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Less Invasive Pedicled Omental-Cranial Transposition in Pediatric Patients With Moyamoya Disease and Failed Prior Revascularization

Navarro, Ramon MD*; Chao, Kevin MD*; Gooderham, Peter A. MD*; Bruzoni, Matias MD; Dutta, Sanjeev MD; Steinberg, Gary K. MD, PhD*

Neurosurgery:
doi: 10.1227/NEU.0000000000000119
Operative Technique
Abstract

BACKGROUND: Patients with moyamoya disease and progressive neurological deterioration despite previous revascularization pose a major treatment challenge. Many have exhausted typical sources for bypass or have ischemia in areas that are difficult to reach with an indirect pedicled flap. Omental-cranial transposition has been an effective, but sparingly used technique because of its associated morbidity.

OBJECTIVE: We have refined a laparoscopic method of harvesting an omental flap that preserves its gastroepiploic arterial supply.

METHODS: The pedicled omentum can be lengthened as needed by dividing it between the vascular arcades. It is transposed to the brain via skip incisions. The flap can be trimmed or stretched to cover ischemic areas of the brain. The cranial exposure is performed in parallel with pediatric surgeons. We performed this technique in 3 pediatric patients with moyamoya disease (aged 5-12 years) with previous superficial temporal artery to middle cerebral artery bypasses and progressive ischemic symptoms. In 1 patient, we transposed omentum to both hemispheres.

RESULTS: Blood loss ranged from 75 to 250 mL. After surgery, patients immediately tolerated a diet and were discharged in 3 to 5 days. The ischemic symptoms of all 3 children resolved within 3 months postoperatively. Magnetic resonance imaging at 1 year showed improved perfusion and no new infarcts. Angiography showed excellent revascularization of targeted areas and patency of the donor gastroepiploic artery.

CONCLUSION: Laparoscopic omental harvest for cranial-omental transposition can be performed efficiently and safely. Patients with moyamoya disease appear to tolerate this technique much better than laparotomy. With this method, we can achieve excellent angiographic revascularization and resolution of ischemic symptoms.

ABBREVIATIONS: MCA, middle cerebral artery

SPECT, single-photon emission computed tomography

STA, superficial temporal artery

TIA, transient ischemic attack

Author Information

*Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine and Lucile Packard Children's Hospital, Stanford, California;

Department of Pediatric Surgery, Stanford University School of Medicine and Lucile Packard Children's Hospital, Stanford, California

Correspondence: Gary K. Steinberg, MD, PhD R281, Department of Neurosurgery and Stanford University, School of Medicine, 300 Pasteur Dr, Stanford, CA 94305-5327. E-mail: gsteinberg@stanford.edu

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Received November 15, 2012

Accepted July 17, 2013

Copyright © by the Congress of Neurological Surgeons