ИСТИНА

Introduction We aimed to describe evolution of our surgical approach to cerebral revascularization in pediatric moyamoya disease (MMD). Methods From 2008 to 2019 in our hospital 53 children with MMD had revascularization surgery for MCA territory (86 operated hemispheres). Median age at surgery was 8 years (2-17). We started from direct-only (STA-MCA bypass only - 5 hemispheres) OR indirect-only procedure (EDAS - 27 hemispheres) and moved to combined direct and indirect revascularization for most patients since 2014. Double (16) or triple (1) bypass was increasingly utilized. For indirect procedure, temporal muscle (11-EDAMS; 8-EDMS) in combination with multiple burr holes (15) was used recently to cover more territory than it was allowed by EDAS or EDS previously. Two-tailed Fisher’s exact test was used for group comparisons. Results Functioning direct anastomosis compared to indirect-only procedure was associated with lower rate of immediate postop ischemic events (TIA or stroke 24% vs. 52%; p=0,01) and higher rate of immediate improvement in NIHSS score (17% vs 0% p=0,03). Median follow-up was 22 months (range 3-84, available for 77% of patients). At last visit NIHSS score improved in 100% after direct in 71% after combined and in 50% after indirect procedure. Angiography showed extensive synangiosis formation in 92% after indirect-only and in 67% after combined procedure. Direct bypass patency was confirmed in all cases after direct and in 94% after combined procedure. ASL MRI perfusion improved in 63% after indirect and in 81% after combined procedure. Conclusion Combined procedure compared to single indirect synangiosis provides better protection from perioperative ischemic events and sometimes gives advantage of immediate improvement. Broad indirect augmentation advantageous in the follow up, although not in every patient. Direct bypass as single procedure is successful in selected cases but may be not adequate for small children or advanced disease with compromised cortical collaterals.