undergoing pedicled TPFF combined revascularization for MMA between May 2016 and December 2018 were retrospectively reviewed. Patients admitted with acute ischemia or a modified Rankin Scale (mRS) score >3 were considered high-risk. RESULTS The median (interquartile range) age was 45.5 (29-56.5) yr. Median mRS score upon admission was 2 (0.8-3.3). Direct anastomosis patency was confirmed in all cases postoperatively. Asymptomatic direct anastomosis occlusion upon follow-up occurred in one case. Median hospitalization time was 12.5 (3.8-18.5) days and median follow-up time was 11.5 (7.8-20) mo. Median mRS upon discharge and at follow-up was 1 (0-4) and 0.5 (0-1.5), respectively. From admission to follow-up, neurologic status improved in 8 (57.1%) and stabilized in 6 (42.9%) patients. Overall, 11/14 (78.6%) patients achieved a good functional outcome (mRS equal or greater than 2). Postoperative Matsushima grades were able to be assigned in 7/14 (50%) patients at a median time of 7.7 (5.3-10.9) mo. All patients achieved some degree of collateral development with 5 (71.5%) of the patients graded as Matsushima A and B. New radiographic ischemia was identified in three patients, all of which were in the high-risk group. Moderate to severe wound complications (3/14) were also limited to the high-risk group. Mild peri-incisional alopecia was found in three (21.4%) patients. CONCLUSION The TPFF combined approach is a viable strategy for revascularization in MMA. This technique may be suboptimal in patients presenting with acute ischemia or those with mRS greater than 3.