Multiterritorial tailored revascularization in adult Moyamoya patients: expanding revascularization approaches to ACA and PCA territories.

Extracranial-intracranial (EC-IC) bypass surgery within the middle cerebral artery (MCA) territory is the gold standard for treating Moyamoya patients once hemodynamic insufficiency is confirmed. Although the anterior (ACA) and posterior cerebral arteries (PCA) are frequently involved, revascularization of these territories is not yet part of the standard treatment regimen; most centers focus exclusively on the MCA. Our approach, however, targets all hemodynamically compromised regions by providing tailored, multi-territorial revascularizations. Indications for additional ACA and/or PCA bypasses are determined by advanced imaging, such as PET-CT or CO2-triggered breath-hold MRI (bh-fMRI), to precisely evaluate cerebrovascular reserve. Here, we present the results of the first large case series focusing on non-MCA revascularization in adult Moyamoya patients. A total of 233 Moyamoya patients were analyzed, of whom 66 (28.3%) underwent 124 non-MCA revascularization procedures. These targeted the ACA (n = 113) and the PCA territories (n = 11). For the ACA, revascularization was predominantly indirect (n = 111 procedures; 98%), with only two direct bypasses (2%). In contrast, PCA revascularization was was more evenly distributed between direct (n = 6, 55%) and indirect (n = 5, 45%) procedures. At the 12-month follow-up, graft patency for direct bypasses and robust collateral development for indirect bypasses were observed in 100% and 93.7% of procedures, respectively. Among the indirect techniques, encephalo-duro-arterio-synangiosis (EDAS) showed the highest angiographic efficacy, followed by encephalo-duro-synangiosis (EDS). Perioperative complications requiring surgical intervention occurred after 5 procedures (4.0%). Over a mean follow-up of 15.2 months, no new strokes were reported. This study comprehensively describes a tailored, multi-territorial revascularization strategy extending beyond the MCA territory in adult patients with Moyamoya disease. ACA and PCA revascularization using direct and indirect techniques is feasible, achieves high rates of angiographic revascularization, and is associated with low perioperative morbidity and favorable follow-up outcomes. These findings support a tailored, multi-territorial approach to hemodynamic compromise beyond the MCA territory.