Tehran University of Medical Sciences Archives of Anesthesiology and Critical Care 2423-5849 0 0 2026 06 01 1613 1613 Muhammad Prandani Division of Neuroanesthesiology, Department of Anesthesiology and Intensive Therapy, Dr. Hasan Sadikin Central General Hospital, Faculty of Medicine, University of Padjadjaran, Bandung, Indonesia. & Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Public Health, and Nursing, Gadjah Mada University, Yogyakarta, Indonesia. Iwan Fuadi Division of Neuroanesthesiology, Department of Anesthesiology and Intensive Therapy, Dr. Hasan Sadikin Central General Hospital, Faculty of Medicine, University of Padjadjaran, Bandung, Indonesia. & Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Public Health, and Nursing, Gadjah Mada University, Yogyakarta, Indonesia. Radian Halimi Division of Neuroanesthesiology, Department of Anesthesiology and Intensive Therapy, Dr. Hasan Sadikin Central General Hospital, Faculty of Medicine, University of Padjadjaran, Bandung, Indonesia. & Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Public Health, and Nursing, Gadjah Mada University, Yogyakarta, Indonesia. Kenanga Sikumbang Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Lambung Mangkurat University, Banjarmasin, Indonesia. Fiandila Deviatika Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Public Health, and Nursing, Gadjah Mada University, Yogyakarta, Indonesia. 2026 04 06 2026 05 11 Moyamoya syndrome (MMS) is a progressive cerebrovascular disorder characterized by stenosis of the internal carotid arteries and the formation of fragile collateral vessels, predisposing patients to cerebral ischemia. In post-stroke and post-craniectomy patients, impaired autoregulation and altered intracranial anatomy present significant anesthetic challenges. Maintaining hemodynamic stability and adequate cerebral perfusion is essential during revascularization procedures such as temporal artery–middle cerebral artery (STA–MCA bypass). We report a 60-year-old man with prior hemorrhagic stroke and previous decompressive craniectomy secondary to MMS who was scheduled for superficial temporal artery–middle cerebral artery (STA–MCA) bypass. Magnetic resonance angiography (MRA) demonstrated occlusion of the right M2 segment of the middle cerebral artery (MCA) and right frontal gliosis. Anesthesia was induced using propofol with a Schnider target-controlled infusion (TCI) model (target effect-site concentration 5 µg/mL), fentanyl 150 µg, intravenous lidocaine 90 mg, and rocuronium 0.8 mg/kg and maintained with propofol TCI combined with a dexmedetomidine infusion. Intraoperatively, systolic blood pressure (SBP) ranged from 96 to 115 mmHg, diastolic pressure from 56 - 72 mmHg, heart rate (HR) from 56 to 72 bpm, and EtCO₂ from 29 to 34 mmHg. Depth of anesthesia monitoring using CONOX showed qCON values between 45 and 57. After STA–MCA anastomosis, superficial temporal artery and middle cerebral artery pressures were 72 mmHg and 54 mmHg, respectively, with a pressure gradient of 18 mmHg and satisfactory Doppler flow. The patient was monitored in the intensive care unit for 24 hours postoperatively with stable hemodynamics and a Glasgow Coma Scale (GCS) score of E4M6Vett and was gradually extubated without neurological complications. This case highlights that propofol–dexmedetomidine TIVA can provide stable hemodynamics, controlled cerebral blood flow, and cerebral metabolic demand and may help maintain cerebral perfusion balance during STA–MCA bypass in patients with impaired cerebral autoregulation. https://aacc.tums.ac.ir/index.php/aacc/article/view/1613