title: Occipital pial synangiosis.
abstract: BACKGROUND
  Indirect revascularization techniques for posterior circulation moyamoya are infrequently described in the literature given the relative rarity of the disease process, particularly in the best candidates for indirect approaches-children.
  
  
  METHODS
  We present a detailed, illustrated video demonstration of the occipital pial synangiosis procedure performed in a 5-year-old child.
  
  
  CONCLUSIONS
  The specific advantages of the pial synangiosis technique-suturing the donor vessel to the pia and a wide arachnoidal opening-can be successfully applied to posterior circulation indirect revascularization.
  
  
  CONCLUSIONS
  • Perioperative hydration and aspirin limit the risk of perioperative stroke. • Pain control and maintained normocapnea limit the risk of perioperative ischemic events. • The posterior auricular artery may be an alternative donor vessel. • The donor vessel is dissected from distal to proximal; forceps protect it during skin incision. • The donor vessel is dissected along a generous length to minimize tension. • Coagulation of the dura is limited as meningeal vessels may serve as synergistic collaterals. • A wide arachnoidal opening facilitates the ingrowth of collateral vessels. • Suturing the donor vessel to the pia ensures it remains well apposed to the brain surface. • The dura is left open to encourage ingrowth of collateral vessels and limit tension on the donor vessel. • EEG monitoring is a crucial adjunct.
authors.affiliation: Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA, bgross1@partners.org.
authors.forename: Bradley A
authors.initials: BA
authors.lastname: Gross
authors.forename: Scellig S
authors.initials: SS
authors.lastname: Stone
authors.forename: Edward R
authors.initials: ER
authors.lastname: Smith
mesh_terms: D002548:Cerebral Revascularization / Q000379:methods*; D002675:Child, Preschool; D003097:Collateral Circulation; D004569:Electroencephalography; D006801:Humans; D009072:Moyamoya Disease / Q000150:complications / Q000601:surgery*; D009778:Occipital Lobe; D010841:Pia Mater / Q000098:blood supply* / Q000601:surgery*; D020521:Stroke / Q000517:prevention & control; D016896:Treatment Outcome