Revascularization procedure
Our protocol for screening, medical management, and surgical management of patients with SCD and MMS has been described previously.2 Indications for surgery include recent stroke or transient ischemic attack (TIA) in the same distribution as cerebral arterial stenosis with the presence of moyamoya collaterals. Patients with remote or asymptomatic strokes generally undergo a physiologic cerebral flow study, such as single-photon emission computed tomography, followed by a similar study with acetazolamide. Following the administration of acetazolamide, if an area of hypoperfusion is found concordant with a stenosed cerebral artery, then revascularization surgery is generally recommended. In general, indirect revascularization procedures such as encephaloduro-arteriosynangiosis are performed; occasionally, direct superficial temporal artery to middle cerebral artery anastomosis has been performed, per surgeon’s preference.