Socioeconomic and Sociodemographic Factors and Utilization of Revascularization Surgery in Moyamoya Disease: A Systematic Review and Meta-Analysis.

INTRODUCTION: Moyamoya disease (MMD) is a rare cerebrovascular disorder in which timely surgical revascularization can prevent stroke. Socioeconomic and sociodemographic factors may influence utilization of revascularization. This systematic review and meta-analysis aimed to quantify associations of household income, insurance type, race or ethnicity, and sex with receipt of revascularization surgery among patients with MMD. METHODS: A search of PubMed, EMBASE, Europe PMC and Scopus was performed on 11 August 2026 following the PRISMA 2020 statement. Studies reporting socioeconomic factors (household income and insurance type) or sociodemographic factors (race or ethnicity and sex) in relation to receipt of revascularization surgery were included. Only comparisons with directly reported stratum-specific event counts and denominators were pooled; Rios-Zermeno 2024 was retained narratively for income because exact full-cohort income-quartile denominators were not reported. Risk ratios (RR) were pooled using inverse-variance random-effects models with τ² estimated by restricted maximum likelihood and confidence intervals (CI) derived by the Hartung-Knapp-Sidik-Jonkman method with the ad hoc variance correction. Each comparison was pooled separately against its pre-specified reference group. RESULTS: Five retrospective observational studies comprising 46,792 study-reported observations from the United States met the inclusion criteria. Three studies contributed to at least one meta-analysis, with two or three studies per comparison. Household-income pooling was limited to Chiu 2021 and Raygor 2022; Rios-Zermeno 2024 reported income-specific bypass counts and utilization percentages but not exact full-cohort income-quartile denominators. No household-income comparison reached statistical significance in the primary analysis; for the lowest versus highest income quartile, RR was 0.75 (95% CI 0.34, 1.65; P = 0.14; I² = 0%). Hispanic patients were less likely than Caucasian patients to undergo revascularization (RR 0.68 [95% CI 0.53, 0.89]; P = 0.02; I² = 0%). No other comparison reached statistical significance. Findings for African American patients (RR 0.58 [95% CI 0.26, 1.31]; P = 0.10), Medicaid beneficiaries compared with self-paying patients (RR 0.60 [95% CI 0.07, 5.36]; P = 0.21), and sex (RR 1.01 [95% CI 0.57, 1.77]; P = 0.92) were inconclusive. CONCLUSIONS: Among patients with MMD, Hispanic ethnicity was associated with lower utilization of revascularization surgery. Household-income, African American, insurance-type, and sex comparisons were imprecise and inconclusive in the primary analyses. Because the evidence base comprises a small number of overlapping United States administrative-database studies, all estimates should be regarded as hypothesis-generating and should not be extrapolated to other health systems.