Patient is a mid-60s woman who presented with 2 weeks of increasingly throbbing right sided headache. She was found to have a right frontal subacute intraparenchymal hemorrhage and left parietal edema with vessel irregularities noted on MRA.

Angiogram noted above demonstrating multifocal luminal narrowing and dilation throughout the distal right MCA and ACA vasculature and also in the posterior circulation through the PCOMM.

She underwent a CT Chest and an extensive rheumatological workup that was negative. Interestingly, CSF was bland. A brain biopsy was recommended, but the patient did not want to proceed. She was started on Cytoxan and a Prednisone taper, and she had no new neurological symptoms and her headaches were almost completely resolved.