Successful Superficial Temporal Artery-Anterior Cerebral Artery Direct Bypass Using a Long Graft for Moyamoya Disease

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Abstract
Although some patients with moyamoya disease need revascularization in the anterior cerebral artery (ACA) territory, there are few reports on direct bypass in the ACA territory because of the difficult surgical technique. To report our technical strategy for superficial temporal artery (STA)-ACA bypass. We performed simultaneous STA-ACA and STA-middle cerebral artery direct bypasses in 7 patients with moyamoya disease using the following strategies: creating 2 separate craniotomies for the 2 bypasses, dissecting a long STA graft and securing a recipient ACA around the bregma for the STA-ACA bypass, and using loose stitches at the anastomoses. One branch of the STA was dissected for a length of approximately 10 cm. The graft coursed on the brain surface under the bone bridge and was directly anastomosed to the cortical branch of the ACA. At the anastomoses, the stitches were widely spaced and loose to facilitate expansion of the orifice. This method prevented kinking of the graft. Postoperative angiograms revealed good patency of the STA-ACA bypass in all patients. After the bypasses, 5 patients no longer had transient ischemic attacks or stroke, 1 patient was almost completely free of transient ischemic attacks, and 1 patient had only residual contralateral symptoms. In all 7 patients, patency of the bypass was satisfactory during follow-up periods ranging from 9 to 23 months (mean 16.4 months). This method of STA-ACA bypass provides successful and reliable direct revascularization of the ACA territory in patients with moyamoya disease. Further investigation of the possible merit of this surgery in improving cognitive function is warranted.