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Presence of Collaterals from the Contralateral Hemisphere on Preoperative Angiogram Predicts Failure of Encephalo-Duro-Arterio-Synangiosis (EDAS) in Adult Patients with Moyamoya Disease

BACKGROUND AND PURPOSE: Moyamoya disease (MMD) is characterized by chronic progressive stenosis of intracranial vessels and subsequent formation of abnormal collateral vessel networks. Indirect revascularization techniques, such as encephalo-duro-arterio-synangiosis (EDAS), promote angiogenesis to restore perfusion but have variable success rates. This study aimed to identify clinical and radiographic predictors of successful collateral vessel in-growth after EDAS, emphasizing the role of contralateral interhemispheric collaterals. MATERIALS AND METHODS: We conducted a single-center retrospective analysis of cerebral hemispheres from adult patients with MMD who underwent EDAS. We assessed demographic characteristics, clinical presentation, procedural details, and clinical and radiographic outcomes. Angiographic outcomes were assessed using the Orbital Grading system. Univariate analysis was performed to identify factors associated with favorable postoperative collateral development. Consequently, preoperative contralateral interhemispheric collateralization was quantitatively evaluated through pixel density analysis on digital subtraction angiography, comparing the Moyamoya-affected hemisphere with the contralateral hemisphere. RESULTS: Sixty-one MMD hemispheres of 43 adult patients were included in the study. Median times to last clinical and angiographic follow-up were 29.9 months and 13.6 months, respectively. Higher Suzuki stages (V and VI; P = <.01) and occlusions of the anterior cerebral artery (ACA; P = .03) and internal carotid artery (ICA; P = .048) were associated with superior postoperative collateralization. The presence of robust contralateral collaterals on preoperative angiography significantly predicted poor postoperative neovascularization ( P = .01). Pixel density analysis showed that increased pixel density ratios of Moyamoya-affected hemisphere to contralateral hemisphere significantly correlated with reduced postoperative collateral vessel formation (Orbital Grading system, OR =130.94, P = .008; Matsushima grading system, OR =52.09, P = .018). CONCLUSIONS: Higher Suzuki stages, and ACA and ICA occlusion predict successful neovascularization after EDAS. The presence of robust preoperative contralateral interhemispheric collaterals is an important predictor of poor collateral vessel in-growth following EDAS. This finding suggests that such collateralization might reduce the local ischemic stimulus required for effective indirect revascularization. These findings could refine surgical decision-making by identifying patients who may be less likely to benefit from EDAS. ACA : anterior cerebral artery DSA : digital subtraction angiography EDAS : encephalo-duro-arterio-synangiosis ICA : internal carotid artery MCA : middle cerebral artery MMD : Moyamoya disease MPI : mean pixel intensity SE : standard error STA : superficial temporal artery