A 55-year-old man who had a history of hypertension was admitted to the neurosurgery department due to dizziness repeatedly for over a year and a sudden onset of syncope 1 month prior. Additionally, he once accepted medical therapy in the neurological department without alleviation. Neurological examination revealed no abnormal signs. Diffusion-weighted imaging (DWI) showed no obvious infarct in the bilateral cerebral cortex. Ultrasound examination of the carotid artery confirmed chronic bilateral stenosis of the carotid artery bifurcation caused by stable fibrous-calcific plaques. In contrast to the normal side, left stenotic anterior cerebral arteries (ACA), middle cerebral artery (MCA) and ICA were hardly detected on preoperative DSA. The left frontal and parietal lobes were mainly supplied by the left posterior cerebral artery without obvious moyamoya vessels in skull base. Preoperative DSA confirmed the frontal and parietal branches of superficial temporal artery (STA) which originates from the external carotid artery deep to the superficial pole of the parotid and ascends anterior to the auditory canal []. Magnetic resonance imaging 3D–arterial spin labeling (MRI 3D-ASL) indicated decreased cerebral blood flow (CBF) in the left cerebral cortex. Dual anastomosis between the superficial temporal artery (STA) and middle cerebral artery (MCA) combined with EDMS on the left side was performed. The patency of the anastomotic stoma was immediately confirmed by indocyanine green video-angiography. Accompanied by nicardipine hydrochloride, systolic blood pressure was strictly controlled at 120–140 mmHg promptly after surgery. During the first few days, the patient presented no additional neurological deterioration. Computed tomography angiography after surgery confirmed no stenosis in recipient vessels. Additionally, T2-weighed MRI and 3D-ASL on the 3rd day after surgery showed a more significantly increased CBF at the anastomosis sites than at the preoperative stage, indicating the effectiveness of revascularization. Nevertheless, this patient developed aphasia and right hemiplegia on the 6th day after surgery with continuous execution of the strict program of blood pressure control. Computed tomography on the same day found that the middle line migrated to the right side and a local low-density lesion in the left frontal lobe near the operative area. Following the application of mannitol and furosemide, the symptoms began to ameliorate on the 16th day after surgery. Nevertheless, MRI 3D-ASL on the 21st day after surgery showed more decreased CBF than at the site of anastomosis on the 3rd day after surgery. T2-weighted MRI showed a massive hyperintensity lesion around the operation area, while DWI revealed no cerebral infarction, indicating massive cerebral edema in the operative area. Ultimately, this patient recovered after 40 days of surgery without any neurologic deficits. MRI 3D-ASL on the 166th day showed bilateral well-developed CBF and DSA on the 180th day presented well-developed revascularization.