Perioperative management of pediatric moyamoya disease Most important perioperative complication in the pediatric moyamoya disease is cerebral ischaemia cause by "crying" due to pain and anxiety. It sometimes happens that after successful bypass surgery, cerebral infarction occurs immediately after surgery simply by crying. Each institute pays much attention to prevent such ischemic events. Recently, Nomura et al reported their experiences to prevent perioperative ischemic complications. Their protocol is as follows: 1. Sedation  Oral intake of sedatives prior to installation of an intravenous line. Intravenous injection of sedatives for neuroimaging examination. Immediate postoperative sedation and pain control after check of the neurological findings. 2. Operative and postoperative wound handling techniques Resolvable subcuticular sutures with steristrip taping for closure of the scalp incision. A suture placed but left unknotted for closure of the incision of drain removal. Soft paraffin gauze applied over the wound with a bandage for fixation of the dressing 3. Others Taping of absorbable lidocaine to skin before venipuncture. Maintenance of a central venous catheter for 1 week after surgery The above-mentioned procedures are not necessarily required to every pediatric patient. I believe that close and mutual reliance between the patients and medical staffs is mandatory. Each institute may have a similar protocol to prevent untoward ischemic events in the management of pediatric moyamoya disease.