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A 36-year-old woman presented with transient diplopia and right-sided paresthesia. MR scan of the brain showed multiple chronic ischaemic lesions in the white matter, linear hyperdensities along sulci and reduced visibility of the middle cerebral arteries (figure 1A– B). Angiography identified progressive narrowing of the internal carotid arteries, with tiny and tortuous lenticulostriate arteries giving a ‘puff of smoke’ appearance, leptomeningeal collaterals from the posterior cerebral arteries and transdural anastomosis (figure 1C– F).
Contributors AG and GF contributed to study conception, design and drafting of the manuscript. AG, GF, AB and FA contributed to acquisition of data. AG, GF and AB contributed to the analysis and interpretation of data. GF contributed to critical revision of the manuscript.
Competing interests None declared.
Patient consent for publication Obtained.
Provenance and peer review Not commissioned. Externally peer reviewed by Neil Scolding, Bristol, UK.