Abstract At this institution a new procedure has been developed that involves anastomosing one of the branches of the superficial temporal artery to one of the major trunks of the middle cerebral artery in the Sylvian fissure. This procedure has been performed in 22 cases to date. Clinical indications for this procedure have fallen into four major categories. This new type of anastomosis produces greater bypass flow than conventional cortical middle cerebral artery anastomoses, and may be a better therapeutic alternative in certain clinical situations. The preoperative and postoperative angiographic evaluation of these patients is discussed. The radiologic results in this series of patients are reviewed.