Journal of Neurosurgery: Pediatrics. 2026;38(2):205–214.
Objective
To compare recurrent ischemic events after surgical revascularization or conservative treatment in children with symptomatic moyamoya arteriopathy.
Methods
Retrospective comparison of 49 children treated at two North American institutions: 24 received nonsurgical management and 25 underwent predominantly indirect revascularization. Median age was 6 years.
Main results
Ipsilateral ischemic event–free survival at 12, 24 and 60 months was 52.8%, 52.8% and 31.7% with nonsurgical management, compared with 87.7%, 83.0% and 83.0% after surgery. Surgical revascularization was associated with a substantially longer time to recurrence (HR 0.15; 95% CI 0.04–0.51).
Interpretation
The findings strongly favor revascularization for children with symptomatic disease. Nevertheless, treatment strategy was closely linked to the institution, making residual confounding likely.
Limitations
Small retrospective cohort, center-dependent treatment allocation and differences in patient selection. The observed association involving race should not be interpreted as causal.
Clinical takeaway
In symptomatic pediatric moyamoya, timely referral for surgical revascularization appears preferable to observation alone.
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