Objective: To re-emphasize that indirect revascularization surgery alone, where multiple burr holes and arachnoid openings are made over both cerebral hemispheres, is beneficial in the treatment of moyamoya disease in children.
Clinical presentation:
We report a 10 year old boy presenting with complaints of episodic headache for the last five years. At the peak of his headache he had visual disturbances and acute onset weakness of left sided limbs, recovering within a few minutes. He had no focal neurological deficits. Radiological investigations revealed abnormal findings, demonstrating the features of moyamoya disease.
Surgical management:
He underwent bilateral multiple burr holes, dural and arachnoid opening over the frontal, parietal and temporal regions of each hemisphere. The elevated periosteal flap was placed in contact with the exposed brain through each burr hole.
Results:
On six months follow up he had only one episode of TIA. Post operative four vessel angiogram demonstrated excellent cerebral revascularization around the burr hole sites, and SPECT imaging showed hypoperfusion in the right temporo-occipital area suggestive of an old infarct with no other perfusion defect in the rest of the brain parenchyma.
Conclusion:
In children with moyamoya disease this relatively simple surgical technique is effective and safe, and can be used as the only treatment without supplementary revascularization procedures. This procedure can be done in a single stage, on both sides, and the number of burr holes made over each hemisphere depends on the extent of the disease.

Key words: indirect revascularization, multiple burr holes, moyamoya disease, children.