Smoker’s disease is a relatively rare cerebrovascular disease, which is mainly caused by chronic progressive stenosis or occlusion of major blood vessels in the cerebral arterial ring bilaterally, followed by the proliferation of abnormal vascular network at the skull base, and these abnormally proliferated small vascular networks, which appear as a cloud of smoke-like images in cerebral angiography, hence the image of the disease is called smoker’s disease. The age of onset of smog is bimodal, with a high incidence in two age groups: adults in their 40s and children under the age of 10. Some patients ask whether medicine works for children with smog. In what cases do they need surgery? In fact, it is largely accepted in the medical community that medication is of little relevance in the treatment of smog. For example, a scholarly paper titled “Treatment and Medications for Smog” published on the Pediatric Neurology Channel of a U.S. physician continuing education website states that medications for smog (MMD) are disappointing and primarily target MMD-related complications. If a patient develops intracranial hemorrhage, blood pressure must be controlled (if hypertension is present). If the patient has had a severe stroke, the patient must be monitored in the ICU until the patient’s condition is stabilized. If the patient has had an ischemic stroke, anticoagulation or antiplatelet medication may be considered. A possible mechanism for the use of anticoagulation or antiplatelet agents is to prevent further strokes, especially in patients with stenosis, where further narrowing or occlusion of the diseased vessel can lead to cerebral infarction. This shows that medication is not the ideal treatment for smog, but mainly for symptom relief, and that surgery is necessary to deal with smog. So when is surgery necessary? Most experts agree that surgery should be performed as soon as the diagnosis of smog is clear. Of course, we are talking about as soon as possible, not immediately, and a certain time lag is needed for different cases. For example, for patients who have had a cerebral infarction, surgery should be requested two weeks to a month after the acute phase of the infarction, while for patients who have had a cerebral hemorrhage, surgery should be performed about three months after the acute phase of the cerebral hemorrhage. At present, the most advanced and ideal surgical method for treating smog is combined vascular bypass surgery, which is a two-pronged procedure of direct bypass + patching to establish a more adequate and complete bypass blood supply channel for the patient’s brain, greatly improving the brain blood supply and achieving a more ideal treatment effect.