Superficial Temporal Artery to Middle Cerebral Artery Bypass for Moyamoya Disease: Surgical Nuances

Moyamoya disease is a progressive pathology that generally presents with ischemic complications in the pediatric age group.1 Direct and indirect revascularization procedures have been shown to augment the cerebral blood flow and prevent disease progression. Some studies have reported better angiographic outcomes with direct revascularization, though its translation into clinical benefit is yet to be proven in prospective studies.1, 2, 3, 4 In addition, direct revascularization is surgically challenging among the pediatric age group due to smaller vessel caliber. We present a case of a 10-year-old girl who presented with symptoms suggestive of transient cerebral ischemia (Video 1). We use a fine bipolar forceps for dissection of superficial fascia over superficial temporal artery (STA) and needle monopolar for elevating the temporalis muscle. The recipient vessel of the appropriate caliber, matching the donor vessel, is selected. An arteriotomy is made in the recipient vessel, following which end-to-side anastomosis of STA to M4 middle cerebral artery is done using 10-0 monofilament nylon suture at a magnification of 15×. First, the heel and toe stitches are taken, followed by an initial central stitch in the front wall, which decreases the likelihood of a through stitch while taking interrupted sutures in the back wall. Anastomosis is then completed with interrupted stitches in the front wall. The patency of bypass is confirmed using indocyanine green angiography. In this article, we attempt to highlight our surgical technique of low-flow STA to M4−middle cerebral artery bypass with special emphasis on tips and tricks for young neurosurgeons to efficiently perform microvascular anastomosis.