Moyamoya Disease Superficial Temporal Artery-to-Middle Cerebral Artery Onlay: 2-Dimensional Operative Video.

The most frequently performed low-flow bypass procedure is the superficial temporal artery (STA) to middle cerebral artery (MCA) bypass. If available, a suitable M2 or M3 cortical branch is anastomosed to the donor vessel. This patient had severe moyamoya disease with an ipsilateral perfusion deficit and transient ischemic attacks. Given the need for revascularization, an STA-to-MCA bypass was performed. There was no suitable recipient M3 branch for direct anastomosis, and therefore an indirect bypass was performed by onlaying the STA onto the cortical surface and suturing the adventitia of the STA to the arachnoid of the underlying cortex. The dural leaflets were then inverted to potentiate further revascularization of the underlying cortex. The patient remained at their neurological baseline and demonstrated an enhanced perfusion of the ipsilateral MCA territory on follow-up evaluation. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.