Many Indirect Anastomosesfor Moyamoya
There are two basic operative methods of surgical anastomosis for moyamoya: direct and indirect. Direct anastomosis is an anastomosis between the scalp artery (superficial temporal artery: STA) and brain artery (middle cerebral artery: MCA). Mostly, single anastomosis is performed, but occasionally two (rarely more than two) anastomoses are performed. Site of anastomosis is also determined occasionally by the results of the examination of the cerebral blood flow. Many neurosurgeons believe that the well-established STA-MCA anastomosis may provide enough blood flow in spite of the site of the anastomosis. Direct anastomosis is usually combined more or less with an indirect anastomosis, but the mode of indirect one in this situation is simple not like an indirect anastomosis which is performed as the main mode of operation.
There are so many modes of indirect anastomoses. Some of them were not performed now. From the paper of Dr. Y Matsushima, who is a pioneer of Encephalo-duro-arterio-synangiosis (EDAS), such modes are shown below.
1. Procedures using scalp artery
1-0. Encephalo-duro-arterio-synangiosis (EDAS). Matsushima Y (1980)
1-1. Cerebroarteriosynangiosis (CAS). Balagura S (1985)
1-2. Modified EDAS = pial synangiosis. Rooney CM (1991), Adelson PD (1995)
1-3. Encephaloarteriosyangiosis (EAS). Lesoin F (1983)
1-4. Encephalo-arterio-synangiosis (EAS). Nakagawa Y (1983)
1-5. EAS (devised for frontal portion). Ichikawa A (1989)
1-6. Multiple EDAS. Tenjin H (1977)
2. Procedures using galea
2-1. Encephalo-galeo-synangiosis (EGS). Ishii R (1986)
2-2. Ribbon procedure (ribbon EDAMS). Tokunaga K (1993)
3. Procedures using dura mater
3-1. Durapexia. Tsubokawa T (1964)
3-2. Encephalo-duro-synangiosis (EDS). Wakuta Y (1964), Ikeda Y (1984)
3-3. Cranial burr holing. Endo M (1989)
3-4. Reversed duropexia. Fujimoto T (1993)
3-5. Multiple burr-hole operation. Kawaguchi T (1996)
3-6. Split duroencephalosynangiosis. Kashiwagi S (1996)
3-7. Dural inversion procedure. Dauser RC (1997)
3-8. Dural edge incision and inversion. Kinugasa K (1993)
3-9. Dural pedicle insertion. Hara Y (1994)
4. Procedures using temporal or other muscles
4-1. Encephalo-myo-synangiosis (EMS). Karasawa J (1997)
4-2. Encephalo-myo-synangiosis (EMS). Takeuchi S (1983)
4-3. Gracilis muscle transplantation. Touho H (1995)
4-4. Serratus anterior muscle free flap transfer. Yoshioka N (1996)
4-5. Latissimus dorsi muscle free flap transfer. Yoshioka N (1997)
5. Procedures using omentum
5-1. Omantal transplantation. Karasawa J (1980)
5-2. Omental transplantation. Havlik N (1997)
6. Procedures using the conbination of the above
6-1. EMAS (EMS + EAS). Nakagawa Y (1983)
6-2. Synangio-dural plasty (SDP). Wanibuchi H (1985)
6-3. Encephalo-duro-arterio-myo-synagniosis (EDAMS). Kinugasa K (1993)
6-4. Combined revascularization. Sato H (1991)
6-5. Galeo-encephalo-duro-arterio-myo-synangiosis (GEDAMS). Nishimoto A (1991)
6-6. Frontal encephalo-myo-arterio-synangiosis. Inoue T (1992)
6-7. Ribbon EDAMS. Tokunaga K (1993)
6-8. Non-anastomotic bypass using temporal muscle, galea, dura mater. Hara Y (1993)
6-9. Fronto-temporo-parietal combined indirect bypass. Matsushima T (1995)
6-10. One-stage extensive indirect vascular reconstructive surgery. Kohno K (1997)
6-11. S-EDAS (split EDAS). Matsushima Y (1998)
6-12. Omentum and serratus anterior muscle free flap transfer. Yoshioka N (1996)
7. Direct and indirect anastomoses combined
7-1. STA-MCA anastomosis and/or encephalomyosynangiosis. Karasawa J (1977)
7-2. STA-MCA anastomosis and encephalo-duro-arterio-myo-synagniosis. Houkin K (1997)
Indirect anastomoses use scalp artery, galea, dura mater, muscle, omentum, or combination of these. The same anastomoses with different sizes of the tissues may result in the different effects of the cerebral blood flow. Even the Japanese neurosurgeons may not understand all of these surgical methods.
Reference:
Matsushima Y: Indirect anastomosis for moyamoya disease. No Shinkei Geka 26:769-786, 1998
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