Figure 3.

This 42-year-old patient with moyamoya disease had a previous superficial temporal artery−middle cerebral artery (MCA) bypass and presented with new transient ischemic attacks despite previous surgery. The patient underwent an occipital artery (OA)-to-MCA bypass (A) using 1 of the distal OA branches for a direct bypass anastomosis (1 asterisk) and the second branch as an encephaloduroarteriosynangiosis (EDAS) (2 asterisks), as well as the dura for dural inversion technique (D). (B−D) A large, slightly curved polymethyl methacrylate implant was used as raw material for cutting of a specific cranioplasty after outlining the size. In this case the top and bottom portion of the implant were left open to allow enough space for the inflow and outflow artery of the direct bypass and EDAS (E) and was then fixated with titanium screws and plates (F) After only Duragen (Integra Lifesciences, Plainsboro Township, New Jersey, USA) was used to close the dura without compressing the graft. Postoperative transcranioplasty Doppler ultrasound (G), as well as computed tomography angiography in coronal reconstruction (H and I), confirmed bypass patency with inflow OA bypass graft (1 asterisk) exiting the distal EDAS branch (2 asterisks).