{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,20]],"date-time":"2025-10-20T10:28:16Z","timestamp":1760956096663,"version":"3.41.2"},"reference-count":27,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2021,6,29]],"date-time":"2021-06-29T00:00:00Z","timestamp":1624924800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Neurol."],"abstract":"<jats:p><jats:bold>Objectives:<\/jats:bold> Moyamoya vasculopathy (MMV) is a rare stenoocclusive cerebrovascular disease associated with increased risk of ischemic and hemorrhagic stroke, which can be treated using surgical revascularization techniques. Despite well-established neurosurgical procedures performed in experienced centers, bypass failure associated with neurological symptoms can occur. The current study therefore aims at characterizing the cases of bypass failure and repeat revascularization at a single center.<\/jats:p><jats:p><jats:bold>Methods:<\/jats:bold> A single-center retrospective analysis of all patients treated with revascularization surgery for MMV between January 2007 and December 2019 was performed. Angiographic data, cerebral blood flow analysis [H<jats:sub>2<\/jats:sub>O PET or single-photon emission CT (SPECT)], MRI, and clinical\/operative data including follow-up assessments were reviewed.<\/jats:p><jats:p><jats:bold>Results:<\/jats:bold> We identified 308 MMV patients with 405 surgically treated hemispheres. Of the 405 hemispheres treated, 15 patients (3.7%) underwent repeat revascularization (median age 38, time to repeat revascularization in 60% of patients was within 1 year of first surgery). The most common cause of repeat revascularization was a symptomatic bypass occlusion (80%). New ischemic lesions were found in 13% of patients prior to repeat revascularization. Persistence of reduced or progressive worsening of cerebrovascular reserve capacity (CVRC) compared with preoperative status was observed in 85% of repeat revascularization cases. Intermediate-flow bypass using a radial artery graft was most commonly used for repeat revascularization (60%) followed by re-superficial temporal artery to middle cerebral artery (re-STA-MCA) bypass (26%). High-flow bypass using a saphenous vein graft and using an occipital artery to MCA bypass was each used once. Following repeat revascularization, no new ischemic events were recorded.<\/jats:p><jats:p><jats:bold>Conclusion:<\/jats:bold> Overall, repeat revascularization is needed only in a small percentage of the cases in MMV. A rescue surgery should be considered in those with neurological symptoms and decreased CVRC. Intermediate-flow bypass using a radial artery graft is a reliable technique for patients requiring repeat revascularization. Based on our institutional experience, we propose an algorithm for guiding the decision process in cases of bypass failure.<\/jats:p>","DOI":"10.3389\/fneur.2021.652967","type":"journal-article","created":{"date-parts":[[2021,6,29]],"date-time":"2021-06-29T04:40:46Z","timestamp":1624941646000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":3,"title":["Surgical Management of Failed Revascularization in Moyamoya Vasculopathy"],"prefix":"10.3389","volume":"12","author":[{"given":"Kristin","family":"Lucia","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"G\u00fcliz","family":"Acker","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nicolas","family":"Schlinkmann","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stefan","family":"Georgiev","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Peter","family":"Vajkoczy","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2021,6,29]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"288","DOI":"10.1001\/archneur.1969.00480090076012","article-title":"Cerebrovascular \u201cmoyamoya\u201d disease. disease showing abnormal net-like vessels in base of brain","volume":"20","author":"Suzuki","year":"1969","journal-title":"Arch Neurol."},{"key":"B2","doi-asserted-by":"publisher","first-page":"245","DOI":"10.2176\/nmc.52.245","article-title":"Guidelines for diagnosis and treatment of moyamoya disease (spontaneous occlusion of the circle of Willis)","volume":"52","author":"Nobuo","year":"2012","journal-title":"Neurol Med Chir"},{"key":"B3","doi-asserted-by":"publisher","first-page":"1012","DOI":"10.1111\/ene.12702","article-title":"Distinct clinical and radiographic characteristics of moyamoya disease amongst European Caucasians","volume":"22","author":"Acker","year":"2015","journal-title":"Eur J Neurol."},{"key":"B4","doi-asserted-by":"publisher","first-page":"793","DOI":"10.3171\/2016.11.JNS161688","article-title":"Meta-analysis of the surgical outcomes of symptomatic moyamoya disease in adults","volume":"128","author":"Jeon","year":"2018","journal-title":"J Neurosurg."},{"key":"B5","doi-asserted-by":"publisher","first-page":"1430","DOI":"10.1161\/STROKEAHA.106.478297","article-title":"Radiological findings, clinical course, and outcome in asymptomatic moyamoya disease: results of multicenter survey in Japan","volume":"38","author":"Kuroda","year":"2007","journal-title":"Stroke."},{"key":"B6","doi-asserted-by":"publisher","first-page":"361","DOI":"10.1159\/000330351","article-title":"Characterization of direct and indirect cerebral revascularization for the treatment of European patients with moyamoya disease","volume":"32","author":"Czabanka","year":"2011","journal-title":"Cerebrovasc Dis."},{"key":"B7","doi-asserted-by":"publisher","first-page":"273","DOI":"10.1016\/j.wneu.2016.07.009","article-title":"Direct bypass versus indirect bypass in adult moyamoya angiopathy with symptoms or hemodynamic instability: a meta-analysis of comparative studies","volume":"94","author":"Kim","year":"2016","journal-title":"World Neurosurg."},{"key":"B8","doi-asserted-by":"publisher","first-page":"e2218","DOI":"10.1097\/MD.0000000000002218","article-title":"The efficacy of surgical treatment for the secondary prevention of stroke in symptomatic moyamoya disease: a meta-analysis","volume":"94","author":"Qian","year":"2015","journal-title":"Medicine."},{"key":"B9","doi-asserted-by":"publisher","first-page":"354","DOI":"10.1016\/j.wneu.2019.04.062","article-title":"Meta-analysis of prognosis of different treatments for symptomatic moyamoya disease","volume":"127","author":"Li","year":"2019","journal-title":"World Neurosurg."},{"key":"B10","doi-asserted-by":"publisher","first-page":"927","DOI":"10.3171\/2009.4.JNS081649","article-title":"Clinical outcome after 450 revascularization procedures for moyamoya disease. clinical article","volume":"111","author":"Guzman","year":"2009","journal-title":"J Neurosurg."},{"key":"B11","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1016\/j.wneu.2015.08.037","article-title":"Radial artery grafts as rescue strategy for patients with moyamoya disease for whom conventional revascularization failed","volume":"85","author":"Hori","year":"2016","journal-title":"World Neurosurg."},{"key":"B12","doi-asserted-by":"publisher","first-page":"E3","DOI":"10.3171\/2009.01.FOCUS08296","article-title":"The contribution of imaging in diagnosis, preoperative assessment, and follow-up of moyamoya disease: a review","volume":"26","author":"Bacigaluppi","year":"2009","journal-title":"Neurosurg Focus."},{"key":"B13","doi-asserted-by":"publisher","first-page":"E195","DOI":"10.1227\/01.NEU.0000336311.60660.26","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","journal-title":"Neurosurgery."},{"key":"B14","doi-asserted-by":"publisher","first-page":"852","DOI":"10.1093\/neuros\/nyx122","article-title":"Strategies for and outcome of repeat revascularization surgery for moyamoya disease: an american institutional series","volume":"81","author":"Teo","year":"2017","journal-title":"Neurosurgery."},{"key":"B15","doi-asserted-by":"publisher","first-page":"41","DOI":"10.1159\/000326077","article-title":"Proposal for a new grading of Moyamoya disease in adult patients","volume":"32","author":"Czabanka","year":"2011","journal-title":"Cerebrovasc Dis."},{"key":"B16","doi-asserted-by":"publisher","first-page":"962","DOI":"10.1227\/NEU.0000000000000139","article-title":"Combined direct and indirect bypass for moyamoya: quantitative assessment of direct bypass flow over time","volume":"73","author":"Amin-Hanjani","year":"2013","journal-title":"Neurosurgery."},{"key":"B17","doi-asserted-by":"publisher","first-page":"938","DOI":"10.1007\/BF01411282","article-title":"Long-term evaluation of EC-IC bypass patency","volume":"138","author":"Schick","year":"1996","journal-title":"Acta Neurochir."},{"key":"B18","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1080\/01616412.1983.11739637","article-title":"Neurosurgical extracranial-intracranial bypass for stroke: with 400 cases","volume":"5","author":"Chater","year":"1983","journal-title":"Neurol Res"},{"key":"B19","doi-asserted-by":"publisher","first-page":"313","DOI":"10.3171\/jns.1976.44.3.0313","article-title":"Clinical experience with extra-intracranial arterial anastomosis in 65 cases","volume":"44","author":"Gratzl","year":"1976","journal-title":"J Neurosurg."},{"key":"B20","doi-asserted-by":"publisher","first-page":"46","DOI":"10.3171\/jns.1988.69.1.0046","article-title":"Superficial temporal-middle cerebral artery bypass: clinical pre- and postoperative angiographic correlation","volume":"69","author":"Jack","year":"1988","journal-title":"J Neurosurg."},{"key":"B21","doi-asserted-by":"publisher","first-page":"376","DOI":"10.1001\/jama.241.4.376","article-title":"Microsurgical treatment of transient cerebral ischemia. preliminary results in 50 patients","volume":"241","author":"Samson","year":"1979","journal-title":"JAMA."},{"key":"B22","doi-asserted-by":"publisher","first-page":"230","DOI":"10.1016\/S0025-6196(12)60315-2","article-title":"Results, complications, and follow-up of 415 bypass operations for occlusive disease of the carotid system","volume":"60","author":"Sundt","year":"1985","journal-title":"Mayo Clin Proc."},{"key":"B23","doi-asserted-by":"publisher","first-page":"464","DOI":"10.1159\/000448812","article-title":"Characterization of clinical and radiological features of quasi-moyamoya disease among European caucasians including surgical treatment and outcome","volume":"42","author":"Acker","year":"2016","journal-title":"Cerebrovasc Dis."},{"key":"B24","doi-asserted-by":"publisher","first-page":"1421","DOI":"10.1007\/s00415-019-09277-1","article-title":"Clinical presentation of Moyamoya angiopathy in Europeans: experiences from Germany with 200 patients","volume":"266","author":"Kraemer","year":"2019","journal-title":"J Neurol."},{"key":"B25","doi-asserted-by":"publisher","first-page":"986","DOI":"10.1093\/neuros\/nyx140","article-title":"Berlin grading system can stratify the onset and predict perioperative complications in adult moyamoya disease","volume":"81","author":"Kashiwazaki","year":"2017","journal-title":"Neurosurgery."},{"key":"B26","doi-asserted-by":"publisher","first-page":"203","DOI":"10.1093\/neuros\/nyz025","article-title":"Validation and application for the Berlin Grading system of moyamoya disease in adult patients","volume":"86","author":"Teo","year":"2020","journal-title":"Neurosurgery."},{"key":"B27","doi-asserted-by":"publisher","first-page":"E18","DOI":"10.3171\/2009.1.FOCUS08303","article-title":"Graft selection in cerebral revascularization","volume":"26","author":"Baaj","year":"2009","journal-title":"Neurosurg Focus"}],"container-title":["Frontiers in Neurology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2021.652967\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,6,29]],"date-time":"2021-06-29T04:40:48Z","timestamp":1624941648000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2021.652967\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,6,29]]},"references-count":27,"alternative-id":["10.3389\/fneur.2021.652967"],"URL":"https:\/\/doi.org\/10.3389\/fneur.2021.652967","relation":{},"ISSN":["1664-2295"],"issn-type":[{"type":"electronic","value":"1664-2295"}],"subject":[],"published":{"date-parts":[[2021,6,29]]},"article-number":"652967"}}