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Background Bypass surgery for moyamoya disease (MMD) mainly used the middle cerebral artery (MCA) as the recipient artery. There is a high risk of ischemia in the blood supply area of the anterior cerebral artery (ACA) during the perioperative period and follow ‐ up period. This study compared and analyzed the efficacy of superficial temporal artery (STA)‐ACA and STA‐MCA double barrel bypass and STA‐MCA double barrel bypass in the treatment of MMD. Methods In total 41 hemispheres of 32 ACA territory ischemic MMD patients were treated from January 2017 to December 2020 in The First Hospital of China Medical University. Separately performed STA‐ACA and STA‐MCA double barrel bypass and encephalo‐myo‐synangiosis (EMS; ACA group, 10 hemispheres of 10 patients) and STA‐MCA double barrel bypass and EMS (MCA group, 31 hemispheres of 25 patients). Compared and analyzed STA blood flow [including cut flow (CF), blood flow and cut flow index (CFI)], bypass vascular patency, cerebral perfusion [including the relative value of mean transit time (MTT), time to peak (TTP), cerebral blood flow (CBF) and cerebral blood volume (CBV)], neurological prognosis [modified Rankin Scale (mRS)], and the cerebral ischemia and intracranial hemorrhage morbidity and mortality in perioperative period and follow‐up period. Results Thirty‐two patients successfully completed 41 hemisphere operations. Intraoperative STA CF value of ACA group was significantly lower than MCA group [24.00 (15.38, 53.00) ml/min vs. 47 (36, 70) ml/min; Z = ‐ 2.547, P = 0.011]. CFI of STA one week after operation of ACA group was significantly greater than MCA group [3.57 (1.66, 4.66) vs. 1.30 (0.75, 1.70); Z = ‐ 2.357, P = 0.018]. No statistical significance between 2 groups in STA blood flow one week after operation [82.00 (62.50, 103.00) ml/min vs. 75.00 (27.90, 104.50) ml/min; Z = ‐ 0.221, P = 0.825]. The ACA group anastomotic patency rate was 12/12 and the MCA group was 81.58% (31/38), the difference was not statistically significant (χ2 = 1.268, P = 0.260). Bilateral frontal ischemia was observed in one hemisphere operation (1/10) in ACA group at perioperative period. Frontal ischemia was observed in 4 hemisphere operations (12.90%) and hemorrhagic temporal occipital infarction was observed in one hemisphere operation (3.23%) in MCA group at perioperative period. There was no statistically significant difference in the morbidity between 2 groups (Fisher exact probability: P = 1.000). No cerebral ischemia, intracranial hemorrhage and death occurred in ACA group, and surgical side frontal ischemia was observed in one hemisphere operation one year after operation in MCA group. There was no statistically significant difference in the morbidity between 2 groups (Fisher exact probability: P = 1.000). ACA group improved in 6 hemisphere operations (6/10), no changed in 3 hemisphere operations (3/10), deteriorated in one hemisphere operation (1/10). MCA group improved in 10 hemisphere operations (32.26%), no changed in 17 hemisphere operations (54.84%), deteriorated in 4 hemisphere operations (12.90%). There was no statistically significant difference between 2 groups (Z = ‐ 1.355, P = 0.223). Conclusions The STA‐ACA and STA‐MCA double barrel bypass in the treatment of ACA territory ischemic MMD patients can obtain good anastomotic patency rate and satisfactory long‐term efficacy. Compared with the STA‐MCA double barrel bypass, this surgery can obtain higher STA CFI, while long‐term outcomes of patients were the same.