Cerebral artery reconstruction for moyamoya disease
Moyamoya disease is a common congenital cerebrovascular occlusive disease that starts with cerebral ischemia in children and may present as cerebral ischemia or cerebral hemorrhage in adults. The disease is chronic and progressive, and early diagnosis and treatment is the key to improving the prognosis and the quality of life of patients.
Low-flow cerebral artery reconstruction, combined with temporalis muscle brain patching, is currently the treatment of choice for patients with smoldering disease with ischemic onset (2014 edition of the Chinese guidelines for secondary prevention of ischemic stroke and TIA).
The aim of the procedure is: to reduce the recurrence rate of ischemic stroke on the operated side by establishing an artificial secondary collateral circulation.
Typical case presentation
Middle-aged, male
Cerebrovascular cta and dsa showed very severe stenosis of the terminal internal carotid arteries, anterior and middle cerebral arteries bilaterally, surrounded by smoke-like (moyamoya) hyperplasia of fine arteries.
Magnetic resonance diffusion imaging showed scattered dotted ischemic lesions in the frontoparietal lobe bilaterally.
The patient’s clinical presentation: decreased muscle strength of the right limb and partial aphasia were predominant.
Treatment strategy
Smoker’s disease is a bilateral cerebrovascular lesion, and the patient has bilateral cerebral ischemia, with left-sided cerebral ischemia being the most severe.
Priority was given to left cerebral artery reconstruction, and right cerebral artery reconstruction was performed three months later.
The donor artery for low-flow cerebral artery reconstruction is usually the superficial temporal artery of the scalp.
The external carotid artery dsa showed that both the frontal and parietal branches of the left superficial temporal artery were well developed in this patient.
Intraoperative measurements showed that the cut flow of the frontal branch of the left superficial temporal artery was 36 ml per minute.
The left inferior M2 trunk was selected as the recipient artery intraoperatively.
The cerebral arteries of the patient with smoker’s disease were in good condition and did not have significant atherosclerosis.
The recipient artery was incised using a diamond knife.
The receptor artery was stained with melanin to increase the visualization of the arterial wall.
Perform a terminal lateral anastomosis of the frontal branch of the left superficial temporal artery and the lower M2 trunk of the left middle cerebral artery.
Use a continuous suture to reduce the difficulty of the operation.
The frontal branch of the left superficial temporal artery, through the lateral fissure, and the left middle cerebral artery M2 are confluent.
The temporalis muscle and dura were then sutured together, and the temporalis muscle was affixed to the surface of the brain tissue, completing both direct and indirect cerebral artery reconstruction in a single operation.
Postoperative ct shows: the temporalis muscle is located below the skull and affixed to the surface of the brain tissue.
One week postoperative cta showed that: the left superficial temporal artery entered the skull through the tunnel of the skull and temporalis muscle, and connected with the left middle cerebral artery to supply blood to the skull, and the filling of the left middle cerebral artery improved significantly.
Three months later, the patency of the anastomosed artery was evaluated and the right cerebral artery reconstruction was performed in parallel.