How I do it – extracranial-intracranial bypass surgery integrating STA-MCA anastomosis, synangiosis, MMA supply, and preservation of recipient artery perforators: the Integrated Method

Background Extracranial-intracranial (EC-IC) bypass is an effective revascularization technique for flow augmentation in conditions like Moyamoya disease and ischemic cerebrovascular disorders. The approach described here combines direct bypass (STA-MCA anastomosis), indirect bypass (encephaloduromyosynangiosis, EDMS), preservation of the middle meningeal artery (MMA), and preservation of recipient artery perforators to optimize outcomes. Method This article outlines a comprehensive surgical strategy emphasizing anatomical considerations, procedural nuances, and the integration of direct and indirect techniques while preserving MMA and recipient artery perforators to augment collateral circulation. Conclusion The Integrated Method described here encompasses four technical aspects so as to enhance revascularization, minimize complications, and improve long-term outcome in carefully selected patients.