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A 74 year old man presented with an episode of loss of consciousness. CT angiography showed stenotic distal internal carotid arteries (ICA), severe stenosis of the left M1 segment, and moderate stenosis of the right M1 segment of the middle cerebral arteries (MCA) (Figure 1A-B). CT perfusion showed delayed perfusion to the left MCA territory (Figure 1C). MRI brain revealed a punctate right frontal infarct (Figure 2A). He was transferred to our hospital for superficial temporal artery - middle cerebral artery (STA-MCA) bypass. However, neurologic exam was notable for right facial droop involving right forehead and incomplete eye closure. MRI of the brain with vessel wall imaging showed thin enhancement of the bilateral ophthalmic and supraclinoid ICA’s and left M1 enhancement (Figure 2B-C). A rash was found behind the right ear with crusted vesicles as well as bilateral cranial nerve 6 palsies. Cerebrospinal fluid had 47 nucleated cells/uL with 37 red blood cells/uL. Glucose was 75 mg/dL and total protein was 57 mg/dL. CSF VZV IgG returned positive at 819.0 and CSF VZV IgM was negative at 0.25. Thus, the diagnosis was VZV vasculitis. He was treated with intravenous acyclovir and transitioned to oral valacyclovir for a 14 day course.