Figure 2: Angiogram performed from the left vertebral artery (a and b) and right common carotid artery (c and d) showing complete occlusion of the internal carotid artery. Enlarged perforator branches from the right external carotid artery giving rise to small corkscrew parenchymal vessels. This is the appearance of “puff of smoke” classical of moyamoya disease. The posterior circulation was also affected, involving both posterior cerebral arteries