Effects of intraoperative inhalational versus intravenous anesthesia on perioperative neurological outcomes and long-term prognosis in patients with moyamoya disease undergoing revascularization surgery: a systematic review and meta-analysis

BACKGROUND: Moyamoya disease (MMD) is a rare cerebrovascular disorder characterized by progressive stenosis of intracranial carotid arteries and abnormal collateral network formation. Surgical revascularization is the standard treatment for stroke prevention, but the optimal intraoperative anesthetic strategy to minimize perioperative neurological complications remains controversial. This meta-analysis compares inhalational versus intravenous anesthesia for perioperative neurological outcomes in MMD patients undergoing revascularization. METHODS: We systematically searched PubMed, Embase, Cochrane Library, and Web of Science from database inception to April 2026, including randomized controlled trials and high-quality observational studies comparing the two anesthesia regimens. Two investigators independently completed literature screening, data extraction, and risk of bias assessment. Random-effects models were applied to pool effect sizes. Primary outcomes included postoperative transient neurological events (TNEs), post-anesthesia care unit (PACU) delirium, and postoperative stroke. Evidence quality was graded using the GRADE system. RESULTS: Eleven studies (1673 patients, 2232 procedures) were included, with 6 studies constituting the core quantitative analysis set. Outcome coverage varied: 5 studies reported TNEs, 2 reported postoperative stroke, and only 1 single-center study reported PACU delirium. Pooled results showed no significant intergroup difference in TNEs (OR = 0.87, 95% CI: 0.55-1.38, P = 0.56, I² = 61%) or postoperative stroke (OR = 1.05, 95% CI: 0.50-2.17, P = 0.91, I² = 0%). Based on limited pediatric data, inhalational anesthesia may be associated with increased PACU delirium risk in children. Qualitative evidence indicated both regimens maintained stable cerebral oxygenation, while propofol-based intravenous anesthesia had advantages in reducing intracranial pressure and improving surgical field exposure. CONCLUSIONS: Current low-to-very-low quality evidence shows no significant difference in major perioperative neurological complications between the two anesthetic regimens for MMD revascularization. Intravenous anesthesia has potential advantages in intraoperative cerebral physiology and surgical conditions, and may be considered preferentially for children at high delirium risk, with limited evidence strength. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD420251272930.