{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,25]],"date-time":"2026-06-25T13:53:09Z","timestamp":1782395589138,"version":"3.54.5"},"reference-count":63,"publisher":"MDPI AG","issue":"13","license":[{"start":{"date-parts":[[2026,6,25]],"date-time":"2026-06-25T00:00:00Z","timestamp":1782345600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Moyamoya disease is a progressive steno-occlusive cerebrovascular disorder in which cerebral perfusion may become highly dependent on systemic arterial pressure, arterial carbon dioxide tension, and collateral flow. Encephaloduroarteriosynangiosis (EDAS) is an indirect revascularization procedure that promotes neovascularization over weeks to months but does not immediately augment cerebral blood flow intraoperatively. Anesthetic management therefore requires preservation of cerebral oxygen delivery during a period of persistent physiologic vulnerability. This narrative review presents a practical perioperative framework for EDAS anesthesia, emphasizing maintenance of mean arterial pressure near baseline or modestly above baseline, avoidance of hypotension and hypovolemia, normoxia, normothermia, and careful regulation of carbon dioxide. Hyperventilation should be avoided because hypocapnia can reduce cerebral blood flow through vasoconstriction, while excessive hypercapnia may contribute to regional maldistribution or steal physiology. Raw electroencephalography may provide cortical ischemia surveillance where available, whereas somatosensory evoked potentials, motor evoked potentials, near-infrared spectroscopy, and transcranial Doppler should be considered adjunctive and institution-dependent. A structured algorithm that integrates hemodynamics, ventilation, oxygen delivery, anesthetic depth, neuromonitoring, and surgical communication may support the timely recognition and correction of intraoperative hypoperfusion.<\/jats:p>","DOI":"10.3390\/jcm15134954","type":"journal-article","created":{"date-parts":[[2026,6,25]],"date-time":"2026-06-25T12:37:55Z","timestamp":1782391075000},"page":"4954","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Anesthetic Management for Encephaloduroarteriosynangiosis in Moyamoya Disease: A Hemodynamic and Neuromonitoring-Integrated Framework"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8800-7968","authenticated-orcid":false,"given":"Vikas","family":"Chauhan","sequence":"first","affiliation":[{"name":"Department of Anesthesiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,25]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","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":"ref_2","doi-asserted-by":"crossref","first-page":"930","DOI":"10.1016\/j.clineuro.2012.09.020","article-title":"An epidemiological survey of moyamoya disease, unilateral moyamoya disease, and quasi-moyamoya disease in Japan","volume":"115","author":"Hayashi","year":"2013","journal-title":"Clin. Neurol. Neurosurg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1226","DOI":"10.1056\/NEJMra0804622","article-title":"Moyamoya disease and moyamoya syndrome","volume":"360","author":"Scott","year":"2009","journal-title":"N. Engl. J. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1056","DOI":"10.1016\/S1474-4422(08)70240-0","article-title":"Moyamoya disease: Current concepts and future perspectives","volume":"7","author":"Kuroda","year":"2008","journal-title":"Lancet Neurol."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"(2012). Research Committee on the Pathology and Treatment of Spontaneous Occlusion of the Circle of Willis; Health Labour Sciences Research Grant for Research on Measures for Intractable Diseases. Guidelines for diagnosis and treatment of moyamoya disease (spontaneous occlusion of the circle of Willis). Neurol. Med. Chir., 52, 245\u2013266.","DOI":"10.2176\/nmc.52.245"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1973","DOI":"10.1161\/STROKEAHA.119.024689","article-title":"Characteristics of moyamoya disease based on national registry data in Japan","volume":"50","author":"Sato","year":"2019","journal-title":"Stroke"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"229","DOI":"10.1016\/j.braindev.2010.09.003","article-title":"Moyamoya disease in children","volume":"33","author":"Takanashi","year":"2011","journal-title":"Brain Dev."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"2644","DOI":"10.1161\/STROKEAHA.108.189696","article-title":"Management of stroke in infants and children: A scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young","volume":"39","author":"Roach","year":"2008","journal-title":"Stroke"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"321","DOI":"10.1016\/S0887-8994(97)00209-9","article-title":"Long-term outcomes of pediatric moyamoya disease monitored to adulthood","volume":"18","author":"Imaizumi","year":"1998","journal-title":"Pediatr. Neurol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1055\/s-2005-868160","article-title":"Surgical management of moyamoya syndrome","volume":"15","author":"Smith","year":"2005","journal-title":"Skull Base"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1523","DOI":"10.3171\/2015.8.JNS15504","article-title":"Direct versus indirect revascularization procedures for moyamoya disease: A comparative effectiveness study","volume":"126","author":"Macyszyn","year":"2017","journal-title":"J. Neurosurg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"100","DOI":"10.1097\/ANA.0b013e3181f84fac","article-title":"Moyamoya disease: A review of the disease and anesthetic management","volume":"23","author":"Parray","year":"2011","journal-title":"J. Neurosurg. Anesthesiol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1213\/ANE.0000000000000470","article-title":"Anesthetic management of patients undergoing intracranial bypass procedures","volume":"120","author":"Chui","year":"2015","journal-title":"Anesth. Analg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1191","DOI":"10.1111\/pan.14001","article-title":"Moyamoya disease in children and its anesthetic implications: A review","volume":"30","author":"Giustini","year":"2020","journal-title":"Paediatr. Anaesth."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"29","DOI":"10.2176\/nmc.17pt1.29","article-title":"A surgical treatment of \u201cmoyamoya\u201d disease: \u201cEncephalo-myo synangiosis\u201d","volume":"17","author":"Karasawa","year":"1977","journal-title":"Neurol. Med. Chir."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1227\/00006123-199209000-00003","article-title":"Surgical treatment of moyamoya disease in pediatric patients\u2014Comparison between the results of indirect and direct revascularization procedures","volume":"31","author":"Matsushima","year":"1992","journal-title":"Neurosurgery"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"3304","DOI":"10.1161\/STROKEAHA.110.598565","article-title":"Neurosurgical advances in the treatment of moyamoya disease","volume":"42","author":"Pandey","year":"2011","journal-title":"Stroke"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1016\/j.wneu.2016.04.083","article-title":"Perioperative complications and long-term outcomes after bypasses in adults with moyamoya disease: A systematic review and meta-analysis","volume":"92","author":"Sun","year":"2016","journal-title":"World Neurosurg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"269","DOI":"10.1007\/s007010050035","article-title":"Neovascularization (angiogenesis) after revascularization in moyamoya disease: Which technique is most useful for moyamoya disease?","volume":"142","author":"Houkin","year":"2000","journal-title":"Acta Neurochir."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1060","DOI":"10.1213\/00000539-199711000-00018","article-title":"Risk factors for neurologic deterioration after revascularization surgery in patients with moyamoya disease","volume":"85","author":"Sakamoto","year":"1997","journal-title":"Anesth. Analg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"2","DOI":"10.5853\/jos.2015.01627","article-title":"Moyamoya disease: Epidemiology, clinical features, and diagnosis","volume":"18","author":"Kim","year":"2016","journal-title":"J. Stroke"},{"key":"ref_22","first-page":"1120","article-title":"The relevance of hemodynamic factors to perioperative ischemic complications in childhood moyamoya disease","volume":"38","author":"Iwama","year":"1996","journal-title":"Neurosurgery"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1016\/0013-4694(94)00235-D","article-title":"Somatosensory evoked potential spinal cord monitoring reduces neurologic deficits after scoliosis surgery: Results of a large multicenter survey","volume":"96","author":"Nuwer","year":"1995","journal-title":"Electroencephalogr. Clin. Neurophysiol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1097\/00004691-199805000-00005","article-title":"Anesthetic effects on electrophysiologic recordings","volume":"15","author":"Sloan","year":"1998","journal-title":"J. Clin. Neurophysiol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1097\/ACO.0000000000001411","article-title":"Update on the anesthesia management in adult patients with moyamoya disease","volume":"37","author":"Yang","year":"2024","journal-title":"Curr. Opin. Anaesthesiol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1055\/s-0039-1677823","article-title":"Intraoperative anesthesiology management and patient outcomes for surgical revascularization for moyamoya disease: A review and clinical experience","volume":"80","author":"Williams","year":"2019","journal-title":"J. Neurol. Surg. A Cent. Eur. Neurosurg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1152\/physrev.1959.39.2.183","article-title":"Cerebral blood flow and oxygen consumption in man","volume":"39","author":"Lassen","year":"1959","journal-title":"Physiol. Rev."},{"key":"ref_28","first-page":"161","article-title":"Cerebral autoregulation","volume":"2","author":"Paulson","year":"1990","journal-title":"Cerebrovasc. Brain Metab. Rev."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"841","DOI":"10.1113\/jphysiol.2013.268953","article-title":"Integrative regulation of human brain blood flow","volume":"592","author":"Willie","year":"2014","journal-title":"J. Physiol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"272","DOI":"10.1161\/01.STR.21.2.272","article-title":"Cerebral hemodynamic change in the child and the adult with moyamoya disease","volume":"21","author":"Kuwabara","year":"1990","journal-title":"Stroke"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"196","DOI":"10.1097\/ALN.0000000000000506","article-title":"Regulation of cerebral autoregulation by carbon dioxide","volume":"122","author":"Meng","year":"2015","journal-title":"Anesthesiology"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1365","DOI":"10.1097\/00000542-199805000-00029","article-title":"Carbon dioxide and the cerebral circulation","volume":"88","author":"Brian","year":"1998","journal-title":"Anesthesiology"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"484","DOI":"10.1172\/JCI101995","article-title":"The effects of altered arterial tensions of carbon dioxide and oxygen on cerebral blood flow and cerebral oxygen consumption of normal young men","volume":"27","author":"Kety","year":"1948","journal-title":"J. Clin. Investig."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1152\/ajplegacy.1964.206.1.25","article-title":"Arterial PCO2 and cerebral hemodynamics","volume":"206","author":"Reivich","year":"1964","journal-title":"Am. J. Physiol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1097\/00008506-199901000-00005","article-title":"Effect of inhalational anesthesia on cerebral circulation in moyamoya disease","volume":"11","author":"Sato","year":"1999","journal-title":"J. Neurosurg. Anesthesiol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"597","DOI":"10.1097\/00004311-196907030-00009","article-title":"The concept of intracerebral steal","volume":"7","author":"Symon","year":"1969","journal-title":"Int. Anesthesiol. Clin."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"949","DOI":"10.3171\/jns.2000.92.6.0949","article-title":"Intracerebral steal phenomenon associated with global hyperemia in moyamoya disease during revascularization surgery","volume":"92","author":"Oshima","year":"2000","journal-title":"J. Neurosurg."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"3193","DOI":"10.1161\/STROKEAHA.107.513408","article-title":"Moyamoya disease in Europeans","volume":"39","author":"Kraemer","year":"2008","journal-title":"Stroke"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1066","DOI":"10.1213\/00000539-199311000-00034","article-title":"Anesthetic management of children with moyamoya syndrome","volume":"77","author":"Soriano","year":"1993","journal-title":"Anesth. Analg."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"270","DOI":"10.1007\/s003810000407","article-title":"Perioperative management protocols for children with moyamoya disease","volume":"17","author":"Nomura","year":"2001","journal-title":"Child\u2019s Nerv. Syst."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"68","DOI":"10.1007\/s003810050044","article-title":"Perioperative factors related to the development of ischemic complications in patients with moyamoya disease","volume":"13","author":"Sato","year":"1997","journal-title":"Child\u2019s Nerv. Syst."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"S110","DOI":"10.1016\/S0303-8467(97)00068-1","article-title":"Anesthetic management of children with moyamoya disease","volume":"99","author":"Kansha","year":"1997","journal-title":"Clin. Neurol. Neurosurg."},{"key":"ref_43","first-page":"e106827","article-title":"Anesthetic management of a patient with factor XIII deficiency undergoing encephaloduroarteriosynangiosis (EDAS): A case report and literature review","volume":"18","author":"Chauhan","year":"2026","journal-title":"Cureus"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1181","DOI":"10.1007\/s00701-010-0638-1","article-title":"Prognostic factors associated with perioperative ischemic complications in adult-onset moyamoya disease","volume":"152","author":"Hyun","year":"2010","journal-title":"Acta Neurochir."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1007\/BF03007690","article-title":"Moyamoya disease\u2014A review of clinical experience and anaesthetic management","volume":"34","author":"Brown","year":"1987","journal-title":"Can. J. Anaesth."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"204","DOI":"10.1097\/00000542-198302000-00033","article-title":"Moyamoya disease and anesthesia","volume":"58","author":"Sumikawa","year":"1983","journal-title":"Anesthesiology"},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Cheng, Y., Zha, C., Che, X., and Wang, Y. (2025). Inhalational versus intravenous anesthetic for cerebrovascular accident outcomes after surgical revascularization for adult moyamoya disease. BMC Anesthesiol., 25.","DOI":"10.1186\/s12871-025-02958-7"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1097\/ANA.0000000000000955","article-title":"Alternate electrode placements to facilitate frontal electroencephalography monitoring in anesthetized and critically ill patients","volume":"37","author":"Isik","year":"2025","journal-title":"J. Neurosurg. Anesthesiol."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"20","DOI":"10.1227\/ONS.0000000000000009","article-title":"Encephaloduroarteriosynangiosis operative technique and intraoperative anesthesia management: Treatment from both sides of the curtain","volume":"22","author":"Chan","year":"2022","journal-title":"Oper. Neurosurg."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"716","DOI":"10.1097\/00000542-200309000-00029","article-title":"Pharmacologic and physiologic influences affecting sensory evoked potentials: Implications for perioperative monitoring","volume":"99","author":"Banoub","year":"2003","journal-title":"Anesthesiology"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1007\/s10877-006-9033-0","article-title":"Intraoperative motor evoked potential monitoring: Overview and update","volume":"20","author":"MacDonald","year":"2006","journal-title":"J. Clin. Monit. Comput."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"430","DOI":"10.1097\/00004691-200210000-00006","article-title":"Anesthesia for intraoperative neurophysiologic monitoring of the spinal cord","volume":"19","author":"Sloan","year":"2002","journal-title":"J. Clin. Neurophysiol."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"i3","DOI":"10.1093\/bja\/aep299","article-title":"Near-infrared spectroscopy as an index of brain and tissue oxygenation","volume":"103","author":"Murkin","year":"2009","journal-title":"Br. J. Anaesth."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"576","DOI":"10.1097\/ACO.0b013e32833e1536","article-title":"Noninvasive cerebral oximetry: Is there light at the end of the tunnel?","volume":"23","author":"Highton","year":"2010","journal-title":"Curr. Opin. Anaesthesiol."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"834","DOI":"10.1097\/ALN.0b013e31824c00d7","article-title":"Impact of extracranial contamination on regional cerebral oxygen saturation: A comparison of three cerebral oximetry technologies","volume":"116","author":"Davie","year":"2012","journal-title":"Anesthesiology"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"1373","DOI":"10.1213\/ANE.0b013e31826dd6a6","article-title":"Review article: Cerebral near-infrared spectroscopy in adults: A work in progress","volume":"115","author":"Ghosh","year":"2012","journal-title":"Anesth. Analg."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"531","DOI":"10.3171\/2017.10.JNS171749","article-title":"Risk factors for and outcomes of postoperative complications in adult patients with moyamoya disease","volume":"130","author":"Zhao","year":"2019","journal-title":"J. Neurosurg."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"442","DOI":"10.1016\/j.surneu.2008.02.031","article-title":"Incidence and risk factors for symptomatic cerebral hyperperfusion following superficial temporal artery\u2013middle cerebral artery anastomosis in patients with moyamoya disease","volume":"71","author":"Fujimura","year":"2009","journal-title":"Surg. Neurol."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"2066","DOI":"10.1038\/jcbfm.2012.110","article-title":"Cerebral blood flow and metabolism of hyperperfusion after cerebral revascularization in patients with moyamoya disease","volume":"32","author":"Kaku","year":"2012","journal-title":"J. Cereb. Blood Flow Metab."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"73","DOI":"10.3171\/2010.4.PEDS09478","article-title":"Postoperative neurological deterioration in pediatric moyamoya disease: Watershed shift and hyperperfusion","volume":"6","author":"Hayashi","year":"2010","journal-title":"J. Neurosurg. Pediatr."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"2610","DOI":"10.1161\/STROKEAHA.112.654723","article-title":"Predictors and clinical features of postoperative hyperperfusion after surgical revascularization for moyamoya disease: A serial single photon emission CT\/positron emission tomography study","volume":"43","author":"Uchino","year":"2012","journal-title":"Stroke"},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"129","DOI":"10.4097\/kja.24481","article-title":"Post-anesthesia care unit delirium in children with moyamoya disease undergoing indirect revascularization: Incidence and risk factors","volume":"78","author":"Liu","year":"2025","journal-title":"Korean J. Anesthesiol."},{"key":"ref_63","first-page":"582","article-title":"A retrospective review of anesthetic management of EDAS surgery for moyamoya disease with EEG and SSEP neuromonitoring","volume":"134","author":"Chauhan","year":"2022","journal-title":"Anesth. Analg."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/13\/4954\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,25]],"date-time":"2026-06-25T13:37:22Z","timestamp":1782394642000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/13\/4954"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,25]]},"references-count":63,"journal-issue":{"issue":"13","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["jcm15134954"],"URL":"https:\/\/doi.org\/10.3390\/jcm15134954","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,25]]}}}