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Introduction/Purpose Moyamoya disease (MMD) is a progressive steno-occlusive arteriopathy of the distal internal carotid arteries (ICAs) defined by the angiographic hallmark of basal collateral networks. Hemorrhagic presentation predominates in adults and carries significant morbidity. Catheter angiography remains the gold standard for diagnosis, Suzuki staging, and detailed mapping of collateral pathways—information critical for planning neurointerventional or surgical revascularization. We present the arteriographic findings in a case of advanced bilateral MMD diagnosed after hemorrhagic stroke, emphasizing the collateral architecture and its implications for potential future endovascular or surgical intervention.Materials/Methods A 52-year-old male presented with altered consciousness after a ground-level fall. CT revealed bilateral occipital subarachnoid hemorrhage, hypothalamic and right precuneal intraparenchymal hematomas, mild hemoventricle, and chronic right temporo-occipital encephalomalacia. MR angiography showed occlusion of the right MCA from its origin, right PCA occlusion from P2, and diffuse narrowing of both ACAs and the left MCA. Four-vessel diagnostic cerebral arteriography was performed via right femoral access (5F sheath, Berenstein catheters, non-ionic low-osmolarity contrast) with selective bilateral injections of the common, internal, and external carotid and vertebral arteries.Results Arteriography confirmed bilateral MMD consistent with Suzuki stage V/VI. The right ICA showed terminal bifurcation occlusion with loss of the ACA and MCA; the left ICA demonstrated cavernous segment stenosis with severe progressive supraclinoid tapering. Bilateral lenticulostriate and thalamoperforating ‘puff of smoke’ collaterals were present. Key neurointerventional findings (Graphic1) included: (1) prominent transdural collateral recruitment via the right middle meningeal artery (MMA) to the frontal and parietal territories, with a direct MMA-to-ACA anastomosis; (2) exuberant transdural supply from the left ascending pharyngeal artery to the parietal cortex; (3) bilateral fetal-type posterior communicating arteries serving as the dominant anterior circulation supply; and (4) left vertebral artery aplasia with a vicarious right vertebral artery. The circle of Willis maintained adequate flow without angiographic signs of hemodynamic failure. The patient recovered to functional independence and was discharged on conservative management with scheduled neuroradiological follow-up. No surgical revascularization was indicated at this stage.Conclusion This case demonstrates the essential role of catheter angiography in the comprehensive evaluation of hemorrhagic MMD, particularly for delineating transdural collateral pathways including MMA-mediated networks. Detailed angiographic mapping of these collaterals is directly relevant to neurointerventional planning, as MMA-dependent territories must be carefully evaluated before any consideration of middle meningeal artery embolization or surgical bypass procedures. In advanced-stage MMD with preserved hemodynamic compensation, conservative management with serial angiographic surveillance is a reasonable strategy.Disclosures L. Sganzerla: None. L. Gortz: None. G. Oliboni: None. G. Volpato: None. P. Carbonera: None. M. Carvalho: None.Abstract E-202 Figure 1