Moyamoya syndrome, a vasculopathy characterized by chronic progressive stenosis at the apices of the intracranial internal carotid arteries, is an increasingly recognized entity which is associated with cerebral ischemia. Diagnosis is made on the basis of clinical and radiographic findings, including a characteristic stenosis of the internal carotid arteries in conjunction with abundant collateral vessel development. Adult moyamoya patients often present with hemorrhage, leading to rapid diagnosis. In contrast, children usually present with transient ischemic attacks or strokes, which may prove more difficult to diagnose because of patient's inadequate verbal and other skills, leading to delayed recognition of the underlying moyamoya. The progression of disease can be slow, with rare, intermittent events, or it can be fulminant, with rapid neurologic decline. However, regardless of the course, it is apparent that moyamoya syndrome, both in terms of arteriopathy and clinical symptoms, inevitably progresses in untreated patients. Surgery is generally recommended for the treatment of patients with recurrent or progressive cerebral ischemic events and associated reduced cerebral perfusion reserve. Many different operative techniques have been described, all with the main goal of preventing further ischemic injury by increasing collateral blood flow to hypoperfused areas of the cortex, using the external carotid circulation as a donor supply. This article discusses the various treatment approaches, with an emphasis on the use of pial synangiosis, a method of indirect revascularization. The use of pial synangiosis is a safe, effective, and durable method of cerebral revascularization in moyamoya syndrome and should be considered as a primary treatment for moyamoya, especially in the pediatric population.