**11.3 Combined techniques**

Houkin et al. first performed a combined revascularization surgery. It combined the superficial temporal artery and M3 branches of the middle cerebral artery (STA-MCA) bypass and encephalo-duro-arterio-myosynangiosis (EDAMS) (**Figure 6**). The aim of the combined procedure is to improve the results to serve as an alternative in case the direct bypass fails and prevents second surgery. The direct bypass immediately improves the hemodynamics [44]. A 2005 systematic review from Japan compared direct, indirect, and combined techniques and found that there is no statistically significant difference between all these techniques in terms of outcome during 58 months of follow-up period [48]. Efficacy of medical and surgical management was also compared in a large survey conducted in Japan and concluded that there is no significant difference between the two [49]. However, in another study, it was found that children initially underwent medical therapy had to ultimately go for revascularization surgery more than the children who underwent surgery in the first instance [38].
