Journal of Clinical Neuroscience 13 (2006) 105108

www.elsevier.com/locate/jocn

Technical note

Indirect revascularisation for paediatric moyamoya disease:

The EDAMS technique
Burak M. Ozgur, Henry E. Aryan *, Michael L. Levy
Division of Neurosurgery, University of California, San Diego, California, USA
Division of Neurosurgery, Childrens Hospital, San Diego, California, USA
Received 18 November 2004; accepted 4 April 2005

Abstract
Moyamoya disease can have devastating eects on paediatric patients as a result of cerebral ischaemia. Several direct and indirect
surgical methods have been devised in order to facilitate revascularisation. Debate has long ensued about which methods are most ecacious and yet safe. The authors describe their experience with a straightforward method for performing the EDAMS (encephaloduro-arterio-myo-synangiosis) technique.
2005 Elsevier Ltd. All rights reserved.
Keywords: Moyamoya; Surgery; Revascularisation; EDAMS; EDAS; Children; Indirect bypass

1. Introduction
Moyamoya disease is a rare condition, rst described by
Takeuchi in the 1950s, as bilateral hypoplasia of the internal carotid arteries.1 Today, moyamoya disease is more
specically characterised by progressive spontaneous
occlusion of the supraclinoid internal carotid arteries, usually bilaterally, with secondary formation of a collateral
capillary network at the base of the brain.
Stroke is rare in the paediatric population. Moyamoya
disease is an important consideration in the dierential
diagnosis of stroke in children. Disease course is extremely
variable: some reports describe rapid progression from
diagnosis to multiple strokes over 12 years, whereas others report symptom-free intervals of up to 8 years. However, some characteristics that signal worse prognosis
include early age of onset, severity of clinical presentation,
rapid progression, and advanced angiographic ndings at
presentation.2
*
Corresponding author. Present address: Division of Neurosurgery,
UCSD Medical Center, 200 W. Arbor Drive, Suite 8893, San Diego, CA
92103-8893, USA. Tel.: +1 619 543 5540; fax: +1 619 543 2769.
E-mail address: hearyan@ucsd.edu (H.E. Aryan).

0967-5868/$ - see front matter 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jocn.2005.04.008

Although, adjuvant medical treatments exist, the mainstay of treatment is surgery. Various techniques aim to
augment the intracranial cortical blood ow using extracranial sources. It is well known that burr holes alone
can lead to revascularisation in patients with moyamoya
disease. Kawaguchi and his associates reported that this
technique was clinically eective.3 The other end of the
surgical spectrum is a supercial temporal artery to middle cerebral artery (STA-MCA) bypass. Although STAMCA anastomosis oers the greatest potential collateral
ow, it has its limitations. The technique was rst used
by Yasargil and was subsequently reported by Krayenbuhl in 1975 to have excellent angiographic and clinical results.4 A signicant limitation to performing a direct
bypass of this sort is the size of the parent and recipient
vessels in children. The diameter of the STA in children
is often 0.5 mm or less, with branches of the MCA even
smaller. Additional issues include the risk of temporary
MCA occlusion potentiating intraoperative stroke or
haemorrhage.
Between these extremes of the surgical spectrum lie
intermediate revascularisation options. EMS (encephalomyosynangiosis) is a technique initially developed by Henschen and initially performed by Karasawa in 1977.5 EDAS

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(encephalo-duro-arterio-synangiosis) was rst reported by

Matsushima in 1981.6 The technique involves suturing a
galeal cu with the intact STA onto the dura, allowing it
to lie adjacent to the cortical surface. On the basis of angiographic evidence, however, this technique has been found
not to produce elaborate postoperative revascularisation.
Pial synangiosis is an additional procedure where the thickened pial arachnoid surface of the brain is incised, and the
STA and its adventitia are directly sutured to the pial surface.7 Excellent results have been reported in 84% of patients who undergo this modication to the EDAS
procedure.8
Our approach is to combine the best elements of all of
these indirect revascularisation techniques into what has
been described as the EDAMS (encephalo-duro-arteriomyo-synangiosis) procedure. Our belief is that risk outweighs benet for a direct bypass in children, relative to
an indirect approach.
2. Technique
The patient is brought into the operating room and general endotracheal intubation is carried out, and intravenous (IV) access is attained. An arterial line is placed, in
preparation for the relatively large amount of blood loss
expected, given that our use of electrocautery is minimised
during this procedure. We generally achieve haemostasis
using oxidised cellulose or gelfoam.
The patient is placed supine with shoulders at one end of
the bed and a shoulder roll under the ipsilateral shoulder
(Fig. 1). The patient should be positioned with the head
turned away from the surgeon. The head is placed in a
doughnut head foam and positioned in a way that allows
the head to be turned approximately 90 (AP diameter parallel to the oor). At this point, the anterior and posterior
branches of the STA are identied with a pencil ultrasound
and marked (Fig. 2). The patient is then prepped and
draped in the usual fashion.
Generally we make the incision similar to a mini-trauma
ap (reverse question mark incision) with its origin approximately 1 cm superior to the root of the zygoma and

Fig. 1. Positioning the patient.

Fig. 2. Mapping the supercial temporal artery and surgical planning.

slightly anterior to the external auditory meatus. The incision curves upward, slightly posterior, and then wraps
anteriorly along the linea temporalis. The incision is made
with a no. 15 blade. In the regions away from the marked
STA branches, surgical scissors are used to perform a supragaleal opening. In this way, the branches of the STA remain adherent to the underlying galea. The scalp ap is
then reected inferiorly and held in place using a moistened
sponge.
Separate incisions using a no. 15 blade are then placed
through the galea, in between the branches of the STA
(Fig. 3). Through these incisions, the underlying temporalis
fascia and muscle is identied. Next, the temporalis muscle
is incised midway between the external auditory meatus
and the lateral canthus with a no. 15 blade (Fig. 4). The
incision is taken down to the underlying bone, and a subsequent incision is made to the most posterior aspect of
the temporalis muscle. The incision is taken superiorly,
leaving an approximately 1 cm cu to the linea temporalis.
Now the temporalis muscle aps can be further freed from

Fig. 3. Galeal incision preserving a cu of galea around the supercial

temporal vessels.

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107

Fig. 6. Cortical exposure and punctate pial incisions into the cortex.
Fig. 4. Temporalis fascia and muscle incisions.

the bony surface and reected inferiorly and apart. Careful

attention must be paid not to transect the suspended
branches of the STA. A burr hole is placed at the most inferior aspect of the exposure. A Freer dissector is used to free
the dura from the overlying bone. Then, utilising a footplate attachment, a small craniotomy is performed and
the bone ap is removed (Fig. 5).
The operating microscope is then brought into the
eld. A large dural window is made in a circular fashion,
initially using a no. 11 blade, then using surgical scissors.
The dural opening is slightly smaller than the craniotomy
ap, and the dura is completely excised. The pial arachnoid surface is then incised sharply using a no. 11 blade
and several punctate incisions overlying and parallel to
the sulci, yet avoiding vascular structures, are made.
We have modied this technique to include a number
of punctures into the actual parenchyma (Fig. 6). The
wound is copiously irrigated with lactated Ringers
solution.

Fig. 5. Burr hole and craniotomy.

Next, the fascial cu of the STA branches are sutured to

the temporalis muscle and surrounding dural edges using
several interrupted 4-0 Neurolon sutures (Fig. 7). The dural
defect is not closed primarily, only sutured to the vascularised ap.
The bone ap is then modied with Leksell rongeurs to
remove bone in order to prevent any compression of the
STA branches that are now draped down into the craniotomy site. The bone is then returned to its normal position and secured in place using titanium plates/screws.
Note that the posterior temporalis muscle/fascia ap is
now intracranial, whereas the anterior ap remains outside the bone ap (Fig. 8). Next, the anterior temporalis
muscle/fascia ap is draped across and sutured posteriorly
over the bone ap in order to preserve cosmesis (Fig. 9).
The wound is again irrigated with copious amounts of
lactated Ringers solution. The scalp ap is then reapproximated to its normal anatomic position. The galeal
layer is closed with several interrupted 4-0 Vicryl sutures.
A 5-0 absorbable chromic suture is used in a running
fashion to reapproximate the skin edges. Skin/tissue glue
is placed over the incision. No additional dressing is applied. The patient is then awoken from anaesthesia and
extubated.

Fig. 7. Arterio-synangiosis. The supercial temporal artery branches with

a galeal cu are sutured to the dural edges and the temporalis muscle ap.

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equivalent results. The senior author of the present paper

has performed the technique presented with its modications for 10 years with good results. Rare complications include intracerebral haemorrhage (from the pial incisions)
and extra-axial haematoma from branches of the STA.
The results and complications have been published previously; this manuscript describes the modied EDAMS
technique.
In our experience, the risks of direct bypass outweigh
the benets in children for this disease process. We have
found our modication of the EDAMS to be successful
in the treatment of the clinical symptoms of moyamoya disease in children. With proper planning and foresight, the
technique can be performed with little risk of morbidity.
Fig. 8. Myo-synangiosis and replacement of the bone ap.

Acknowledgement
The authors would like to acknowledge the artistic contributions of Mr Bill Winn of Atlanta, GA, USA.
References

Fig. 9. Anterior temporalis ap is placed supercial to the bone ap to

preserve cosmesis.

3. Conclusion
Moyamoya disease can be devastating to its victims.
There continues to be erce debate about whether direct
STA-MCA bypass is necessary, or if one of the various
forms of indirect revascularisation techniques leads to

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