Combined Bypass Technique for Contemporary Revascularization of Unilateral MCA and Bilateral Frontal Territories in Moyamoya Vasculopathy

  • Annick Kronenburg
  • Giuseppe Esposito
  • Jorn Fierstra
  • Kees P. Braun
  • Luca Regli
Part of the Acta Neurochirurgica Supplement book series (NEUROCHIRURGICA, volume 119)


Moyamoya vasculopathy (MMV) leads to chronic hypoperfusion predominantly in the middle cerebral artery (MCA) and anterior cerebral artery (ACA) territories. Most revascularization techniques focus on revascularization of the MCA territory. Augmentation of blood flow in the frontal area is important for neurocognition and lower extremity function. In this article we describe a new combined (direct and indirect) one-stage bypass technique consisting of a superficial temporal artery to middle cerebral artery (STA-MCA) bypass with encephalo-duro-synangiosis (EDS) for unilateral MCA revascularization, along with an encephalo-duro-periosteal-synangiosis (EDPS) for bifrontal blood flow augmentation. The strength of this technique is the revascularization of three vascular territories during a single surgical intervention: the MCA unilaterally; and the frontal territories bilaterally. Bifrontal EDPS may also be considered as a supplementary independent procedure for patients who previously underwent revascularization treatment in the MCA territory, but develop symptoms due to frontal hypoperfusion.


Bilateral frontal territories Bypass surgery STA-MCA bypass Indirect revascularization Moyamoya Neurocognition 



Anterior cerebral artery


Cerebral blood flow


Cerebrovascular reserve












[15O]H2O-positron emission tomography


Internal carotid artery


Interhemispheric fissure


Middle cerebral artery


Moyamoya disease


Moyamoya syndrome


Moyamoya vasculopathy


Superior sagittal sinus


Superficial temporal artery


Transient ischemic attack


Conflict of Interest

We declare that we have no conflict of interest.


  1. 1.
    Baaj AA, Agazzi S, Sayed ZA, Toledo M, Spetzler RF, van Loveren H (2009) Surgical management of moyamoya disease: a review. Neurosurg Focus 26(4):E7PubMedCrossRefGoogle Scholar
  2. 2.
    Festa JR, Schwarz LR, Pliskin N, Cullum CM, Lacritz L, Charbel FT, Mathews D, Starke RM, Connolly ES, Marshall RS, Lazar RM (2010) Neurocognitive dysfunction in adult moyamoya disease. J Neurol 257(5):806–815PubMedCrossRefGoogle Scholar
  3. 3.
    Fung LW, Thompson D, Ganesan V (2005) Revascularisation surgery for paediatric moyamoya: a review of the literature. Childs Nerv Syst 21(5):358–364PubMedCrossRefGoogle Scholar
  4. 4.
    Houkin K, Ishikawa T, Yoshimoto T, Abe H (1997) Direct and indirect revascularization for moyamoya disease surgical techniques and perioperative complications. Clin Neurol Neurosurg 99:S142–S145PubMedCrossRefGoogle Scholar
  5. 5.
    Ibrahimi DM, Tamargo RJ, Ahn ES (2010) Moyamoya disease in children. Childs Nerv Syst 26(10):1297–1308PubMedCrossRefGoogle Scholar
  6. 6.
    Ishii R, Takeuchi S, Ibayashi K, Tanaka R (1984) Intelligence in children with moyamoya disease: evaluation after surgical treatments with special reference to changes in cerebral blood flow. Stroke 15(5):873–877PubMedCrossRefGoogle Scholar
  7. 7.
    Ishikawa T, Houkin K, Kamiyama H, Abe H (1997) Effects of surgical revascularization on outcome of patients with pediatric moyamoya disease. Stroke 28(6):1170–1173PubMedCrossRefGoogle Scholar
  8. 8.
    Ishikawa T, Kamiyama H, Kuroda S, Yasuda H, Nakayama N, Takizawa K (2006) Simultaneous superficial temporal artery to middle cerebral or anterior cerebral artery bypass with pan-synangiosis for moyamoya disease covering both anterior and middle cerebral artery territories. Neurol Med Chir (Tokyo) 46(9):462–468CrossRefGoogle Scholar
  9. 9.
    Khan N, Regli L (2011) STA-MCA microanastomosis: surgical technique. In: Abdulrauf SI (ed) Cerebral revascularization: techniques in extracranial-to-intracranial bypass surgery. Saunders/Elsevier, Philadelphia, pp 93–97CrossRefGoogle Scholar
  10. 10.
    Khan N, Schuknecht B, Boltshauser E, Capone A, Buck A, Imhof HG, Yonekawa Y (2003) Moyamoya disease and Moyamoya syndrome: experience in Europe; choice of revascularisation procedures. Acta Neurochir (Wien) 145(12):1061–1071CrossRefGoogle Scholar
  11. 11.
    Kim CY, Wang KC, Kim SK, Chung YN, Kim HS, Cho BK (2003) Encephaloduroarteriosynangiosis with bifrontal encephalogaleo (periosteal) synangiosis in the pediatric moyamoya disease: the surgical technique and its outcomes. Childs Nerv Syst 19(5–6):316–324PubMedCrossRefGoogle Scholar
  12. 12.
    Kim SK, Cho BK, Phi JH, Lee JY, Chae JH, Kim KJ, Hwang YS, Kim IO, Lee DS, Lee J, Wang KC (2010) Pediatric moyamoya disease: an analysis of 410 consecutive cases. Ann Neurol 68(1):92–101PubMedCrossRefGoogle Scholar
  13. 13.
    Kinugasa K, Mandai S, Koji T, Kamata I, Sugiu K, Handa A, Ohmoto T (1994) Ribbon encephalo-duro-myo-synangiosis for moyamoya disease. Surg Neurol 41:455–461PubMedCrossRefGoogle Scholar
  14. 14.
    Kuroda S, Houkin K (2008) Moyamoya disease: current concepts and future perspectives. Lancet Neurol 7(11):1056–1066PubMedCrossRefGoogle Scholar
  15. 15.
    Kuroda S, Houkin K, Ishikawa T, Nakayama N, Ikeda J, Ishii N, Kamiyama H (2004) Determinants of intellectual outcome after surgical revascularization in pediatric moyamoya disease: a multivariate analysis. Childs Nerv Syst 20(5):302–308PubMedCrossRefGoogle Scholar
  16. 16.
    Kuroda S, Houkin K, Ishikawa T, Nakayama N, Iwasaki Y (2010) Novel bypass surgery for moyamoya disease using pericranial flap: its impacts on cerebral hemodynamics and long-term outcome. Neurosurgery 66(6):1093–1101PubMedCrossRefGoogle Scholar
  17. 17.
    Lee JY, Phi JH, Wang KC, Cho BK, Shin MS, Kim SK (2011) Neurocognitive profiles of children with moyamoya disease before and after surgical intervention. Cerebrovasc Dis 31(3):230–237PubMedCrossRefGoogle Scholar
  18. 18.
    Ohtaki M, Uede T, Morimoto S, Nonaka T, Tanabe S, Hashi K (1998) Intellectual functions and regional cerebral haemodynamics after extensive omental transplantation spread over both frontal lobes in childhood moyamoya disease. Acta Neurochir (Wien) 140(10):1043–1053, discussion 1052–3CrossRefGoogle Scholar
  19. 19.
    Pandey P, Steinberg GK (2011) Neurosurgical advances in the treatment of moyamoya disease. Stroke 42(11):3304–3310PubMedCrossRefGoogle Scholar
  20. 20.
    Park JH, Yang SY, Chung YN, Kim JE, Kim SK, Han DH, Cho BK (2007) Modified encephaloduroarteriosynangiosis with bifrontal encephalogaleoperiosteal synangiosis for the treatment of pediatric moyamoya disease. Technical note. J Neurosurg 106(3 Suppl):237–342PubMedGoogle Scholar
  21. 21.
    Scott RM, Smith ER (2009) Moyamoya disease and moyamoya syndrome. N Engl J Med 360(12):1226–1237PubMedCrossRefGoogle Scholar
  22. 22.
    Smith ER, Scott RM (2008) Progression of disease in unilateral moyamoya syndrome. Neurosurg Focus 24(2):E17PubMedCrossRefGoogle Scholar
  23. 23.
    Song YS, Oh SW, Kim YK, Kim S-K, Wang K-C, Lee DS (2012) Hemodynamic improvement of anterior cerebral artery territory perfusion induced by bifrontal encephalo (periosteal) synangiosis in pediatric patients with moyamoya disease: a study with brain perfusion SPECT. Ann Nucl Med 26(1):47–57PubMedCrossRefGoogle Scholar
  24. 24.
    Weinberg DG, Rahme RJ, Aoun SG, Batjer HH, Bendok BR (2011) Moyamoya disease: functional and neurocognitive outcomes in the pediatric and adult population. Neurosurg Focus 30(6):E21PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2014

Authors and Affiliations

  • Annick Kronenburg
    • 1
  • Giuseppe Esposito
    • 2
  • Jorn Fierstra
    • 2
  • Kees P. Braun
    • 1
  • Luca Regli
    • 2
  1. 1.Department of Neurology and NeurosurgeryBrain Center Rudolf Magnus, UMC UtrechtUtrechtThe Netherlands
  2. 2.Department of NeurosurgeryUniversity Hospital ZürichZürichSwitzerland

Personalised recommendations