What questions should I ask the surgeon before undergoing Moyamoya revascularization surgery?

Key Questions to Ask Before Moyamoya Revascularization Surgery

Before undergoing Moyamoya revascularization surgery, you should ask your surgeon about the specific type of procedure they recommend (direct, indirect, or combined bypass), their experience with this specific procedure, and their complication rates compared to national standards. 1

Questions About Surgical Approach

• Which type of revascularization procedure do you recommend for my specific case?

  • Direct bypass (STA-MCA)
  • Indirect bypass (EDAS, EMS, pial synangiosis)
  • Combined approach 2, 1

• Why is this specific approach best for my condition?

  • For hemorrhagic presentation, direct bypass is typically preferred 2
  • For ischemic presentation, combined procedures often provide optimal outcomes 1

• What are the success rates for this specific procedure in patients with my presentation (ischemic vs. hemorrhagic)?

  • Direct bypass has shown reduction in rebleeding from 7.6%/year to 2.7%/year in hemorrhagic cases 2
  • Combined procedures have shown annual risks of only 0.4% for symptomatic hemorrhage and 0.2% for infarction 3

Questions About Surgeon Experience

• How many Moyamoya revascularization procedures have you personally performed?
• What is your success rate with this specific procedure?
• What is your complication rate compared to published standards?
• Do you specialize in Moyamoya disease specifically?

Questions About Perioperative Management

• What specific measures will you take to prevent perioperative complications?

  • How will blood pressure be managed during and after surgery? 2, 1
  • What protocols do you follow for maintaining normocapnia? 2
  • How will you maintain proper hydration and avoid hypotension? 2, 1

• What medications should I avoid before surgery?

  • Specifically ask about antiplatelet therapy management 1
  • Ask about medications that cause vasoconstriction or inhibit vasodilation 2, 1

Questions About Potential Complications

• What are the specific risks of this procedure?

  • Risk of cerebral hyperperfusion syndrome (occurs in approximately 16.5% of cases) 2, 1
  • Risk of perioperative stroke
  • Risk of unsuccessful revascularization (requiring repeat surgery) 4

• How will you monitor for and manage cerebral hyperperfusion syndrome?

  • What blood pressure targets will be maintained? 1
  • What symptoms should I report immediately?

Questions About Recovery and Follow-up

• What is the expected hospital stay?

• What restrictions will I have after surgery?

• What is the typical recovery timeline?

• What follow-up imaging will be performed to assess surgical success?

  • When will the first post-operative imaging be done?
  • What imaging modalities will be used (angiography, MRI, CT perfusion)? 1

• How long before we can determine if the surgery was successful?

  • Direct bypass provides immediate revascularization
  • Indirect bypass requires weeks to months for collateral formation 2

Questions About Long-term Outcomes

• What is the expected long-term outcome for my specific condition?

  • Studies show clinical improvement typically stabilizes around 6 months after surgery 3
  • Revascularization area continues to improve over time (54.8% at 5 years vs. 44.2% at 6 months) 3

• What is the likelihood I will need additional procedures in the future?

  • Ask about the possibility of needing surgery on the contralateral side if disease is currently unilateral 1
  • Ask about the possibility of needing repeat revascularization if the first procedure is unsuccessful 4

• What medications will I need to take long-term after surgery?

  • Specifically ask about antiplatelet therapy (typically aspirin 75-100mg daily) 1

Questions About Alternatives

• What happens if I don't have surgery?
• Are there any alternative treatments to surgery for my condition?
• Would I be a candidate for clinical trials?

Remember that direct bypass procedures are technically more demanding but provide immediate revascularization, while indirect procedures rely on angiogenic proliferation over time. The optimal approach depends on your specific presentation, age, and vascular anatomy 2, 1.