The seven cases of the so-called moyamoya disease were treated with superficial temporal-middle cerebral artery (STA-MCA) bypass in the last two years. There were four adults and three children in this study. The follow-up period ranged 2 months to one year and eleven months postoperatively. Five patient had excellent or good results and two had worse. The STA-MCA bypass appears to be effective for so-called moyamoya disease. The multiple anastomosis may be required especially in the juvenile case.

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Since the pathogenesis of so-called moyamoya disease is still unknown, no definitive method of treatment has been established for this condition. The authors report the results of 5 superficial temporalmiddle cerebral artery (STA-MCA) anastomoses, performed on 3 adult cases with so-called moyamoya disease.
The follow-up period ranged from 6 months to 21 months. Excellent results were obtained in two cases, and a fair result in the other.
In all the cases, follow-up angiograms revealed a wide patency of the anastomoses with appreciable increase of natural cerebral vasculature, and disappearance of the abnormal vascular networks (moyamoya vessels) at the base of the brain.
The disappearance of the moyamoya vessels following the surgery supports the theory that the moyamoya vessels are the collaterals which have been developed following occlusion of the major vessels at the base of the brain.
From the therapeutic point of view, it is obvious that the creation of the new collateral by means of STA-MCA anastomosis increases blood supply to the brain. Also, this creation of the new collateral can be expected to decrease chances of hemorrhaging from the moyamoya vessels as the vessels markedly decreased or disappeared following the surgery.

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Disseminated intravascular coagulation (DIC) may play an important role in producing symptoms in many diseases. We operated 72 consecutive patients with cerebrovascular disorders for the past 3 years and 2 cases out of them developed DIC after STA-MCA by-pass surgery. Case 1. This 53-year-old woman with 3 times previous TIA episodes in the past 5 years suddenly developed right hemiparesis. Arteriogram showed a narrowing of branches of the It-MCA. Two days after STA-MCA anastomosis, blood pressure rose progressively to more than 200mm Hg and bleeding diathesis appeared. Wound exploration disclosed subcortical intracerebral hematoma in the temporal lobe. The site of anastomosis was intact and arteries were all patent. The laboratory data indicated an existence of DIC for more several days. Case 2. This 62-year-old man suddenly suffered from right hemiparesis. Arteriogram revealed irregularity and stenosis of the wall of internal carotid artery and branches of It-MCA. The STA-MCA anastomosis was performed. He was uneventful immediately after the surgery, but 6 hours later massive bleeding was suddenly noted in the epidural drain. Only a small subgaleal hematoma was found by wound exploration. Platelet count was noted gradually decreased by repeated tests on the same day, and also other laboratory data indicated a status of DIC. The patient died 3 days after the surgery. First case developed Colitis ulcerosa 14 days after a by-pass surgery. But in the second case, no other basic disorders were noted. Although an etiology of DIC has still been controversial, we suppose that cerebral ischemic lesion per se could be an etiologic factor in DIC.

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Eighty cases underwent the STA-MCA bypass 83 times by one of the authors during the last five years. Some parts of the results have been reported elsewhere. Complications and their countermeasures are now discussed. Patency of the bypass graft has been 83% in the early cases and 100% in the last 20 cases. Overall mortality is 3.6% and morbidity 4.8%.
Two patients died of cerebellar hemorrhage due to a post-operative hypertension above 220 mmHg of systolic pressure. The other died of septicemia following skin flap infection. Deterioration of neurological deficits took place in four cases; two cases of stroke in spite of patent bypass, the other cases of malignant hyperthermia and subdural hematoma respectively. Subdural hematoma complicated in two cases, which include the morbid case mentioned above and the other case recovered from aphasia completely after the removal of the hematoma. Infection was recognized in three cases, which includes the case of septicemia described already and the other two cases with only localized skin flap infection. Marginal skin necrosis treated conservatively without further problems was observed in four cases. Three cases suffered from convulsive seizures postoperatively.
Postoperative hypertension, subdural hematoma and infection seem to be the most important clinical features which would provoke serious neurological deficits and their countermeasures should be performed promptly and efficiently.

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