Comparison of Direct and Indirect Bypass for Moyamoya Disease

1. Comparison of Direct and Indirect Bypass for Moyamoya Disease Jared Pisapia MGH Neurosurgery Grand Rounds September 23, 2010

2. Overview • Moyamoya disease (MMD) • Case presentation • Clinical course • Surgical approach (EDAS) • Revascularization options • Indirect • Direct • Evidence supporting revascularization techniques

3. www.brain-aneurysm.com

4. Moyamoya Disease (MMD) • More common in Asian populations • Incidence: < 1/100,000 • Bimodal age of presentation • Pediatric (Ischemia) • Adults (Hemorrhage) • Treatment– Revascularization

5. Case Report • JB is a 32 year old RH woman with PMH of congenital rubella syndrome referred by PCP to MGH ED for evaluation of R MCA stenosis • Intermittent numbness: L facial (V2 and V3), R finger/toe x 1 month • Episodes increased in frequency over prior year; lasting less than 20 min and resolving spontaneously

6. Case Report • Outpatient MRI • multifocal stenoses in anterior and posterior circulation • PMH/PSH: as above • Meds: OCP • FH: Ischemic stroke, 72 year old father • SH: clerk, non-smoker

7. CTA • Multiple intracranial stenoses • Bilateral involvement of the supraclinoid ICAs and ICA terminus • Near-occlusion of right M1 segment with intact flow distally

8. Brain MRI • > 3 small DWI and T2- hyperintense lesions • Recent infarcts • Embolic or low-flow infarcts • No evidence of ICH

9. Hospital course • She was placed on ASA 81 mg daily and her OCP was discontinued • She was discharged without further symptoms • Follow-up in Neurosurgery Clinic; scheduled for EDAS for revascularization

10. Encephaloduroarteriosynangiosis (EDAS) • Transposition of a segment of superficial temporal artery (STA) to surface of brain • Formation of spontaneous anastomoses between the arteries of the cerebral cortex, dura mater, and the scalp

12. EDAS HEAD

20. Multiple Burr Holes Baaj et al., 2009

21. Indirect Bypass: EDAS • main trunk of the STA • posterior branch of the STA • anterior branch of the STA • galeal flap • dura mater

22. Direct Bypass: STA-MCA bypass Baaj et al., 2009)

23. Direct and Indirect Bypass: STA-MCA Anastomosis + EMS. Combination: b. posterior branch of the STA; c. anterior branch of the STA; f. temporal muscle; g. branch of the MCA; h. anastomosis Matsushima et al., 1998

24. Additional Indirect Options • EMAS = EDAS + EMS • EDAMS = EMAS + dura (includes middle meningeal artery) • Multiple burr holes Baaj et al., 2009; Chang SD, Steinber GK, 2010

25. Multiple Combined Indirect Bypass a. main trunk of the STA; b. posterior branch of the STA; c. anterior branch of the STA; d. galeal flap; e. dura mater; f. temporal muscle; Matsushima et al., 1998

26. Indirect vs. Combined vs. Direct Bypass • 50 patients with pediatric MMD, 76 hemispheres, • Direct STA-MCA is associated with the greatest postoperative collateral formation and clinical improvement • EDAS and MCI were safer, and MCI caused formation of collaterals in the ACA distribution and is best procedure in children Matsushima et al., 1998

27. Rebleeding in Hemorrhagic MMD • STA-MCA bypass in prevention of future stroke, including rebleeding or ischemia • Recurrent ICH occurred less frequently in patients undergoing STA-MCA bypass than those who underwent EDAS • Authors recommend STA-MCA bypass over indirect bypass for patients presenting with intracranial hemorrhage Kawaguchi et al., 2000)

28. Adults vs. Pediatric; Ischemia • 23 patients underwent indirect bypass • 16 adults (mean 35, 20-59 years old) • 7 children (mean 10, 3-16 years old) • Good collaterals on postoperative angiography • 7/7 pediatrics, 7/16 adults • Advancing age decreases development of collaterals through indirect bypass • Direct bypass is main treatment option for patients > 40 years

29. Comparison of Direct versus Indirect Indirect (EDAS) Direct (STA-MCA bypass) Technically difficult; size and progressive MCA occlusion Immediate revascularization Symptomatic cerebral hyperperfusion, although transient • Useful if inadequate donor artery grafts • At least several weeks required to form collaterals • Easier and safer in patients with serious medical comorbities

30. Conclusions • The most appropriate revascularization procedure for patients with MMD is not fully defined. • Case series are limited by inadequate power, selection bias, and inherent differences in patient characteristics. • Choice of procedure may depend on surgeon’s experience, nature of symptoms, and patient age.

31. References • Baaj AA, Agazzi S, Sayed ZA, Toledo M, Spetzler RF, van Loveren H: Surgical management of Moyamoya disease: a review. Neurosurg Focus 26(4):E7, 2009 • Kawaguchi S, Okuno S, Sakaki T: Effect of direct arterial bypass on the prevention of future stroke in patients with the hemorrhagic variety of moyamoya disease. J Neurosurg 93:397-410, 2000. • Matsushima T, Inoue T, Ikezaki K, Matsukado K, Natori Y, Inamura T, et al: Multiple combined indirect procedure for the surgical treatment of children with moyamoya disease. A comparison with single indirect anastomosis with direct anastomosis. Neurosurg Focus 5(5):4, 1998 • Mizoi K, Kayama T, Yoshimoto T, Nagamine Y.:Indirect revascularization for moyamoya disease: is there a beneficial effect for adult patients? Surg Neurol 45:541-9, 1996. • Starke RM, Komotar RJ, Connolly ES: Optimal surgical treatment for moyamoya disease in adults: direct versus indirect bypass. Neurosurg Focus 26(4):E8, 2009.

32. Acknowledgements • Christopher S. Ogilvy, M.D. • Brian V. Nahed, M.D. • Brian P. Walcott, M.D. • Robert L. Martuza, M.D. • Neurosurgery Department