Buerger's disease is a non-atherosclerotic, segmental inflammatory vasculitis that primarily affects small and medium-sized arteries and veins. It is most commonly seen in smokers, and usually presents with distal extremity ischemia, claudication, or ulcerations, and may lead to gangrene requiring amputation. Cerebral involvement represents a markedly unusual manifestation of Buerger's disease and a rare etiology for stroke in the young.

A 36-year-old woman with a history of tobacco use including daily vaping, hypertension, and migraines presented with 2-3 weeks of progressive left homonymous hemianopsia. CT head showed an acute-subacute infarct in the right occipital lobe and a chronic infarct in the left corona radiata. MRI was avoided due to retained foreign bodies from a prior gunshot wound. The patient was discharged on Aspirin and statin therapy.

One month later, she developed worsening left field loss. Repeat CT head revealed a new infarct in the right thalamus and basal ganglia. Cerebral angiography was performed and demonstrated bilateral distal vessel irregularities including corkscrew collaterals consistent with cerebral Buerger’s disease. Notably, the patient was diagnosed with Buerger's disease three years earlier following an episode of toe discoloration and delayed capillary refill, both of which improved following smoking cessation.

She was managed with aspirin, atorvastatin, discontinuation of oral contraceptives, and reinforced tobacco cessation.

Buerger’s disease should be considered in the differential diagnosis of stroke in young patients. Corkscrew collaterals on CT-A in a young patient that smokes should raise suspicion for the condition and digital subtraction can confirm the diagnosis. Management is challenging, particularly with rising use of vaping and nicotine pouches as potential risks for relapse. The role of antithrombotics, statins, and vasodilators (calcium channel blockers, prostaglandins) in cerebral disease remains uncertain.