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Surgical Outcomes for Moyamoya Angiopathy at Barrow Neurological Institute With Comparison of Adult Indirect Encephaloduroarteriosynangiosis Bypass, Adult Direct Superficial Temporal ArterytoMiddle Cerebral Artery Bypass, and Pediatric Bypass: 154 Revascularization Surgeries in 140 Affected Hemispheres

Abla, Adib A. MD*; Gandhoke, Gurpreet MD*; Clark, Justin C. MD*; Oppenlander, Mark E. MD*; Velat, Gregory J. MD; Zabramski, Joseph M. MD*; Albuquerque, Felipe C. MD*; Nakaji, Peter MD*; Spetzler, Robert F. MD*; Wanebo, John E. MD*

doi: 10.1227/NEU.0000000000000017
Research-Human-Clinical Studies

BACKGROUND: Untreated, moyamoya angiopathy is a progressive vaso-occlusive process that can lead to ischemic or hemorrhagic stroke.

OBJECTIVE: To review 1 institution’s surgical experience with both direct and indirect bypass (encephaloduroarteriosynangiosis) in adult and pediatric groups.

METHODS: A retrospective review was conducted of a consecutive series of patients treated for moyamoya angiopathy between 1995 and 2009.

RESULTS: Thirty-nine adult patients underwent indirect bypass as their initial therapy; 29 adult patients underwent direct bypass. Twenty-four pediatric patients included 20 indirect bypasses and 4 direct bypasses. Overall, 140 hemispheres were treated; 48 patients received revascularization of both hemispheres. There were 14 additional revascularization procedures (10% per hemisphere) performed over a site of continued hypoperfusion postoperatively. Fourteen postoperative ischemic strokes occurred during the entire follow-up (10% per hemisphere), and the Kaplan-Meier analysis was not significantly different between groups (P = .59). Four grafts (9.09%) had failed at radiographic follow-up of the 44 direct bypasses performed. Before the initial surgery, the modified Rankin Scale score was 1.58 ± 0.93, 1.48 ± 0.74, and 1.8 ± 1.1 in the pediatric, adult direct, and adult indirect groups (P = .39). At last follow-up, it was 1.29 ± 1.31, 1.09 ± 0.90, and 1.94 ± 1.51 (P = .04) in the pediatric, adult direct, and adult indirect groups.

CONCLUSION: This series demonstrates that both direct and indirect bypasses can be equally effective in preventing stroke. However, in adult patients, direct bypass patients had significantly greater improvement in symptoms, as seen in modified Rankin Scale scores. Pediatric patients, despite undergoing predominantly indirect bypasses, fared roughly the same as the adults in the direct bypass group.

ABBREVIATIONS: CTA, computed tomographic angiography

CTP, computed tomographic perfusion imaging

EDAS, encephaloduroarteriosynangiosis

MCA, middle cerebral artery

mRS, modified Rankin Scale

STA, superficial temporal artery

*Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona

Department of Neurosurgery, University of Florida, Gainesville, Florida

Correspondence: John E. Wanebo, MD, c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ 85013. E-mail:

Received June 20, 2012

Accepted May 31, 2013

Copyright © by the Congress of Neurological Surgeons