In adults with moyamoya angiopathy at Suzuki stages I-III, no significant between-group differences were detected between direct and indirect revascularization in any studied clinical outcomes, suggesting technique selection can be individualized to anatomy, hemodynamics, and center expertise.
Overall perioperative stroke rates did not differ significantly between indirect and direct revascularization groups in unadjusted analysis.
After propensity score weighting, the lack of significant difference in perioperative stroke between direct and indirect revascularization persisted.
Follow-up stroke rates did not significantly differ between indirect and direct revascularization groups.
No significant differences were found between direct and indirect revascularization for symptomatic perioperative stroke, intraoperative complications, discharge NIHSS/mRS, or length of stay.
The study population consisted of adults with moyamoya angiopathy restricted to Suzuki stages I-III, a stage-specific cohort not commonly studied in isolation.
The authors conclude that surgical technique selection for early-stage moyamoya can be individualized rather than standardized based on available outcome evidence.
Moyamoya angiopathy is a rare cerebrovascular disease in which the brain's major arteries gradually narrow, leading to stroke risk. Surgeons can treat it by either directly connecting a scalp artery to a brain artery (direct revascularization) or by placing tissue against the brain surface to encourage new blood vessel growth over time (indirect revascularization). This study examined whether one approach was safer or more effective than the other specifically in patients with early-to-moderate disease (Suzuki stages I through III), using data from 208 surgical procedures across 13 academic medical centers. The researchers found no statistically significant differences between the two surgical techniques across any of the outcomes they measured — including stroke during or after surgery, complications during the operation, neurological status at hospital discharge, length of hospital stay, or stroke occurring during follow-up. These findings held up even after using advanced statistical methods (propensity score weighting) to account for differences between the two patient groups. Stroke-free survival over time was also similar between the two groups. This research suggests that for adults with early-stage moyamoya disease, neither direct nor indirect bypass surgery appears clearly superior in terms of the clinical outcomes studied. Rather than a one-size-fits-all recommendation, the findings support tailoring the choice of surgical technique to each patient's specific anatomy, blood flow patterns, and the expertise available at the treating medical center. The authors emphasize that larger prospective studies with more standardized measurements are needed to further refine surgical decision-making for this condition.
Musmar B, Roy J, Abdalrazeq H, El-Hajj V, Rizzuto M, Lan M, et al.. (2026). Direct Versus Indirect Bypass in Early-Stage Moyamoya (Suzuki I-III): A Propensity Score-Weighted Study.. Translational stroke research. https://doi.org/10.1007/s12975-026-01448-3