3D DSA-Guided Keyhole STA-MCA Bypass in Moyamoya Vasculopathy

Background: Large incisions and bone flaps may cause psychological resistance to surgery in some patients with Moyamoya disease (MMD) and syndrome (MMS), leading to disease progression and loss of future direct revascularization opportunities. Adopting robust neuroanatomical knowledge, the preoperative selection of adequate donor and recipient arteries becomes feasible in performing a minimally invasive bypass. Objective: This study aims to present a practical technique for selecting the recipient and donor arteries based on angiographical data and neuroanatomical knowledge for performing a successful keyhole STA-MCA bypass in patients with moyamoya vasculopathy. Methods: The study enrolled a cohort of eight Moyamoya syndrome patients and two Moyamoya disease patients who underwent keyhole STA-MCA bypass. Prior to bypass surgery, three-dimensional digital subtraction angiography (DSA) was employed to identify appropriate donor and recipient arteries with a more significant pressure difference (ΔP). The spatial location of the donor and recipient arteries guided the design of the skin incision and minicraniotomy. A linear incision was employed when the recipient artery ran parallel under the donor artery, whereas a curvilinear incision was used when the distance between the donor and recipient arteries was significant, based on angiographical calculations. All surgical procedures were carried out under a surgical microscope. Results: The average length of the skin incisions was 4.2 cm, and the average diameter of the craniotomies size was 2.05 cm. All the targeted recipient arteries were found at the center of the minicraniotomy. Intraoperative indocyanine green test or postoperative DSA confirmed the anastomosis patency in all stomas. At the first postoperative angiography follow-up test, 80% of the recruited patients exhibited Matsushima Grade A. Conclusion: By acquiring good neurosurgical anatomy and adopting our technique, keyhole STA-MCA could be widely accepted as an alternative surgical option for early Suzuki stages moyamoya vasculopathy patients, mainly for those with cosmetic concerns.