Authored by Vince Murdock, moyamoya survivor and the Miles for Moyamoya team. Sources cited inline and listed in full at the page bottom. Last updated: 25 May 2026.
There is no medical therapy proven to reverse the underlying arterial narrowing. Medication is adjunctive.
The 2023 AHA/ASA Scientific Statement on adult moyamoya is clear: no medical therapy has demonstrated reversal or arrest of disease progression. Antiplatelets, blood pressure control, and lifestyle measures play a supporting role around the central treatment, which is surgical revascularisation.
Antiplatelet therapy (aspirin). Daily low-dose aspirin is reasonable in ischemic-onset moyamoya per the 2021 AHA/ASA guidelines, although no randomised trial has demonstrated stroke reduction in moyamoya specifically (Benefits and Risks of Antiplatelet Therapy in Moyamoya, Frontiers in Neurology 2023). Antiplatelets are generally avoided in hemorrhagic-onset disease because of rebleed risk.
Cilostazol. A phosphodiesterase-3 inhibitor with vasodilatory and antiplatelet effects. Korean nationwide data have linked cilostazol use to improved survival; the 2023 AHA/ASA Scientific Statement highlights cilostazol as a promising agent worth further study.
Vascular risk factor control. Blood pressure, lipids, diabetes, and smoking cessation. Standard cerebrovascular hygiene, but particularly important in moyamoya because every additional insult to compromised vessels matters.
The six-stage angiographic classification, in standard global use since Suzuki and Takaku's seminal 1969 paper.
| Stage | Angiographic finding |
|---|---|
| I | Narrowing of the carotid fork (terminal ICA only) |
| II | Initiation of basal moyamoya vessels; anterior and middle cerebral arteries dilated |
| III | Intensification of basal moyamoya; ACA/MCA disappearing; the classic 'puff of smoke' is most prominent |
| IV | Minimisation of basal moyamoya; posterior cerebral artery involvement begins |
| V | Reduction of moyamoya; external carotid artery collaterals develop |
| VI | Disappearance of moyamoya; brain perfused entirely via external carotid and vertebrobasilar collaterals |
Higher Suzuki stage correlates with greater hemodynamic compromise and stroke risk. The classic "puff of smoke" appearance peaks at Stages III-IV and disappears by Stage VI as external collateral pathways take over (Radiopaedia, Suzuki staging system).
Three approaches: direct bypass, indirect bypass, and combined. Each has clear indications by patient age and disease pattern.
The superficial temporal artery is microsurgically anastomosed to a cortical branch of the middle cerebral artery, restoring immediate blood flow to ischemic territory. First described for moyamoya in the 1970s and the workhorse adult procedure for decades. Pros: immediate flow. Cons: technically demanding; requires donor artery of adequate calibre.
Vascularised tissue is laid over the cortical surface to stimulate new vessel growth (neoangiogenesis) over weeks to months. Variants include EDAS (STA on brain surface), EMS (temporalis muscle flap), pial synangiosis (donor adventitia sutured directly to pia, developed at Boston Children's by Dr R. Michael Scott in 1985), and multiple burr holes. Pros: simpler operation; works well in children. Cons: blood flow benefit develops over months, not immediately.
Both techniques in one operation: immediate STA-MCA flow boost plus indirect tissue overlay for long-term neoangiogenesis. Increasingly favoured in adults. A 2025 safety analysis of STA-MCA + EDAS reported significant cerebral hemodynamic and neurological improvement without increased complications (PMC11936565). Pros: immediate plus durable. Cons: longer operative time.
Indications by patient type. Children typically receive indirect techniques (especially pial synangiosis) because paediatric cortical vessels are too small for reliable direct anastomosis and children develop robust neovascularisation (Boston Children's Hospital). Adults are generally offered direct or combined bypass; direct procedures show superior short-term symptom improvement in adults.
What is not recommended. The 2023 AHA/ASA Scientific Statement explicitly does not recommend endovascular stenting or angioplasty for moyamoya. The underlying problem is progressive intimal thickening, not focal atherosclerotic plaque, and these procedures have high failure rates in moyamoya vessels.
Hemorrhagic moyamoya. Surgical revascularisation reduces rebleed rates from the natural-history range to roughly 12-17% post-surgery in Stanford's published series. Even hemorrhagic-onset patients benefit from bypass once stabilised.
5.5%
VS 40%
Stanford's 5-year post-bypass stroke or death rate (5.5%) compared with the roughly 40% natural-history 5-year stroke risk untreated. The case for surgery is unambiguous in the 2023 AHA/ASA Scientific Statement.
Read about recovery →Centre volume strongly predicts outcomes. A 2016 Boston Children's study showed high-volume centres had significantly lower complication rates, shorter length of stay, and better discharge dispositions than low-volume centres.
Palo Alto, California. Lead: Dr. Gary K. Steinberg, MD, PhD. Volume: 450+ procedures across 264 patients in the reported 1991-2008 cohort. Outcomes: 5-year stroke/death risk 5.5%; surgical morbidity 3.5% per hemisphere. Where Vince had his surgery. Largest moyamoya referral centre in the world. Treats adults and children. Offers direct (STA-MCA), indirect (EDAS, EMS), and combined revascularisation.
Boston, Massachusetts. Lead: Dr. Edward Smith (programme lead). Dr. R. Michael Scott pioneered pial synangiosis here in 1985.. Volume: Highest-volume paediatric moyamoya centre in the world, treating 40-50 children per year. Outcomes: Documented superior outcomes versus lower-volume centres (Smith et al., 2016). Pediatric specialty. Pial synangiosis technique developed and refined here.
Rochester, Minnesota. Lead: Multidisciplinary cerebrovascular team. Volume: Major referral destination, particularly for the central US. Outcomes: Mayo Clinic publishes peer-reviewed cerebrovascular outcomes; centre-specific moyamoya outcomes available on request. Nationally recognised interdisciplinary moyamoya team. Adult and paediatric care.
Boston, Massachusetts. Lead: Adult cerebrovascular and stroke programme leadership. Volume: High-volume adult cerebrovascular centre. Outcomes: Affiliated with Harvard Medical School; coordinates transitional adolescent/adult care with Boston Children's.. Adult focus, often the destination when paediatric patients age out of Boston Children's.
Cleveland, Ohio. Lead: Cerebrovascular Center team. Volume: Established moyamoya programme. Outcomes: Centre-specific outcomes available via Cleveland Clinic publications. Diagnostic workup, medical management, revascularisation in one centre.
Baltimore, Maryland. Lead: Comprehensive Stroke Center leadership. Volume: Adult and paediatric moyamoya programmes. Outcomes: Hopkins publishes cerebrovascular outcomes; centre-specific moyamoya outcomes on request. Paediatric programme through Johns Hopkins Children's Center.
San Francisco, California. Lead: Team-based moyamoya programme. Volume: Established UCSF cerebrovascular caseload. Outcomes: UCSF publishes peer-reviewed cerebrovascular outcomes. Combines vascular neurology, neurosurgery, and neuroradiology. Affiliated with UCSF Benioff Children's Hospital for paediatric care.
Additional notable centres: UT Southwestern (Dallas, Peter O'Donnell Jr. Brain Institute), Barrow Neurological Institute (Phoenix), NYU Langone, Northwestern, University of Chicago, Children's National (Washington DC), Children's Hospital of Philadelphia, Seattle Children's. Ask any prospective surgical team how many moyamoya cases they perform per year and request published outcomes data.
Treatment is one of four pages in our moyamoya cluster.
What moyamoya is, demographics, how it affects the brain.
Adult vs paediatric presentation, 62% misdiagnosis, red flags.
Post-bypass timeline, return to activity, stroke recurrence data.
Treatment decisions for moyamoya are individual and depend on age, presentation, Suzuki stage, hemodynamic reserve, and centre experience. This page is awareness and education, not medical advice. See our editorial policy for how we source and review content.
No medical therapy is proven to reverse or halt the underlying arterial narrowing. The only treatment with demonstrated long-term stroke reduction is surgical revascularisation (bypass surgery). Medical management with antiplatelets and vascular risk factor control plays a supporting, not primary, role.
Direct bypass (STA-MCA) connects a scalp artery directly to a brain artery, giving immediate blood flow. Indirect bypass lays vascularised tissue against the brain surface, prompting new vessels to grow over weeks to months. Combined procedures use both for immediate plus durable benefit.
Children typically receive indirect bypass (often pial synangiosis) because their cortical vessels are too small for reliable direct anastomosis and they develop robust new vessels. Adults are usually offered direct or combined bypass, where the immediate flow boost translates into faster symptom improvement.
Suzuki and Takaku's 1969 six-stage angiographic classification describes how moyamoya progresses, from early narrowing of the carotid fork (Stage 1) through the classic 'puff of smoke' appearance (Stage 3-4) to total disappearance of moyamoya vessels and external carotid takeover (Stage 6). Higher stage means greater hemodynamic compromise.
No. The 2023 AHA/ASA Scientific Statement explicitly does not recommend endovascular stenting or angioplasty for moyamoya. These procedures fail at high rates in moyamoya vessels because the underlying problem is progressive intimal thickening rather than focal atherosclerotic plaque.
Better bypass techniques, better post-op care, earlier diagnosis. Every dollar Miles for Moyamoya raises goes toward changing the treatment options available to the next patient.