*Medical Management in Moyamoya Disease DOI: http://dx.doi.org/10.5772/intechopen.95775*

prescribed antiplatelet benefited from reducing mortality, especially patients who received Cilostazol [21]. In contrast, Yamada et al. showed no benefit of antiplatelet treatment to prevent recurrent cerebral infarction in 344 Moyamoya patients with TIA or previous ischemic events in Japan [14].

The dual antiplatelet regimen has no role in Moyamoya disease, even in single regimen failure, due to the high risk for bleeding complications. The Japanese guidelines for Moyamoya disease management recommend using antiplatelet therapy as cerebral ischemic prevention, but with grade C level (can be considered, but adequate scientific rationale lacking) [22]. The long-term use of antiplatelet therapy for secondary ischemic prevention remains controversial because of the high risk for intracranial hemorrhage [12, 22].

The anticoagulants consist of the vitamin-K antagonist, heparin, low-molecularweight heparin (LMWH), and non-vitamin-K antagonist. Due to the high risk of bleeding in Moyamoya disease, anticoagulants have no role in ischemic prevention, even in surgical or antiplatelet failure. Intravenous thrombolytic treatment with the recombinant tissue plasminogen activator (rtPA) is a standard treatment in acute ischemic stroke [23]. The Japanese guidelines for Moyamoya disease management recommend not giving the rtPA during acute ischemic stroke presentation due to the high risk of bleeding [22].

In summary, the single antiplatelet regimen with Aspirin, Clopidogrel, or Cilostazol may be useful for secondary ischemic prevention in Moyamoya patients with cerebral infarct or transient ischemic attack (TIA). The anticoagulants with the vitamin-K antagonist, heparin, low-molecular-weight heparin (LMWH), or non-vitamin-K antagonist have no role in Moyamoya patients. Intravenous rtPA has no role in Moyamoya patients with acute ischemic stroke. **Table 1** shows a summary of antithrombotic therapy in Moyamoya disease.
