Abstract Pial synangiosis is a method of indirect surgical revascularization developed at our institution for the treatment of moyamoya disease in pediatric patients. Similar surgical principles are employed in adult cases, often performed because of lack of an adequate donor vessel. Standardized protocols, including preadmission for preoperative intravenous hydration and aspirin administration, as well as intraoperative electroencephalography, are routinely employed to minimize operative risk. Perioperative heparinization is not required. The patient is positioned supine, without skull fixation, and the parietal branch of the superficial temporal artery is mapped with Doppler ultrasonography. The artery is microscopically dissected from distal to proximal, leaving a cuff of tissue around the vessel and elevated from the temporalis. The microscope is then removed, the temporalis is opened in a cruciate fashion, and a generous craniotomy is performed, with care to drill away from the exposed artery. The dura is then opened widely (preserving dural collateral vessels), followed by microscopic opening of the arachnoid in as many areas as possible. The donor vessel is then sutured to the pia with 10-0 nylons. The dural leaflets are laid on the brain (without suturing). Closure is completed with saline-soaked gelfoam, with fixation of the bone flap, and muscle reapproximation in the horizontal plane. The galea is closed, followed by the use of resorbable skin suture in pediatric patients. If indicated, the second hemisphere may be performed under the same anesthetic, reducing anesthetic risks and avoiding delayed revascularization. Postoperatively, the patient is awakened and transferred to the intensive care unit. Moyamoya, Pial synangiosis, Operative protocols, Stroke Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy125 View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy125 General Principles for Pial Synangiosis in Pediatric Moyamoya Patients: 2-Dimensional Operative Video General Principles for Pial Synangiosis in Pediatric Moyamoya Patients: 2-Dimensional Operative Video Close COMMENT Pediatric moyamoya vasculopathy has been associated with ∼6% of childhood strokes. Employing a proactive stance by pursuing early surgical intervention, ideally prior to the development of clinical symptoms has been shown as the most important determinant of overall outcome as well as providing unique opportunity for these children to substantively reduce risk of perioperative complications. Various surgical techniques have been described with a common denominator of preventing further ischemic injury by increasing collateral blood flow to hypoperfused areas of cerebral cortex. Pial synagiosis is one of the surgical methods to achieve safe, effective, and durable cerebral revascularization in pediatric moyamoya patients. The authors present a well-organized description of pial synagiosis including pearls and other tricks that have not been shown like this before. In a specific set of narrated steps, the dura is cut to multiple flaps, the arachnoid is dissected widely and the superficial temporal artery is approximated to the cerebral cortex. The resultant flow augmentation is achieved by a significant increase in the surface area of extra-axial vascular supply exposed to the pial surface. Oded Goren Clemens M. Schirmer Wilkes-Barre, Pennsylvania Copyright © 2018 by the Congress of Neurological Surgeons This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
Operative Neurosurgery – Oxford University Press
Published: May 18, 2018
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