Enhanced Recovery After Surgery Consensus Protocol for Cerebral Bypass in Moyamoya Disease

Background

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Objective

Moyamoya disease (MMD) is a progressive cerebrovascular disorder treated primarily with surgical revascularization to prevent stroke recurrence. Despite established surgical techniques, standardized perioperative care protocols remain limited, potentially leading to variable outcomes and perioperative complications. Enhanced Recovery After Surgery (ERAS) protocols have demonstrated improved outcomes across surgical disciplines but have not been systematically applied to cerebral bypass surgery for MMD. The objective was to develop evidence-based ERAS recommendations for perioperative management of patients undergoing direct cerebral bypass surgery for MMD, based on a systematic literature review and expert consensus.

Methods

A multidisciplinary guideline development group was formed including cerebrovascular neurosurgery, neurointensive care, vascular neurology, neurophysiological monitoring, and anesthesiology experts. A comprehensive literature review of PubMed databases was conducted using systematic search strategies. The Grading of Recommendations Assessment, Development, and Evaluation system was used to evaluate evidence quality and recommendation strength.

Results

Thirty-two studies met inclusion criteria for analysis. Seven primary categories of perioperative care were identified: patient selection, preoperative optimization, anesthesia and analgesia, intraoperative neuromonitoring, surgical strategy, postoperative management, and follow-up and recovery protocols. Strong recommendations were developed for 34 specific interventions across the perioperative continuum.

Conclusion

This consensus statement provides the first comprehensive ERAS protocol for direct cerebral bypass surgery in patients with MMD. Implementation of these evidence-based recommendations may improve patient outcomes, reduce complications, and standardize perioperative care.