{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T11:36:41Z","timestamp":1790163401895,"version":"4.1.0"},"reference-count":44,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JNS"],"published-print":{"date-parts":[[2011,8]]},"abstract":"\nObject<\/jats:title>\nRevascularization for moyamoya disease, either by direct anastomosis or indirect procedures, is an accepted and effective form of treatment for prevention of future ischemic events. Indirect procedures do not provide sufficient collateral vessels in a subset of patients, who then have persistent or new symptoms. Repeat revascularization procedures may be recommended for these patients.<\/jats:p><\/jats:sec>\n\nMethods<\/jats:title>\nSixteen patients underwent repeat revascularization after undergoing an indirect procedure in the same hemisphere. These patients were included in the study, and a retrospective review of their clinical details, neuroimaging results, surgical details, and outcome was performed. Direct revascularization was the procedure of choice; however, in patients with no acceptable recipient vessel (> 0.6 mm) the authors added a second indirect procedure for further revascularization.<\/jats:p><\/jats:sec>\n\nResults<\/jats:title>\nOver the last 19 years, 16 patients (8 male and 8 female patients, age range 5\u201348 years, mean 16.7 years, 10 pediatric and 6 adult patients) underwent repeat revascularization for moyamoya disease. Initially all patients presented with ischemic symptoms (4 transient ischemic attacks [TIAs] and 12 strokes; 2 patients had bilateral symptoms). Angiography revealed that 13 patients had bilateral disease, and 3 had unilateral disease. Initial surgery was bilateral encephaloduroarteriosynangiosis (EDAS) in 9, unilateral EDAS alone in 3, unilateral EDAS with contralateral superficial temporal artery\u2013middle cerebral artery (STA-MCA) bypass in 2, bilateral encephalomyosynangiosis (EMS) in 1, and unilateral EMS in 1. Thirteen of the 16 patients continued to have TIAs in the hemisphere ipsilateral to surgery, whereas 1 patient had seizures and cognitive deficit, 1 had asymptomatic infarct on MR imaging, and 1 had visual symptoms. Poor revascularization was seen on angiography studies in all patients. The median duration between the surgeries was 24 months (3 months\u201310 years).<\/jats:p>\nRepeat revascularization was performed in 23 hemispheres (16 patients). Direct revascularization was performed in 14 hemispheres (60.9%): STA-MCA bypass in 10, external carotid artery\u2013MCA vein bypass in 2, occipital artery (OA)\u2013MCA in 1, and OA\u2013posterior cerebral artery in 1 hemisphere. Indirect revascularization was performed for patients without an acceptable recipient vessel, and was done in 9 hemispheres. The procedures included EMS (4 hemispheres), repeat EDAS (2), and omental transposition (3). There was 1 postoperative death in a patient undergoing a high-flow vein graft implantation. None of the other patients experienced any neurological worsening after surgery.<\/jats:p>\nFollow-up was available in all patients, ranging from 3 to 144 months (mean 34 months, median 12 months). Of the 15 patients who survived repeat revascularization surgery, 12 (80%) were free from any TIA, stroke, or any other neurological symptoms. Two patients had occasional TIAs, less frequent than before, whereas 1 patient had frequent TIAs and underwent revision of the revascularization. Angiographic studies were available in 11 patients, and showed improved flow in the hemispheres in 10 patients. Follow-up MR imaging performed at 6 months did not reveal a new infarct in any patient.<\/jats:p><\/jats:sec>\n\nConclusions<\/jats:title>\nRepeat revascularization procedures are effective for patients who are clinically symptomatic and have inadequate collateral vessels following indirect procedures. Although direct procedures are preferred, the choice of procedure depends on the operative findings and the status of donor and recipient vessels.<\/jats:p><\/jats:sec>","DOI":"10.3171\/2011.3.jns101908","type":"journal-article","created":{"date-parts":[[2011,8,1]],"date-time":"2011-08-01T15:03:22Z","timestamp":1312211002000},"page":"328-336","source":"Crossref","is-referenced-by-count":38,"title":["Outcome of repeat revascularization surgery for moyamoya disease after an unsuccessful indirect revascularization"],"prefix":"10.3171","volume":"115","author":[{"given":"Paritosh","family":"Pandey","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gary K.","family":"Steinberg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"4","key":"b1-jns101908","series-title":"Neurosurg Focus","first-page":"E11","article-title":"Moyamoya disease: a summary","volume":"26","author":"Burke","year":"2009"},{"key":"b2-jns101908","series-title":"Pediatr Neurosci","first-page":"58","article-title":"Failure of encephalo-duro-arterio-synangiosis procedure in moyamoya disease","volume":"12","author":"Cahan","year":"1986"},{"key":"b3-jns101908","series-title":"Techniques in Neurosurgery","first-page":"86","article-title":"Superficial temporal artery to middle cerebral artery anastomosis","volume":"6","author":"Chang","year":"2000"},{"issue":"4","key":"b4-jns101908","series-title":"Neurosurg Focus","first-page":"E9","article-title":"Age-dependent revascularization patterns in the treatment of moyamoya disease in a European patient population","volume":"26","author":"Czabanka","year":"2009"},{"key":"b5-jns101908","series-title":"Surg Neurol","first-page":"273","article-title":"Temporary neurologic deterioration due to cerebral hyperperfusion after superficial temporal artery-middle cerebral artery anastomosis in patients with adult-onset moyamoya disease","volume":"67","author":"Fujimura","year":"2007"},{"key":"b6-jns101908","series-title":"Surg Neurol","first-page":"442","article-title":"Incidence and risk factors for symptomatic cerebral hyperperfusion after superficial temporal artery-middle cerebral artery anastomosis in patients with moyamoya disease","volume":"71","author":"Fujimura","year":"2009"},{"key":"b7-jns101908","series-title":"Childs Nerv Syst","first-page":"358","article-title":"Revascularisation surgery for paediatric moyamoya: a review of the literature","volume":"21","author":"Fung","year":"2005"},{"key":"b8-jns101908","series-title":"Neurosurgery","first-page":"50","article-title":"Direct and combined revascularization in pediatric moyamoya disease","volume":"45","author":"Golby","year":"1999"},{"key":"b9-jns101908","series-title":"J Neurosurg","first-page":"927","article-title":"Clinical outcome after 450 revascularization procedures for moyamoya disease. Clinical article","volume":"111","author":"Guzman","year":"2009"},{"key":"b10-jns101908","series-title":"Neurosurg Clin N Am","first-page":"565","article-title":"Direct bypass techniques for the treatment of pediatric moyamoya disease","volume":"21","author":"Guzman","year":"2010"},{"key":"b11-jns101908","series-title":"Surgery","first-page":"156","article-title":"Encephalo-omental synangiosis in the management of moyamoya disease","volume":"111","author":"Havlik","year":"1992"},{"key":"b12-jns101908","series-title":"Neurosurgery","first-page":"E195","article-title":"Additional surgery for postoperative ischemic symptoms in patients with moyamoya disease: the effectiveness of occipital artery-posterior cerebral artery bypass with an indirect procedure: technical case report","volume":"64","author":"Hayashi","year":"2009"},{"key":"b13-jns101908","series-title":"Acta Neurochir (Wien)","first-page":"269","article-title":"Neovascularization (angiogenesis) after revascularization in moyamoya disease. Which technique is most useful for moyamoya disease?","volume":"142","author":"Houkin","year":"2000"},{"key":"b14-jns101908","series-title":"Neurol Res","first-page":"341","article-title":"The effect of encephalo-myo-synangiosis on abnormal collateral vessels in childhood moyamoya disease","volume":"22","author":"Irikura","year":"2000"},{"key":"b15-jns101908","series-title":"Neurol Med Chir (Tokyo)","first-page":"462","article-title":"Simultaneous superficial temporal artery to middle cerebral or anterior cerebral artery bypass with pansynangiosis for Moyamoya disease covering both anterior and middle cerebral artery territories","volume":"46","author":"Ishikawa","year":"2006"},{"key":"b16-jns101908","series-title":"Pediatr Neurosurg","first-page":"14","article-title":"Long-term outcomes of pediatric moyamoya disease treated by encephalo-duro-arterio-synangiosis","volume":"36","author":"Isono","year":"2002"},{"key":"b17-jns101908","series-title":"Neurol Med Chir (Tokyo)","first-page":"29","article-title":"A surgical treatment of \u201cmoyamoya\u201d disease \u201cencephalo-myo synangiosis\u201d","volume":"17","author":"Karasawa","year":"1977"},{"key":"b18-jns101908","series-title":"J Neurosurg","first-page":"192","article-title":"Cerebral revascularization using omental transplantation for childhood moyamoya disease","volume":"79","author":"Karasawa","year":"1993"},{"key":"b19-jns101908","series-title":"Acta Neurochir (Wien)","first-page":"1061","article-title":"Moyamoya disease and Moyamoya syndrome: experience in Europe; choice of revascularisation procedures","volume":"145","author":"Khan","year":"2003"},{"key":"b20-jns101908","series-title":"Clin Neurol Neurosurg","first-page":"125","article-title":"Surgical results in pediatric moyamoya disease: angiographic revascularization and the clinical results","volume":"109","author":"Kim","year":"2007"},{"key":"b21-jns101908","series-title":"Cerebrovasc Dis","first-page":"580","article-title":"Transient hyperperfusion after superficial temporal artery\/middle cerebral artery bypass surgery as a possible cause of postoperative transient neurological deterioration","volume":"25","author":"Kim","year":"2008"},{"key":"b22-jns101908","series-title":"Neurosurgery","first-page":"88","article-title":"Combined encephaloduroarteriosynangiosis and bifrontal encephalogaleo (periosteal) synangiosis in pediatric moyamoya disease","volume":"50","author":"Kim","year":"2002"},{"key":"b23-jns101908","series-title":"J Neurosurg","first-page":"896","article-title":"The role of indirect extracranial-intracranial bypass in the treatment of symptomatic intracranial atheroocclusive disease. Clinical article","volume":"110","author":"Komotar","year":"2009"},{"key":"b24-jns101908","series-title":"Acta Neurochir (Wien)","first-page":"129","article-title":"Reoperation for moyamoya disease refractory to encephalo-duro-arterio-synangiosis","volume":"107","author":"Matsushima","year":"1990"},{"key":"b25-jns101908","series-title":"Acta Neurochir (Wien)","first-page":"135","article-title":"Surgical treatment for paediatric patients with moyamoya disease by indirect revascularization procedures (EDAS, EMS, EMAS)","volume":"98","author":"Matsushima","year":"1989"},{"issue":"5","key":"b26-jns101908","series-title":"Neurosurg Focus","first-page":"e4","article-title":"Multiple combined indirect procedure for the surgical treatment of children with moyamoya disease. A comparison with single indirect anastomosis and direct anastomosis","volume":"5","author":"Matsushima","year":"1998"},{"key":"b27-jns101908","series-title":"Pediatr Neurosci","first-page":"326","article-title":"Failure of encephalo-duro-arterio-synangiosis procedure in moyamoya disease","volume":"12","author":"Matsushima","year":"1986"},{"key":"b28-jns101908","series-title":"Surg Neurol","first-page":"313","article-title":"A new surgical treatment of moyamoya disease in children: a preliminary report","volume":"15","author":"Matsushima","year":"1981"},{"key":"b29-jns101908","series-title":"Neurosurgery","first-page":"928","article-title":"Angiographic revascularization of the brain after encephaloduroarteriosynangiosis: a case report","volume":"21","author":"Matsushima","year":"1987"},{"issue":"2","key":"b30-jns101908","series-title":"Neurosurg Focus","first-page":"E15","article-title":"Long-term outcome of superficial temporal artery-middle cerebral artery bypass for patients with moyamoya disease in the US","volume":"24","author":"Mesiwala","year":"2008"},{"key":"b31-jns101908","series-title":"J Neurosurg","first-page":"537","article-title":"Pitfalls in the surgical treatment of moyamoya disease. Operative techniques for refractory cases","volume":"68","author":"Miyamoto","year":"1988"},{"key":"b32-jns101908","series-title":"Surg Neurol","first-page":"541","article-title":"Indirect revascularization for moyamoya disease: is there a beneficial effect for adult patients?","volume":"45","author":"Mizoi","year":"1996"},{"key":"b33-jns101908","series-title":"Pediatr Neurol","first-page":"199","article-title":"Encephaloduroarteriosynangiosis (EDAS) for the treatment of childhood moyamoya disease","volume":"10","author":"Ross","year":"1994"},{"issue":"6 Suppl","key":"b34-jns101908","series-title":"J Neurosurg","first-page":"437","article-title":"Multiple bur hole surgery for the treatment of moyamoya disease in children","volume":"105","author":"Sainte-Rose","year":"2006"},{"issue":"2 Suppl Pediatrics","key":"b35-jns101908","series-title":"J Neurosurg","first-page":"142","article-title":"Long-term outcome in children with moyamoya syndrome after cranial revascularization by pial synangiosis","volume":"100","author":"Scott","year":"2004"},{"issue":"4","key":"b36-jns101908","series-title":"Neurosurg Focus","first-page":"E8","article-title":"Optimal surgical treatment for moyamoya disease in adults: direct versus indirect bypass","volume":"26","author":"Starke","year":"2009"},{"key":"b37-jns101908","series-title":"Stroke","first-page":"104","article-title":"Moyamoya disease\u2014a review","volume":"14","author":"Suzuki","year":"1983"},{"key":"b38-jns101908","series-title":"Neurosurgery","first-page":"324","article-title":"Surgical treatment for pediatric moyamoya disease: use of the superficial temporal artery for both areas supplied by the anterior and middle cerebral arteries","volume":"40","author":"Suzuki","year":"1997"},{"key":"b39-jns101908","series-title":"No Shinkei Geka","first-page":"997","article-title":"[Strategy for vascular reconstruction for failed indirect anastomosis in adult Moyamoya disease\u2014a case report]","volume":"31","author":"Touho","year":"2003"},{"key":"b40-jns101908","series-title":"Neurosurgery","first-page":"935","article-title":"Surgical reconstruction of failed indirect anastomosis in childhood Moyamoya disease","volume":"32","author":"Touho","year":"1993"},{"key":"b41-jns101908","series-title":"Surg Neurol","first-page":"550","article-title":"Omental transplantation using a superficial temporal artery previously used for encephaloduroarteriosynangiosis","volume":"45","author":"Touho","year":"1996"},{"issue":"Suppl 2","key":"b42-jns101908","series-title":"Clin Neurol Neurosurg","first-page":"S118","article-title":"Combined encephalo-arterio-synangiosis and encephalo-myo-synangiosis in the treatment of moyamoya disease","volume":"99","author":"Tu","year":"1997"},{"issue":"2","key":"b43-jns101908","series-title":"Neurosurg Focus","first-page":"E16","article-title":"Moyamoya disease in pediatric patients: outcomes of neurosurgical interventions","volume":"24","author":"Veeravagu","year":"2008"},{"key":"b44-jns101908","series-title":"Skull Base","first-page":"27","article-title":"Moyamoya disease in adults: the role of cerebral revascularization","volume":"15","author":"Zipfel","year":"2005"}],"container-title":["Journal of Neurosurgery"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg\/115\/2\/article-p328.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg\/115\/2\/article-p328.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg\/115\/2\/article-p328.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,3,27]],"date-time":"2023-03-27T03:03:19Z","timestamp":1679886199000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg\/115\/2\/article-p328.xml"}},"subtitle":["Clinical article"],"short-title":[],"issued":{"date-parts":[[2011,8]]},"references-count":44,"journal-issue":{"issue":"2"},"URL":"https:\/\/doi.org\/10.3171\/2011.3.jns101908","relation":{},"ISSN":["0022-3085","1933-0693"],"issn-type":[{"value":"0022-3085","type":"print"},{"value":"1933-0693","type":"electronic"}],"subject":[],"published":{"date-parts":[[2011,8]]}}}