Safety and long-term outcomes following bypass surgery in pediatric versus adult patients with Moyamoya disease: a multicenter cohort study.

OBJECTIVE

Moyamoya disease (MMD) is a progressive cerebrovascular disorder and an important cause of childhood stroke. Surgical revascularization is the established treatment for symptomatic disease. However, comparative data examining perioperative safety and long-term outcomes between pediatric and adult patients remain limited. This study hence aimed to evaluate whether age influences postoperative complications, early neurological outcomes, and long-term stroke risk following direct and/or indirect bypass surgery.

METHODS

We conducted a retrospective multicenter cohort study of patients with MMD who underwent surgical revascularization at 13 academic centers across North America between 2008 and 2022. The primary outcomes were overall postoperative complications and long-term stroke occurrence. Comparisons between pediatric (≤ 18 years) and adult (> 18 years) hemispheres were performed using overlap propensity score weighting (PSW) to adjust for differences in baseline characteristics. Sensitivity analyses were conducted in patients with ≥ 2 years of follow-up.

RESULTS

A total of 567 hemispheres (523 adult, 44 pediatric) were included. Adults had higher rates of vascular comorbidities, whereas pediatric patients more frequently presented with congenital conditions and earlier Suzuki grades. Pre- and post-PSW analyses demonstrated no significant age-related differences in outcomes (p ≥ 0.05). On weighted regression, age was not associated with postoperative complications (OR 0.92; 95% CI 0.41-2.05), discharge neurological status (mRS: OR 1.08; 95% CI 0.52-2.21; and NIHSS: OR 0.97; 95% CI 0.45-2.10), or long-term cerebrovascular events (OR 0.88; 95% CI 0.28-2.74). On sensitivity analysis of patients with > 2 years of follow-up, no pediatric hemispheres experienced stroke compared with 12% of adult hemispheres, though this difference was not statistically significant (p = 0.14).

CONCLUSIONS

Despite marked differences in baseline comorbidities and angiographic severity, pediatric and adult patients experienced similar perioperative outcomes and long-term stroke risk after bypass surgery. These findings support the durability and safety of both direct and indirect revascularization across age groups.