Abstract
Objective: Moyamoya vasculopathy (MMV) coexisting with meningioma has rarely been reported and poses a surgical challenge because tumor exposure may disrupt transdural collaterals, whereas revascularization may alter perioperative hemodynamics. The optimal surgical sequence remains unclear. Methods: We retrospectively reviewed 4 female patients with concurrent MMV and meningioma who underwent one-stage tumor resection followed by superficial temporal artery (STA) - middle cerebral artery (MCA) bypass and encephalo-duro-myo-pericranio-synangiosis (EDMPS) between September 2024 and May 2025. Surgical strategy, perioperative complications, radiological findings, and clinical outcomes were analyzed. Results: Tumor removal and planned revascularization were completed in all patients. Follow-up digital subtraction angiography (DSA) confirmed bypass patency in all patients, and mean transit time (MTT) in the revascularized MCA territory decreased from 5.75 s preoperatively to 4.50 s at follow-up. No perioperative mortality, postoperative stroke, new permanent neurological deficit, or tumor recurrence was observed during 13–21 months of follow-up. One patient developed transient cerebral hyperperfusion syndrome which improved with blood pressure control and medical treatment. Conclusions: In this four-patient series, one-stage tumor resection followed by combined direct and indirect revascularization was feasible in selected patients with concurrent MMV and meningioma. Key technical considerations include preservation of donor arteries and transdural collaterals, individualized craniotomy planning, and careful perioperative hemodynamic management. Additional cases with longer follow-up and comparative data are needed to clarify patient selection and long-term outcomes.