I just have a question about the pros and cons of a Direct and Indirct Bypass.  My wife's surgeon has done a direct bypass on the left side with multiple burr holes.  Before the first surgery the surgeon said that he would do an indirect bypass unless he found that she required blood now, thus going the direct bypass route.  He found that she needed blood flow now, so he performed the direct bypass.  Her next surgery is my concern.  The reason for my concern is, everywhere I have read (not much I might add) the indirect is performed on children or adults that have underdelvelops arteries to bypass from.  The direct bypass is preformed on adults with developed bypass arteries and I saw no mention of needed blood now for the bases of performing it.  Question, has anyone heard anything about indirect and direct bypasses done based on blood flow needs at the time of surgery?  My concern is if the surgeon is doing the best thing for my wife.   My wife has occlusion on the otherside also, but not enough to cause the puff of smoke, so I have a feeling that he will perform the indirect bypass. The surgeon has also mentioned that the indirect bypass is two hours shorter thus less risk under general anesthetic.  Just for everyone's info our surgeon also adds two burr holes (that makes three incisions into the skull), so your talking about a 10 hour surgery.  Thanks

Wayne

Sara,

Thanks for your helpful response and kind words.  I did my homework on this one after the first post, so I hope I can help others with this also.  I first posed the question after a patient under insurance said that he had EDAS (indirect) with burr holes.  One month after surgery he became numb on one side of his hips.  This shows that he is not getting enough blood flow, but it has only been one month and it takes 6 – 12 months to completely form arteries after surgery.  It seems that his condition progressed faster then the formation of the arteries for EDAS (indirect) surgery.  He might have needed the EC-IC (direct) surgery to get blood flow soon.  The doctor made that choice and defiantly had his reason.  I am not a doctor and there are a ton of reasons why a doctor might chose EDAS on a case by case bases (donor artery to small, general anesthetic risk etc). This sent me on a pursuit on what is the best.  I consulted a neurosurgeon in Japan where the most Moya Moya cases are.  He responded.

Generally, there is no gold standard for the bypass surgery in moyamoya disease. Many neurosurgeons in Japan who specialize in this field prefer direct surgery, even if the patients are children. However, some neurosurgeons prefer indirect surgery especially for children. Multiple burr holes surgery is not a major (standard) surgery either for children or adults. The reason why we do not prefer indirect surgery or burr hole surgery is its unpredictability or unreliability to improve the cerebral blood flow.

I do not deny the indirect surgery for adults. The indication of the surgery should be individualized in consideration of the angio-architecture of the brain, symptoms of the patients, and ability of the neurosurgeons.

Japan uses the EC-IC surgery on adults as well as children.  This does not mean that EDAS or Burr holes should not be used and I am going to explain why.

In Japan doctors tend to do what they know works so if one doctor found EC-IC to work all the doctors will do that and not change.  You can bring in newer techniques but they will more then likely stick to the old because it is hard to change. I work in pathology and my company develops equipment to process specimens.  There is a cutting machine that 40 years ago used a sliding technique.  Since then we now use a completely different rotary system.  It is faster, more reliable and less strain on the body.  This technology came in to play 20 years ago.  Everywhere else in the world uses the new system except for Japan.  They have had 20 years to change, but because they are used to doing it that way.  It is not a bad thing at all, there are always disadvantges and advantages in operating in that way.  I am not trying to debate US and Japan surgical procedures either, but if you are going to read or ask advice overseas you must always be aware of that. 

EDAS and burr holes are new techniques and in the States doctors will push and offer these newer techniques faster.  Everyday neurosurgery has something new that doctors seem to embrace quickly.  My doctor has done well over a hundred bypasses for MM.  Two have had strokes after surgery (General Anesthetic draw backs) but everyone is still alive and that puts him way over the average.  He takes cases other neurosurgeons reject because of risk and he pulls them through.  I guess that is why he was ranked number one stroke surgeon in 2003.   I came to the conclusion that I do not know anything and maybe I should listen to him.


Wayne

Wayne -

I enjoy reading your posts - they are intellectual and thought provoking.  Anyway, who is your wife's surgeon again?  I went to Dr. Scott in Boston.  I believe he only does the indirect method.  However, there is a Q&A on the links page and he talked about using a different kind of anesthesia for MM patients.  I was just wondering if you had come across that post and I was wondering what your thoughts were.

-Shari

Hey everyone,

I feel kind of bad for saying that in Japan they tend to stick to just what works the most.  Though true, I guess I should have said, after a test in Japan EDAS was 85% effective and EC-IC is 95% effective, so everyone will perform EC-IC.  As far as doctors that perform EDAS, I think they may have found a technique with EDAS that effectiveness is as high as EC-IC.  I think that is how the doctors in the states that perform EDAS have done just that.  EDAS is also not as risky as EC-IC according to my doctor.  So I looked even further.  I read some where that 75% of MM cases in the U.S. are not primary MM, but rather due to other illnesses.  This will make surgery more complicated and may be the reason EDAS may be a choice of some doctors.  99% of the cases in Japan (several thousand a year) are primary, so they have not run into the complications that we might see in the States, especially with children and those fragile arteries.  Also if it were not for Japan, none of us would have had any of these surgeries available.  Right now they are working on another technique called Omental Transposition.  I could not find anyone working on this in the US, but that does not mean they don’t. 

Japanese have reported sharp increases of primary MM in a Korea and China.  The increases are due to awareness and technology reaching those areas.  Now the belief in Japan is that this is a Mongolian based disease embedded in the chromosomes.    Because of the larger numbers in Asia, I believe if there ever is a treatment besides surgery, it will be found over there.  I read somewhere on this sight about primary MM in Native Americans, which are also a Mongolian based race.  I wonder if any of the 25% of direct MM in US have any Native American in them.  Who knows?

Mary,

thanks for pushing me to actually ask the doctor in Japan.  The doctor responded one hour after I sent the email.  Thank you so much, and yes there is a point that it is out of  your hands and it stinks.

Shari,

I was going to send you an email because, I read one of your previous posts and you wrote you had an EDAS.  My wife’s doctor is Dr. Neil Martin at UCLA.  He is a very good surgeon that will take on the impossible.  I asked him direct about why he prefers EDAS over EC-IC.  He just said it is less risky and he actually knows the EC-IC is the most predictable, but he goes by the condition of the patient.  He said if I see that there are potential problems, he wants to get out as soon as possible.  He said that he might do EC-IC on my wife on the other side, but will play it by ear during the next surgery.  Dr. Scott is great and the best with EDAS that I have seen. Dr. Martin does also burr holes with EDAS or EC-IC.  Have you heard of any other doctors doing that?  Oh by the way, I read the first post by the individual that had EDAS and needed blood flow.  It seems his first surgery was 17 hours, which screams complications.  Now I can see why EDAS was chosen in that case.  Oh and I will read the link about anesthesia.  I will get information from Japan about that also.  Thanks

Lee,

You and you husband are to kind.  Also you are not silly at all and it is great you are reading and preparing. 

mpressions wrote on Aug 24^th, 2004 at 3:24pm:


Could you please provide a link to the information you wrote regarding the 75% rate.  I ask this for two reasons: 
1. Currently, on this board alone, most, but certainly not all, people qualify for primary MM.
2.  Dr. Scott wrote in a paper published Feb 2004 (available on PubMed) that out of "143 patients, 66 showed no predisposing conditions".   That would be approximately 46% that qualify as primary.
3.  Dr. Y. Yonekawa also published a study in 2004 (available on PubMed) that approximately "50% of patients have no known cause."

I really hope that those with MM have doctors that think to ask about their past medical history and run some other tests to see what else, if anything, is going on!  My neuro ran the gamut with tests and every possible question trying to come up with a connection to something else and couldn't. 

In regards to the pros and cons of direct and indirect surgeries, after 2 years of research I have concluded that it basically comes down to the doctor and the particular patient.  Some big conclusion I've come to huh?  HaHa.  I know doctors, in general, prefer the indirect for children because of the small blood vessels/arteries but with adults it seems to be a toss-up.  DJ once posted a link to a paper (which I now can't find for the life of me) that mentioned basically that some doctors prefer the indirect because it's simply easier to do and, like you mentioned, less risky.  But, if immediate blood flow is needed the direct method is the way to go.   After doing even more research tonight, in order to get more recent publications, I still found that *most* doctors still prefer the direct method for adults but that the debate still rages on.   Dr. D.W. Newell (June 2004) wrote that the "STA-MCA is an elegant procedure that was developed and first performed by M. Gazi Yasargil.  It has been used by neurosurgeons for more than 30 years in the management of neurovascular disorders.  Mastering the technique requires not only precise and fine skills but also devoted training in the microsurgery laboratory."   Dr. H. Touho reported in Sept. 2003 of many cases of "failed indirect surgeries which then went on to have direct surgery."   Who knows really what is best.    Perhaps the best thing to do is what you are doing- put the decision into the hands of a surgeon that specializes in and has a lot of experience with MM.  I figure if that surgeon has a wonderful track record with whatever they are doing then run with it.  In other words, if it ain't broke, don't fix it.

I did find information about the omental surgery too.  Dr. H. Touho (PubMed May 2004) writes that the "Intracranial omental transplantation is sometimes indicated for treatment in certain cases.  The surgical process is thought to be complicated and time consuming."   Also, Dr. Steinberg at Stanford also mentions this surgery as an option in a paper he wrote which can be found in the above "Medical Info" links and then go to "Moyamoya surgery".  Although I haven't heard of anyone on this board having had this surgery yet. 

We had talked once about putting up more poll questions on this board in the past.  Two of the questions being:  what type of surgery did you have and do you have any illness and/or any known cause contributing to your MM.  Hopefully Deej can put that up in the near future because it sure would be interesting to see what the average answers are here in our little MM world.

Lisa

Lisa,

     Thank you for sharing your information.  I love you guys.  It's great to be able to come here and chat and share what we are dealing with.  I truly believe that ten years from now, MM will no longer be a 'rare' disease.  

     Also, just to share some tidbits I have found out.  I was explained that Primary MM is in your 'genes'.   My MM has been causing symptoms from birth.  Secondary MM comes from the onset of another disease or situational circumstances.  Some examples I was given are: Sickle Cell Anemia, Lupus, Muscular Dystropy, and the combination of Birth Control and Smoking.   I have also been speaking with a neuro-dialogist from Seoul, South Korea.  He has joined our message board before.  He has been very helpful.  Here is his information:

   

cji
radiologycji@yahoo.co.kr

Don't know if any of this is helpful.  Just sharing what I was told.

Lee

I was 17 when I had the surgery done by doctor Stott, and I am fine..

phil wrote on Aug 26^th, 2004 at 3:12am:


Dr. Scott did my surgery when I was 28 (he sees adults up to age 35).  I don't think it's a matter of artery growth in children versus adults.  I think it's just a matter of which surgery the surgeon has perfected.  By the way, for one side, Dr. Scott actually did a different kind of surgery on me.  I had TMJ surgery on my jaw when I was in high school.  Because of that surgery, the temporal artery, which is the one he uses for the EDAS, was not available on my left side.  Consequently, he had to actually turn a muscle "inside out" for my left side.  Dr. Scott said this is the technique used in Japan.

-Shari

Thank you Jin-Il for you two posts on this one and on the Direct bypass !!!!  Good to have someone from the medical field to join in.

I would like a copy of that article you mentioned...my email is  ck.mcwilliams@cox.net 

I'm wondering since I see one person call the STA-MCA a direct bypass and another person call the STA-MCA an indirect bypass...are there two versions of this surgery?

Cara had the STA-MCA surgery and the EMS surgery on both sides.  I'm trying to decide if they both are indirect or one is direct and the other is indirect.   I realize direct is providing immediate blood flow but also for people who have developed arteries (I know Cara's arteries were very small - 1mm and "toilet paper tissue thin") so that made me think hers was indirect because her arteries were underdeveloped.  He did not know if that bypass would work, or remain open.  They monitor her condition (blood flow) with the doppler stick (I wished I could hear it but being deaf I couldn't)( I finally asked Dr. Meyer's resident Dr. Utter to describe what it sounded like...he said like a heartbeat.  When he said that...I made a wooshing sound in a heartbeat rhythm everyone looked at me surprised that I would make a sound I couldn't hear.   Anyway I seem to be getting more into the details of this MM disorder now that Cara has had it done...wishing I got into it before she had it so I could have asked Dr. Meyer personally !!!

Have a great day !!

CarasMOM

Thanks DJ...you set me straight. 

Thanks    CarasMOM