• Mario Teo, Jeremiah Johnson, and Gary K Steinberg.
• Department of Neurosurgery, Stanford Stroke Center, Stanford University Medical Center, Stanford, California.
• Neurosurgery. 2017 Nov 1; 81 (5): 852-859.

BackgroundRevascularization for moyamoya disease (MMD) effectively prevents future ischemic events. However, small subsets of patients with persistent or new symptoms due to inadequate collateralization require repeat revascularizations.ObjectiveTo investigate the clinical and radiological outcome of repeat revascularization in MMD patients with previous indirect or direct bypasses.MethodsSingle institution, retrospective analysis of a prospective MMD database.ResultsFrom 1991 to 2014, this institution performed 1244 revascularization bypasses (1107 direct, 137 indirect) in 765 patients, of whom 57 were repeat revascularizations (38 indirect, 19 direct bypass). When initially performed at the institution, the repeat revascularization rate was 4% for indirect and 1% for direct bypasses (P = .03). Cohorts with previous indirect vs direct bypass were slightly younger (mean age 23 vs 30 yr), with fewer females (61% vs 84%, P = .08), and a similar mean duration between initial bypass and repeat revascularization (49 vs 47 mo). Both groups had similar repeat revascularization due to transient ischemic attacks (66% vs 63%). One acute graft occlusion in the previous direct bypass group was revised within 1 wk postoperatively. Over 50% of the repeat revascularizations in both groups were direct bypasses; the major difference being that the repeat bypass in the direct group was to augment another vascular territory. At nearly 5 yr mean follow-up, over 80% of patients in both groups are well, free from stroke/transient ischemic attack symptoms, with excellent radiological results.ConclusionRepeat revascularization can safely and effectively prevent future ischemic events. Indirect bypass has a higher rate of repeat revascularization than direct bypass.Copyright © 2017 by the Congress of Neurological Surgeons

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