Exploring Variability in Direct, Indirect, and Combined Revascularization for Pediatric Moyamoya: A Narrative Review

Various surgical approaches are available for treating symptomatic pediatric moyamoya. However, there is still considerable debate about the ideal treatment modality, particularly among direct bypass (DB), indirect bypass (IB), and combined bypass (CB). Our aim in this study is to comparatively evaluate these surgical options, emphasizing technical considerations, complication risk profiles, and evidence-based short- and long-term clinical outcomes. A comprehensive literature review was performed through May 2026 using the PubMed and Google Scholar databases, incorporating MeSH terms "pediatric moyamoya", "direct", "indirect", and "combined". A total of 88 articles, published up to December 2025, were included in the final full-text review and analyzed for surgical approach, efficacy, risks, and outcomes. The articles comprised 30 retrospective cohort studies, 6 case series and case reports, 6 systematic reviews and meta-analyses, 10 literature reviews, 4 guidelines, 5 prospective studies, 23 imaging and physiological studies, and 4 basic and translational studies. The advantages and limitations of the revascularization techniques were described. Overall, DB, IB, and CB all yielded more favorable outcomes than conservative management, with no single approach demonstrating universal superiority. While DB and CB immediately restored cerebral blood flow to ischemic areas, IB demonstrated comparable clinical and neurocognitive outcomes, with lower technical complexity and operative risk. First-line management of pediatric moyamoya should be determined on a case-by-case basis, taking into account the neurosurgeon's surgical experience and expertise.