Outcomes of bypass surgery in asymptomatic moyamoya angiopathy: A multicenter study with propensity-score weighting

Basel Musmar; Hammam Abdalrazeq; Joanna M. Roy; Nimer Adeeb; Elias Atallah; Kareem El Naamani; Ching Jen Chen; Roland Jabre; Hassan Saad; Jonathan A. Grossberg; Adam A. Dmytriw; Aman B. Patel; Mirhojjat Khorasanizadeh; Christopher S. Ogilvy; Andre Monteiro; Adnan Siddiqui; Gustavo M. Cortez; Ricardo A. Hanel; Alejandro M. Spiotta; Anthony J. Piscopo; David M. Hasan; Mohammad Ghorbani; Joshua Weinberg; Shahid M. Nimjee; Mohamed M. Salem; Jan Karl Burkhardt; Akli Zetchi; Charles Matouk; Brian M. Howard; Rosalind Lai; Rose Du; Rawad Abbas; Abdelaziz Amllay; Alfredo Munoz; Nabeel A. Herial; Stavropoula I. Tjoumakaris; Michael Reid Gooch; Christina Notarianni; Bharat Guthikonda; Robert H. Rosenwasser; Pascal Jabbour

doi:10.1093/esj/23969873251365504

Outcomes of bypass surgery in asymptomatic moyamoya angiopathy: A multicenter study with propensity-score weighting

Basel Musmar
, Hammam Abdalrazeq
, Joanna M. Roy
, Nimer Adeeb
, Elias Atallah
, Kareem El Naamani
, Ching Jen Chen
, Roland Jabre
, Hassan Saad
, Jonathan A. Grossberg
, Adam A. Dmytriw
, Aman B. Patel
, Mirhojjat Khorasanizadeh
, Christopher S. Ogilvy
, Andre Monteiro
, Adnan Siddiqui
, Gustavo M. Cortez
, Ricardo A. Hanel
, Alejandro M. Spiotta
, Anthony J. Piscopo

David M. Hasan, Mohammad Ghorbani, Joshua Weinberg, Shahid M. Nimjee, Mohamed M. Salem, Jan Karl Burkhardt, Akli Zetchi, Charles Matouk, Brian M. Howard, Rosalind Lai, Rose Du, Rawad Abbas, Abdelaziz Amllay, Alfredo Munoz, Nabeel A. Herial, Stavropoula I. Tjoumakaris, Michael Reid Gooch, Christina Notarianni, Bharat Guthikonda, Robert H. Rosenwasser, Pascal Jabbour

Neurosurgery

Thomas Jefferson University
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Harvard University
Cooper University Health Care
SUNY Buffalo
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Iran University of Medical Sciences
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Good Samaritan Hospital Medical Center
University of Pennsylvania
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Research output: Contribution to journal › Article › peer-review

Abstract

Abstract Introduction Asymptomatic moyamoya angiopathy (MMA) is increasingly detected through noninvasive imaging; however, its optimal management remains controversial. This multicenter retrospective cohort study compared outcomes in asymptomatic versus symptomatic MMA patients undergoing surgical revascularization. Patients and methods A total of 475 patients treated with bypass surgery across multiple academic centers were included, with 56 (11.8%) classified as asymptomatic and 419 (88.2%) as symptomatic. Baseline demographics, surgical characteristics, and outcomes-including perioperative stroke, intraoperative complications, and follow-up stroke events-were collected. Asymptomatic MMA was defined as the absence of any prior ischemic or hemorrhagic stroke, seizures, or other neurological symptoms at the time of diagnosis. Both unadjusted analyses and propensity score weighting using inverse probability of treatment weighting (IPTW) were performed to adjust for potential confounders. Results In the unadjusted analysis, asymptomatic patients had significantly lower rates of all perioperative strokes (1.7% vs 11.4%; p = 0.05) and intraoperative complications (1.7% vs 11.2%; p = 0.05) compared to symptomatic patients. Additionally, follow-up stroke rates were lower in the asymptomatic group (1.7% vs 11.2%; p = 0.05). After IPTW adjustment, the reduction in intraoperative complications (OR: 0.08, 95% CI: 0.01–0.64; p = 0.01) and follow-up stroke rates (OR: 0.12, 95% CI: 0.01–0.91; p = 0.04) persisted, while differences in overall perioperative stroke were not statistically significant. Conclusion Bypass surgery in selected asymptomatic MMA patients is associated with reduced intraoperative complications, and fewer follow-up stroke rates. These findings support the careful consideration of surgical intervention in asymptomatic patients, emphasizing the importance of patient selection for optimal outcomes.

Original language	English
Journal	European Stroke Journal
Volume	11
Issue number	1
DOIs	https://doi.org/10.1093/esj/23969873251365504
State	Published - Mar 2026

Keywords

IPTW%
MMA
asymptomatic
bypass
stroke

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10.1093/esj/23969873251365504

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Musmar, B., Abdalrazeq, H., Roy, J. M., Adeeb, N., Atallah, E., El Naamani, K., Chen, C. J., Jabre, R., Saad, H., Grossberg, J. A., Dmytriw, A. A., Patel, A. B., Khorasanizadeh, M., Ogilvy, C. S., Monteiro, A., Siddiqui, A., Cortez, G. M., Hanel, R. A., Spiotta, A. M., ... Jabbour, P. (2026). Outcomes of bypass surgery in asymptomatic moyamoya angiopathy: A multicenter study with propensity-score weighting. European Stroke Journal, 11(1). https://doi.org/10.1093/esj/23969873251365504

@article{f5840609c6864d5ebff499c7d3ff2439,

title = "Outcomes of bypass surgery in asymptomatic moyamoya angiopathy: A multicenter study with propensity-score weighting",

abstract = "Abstract Introduction Asymptomatic moyamoya angiopathy (MMA) is increasingly detected through noninvasive imaging; however, its optimal management remains controversial. This multicenter retrospective cohort study compared outcomes in asymptomatic versus symptomatic MMA patients undergoing surgical revascularization. Patients and methods A total of 475 patients treated with bypass surgery across multiple academic centers were included, with 56 (11.8\%) classified as asymptomatic and 419 (88.2\%) as symptomatic. Baseline demographics, surgical characteristics, and outcomes-including perioperative stroke, intraoperative complications, and follow-up stroke events-were collected. Asymptomatic MMA was defined as the absence of any prior ischemic or hemorrhagic stroke, seizures, or other neurological symptoms at the time of diagnosis. Both unadjusted analyses and propensity score weighting using inverse probability of treatment weighting (IPTW) were performed to adjust for potential confounders. Results In the unadjusted analysis, asymptomatic patients had significantly lower rates of all perioperative strokes (1.7\% vs 11.4\%; p = 0.05) and intraoperative complications (1.7\% vs 11.2\%; p = 0.05) compared to symptomatic patients. Additionally, follow-up stroke rates were lower in the asymptomatic group (1.7\% vs 11.2\%; p = 0.05). After IPTW adjustment, the reduction in intraoperative complications (OR: 0.08, 95\% CI: 0.01–0.64; p = 0.01) and follow-up stroke rates (OR: 0.12, 95\% CI: 0.01–0.91; p = 0.04) persisted, while differences in overall perioperative stroke were not statistically significant. Conclusion Bypass surgery in selected asymptomatic MMA patients is associated with reduced intraoperative complications, and fewer follow-up stroke rates. These findings support the careful consideration of surgical intervention in asymptomatic patients, emphasizing the importance of patient selection for optimal outcomes.",

keywords = "IPTW\%, MMA, asymptomatic, bypass, stroke",

author = "Basel Musmar and Hammam Abdalrazeq and Roy, \{Joanna M.\} and Nimer Adeeb and Elias Atallah and \{El Naamani\}, Kareem 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 Andre Monteiro and Adnan Siddiqui and Cortez, \{Gustavo M.\} and Hanel, \{Ricardo A.\} and Spiotta, \{Alejandro M.\} and Piscopo, \{Anthony J.\} and Hasan, \{David M.\} and Mohammad Ghorbani and Joshua Weinberg and Nimjee, \{Shahid M.\} 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 Rawad Abbas and Abdelaziz Amllay and Alfredo Munoz and Herial, \{Nabeel A.\} and Tjoumakaris, \{Stavropoula I.\} and Gooch, \{Michael Reid\} and Christina Notarianni and Bharat Guthikonda and Rosenwasser, \{Robert H.\} and Pascal Jabbour",

note = "Publisher Copyright: {\textcopyright} The Author(s) 2026. Published by Oxford University Press on behalf of the European Stroke Organisation 2026",

year = "2026",

month = mar,

doi = "10.1093/esj/23969873251365504",

language = "English",

volume = "11",

journal = "European Stroke Journal",

issn = "2396-9873",

publisher = "SAGE Publications Inc.",

number = "1",

}

Musmar, B, Abdalrazeq, H, Roy, JM, Adeeb, N, Atallah, E, El Naamani, K, Chen, CJ, Jabre, R, Saad, H, Grossberg, JA, Dmytriw, AA, Patel, AB, Khorasanizadeh, M, Ogilvy, CS, Monteiro, A, Siddiqui, A, Cortez, GM, Hanel, RA, Spiotta, AM, Piscopo, AJ, Hasan, DM, Ghorbani, M, Weinberg, J, Nimjee, SM, Salem, MM, Burkhardt, JK, Zetchi, A, Matouk, C, Howard, BM, Lai, R, Du, R, Abbas, R, Amllay, A, Munoz, A, Herial, NA, Tjoumakaris, SI, Gooch, MR, Notarianni, C, Guthikonda, B, Rosenwasser, RH & Jabbour, P 2026, 'Outcomes of bypass surgery in asymptomatic moyamoya angiopathy: A multicenter study with propensity-score weighting', European Stroke Journal, vol. 11, no. 1. https://doi.org/10.1093/esj/23969873251365504

TY - JOUR

T1 - Outcomes of bypass surgery in asymptomatic moyamoya angiopathy

T2 - A multicenter study with propensity-score weighting

AU - Musmar, Basel

AU - Abdalrazeq, Hammam

AU - Roy, Joanna M.

AU - Adeeb, Nimer

AU - Atallah, Elias

AU - El Naamani, Kareem

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 - Monteiro, Andre

AU - Siddiqui, Adnan

AU - Cortez, Gustavo M.

AU - Hanel, Ricardo A.

AU - Spiotta, Alejandro M.

AU - Piscopo, Anthony J.

AU - Hasan, David M.

AU - Ghorbani, Mohammad

AU - Weinberg, Joshua

AU - Nimjee, Shahid M.

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 - Abbas, Rawad

AU - Amllay, Abdelaziz

AU - Munoz, Alfredo

AU - Herial, Nabeel A.

AU - Tjoumakaris, Stavropoula I.

AU - Gooch, Michael Reid

AU - Notarianni, Christina

AU - Guthikonda, Bharat

AU - Rosenwasser, Robert H.

AU - Jabbour, Pascal

PY - 2026/3

Y1 - 2026/3

N2 - Abstract Introduction Asymptomatic moyamoya angiopathy (MMA) is increasingly detected through noninvasive imaging; however, its optimal management remains controversial. This multicenter retrospective cohort study compared outcomes in asymptomatic versus symptomatic MMA patients undergoing surgical revascularization. Patients and methods A total of 475 patients treated with bypass surgery across multiple academic centers were included, with 56 (11.8%) classified as asymptomatic and 419 (88.2%) as symptomatic. Baseline demographics, surgical characteristics, and outcomes-including perioperative stroke, intraoperative complications, and follow-up stroke events-were collected. Asymptomatic MMA was defined as the absence of any prior ischemic or hemorrhagic stroke, seizures, or other neurological symptoms at the time of diagnosis. Both unadjusted analyses and propensity score weighting using inverse probability of treatment weighting (IPTW) were performed to adjust for potential confounders. Results In the unadjusted analysis, asymptomatic patients had significantly lower rates of all perioperative strokes (1.7% vs 11.4%; p = 0.05) and intraoperative complications (1.7% vs 11.2%; p = 0.05) compared to symptomatic patients. Additionally, follow-up stroke rates were lower in the asymptomatic group (1.7% vs 11.2%; p = 0.05). After IPTW adjustment, the reduction in intraoperative complications (OR: 0.08, 95% CI: 0.01–0.64; p = 0.01) and follow-up stroke rates (OR: 0.12, 95% CI: 0.01–0.91; p = 0.04) persisted, while differences in overall perioperative stroke were not statistically significant. Conclusion Bypass surgery in selected asymptomatic MMA patients is associated with reduced intraoperative complications, and fewer follow-up stroke rates. These findings support the careful consideration of surgical intervention in asymptomatic patients, emphasizing the importance of patient selection for optimal outcomes.

AB - Abstract Introduction Asymptomatic moyamoya angiopathy (MMA) is increasingly detected through noninvasive imaging; however, its optimal management remains controversial. This multicenter retrospective cohort study compared outcomes in asymptomatic versus symptomatic MMA patients undergoing surgical revascularization. Patients and methods A total of 475 patients treated with bypass surgery across multiple academic centers were included, with 56 (11.8%) classified as asymptomatic and 419 (88.2%) as symptomatic. Baseline demographics, surgical characteristics, and outcomes-including perioperative stroke, intraoperative complications, and follow-up stroke events-were collected. Asymptomatic MMA was defined as the absence of any prior ischemic or hemorrhagic stroke, seizures, or other neurological symptoms at the time of diagnosis. Both unadjusted analyses and propensity score weighting using inverse probability of treatment weighting (IPTW) were performed to adjust for potential confounders. Results In the unadjusted analysis, asymptomatic patients had significantly lower rates of all perioperative strokes (1.7% vs 11.4%; p = 0.05) and intraoperative complications (1.7% vs 11.2%; p = 0.05) compared to symptomatic patients. Additionally, follow-up stroke rates were lower in the asymptomatic group (1.7% vs 11.2%; p = 0.05). After IPTW adjustment, the reduction in intraoperative complications (OR: 0.08, 95% CI: 0.01–0.64; p = 0.01) and follow-up stroke rates (OR: 0.12, 95% CI: 0.01–0.91; p = 0.04) persisted, while differences in overall perioperative stroke were not statistically significant. Conclusion Bypass surgery in selected asymptomatic MMA patients is associated with reduced intraoperative complications, and fewer follow-up stroke rates. These findings support the careful consideration of surgical intervention in asymptomatic patients, emphasizing the importance of patient selection for optimal outcomes.

KW - IPTW%

KW - MMA

KW - asymptomatic

KW - bypass

KW - stroke

UR - https://www.scopus.com/pages/publications/105028999586

U2 - 10.1093/esj/23969873251365504

DO - 10.1093/esj/23969873251365504

M3 - Article

C2 - 41614506

AN - SCOPUS:105028999586

SN - 2396-9873

VL - 11

JO - European Stroke Journal

JF - European Stroke Journal

IS - 1

ER -

Outcomes of bypass surgery in asymptomatic moyamoya angiopathy: A multicenter study with propensity-score weighting

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