59 year old female with history of hypertension and prior left MCA aneurysm status post stent assisted coiling (2007) and right MCA aneurysm (2010) status post stenting. She initially presented for surveillance imaging, which showed persistent aneurysmal occlusion, but was lost to follow-up in 2013. In October 2019 she presented with sudden onset vomiting followed by a headache, followed by rapid loss of consciousness. Imaging showed diffuse intraventricular hemorrhage with subarachnoid blood in the basilar cisterns, consistent with a modified Fisher 4 grade SAH. She was comatose with intact brainstem reflexes and extensor posturing. A conventional angiogram did not show a new aneurysm or recurrence of prior aneurysms but there was an occlusion of the right MCA distal to the internal carotid artery bifurcation with extensive collateralization with a moyamoya-like pattern seen in temporal lobe vessels. The SAH was thought to be the result of the moyamoya related changes with rupture of the collateral lenticulostriate vessels. She was managed medically in the intensive care unit however exam remained poor despite management of hydrocephalus.