Puff-of-Smoke Appearance

In brief: “Puff of smoke” is a descriptive angiographic phrase for a network of fine collateral vessels near progressively narrowed arteries at the base of the brain.

Use in moyamoya disease

The Japanese word moyamoya conveys a hazy or smoky appearance. These vessels are not smoke and are not a single abnormal mass. They are collateral pathways that develop as the usual arterial routes narrow. Their appearance is best characterized with catheter angiography, although MRA can also show abnormal basal and periventricular networks.

The phrase alone does not establish the complete diagnosis. Clinicians also evaluate where the stenosis is centered, whether disease is unilateral or bilateral, arterial remodeling, alternative causes, associated conditions, and brain injury. [1]

Clinical detail

Collateral networks evolve over time. Later angiographic stages may show reduction of basal moyamoya vessels as external carotid and other collateral pathways become more prominent.