Our case illustrates that very rare asymmetric patterns of white matter damage can be seen with ALD, the commonest pattern being symmetrical MRI T2/FLAIR hyperintensities in the parieto-occipital regions and splenium of the corpus callosum; it is estimated that such asymmetry, is seen in under 5% of ALD cases and can be mistaken for other pathological processes such as tumours or trauma. Our patient also suffered from large vessel atherosclerotic disease which is commonly seen in the general and stroke populations. His occluded left MCA was the ‘red herring’ that resulted in a misdiagnosis of stroke, with this rare asymmetric ALD-related demyelination representing the radiological ‘chameleon’ mimicking it.