The current indications for cerebral bypass surgery are unquestionably diminishing. As a result of rapid and progressive advances, endovascular techniques are now capable of dealing with more and more challenging aneurysms that could have been optimally managed only with open surgical techniques just afewyearsago. Similarly, therecent resultsof the Carotid Occlusion Surgery Study (COSS) have emphasized the effectiveness of modern medical therapy for the management of intracranial ischemia and dampened enthusiasm for bypass surgery (3). However, despite these advances, there still remains a subset of patients who benefit from revascularization surgery. InapaperrecentlypublishedinWORLD NEUROSURGERY, Kalanietal. attempt to define the current indications and outcomes of bypass surgery in the modern endovascular era. The authors present a contemporary series of direct cerebrovascular revascularization procedures performed at the Barrow Neurological Institute (BNI) over a 7-year period (2006e2013). There were 131 direct bypass procedures performed in 121 patients. Indications for bypass surgery included moyamoya disease in 40 patients (47 bypasses), complex aneurysms in 54 patients (56 bypasses), and occlusive vascular disease in27 patients (28 bypasses).Amongpatients with moyamoya angiopathy, revascularization resulted in improvement of symptomsin 77.5%.Morbidity and mortality rates were 5%and 0%, respectively. Long-term angiographic follow-up was available in only 60% of the patients and demonstrated graft patency in 96.8%. Among the patients with complex aneurysms, 81.5% of the patients had afavorable outcome. Morbidity and mortality rates were 16.6% and 13%, respectively. Long-term angiographic follow-up was available in 94.4% of the surviving patients and demonstrated graft patency in 76.7%. Among patients with occlusive vascular disease, symptom improvement was seen in 55.5%. Morbidity and mortality rates were 14.8% and 0%, respectively. Long-term angiographic follow-up was available in 59.3% of patients and showed a 100% graft patency rate. It is always useful to hear the experience of such a renowned center as the BNI. The article has some limitations, such as the retrospective nature of the review; the heterogeneous group of patients; and the limited long-term angiographic follow-up, particularly in the patients with moyamoya disease and vascular occlusive disease. This single-institution experience limits the general applicability of the results; very few surgeons in the world can hope to achieve the generally excellent results reported in this study. The authors use the Glasgow Outcome Scale, which was originally designed for assessment of outcomes in patients with severe head trauma. Although a Glasgow Outcome Scale score of 4 may be a “good” result for a patient with a severe head injury, such an outcome (“independent withmildto moderateneurologic deficit”) maynot be a “good” outcome for an intact patient presenting with an asymptomatic complex aneurysm. Use of the modified Rankin Scale, which is a more accurate indicator of outcomes, may have been