How I do it: operative nuances of multiple burr hole surgery for moyamoya disease and syndrome

Abstract

Background

Burr hole surgery for moyamoya disease and moyamoya syndrome is known to be an effective, versatile, and relatively simple revascularization technique. We will focus on the technical operative aspects of multiple burr hole surgery as we perform it in our center.

Methods

Periosteal flaps are prepared and placed in a burr hole with beveled edge, after opening the dura and arachnoid membrane, in order to facilitate neovascularization into the ischemic cortex.

Conclusions

Burr hole surgery is a versatile treatment modality for moyamoya and moyamoya-like disease. Success can be maximized by having a meticulous operative technique.

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Abbreviations

MMD:

moyamoya disease

MMS:

moyamoya syndrome

ICA:

internal carotid artery

STA:

superficial temporal artery

MCA:

medial cerebral artery

CSF:

cerebrospinal fluid

CPP:

cerebral perfusion pressure

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Acknowledgments

The authors of this study would like to acknowledge Tatjana Blondé (medical illustrations), the OR technical support team of the Antwerp University Hospital (intraoperative photographs), Lord Ilia Lavrysen (video-editing), and Barbara Blokland (proofreading of manuscript).

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Correspondence to Eno Lavrysen.

Ethics declarations

Conflict of interest

First author Dr. Eno Lavrysen declares that he has no conflict of interest. Second author Prof. Dr. Tomas Menovsky declares that he has no conflict of interest.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

This article is part of the Topical Collection on Pediatric Neurosurgery

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00:08–00:30 s: Patient positioning and dissection in the avascular plane between periosteum and galea aponeurotica. Notice the way the scalpel is placed on the periosteum with the sharp edge pointed toward the inner side of the galea and turned at a 45-degree angle. At the same time, traction is applied to the skin flap containing the galea aponeurotica to ease dissection. 00:35–00:42 s: First image = completely prepared periosteum. Second image = marking the periosteal flaps using a triangle form. Third image = alternative, more U-shaped flaps. 00:43–00:46 s: Incision of the periosteum, creating the flap. It this to be mentioned that avoiding the use of electrocautery is preferred when possible, in order to maximize vascularization potential of the edges of the periosteal (and/or meningeal) flaps. 00:47–00:58 s: Careful separation of the periosteal flap from the cranial bone in order to prepare the surface for placement of the burr hole. 01:03–01:21 s: CREATION of burr hole using the drill bit. Notice how in the medial part of the burr hole (upper side in the frame) a beveled edge is created. 01:26–01:31 s: Hemostasis of epidural bleeding and bone bleeding using gelatin foam. A Penfield dissector is used to push the gelatin foam into the epidural edges of the burr hole and in the bleeding bone. Bone wax, oxidized cellulose, etc. are alternatives. 01:37–01:45 s: Dural incision. Notice the use of an instrument in order to protect the arachnoidal layer. Coagulation of the meningeal edges is avoided in order to maximize vascularization potential from these edges, which can be of greater importance than from the periosteal flaps in some cases. 01:46–01:57 s: Opening of the arachnoid membrane using a scissor. The bevel of a needle can also be used. Notice the cortex which is being exposed. 01:58–02:16 s: Placement of the periosteal flaps on the exposed cortex in the subarachnoidal space. 02:18–02:34 s: Placement of fibrin sealant in into the burr hole to prevent CSF-leakage and hematoma inflow, two of the most important postoperative complications of this procedure. 02:36–02:59 s: Another example of placement of the periosteal flap on the cortex. (MOV 283226 kb)

ESM 1

00:08–00:30 s: Patient positioning and dissection in the avascular plane between periosteum and galea aponeurotica. Notice the way the scalpel is placed on the periosteum with the sharp edge pointed toward the inner side of the galea and turned at a 45-degree angle. At the same time, traction is applied to the skin flap containing the galea aponeurotica to ease dissection. 00:35–00:42 s: First image = completely prepared periosteum. Second image = marking the periosteal flaps using a triangle form. Third image = alternative, more U-shaped flaps. 00:43–00:46 s: Incision of the periosteum, creating the flap. It this to be mentioned that avoiding the use of electrocautery is preferred when possible, in order to maximize vascularization potential of the edges of the periosteal (and/or meningeal) flaps. 00:47–00:58 s: Careful separation of the periosteal flap from the cranial bone in order to prepare the surface for placement of the burr hole. 01:03–01:21 s: CREATION of burr hole using the drill bit. Notice how in the medial part of the burr hole (upper side in the frame) a beveled edge is created. 01:26–01:31 s: Hemostasis of epidural bleeding and bone bleeding using gelatin foam. A Penfield dissector is used to push the gelatin foam into the epidural edges of the burr hole and in the bleeding bone. Bone wax, oxidized cellulose, etc. are alternatives. 01:37–01:45 s: Dural incision. Notice the use of an instrument in order to protect the arachnoidal layer. Coagulation of the meningeal edges is avoided in order to maximize vascularization potential from these edges, which can be of greater importance than from the periosteal flaps in some cases. 01:46–01:57 s: Opening of the arachnoid membrane using a scissor. The bevel of a needle can also be used. Notice the cortex which is being exposed. 01:58–02:16 s: Placement of the periosteal flaps on the exposed cortex in the subarachnoidal space. 02:18–02:34 s: Placement of fibrin sealant in into the burr hole to prevent CSF-leakage and hematoma inflow, two of the most important postoperative complications of this procedure. 02:36–02:59 s: Another example of placement of the periosteal flap on the cortex. (MOV 283226 kb)

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Lavrysen, E., Menovsky, T. How I do it: operative nuances of multiple burr hole surgery for moyamoya disease and syndrome. Acta Neurochir 161, 171–175 (2019). https://doi.org/10.1007/s00701-018-3743-1

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Keywords

  • Burr holes
  • Extracranial-intracranial bypass
  • Indirect revascularization
  • Moyamoya disease
  • Moyamoya syndrome
  • Multiple burr hole surgery
  • Pediatric neurosurgery