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J Neurol Surg B Skull Base
DOI: 10.1055/a-2717-2888
Original Article

Single-Barrel versus Double-Barrel Superficial Temporal Artery-to-Middle Cerebral Artery Bypass in Moyamoya Disease: A Systematic Review and Meta-Analysis of Postoperative Stroke Outcomes

Authors

  • David Cho

    1   Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma, United States

  • Vincent Dieu

    1   Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma, United States

  • Cory Greer

    1   Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma, United States

  • Gerardo Duran

    1   Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma, United States

  • Abdurrahman F. Kharbat

    1   Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma, United States

  • Michael J. Feldman

    1   Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma, United States

  • Andrew M. Bauer

    1   Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma, United States

  • Christopher S. Graffeo

    1   Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma, United States
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Abstract

Background

Moyamoya disease (MMD) involves progressive stenosis of intracranial arteries and compensatory collateral vessel formation. A novel modification of the single-barrel superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass, the double-barrel bypass, offers increased postoperative flow or draw, although longer operative time. Currently, there is a lack of consensus regarding the impact of the novel double-barrel STA-MCA bypass on the incidence of postoperative stroke for patients undergoing direct extracranial–intracranial bypass for MMD.

Methods

We performed a Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA)-compliant systematic review of MEDLINE and Embase from inception through March 2024. A supplemental bibliographic review in Google Scholar was also performed to screen for additional candidate citations. Among 95 candidate citations, 16 underwent full-text review; 5 met the study criteria and were included in a meta-analysis of proportions using random-effects modeling.

Results

There was no significant difference in postoperative stroke following single-barrel compared with double-barrel bypass (odds ratio [OR] = 1.28, 95% confidence interval [CI] = 0.26–6.3, p = 0.77). Studies reported either median or mean follow-up times, with an approximate mean of 20.2 months (range, 7–190). Interstudy heterogeneity was minimal (I 2 = 0%). Sensitivity analyses excluding studies with follow-up times under 12 months (OR = 1.12, 95% CI = 0.18–8.39, p = 0.85) and studies using STA-MCA bypass with adjunct indirect procedures (OR = 0.65, 95% CI = 0.08–5.09, p = 0.68) validated primary findings. Funnel plots and Egger's test were negative for publication bias.

Conclusion

Double-barrel STA-MCA bypass does not appear to provide additional postoperative stroke protection or vulnerability compared with the single-barrel; however, given the relatively limited follow-up times, these results may underrepresent long-term benefits. Well-controlled long-term studies are needed to better interrogate the optimal treatment strategies for this vulnerable patient population.

Keywords

Moyamoya disease - cerebral revascularization - superficial temporal artery - middle cerebral artery - stroke - postoperative complications - meta-analysis

Note

This study was previously presented as a podium presentation at the NASBS 34th Annual Meeting and 9th World Congress of the World Federation of Skull Base Societies Meeting, February 13–16, 2025, New Orleans, LA.




Publication History

Received: 01 May 2025

Accepted: 05 October 2025

Accepted Manuscript online:
07 October 2025

Article published online:
23 October 2025

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