Let's discuss the technique of Encephaloduroarteriosynangiosis, for symptomatic Moya-Moya disease. This is a 32 year-old female, who presented with hemorrhagic form of Moya-Moya disease. You can see the Moya-Moya changes on Preoperative Angiogram. Despite the use of anticoagulation, she remained asymptomatic and also suffered from a spontaneous Intracranial Hemorrhage. She subsequently underwent the procedure prior to consideration of a Synangiosis aspect study with Diamox. Challenge further confirmed Hypoperfusion in the left hemisphere. Let's go ahead and review the nuance of technique. The two branches of the superficial temporal artery were mapped. In this case, the frontal one appear to be more dominant than the prior one. Therefore, the scalpel incision had to be adjusted to preserve the frontal branch. Usually the prior one is more dominant. As you can see, I use this incision incorporating the route of the superficial temporal artery that was harvested and isolated. As you can see here, before dissecting the temporalis muscle, in case the artery, in a piece of glove, cut to the appropriate shape to protect the artery during performance of the craniotomy and drilling. Next, I'll go ahead and dissect the scalp more posteriorly to expose the frontal temporal bone beyond the margins of the superficial temporal artery. Obviously, the front branch was left intact. Temporalis muscle was dissected, just at the location of the root of the superficial temporal artery. So, the artery can be translocated and be placed over the Pial of the Brain without significant torsion of its root. Here's the pre-temporal line. Area of the Tarion is located here. A limited Craniotomy is completed. Again, the root of the artery is always taken into account during performance of the dural incision or the Craniotomy. In this case, they're out of the middle Meningeal artery. It was somewhat unusual. As you can see, the dura was cut around the artery and the dural inversion technique was used to allow the Pial of the Brain to interface with the vascular surface of the Dura, fed by the middle Meningeal Artery. Following the dural invasion technique, the temporalis muscle was laid over the Pial. The artery was released as much as possible, distally, to be able to place the artery or the brain. And interface the artery with the brain, as much as possible, to allow for delayed Pial Vascularization. Here, you can see the artery was very much tethered to the scalp. Next, the piece of Gelfoam sheet was placed onto the space where the surface of the brain was left exposed. Bony opening protected the route of the superficial temporal artery. Following fixation of the bone flap using mini plates, muscle was closed. But again, the superficial temporal artery at its root was carefully accounted for. Micro Doppler probe was used to assure patency of the superficial temporal artery before closure of the scalp. And the Postoperative CT Scan demonstrated no complicating features. Thank you.
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