title: Multiple burr hole surgery as a treatment modality for pediatric moyamoya disease.
abstract: OBJECTIVE
  To re-emphasize that indirect revascularization surgery alone, where multiple burr holes and arachnoid openings are made over both cerebral hemispheres, is beneficial in the treatment of moyamoya disease (MMD) in children.
  
  
  METHODS
  We report a 10-year-old boy who presented with complaints of episodic headache for the last 5 years. At the peak of his headache he had visual disturbances and acute onset weakness of left-sided limbs, recovering within a few minutes. He had no focal neurological deficits. Radiological investigations revealed abnormal findings, demonstrating the features of MMD.
  He underwent bilateral multiple burr holes, dural and arachnoid opening over the frontal, parietal and temporal regions of each hemisphere. The elevated periosteal flap was placed in contact with the exposed brain through each burr hole.
  
  
  RESULTS
  On 6-months follow-up he had only one episode of transient ischemic attack. Postoperative four vessel angiogram demonstrated excellent cerebral revascularization around the burr hole sites, and single photon emission computerized tomography imaging showed hypoperfusion in the right temporo-occipital area suggestive of an old infarct with no other perfusion defect in the rest of the brain parenchyma.
  
  
  CONCLUSIONS
  In children with MMD this relatively simple surgical technique is effective and safe, and can be used as the only treatment without supplementary revascularization procedures. This procedure can be done in a single stage on both sides and the number of burr holes made over each hemisphere depends on the extent of the disease.
authors.affiliation: Dr. Achanta Lakshmipathi Neurosurgical Centre, Post Graduate Institute of Neurological Surgery, V.H.S Hospital, Chennai, India.
authors.forename: Ravindranath
authors.initials: R
authors.lastname: Kapu
authors.forename: Nigel Peter
authors.initials: NP
authors.lastname: Symss
authors.forename: Goutham
authors.initials: G
authors.lastname: Cugati
authors.forename: Anil
authors.initials: A
authors.lastname: Pande
authors.forename: Chakravarthy M
authors.initials: CM
authors.lastname: Vasudevan
authors.forename: Ravi
authors.initials: R
authors.lastname: Ramamurthi