PRECISION REVASCULARIZATION IN ADULT MOYAMOYA DISEASE: HEMODYNAMIC PHENOTYPING, DIRECT AND COMBINED BYPASS, HYPERPERFUSION CONTROL, AND PERSONALIZED SURGICAL TARGETING Abstract

Аннотация

Background. Adult moyamoya disease is a progressive occlusive cerebrovascular arteriopathy characterized by stenosis of the terminal internal carotid circulation, development of fragile collateral networks, impaired cerebrovascular reserve, and risk of ischemic or hemorrhagic stroke. Surgical revascularization is the principal disease-modifying treatment in symptomatic and hemodynamically compromised patients. However, the optimal strategy cannot be reduced to a universal choice between direct, indirect, and combined bypass because adult moyamoya disease encompasses heterogeneous ischemic, hemorrhagic, asymptomatic, cognitive, and collateral-dominant phenotypes.
Materials and Methods. A structured narrative review was performed using contemporary guidelines,  randomized  and  prospective  studies,  population-based  cohorts,  hemodynamic investigations,  and  surgical  series  published  through  August  2026.  Evidence  was  synthesized regarding  direct  superficial  temporal  artery–middle  cerebral  artery  bypass,  indirect  synangiosis, combined  revascularization,  cerebral  perfusion  imaging,  cerebrovascular  reserve,  periventricular collateral anatomy, postoperative hyperperfusion, cerebral infarction, cognition, and genetic predictors of revascularization.
Results. Direct bypass provides immediate flow augmentation, whereas indirect procedures depend  on  delayed  extracranial–intracranial  neoangiogenesis.  Combined  surgery  offers  both mechanisms and may provide broader long-term revascularization in adults. Hemorrhagic moyamoya represents a distinct surgical phenotype in which bypass can reduce rebleeding risk, particularly in patients  with  high-risk  posterior  hemorrhage  and  fragile  periventricular  collateral  pathways.  In ischemic moyamoya, surgical selection should integrate symptoms with objective hemodynamic compromise rather than angiographic stenosis alone. Cerebral hyperperfusion syndrome remains a major postoperative complication after direct bypass and is associated with impaired autoregulation, regional perfusion abnormalities, and abrupt redistribution of blood flow. Newer CT perfusion, arterial spin labeling, Flow800, Doppler, and genetic approaches are increasingly capable of predicting postoperative perfusion patterns and neoangiogenesis.
Conclusion. Adult moyamoya surgery is evolving from standardized bypass selection toward precision  revascularization.  The  optimal  operation  should  be  determined  by  clinical  phenotype, regional  cerebrovascular  reserve,  collateral  architecture,  recipient-vessel  anatomy,  genetic background,  and  predicted  perioperative  hemodynamic  response.  Direct  flow  augmentation  and indirect  neoangiogenesis  should  be  regarded  as  complementary  physiological  tools  rather  than competing techniques.
Keywords: moyamoya  disease;  cerebral  revascularization; STA–MCA bypass; combined bypass;  indirect  bypass;  cerebral  perfusion;  cerebrovascular  reserve;  cerebral  hyperperfusion syndrome; RNF213; precision cerebrovascular surgery.