Objective To investigate the effects of combined direct and indirect revascularization in the treatment of ischemic moyamoya disease.Methods Combined superficial temporal artery middle cerebral artery anastomosis and encephalo-duro-myo-synangiosis (EDMS) were performed in 20 adult patients with ischemic moyamoya disease,who were followedup for six months to two years.The postoperative outcomes were evaluated by CTA,DSA,MRI and PWI.Results The postoperative external carotid angiography at 6 months and 12 months revealed that the STA-MCA bypass was patent in 17 patients.12 of 17 patients were also patent at 24 months after the procedure.The extensive development of surgical collaterals from MMA and deep temporal artery through indirect bypass were observed in all patients.18 patients were free of transient ischemic attack within one year.Conclusions Combined STA MCA bypass and EDMS could provide a significant reciprocal benefit.It was a safe and effective option to improve the short-and long-term outcomes in patients with ischemic moyamoya disease.