STA-M3 bypass in moya-moya disease without response a clinical treatment: case report

Case presentation: JA, 31 anos, female, presented at the ER on September 2017, with severe headache and left hemiparesis. CT scan showed ischemic stroke. After standard workup, she received aspirin plus plavix and sent home. Two months later, the patient came back. presenting acute worsening of the strength on her left side, despite best medical therapy. After discharge, she continued on rehabilitation and came to us for further investigation.

Discussion: She presented improvement on her left side hemiparesis, being M3 on upper limb and M4 inferior limb, but was still having episodes of headache, refractory to topiramate and amitriptyline. An angiography that showed a severe stenoses on the M1 segment of the right middle cerebral artery (MCA) associated with Moya-Moya like colateral vessels, resembling the pattern of “puff of smoke”. Perfusion/Difusion MRI showed hypoperfusion in the right cerebral hemisphere. We opted for the surgical treatment, using a direct revascularization technique, the STA-MCA bypass. Surgical technique: the patient is positioned with the head turned to the left side, placed in three-point pin fixation. A handheld standard Doppler ultrasound probe is used to identify the location of the STA and its branches. An incision is made beginning over the zygoma, with a #15 blade. The parietal branch was dissected. A fronto temporal craniotomy was the performed, exposing the opercular portion of the Sylvian fissure. We choose the posterior temporal branch of the inferior trunk of the right MCA. Prepate the recipient vessel for the trapping and anastomoses. Nylon 10–0 suture was used. Total time of temporary clipping was 25 minutes. Patency was tested using intraoperative microdoppler. On first PO day, she referred improvement on left side strength, and no headache. Control AngioCT showed patency of the anastomosis, and no new ischemic areas. She was discharge from the ICU the next day, and sent home the day after. At three-month follow-up, patient presented complete resolution of the neurological deficts and no new episodes of headache. A new perfusion-difusion MRI/A showed improved perfusion and bypass patency.

Final Coments: Direct revascularization is the treatment of choice for patients MMD presenting with ischemic events and the STA-MCA bypass is the procedure of choice.