Efficacy and Safety of Combined Revascularization Surgery for Moyamoya Disease: Standard Procedure and Perioperative Management

Abstract Objective : Revascularization surgery such as superficial temporal artery–middle cerebral artery (STA-MCA) bypass is a standard management choice for symptomatic moyamoya disease (MMD) patients, with either ischemic or hemorrhagic presentation. We sought to clarify the efficacy and safety of institutional standardized revascularization procedures for MMD. Materials and methods : The present study includes 37 consecutive patients with MMD (2–60 years old, 42.0 on average) undergoing revascularization surgery on 42 affected hemispheres. Direct-indirect combined revascularization surgery was performed on most hemispheres (41/42, 97.6%), including STA-MCA bypass (39 hemispheres) and occipital artery–posterior cerebral artery bypass (2 hemispheres). All patients underwent standardized perioperative management with strict blood pressure control (110-130 mmHg) based on routine single-photon emission computed tomography (SPECT) 1 and 7 days after surgery. Then we investigated the outcome of surgeries, focusing mainly on that of combined revascularization procedures. Results : The outcome of 42 surgeries was favorable in all cases, except for one adult (2.3%) manifesting with cerebral hyperperfusion syndrome leading to neurological worsening. None of the patients developed perioperative cerebral infarction (0/42; 0%), and the patency of the direct bypass was confirmed via MRA in all patients undergoing combined procedure (41/41, 100%). Two patients suffered wound-healing delay, one of which required resuture. Conclusion : The combined revascularization surgery is a safe and effective treatment for MMD, while local cerebral hyperperfusion is a potential complication that should be avoided through intensive perioperative care.