To investigate whether revascularization surgery can better prevent the recurrence of stroke and improve survival rate in adult patients with moyamoya disease compared to conservative treatment. Methods: The clinical data and follow-up results of 279 adult moyamoya patients were retrospectively analyzed. Results: In this study, 133 patients underwent revascularization surgery and 146 patients received conservative treatment. The revascularization surgery patients showed a lower mean age than the conservative treatment patients (P<0.05). In the revascularization surgery group, 15 patients (11.8%) developed complications during the perioperative period; at follow-up, the numbers of patients with a >2 mRS scores, recurrences of stroke, and deaths in the revascularization surgery group were lower than that in the conservative treatment group (P<0.05). The revascularization surgery group showed a lower rate of stroke recurrence compared to the conservative treatment group (P=0.016). The revascularization surgery group also showed a longer survival time without stroke than the conservative treatment group (P=0.014). In the subgroup analysis, survival time without stroke was significantly longer in the revascularization surgery group for hemorrhagic patients (P=0.036); survival time without stroke did not differ between treatment types for ischemic patients (P>0.05). Conclusion: Revascularization surgery is superior to conservative treatment in improving the prognosis and lowering the stroke recurrence rate in adult moyamoya patients and particularly in hemorrhagic-onset patients. For ischemic-type moyamoya, the benefits of revascularization surgery are less apparent.