Non-anastomotic bypass surgery for childhood moyamoya disease using dural pedicle insertion over the brain surface combined with encephalogaleomyosynangiosis

BACKGROUND Anastomotic bypass surgery for childhood moyamoya disease provides more rapid improvement of blood circulation than indirect non-anastomotic bypass surgery, bur there are several problems, such as the technical difficulty of the operation, the extended period of anesthesia, and temporary occlusion of blood flow in the vessels of the brain surface. METHODS We describe a new non-anastomotic bypass procedure using dural pedicle insertion over the brain surface combined with encephalogaleomyosynangiosis and preservation of the superficial temporal artery (STA). We treated nine patients with childhood moyamoya disease admitted to our institution from 1989 through 1994. The operative field was determined based on the ischemic site identified by preoperative neuroimaging methods. Our procedure was performed in a total of 15 hemispheres, and the patients have been followed up for 5 months to 5 years after operation. RESULTS Cerebral angiography, cerebral blood flow measurements, and clinical symptoms and signs were improved at the operation site in all patients. Because the STA and the superficial portion of the temporal muscle attached to the skin flap were preserved, the skin at the operation site was not depressed and no necrosis, infection, or alopecia developed. CONCLUSION Childhood moyamoya disease is progressive, so repeated bypass surgery may be required. Therefore, non-anastomotic bypass surgery is better for the first operation because the STA is preserved. The present procedure using temporal muscle, galea, and dura can be extended over a wider brain surface than the operative field, and is suitable for establishing collateral circulation in the frontal lobe. Blood flow in the skin flap is maintained, so the cosmetic result is satisfactory. (C) 1999 by Elsevier Science Inc.