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| IJCEM Copyright © 2008-All rights reserved. Published by e-Century Publishing Corporation, Madison, WI 53711 |
Int J Clin Exp Med 2013;6(3):231-238
Case Report
Perioperative care of the pediatric patient for pial synangiosis surgery
Matthew DiGiusto, Tarun Bhalla, Ronald Grondin, Joseph D Tobias
The Ohio State School of Medicine, Columbus, Ohio; Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital
and the Ohio State University, Columbus, Ohio; Department of Neurosurgery, Nationwide Children’s Hospital, Columbus, Ohio
Received January 11, 2013; Accepted February 17, 2013; Epub March 21, 2013; Published March 31, 2013
Abstract: Moyamoya disease (MMD) is a cerebrovascular occlusive disorder which causes recurrent strokes and transient ischemic
attacks in children. The arteriopathy of MMD targets the internal carotid arteries (ICA) and their branches resulting in ischemia of the ICA
circulation. Small perforator branches of the ICA dilate to provide collateral perfusion to ischemic areas. This small vessel dilatation
creates the characteristic angiographic appearance that gives the disease its name (“moyamoya” after the Japanese expression for
“something hazy just like a puff of cigarette smoke drifting in the air”). Best medical management involves the prevention of
thromboembolic events with antiplatelet agents, maintaining adequate hydration, and avoidance of hyperventilation which can
contribute to cerebral vasoconstriction. Presently there are no definitive medical options to halt or correct the process of MMD. Surgical
procedures include both direct and indirect revascularization. Direct revascularization involves anastomosis of a branch of the external
carotid artery to a branch of the internal carotid artery (STA-MCA bipass). However, indirect procedures are often chosen in the pediatric
population due to the technical difficulty of direct procedures related to small diameter blood vessels. Indirect procedures rely on
neovascularization, so the increase in cerebral blood flow is delayed beyond the immediate postoperative period. One such indirect
procedure is pial synangiosis, which involves suturing the adventitia of the superficial temporal artery to the pial surface of the cerebral
cortex after opening of the arachnoid. The authors present two pediatric patients who required anesthetic care for pial synangiosis
surgery. The perioperative care of such patients is reviewed and suggestions presented for the intraoperative anesthetic management.
(IJCEM1301006).
Keywords: Perioperative care, pediatric patient, pial synangiosis surgery, Moyamoya disease
Address correspondence to: Dr. Joseph D Tobias, Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital,
700 Chil-dren’s Drive, Columbus, Ohio 43205. Phone: 614-722-4200; Fax: 614-722-4203; E-mail: Joseph.
Tobias@Nationwidechildrens.org
Case Report
Perioperative care of the pediatric patient for pial synangiosis surgery
Matthew DiGiusto, Tarun Bhalla, Ronald Grondin, Joseph D Tobias
The Ohio State School of Medicine, Columbus, Ohio; Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital
and the Ohio State University, Columbus, Ohio; Department of Neurosurgery, Nationwide Children’s Hospital, Columbus, Ohio
Received January 11, 2013; Accepted February 17, 2013; Epub March 21, 2013; Published March 31, 2013
Abstract: Moyamoya disease (MMD) is a cerebrovascular occlusive disorder which causes recurrent strokes and transient ischemic
attacks in children. The arteriopathy of MMD targets the internal carotid arteries (ICA) and their branches resulting in ischemia of the ICA
circulation. Small perforator branches of the ICA dilate to provide collateral perfusion to ischemic areas. This small vessel dilatation
creates the characteristic angiographic appearance that gives the disease its name (“moyamoya” after the Japanese expression for
“something hazy just like a puff of cigarette smoke drifting in the air”). Best medical management involves the prevention of
thromboembolic events with antiplatelet agents, maintaining adequate hydration, and avoidance of hyperventilation which can
contribute to cerebral vasoconstriction. Presently there are no definitive medical options to halt or correct the process of MMD. Surgical
procedures include both direct and indirect revascularization. Direct revascularization involves anastomosis of a branch of the external
carotid artery to a branch of the internal carotid artery (STA-MCA bipass). However, indirect procedures are often chosen in the pediatric
population due to the technical difficulty of direct procedures related to small diameter blood vessels. Indirect procedures rely on
neovascularization, so the increase in cerebral blood flow is delayed beyond the immediate postoperative period. One such indirect
procedure is pial synangiosis, which involves suturing the adventitia of the superficial temporal artery to the pial surface of the cerebral
cortex after opening of the arachnoid. The authors present two pediatric patients who required anesthetic care for pial synangiosis
surgery. The perioperative care of such patients is reviewed and suggestions presented for the intraoperative anesthetic management.
(IJCEM1301006).
Keywords: Perioperative care, pediatric patient, pial synangiosis surgery, Moyamoya disease
Address correspondence to: Dr. Joseph D Tobias, Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital,
700 Chil-dren’s Drive, Columbus, Ohio 43205. Phone: 614-722-4200; Fax: 614-722-4203; E-mail: Joseph.
Tobias@Nationwidechildrens.org
