Elsevier

World Neurosurgery

Volume 108, December 2017, Pages 994.e1-994.e5
World Neurosurgery

Case Report
Long-Term Patency of Posterior Auricular Artery—Middle Cerebral Artery Bypass for Adult-Onset Moyamoya Disease: Case Report and Review of Literature

https://doi.org/10.1016/j.wneu.2017.09.005Get rights and content

Background

Direct extracranial-intracranial (EC-IC) bypass is one of the fundamental techniques to prevent recurrent stroke in patients with adult-onset ischemic moyamoya disease. When the standard superficial temporal artery (STA) cannot be used for a graft, the posterior auricular artery (PAA) can be a potential surrogate graft.

Case Description

In this article, the authors reported a 34-year-old female patient suffering from ischemic moyamoya disease. To widely revascularize the anterior half of the hemisphere, direct double EC-IC bypass was considered beneficial; however, she had only a single-branched STA but had a prominent branch of the PAA. After discussion, a direct double surgical revascularization was successfully performed using a combination of the STA–middle cerebral artery (MCA) and the PAA-MCA bypass. The authors herein reported the detailed surgical technique of the PAA-MCA bypass with an informative video of the actual procedure. To clearly define the feasibility of PAA-MCA bypass, the authors also conducted a literature review, yielding 3 previous articles describing the bypass.

Conclusion

In conclusion, the PAA becomes a potential donor for EC-IC bypass as long as its diameter is approximately 1.0 mm. Even though the PAA-MCA bypass is not primarily considered in the initial revascularization, it can be useful as a combination bypass with other grafts or as a rescue for recurrent ischemia.

Introduction

Moyamoya disease is a rare cerebrovascular disorder causing progressive occlusion of the internal carotid artery, as well as its main branches including the middle cerebral artery (MCA), resulting in cerebral ischemia, intracranial hemorrhage, and cognitive impairment.1, 2, 3 Direct surgical revascularization is an established treatment to prevent cerebrovascular accidents in adult-onset moyamoya disease.4, 5, 6 Although the superficial temporal artery (STA) is usually considered the best donor artery due to its anatomic location, diameter, and ease of harvest, surgeons sometimes need to use other arterial grafts because of anatomic variations7, 8 or under special circumstances (e.g., when multiple revascularization is necessary or when the STA cannot be used for some reason). The occipital artery can serve as an alternative donor,9, 10, 11 but the procedure tends to be highly invasive with a large skin incision, as well as prolonged operation time. In such cases, the posterior auricular artery (PAA), which is not usually considered as a graft for arterial bypass, can be a surrogate graft owing to its anatomic similarity to the STA if it has a sufficient diameter. In the present article, we report a case illustration of the PAA-MCA bypass with a detailed description of the surgical procedure and review of literature.

Section snippets

History and Examination

The patient was a 34-year-old female complaining of aphasia and memory disturbance caused by cerebral infarction due to moyamoya disease (Figure 1A and C). Her symptoms and the result of 123I-IMP single-photon emission computed tomography (SPECT) were suggestive of a wide area of reduced vascular reserve in the left frontal and temporal lobe (Figure 1B). To widely revascularize the anterior half of the hemisphere, direct double extracranial-intracranial (EC-IC) bypass was considered beneficial.

Review of Literature

We searched articles describing direct surgical revascularization using the posterior auricular artery in the treatment of ischemic stroke and its outcome using PubMed search. Only articles written in English were reviewed.

Only 3 articles reported 5 cases of PAA-MCA bypass with their outcomes to date (Table 1).12, 13, 14 Horiuchi et al12 used the PAA-MCA bypass as the third surgical revascularization for a patient suffering from recurrent ischemic stroke even after successful direct

Discussion

The authors reported the detailed surgical technique of the PAA-MCA bypass with an informative video of the actual procedure. To our knowledge, there are only 3 previous case reports describing PAA-MCA bypass12, 13, 14 and few technical details have been reported to date. The present article thus highlighted the actual surgical procedures and the argument regarding feasibility of the bypass. We could also confirm long-term patency of the PAA-MCA bypass over 2 years. We made a cut in the

Conclusion

The PAA becomes a potential donor for the EC-IC bypass. The PAA-MCA bypass is useful as a combination bypass with other grafts for an initial revascularization or as a rescue bypass for recurrent ischemia.

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Conflict of interest statement: The authors report no conflicts of interest concerning the materials or methods used in this study or the findings specified in this paper.

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