Surgical Techniques in Moyamoya Vasculopathy: Tricks of the Trade

Surgical Techniques in Moyamoya Vasculopathy: Tricks of the Trade
Title Page
Copyright
Contents
Foreword
Preface
Contributors
Part 1 General Concepts
	1 Perioperative Management and Considerations
		1.1 Physiology
			1.1.1 Basic Physiology of Cerebral Blood Flow
			1.1.2 What Is Different in Patients with Moyamoya Disease?
		1.2 Anesthesia
			1.2.1 Choice of Anesthesia Technique
			1.2.2 Preoperative Evaluation and Premedication
			1.2.3 Monitoring
			1.2.4 Targets of Anesthesia
			1.2.5 Induction and Maintenance
			1.2.6 Emergence
		1.3 Postoperative Care for Moyamoya Disease Patients
			1.3.1 Where?
			1.3.2 Pain Control
		1.4 Threats of Anesthesia for Moyamoya Disease Surgery
			1.4.1 Ischemic Stroke and Transient Ischemic Attacks
			1.4.2 Cerebral Hyperperfusion Syndrome
		References
		Suggested Readings
	2 General Principles of Direct Bypass Surgery
		2.1 History and Initial Description
		2.2 Analysis of Hemodynamic Compromise for Direct Bypass Surgery
		2.3 Key Principles of Direct Revascularization Surgery
			2.3.1 Graft Choice
			2.3.2 Recipient Artery
			2.3.3 Standardized Strategies versus Targeted Bypass Procedures
			2.3.4 Peri- and Intraoperative Management and Neuroprotection
			2.3.5 Intraoperative Flow Assessment
		2.4 General Complications and Risk Stratification
		References
	3 General Principles of Indirect Bypass Surgery
		3.1 Introduction
		3.2 History and Initial Description
		3.3 Pathophysiology
		3.4 Concept of Indirect Bypass Surgery
		References
Part 2 Indirect Revascularization
	4 Multiple Burr Holes
		4.1 History and Initial Description
		4.2 Indications
		4.3 Key Principles
		4.4 SWOT Analysis
			4.4.1 Strengths
			4.4.2 Weakness
			4.4.3 Opportunities
			4.4.4 Threats
		4.5 Contraindications
		4.6 Special Considerations
			4.6.1 Imaging
			4.6.2 Patient
		4.7 Pitfalls, Risk Assessment, and Complications
		4.8 Special Instructions, Position, and Anesthesia
			4.8.1 Anesthesia
			4.8.2 Position
		4.9 Skin Incision and Key Surgical Steps
		4.10 Difficulties Encountered
		4.11 Bailout, Rescue, and Salvage Maneuvers
		4.12 Tips, Pearls, and Lessons Learned
		References
	5 Encephalo-myo-synangiosis
		5.1 History and Initial Description
		5.2 Indications
		5.3 Key Principles
		5.4 SWOT Analysis
			5.4.1 Strengths
			5.4.2 Weaknesses
			5.4.3 Opportunities
			5.4.4 Threats
		5.5 Contraindications
		5.6 Special Considerations
		5.7 Pitfalls, Risk Assessment, and Complications
		5.8 Special Instructions, Position, and Anesthesia
		5.9 Key Surgical Steps
			5.9.1 Patient Position and Skin Incision
			5.9.2 Pterional Skin Incision
			5.9.3 Separate Skin and Muscle Flaps
			5.9.4 Mobilization of the Temporalis Muscle
			5.9.5 Elevation of the Muscle Flap
			5.9.6 Craniotomy and Drilling of the Sphenoid Wing
			5.9.7 Opening of the Dura and Encephaloduro-synangiosis
			5.9.8 Suturing of the Muscle Fascia to the Edge of the Dural Opening
			5.9.9 Bone Flap Reimplantation
		5.10 Difficulties Encountered
		5.11 Bailout, Rescue, and Salvage Maneuvers
		5.12 Tips, Pearls, and Lessons Learned
		References
	6 Encephalo-duro-arterio-synangiosis: Pediatric
		6.1 History and Initial Description
		6.2 Indications
		6.3 Key Principles
		6.4 SWOT Analysis
			6.4.1 Strengths
			6.4.2 Weaknesses
			6.4.3 Opportunities
			6.4.4 Threats
		6.5 Contraindications
			6.5.1 General Contraindications to Revascularization Surgery
			6.5.2 Specific Contraindications to EDAS
		6.6 Special Considerations
		6.7 Pitfalls, Risk Assessment, and Complications
		6.8 Special Instructions, Position, and Anesthesia
		6.9 Patient Position with Skin Incision and Key Surgical Steps
		6.10 Difficulties Encountered
		6.11 Bailout, Rescue, and Salvage Maneuvers
		6.12 Tips, Pearls, and Lessons Learned
		Suggested Readings
	7 Encephalo-duro-arterio-synangiosis: In Adults
		7.1 History and Initial Description
			7.1.1 Literature Support for the Use of EDAS in Adults
		7.2 Indications
		7.3 Key Principles for the EDAS Surgery in Adults
		7.4 SWOT Analysis
			7.4.1 Strengths
			7.4.2 Weaknesses
			7.4.3 Opportunities
			7.4.4 Threats
		7.5 Specific Adult EDAS Contraindications
			7.5.1 Absolute
			7.5.2 Relative
			7.5.3 Not Contraindications
		7.6 Special Considerations
			7.6.1 Care Beyond the Surgical Field
		7.7 Risk Assessment and Complications
		7.8 Preoperative Workup
			7.8.1 Specific Consideration with Anticoagulation
		7.9 Patient Preparation
			7.9.1 Patient Position with Skin Incision
		7.10 Surgical Steps
			7.10.1 STA Dissection
			7.10.2 STA Care and Preservation
			7.10.3 Craniotomy
			7.10.4 Middle Meningeal Artery Preservation
			7.10.5 Cerebrospinal Fluid Release
			7.10.6 Dural Flaps Preparation and Superficial Temporal Artery Fixation
			7.10.7 Craniotomy Closure
		7.11 Difficulties Encountered and Pearls of Management
		7.12 Pitfalls
		7.13 Bailout, Rescue, and Salvage Maneuvers
		7.14 Postoperative Care
			7.14.1 Patient Surveillance
			7.14.2 EDAS Functional Assessment
			7.14.3 EDAS Angiographic Assessment
			7.14.4 Advanced Imaging
		References
	8 Bifrontal Encephalo-duro-periosteal-synangiosis Combined with STA–MCA Bypass
		8.1 History and Initial Description
		8.2 Indications
		8.3 Key Principles
		8.4 SWOT Analysis
		8.5 Contraindications
		8.6 Special Considerations
		8.7 Complications
		8.8 Special Instructions and Anesthesia
		8.9 Patient Position with Skin Incision and Key Surgical Steps
			8.9.1 Direct (STA–MCA) and Indirect (EDMS) Bypass for Unilateral MCA Territory Revascularization
			8.9.2 Bifrontal EDPS
		8.10 Difficulties Encountered
		8.11 Bailout, Rescue, and Salvage Manoeuvres
		8.12 Tips, Pearls, and Lessons Learned
		References
Part 3 Direct Revascularization
	9 STA–MCA Bypass for Direct Revascularization in Moyamoya Disease
		9.1 History and Initial Description
		9.2 Indications
		9.3 Key Principles
		9.4 SWOT Analysis
			9.4.1 Strengths
			9.4.2 Weaknesses
			9.4.3 Opportunities
			9.4.4 Threats
		9.5 Contraindications
		9.6 Special Considerations
			9.6.1 Preoperative Imaging
			9.6.2 Anticoagulation
			9.6.3 Other Considerations
		9.7 Pitfalls, Risk Assessment, and Complications
		9.8 Special Instructions, Position, and Anesthesia
		9.9 Patient Position with Skin Incision and Key Surgical Steps
			9.9.1 Preparation
			9.9.2 Surgical Technique
		9.10 Difficulties Encountered
		9.11 Bailout, Rescue, and Salvage Maneuvers
		9.12 Tips, Pearls, and Lessons Learned
			9.12.1 Preoperative Evaluations
			9.12.2 Technical Tips
			9.12.3 Postoperative Care
		References
	10 Double-Barrel Bypass in Moyamoya Disease
		10.1 History and Initial Description
		10.2 Indications
		10.3 Key Principles of the Double-Barrel Bypass
		10.4 SWOT Analysis
			10.4.1 Strengths
			10.4.2 Weaknesses
			10.4.3 Opportunity
			10.4.4 Threats
		10.5 Contraindications
		10.6 Special Considerations
		10.7 Risk Assessment and Complications
		10.8 Special Instructions, Position, and Anesthesia
			10.8.1 Preoperative Workup
			10.8.2 Patient Position
			10.8.3 Anesthesia
		10.9 Skin Incision and Key Surgical Steps
			10.9.1 Skin Incision and Dissection of STA
			10.9.2 Temporal Muscle Dissection and Craniotomy
			10.9.3 Dural Opening
			10.9.4 Anastomotic Site Selection
			10.9.5 Donor STA Preparation
			10.9.6 Recipient MCA Branch Preparation
			10.9.7 MCA Arteriotomy
			10.9.8 Anastomosis
			10.9.9 Graded Release of the Temporary Clips and Hemostasis
			10.9.10 Second Anastomoses
			10.9.11 Closure Phase
			10.9.12 Postoperative Care
		10.10 Difficulties Encountered
		10.11 Bailout, Rescue, and Salvage Maneuvers
		10.12 Tips, Pearls, and Lessons Learned
		References
	11 Occipital Artery–Middle Cerebral Artery Bypass in Moyamoya Disease
		11.1 History and Initial Description
		11.2 Indications
		11.3 Key Principles
		11.4 SWOT Analysis
			11.4.1 Strengths
			11.4.2 Weaknesses
			11.4.3 Opportunities
			11.4.4 Threats
		11.5 Contraindications
		11.6 Special Considerations
		11.7 Pitfalls, Risk Assessment, and Complications
		11.8 Special Instructions, Position, and Anesthesia
		11.9 Patient Position with Skin Incision and Key Surgical Steps
		11.10 Difficulties Encountered
		11.11 Bailout, Rescue, and Salvage Maneuvers
		11.12 Tips, Pearls, and Lessons Learned
		References
	12 STA–ACA/MCA Double Bypasses with Long Grafts
		12.1 History and Initial Description
		12.2 Indications
		12.3 Key Principle of STA–ACA/MCA Double Bypasses with Long Grafts
		12.4 SWOT Analysis
			12.4.1 Strength
			12.4.2 Weaknesses
			12.4.3 Opportunity
			12.4.4 Threats
		12.5 Contraindications
		12.6 Special Considerations
		12.7 Pitfalls, Risk Assessment, and Complications
		12.8 Special Instructions, Position, and Anesthesia
		12.9 Patient Position with Skin Incision and Key Surgical Steps
		12.10 Difficulties Encountered
		12.11 Bailout, Rescue, and Salvage Maneuvers
		12.12 Tips, Pearls, and Lessons Learned
			12.12.1 Graft Management
			12.12.2 Anastomosis
			12.12.3 Training
		Suggested Readings
	13 Double Anastomosis Using Only One Branch of the Superficial Temporal Artery: Single-Vessel Double Anastomosis
		13.1 History and Initial Description
		13.2 Indications
		13.3 Key Principles
		13.4 SWOT Analysis
			13.4.1 Strengths
			13.4.2 Weaknesses
			13.4.3 Opportunities
			13.4.4 Threats
		13.5 Contraindications
		13.6 Special Considerations
		13.7 Pitfalls, Risk Assessment, and Complications
		13.8 Special Instructions, Position, and Anesthesia
		13.9 Skin Incision and Key Surgical Steps
		13.10 Difficulties Encountered
		13.11 Bailout, Rescue, and Salvage Maneuvers
		13.12 Tips, Pearls, and Lessons Learned
		References
		Suggested Readings
Part 4 Combined Revascularization
	14 Combined STA–MCA Bypass and Encephalo-myo-synangiosis
		14.1 History and Initial Description
		14.2 Indications
		14.3 Key Principles
		14.4 SWOT Analysis
			14.4.1 Strengths
			14.4.2 Weaknesses
			14.4.3 Opportunities
			14.4.4 Threats
		14.5 Contraindications
		14.6 Special Considerations
		14.7 Pitfalls, Risk Assessment, and Complications
		14.8 Special Instructions, Position, and Anesthesia
		14.9 Patient Position and Key Surgical Steps 97
		14.10 Difficulties Encountered
		14.11 Bailout, Rescue, and Salvage Maneuvers
		14.12 Tips, Pearls, and Lessons learned
		References
	15 STA–MCA Bypass and EMS/EDMS
		15.1 History and Initial Description
		15.2 Indications
		15.3 Key Principles
		15.4 SWOT Analysis
			15.4.1 Strengths
			15.4.2 Weaknesses
			15.4.3 Opportunities
			15.4.4 Threats
		15.5 Contraindications
		15.6 Special Considerations
		15.7 Pitfalls, Risk Assessment, and Complications
		15.8 Special Instructions, Position, and Anesthesia
		15.9 Patient Position with Skin Incision and Key Surgical Steps
		15.10 Difficulties Encountered
		15.11 Bailout, Rescue, and Salvage Maneuvers
		15.12 Tips, Pearls, and Lessons Learned
		References
	16 Combined Direct (STA–MCA) and Indirect (EDAS) EC–IC Bypass
		16.1 History and Initial Description
		16.2 Indications
		16.3 Key Principles
		16.4 SWOT Analysis
		16.5 Contraindications
		16.6 Special Considerations
			16.6.1 Preoperative Considerations
			16.6.2 Postoperative Considerations
		16.7 Pitfalls, Risk Assessment, and Complications
		16.8 Special Instructions, Position, and Anesthesia
		16.9 Patient Position with Skin Incision and Key Surgical Steps
			16.9.1 Description of the Technique
		16.10 Difficulties Encountered
		16.11 Bailout, Rescue, and Salvage Maneuvers
		16.12 Tips, Pearls, and Lessons Learned
		References
	17 STA–MCA Anastomosis and EDMAPS
		17.1 History and Initial Description
			17.1.1 STA–MCA Anastomosis and EDMAPS as an \"Ultimate\" Bypass
		17.2 Indications and Contraindications
			17.2.1 Asymptomatic Moyamoya Disease
			17.2.2 Ischemic-Tpe Moyamoya Disease
			17.2.3 Hemorrhagic-Type Moyamoya Disease
		17.3 Key Principles
		17.4 SWOT Analysis
		17.5 Special Considerations
		17.6 Pitfalls, Risk Assessment, and Complications
		17.7 Special Instructions and Anesthesia
		17.8 Patient Position with Skin Incision and Key Surgical Steps
			17.8.1 Skin Incision and Donor Tissue Preparation
			17.8.2 Craniotomy and Dural Opening
			17.8.3 Direct STA–MCA Anastomosis
			17.8.4 Indirect Bypass and Cranioplasty
		17.9 Difficulties Encountered
			17.9.1 Preservation of Scalp Blood Flow
			17.9.2 Preservation of the MMA during Craniotomy
			17.9.3 ICG Videoangiography before Craniotomy 124
			17.9.4 STA–MCA Anastomosis
		17.10 Bailout, Rescue, and Salvage Maneuvers
		References
	18 STA–MCA Bypass and Encephalo-duro-arterio-synangiosis
		18.1 History and Initial Description
		18.2 Indications
		18.3 Key Principles
		18.4 SWOT Analysis
			18.4.1 Strengths
			18.4.2 Weaknesses
			18.4.3 Opportunity
			18.4.4 Threat
		18.5 Contraindications
		18.6 Special Considerations
		18.7 Pitfalls, Risk Assessment, and Complications
		18.8 Special Instructions, Position, and Anesthesia
		18.9 Patient Position with Skin Incision and Key Surgical Steps
			18.9.1 Position
			18.9.2 Skin Incision and STA Harvest
			18.9.3 Craniotomy
			18.9.4 Recipient Vessel Preparation
			18.9.5 Donor Vessel Preparation
			18.9.6 STA–MCA Bypass
			18.9.7 Encephalo-arterio-synangiosis
			18.9.8 Encephalo-duro-synangiosis
			18.9.9 Closure
		18.10 Difficulties Encountered
			18.10.1 Donor Vessel
			18.10.2 Craniotomy/Durotomy
			18.10.3 Recipient Vessel
			18.10.4 Anastomosis
			18.10.5 Closure
		18.11 Bailout, Rescue, and Salvage Maneuvers
		18.12 Tips, Pearls, and Lessons Learned
			18.12.1 Preoperative Management
			18.12.2 Intraoperative Anesthetic Management
			18.12.3 Intraoperative Technique
		References
	19 Individualized Extracranial-Intracranial Revascularization in the Treatment of Late-Stage Moyamoya Disease
		19.1 History and Initial Description
		19.2 Indications
		19.3 Key Principles
		19.4 SWOT Analysis
			19.4.1 Strength
			19.4.2 Weaknesses
			19.4.3 Opportunities
			19.4.4 Threats
		19.5 Contraindications
		19.6 Special Considerations
		19.7 Pitfalls, Risk Assessment, and Complications
		19.8 Special Instructions, Position, and Anesthesia
		19.9 Patient Position with Skin Incision and Key Surgical Steps
			19.9.1 Skin Incision
			19.9.2 Temporal Muscle
			19.9.3 Bone Flap
			19.9.4 Dura Mater
			19.9.5 Target Revascularization
			19.9.6 The Simplest Anastomosis Techniques
		19.10 Difficulties Encountered
		19.11 Bailout, Rescue, and Salvage Maneuvers
		19.12 Tips, Pearls, and Lessons Learned
		Suggested Readings
Part 5 Rescue Strategies for Repeat Surgery
	20 Omental–Cranial Transposition
		20.1 Background
			20.1.1 History
		20.2 Indications
		20.3 Key Principles
		20.4 SWOT Analysis
			20.4.1 Strength
			20.4.2 Weakness
			20.4.3 Opportunity
			20.4.4 Threat
		20.5 Contraindications
		20.6 Special Considerations
		20.7 Risk Assessment: Our Experience
		20.8 Preoperative Workup
			20.8.1 Specific Consideration with Anticoagulation
		20.9 Patient Preparation
			20.9.1 Patient Position with Skin Incision
		20.10 Surgical Steps
			20.10.1 Key Procedural Step 1: Omental Harvest
			20.10.2 Key Procedural Step 2: Delivery and Tunneling
			20.10.3 Key Procedural Step 3: Craniotomy
		20.11 Tips, Pearls, and Lessons Learned
		20.12 Pitfalls
		20.13 Bailout, Rescue, and Salvage Maneuvers
		20.14 Postoperative Care
			20.14.1 Patient Surveillance
			20.14.2 Bypass Function Assessment
		20.15 Case Illustrations
			20.15.1 Case 1
			20.15.2 Case 2
		20.16 Conclusion
		Suggested Readings
	21 ECA–MCA Bypass with Radial Artery Graft
		21.1 History and Initial Description
		21.2 Indications
		21.3 Key Principles
		21.4 SWOT Analysis
			21.4.1 Strength
			21.4.2 Weaknesses
			21.4.3 Opportunity
			21.4.4 Threat
		21.5 Contraindications
		21.6 Special Considerations
		21.7 Pitfalls, Risk Assessment, and Complications
		21.8 Special Instructions, Position, and Anesthesia
		21.9 Patient Position with Skin Incision and Key Surgical Steps
		21.10 Difficulties Encountered
		21.11 Bailout, Rescue, and Salvage Maneuvers
		21.12 Tips, Pearls, and Lessons Learned
		References
	22 OA–MCA or OA–PCA Bypass
		22.1 Background
			22.1.1 History
		22.2 Indication
		22.3 Key Principles
		22.4 SWOT Analysis
			22.4.1 Strength
			22.4.2 Weakness
			22.4.3 Opportunity
			22.4.4 Threat
		22.5 Contraindications
			22.5.1 Relative Contraindications
		22.6 Special Considerations
		22.7 Risk Assessment—Stanford Experience
		22.8 Preoperative Workup
			22.8.1 Specific Consideration with Anticoagulation
		22.9 Patient Preparation
			22.9.1 Patient Position with Skin Incision
		22.10 Surgical Steps
			22.10.1 Key Procedural Step 1: OA Harvest
			22.10.2 Key Procedural Step 2: Craniotomy and Dural Opening
			22.10.3 Key Procedural Step 3: Prepare Recipient Vessel
			22.10.4 Key Procedural Step 4: Prepare Donor Vessel
			22.10.5 Key Procedural Step 5: Microanastomosis
			22.10.6 Key Procedural Step 6: Ensure Bypass Graft Patency
			22.10.7 Key Procedural Step 7: Closure
		22.11 Tips, Pearls, and Lessons Learned
		22.12 Pitfalls
		22.13 Bailout, Rescue, and Salvage Maneuvers
		22.14 Postoperative Care
			22.14.1 Patient Surveillance
			22.14.2 Bypass Function Assessment
		22.15 Case Illustrations
			22.15.1 Case 1: OA–PCA Bypass
			22.15.2 Case 2: OA–MCA Bypass
		22.16 Conclusion
		Suggested Readings
	23 PAA–MCA Bypass
		23.1 History and Initial Description
		23.2 Indications
		23.3 Key Principles
		23.4 SWOT Analysis
			23.4.1 Strengths
			23.4.2 Weakness
			23.4.3 Opportunity
			23.4.4 Threat
		23.5 Contraindications
		23.6 Special Considerations
		23.7 Pitfalls, Risk Assessment, and Complications
		23.8 Special Instructions, Position, and Anesthesia
		23.9 Patient Position with Skin Incision and Key Surgical Steps
		23.10 Difficulties Encountered
		23.11 Bailout, Rescue, and Salvage Maneuvers
		23.12 Tips, Pearls, and Lessons Learned
		References
Index