Abstract
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.
Published Version
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