{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,29]],"date-time":"2026-07-29T00:58:39Z","timestamp":1785286719038,"version":"3.55.0"},"reference-count":16,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"4","license":[{"start":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T00:00:00Z","timestamp":1785110400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2026,7,27]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND<\/jats:title>\n                    <jats:p>Surgical revascularization is the cornerstone of treatment for moyamoya angiopathy (MMA), yet postoperative contralateral progression and the timing of surgery after acute ischemia remain controversial. While current guidelines recommend delaying bypass after a recent ischemic event, rapidly progressive symptoms may necessitate urgent intervention.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>OBSERVATIONS<\/jats:title>\n                    <jats:p>A 26-year-old woman with unilateral MMA underwent a left superficial temporal artery\u2013middle cerebral artery (STA-MCA) bypass for recurrent ischemic events and impaired cerebrovascular reserve. Despite initial improvement and confirmed bypass patency, she developed contralateral ischemic symptoms 3 weeks later, with new right internal carotid artery\u2013MCA stenosis and vessel wall enhancement. CSF analysis revealed herpes simplex virus 2 positivity, and a heterozygous factor V Leiden mutation was identified. Despite antiviral and corticosteroid therapy, ischemic deficits worsened. An emergency right STA-MCA bypass was performed under dual antiplatelet therapy (DAPT), resulting in immediate symptom resolution and sustained graft patency.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>LESSONS<\/jats:title>\n                    <jats:p>MMA may rapidly progress from unilateral to bilateral involvement. When medical therapy fails, urgent revascularization\u2014even under DAPT\u2014can be safe and effective. Vigilant postoperative surveillance and readiness for contralateral bypass are crucial in atypical, rapidly evolving cases.<\/jats:p>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/thejns.org\/doi\/10.3171\/CASE25903\">https:\/\/thejns.org\/doi\/10.3171\/CASE25903<\/jats:ext-link>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/case25903","type":"journal-article","created":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T00:01:20Z","timestamp":1784678480000},"source":"Crossref","is-referenced-by-count":0,"title":["Emergency superficial temporal artery\u2013middle cerebral artery bypass under dual antiplatelet therapy: an extreme salvage procedure for a misleading moyamoya case. Illustrative case"],"prefix":"10.3171","volume":"12","author":[{"given":"Paolo","family":"Ferroli","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Biagia","family":"La Pira","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, ASST Santi Paolo e Carlo, Ospedale S. Carlo Borromeo, Milan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-8797-0618","authenticated-orcid":true,"given":"Edoardo Maria","family":"Barbieri","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan"},{"name":"University of Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marco","family":"Schiariti","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Morgan","family":"Broggi","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3789-957X","authenticated-orcid":true,"given":"Francesco","family":"Restelli","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leonardo","family":"Maresca","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan"},{"name":"University of Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-4309-3222","authenticated-orcid":true,"given":"Luca","family":"Mattioli","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan"},{"name":"University of Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Riccardo","family":"Ciocca","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan"},{"name":"University of Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erica","family":"Boccardi","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan"},{"name":"University of Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michela","family":"Moretti","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Isabella","family":"Canavero","sequence":"additional","affiliation":[{"name":"Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7836-2122","authenticated-orcid":true,"given":"Benedetta","family":"Storti","sequence":"additional","affiliation":[{"name":"Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2370-840X","authenticated-orcid":true,"given":"Irene","family":"Scala","sequence":"additional","affiliation":[{"name":"Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0423-8759","authenticated-orcid":true,"given":"Nicola","family":"Rifino","sequence":"additional","affiliation":[{"name":"Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-3070-3529","authenticated-orcid":true,"given":"Giuseppe","family":"Ganci","sequence":"additional","affiliation":[{"name":"Neurointerventional Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna","family":"Bersano","sequence":"additional","affiliation":[{"name":"Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"1","key":"bib1","series-title":"Eur Stroke J","first-page":"55","article-title":"European Stroke \u00adOrganisation (ESO) guidelines on moyamoya angiopathy endorsed by Vascular European Reference Network (VASCERN)","volume":"8","author":"Bersano","year":"2023","unstructured":"Bersano AKhan NFuentes BEuropean Stroke \u00adOrganisation (ESO) guidelines on moyamoya angiopathy endorsed by Vascular European Reference Network (VASCERN). 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