Hybrid surgical and endovascular approach for bilateral symptomatic moyamoya disease: a single-center preliminary experience.

BACKGROUND

Bilateral ischemic manifestations in Moyamoya disease (MMD) pose substantial therapeutic challenges, particularly in cases characterized by heterogeneous cerebrovascular involvement where one hemisphere presents with complete occlusion while the contralateral side exhibits severe stenosis. Contemporary treatment paradigms frequently prove inadequate in addressing this complex clinical scenario, often failing to achieve optimal revascularization outcomes and long-term symptom management.

OBJECTIVE

To perform a preliminary evaluation of the efficacy and safety of a hybrid surgical strategy in adults with bilateral ischemic MMD.

METHODS

Eight adult patients (mean age 39±12.2 years) were treated. The occluded hemisphere underwent direct/combined bypass, while the stenotic side received endovascular balloon angioplasty. Perioperative imaging (CT/MR/ultrasound) and clinical/magnetic resonance angiography (MRA) follow-ups were performed.

RESULTS

The surgical success rate was 100%. One patient required emergency stenting for an acute dissection post-angioplasty but recovered well. No other perioperative infarctions occurred (one case of delayed occlusion on the expanded side with new infarction). During follow-up, one patient developed ischemic symptoms with stenosis progression on the angioplasty side, necessitating subsequent bypass. The remaining six patients remained symptom-free. Postoperative digital subtraction angiography (DSA) in four patients confirmed excellent revascularization (Grade A/B) without worsening stenosis.

CONCLUSION

A hybrid surgical approach combining bypass surgery and balloon angioplasty may offer a viable treatment option for bilateral MMD.