Neurosurg Focus
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Considering three different bypass procedures now in use, (single indirect nonanastomotic bypass procedure, multiple combined indirect (MCI) nonanastomotic procedure and direct anastomosis), the authors attempted to identify the most appropriate bypass procedure for treating ischemic-type moyamoya disease in children. The authors performed three procedures (the original encephaloduroarteriosynangiosis [EDAS] alone, the frontotemporoparietal combined indirect bypass procedure, and the superficial temporal artery--middle cerebral artery [STA-MCA] anastomosis with encephalomyosynangiosis [EMS]) on 72 hemispheres in 50 patients with pediatric moyamoya disease. Analyses were then performed to compare postoperative collateral vessel formation found on angiograms, complications, and clinical improvements. ⋯ However, the single and multiple combined indirect nonanastomotic bypass procedures were found to be safer than direct anastomosis. Furthermore, the frontotemporoparietal combined indirect bypass procedure caused the formation of collateral circulation not only in the MCA but also in the ACA distribution. Based on analysis of these findings, the authors recommend the MCI procedure as the appropriate surgical procedure in the treatment of children with moyamoya disease, although the best treatment is the STA-MCA anastomosis with EMS when feasible.