Value of Burr-Hole Surgery as an Adjunct to Encephaloduroarteriosynangiosis in Treatment of Adult Moyamoya Disease: A Case Series

BACKGROUND: Using a single indirect revascularization technique in adult patients with moyamoya disease has been associated with inconsistent outcomes. Herein, we aimed to describe treatment outcomes following combined encephaloduroarteriosynangiosis plus burr-hole surgery (BHS) in adult moyamoya disease. METHODS: Encephaloduroarteriosynangiosis combined with 1 anterior and 1 posterior burr hole per hemisphere was performed in 16 adults with moyamoya disease who presented to our center between 2013 and 2019. Patients were followed with clinical reassessments and cerebral angiograms to evaluate for neovascularization. RESULTS: Combined encephaloduroarteriosynangiosis and BHS procedures were performed on 24 hemispheres in 16 patients. Follow-up ranged from 9 to 57 months, during which no new ischemic or hemorrhagic events, perioperative or long-term complications, or deterioration of symptoms was observed. Follow-up angiography showed evidence of additional neovascularization provided by the burr holes in 18 of the 24 hemispheres. Of 9 hemispheres with poor revascularization response to encephaloduroarteriosynangiosis, 5 achieved neovascularization at the burr-hole sites. Older age, smoking, and cerebral infarction or hemorrhage on preoperative magnetic resonance imaging tended to correlate with absence of neovascularization following BHS. CONCLUSIONS: BHS is a simple and safe procedure that can be done simultaneously with other indirect or direct revascularization procedures. It can provide additional neovascularization even in patients unresponsive to encephaloduroarteriosynangiosis (EDAS) and can be tailored to improve the blood flow in any vascular territory that may not be properly covered by standard revascularization procedures. We find value in adding BHS as an adjunct to other indirect or direct revascularization techniques such as encephaloduroarteriosynangiosis for treatment of adult moyamoya disease.