Surgical treatment for pediatric moyamoya disease: use of the superficial temporal artery for both areas supplied by the anterior and middle cerebral arteries.

Abstract

To revascularize ischemic territories of both the anterior cerebral artery (ACA) and the middle cerebral artery (MCA), a simple and effective combined bypass operation was performed in 36 pediatric patients with moyamoya disease during the past 8 years. The branches of the superficial temporal artery (STA) were used to revascularize the ACA and MCA territories. In children older than 5 years, the parietal branch of the STA was usually used for an end to side anastomosis with a cortical branch of the MCA. In children who were younger than 5 years, the parietal branch of the STA was used for an encephaloduroarteriosynangiosis instead of a direct anastomosis. Encephaloduroarteriosynangiosis, using the proximal part of the intact frontal branch of the STA, and encephalomyosynangiosis, using the temporal muscle, were also performed in all patients to stimulate spontaneous anastomosis. In addition, bilateral frontal burr holes were made in all patients to induce vascularization of the ACA territories from the distal part of the intact frontal branch of the STA. The first operation was performed on the dominant side, then a similar procedure was performed on the opposite side after an interval of at least 3 months. Postoperative clinical symptoms and the findings from magnetic resonance imaging, magnetic resonance angiography, angiography, and electroencephalography demonstrated improvement in all patients. These results suggest that the placement of bilateral burr holes (while leaving the frontal branch of the STA intact), in addition to the STA-MCA anastomosis, encephaloduroarteriosynangiosis, and encephalomyosynangiosis, is very effective in vascularizing the ischemic ACA and MCA territories in pediatric patients with moyamoya disease.