Collateral circulation after revascularization in moyamoya disease: influencing factors and underlying mechanisms

Cerebral revascularization is a primary treatment for moyamoya disease and is generally considered to improve cerebral perfusion while potentially reducing the risk of stroke recurrence. However, the efficiency of postoperative collateral circulation formation varies significantly among individuals, and some patients continue to experience adverse events, such as recurrent ischemia or cerebral hemorrhage, which may be related to inadequate collateralization. Therefore, identifying the factors influencing the formation of collateral circulation after cerebral revascularization is critical for the treatment of moyamoya disease. Previous studies suggest that multiple factors are associated with postoperative collateral vessel formation, including genetic susceptibility (such as the RNF213 p. R4810K variant and microRNA regulation), angiogenic growth factors (such as VEGF, PDGF, and TGF-β1), soluble receptors (e.g., sTie-2), cellular components (including circulating endothelial progenitor cells and mesenchymal stem cells), structural regulators such as Caveolin-1, as well as clinical variables including surgical modality, patient age, and superficial temporal artery blood flow. This article systematically reviews current evidence on factors associated with collateral circulation formation after cerebral revascularization in patients with moyamoya disease, with the aim of informing future research and optimizing treatment strategies.