**11.1 Direct surgical treatment**

A branch of the external carotid artery is connected to the branch of the internal carotid artery beyond the stenosis to bypass the stenosed segment. Superficial temporal artery to middle cerebral artery (STA-MCA) (**Figure 4**) bypass is the commonly used technique [45]. Other less common direct techniques are STA-ACA, STA-PCA, and occipital artery-PCA anastomosis. These direct techniques are used when an immediate recirculation is indicated. The major drawback is that this cannot be easily done in children with MMD because of the smaller size of donor and recipient arteries.
