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Long-term follow-up results in 142 adult patients with moyamoya disease according to management modality

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To clarify the most beneficial treatment of the management modality based on our experience with adult moyamoya disease (MMD).


From 1998 to 2010, clinical results of 142 patients (ischemic, 98; hemorrhagic, 44) with adult MMD were investigated according to management modality. Revascularization surgery (direct, indirect, and combined bypass) was performed in 124 patients. We observed the clinical course of 18 patients who were treated conservatively. Clinical outcome, angiographic features, hemodynamic change, and incidence of recurrent stroke were investigated pre- and postoperatively.


In patients with ischemic MMD, direct and combined bypasses were more effective treatments to prevent recurrent ischemic stroke than indirect bypass surgery (P < 0.05). In patients with hemorrhagic MMD, rebleeding was less likely to occur in patients who had undergone bypass surgery. However, no significant difference was observed in the rebleeding rate between patients with and without revascularization surgery (P > 0.05). An angiogram after bypass surgery comparing the extent of revascularization and reduction of moyamoya vessels in patients treated with direct, indirect, and combined bypass showed a significant difference (P < 0.05) in favor of direct and combined bypass. Postoperative angiographic changes and SPECT results demonstrated significant statistical correlation (P < 0.05).


Revascularization surgery was effective in further ischemic stroke prevention to a statistically significant extent. Direct and combined bypasses were more effective to prevent recurrent ischemic stroke than indirect bypass. However, there is still no clear evidence that revascularization surgery significantly prevents rebleeding in adult MMD patients. More significant angiographic changes were observed in direct and combined bypasses compared with indirect bypass.

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Correspondence to Pil-Woo Huh.

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This is a valuable contribution to the literature in that the study provides high-quality, rigorous follow-up of a large patient sample. It provides potentially important data to guide the choice of bypass (direct/combined vs. indirect). This is achieved by correlating the treatment with an evaluation of the clinical and imaging outcomes, and provides comparative evidence as to the clinical value of direct/combined, indirect, and conservative management. A caveat remains that this is a retrospective study in which the treatments were not randomly allocated. Nonetheless, it is of significant interest to those who treat patients with adult moyamoya disease.

Michael Tymianski

Toronto, Canada

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Lee, SB., Kim, DS., Huh, PW. et al. Long-term follow-up results in 142 adult patients with moyamoya disease according to management modality. Acta Neurochir 154, 1179–1187 (2012).

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