This case is of a 40-year-old female that presented to ED with recurrent TIA episodes causing left arm, leg and face weakness with dysarthria (despite angiographically the left side seems more severe).

MRA and CTA demonstrated bilateral M1 occlusion with a 'puff of smoke' appearance. The patient underwent a cerebral angiogram which confirmed high-grade M1 occlusion bilaterally with the formation of multiple small collaterals from the anterior and posterior cerebral arteries. The left side was more severe. These imaging findings were consistent with moyamoya syndrome. 

She was admitted under the Stroke team for medical management. Telemetry for 4 days did not reveal atrial fibrillation. MR brain did not show any evidence of a new stroke (DWI negative). Dual antiplatelet therapy was commenced as well as high dose statin. The patient had a negative vasculitis and thrombophilia screen. 

The patient was discussed in our hospital's Cerebrovascular Meeting and is booked for extracranial-intracranial (EC-IC) bypass surgery.