Smoke disease is a rare abnormal cerebrovascular disease of the skull base, characterized by chronic progressive stenosis or occlusion of the ends of the internal carotid arteries bilaterally, as well as the beginning of the middle cerebral artery of the anterior cerebral artery, and secondary to the formation of an abnormal vascular network of the skull base. There are two main groups of people with the disease, children under 10 years old and adults around 40 years old, and the symptoms are mainly cerebral ischemia and cerebral hemorrhage. When the blood supply to the brain is insufficient, the skull base will proliferate some compensatory vessels. So, does smog disease compensate well and do I still need surgery? There are very few patients who can reach stage VI and have a relatively good compensation to achieve the blood supply demand. In this case, surgery is not necessary. But it does not mean that so patients will have this opportunity, most patients will still have symptoms such as cerebral hemorrhage cerebral ischemia. Because of this abnormal vascular network at the base of the skull on cerebral angiograms, in the form of smoke, it is called smoggy disease. This disease, there is no exact effective drugs. It can be treated symptomatically with cerebral vasodilators, anti-platelet aggregation drugs and anticoagulants, but attention should be paid to the adverse effects of the drugs, and if necessary, it can be treated by surgery, intracranial and extracranial revascularization, and surgery is the main treatment for smog disease smog syndrome, which can effectively prevent and treat ischemic strokes. The surgical treatment of smog is divided into direct bypass surgery, indirect bypass surgery and combined vascular bypass surgery. Direct bypass surgery refers to re-establishing new blood flow channels to ensure adequate cerebral blood flow, by directly bypassing the intracranial and extracranial vessels to anastomose and rapidly improve cerebral blood supply. Indirect bypass surgery involves attaching muscle and meningeal tissues, which are rich in extracranial blood supply, to the surface of the brain inside the skull, so it is also called patching surgery. The brain automatically draws blood vessels from these tissues to form spontaneous anastomoses with the cortical vessels. The blood supply to the brain is reconstructed through extracranial blood flow to the intracranial area to relieve the inadequate supply of blood to the intracerebral arteries. By establishing a pathway for blood supply from normal vessels outside the brain to the intracerebral area, the intracerebral blood flow is improved, and after the blood supply to the brain is improved, the need for smoke-like vessels will gradually decrease, thus reducing the patient’s risk of reoccurring cerebral ischemia and cerebral hemorrhage and improving the patient’s prognosis. Combined vascular bypass surgery is based on the advantages and disadvantages of the two traditional procedures, bypass + patching in one surgery, based on the bypass and multi-factor patching, the establishment of multiple blood flow pathways, can provide abundant blood to the patient’s brain tissue, which can have the advantages of the patching surgery (larger blood supply to the brain) and give the new blood vessels the time needed to grow (by the direct bypass vessels to maintain normal blood supply). This avoids the development of a stroke before the neovascularization occurs. This is superior to direct bypass and indirect bypass alone. It is clear that the best surgical treatment for smog is a combined bypass procedure that takes the best of both worlds. The surgery has a higher cure rate and less risk. Patients are advised to learn more and communicate with their doctors when choosing the surgery. A skilled physician will be better able to manipulate the direction of the surgery and avoid unnecessary surgical risks.