Recurrent Ischemic Events in Adult Moyamoya Disease: A Case Report of Persistent Symptoms Despite Encephaloduroarteriosynangiosis (EDAS) Surgery

Moyamoya disease (MMD) is a rare cerebrovascular disorder characterized by progressive stenosis of the intracranial arteries, which can lead to the development of fragile collateral vessels. The surgical revascularization, especially encephaloduroarteriosynangiosis (EDAS), is commonly employed among MMD patients. However, due to the slower development of collateral circulation in adult patients, the effectiveness of EDAS in adults has been questioned. Conversely, direct revascularization procedures, such as superficial temporal artery to middle cerebral artery (STA-MCA) bypass, have provided immediate restoration of blood flow and shown favorable outcomes among adult MMD patients. This report presents the case of a 39-year-old Hispanic female patient who was diagnosed with MMD and experienced multiple ischemic events despite EDAS. Subsequent imaging revealed progression of stenosis in both the anterior and posterior circulations. Given subsequent clinical deterioration, the patient opted for a right craniotomy for STA-MCA bypass. This surgical invention resulted in improved cerebral perfusion and stabilization of her neurological status. This case illustrates the complexity of managing adult-onset Moyamoya disease and suggests that indirect revascularization alone may not provide sufficient long-term hemodynamic stability in patients with advanced or progressive disease. These findings support consideration of direct or combined surgical approaches in carefully selected adult patients.