<%server.execute "isdev.asp"%> Multiple burr hole surgery as a treatment modality for pediatric moyamoya disease Kapu R, Symss NP, Cugati G, Pande A, Vasudevan CM, Ramamurthi R - J Pediatr Neurosci
home : about us : ahead of print : current issue : archives search instructions : subscriptionLogin 
Users online: 139      Small font sizeDefault font sizeIncrease font size Print this page Email this page

  Table of Contents    
Year : 2010  |  Volume : 5  |  Issue : 2  |  Page : 115-120

Multiple burr hole surgery as a treatment modality for pediatric moyamoya disease

Dr. Achanta Lakshmipathi Neurosurgical Centre, Post Graduate Institute of Neurological Surgery, V.H.S Hospital, Chennai, India

Date of Web Publication24-Jan-2011

Correspondence Address:
Nigel Peter Symss
Dr. Achanta Lakshmipathi Neurosurgical Centre, Post Graduate Institute of Neurological Surgery, V.H.S Hospital, Taramani, Chennai - 600113
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1817-1745.76102

Rights and Permissions



Objective : To re-emphasize that indirect revascularization surgery alone, where multiple burr holes and arachnoid openings are made over both cerebral hemispheres, is beneficial in the treatment of moyamoya disease (MMD) in children. Clinical Presentation : We report a 10-year-old boy who presented with complaints of episodic headache for the last 5 years. At the peak of his headache he had visual disturbances and acute onset weakness of left-sided limbs, recovering within a few minutes. He had no focal neurological deficits. Radiological investigations revealed abnormal findings, demonstrating the features of MMD. Surgical Management : He underwent bilateral multiple burr holes, dural and arachnoid opening over the frontal, parietal and temporal regions of each hemisphere. The elevated periosteal flap was placed in contact with the exposed brain through each burr hole. Results : On 6-months follow-up he had only one episode of transient ischemic attack. Postoperative four vessel angiogram demonstrated excellent cerebral revascularization around the burr hole sites, and single photon emission computerized tomography imaging showed hypoperfusion in the right temporo-occipital area suggestive of an old infarct with no other perfusion defect in the rest of the brain parenchyma. Conclusion : In children with MMD this relatively simple surgical technique is effective and safe, and can be used as the only treatment without supplementary revascularization procedures. This procedure can be done in a single stage on both sides and the number of burr holes made over each hemisphere depends on the extent of the disease.

Keywords: Children, indirect revascularization, moyamoya disease, multiple burr holes

How to cite this article:
Kapu R, Symss NP, Cugati G, Pande A, Vasudevan CM, Ramamurthi R. Multiple burr hole surgery as a treatment modality for pediatric moyamoya disease. J Pediatr Neurosci 2010;5:115-20

How to cite this URL:
Kapu R, Symss NP, Cugati G, Pande A, Vasudevan CM, Ramamurthi R. Multiple burr hole surgery as a treatment modality for pediatric moyamoya disease. J Pediatr Neurosci [serial online] 2010 [cited 2023 Dec 5];5:115-20. Available from: https://www.pediatricneurosciences.com/text.asp?2010/5/2/115/76102

   Introduction Top

Moyamoya, meaning a "hazy puff of smoke" in Japanese, was first described by Takeuchi and Shimizu in 1957. [1] It is a chronic, occlusive cerebrovascular disease involving bilateral stenosis or occlusion of the terminal portion of the internal carotid arteries (ICAs) and/or the proximal portions of the anterior cerebral arteries (ACAs), middle cerebral arteries (MCAs) and also the posterior circulation, with an abnormal vascular network at the base of the brain. [2] It is the most common pediatric cerebrovascular disease in Eastern Asia. The clinical presentation of moyamoya disease (MMD) in children usually includes episodes of transient ischemic attacks (TIAs), whereas in adults it is intracranial hemorrhage. [3],[4] Very little is known about the pathogenesis of MMD, and thus curative treatment is still elusive. However, the benefits of revascularization surgery for the ischemic type of MMD are well-established. [5] Several surgical techniques have been described, in which revascularization of the ischemic regions of the brain is attempted. Direct revascularization by superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and indirect methods such as encephalomyosynangiosis (EMS), encephaloduroarteriosynangiosis (EDAS), encephaloduroarteriomyosynangiosis (EDAMS), omental graft have been performed with varying results [6],[7],[8],9[],[10],[11] and a combination of direct and indirect revascularization techniques have also been attempted. [12],[13],[14] Most surgical procedures have aimed at increasing the blood supply primarily to the MCA territory and do not directly benefit the ACA territory. [4],[12],[15],[16]

Clinical presentation

History and presentation : This 10-year-old male child presented with complaints of chronic episodic headache of 5-years duration. Initially, at the peak of his headache he had only weakness of the left upper limb, but as his symptoms progressed he also developed weakness of the left lower limb, with speech and visual disturbances, lasting for a few minutes, followed by complete recovery. Six months prior to his admission he experienced four such episodes per day, with each attack of ischemia lasting for half an hour, followed by complete recovery. There was no history of loss of consciousness, or tonic clonic movements suggestive of a seizure. He was started on anticonvulsants elsewhere. There was no contributory family history.


On examination, the child was conscious, oriented with normal higher intellectual functions, with an intelligent quotient corresponding to his age. His fundi and cranial nerves functions were normal and he had no spinomotor or sensory deficits. His other systemic examination was normal.

Radiological investigations

MRI and CT scan of the brain plain and contrast study showed multiple lacunar infarcts bilaterally [Figure 1]. MR angiogram of the brain showed bilateral stenosis of the ICA distal to the supraclinoid segment and in the posterior circulation [Figure 2]. Digital subtraction four-vessel angiography confirmed bilateral multiple stenosis of the supraclinoid portion of the ICA as well as stems of the ACA and MCAs and the posterior circulation with multiple collaterals arising proximal to the occluded vessels and from the external carotid artery [Figure 3]. Single photon emission computerized tomography (SPECT) images of the brain showed hypoperfusion in the right temporo-occipital area suggestive of an old infarct, with other areas in the brain parenchyma showing normal perfusion [Figure 4]. Adenosine brain SPECT study for evaluation of cerebrovascular reserve in stress and at rest showed a matched perfusion defect in the right temporo-occipital area, with no evidence of a new perfusion defect.
Figure 1 :CT and MRI of the brain showing multiple lacunar infarcts bilaterally.

Click here to view
Figure 2 :MR angiogram of the brain showing bilateral stenosis of the supraclinoid segment of the internal carotid artery and posterior circulation with multiple collaterals.

Click here to view
Figure 3 :Digital subtraction four-vessel angiography showing bilateral multiple areas of stenosis of the supraclinoid portion of the internal carotid artery and the anterior cerebral, middle cerebral arteries and the posterior circulation with multiple collaterals arising proximal to the occluded vessels and from the external carotid artery

Click here to view
Figure 4 :SPECT images of the brain showing hypoperfusion in the right temporo-occipital area suggestive of an old infarct, with other areas in brain parenchyma showing normal perfusion.

Click here to view

Surgical technique

Under general anesthesia, with the patient in supine position, head kept neutral and flexed so that there is good exposure of the calvaria, a bicoronal skin flap was marked. The skin was infiltrated with saline solution in the subgaleal plane as this makes the dissection easier. The skip flap was turned taking care to preserve the galea aponeurotica and scalp blood supply. The periosteum was left attached to the bone, preserving the vessels as this will form the collateral network. Multiple triangular-shaped incisions were made in the periosteum and elevated as small flaps to expose the bone. Five burr holes were made on each side over the frontal, temporal and parietal region. The burr holes are made at each exposed area, using a high-speed drill, about 3 cm apart and 3 cm off the midline to prevent injury to the sagittal sinus. The surgical microscope is then used and the dura was opened through the burr holes, preserving the meningeal arteries. The arachnoid and the pia are then opened just enough to ensure a true opening without causing significant bleeding. Cautery was avoided to preserve the potential anastomotic vessels. The elevated periosteal flaps were laid over the exposed brain through the corresponding burr holes [Figure 5]. The galea was carefully replaced and the scalp was closed in two layers. A compressive head dressing was applied for 5 days. Postoperatively there was no cerebrospinal fluid (CSF) leak. The child is doing well and on 6-months follow-up had one episode of TIA. The postoperative effectiveness of the neovascularization was demonstrated 6 months later by four-vessel angiogram showing excellent cerebral revascularization around the burr hole sites [Figure 6] and SPECT imaging [Figure 7] showed hypoperfusion in the right temporo-occipital area suggestive of an old infarct. There were no other perfusion defects in the rest of the brain parenchyma.
Figure 5 :Intraop pictures showing multiple burr holes drilled over the exposed areas of bone, through small incisions in the perisoteum a) scalp elevation, b) periosteal elevation, c) burr holes and dural opening and d) periosteal flap placed in direct contact with the brain.

Click here to view
Figure 6 :Postoperative four-vessel angiogram done after 6 months showing excellent cerebral revascularization around the burr hole sites.

Click here to view
Figure 7 :Postoperative SPECT imaging showing hypoperfusion in the right temporo-occipital area suggestive of an old infarct. There is evidence of no other perfusion defects seen in the rest of the brain parenchyma.

Click here to view

   Discussion Top

Endo et al., in 1989 demonstrated marked neovascularization across a frontal burr hole, which was used for external drainage of an intraventricular hemorrhage in a child with MMD. [12] On the basis of this, they used additional frontal burr holes with EMS for treating children with MMD, and found better revascularization of the frontal area when compared to EMS alone. Kawaguchi et al, [17] performed the burr hole procedure alone in 1 adult and Sainte-Rose et al, [18] used the similar procedure of indirect revascularization in 14 children. They both demonstrated excellent revascularization without the necessity of a supplementary procedure.

Even though the pathogenesis of MMD remains unclear, there are prominent pathological features noted; proliferation and migration of smooth muscle cells in the intima, leading to intimal thickening with morphological and biochemical alteration of extracellular matrix components such as elastin, collagen and proteoglycans [2],[19] without signs of any inflammation or atheromatous plaque. [1],[20] Junichi et al, [21] found MMD to have a bimodal peak of distribution with the first peak at 10 years and the second in the fourth decade. Clinically our patient had a history of multiple episodes of TIA, with radiological evidence of an area of chronic infarction which categorized him to be in stage IV Matsushima clinical grading of MMD. [9] Based on the angiographical findings, the patient was in Suzuki and Takaku stage IV; he had progressive narrowing of all the main cerebral arteries with almost complete disappearance of the posterior cerebral artery with minimal residual patency of basal vessels and the development of extracranial collateral vessels. [2],[22] SPECT scan is the most commonly used test for evaluation of the hemodynamic changes in MMD and the finding of hypoperfusion generally correlates well with the clinical symptoms. [23] Preoperatively we did an adenosine brain SPECT study for evaluation of cerebrovascular reserve in stress and at rest. Adenosine infusion causes vasodilatation of cerebral arteries and can be used for the investigation of cerebrovascular perfusion capacity in patients with carotid occlusive disease. One advantage in the use of adenosine over acetazolamide is the possibility of interrupting the test with reversal of clinical symptoms or patient discomfort within a few minutes. [24]

The surgical procedures performed for ischaemic type of MMD can be classified into three categories: direct bypass, indirect bypass and combined revascularization techniques. The results obtained have been reported to be excellent, but it is still not clear which technique is the safest and most effective. Direct procedure includes STA-MCA anastomosis. This procedure was first adopted by Yasargil and repeated by Karyenbuhl. [25] The early improvement of cerebral hemodynamics is considered to be one of the major advantages of this procedure. [26],[27] However, the clinical outcome is not different from that achieved by an indirect procedure, thus making its benefit questionable. Also this procedure has limitations in the treatment of pediatric MMD, due to the small size of the donor and recipient vessels and the need for temporary occlusion of blood flow in the cortical artery during anastomosis. [15],[16] The indirect methods described are EMS, EDAS, EDAMS, omental flaps and pial synangiosis [6],[7],[8],[9] and combinations of direct and indirect revascularization surgeries have also been done. [12],[13],[14] The principle of indirect revascularization in patients with MMD is based on the natural ability of collateral vessels to develop in these patients and, that revascularization of the ischemic brain areas can be achieved from an extracranial blood supply. Indirect procedures bring in circulation to the intracranial regions by introducing newly developed vasculature from newly approximated tissues. [28] Although not a specific marker for moyamoya, elevated basic fibroblast growth factor (bFGF) in CSF may serve as a weak predictor of the extent of angiogenesis to be expected in indirect revascularization procedures. [29] Yoshimoto et al, analyzed CSF samples obtained in patients with MMD and found changes in the CSF cytokines that act in an angiogenic manner. [30]

Based on the child's clinical and radiological findings we decided to do an indirect revascularization surgery, by making multiple burr holes and arachnoid openings over both cerebral hemispheres. Five burr holes were made in the frontotemporoparietal area of each hemisphere, as the child had symptoms of TIA, causing leg and hand weakness, with visual disturbances. The number of burr holes made depends on the site and extent of the disease. Sainte-Rose et al, [18] from their study have demonstrated an early improvement in cerebral perfusion following placement of multiple burr holes and use this technique in all patients with MMD.

In children with MMD undergoing indirect revascularization techniques, or combined procedures, the extent of revascularization is dependent on the area and size of contact between the extracranial tissue and the brain, and Houkin et al, conclude that as much brain as possible be exposed and the external tissues be applied as widely as possible. [13] STA-MCA and EMS procedures improve symptoms mostly related to the MCA territory. They did not improve symptoms of TIA with leg weakness, abnormal cognition, and visual field defects due to ischemia in the areas supplied mainly by the ACA and posterior cerebral artery. [6],[31],[32] Also, it is well known that MMD in children is dynamic and progressive, [3] thus deterioration of blood flow in the ACA territory can progress despite good collateral formation in the MCA territory.

   Conclusion Top

This technique described can be performed in a single stage, on both sides by using a bicoronal flap, where multiple burr holes can be placed over the whole hemisphere where necessary. The procedure is short and safe, with excellent revascularization of most of the cortex underlying the burr holes, and additional revascularization surgeries are not required. The duration is short-making it an option in high-risk cases.

   References Top

1.Fukui M. Current state of study on moyamoya disease in Japan. Surg Neurol 1997;47:138-43.   Back to cited text no. 1
2.Suzuki J, Takaku A. Cerebravascular "moyamoya" disease: Showing as normal net-like vesels in the base of the brain. Arch Neurol 1969;20:288-99.   Back to cited text no. 2
3.Suzuki R, Kodama N. Moyamoya disease: A review. Stroke 1983;14:104-9.  Back to cited text no. 3
4.Ueki K, Meyer FB, Mellinger JF. Moyamoya disease: The disorder and surgical treatment. Mayo Clin Proc 1994;69:749-57.  Back to cited text no. 4
5.Imaizumi T, Hayashi K, Saito K, Osawa M, Fukuyama Y. Long- term outcomes of Pediatric moyamoya disease monitored to adulthood. Pediatr Neurol 1998;18:321-5.  Back to cited text no. 5
6.Adelson PD, Scott RM. Pial synagiosis for moyamoya syndrome in children. Pediatr Neurosurg 1995;23:26-33.  Back to cited text no. 6
7.Fujitha K, Tamaki N, Matsumoto S. Surgical treatment of moyamoya disease in children: Which is more effective procedure, EDAS or EMS? Childs Nerv Syst 1986;2:134-8.  Back to cited text no. 7
8.Matsushima T, Fukui M, Kitamura K, Hasuo K, Kuwabara Y, Kurokawa T. Encephalo-duro-arterio-synangiosis in children with moyamoya disease. Acta Neurochir (Wien) 1990;104:96-102.   Back to cited text no. 8
9.Matsushima T, Inoue TK, Suzuki SO, Inoue T, Ikezaki K, Fukui M, et al. Surgical techniques and the results of a fronto-temporo-parietal combined indirect bypass procedure for children with moyamoya disease: A comparison with the results of encephalo-duro arterio-synangiosis alone. Clin Neurol Neurosurg 1997;99:123-7.  Back to cited text no. 9
10.Matsushima Y, Fukai N, Tanaka K, Tsuruoka S, Inaba Y, Aoyagi M, et al. A new surgical treatment of moyamoya disease in children: A preliminary report. Surg Neurol 1981;15:313-20.  Back to cited text no. 10
11.Matsushima Y, Inaba Y. Moyamoya disease in children and its surgical treatment: Introduction of a new surgical procedure and its follow-up angiograms. Childs Brain 1984;11:155-70.  Back to cited text no. 11
12.Endo M, Kawano N, Miyaska Y, Yada K. Cranial burr hole for revasularization in moyamoya disease. J Neurosurg 1989;71:180-5.  Back to cited text no. 12
13.Houkin K, Kamiyama H, Takahashi A, Kuroda S, Abe H. Combined revascularization surgery for childhood moyamoya disease: STA-MCA and encephalo-duro-arterio-myosynangiosis. Childs Nerv Syst 1997;13:24-9.   Back to cited text no. 13
14.Sakamoto T, Kawaguchi M, Kurehara K, Kitaguchi K, Furuya H, Karasawa J. Postoperative neurological deterioration following the revascularization surgery in children with moyamoya disease. J Neurosurg Anesthesiol 1998;10:37-41.   Back to cited text no. 14
15.Iwama T, Hashimoto N, Miyake H, Yonekawa Y. Direct revascularization to the anterior cerebral artery territory in patients with moyamoya disease: Report of five cases. Neurosurgery 1998;42:1157-62.  Back to cited text no. 15
16.Robertson RL, Burrows PE, Barnes PD, Robson CD, Poussaint TY, Scott RM. Angiographic changes after pial synangiosis in childhood moyamoya disease. AJNR Am J Neuroradiol 1997;18:837-45.  Back to cited text no. 16
17.Kawaguchi T, Fujita S, Hosoda K, Shose Y, Hamano S, Iwakura M, et al. Multiple burr hole operation for adult moyamoya disease. J Neurosurg 1996;84:468-76.   Back to cited text no. 17
18.Sainte-Rose C, Oliveira R, Puget S, Beni-Adani L, Boddaert N, Thorne J, et al. Multiple burr hole surgery for the treatment of moyamoya disease in children. J Neurosurg 2006;105:437-43.   Back to cited text no. 18
19.Fukui M, Kano S, Sueiski K, Ilezaki K. Moyamoya disease. Neuropathology 2000;20:S61-4.  Back to cited text no. 19
20.Maki Y, Enomoto T. Moyamoya disease. Childs Nerv Syst 1988;4:204-12.  Back to cited text no. 20
21.Junichi M, Jun O, Takenori Y. Moyamoya disease. In: Barnett H, Mohr J, Bernett M, editors. Stroke: Pathophysiology, diagnosis and management. 3 rd edition. Edinburgh: Churchill Livingstone; 1998. p. 815-31.  Back to cited text no. 21
22.Suzuki J, Takaku A, Kodama N, Sato S. An attempt to treat Cerebravascular "moyamoya" disease in children. Childs Brain 1975;1:193-206.   Back to cited text no. 22
23.Mountz JM, Foster NL, Ackermann RJ, Bluemlein L, Petry NA, Kuhl DE. SPECT imaging of moyamoya disease using 99m Tc-HM-PAO: Comparison with computed tomography findings. J Comput Tomogr 1988;12:247-50.  Back to cited text no. 23
24.Soricelli A, Postiglione A, Cuocolo A, De Chiara S, Ruocco A, Brunetti A, et al. Effect of adenosine on cerebral blood flow as evaluated by single-photon emission computed tomography in normal subjects and in patients with occlusive carotid disease a comparison with acetazolamide. Stroke 1995;26:1572-6.  Back to cited text no. 24
25.Karyenbuhl H. The Moyamoya syndrome and the neurosurgeon. Surg Neurol 1975;4:353-60.  Back to cited text no. 25
26.Houkin K, Ishikawa T, Yoshimoto T, Abe H. Direct and indirect revascularization for moyamoya disease: Surgical techniques and peri-operative complications. Clin Neurol Neurosurg 1997;99:142-5.   Back to cited text no. 26
27.Ishikawa T, Houkin K, Kamiyama H, Abe H. Effects of surgical revascularization on outcome of patients with pediatric moyamoya disease. Stroke 1997;28:1170-3.  Back to cited text no. 27
28.Burke GM, Burke AM, Sherma AK, Hurley MC, Batjer HH, Bendok BR. Moyamoya disease: A summary. Neurosurg Focus 2009;26:E11.  Back to cited text no. 28
29.Malek AM, Connors S, Robertson RL, Folkman J, Scott RM. Elevation of cerebrospinal fluid levels of basic fibroblast growth factor in moyamoya and central nervous system disorders. Pediatr Neurosurg 1997;27:182-9.  Back to cited text no. 29
30.Yoshimoto T, Houkin K, Takahashi A, Abe H. Evaluation of cytokines in cerebrospinal fluid from patients with moyamoya disease. Clin Neurol Neurosurg 1997;99:218-20.  Back to cited text no. 30
31.Matsushima T, Inoue T, Suzuki SO, Fujii K, Fukui M, Hasuo K. Surgical treatment of moyamoya disease in pediatric patients-comparison between the results of indirect and direct revascularization procedures. Neurosurgery 1992;31:401-5.   Back to cited text no. 31
32.Sakamoto H, Kitano S, Yasui T, Komiyama M, Nishikawa M, Iwai Y, et al. Direct extracranial-intracranial bypass for children with moyamoya disease. Clin Neurol Neurosurg 1997;99:128-33.  Back to cited text no. 32


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

This article has been cited by
1 Posterior cerebral territory ischemia in pediatric moyamoya: Surgical techniques and long-term clinical and radiographic outcomes
Alaa Montaser, Ari D. Kappel, Jessica Driscoll, Emily Day, Madeline Karsten, Alfred P. See, Darren B. Orbach, Edward R. Smith
Child's Nervous System. 2023;
[Pubmed] | [DOI]
2 ASL-MRI-guided evaluation of multiple burr hole revascularization surgery in Moyamoya disease
Anders Lewén, Markus Fahlström, Ljubisa Borota, Elna-Marie Larsson, Johan Wikström, Per Enblad
Acta Neurochirurgica. 2023;
[Pubmed] | [DOI]
3 How to reduce the complication rate of multiple burr holes surgery in moyamoya angiopathy
M. Soler-Rico, M. Di Santo, G. Vaz, V. Joris, E. Fomekong, S. Guillaume, M. Van Boven, C. Raftopoulos
Acta Neurochirurgica. 2023;
[Pubmed] | [DOI]
4 The sick(le) brain and spine: neuroimaging findings in paediatric patients with sickle cell disease
V. Sousa Abreu, S. Xavier, M. Santos, R. Lopes da Silva, P. Kjöllerström, C. Conceição
Clinical Radiology. 2023;
[Pubmed] | [DOI]
5 Salvage multiple burr hole surgery in patients with Moyamoya disease: efficacy evaluation using probabilistic independent component analysis of dynamic susceptibility contrast perfusion MRI
Bio Joo, Jinna Kim, Jun Kyu Hwang, Kyu-Won Shim, Seung-Koo Lee
Neuroradiology. 2022;
[Pubmed] | [DOI]
6 Clinical Management of Moyamoya Patients
Isabella Canavero, Ignazio Gaspare Vetrano, Marialuisa Zedde, Rosario Pascarella, Laura Gatti, Francesco Acerbi, Sara Nava, Paolo Ferroli, Eugenio Agostino Parati, Anna Bersano
Journal of Clinical Medicine. 2021; 10(16): 3628
[Pubmed] | [DOI]
7 Long-term clinical and radiographic outcomes after pial pericranial dural revascularization: a hybrid surgical technique for treatment of anterior cerebral territory ischemia in pediatric moyamoya disease
Alaa Montaser, Jessica Driscoll, Hudson Smith, Madeline B. Karsten, Emily Day, Tina Mounlavongsy, Darren B. Orbach, Edward R. Smith
Journal of Neurosurgery: Pediatrics. 2021; 28(3): 351
[Pubmed] | [DOI]
8 Encephaloduroarteriosynangiosis and encephalomyoarteriosynangiosis for treatment of moyamoya syndrome in pediatric patients with sickle cell disease
Christoph J. Griessenauer, Jeffrey D. Lebensburger, Michelle H. Chua, Winfield S. Fisher, Lee Hilliard, Christina J. Bemrich-Stolz, Thomas H. Howard, James M. Johnston
Journal of Neurosurgery: Pediatrics. 2015; 16(1): 64
[Pubmed] | [DOI]
9 Burr holes for moyamoya
Mukerji, N., Steinberg, G.K.
World Neurosurgery. 2014; 81(1): 29-31
10 Vascular collateralization along ventriculoperitoneal shunt catheters in moyamoya disease
Singla, A. and Lin, N. and Ho, A.L. and Scott, R.M. and Smith, E.R.
Journal of Neurosurgery: Pediatrics. 2013; 11(6): 710-712
11 Vascular collateralization along ventriculoperitoneal shunt catheters in moyamoya disease
Amit Singla, Ning Lin, Allen L. Ho, R. Michael Scott, Edward R. Smith
Journal of Neurosurgery: Pediatrics. 2013; 11(6): 710
[Pubmed] | [DOI]
12 Effectiveness of Burr Holes for Indirect Revascularization in Patients with Moyamoya Disease—A Review of the Literature
Nancy McLaughlin,Neil A. Martin
World Neurosurgery. 2013;
[Pubmed] | [DOI]
13 Surgical Outcomes for Moyamoya Angiopathy at Barrow Neurological Institute With Comparison of Adult Indirect Encephaloduroarteriosynangiosis Bypass, Adult Direct Superficial Temporal Artery–to–Middle Cerebral Artery Bypass, and Pediatric Bypass
Adib A. Abla,Gurpreet Gandhoke,Justin C. Clark,Mark E. Oppenlander,Gregory J. Velat,Joseph M. Zabramski,Felipe C. Albuquerque,Peter Nakaji,Robert F. Spetzler,John E. Wanebo
Neurosurgery. 2013; 73(3): 430
[Pubmed] | [DOI]
14 Imaging After Direct and Indirect Extracranial-Intracranial Bypass Surgery
Daniel T. Ginat,Edward R. Smith,Richard L. Robertson,R. Michael Scott,Pamela W. Schaefer
American Journal of Roentgenology. 2013; 201(1): W124
[Pubmed] | [DOI]
15 Observation of indirect neorevascularization after leptomeningeal biopsy in a 34-year-old woman with moyamoya syndrome - Should burr holes be considered as an alternative revascularization technique in younger adults with moyamoya?
Purrucker, J.C. and Rohde, S. and Stampfl, S. and Ringleb, P.A.
Cerebrovascular Diseases. 2012; 33(1): 94-95


Print this article  Email this article
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (2,470 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

    Article Figures

 Article Access Statistics
    PDF Downloaded205    
    Comments [Add]    
    Cited by others 15    

Recommend this journal