How I do it: operative nuances of multiple burr hole surgery for moyamoya disease and syndrome.

BACKGROUND: Burr hole surgery for moyamoya disease and moyamoya syndrome is known to be an effective, versatile, and relatively simple revascularization technique. We will focus on the technical operative aspects of multiple burr hole surgery as we perform it in our center.

METHODS: Periosteal flaps are prepared and placed in a burr hole with beveled edge, after opening the dura and arachnoid membrane, in order to facilitate neovascularization into the ischemic cortex.

CONCLUSIONS: Burr hole surgery is a versatile treatment modality for moyamoya and moyamoya-like disease. Success can be maximized by having a meticulous operative technique.