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BACKGROUND AND PURPOSE: Choroidal collateral anastomosis is associated with hemorrhage recurrence in patients with Moyamoya disease. However, the relationship between recurrent ipsilateral hemorrhage and choroidal collateral anastomosis subtypes (anterior choroidal artery anastomosis, lateral posterior choroidal artery anastomosis, and medial posterior choroidal artery anastomosis) is unclear. This study aimed to assess this potential association in adult patients with Moyamoya disease. MATERIALS AND METHODS: Patients angiographically diagnosed with Moyamoya disease who underwent conservative treatment between January 2008 and December 2018 were included in this retrospective study. Two readers assessed the angiographic images to identify choroidal collateral anastomosis subtypes, and Cox proportional hazard regression models were used to estimate the risk of recurrent hemorrhage associated with each subtype. RESULTS: Thirty-nine patients (mean age ¼ 45.2 years) were included in this study. During 52.4 6 37.0 months of follow-up, recurrent ipsilateral hemorrhage occurred in 48.7% (19/39) of patients. Patients with recurrent hemorrhage had a higher prevalence of choroidal collateral (94.8% versus 60.0%; P ¼ .02) and lateral posterior choroidal artery (78.9% versus 25.0%; P , .01) anastomoses than those without recurrent hemorrhage. Lateral posterior choroidal artery anastomosis was associated with recurrent hemorrhage before (hazard ratio ¼ 6.66; 95% CI, 2.18-20.39; P , .01) and after (hazard ratio ¼ 5.78; 95% CI, 1.58-21.13; P , .01) adjustments were made for age, sex, and other confounding factors. CONCLUSIONS: Choroidal collateral anastomosis is responsible for most cases of recurrent hemorrhage in adult patients with Moyamoya disease; lateral posterior choroidal artery anastomosis is a significant risk factor for these recurrent events. ABBREVIATIONS: AChA ¼ anterior choroidal artery; ChCA ¼ choroidal collateral anastomosis; HR ¼ hazard ratio; LPChA ¼ lateral posterior choroidal artery; MMD ¼ Moyamoya disease; MPChA ¼ medial posterior choroidal artery M oyamoya disease (MMD) is an uncommon but potentially catastrophic cerebrovascular disorder characterized by progressive occlusion in the terminal portion of the internal carotid artery and its main branches within the circle of Willis. 1