We present an indirect revascularization technique using the dural arterial supply as the donor vessels. At surgery, the dura near the anterior and posterior branches of the middle meningeal artery was split into outer and inner layers, and the split surfaces of the outer layers were attached to the cortical surface of the frontal and parieto-occipital regions (Split duroencephalosynangiosis (Split DES)).
This procedure, combined with encephalo-duro-arterio-synangiosis (EDAS), was applied to 27 hemispheres in 19 patients with pediatric moyamoya disease (mean age, 6 years). All the patients were symptom free by 1.5 years after surgery. Postoperative superselective angiograms of the middle meningeal artery demonstrated effective cortical revascularization through the dural arteries in all cases.
Comparison of the sequential angiographic changes between EDAS and Split DES showed that the revascularization occurred as early as 2 weeks postoperatively with the split DES. The Split DES described here is a useful addition to indirect revascularization techniques, allowing extension of the area of revascularization.
