Objective Surgical revascularization is the main treatment for ischemic type moyamoya disease (MMD), but the efficacy for stroke prevention and prognosis is still controversial. A multicenter retrospective study was performed to investigate the efficacy of surgical treatment. Methods Clinical, neuroradiologic and follow-up data of 462 patients with ischemic type MMD disease from Xiangya Hospital of Central South University, Changde People"s Hospital, and Hunan Children"s Hospital were analyzed in this study. Propensity score matching was used to generate matched pairs based on age, sex, factors associated with stroke, cerebral infarction, white matter hyperintensities, Suzuki stages, bilateral MMD, posterior cerebral artery involvement, associated aneurysm. Kaplan-Meier curve was used to compare the recurrence rate of stroke between surgical and conservative treatment. Multifactorial Cox regression analyses were carried out to find the risk factors for recurrent stroke in patients with surgical treatment. Results The mean follow-up duration was 33.6 months. Thirty-one (12.8%) patients had new stroke in 242 surgically treated patients and 63 (28.6%) patients had new stroke in 220 conservatively treated patients, respectively. By one-to-one propensity score matching, 185 pairs were selected. Kaplan-Meier curve suggested a significant difference in the incidence of recurrent stroke (Log rank, P=0.018). Multivariable Cox regression analysis revealed posterior cerebral artery involvement (HR 5.162, 95% CI 2.343-11.375; P<0.001) and cerebral white matter hyperintensities (HR 2.287, 95% CI 1.083-4.828; P=0.030) were risk factors for recurrent stroke after surgery. There was no difference between the two surgical procedures (combined and indirect revascularization) for recurrent stroke (P=0.777). Conclusions Compared with conservative treatment, surgical revascularization can reduce the incidence of recurrent stroke and achieve favorable outcome in ischemic type MMD disease, and different surgical procedures are both effective.