Effectiveness of burr holes for indirect revascularization in patients with moyamoya disease-a review of the literature.

OBJECTIVE: Moyamoya disease (MMD) has inspired the development and refinement of numerous surgical techniques to induce revascularization in hypoperfused territories. Over the last 3 decades, the use of burr hole surgery has progressively gained popularity. Used either in combination with another direct or indirect procedure or as the sole method for revascularization, burr hole surgery can be tailored to each patient's specific needs. We reviewed the conceptual progress, the technical evolution, and the clinical and radiological data following burr hole surgery.
METHODS: Pubmed and Medline databases were searched for publications from 1970 to 2012 relating to the use of burr holes in the surgical management of MMD. The reference sections of each article were reviewed, and pertinent articles were identified.
RESULTS: A review of case reports and case series using burr hole surgery for MMD testifies to the progressive refinement in the decision process and key technical aspects of this procedure. Favorable clinical and angiographic results have been documented in the pediatric and adult MMD population after burr holes, used either in combination with direct or indirect revascularization techniques, or more recently alone in the setting of multiple burr holes. The superficial temporal artery and middle meningeal artery have both been found to contribute to revascularization via burr holes.
CONCLUSIONS: Burr hole surgery is an important and versatile tool in the armamentarium of surgeons treating children and adults with MMD, allowing tailoring of the revascularization. Further studies should help to determine factors that may help predict optimal revascularization from this surgical technique.