title: Decompressive hemicraniectomy in the management of acute stroke in children with Moyamoya disease: the difficult balance between the spontaneous postoperative revascularization process and the need for cranial reconstruction.
abstract: BACKGROUND
  The decompressive hemicraniectomy (DCH) after malignant middle cerebral artery infarction in children is a rare procedure, and the indication is discussed as being controversial. Etiological Moyamoya disease has some additional challenges concerning the therapeutic strategy that have not mentioned in the recent literature, as it is dependent on special pathophysiology.
  
  
  METHODS
  We report a case of a four-year-old patient with a decompressive hemicraniectomy after malignant middle cerebral artery infarction on the right hemisphere based on a Moyamoya syndrome with proximal MCA occlusions on both sides. After the decompression there was a good restitution of the hemiparesis, aphasia, and consciousness loss on admission. The bone flap replacement is usually done after three month in our department to ensure brain swelling has subsided. In this patient the cranioplasty was not arranged because of the development of collateral vessels to the right motor region through the craniotomy defect, to protect the supply of the eloquent cortex.
  
  
  CONCLUSIONS
  We conclude that the indication of DCH and postoperative treatment should be discussed individually, especially when neovascularisation developments can occur like in Moyamoya disease. An important point is the right timing for bone flap replacement, which should be directly after cerebral edema has subsided prior to the evolution of collaterals through the craniotomy defect. Additionally, leaving the opportunity for neovascularization through smaller defects has to be taken into account.
authors.affiliation: Department of Neurosurgery, University Medical Center Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany. marc.hohenhaus@uniklinik-freiburg.de.
authors.forename: Marc
authors.initials: M
authors.lastname: Hohenhaus
authors.affiliation: Department of Neurosurgery, University Medical Center Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.
authors.forename: Mukesch Johannes
authors.initials: MJ
authors.lastname: Shah
authors.affiliation: Department of Pediatrics, University Medical Center Freiburg, Mathildenstrasse 1, 79106, Freiburg, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Eckenweiler
authors.affiliation: Department of Neurosurgery, University Medical Center Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.|Department of Neurosurgery, University Hospital UZ Brussel, Laarbeeklaan 101, 1090, Brussel, Belgium.
authors.forename: Vera
authors.initials: V
authors.lastname: van Velthoven
mesh_terms: D015901:Angiography, Digital Subtraction; D002675:Child, Preschool; D003399:Craniotomy / Q000379:methods*; D019299:Decompression, Surgical / Q000379:methods*; D006801:Humans; D018810:Magnetic Resonance Angiography; D008279:Magnetic Resonance Imaging; D008297:Male; D009072:Moyamoya Disease / Q000150:complications* / Q000601:surgery*; D019651:Plastic Surgery Procedures; D020521:Stroke / Q000150:complications* / Q000601:surgery*
keywords: Bone flap replacement; Cranioplasty; Decompressive hemicraniectomy; Infarction; Moyamoya