MATERIAL and METHODS: 11 patients who were treated with an indirect bypass procedures at our clinic and followed for at least three years were retrospectively examined. 19 surgical interventions were performed for 18 patient hemispheres pertaining to these patients. 4 indirect surgical revascularization methods were used for three patient hemispheres. On the other hand, indirect procedures combined with pial synangiosis were applied in 11 operations. In addition, the “multiple burr-hole surgery” method was used in 4 four operations performed for two patients.

RESULTS: The clinical success rate was 66.6% for patients where the techniques were applied with pial synangiosis. No new ischemic or hemorrhagic attack was observed during the follow-up period in any of these patients in this series.

CONCLUSION: Pial synangiosis is a modification that Increases the success rate of indirect surgical methods. In addition, high success rates have been reported in recent publications related to multiple burr-hole surgery. This method is a candidate choice of surgical intervention for selected patients. Keywords : Moyamoya disease, Indirect bypass, Pediatric, Pial synangiosis