Meta-analysis of the surgical outcomes of symptomatic moyamoya disease in adults

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The purpose of this study was to evaluate treatment outcomes of future stroke prevention, perioperative complications, and angiographic revascularization in adults with symptomatic moyamoya disease (MMD) according to treatment modalities and surgical techniques.


A systemic literature review was performed based on searches of the PubMed, Embase, and Cochrane Central databases. A fixed-effects model was used in cases of heterogeneity less than 50%. Publication bias was determined by Begg’s funnel plot, Egger’s test of the intercept, and the Begg and Mazumdar rank correlation test.


Eleven articles were included in the meta-analysis. Bypass surgery significantly decreased the future stroke events compared with conservative treatments in adult MMD (odds ratio [OR] 0.301, p < 0.001). Direct bypass showed better future stroke prevention than indirect bypass (OR 0.494, p = 0.028). There was no meaningful difference in perioperative complications between direct and indirect bypass (OR 0.665, p = 0.176). Direct bypass was associated with better angiographic outcomes than indirect bypass (OR 6.832, p < 0.001).


Bypass surgery can be effective in preventing future stoke events in adults with MMD. Direct bypass seems to provide better risk reduction with respect to stroke than indirect bypass in these patients.

ABBREVIATIONS CI = confidence interval; ICA = internal carotid artery; MCA = middle cerebral artery; MMD = moyamoya disease; NOS = Newcastle-Ottawa Scale; OR = odds ratio; TIA = transient ischemic attack.

Article Information

Correspondence Jeong Eun Kim, Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea. email:

INCLUDE WHEN CITING Published online May 5, 2017; DOI: 10.3171/2016.11.JNS161688.

Disclosures This study was supported by BioGreen 21 (PJ01121401) of the Rural Development Administration.

© AANS, except where prohibited by US copyright law.



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    Flow diagram for identification of relevant studies.

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    Forest plots for future stroke events in all adult MMD patients included in the studies (A), future stroke events in MMD patients with hemorrhage presentation (B), and future stroke events in MMD patients with ischemic presentation (C). MH = Mantel-Haenszel.

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    Funnel plot for publication bias in future stroke events in total adult MMD patients.

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    Forest plots for analyses of future stroke events according to surgical procedures (A), perioperative complications according to surgical procedures (B), and good angiographic outcomes according to surgical procedures (C).

  • View in gallery

    Funnel plot for publication bias in future stroke events according to surgical procedures in adult MMD patients.



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