Double-barrel STA-MCA bypass for cerebral revascularization: lessons learned from a 10-year experience

2021 ◽  
pp. 1-9
Author(s):  
Peter Kan ◽  
Visish M. Srinivasan ◽  
Aditya Srivatsan ◽  
Ascher B. Kaufmann ◽  
Jacob Cherian ◽  
...  
Keyword(s):  
Moyamoya Disease ◽  
Ct Perfusion ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Graft Patency ◽  
Lessons Learned ◽  
Cerebral Revascularization ◽  
Perioperative Outcomes ◽  
Perfusion Studies

OBJECTIVE In select patients, extracranial-intracranial (EC-IC) bypass remains an important tool for cerebral revascularization. Traditionally, superficial temporal artery–middle cerebral artery (STA-MCA) bypass was performed using one limb of the STA only. In an attempt to augment flow and to direct flow to different ischemic areas of the brain, the authors adopted a “double-barrel” technique in which both branches of the STA are used to revascularize distinct MCA territories. METHODS A series of consecutive double-barrel STA-MCA bypasses performed between 2010 and 2020 were reviewed. Each anastomosis was directed to augment flow to a territory most at risk based on preoperative perfusion studies, cerebral angiography, and intraoperative indocyanine green data. CT perfusion and CTA were routinely used to evaluate postoperative augmentation and graft patency. Patient perioperative outcomes, surgical complications, and modified Rankin Scale (mRS) scores at the last follow-up were reported. RESULTS Forty-four patients (16 males, 28 females) successfully underwent double-barrel STA-MCA bypass on 54 cerebral hemispheres: 28 operations were for moyamoya disease, 23 for atherosclerotic disease refractory to medical therapy, 2 for complex cerebral aneurysms, and 1 for carotid occlusion as a sequela of cavernous meningioma growth. Ten patients underwent multiple operations, 9 of whom had moyamoya disease/syndrome, with the subsequent operation on the contralateral hemisphere. The average patient age at surgery was 45.1 years (range 14–73 years), with a mean follow-up time of 22.1 months. Intraoperative graft patency was confirmed in 100% of cases, and 101 (98.1%) of the 103 anastomoses with imaging follow-up were patent. Perfusion to the revascularized hemisphere was improved in 88.2% of cases. Perioperative ischemic and hemorrhagic complications occurred in 8 procedures (2 were asymptomatic), whereas remote ischemic and hemorrhagic events occurred in 7 cases. There was no mortality in the series, and the mean patient mRS scores were 1.72 at presentation and 1.15 at the last follow-up. CONCLUSIONS The high rates of intraoperative and postoperative patency support the feasibility of dual-anastomosis STA-MCA bypass for revascularization. The perioperative complication rate is not significantly different from that of single-anastomosis bypass. The functional outcomes at follow-up and perfusion improvement postoperatively support the efficacy and safety of this method as a treatment strategy.

Treatment of moyamoya disease in the adult population with pial synangiosis

2014 ◽  
Vol 120 (3) ◽  
pp. 612-617 ◽  
Author(s):  
Ning Lin ◽  
Joshua P. Aronson ◽  
Sunil Manjila ◽  
Edward R. Smith ◽  
R. Michael Scott
Keyword(s):  
Moyamoya Disease ◽  
Adult Population ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Adult Patients ◽  
Cerebral Revascularization ◽  
Age At Surgery ◽  
Indirect Revascularization ◽  
Revascularization Surgery

Object Surgical treatment of moyamoya disease in the adult population commonly uses direct revascularization, the superficial temporal artery (STA) to middle cerebral artery (MCA) bypass (STA-MCA). Pial synangiosis, a method of indirect revascularization, has been used in adult patients with moyamoya when STA-MCA bypass was not technically feasible. Although the effectiveness of pial synangiosis has been well described in children, only limited reports have examined its role in adult patients with moyamoya disease. In this study the authors report on their experience with pial synangiosis revascularization for this population. Methods The authors reviewed the clinical and radiographic records of all adult patients (≥ 18 years of age) with moyamoya disease who underwent cerebral revascularization surgery using pial synangiosis at a single institution. Results From 1985 to 2010, 66 procedures (6 unilateral, 30 bilateral) were performed on 36 adult patients with moyamoya disease. The mean age at surgery was 28.3 years, and 30 patients were female. Twenty-eight patients (77.8%) presented with transient ischemic attacks (TIAs), 24 (66.7%) with stroke, and 3 (8.3%) with hemorrhage. Preoperative Suzuki stage was III or higher in 50 hemispheres (75.8%) and 3 patients had undergone prior treatments to the affected hemisphere before pial synangiosis surgery. Clinical follow-up was available for an average of 5.8 years (range 0.6–14.1 years), with 26 patients (72.2%) followed for longer than 2 years. Postoperative angiography was available for 24 patients and 46 revascularized hemispheres, and 39 (84.8%) of the 46 hemispheres demonstrated good collateral formation (Matsushima Grade A or B). Postoperative complications included 3 strokes, 5 TIAs, and 2 seizures, and there was no hemorrhage during the follow-up period. One patient required additional revascularization surgery 8 months after pial synangiosis. Conclusions Pial synangiosis is a safe and durable method of cerebral revascularization in adult patients with moyamoya and can be considered as a potential treatment option for moyamoya disease in adults.

scholarly journals Moyamoya Disease Superficial Temporal Artery-to-Middle Cerebral Artery Onlay: 2-Dimensional Operative Video

2020 ◽  
Vol 18 (6) ◽  
pp. E229-E229
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Middle Cerebral Artery ◽  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Superficial Temporal Artery ◽  
Video Recording ◽  
Temporal Artery ◽  
Low Flow ◽  
Institutional Review ◽  
Direct Anastomosis

Abstract The most frequently performed low-flow bypass procedure is the superficial temporal artery (STA) to middle cerebral artery (MCA) bypass. If available, a suitable M2 or M3 cortical branch is anastomosed to the donor vessel. This patient had severe moyamoya disease with an ipsilateral perfusion deficit and transient ischemic attacks. Given the need for revascularization, an STA-to-MCA bypass was performed. There was no suitable recipient M3 branch for direct anastomosis, and therefore an indirect bypass was performed by onlaying the STA onto the cortical surface and suturing the adventitia of the STA to the arachnoid of the underlying cortex. The dural leaflets were then inverted to potentiate further revascularization of the underlying cortex. The patient remained at their neurological baseline and demonstrated an enhanced perfusion of the ipsilateral MCA territory on follow-up evaluation. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Abstract TP449: Clinical and Angiographic Outcomes From Combined Direct and Indirect Bypass in Adult Patients with Moyamoya Disease: A Retrospective Study of 76 Procedures

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jinbing Zhao ◽  
Hongyi Liu ◽  
Yuanjie Zou ◽  
Shengxue He
Keyword(s):  
Moyamoya Disease ◽  
Cerebral Perfusion ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Vessel Diameter ◽  
Adult Patients ◽  
Neurological Dysfunction ◽  
Neurological Deficits ◽  
Main Trunk

Objective: Surgical revascularization is the mainstay of treatment for moyamoya patients. This study was to evaluate the progonosis of combined direct and indirect procedure for moyamoya disease patients. Methods: 76 cerebral hemispheres from 64 adult moyamoya patients undergoing combined superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and encephalo-duro-myo-synangiosis (EDMS) were reviewed retrospectively. The mean follow-up period was 23±14m (6m-70m). CT or MR perfusion and Digital subtraction angiography (DSA) were performed for preoperative diagnosis and postoperative evaluation of cerebral perfusion and revascularization. mRS score, angiographic collateralization score, vessel diameter were recorded to measure neurological dysfunction, revascularization area and vascular compensatory effect respectively. Results: Among the 64 MMD patients, 69 hemispheres received combined direct and indirect operations; 7 hemispheres only received indirect operations. During our follow-up periods, neurological deficits of 57/64 patients (89.1%) were partially alleviated. mRS was significantly decreased after operations not only in all patients, but also in stroke subgroup or hemorrhage subgroup. Generally, good revascularization was established in most of the patients by combined bypass. 92.1% (70/74) sides was scored 2 and 77.6% (59/74) sides was scored 3 determined by angiographic collateralization score. Compared to the preoperative situations (2.60±0.65mm), the calibers of STA main trunk increased profoundly in at postoperative 10 days (3.32±1.05mm, p<0.05 versus pre-operation), and shrinked back to preoperative status at 6 months (2.24±1.00mm, p>0.05 versus pre-operation) and 12 months (2.36±0.73mm, p>0.05 versus pre-operation). Conclusion: Our findings strongly suggested that combined STA-MCA bypass and EDMS provided efficient revascularization and excellent results in preventing strokes and hemorrhage in adult patients. The direct STA-MCA bypass provided early augmentation of cerebral perfusion, whereas the indirect EDMS provided a more durable long-term revascularization, indicating a complementary relationship between the two revascularization methods.

scholarly journals Long-term outcome after STA-MCA anastomosis for moyamoya disease

1998 ◽  
Vol 5 (5) ◽  
pp. E7 ◽  
Author(s):  
Susumu Miyamoto ◽  
Yoshinori Akiyama ◽  
Izumi Nagata ◽  
Jun Karasawa ◽  
Kazuhiko Nozaki ◽  
...  
Keyword(s):  
Moyamoya Disease ◽  
Social Life ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Temporal Muscle ◽  
Cerebral Ischemic

A long-term assessment was performed to determine the posttreatment clinical course of 113 patients with moyamoya disease. All patients sustained cerebral ischemic attacks and underwent superficial temporal artery-middle cerebral artery anastomosis with or without temporal muscle grafting. The follow-up duration was 3 to 24 years (mean 14.4 ± 5.8 [standard deviation]). Complete cessation of the ischemic episodes was obtained in 110 of 113 patients. One hundred patients were able to return to independent acitvities of daily living. Intellectual delays prevented 24 patients from engaging in an independent social life. Although intracranial bleeding is one of the common manifestations in moyamoya disease, hemorrhage was not detected in the 113 patients who underwent cerebral revascularization.

scholarly journals Late (5–20 years) outcomes after STA-MCA anastomosis and encephalo-duro-myo-arterio-pericranial synangiosis in patients with moyamoya disease

2020 ◽  
pp. 1-8 ◽  
Author(s):  
Satoshi Kuroda ◽  
Naoki Nakayama ◽  
Shusuke Yamamoto ◽  
Daina Kashiwazaki ◽  
Haruto Uchino ◽  
...  
Keyword(s):  
Disease Progression ◽  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Hemorrhagic Stroke ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Initial Surgery ◽  
Study Results ◽  
Late Morbidity

OBJECTIVESurgical revascularization is known to reduce the incidence of further ischemic and hemorrhagic events in patients with moyamoya disease, but the majority of previous studies report only short-term (< 5 years) outcomes. Therefore, in this study the authors aimed to evaluate late (5–20 years) outcomes of moyamoya patients after superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis and indirect bypass (encephalo-duro-myo-arterio-pericranial synangiosis [EDMAPS]).METHODSCumulative incidences of late morbidity/mortality and disease progression were evaluated among 93 patients who underwent STA-MCA anastomosis and EDMAPS. All of the patients were prospectively followed up for longer than 5 years postsurgery (10.5 ± 4.4 years). There were 35 pediatric and 58 adult patients. Initial presentation included transient ischemic attack/ischemic stroke in 80 patients and hemorrhagic stroke in 10 patients, and 3 patients were asymptomatic. Surgery was performed in a total of 141 hemispheres. Follow-up MRI/MRA was performed within a 6- or 12-month interval during the follow-up periods.RESULTSDuring the follow-up periods, 92/93 patients were free from any stroke or death, but 1 patient had a recurrence of hemorrhagic stroke (0.10% per patient-year). Disease progression occurred in the territory of the contralateral carotid or posterior cerebral artery (PCA) in 19 hemispheres of 15 patients (1.5% per patient-year). The interval between initial surgery and disease progression varied widely, from 0.5 to 15 years. Repeat bypass surgery for the anterior and posterior circulation resolved ischemic attacks in all 10 patients.CONCLUSIONSThe study results indicate that STA-MCA anastomosis and EDMAPS would be the best choice to prevent further ischemic and hemorrhagic stroke for longer than 10 years on the basis of the demonstrated widespread improvement in cerebral hemodynamics in both the MCA and ACA territories in the study patients. However, after 10 years postsurgery regular follow-up is essential to detect disease progression in the territory of the contralateral carotid artery and PCA and prevent late cerebrovascular events.

The role of indirect extracranial-intracranial bypass in the treatment of symptomatic intracranial atheroocclusive disease

2009 ◽  
Vol 110 (5) ◽  
pp. 896-904 ◽  
Author(s):  
Ricardo J. Komotar ◽  
Robert M. Starke ◽  
Marc L. Otten ◽  
Maxwell B. Merkow ◽  
Matthew C. Garrett ◽  
...  
Keyword(s):  
Cerebral Infarction ◽  
Cerebral Artery ◽  
Medical Management ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Graft Patency ◽  
Flow Reversal ◽  
Control Group ◽  
Hemodynamic Failure

Object The optimal treatment of medically refractory intracranial atheroocclusive disease remains unclear. The EC-IC Bypass Study Investigators found that patients with internal carotid and middle cerebral artery (ICA and MCA) occlusion received no benefit from direct superficial temporal artery to MCA bypass, and that patients with ICA occlusion and MCA stenosis may have actually fared worse after surgery, perhaps in part due to flow reversal in critical perforator-bearing segments. Although the results of recent investigations have suggested that direct bypass may be beneficial in a subgroup of patients with hemodynamic failure secondary to unilateral ICA occlusion, similar data do not exist for patients with hemodynamic failure from other intracranial stenoocclusive diseases. Indirect bypass via encephaloduroarteriosynangiosis offers a surgical alternative that may avoid rapid flow reversal while providing additional flow to at-risk, distal vascular territories. Methods Twelve patients with medically resistant hemodynamic failure from intracranial atheroocclusive disease underwent indirect vascular bypass. Eight patients had ICA occlusion and coexistent MCA stenosis, 1 patient had tandem ICA stenoses and MCA stenosis, 1 patient had tandem ICA and MCA occlusion, 1 patient had ICA and posterior cerebral artery occlusion and an ischemic hemisphere supplied via a proximal superficial temporal artery branch, and 1 patient had poor donor arteries and severe medical comorbidities that precluded the use of general anesthesia. Patient evaluation included clinical assessment of neurological status, CT scanning, MR imaging, digital subtraction angiography, and transcranial Doppler ultrasonography with CO2 reactivity, or SPECT with acetazolamide challenge. Patient records were reviewed and patients were interviewed for outcome assessment, including transient ischemic attack (TIA), cerebral infarction, change in cerebral perfusion, graft patency, and functional level according to the modified Rankin scale. Kaplan-Meier cumulative failure curves for the primary end point of cerebral infarction were used to compare these patients to a control group of 81 patients derived from the literature who received medical management for severe symptomatic hemodynamic failure. Results Eleven patients underwent encephaloduroarteriosynangiosis and 1 patient received bur holes with dural and arachnoid incisions; the mean length of follow-up was 51.2 ± 40.1 months. Five patients had decreased perfusion on follow-up despite graft patency, and 10 patients suffered new infarctions or TIAs during the follow-up period. Five patients (42%) suffered infarctions within 1 year of surgery. A meta-analysis of 4 studies of patients with symptomatic ICA occlusion and severe hemodynamic failure who underwent medical treatment revealed a new infarction rate of 30% in the first year after entry into the study. There was no significant difference between patients with severe hemodynamic failure who underwent surgery and those in the medically treated control group (log-rank test, p = 0.179). Conclusions The authors found that indirect bypass does not promote adequate pial collateral artery development and appears to be of limited utility in patients with symptomatic ICA or MCA stenoocclusive disease and secondary hemodynamic failure. Rates of postoperative TIAs or cerebral infarctions after indirect bypass in this patient population do not differ from previous reports in patients who received medical management only.

Clinical and Angiographic Outcomes From Indirect Revascularization Surgery for Moyamoya Disease in Adults and Children: A Review of 63 Procedures

Neurosurgery ◽  
2011 ◽  
Vol 68 (1) ◽  
pp. 34-43 ◽  
Author(s):  
Joshua R. Dusick ◽  
Nestor R. Gonzalez ◽  
Neil A. Martin
Keyword(s):  
Moyamoya Disease ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Middle Meningeal Artery ◽  
Subdural Hemorrhages ◽  
Adults And Children ◽  
Indirect Revascularization ◽  
Burr Holes ◽  
Revascularization Surgery

Abstract BACKGROUND: Several forms of indirect cerebral revascularization have been proposed to promote neovascularity to the ischemic brain. OBJECTIVE: To present clinical and angiographic outcomes of indirect revascularization by encephaloduroarteriosynangiosis and burr holes for the treatment of Moyamoya disease in adults and children. METHODS: Data from 63 hemispheres treated in 42 patients (average age, 30 years; 33 adults; 30 female patients; median follow-up, 14 months) were reviewed. In hemispheres with preoperative and postoperative (6- to 12-month) angiograms available, superficial temporal artery (STA) and middle meningeal artery (MMA) diameters were measured. Preoperative and postoperative corrected arterial sizes were compared. RESULTS: Seven patients (17%) had transient ischemic attacks that resolved within 1 month of surgery. No patients suffered moyamoya-related hemorrhage after treatment. Two patients developed additional symptoms many years after surgery. In 18 hemispheres with preoperative and postoperative angiograms, there was an average postoperative increase in STA and MMA diameters of 51% (P = .003) and 49% (P = .002), respectively. Both children and adults displayed revascularization. Two patients did not demonstrate increased vessel size. STA blush and new branches and MMA blush and new branches were identified in 12, 14, 14, and 16 hemispheres, respectively. Angiographic blush was identified in 59% of frontal and 19% of parietal burr holes (P = .03). Surgical complications included 2 subdural hemorrhages requiring evacuation and 2 new ischemic deficits (1 transient). CONCLUSION: Indirect revascularization by encephaloduroarteriosynangiosis and burr holes for moyamoya results in long-term resolution of ischemic and hemorrhagic manifestations in 95% of adults and children. The MMA appears to contribute significantly to the revascularization on follow-up angiograms with increased size and neovascularity comparable to that of the STA. Angiographically, parietal burr holes do not contribute as significantly as frontal burr holes.

Single Vessel Double Anastomosis for Flow Augmentation – A Novel Technique for Direct Extracranial to Intracranial Bypass Surgery

2019 ◽  
Vol 17 (4) ◽  
pp. 365-375 ◽  
Author(s):  
Gregory D Arnone ◽  
Ziad A Hage ◽  
Fady T Charbel
Keyword(s):  
Bypass Surgery ◽  
Clinical Status ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Graft Patency ◽  
Flow Index ◽  
Novel Technique ◽  
Single Vessel ◽  
Bypass Patency

AbstractBACKGROUNDA double anastomosis using a single superficial temporal artery (STA) donor branch for both a proximal side-to-side (S2S) and a distal end-to-side anastomosis is a novel direct bypass technique for use in selected patients necessitating flow augmentation.OBJECTIVETo describe the single-vessel double anastomosis (SVDA) technique, including its indications, advantages, and limitations, in addition to reporting our cases series of patients who underwent a SVDA bypass surgery.METHODSPatients undergoing a SVDA bypass at a single institution between January 2010 and February 2016 were retrospectively reviewed. Intraoperative flow data was collected, including STA cut-flow, bypass flows, and cut flow index (CFI). Bypass patency was assessed by cerebral angiography and quantitative magnetic resonance angiography with noninvasive optimal vessel analysis. Adverse events occurring during the hospital stay and clinical status at last follow up was recorded.RESULTSSeven patients underwent SVDA bypass. Mean follow-up was 14.5 mo. Initial CFI for the S2S bypasses averaged 0.56 ± 0.25 and CFI after the SVDA averaged 1.15 ± 0.24. There was a statistically significant average difference in CFI before and after the SVDA bypass (p < .013). Thirteen bypasses (93%) were patent postoperatively, and remained patent at last follow up. Four patients experienced various postoperative complications. None of the patients had a new stroke since hospital discharge.CONCLUSIONSVDA is a novel technique that can be advantageous for selected cases of extracranial-to-intracranial bypass. Expertise in bypass procedures is a necessary prerequisite. Graft patency rates and complications appear comparable to other bypass techniques.

Development of Arteriovenous Fistula After Revascularization Bypass for Moyamoya Disease

2014 ◽  
Vol 11 (1) ◽  
pp. E202-E206 ◽  
Author(s):  
Abdullah H Feroze ◽  
Jacob Kushkuley ◽  
Omar Choudhri ◽  
Jeremy J Heit ◽  
Gary K Steinberg ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Arteriovenous Fistula ◽  
Moyamoya Disease ◽  
Bypass Surgery ◽  
De Novo ◽  
Artery Bypass ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Fistula Formation

Abstract BACKGROUND AND IMPORTANCE Moyamoya disease is a rare cerebrovascular disorder often treated by direct and indirect revascularization bypass techniques as a result of a typically devastating disease course and poor response to medical therapy. In this report, we describe the formation and subsequent management of a de novo arteriovenous fistula identified in the setting of a patient treated with direct bypass surgery, a previously unreported phenomenon. CLINICAL PRESENTATION A 51-year-old woman presenting with Suzuki stage IV bilateral moyamoya disease underwent bilateral extracranial-to-intracranial superficial temporal artery--to--middle cerebral artery bypass without complication at our institution. At the 6-month follow-up, she demonstrated no evidence of residual neurological deficits or continued symptoms despite documentation of an arteriovenous fistula arising at the site of the right extracranial-to-intracranial bypass on routine follow-up cerebral angiography. CONCLUSION We present the first reported case of de novo arteriovenous fistula formation after superficial temporal artery-to-middle cerebral artery bypass for the treatment of moyamoya disease. Treatment of such iatrogenic arteriovenous fistulae fed by a patent bypass vessel may prove challenging without associated compromise of the bypass, meriting careful evaluation of all potential therapeutic options. The fistula described herein most likely occurred secondary to recanalization of a previously thrombosed vein of Trolard. This case demonstrates the possibility of arteriovenous fistula formation as a potential sequela of revascularization bypass surgery and lends support to the previously described traumatic origin of fistula formation.

Effect of direct arterial bypass on the prevention of future stroke in patients with the hemorrhagic variety of moyamoya disease

2000 ◽  
Vol 93 (3) ◽  
pp. 397-401 ◽  
Author(s):  
Shoichiro Kawaguchi ◽  
Shuzo Okuno ◽  
Toshisuke Sakaki
Keyword(s):  
Moyamoya Disease ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Ischemic Event ◽  
Content Type ◽  
Kaplan Meier ◽  
Significant Difference ◽  
Direct Bypass ◽  
Fine Print

Object. The authors evaluated the effects of superficial temporal artery—middle cerebral artery (STA—MCA) bypass in the prevention of future stroke, including rebleeding or an ischemic event, in patients suffering from hemorrhagic moyamoya disease by comparing this method with indirect bypass and conservative treatment.Methods. Twenty-two patients who had hemorrhagic moyamoya disease but no aneurysm comprised the study group. These patients' clinical charts were examined with respect to their treatment and clinical course after an initial hemorrhagic episode. The mean age of the patients was 43 years and the follow-up period ranged from 0.8 to 15.1 years, with a mean of 8 years. Eleven patients (50%) were conservatively treated. Among the 11 patients who were surgically treated, STA—MCA bypass was performed in six patients (27%) and encephaloduroarteriosynangiosis (EDAS) in the other five patients (23%). Nine patients (41%) presented with an ischemic or rebleeding event during the follow-up period. The incidence of future stroke events in patients who had undergone an STA—MCA bypass was significantly lower (p < 0.05) than that in patients who had been treated conservatively or with EDAS. Kaplan—Meier plots comparing stroke-free times in patients treated with direct bypass and those in patients who conservatively or with indirect bypass showed a significant difference (p < 0.05) in favor of direct bypass.Conclusions. The effect of STA—MCA bypass on the prevention of recurrent hemorrhage or an ischemic event in patients with hemorrhagic moyamoya disease has been statistically confirmed in this study.

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