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.
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Gross, B.A., Stone, S.S. & Smith, E.R. Occipital pial synangiosis. Acta Neurochir 156, 1297–1300 (2014) doi:10.1007/s00701-014-2044-6
- Moyamoya posterior circulation
- EC-IC bypass
- Pial synangiosis