Do Patients with Moyamoya Disease Need Surgical Treatment?

Moyamoya disease is a rare, progressive cerebrovascular disorder that primarily affects the blood vessels at the base of the brain. Over time, the internal carotid arteries narrow or become blocked, leading to reduced blood flow and an increased risk of stroke—especially in children and young adults. Given its potentially severe neurological consequences, timely and effective intervention is crucial.

Why Conservative Treatment Is Not Sufficient

Currently, there is broad consensus within the medical community that non-surgical or conservative treatments offer limited benefits for moyamoya disease. Medications such as antiplatelet agents may be used temporarily, particularly in patients experiencing recent ischemic episodes, to help manage symptoms and reduce the risk of clot formation. However, these pharmacological approaches come with significant limitations.

The Risks of Drug-Based Management

Antiplatelet and anticoagulant therapies can disrupt the delicate balance between preventing ischemia and triggering hemorrhage. In moyamoya patients, where fragile collateral vessels develop to compensate for blocked arteries, even minor changes in coagulation status can lead to catastrophic outcomes—either bleeding into the brain or further ischemic events. This makes long-term medication management unreliable and potentially dangerous.

Surgery as the Gold Standard Treatment

Once a definitive diagnosis is made, surgical revascularization is widely regarded as the most effective treatment strategy. The primary goal of surgery is to restore adequate cerebral blood flow by creating new pathways for oxygen-rich blood to reach the brain. Procedures such as direct bypass (e.g., STA-MCA anastomosis) or indirect bypass techniques (like EDAS or EMS) have shown excellent long-term outcomes in reducing stroke risk and improving quality of life.

When to Consider Surgery

While immediate surgery may be delayed during periods of acute neurological instability or frequent transient ischemic attacks (TIAs), once the patient stabilizes, prompt surgical intervention is strongly recommended. Delaying surgery increases the risk of permanent brain damage due to recurrent strokes. Early revascularization not only prevents future ischemic events but also helps protect cognitive function and motor skills.

In summary, while medical therapy may play a supportive role in the short term, it cannot halt the progression of moyamoya disease. For lasting protection against stroke and optimal neurological outcomes, surgical treatment remains the cornerstone of care. Patients diagnosed with this condition should consult with a specialized neurosurgical team to determine the best timing and approach for revascularization surgery.