What evidence exists on the efficacy of antiplatelet therapy for moyamoya disease?
Several meta-analyses and case series have compared antiplatelet therapy with surgical bypass or observation alone with mixed results.393,397 399 Although some found a benefit or no difference with antiplatelet therapy, others found surgery to be more effective. A propensity score matched analysis by Onozuka found that prehospital antiplatelet use was significantly associated with good functional status on hospital admission for patients with non-hemorrhagic moyamoya disease in Japan. An international survey of perceived experts in the treatment of moyamoya disease reported that the majority of non-Asian respondents recommended antiplatelet therapy, in contrast to their Asian counterparts. Antiplatelet therapy may also be of benefit in conjunction with surgical revascularization. However, many studies include patients with both ischemic and hemorrhagic moyamoya disease, and conclusions are often based on subgroup analyses. There are no prospective RCTs comparing the efficacy of the most common surgical revascularization procedures used for the prevention of ischemic events in this patient population.