Surgical anastomosis Direct anastomosis Anastomosis between the frontal (anterior) branch and/or the parietal (posterior) branch of the superficial temporal artery and the cortical branch(es) of the middle cerebral artery. This surgical method provides rather enough blood flow immediately after surgery. However, in the pediatric cases, highly refined anastomotic technique is require because the calibers of the cortical arteries are so small, i.e., less than 1.0 mm. It is less common to perform direct anastomoses alone, but combined direct and indirect anastomoses are more common surgical techniques today. Indirect anastomosis Galea (G), temporal muscle (M), periostium, dura mater (D) could be placed directly over the brain surface. Spontaneous anastomosis is established between them. There soft tissues are supplied by superficial temporal artery, deep temporal artery, middle meningeal artery (A). During operation (synangiosis: S), these arteries should be preserved. Although indirect anastomosis had no immediate effect on the cortical blood flow, enough blood supply through the newly established anastomosis is commonly observed especially in the pediatric cases. EDAS or EMS is the capitals of the materials used for anastomosis. Combined anastomosis Both direct and indirect anastomoses are performed at once. There are many minor modification among these methods. In case of occlusion of the direct anastomosis, indirect anastomoses may play a role to supply blood flow gradually as "fail safe". Direct vs indirect anastomoses There is no consensus on the better (best) surgical anastomosis among Japanese neurosurgeons. Those who support direct anastomosis favor it because direct one provides immediate, enough blood flow, and they think in mind that those favor indirect one have no good hands. Those who support indirect one believe that direct anastomosis may carry unnecessarily enough blood, and it may prevent normal development of spontaneous anastomosis by indirect one. Anyway, there is no conclusion on this debate. Surgical complications Incidence of surgical complication is very low. However, it is not null. In fact, there is a case report on the surgical death due to postoperative hemorrhage. It is advised to talk with your doctor about possible surgical complications before surgery. Surgical complications include postoperative hemorrhage (subdural, epidural, subcutaneous, and intracerebral hemorrhage), anemia (due to intraoperative hemorrhage), cerebral infarction (due to perioperative hypotension, hypocapnia, and prolonged temporal occlusion of the cerebral artery), transient ischemic attack, skin (scalp) necrosis, wound infection and seizure.