Tailored, multi-territorial revascularization extending beyond the MCA territory in adult Moyamoya patients is feasible, achieves high rates of angiographic revascularization, and is associated with low perioperative morbidity and favorable follow-up outcomes.
A substantial proportion of Moyamoya patients required non-MCA revascularization procedures targeting ACA and PCA territories.
ACA revascularization was performed predominantly using indirect techniques, while PCA revascularization was more evenly distributed between direct and indirect approaches.
At 12-month follow-up, direct bypass graft patency and indirect bypass collateral development were achieved at high rates.
Perioperative complications requiring surgical intervention were infrequent.
No new strokes were reported during the follow-up period.
Indications for ACA and PCA bypass were determined by advanced imaging to evaluate cerebrovascular reserve.
EC-IC bypass surgery within the MCA territory is described as the gold standard for Moyamoya treatment, but most centers do not routinely revascularize ACA or PCA territories.
Moyamoya disease is a rare condition in which the main arteries supplying the brain gradually narrow and block, leading to stroke risk. The standard surgical treatment involves creating a bypass around the blocked middle cerebral artery (MCA), but other brain regions — supplied by the anterior cerebral artery (ACA) and posterior cerebral artery (PCA) — are often also affected and are typically not treated surgically. This study examined whether extending bypass surgery to these additional territories is safe and effective in adult patients. Researchers analyzed 233 adult Moyamoya patients and found that 66 of them (about 28%) needed surgical revascularization beyond the MCA, resulting in 124 additional procedures targeting the ACA and PCA. Using advanced brain imaging to identify which regions had compromised blood flow, surgeons performed both direct bypass connections and indirect techniques (where tissue is placed on the brain surface to encourage new vessel growth). At 12-month follow-up, 100% of direct bypasses remained open and 93.7% of indirect procedures showed good new blood vessel development. Complications requiring further surgery occurred in only 4% of procedures, and no new strokes were recorded over an average follow-up of about 15 months. This research suggests that a tailored, multi-territorial approach to Moyamoya surgery — one that addresses all compromised brain regions rather than focusing solely on the MCA — is both feasible and associated with low complication rates and good angiographic outcomes. The findings may support a shift toward more comprehensive revascularization strategies in Moyamoya care, particularly when advanced imaging confirms that blood flow is inadequate in ACA or PCA territories.
Roder C, Orden Schiniotakis A, Haas P, Hurth H, Wiggenhauser L, Zerweck L, et al.. (2026). Multiterritorial tailored revascularization in adult Moyamoya patients: expanding revascularization approaches to ACA and PCA territories.. Neurosurgical review. https://doi.org/10.1007/s10143-026-04455-y