Kuroda Satoshi, Houkin Kiyohiro
Department of Neurosurgery, Hokkaido University Hospital, Sapporo, Hokkaido, Japan.
Neurol Med Chir (Tokyo). 2012;52(5):287-94. doi: 10.2176/nmc.52.287.
This review describes the basic concepts of surgical revascularization for moyamoya disease, including direct and indirect bypass surgery. Direct bypass surgery can improve cerebral hemodynamics and reduce further ischemic events immediately after surgery, but may be technically challenging in some pediatric patients. Indirect bypass surgery is simple and has widely been used. However, its beneficial effects can be achieved 3 to 4 months after surgery, and surgical design is quite important to determine the extent of surgical collateral pathways. Combined bypass procedure, especially superficial temporal artery (STA) to middle cerebral artery anastomosis and indirect bypass, encephalo-duro-myo-arterio-pericranial synangiosis, is a safe and effective option to improve the short- and long-term outcome in patients with moyamoya disease. Alternative techniques are also described for specific cases with profound cerebral ischemia in the anterior cerebral artery or posterior cerebral artery territory. Special techniques to safely complete bypass surgery and avoid perioperative complications are presented, including methods to prevent delayed wound healing, to avoid facial nerve palsy after surgery, and to preserve the STA and middle meningeal artery during skin incision and craniotomy. Finally, the importance of careful management of patients is emphasized to reduce the incidence of perioperative complications, including ischemic stroke and hyperperfusion syndrome.
本综述描述了烟雾病外科血运重建的基本概念，包括直接和间接搭桥手术。直接搭桥手术可改善脑血流动力学，并在术后立即减少进一步的缺血事件，但在一些儿科患者中技术上可能具有挑战性。间接搭桥手术简单且已被广泛应用。然而，其有益效果在术后3至4个月才能显现，并且手术设计对于确定手术侧支通路的范围非常重要。联合搭桥手术，尤其是颞浅动脉（STA）至大脑中动脉吻合术和间接搭桥手术，即脑-硬膜-肌-动脉-颅骨膜联合血管吻合术，是改善烟雾病患者短期和长期预后的一种安全有效的选择。还描述了针对大脑前动脉或大脑后动脉区域存在严重脑缺血的特定病例的替代技术。介绍了安全完成搭桥手术并避免围手术期并发症的特殊技术，包括预防伤口愈合延迟、避免术后面神经麻痹以及在皮肤切口和开颅手术期间保留STA和脑膜中动脉的方法。最后，强调了对患者进行仔细管理以降低围手术期并发症（包括缺血性卒中和高灌注综合征）发生率的重要性。
