Bring a large pot of salted water to a boil and cook pasta according to package directions until al dente. Reserve 1 cup of pasta water before draining.
Heat olive oil in a large skillet over medium heat. Add diced onion and sauté for 4-5 minutes until translucent and beginning to soften.
Add minced garlic and cook for another 30-60 seconds until fragrant, being careful not to burn it.
Reduce heat to medium-low and add the pumpkin purée, stirring to combine with the onion and garlic mixture.
Dissolve the miso paste in the broth by whisking them together in a small bowl, then pour into the skillet. The miso can clump if added directly, so this extra step ensures a smooth sauce.
Add cream, maple syrup, and red pepper flakes (if using). Stir to combine and let simmer gently for 5-7 minutes to meld flavors and thicken slightly.
Transfer the mixture to a blender and purée until completely smooth, or use an immersion blender directly in the pan. Return to the skillet if you used a standard blender.
Add butter if using and stir until melted and incorporated into the sauce. The butter adds a beautiful silkiness to the final texture.
Add the drained pasta directly to the sauce and toss to coat thoroughly. If the sauce seems too thick, gradually add some of the reserved pasta water until you reach your desired consistency.
Taste and adjust seasoning with salt and pepper. The miso is salty, so you may not need much additional salt.
Serve immediately, topped with toasted pine nuts, chopped fresh sage, and a sprinkle of Parmesan cheese if desired.