MOYAMOYA TREATMENTS
This is for informational purposes only and should not be used as medical advice.
Always consult a medical physician when making decisions on care and treatment.
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Do I really need brain surgery?
Every patient comes with a unique medical history that is central to any final surgical decision, but the majority of moyamoya patients need, and benefit from, surgical intervention. Where it often becomes confusing for newly diagnosed patients are decisions around when to do surgery and what type of surgery to have.
Current Surgical Options for Moyamoya Disease - PMC (nih.gov)
“Watch and Wait”
It is not unusual to hear reports from newly diagnosed moyamoya patients who have been advised that surgery can wait. Generally, this is followed by the explanation that the brain has already started to “fix” itself by developing new, collateral vessels to provide additional blood flow. Patients are advised to start anti-coagulant therapy and follow-up on an annual basis or as new symptoms evolve with imaging. It is critical that decisions on surgical timing be made in conjunction with a neurosurgeon who has extensive experience treating moyamoya patients. While there are cases when waiting on surgery will be the least risky approach, experienced moyamoya specialists typically opt for a proactive approach to surgical intervention. This is because the collateral vessels are fragile and prone to breaking. When they are relied on to provide primary blood flow, there is an increased risk for hemorrhagic stroke.
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What type of surgery should I have?
Surgical decisions are best made in conjunction with your neurosurgeon and are driven by your individual medical history, risk profile and specifics of moyamoya progression.
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Direct Revascularization Surgeries: Direct bypass surgeries have been an intervention for moyamoya since the early '70s. Scalp arteries are connected directly to brain arteries creating a bypass around occlusions in the internal carotid arteries generating an immediate improvement to blood flow. STA-MCA Bypass (also known as the extracranial to intracranial bypass graft [EC-IC] bypass) is the most common direct bypass procedure. The STA-MCA bypass uses a branch of a scalp artery (STA) for direct anastomosis (connection) to a branch of the brain artery (MCA) on the outer surface of the brain. By laying the STA across the brain it creates a secondary indirect bypass which stimulates further revascularization and blood flow. Most patients see continued improvement over the first several months.
Indirect Revascularization Surgeries: Indirect bypass surgeries are intended to stimulate blood vessel growth to the brain. There are several types of indirect bypass surgeries.
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EDAS (encephalo-duro-arterio-synangiosis) uses a branch of the superficial temporal artery (STA). It is laid directly on the surface of the brain and new blood vessels grow from this section of the artery into the brain.
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Pial Synangiosis is a modification of the EDAS procedure. In this surgery, the healthy artery is sutured to the innermost of the brain’s three coverings to stimulate new blood vessel growth.
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EMS (encephalo-myo-synangiosis) uses the temporalis muscle. The muscle is dissected, then tunneled through an opening in the skull and laid on the surface of the brain.
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Omental Bypass relies on the greater omentum as a rich source of blood flow from the lining in the abdomen, to stimulate new vessel growth. The omentum is dissected and tunneled from the abdomen along the chest, neck and through the cranium where it is laid across the brain. This is typically considered as a rescue surgery and generally only done when other surgical approaches are not viable or previous surgeries have not produced enough blood flow.​
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Burr holes can be used in combination with direct or indirect surgeries to enhance blood flow or alone in a series of burr holes mapped to stimulate new growth in ischemic areas.
References - Stanford University, Boston Children's Hospital, Columbia neurosurgery. https://www.ahajournals.org/doi/full/10.1161/strokeaha.117.018563