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Published on: January 18, 2018
Optimizing Surgical Timing to Reduce Stroke Risk in Pediatric Moyamoya Disease
Jiali Xu1, Bin Li2, Heguan Fu2
1Department of Rehabilitation Medicine, Neurology Center, Beijing Shijitan Hospital, Capital Medical University, China (J.X., X.J., X.C.).
Insights
Optimal surgical timing for pediatric moyamoya disease reduces stroke risk. Intervention within 2.5 months for infarction-onset, 6.5 months for high-risk TIA-onset, and 5 years for nonischemic cases is recommended.
Area of Science:
- Pediatric Neurology
- Neurosurgery
- Vascular Neurology
Background:
- Moyamoya disease poses a significant stroke risk in children.
- Optimal surgical timing for revascularization remains unclear, hindering clinical decisions.
- Evidence guiding surgical intervention timing for pediatric moyamoya disease is limited.
Purpose of the Study:
- To determine optimal surgical timing for pediatric moyamoya disease based on symptom presentation.
- To identify specific time intervals for revascularization surgery to minimize stroke risk.
- To analyze the impact of surgical timing on preoperative and perioperative stroke events.
Main Methods:
- Retrospective review of 736 pediatric moyamoya disease patients undergoing revascularization.
- Categorization by symptom onset: infarction, transient ischemic attack (high/low risk), or nonischemic.
- Statistical analysis using ROC curves and multivariate analysis to determine surgical timing thresholds.
Main Results:
- For infarction-onset and high-risk TIA-onset, surgery within 2.5 and 6.5 months, respectively, reduced cerebral infarction risk.
- For nonischemic patients, surgery within 5 years reduced cerebral hemorrhage risk.
- Earlier surgery in infarction or high-risk TIA cases did not elevate perioperative stroke incidence.
Conclusions:
- Surgical timing is crucial for mitigating stroke risk in pediatric moyamoya disease.
- Recommended surgical windows: 2.5 months (infarction-onset), 6.5 months (high-risk TIA-onset), and 5 years (nonischemic).
- Timely revascularization is safe and effective in reducing stroke events in pediatric moyamoya disease.
Background:
Identifying the optimal surgical timing is critical for reducing stroke risk in pediatric patients with moyamoya disease, but evidence to guide clinical decision-making remains limited. This study aimed to determine the optimal surgical timing based on different symptom onset patterns.
Methods:
We retrospectively reviewed pediatric patients with moyamoya disease who underwent revascularization surgery at a single center in China between July 2007 and July 2018. Patients were categorized by symptom onset pattern: infarction-onset, transient ischemic attack (TIA)-onset, or nonischemic. The TIA-onset group was further subdivided into high-risk and low-risk subgroups. Data on preoperative/perioperative stroke events and diagnosis-to-operation intervals were collected. Receiver operating characteristic curves and multivariate analyses were used to identify surgical timing thresholds. Stroke incidences were compared across groups stratified by surgical interval.
Results:
A total of 736 patients (mean age 7.2±3.9 years; 50.7% male) were included. The incidence density of preoperative cerebral infarction was 11.83 per 1000 person-months, while that of cerebral hemorrhage was 1.21 per 1000 person-months. For patients with infarction-onset and high-risk TIA-onset patterns, a surgical waiting time exceeding 2.5 months (area under the curve, 0.722; specificity, 0.561; sensitivity, 0.882; P<0.001) and 6.5 months (area under the curve, 0.631; specificity, 0.400; sensitivity, 0.804; P=0.006), respectively, was associated with a significantly increased risk of preoperative cerebral infarction. In nonischemic patients, a prolonged surgical waiting time exceeding 5 years (area under the curve, 0.761; specificity, 0.856; sensitivity, 0.571; P<0.05) was associated with a significantly increased risk of cerebral hemorrhage. For patients with initial symptoms of infarction or high-risk TIA, earlier surgery did not increase the incidence of perioperative stroke events.
Conclusions:
For children with moyamoya disease, surgical intervention was beneficial within 2.5 months for patients with infarction-onset, 6.5 months for patients with high-risk TIA onset, and 5 years for nonischemic patients in reducing stroke risk.
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