• Kristine Ravina, Paul E Kim, Robert C Rennert, Erik M Wolfswinkel, Ben A Strickland, Joseph N Carey, and Jonathan J Russin.
• Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
• World Neurosurg. 2019 Dec 1; 132: e259-e273.

BackgroundThe pedicled temporoparietal fascial flap (TPFF) with a direct superficial temporal (STA) artery to middle cerebral artery (MCA) bypass is a novel combined revascularization approach for moyamoya angiopathy (MMA). With this case series, we aim to report the initial experience with pedicled TPFF combined revascularization for MMA treatment.MethodsData from 14 consecutive patients undergoing pedicled TPFF combined revascularization for MMA between May 2016 and December 2018 were retrospectively reviewed. Patients admitted with acute ischemia or a modified Rankin Scale (mRS) score >3 were considered high risk.ResultsMean ± standard deviation age on surgery was 41.9 ± 15.4 years. Three of 14 patients (21.4%) presented with an mRS score >3. Nine of 14 patients (64.3%) presented with ischemic stroke, 4 of whom (44.4%) had acute ischemia. Direct anastomosis patency was confirmed in all cases postoperatively. Mean hospitalization time was 13 ± 9.3 days and mean follow-up time was 14.1 ± 9.3 months. From admission to follow-up, neurologic status improved in 8 patients (57.1%) and stabilized in 6 patients (42.9%). Overall, 11/14 patients (78.6%) achieved good functional outcome (mRS score ≤2). All patients achieved some radiographic collateral development, with 5 (71.5%) graded as Matsushima A and B. Three patients developed new radiographic ischemia and 3 experienced wound complications, all in the high-risk group.ConclusionsThe TPFF combined approach is a viable strategy for revascularization in MMA. This technique may be suboptimal in patients presenting with acute ischemia and/or mRS score >3.Copyright © 2019 Elsevier Inc. All rights reserved.

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