{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,24]],"date-time":"2026-10-24T01:42:59Z","timestamp":1792806179946,"version":"4.5.0"},"reference-count":15,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"3","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2022,3,1]]},"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVE<\/jats:title>\n                    <jats:p>Cerebral extracranial-intracranial (EC-IC) direct bypass is a commonly used procedure for ischemic vasculopathy. A previously described variation of this technique is to utilize one donor artery to supply two recipient arteries, which the authors designate as 1D2R. The purpose of this study is to present a single surgeon\u2019s series of 1D2R direct bypasses for moyamoya and ischemia using detailed clinical, angiographic, and intraoperative blood flow measurement data. To the authors\u2019 knowledge, this is the largest series reported to date.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS<\/jats:title>\n                    <jats:p>Hospital, office, and radiographic imaging records for all patients who underwent cerebral revascularization using a 1D2R bypass by the senior author were reviewed. The patients\u2019 demographic information, clinical presentation, associated medical conditions, intraoperative information, and postoperative course were obtained from reviewing the medical records.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS<\/jats:title>\n                    <jats:p>A total of 21 1D2R bypasses were performed in 19 patients during the study period. Immediate bypass patency was 100% and was 90% on delayed follow-up. The mean initial cut flow index (CFI(i)) was 0.64 \u00b1 0.33 prior to the second anastomosis and the mean final value (CFI(f)) was 0.94 \u00b1 0.38 after the second anastomosis (p &lt; 0.001). The overall bypass flow increased on average by 50% (mean 17.9 ml\/min, range \u221210 to 40 ml\/min) with the addition of the second anastomosis. There was no significant difference in the overall flow measurements when the end-to-side anastomosis or side-to-side anastomosis was performed first. There was a statistically significant difference in the proportion of patients with a modified Rankin Scale (mRS) score of 0 or 1 postoperatively compared to preoperatively (p &lt; 0.01). Through the application of Poiseuille\u2019s law, the authors analyzed flow dynamics, deduced the component vascular resistances based on an analogy to electrical circuits and Ohm\u2019s law, and introduced the new concepts of \u201csecond anastomosis relative augmentation\u201d and \u201csecond anastomosis sink index\u201d in the evaluation of 1D2R bypasses.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS<\/jats:title>\n                    <jats:p>The application of the 1D2R technique in a series of 19 consecutive patients undergoing direct EC-IC bypass for flow augmentation demonstrated high patency rates, statistically significantly higher CFIs compared to 1D1R, and improved mRS scores at last clinical follow-up. Additionally, the technique allows a shorter dissection time and preserves blood flow to the scalp. The routine utilization of intraoperative volumetric flow measurements in such surgeries allows a deeper understanding of the hemodynamic impact on individual patients.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/2021.2.jns204333","type":"journal-article","created":{"date-parts":[[2021,8,20]],"date-time":"2021-08-20T03:57:35Z","timestamp":1629431855000},"page":"627-636","source":"Crossref","is-referenced-by-count":22,"title":["One-donor, two-recipient extracranial-intracranial bypass series for moyamoya and cerebral occlusive disease: rationale, clinical and angiographic outcomes, and intraoperative blood flow analysis"],"prefix":"10.3171","volume":"136","author":[{"given":"Nickalus R.","family":"Khan","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Victor M.","family":"Lu","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Turki","family":"Elarjani","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael A.","family":"Silva","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aria M.","family":"Jamshidi","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Iahn","family":"Cajigas","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jacques J.","family":"Morcos","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"5","key":"b1","series-title":"J Neurosurg","first-page":"927","article-title":"Clinical outcome after 450 revascularization procedures for moyamoya disease. Clinical article","volume":"111","author":"Guzman R","year":"2009","unstructured":"Guzman R, Lee M, Achrol A,  Clinical outcome after 450 revascularization procedures for moyamoya disease. Clinical article. J Neurosurg. 2009;111(5):927\u2013935."},{"issue":"5","key":"b2","series-title":"Pediatrics","first-page":"e694","article-title":"Moyamoya syndrome associated with Down syndrome: outcome after surgical revascularization","volume":"116","author":"Jea A","year":"2005","unstructured":"Jea A, Smith ER, Robertson R, Scott RM. Moyamoya syndrome associated with Down syndrome: outcome after surgical revascularization. Pediatrics. 2005;116(5):e694\u2013e701."},{"issue":"2 Suppl Pediatrics","key":"b3","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 RM","year":"2004","unstructured":"Scott RM, Smith JL, Robertson RL,  Long-term outcome in children with moyamoya syndrome after cranial revascularization by pial synangiosis. J Neurosurg. 2004;100(2 Suppl Pediatrics):142\u2013149."},{"issue":"5","key":"b4","series-title":"Neurosurgery","first-page":"656","article-title":"Early versus delayed extracranial-intracranial bypass surgery in symptomatic atherosclerotic occlusion","volume":"85","author":"Rice CJ","year":"2019","unstructured":"Rice CJ, Cho SM, Taqui A,  Early versus delayed extracranial-intracranial bypass surgery in symptomatic atherosclerotic occlusion. Neurosurgery. 2019;85(5):656\u2013663."},{"issue":"1 Suppl Operative","key":"b5","series-title":"Neurosurgery","first-page":"ons30","article-title":"Double-barrel bypass for cerebral ischemia: technique, rationale, and preliminary experience with 10 consecutive cases","volume":"73","author":"Duckworth EA","year":"2013","unstructured":"Duckworth EA, Rao VY, Patel AJ. Double-barrel bypass for cerebral ischemia: technique, rationale, and preliminary experience with 10 consecutive cases. Neurosurgery. 2013;73(1 Suppl Operative):ons30\u2013ons38."},{"issue":"1","key":"b6","series-title":"Oper Neurosurg (Hagerstown)","first-page":"112","article-title":"Side-to-side and end-to-side double anastomosis using the parietal-branch of the superficial temporal artery\u2014a novel technique for extracranial to intracranial bypass surgery: 3-dimensional operative video","volume":"16","author":"Arnone GD","year":"2019","unstructured":"Arnone GD, Hage ZA, Charbel FT. Side-to-side and end-to-side double anastomosis using the parietal-branch of the superficial temporal artery\u2014a novel technique for extracranial to intracranial bypass surgery: 3-dimensional operative video. Oper Neurosurg (Hagerstown). 2019;16(1):112\u2013114."},{"issue":"4","key":"b7","series-title":"Oper Neurosurg (Hagerstown)","first-page":"365","article-title":"Single vessel double anastomosis for flow augmentation\u2014a novel technique for direct extracranial to intracranial bypass surgery","volume":"17","author":"Arnone GD","year":"2019","unstructured":"Arnone GD, Hage ZA, Charbel FT. Single vessel double anastomosis for flow augmentation\u2014a novel technique for direct extracranial to intracranial bypass surgery. Oper Neurosurg (Hagerstown). 2019;17(4):365\u2013375."},{"issue":"1)(suppl","key":"b8","series-title":"Neurosurgery","first-page":"75","article-title":"The cut flow index: an intraoperative predictor of the success of extracranial-intracranial bypass for occlusive cerebrovascular disease","volume":"56","author":"Amin-Hanjani S","year":"2005","unstructured":"Amin-Hanjani S, Du X, Mlinarevich N,  The cut flow index: an intraoperative predictor of the success of extracranial-intracranial bypass for occlusive cerebrovascular disease. Neurosurgery. 2005;56(1)(suppl):75\u201385."},{"issue":"5","key":"b9","series-title":"J Neurosurg","first-page":"1396","article-title":"The cut flow index revisited: utility of intraoperative blood flow measurements in extracranial-intracranial bypass surgery for ischemic cerebrovascular disease","volume":"133","author":"Stapleton CJ","year":"2020","unstructured":"Stapleton CJ, Atwal GS, Hussein AE,  The cut flow index revisited: utility of intraoperative blood flow measurements in extracranial-intracranial bypass surgery for ischemic cerebrovascular disease. J Neurosurg. 2020;133(5):1396\u20131400."},{"issue":"2","key":"b10","series-title":"Neurosurg Focus","first-page":"E20","article-title":"Flow-assisted surgical cerebral revascularization","volume":"24","author":"Ashley WW","year":"2008","unstructured":"Ashley WW, Amin-Hanjani S, Alaraj A,  Flow-assisted surgical cerebral revascularization. Neurosurg Focus. 2008;24(2):E20."},{"issue":"3","key":"b11","series-title":"Arch Neurol","first-page":"288","article-title":"Cerebrovascular \u201cmoyamoya\u201d disease. Disease showing abnormal net-like vessels in base of brain","volume":"20","author":"Suzuki J","year":"1969","unstructured":"Suzuki J, Takaku A. Cerebrovascular \u201cmoyamoya\u201d disease. Disease showing abnormal net-like vessels in base of brain. Arch Neurol. 1969;20(3):288\u2013299."},{"issue":"5","key":"b12","series-title":"Stroke","first-page":"604","article-title":"Interobserver agreement for the assessment of handicap in stroke patients","volume":"19","author":"van Swieten JC","year":"1988","unstructured":"van Swieten JC, Koudstaal PJ, Visser MC,  Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988;19(5):604\u2013607."},{"issue":"2","key":"b13","series-title":"Stroke","first-page":"171","article-title":"Course of carotid artery occlusions with impaired cerebrovascular reactivity","volume":"23","author":"Kleiser B","year":"1992","unstructured":"Kleiser B, Widder B. Course of carotid artery occlusions with impaired cerebrovascular reactivity. Stroke. 1992;23(2):171\u2013174."},{"issue":"8","key":"b14","series-title":"Stroke","first-page":"963","article-title":"Noninvasive assessment of CO2-induced cerebral vasomotor response in normal individuals and patients with internal carotid artery occlusions","volume":"19","author":"Ringelstein EB","year":"1988","unstructured":"Ringelstein EB, Sievers C, Ecker S,  Noninvasive assessment of CO2-induced cerebral vasomotor response in normal individuals and patients with internal carotid artery occlusions. Stroke. 1988;19(8):963\u2013969."},{"issue":"3","key":"b15","series-title":"Childs Brain","first-page":"155","article-title":"Moyamoya disease in children and its surgical treatment. Introduction of a new surgical procedure and its follow-up angiograms","volume":"11","author":"Matsushima Y","year":"1984","unstructured":"Matsushima Y, Inaba Y. Moyamoya disease in children and its surgical treatment. Introduction of a new surgical procedure and its follow-up angiograms. Childs Brain. 1984;11(3):155\u2013170."}],"container-title":["Journal of Neurosurgery"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg\/136\/3\/article-p627.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg\/136\/3\/article-p627.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg\/136\/3\/article-p627.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,24]],"date-time":"2026-10-24T01:34:11Z","timestamp":1792805651000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg\/136\/3\/article-p627.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,3,1]]},"references-count":15,"journal-issue":{"issue":"3"},"URL":"https:\/\/doi.org\/10.3171\/2021.2.jns204333","relation":{},"ISSN":["0022-3085","1933-0693"],"issn-type":[{"value":"0022-3085","type":"print"},{"value":"1933-0693","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,3,1]]}}}