How do you determine which type of re-vascularization technique is appropriate to treat a patient with Moya Moya disease?

There are 2 types: indirect and direct. The direct bypass involves suturing a branch of the STA to a cortical branch of the MCA. This is by far the best method to treat ADULT cases. In children, the INDIRECT method, which is easier and does not involve direct suturing of arteries together, is usually adequate in providing long-term revascularization. There are several forms of INDIRECT, including using the temporalis muscle, the inversion of the dura, or in-situ passage of the superficial tempor...

I was recently asked this same question by another physician and provided this answer:

The honest answer is that the evidence for selecting a direct or indirect bypass is limited and imperfect. There are no large randomized controlled trials, and most data comes from retrospective cohort studies and meta-analyses. The key factors favoring direct bypass for moyamoya are age, cerebrovascular reserve, and size of the donor and recipient arteries. That said, I have a bias for direct bypass when poss...