Direct Versus Indirect Bypass in Early-Stage Moyamoya (Suzuki I-III): A Propensity Score-Weighted Study

Basel Musmar; Joanna M. Roy; Hammam Abdalrazeq; Victor Gabriel El-Hajj; Michael Rizzuto; Matthews Lan; Pious Patel; Michael Baldassari; Arbaz Momin; Yazan Shamli Oghli; Marissa Tucci; Joseph Schaefer; Caitlin Ritz; Keenan Piper; Marc Mounzer; Kareem El Naamani; Ching Jen Chen; Roland Jabre; Hassan Saad; Jonathan A. Grossberg; Adam A. Dmytriw; Aman B. Patel; Mirhojjat Khorasanizadeh; Christopher S. Ogilvy; Ajith J. Thomas; Andre Monteiro; Adnan Siddiqui; Gustavo M. Cortez; Ricardo A. Hanel; Guilherme Porto; Alejandro M. Spiotta; Anthony J. Piscopo; David M. Hasan; Mohammad Ghorbani; Joshua Weinberg; Shahid M. Nimjee; Kimon Bekelis; Mohamed M. Salem; Jan Karl Burkhardt; Akli Zetchi; Charles Matouk; Brian M. Howard; Rosalind Lai; Rose Du; Stavropoula I. Tjoumakaris; Michael Reid Gooch; Robert H. Rosenwasser; Pascal Jabbour

doi:10.1007/s12975-026-01448-3

Direct Versus Indirect Bypass in Early-Stage Moyamoya (Suzuki I-III): A Propensity Score-Weighted Study

Basel Musmar
, Joanna M. Roy
, Hammam Abdalrazeq
, Victor Gabriel El-Hajj
, Michael Rizzuto
, Matthews Lan
, Pious Patel
, Michael Baldassari
, Arbaz Momin
, Yazan Shamli Oghli
, Marissa Tucci
, Joseph Schaefer
, Caitlin Ritz
, Keenan Piper
, Marc Mounzer
, Kareem El Naamani
, Ching Jen Chen
, Roland Jabre
, Hassan Saad
, Jonathan A. Grossberg

Adam A. Dmytriw, Aman B. Patel, Mirhojjat Khorasanizadeh, Christopher S. Ogilvy, Ajith J. Thomas, Andre Monteiro, Adnan Siddiqui, Gustavo M. Cortez, Ricardo A. Hanel, Guilherme Porto, Alejandro M. Spiotta, Anthony J. Piscopo, David M. Hasan, Mohammad Ghorbani, Joshua Weinberg, Shahid M. Nimjee, Kimon Bekelis, Mohamed M. Salem, Jan Karl Burkhardt, Akli Zetchi, Charles Matouk, Brian M. Howard, Rosalind Lai, Rose Du, Stavropoula I. Tjoumakaris, Michael Reid Gooch, Robert H. Rosenwasser, Pascal Jabbour

Neurosurgery

Thomas Jefferson University
University of Arizona
Creighton University Medical Center
Emory University
University of Toronto
Harvard University
Cooper University Health Care
SUNY Buffalo
Baptist Health
Medical University of South Carolina
University of Iowa
Duke University
Iran University of Medical Sciences
Ohio State University
Good Samaritan Hospital Medical Center
University of Pennsylvania
Yale University

Research output: Contribution to journal › Article › peer-review

Abstract

Moyamoya angiopathy (MMA) lacks stage-specific comparative evidence for surgical strategy. Because many studies mix Suzuki grades, potential technique effects may be obscured. We compared direct revascularization (DR) with indirect revascularization (IR) in a stage-restricted cohort (Suzuki I-III), using propensity score weighting (PSW). We conducted a multicenter retrospective cohort study across 13 academic centers. Adults with confirmed MMA (Suzuki I-III) who underwent DR or IR were included. Patients < 16 years and combined procedures were excluded. Outcomes were symptomatic stroke, overall perioperative stroke, intraoperative complications, discharge NIHSS/mRS, length of stay, and follow-up stroke. PSW used Covariate Balancing Propensity Scores (CBPS) with absolute standardized mean difference (ASMD) diagnostics. Group differences were modeled with logistic/linear regression, and stroke-free survival was compared by Kaplan-Meier/log-rank. We analyzed 208 hemispheres (IR = 104; DR = 104). Baseline demographics and comorbidities were similar. Unadjusted analyses showed no significant differences in overall perioperative stroke (10.5% IR vs. 8.6% DR; p=.63), symptomatic perioperative stroke, intraoperative complications, discharge NIHSS/mRS, length of stay, or follow-up stroke (8.6% IR vs. 5.8% DR; p=.43). Stroke-free survival did not differ (log-rank p=.40). After PSW, findings remained unchanged across endpoints (e.g., all perioperative stroke OR 1.82; 95% CI, 0.61 to 5.45; p=.27). In adults with MMA at Suzuki I-III, no significant between-group differences were detected between DR and IR in the studied clinical outcomes. Technique selection can be individualized to anatomy, hemodynamics, and center expertise. Prospective, stage-stratified studies with standardized angiographic and hemodynamic endpoints are warranted.

Original language	English
Article number	55
Journal	Translational Stroke Research
Volume	17
Issue number	3
DOIs	https://doi.org/10.1007/s12975-026-01448-3
State	Published - Jun 2026

Keywords

Bypass
Direct
Indirect
Moyamoya
Suzuki

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10.1007/s12975-026-01448-3

Cite this

Musmar, B., Roy, J. M., Abdalrazeq, H., El-Hajj, V. G., Rizzuto, M., Lan, M., Patel, P., Baldassari, M., Momin, A., Oghli, Y. S., Tucci, M., Schaefer, J., Ritz, C., Piper, K., Mounzer, M., Naamani, K. E., Chen, C. J., Jabre, R., Saad, H., ... Jabbour, P. (2026). Direct Versus Indirect Bypass in Early-Stage Moyamoya (Suzuki I-III): A Propensity Score-Weighted Study. Translational Stroke Research, 17(3), Article 55. https://doi.org/10.1007/s12975-026-01448-3

@article{8ca672b21f2a4505bbc2fa0efd6877ff,

title = "Direct Versus Indirect Bypass in Early-Stage Moyamoya (Suzuki I-III): A Propensity Score-Weighted Study",

abstract = "Moyamoya angiopathy (MMA) lacks stage-specific comparative evidence for surgical strategy. Because many studies mix Suzuki grades, potential technique effects may be obscured. We compared direct revascularization (DR) with indirect revascularization (IR) in a stage-restricted cohort (Suzuki I-III), using propensity score weighting (PSW). We conducted a multicenter retrospective cohort study across 13 academic centers. Adults with confirmed MMA (Suzuki I-III) who underwent DR or IR were included. Patients < 16 years and combined procedures were excluded. Outcomes were symptomatic stroke, overall perioperative stroke, intraoperative complications, discharge NIHSS/mRS, length of stay, and follow-up stroke. PSW used Covariate Balancing Propensity Scores (CBPS) with absolute standardized mean difference (ASMD) diagnostics. Group differences were modeled with logistic/linear regression, and stroke-free survival was compared by Kaplan-Meier/log-rank. We analyzed 208 hemispheres (IR = 104; DR = 104). Baseline demographics and comorbidities were similar. Unadjusted analyses showed no significant differences in overall perioperative stroke (10.5\% IR vs. 8.6\% DR; p=.63), symptomatic perioperative stroke, intraoperative complications, discharge NIHSS/mRS, length of stay, or follow-up stroke (8.6\% IR vs. 5.8\% DR; p=.43). Stroke-free survival did not differ (log-rank p=.40). After PSW, findings remained unchanged across endpoints (e.g., all perioperative stroke OR 1.82; 95\% CI, 0.61 to 5.45; p=.27). In adults with MMA at Suzuki I-III, no significant between-group differences were detected between DR and IR in the studied clinical outcomes. Technique selection can be individualized to anatomy, hemodynamics, and center expertise. Prospective, stage-stratified studies with standardized angiographic and hemodynamic endpoints are warranted.",

keywords = "Bypass, Direct, Indirect, Moyamoya, Suzuki",

author = "Basel Musmar and Roy, \{Joanna M.\} and Hammam Abdalrazeq and El-Hajj, \{Victor Gabriel\} and Michael Rizzuto and Matthews Lan and Pious Patel and Michael Baldassari and Arbaz Momin and Oghli, \{Yazan Shamli\} and Marissa Tucci and Joseph Schaefer and Caitlin Ritz and Keenan Piper and Marc Mounzer and Naamani, \{Kareem El\} and Chen, \{Ching Jen\} and Roland Jabre and Hassan Saad and Grossberg, \{Jonathan A.\} and Dmytriw, \{Adam A.\} and Patel, \{Aman B.\} and Mirhojjat Khorasanizadeh and Ogilvy, \{Christopher S.\} and Thomas, \{Ajith J.\} and Andre Monteiro and Adnan Siddiqui and Cortez, \{Gustavo M.\} and Hanel, \{Ricardo A.\} and Guilherme Porto and Spiotta, \{Alejandro M.\} and Piscopo, \{Anthony J.\} and Hasan, \{David M.\} and Mohammad Ghorbani and Joshua Weinberg and Nimjee, \{Shahid M.\} and Kimon Bekelis and Salem, \{Mohamed M.\} and Burkhardt, \{Jan Karl\} and Akli Zetchi and Charles Matouk and Howard, \{Brian M.\} and Rosalind Lai and Rose Du and Tjoumakaris, \{Stavropoula I.\} and Gooch, \{Michael Reid\} and Rosenwasser, \{Robert H.\} and Pascal Jabbour",

note = "Publisher Copyright: {\textcopyright} The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2026.",

year = "2026",

month = jun,

doi = "10.1007/s12975-026-01448-3",

language = "English",

volume = "17",

journal = "Translational Stroke Research",

issn = "1868-4483",

publisher = "Springer",

number = "3",

}

Musmar, B, Roy, JM, Abdalrazeq, H, El-Hajj, VG, Rizzuto, M, Lan, M, Patel, P, Baldassari, M, Momin, A, Oghli, YS, Tucci, M, Schaefer, J, Ritz, C, Piper, K, Mounzer, M, Naamani, KE, Chen, CJ, Jabre, R, Saad, H, Grossberg, JA, Dmytriw, AA, Patel, AB, Khorasanizadeh, M, Ogilvy, CS, Thomas, AJ, Monteiro, A, Siddiqui, A, Cortez, GM, Hanel, RA, Porto, G, Spiotta, AM, Piscopo, AJ, Hasan, DM, Ghorbani, M, Weinberg, J, Nimjee, SM, Bekelis, K, Salem, MM, Burkhardt, JK, Zetchi, A, Matouk, C, Howard, BM, Lai, R, Du, R, Tjoumakaris, SI, Gooch, MR, Rosenwasser, RH & Jabbour, P 2026, 'Direct Versus Indirect Bypass in Early-Stage Moyamoya (Suzuki I-III): A Propensity Score-Weighted Study', Translational Stroke Research, vol. 17, no. 3, 55. https://doi.org/10.1007/s12975-026-01448-3

TY - JOUR

T1 - Direct Versus Indirect Bypass in Early-Stage Moyamoya (Suzuki I-III)

T2 - A Propensity Score-Weighted Study

AU - Musmar, Basel

AU - Roy, Joanna M.

AU - Abdalrazeq, Hammam

AU - El-Hajj, Victor Gabriel

AU - Rizzuto, Michael

AU - Lan, Matthews

AU - Patel, Pious

AU - Baldassari, Michael

AU - Momin, Arbaz

AU - Oghli, Yazan Shamli

AU - Tucci, Marissa

AU - Schaefer, Joseph

AU - Ritz, Caitlin

AU - Piper, Keenan

AU - Mounzer, Marc

AU - Naamani, Kareem El

AU - Chen, Ching Jen

AU - Jabre, Roland

AU - Saad, Hassan

AU - Grossberg, Jonathan A.

AU - Dmytriw, Adam A.

AU - Patel, Aman B.

AU - Khorasanizadeh, Mirhojjat

AU - Ogilvy, Christopher S.

AU - Thomas, Ajith J.

AU - Monteiro, Andre

AU - Siddiqui, Adnan

AU - Cortez, Gustavo M.

AU - Hanel, Ricardo A.

AU - Porto, Guilherme

AU - Spiotta, Alejandro M.

AU - Piscopo, Anthony J.

AU - Hasan, David M.

AU - Ghorbani, Mohammad

AU - Weinberg, Joshua

AU - Nimjee, Shahid M.

AU - Bekelis, Kimon

AU - Salem, Mohamed M.

AU - Burkhardt, Jan Karl

AU - Zetchi, Akli

AU - Matouk, Charles

AU - Howard, Brian M.

AU - Lai, Rosalind

AU - Du, Rose

AU - Tjoumakaris, Stavropoula I.

AU - Gooch, Michael Reid

AU - Rosenwasser, Robert H.

AU - Jabbour, Pascal

N1 - Publisher Copyright: © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2026.

PY - 2026/6

Y1 - 2026/6

N2 - Moyamoya angiopathy (MMA) lacks stage-specific comparative evidence for surgical strategy. Because many studies mix Suzuki grades, potential technique effects may be obscured. We compared direct revascularization (DR) with indirect revascularization (IR) in a stage-restricted cohort (Suzuki I-III), using propensity score weighting (PSW). We conducted a multicenter retrospective cohort study across 13 academic centers. Adults with confirmed MMA (Suzuki I-III) who underwent DR or IR were included. Patients < 16 years and combined procedures were excluded. Outcomes were symptomatic stroke, overall perioperative stroke, intraoperative complications, discharge NIHSS/mRS, length of stay, and follow-up stroke. PSW used Covariate Balancing Propensity Scores (CBPS) with absolute standardized mean difference (ASMD) diagnostics. Group differences were modeled with logistic/linear regression, and stroke-free survival was compared by Kaplan-Meier/log-rank. We analyzed 208 hemispheres (IR = 104; DR = 104). Baseline demographics and comorbidities were similar. Unadjusted analyses showed no significant differences in overall perioperative stroke (10.5% IR vs. 8.6% DR; p=.63), symptomatic perioperative stroke, intraoperative complications, discharge NIHSS/mRS, length of stay, or follow-up stroke (8.6% IR vs. 5.8% DR; p=.43). Stroke-free survival did not differ (log-rank p=.40). After PSW, findings remained unchanged across endpoints (e.g., all perioperative stroke OR 1.82; 95% CI, 0.61 to 5.45; p=.27). In adults with MMA at Suzuki I-III, no significant between-group differences were detected between DR and IR in the studied clinical outcomes. Technique selection can be individualized to anatomy, hemodynamics, and center expertise. Prospective, stage-stratified studies with standardized angiographic and hemodynamic endpoints are warranted.

AB - Moyamoya angiopathy (MMA) lacks stage-specific comparative evidence for surgical strategy. Because many studies mix Suzuki grades, potential technique effects may be obscured. We compared direct revascularization (DR) with indirect revascularization (IR) in a stage-restricted cohort (Suzuki I-III), using propensity score weighting (PSW). We conducted a multicenter retrospective cohort study across 13 academic centers. Adults with confirmed MMA (Suzuki I-III) who underwent DR or IR were included. Patients < 16 years and combined procedures were excluded. Outcomes were symptomatic stroke, overall perioperative stroke, intraoperative complications, discharge NIHSS/mRS, length of stay, and follow-up stroke. PSW used Covariate Balancing Propensity Scores (CBPS) with absolute standardized mean difference (ASMD) diagnostics. Group differences were modeled with logistic/linear regression, and stroke-free survival was compared by Kaplan-Meier/log-rank. We analyzed 208 hemispheres (IR = 104; DR = 104). Baseline demographics and comorbidities were similar. Unadjusted analyses showed no significant differences in overall perioperative stroke (10.5% IR vs. 8.6% DR; p=.63), symptomatic perioperative stroke, intraoperative complications, discharge NIHSS/mRS, length of stay, or follow-up stroke (8.6% IR vs. 5.8% DR; p=.43). Stroke-free survival did not differ (log-rank p=.40). After PSW, findings remained unchanged across endpoints (e.g., all perioperative stroke OR 1.82; 95% CI, 0.61 to 5.45; p=.27). In adults with MMA at Suzuki I-III, no significant between-group differences were detected between DR and IR in the studied clinical outcomes. Technique selection can be individualized to anatomy, hemodynamics, and center expertise. Prospective, stage-stratified studies with standardized angiographic and hemodynamic endpoints are warranted.

KW - Bypass

KW - Direct

KW - Indirect

KW - Moyamoya

KW - Suzuki

UR - https://www.scopus.com/pages/publications/105039336821

U2 - 10.1007/s12975-026-01448-3

DO - 10.1007/s12975-026-01448-3

M3 - Article

C2 - 42138779

AN - SCOPUS:105039336821

SN - 1868-4483

VL - 17

JO - Translational Stroke Research

JF - Translational Stroke Research

IS - 3

M1 - 55

ER -

Direct Versus Indirect Bypass in Early-Stage Moyamoya (Suzuki I-III): A Propensity Score-Weighted Study

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Keywords

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